The Truth about Perimenopause, HRT and Breast Cancer Risk with Dr. Heather Hirsch & Tamsen Fadal

Summary

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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

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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.

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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)

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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)

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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.

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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.

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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.”

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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.

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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)

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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)

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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.

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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)

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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

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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.

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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)

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Transcript

[Tamsen Fadal]

Lemonade.

[Chelsea Clinton]

Welcome to that Can't Be True, a show that sorts fact from fiction, especially on issues impacting our health. I'm Chelsea Clinton. For our mothers, and particularly our grandmothers, menopause was too often a hush hush conversation. In fact, many women probably suffered largely in silence. Just like getting your period was too often a taboo topic, the end of your period was arguably even more so. And perimenopause, well, most people going through it didn't even know there was a word for it. Thankfully, so much of that has changed. Menopause is really having a moment. And as a result, there's just so much information about menopause swirling around on social media, from diet and exercise to recent breaking news on HRT or hormone replacement therapy. And so today I wanted to take a step back and dig into what the facts really are. And Joining me are Dr. Heather Hirsch, a board certified internist with a focus on women's health, particularly midlife and menopause. She's the founder of the Menopause Clinic at the Brigham and Women's Hospital in Boston and author of the new book the Perimenopause Survival Guide. And also joining us is Tamsen Fadal, a former TV news anchor turned menopause awareness advocate. She co produced the documentary the M Factor and is also the author of how to Menopause. Hi. I'm so sorry to be late. I actually was at my, well, woman's visit this morning and.

[Tamsen Fadal]

Nice, good.

[Chelsea Clinton]

They were running a little bit late and so then I'm late.

[Dr. Heather Hirsch]

Yes, we know that those doctors run late, like myself included.

[Chelsea Clinton]

So I always feel like, though often it's like, you know, someone was just delivering a baby and it always just feels way more important than like anything else happening.

[Dr. Heather Hirsch]

So that's kind of nice. You just had that experience and now we're going to be talking about women's health.

[Tamsen Fadal]

I.

[Dr. Heather Hirsch]

It's so relatable.

[Chelsea Clinton]

It's a good segue.

[Dr. Heather Hirsch]

Good morning, Tamsen. It's so good to see you.

[Tamsen Fadal]

Hi there. How are you doing?

[Dr. Heather Hirsch]

Fantastic, actually.

[Tamsen Fadal]

Good, good.

[Chelsea Clinton]

Well, really just both. Thank you so much. I am incredibly grateful that we could have a journalist and a doctor with us as we kind of talk about menopause and perimenopause and what we know and what we. I don't know, actually. And so I wonder if Dr. Hirsch, you know, as we kind of begin our conversation, could you just briefly define menopause for us? Like, what is it? What are the different stages? Just to understand, like a basic fundamental level.

[Dr. Heather Hirsch]

Yeah, I always think this is honestly a great place to start, because even though I'm a clinician and on social media, I say the word menopause a lot, but it. You're right, it means a lot of things. So if we start with the definition of menopause by the textbook, this is one year of no periods. So 300 and, you know, 65 days of no periods. And on that one day, you can say, aha. Today is menopause. It's been one year of no periods. And every day after that, you're post menopausal. And this is interesting because just like if you've ever had a baby, you're always postpartum. Once you're postpartum, you're always postpartum. And so once you're postmenopausal, you're always postmenopausal. And then also the time leading up to menopause where women are experiencing some change in symptoms is called perimenopause. And so perimenopause can be split into early perimenopause and late perimenopause.

[Chelsea Clinton]

And does everyone go through perimenopause?

[Dr. Heather Hirsch]

Everyone will go through perimenopause. And this is a time when the hormones are actually starting to slowly decline. And so as those hormones are declining, that's your perimenopausal phase. And in early perimenopause, periods can tend to sometimes get heavier or more closer together. Women can start to experience insomnia or anxiety as the progesterone starts to decline, which can also cause some spotting in between periods. And then in later perimenopause, that's when the periods really start to space out more and more. And that's when estrogen starts to also really decline. So they might also experience hot flashes, night sweats, vaginal dryness, dry skin, brain fog, mood changes, irritability. And so those are your perimenopausal symptoms. And then then really before that, you're pre menopausal. So you've got your pre menopausal stage, perimenopausal menopause, which is one year of no periods, and then postmenopausal stage Tamsyn.

[Chelsea Clinton]

I know in your book how to Menopause, which I love that it's how. Thank you. You discuss the symptoms that we just heard from Dr. Hirsch, but also many others.

[Tamsen Fadal]

Yeah, I'm glad you bring that up, because I think it's so important to just be aware of it all. And I think that's what the scariest part Is right. Of just the not knowing. You have things that just don't feel. 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. But I've come on the other side of it now and feeling great. So I always want to go into that conversation saying, like, yes, there are. Not everyone's going to have all the symptoms. Right? Everybody goes by this differently. But there are some that, you know, we don't talk about very much. I mean, I think brain fog now has got some vocabulary around it that it didn't have before. I think before you just felt like something was really right, something was really wrong with you. I think, you know, some of the other ones are the lack of libido. I actually got stopped at a restaurant yesterday and three women were sitting there talking. And they said, hey, we were, you know, we, we follow you on Instagram. And we were just talking about the fact that none of us have a libido anymore over breakfast. And so I feel like we're finally starting to have those conversations. But they're not things that I had ever heard about before, though I want to tell women that it's. Everything doesn't just happen, you know, in the doctor's office. This is a360 right. Of impacting all parts of our lives.

[Chelsea Clinton]

You know, Dr. Hirsch, you just as I was listening to Tamsen and I was reflecting on conversations I've had with my friends who, though sometimes will say, like, am I in menopause? Am I in perimenopause? But I've maybe always had like night sweats or hot flashes. Like, I think I've had those since I went through puberty. So how would I know if anything is different? What advice do you give people to maybe ask, like, slightly different or deeper questions, like, of their own bodies and of their own experiences to really elucidate whether they're in perimenopause or. No, not yet.

[Dr. Heather Hirsch]

This question I get asked all the time, which is, how do I know if it's just not this colleague that is driving me crazy? Or is it perimenopause?

[Tamsen Fadal]

Is it.

[Dr. Heather Hirsch]

Is it, you know, I can't sleep because maybe you just had a newborn. You know, lots of women are delaying fertility, um, and they're having babies now in their 40s, you know, is it perimenopause or do I have a new baby? Did my mother in law just move in with me? Is that why I lost my libido or Is it perimenopause or menopause?

[Tamsen Fadal]

Right.

[Chelsea Clinton]

These all sound like very real questions.

[Dr. Heather Hirsch]

Very real questions. My patients ask me these all the time, as do my friends and my sisters. Right. And so, well, common things happen commonly. So if you are born with ovaries, eventually that ovarian function is going to start to decline. And so it's helpful to start tracking. And sometimes if you're in perimenopause, you might see things happening in a cyclic pattern, which might be your first clue that it could be perimenopause. If your periods have stopped and it's menopause, you might want to look at that tracking and say, okay, I'm having more bad days than good days. I'm having, you know, more nights where I'm not sleeping. I'm having more days where I'm struggling at work. I'm feeling socially isolated. I'm not going out with my friends. As Tamson said, this feeling of not feeling like myself anymore. And then sometimes the best way to tell if it really is a hormonal change is if you're a woman who is a good candidate to start hormone therapy. If you start hormone therapy and those symptoms go away, you kind of start to realize, okay, that really was my perimenopausal. And so in many ways, some forms of treatment can also be quite diagnostic as well as therapeutic.

[Chelsea Clinton]

That's fascinating. I do want to, you know, move into talking about treatment and specifically hormone replacement therapy, though, before we do that. I think, Dr. Hirsch, one of the other challenges is people enter perimenopause and menopause at very different ages.

[Dr. Heather Hirsch]

Yeah. Premature menopause is menopause before age 40 and then early menopause, menopause between the ages of 40 and 45. And more women are having elective bilateral ovarian surgeries, removal of their ovaries for things like high risk genetic mutations for breast and ovarian cancers. So I have many patients who are 37 who have surgical premature menopause. 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. And so, yeah, the. You're absolutely right. The ranges are very, very big. So really thinking about the patient's history, their surgical history, the symptoms, that they're experienc and putting that together, I really think that many women get dismissed. They're told they're too young, they're in their 30s, and so you know, opening up this discourse means we have a lot of different phenotypes of women who are starting to examine what's right for them.

[Chelsea Clinton]

Yeah, thank you so much for sharing that. I do now want to go to HRT or hormone replacement therapy because there's been some news around HRT recently. And so I want to play a clip from CBS News and then kind of ask for each of your reactions to that.

[Tamsen Fadal]

The FDA is announcing that it will remove warnings on many menopause hormone therapies. This is a move that could help tens of millions of women. These are these so called black box warnings. It's the highest level of alert. They have been on treatments containing estrogen since 2003, cautioning about an increased risk of breast cancer, stroke, and possible dementia. Well, today the FDA commissioner, Dr. Marty Makary, says the data not only indicates the treatment is, but that it also has many benefits. That's right.

[Chelsea Clinton]

So quite about face from 20 years ago. And Tamsen, I'm so curious for you as someone who's been so forthright about your journey through menopause and also clearly as a journalist and an author has spoken to so many women about theirs. What did you hear in those conversations around the concerns or the questions, the fears around hrt? And how do you think this recent decision could affect the women that you've interviewed that you featured? Just people in your life?

[Tamsen Fadal]

Yeah, it's interesting. I woke up the morning after the announcement and it was the first time in 23 years that the word menopause was in every headline across every newspaper. I mean, really, it's the first time. And so the good news, what I felt about that was, oh my gosh, people are seeing the word and we're going to start normalizing the word. I think that this is good news for a lot of women because they feel like they're armed with something to be able to walk into the doctor's office and start that conversation. I think there has been a lot of fear from the 2002 study, the women's Health Initiative, where there was a misinterpretation of data that scared a lot of women. I for one, lost my mother to breast cancer. So I never thought I was a candidate for hormone therapy. The first doctor that prescribed me prescribed me antidepressants, saying, you know, if you're worried and we're not really sure if you should do it or shouldn't do it. And then I went to a couple of different doctors. You know, I really had to do this search. And that's what I hear a lot of women having to do, run around doctor to doctor to try to figure out what to do. And the onus is on the women, you know, too, to interpret what's best for them, educate themselves and then find a doctor that's willing to talk about it. So I'm hopeful that this helps women feel a little more comfortable in the conversation, educates them a little bit further and, and then I hope that they understand that there's other options beside hormone therapy to consider. There are non hormonal options out there. There's lifestyle changes that we can start much, much earlier. We don't have to wait to be in perimenopause or menopause. So I do feel good. And I was in Miami not too long ago and I was crossing the street and a woman yelled out to me out of the window, hey, Tamsen, I'm in perimenopause. And threw her fist up in the air and I went, we're normalizing the conversation. And it's the younger women that I think are really going to be the beneficiaries what's happening right now. So they don't have this stopping point in their lives where they don't sleep, don't recognize their body, can't think at work, could feel confused, don't know why their periods are irregular and they're actually able to be forward, you know, be able to be proactive in terms of treatment. And it gets me real excited for them and their quality of life, you know.

[Chelsea Clinton]

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[Chelsea Clinton]

So, Tamsa, what questions do you think people should be asking their doctors? You know, if Dr. Hirsch is focused on kind of what she can do to help retrain or maybe for the first time, train, you know, clinicians and allied health professionals, what, what questions should people be asking their doctors about?

[Tamsen Fadal]

Am I a candidate for hormone therapy or am I not? If I am, what's too soon, you know, to start it, because I don't want to get to a place where it's, it's too late, which is unfortunately what's happened to a lot of women that are in, that are post menopausal right now that really didn't get offered it. And then, you know, other questions like the benefits and risks for somebody that's in my category, if it's right for me, how long do I stay on it? And we, we pretty much know that you can stay on it for forever. Are there other things that you can suggest for a lack of sleep or whatever those other symptoms are? And then I think a real important conversation, which is one that I didn't know to have even several years into my research, was about vaginal estrogen, which is something I think that we've really determined. And Dr. Hirsch, correct me if I'm wrong, every woman, for the most part, is a candidate for and probably should be on as we go down the line in terms of longevity.

[Chelsea Clinton]

So Dr. Hirsch, wonder if you maybe can talk about the differences of vaginal estrogen versus kind of the other ways in which we might get hormone replacement therapy, whether orally or on a patch. And just super specifically, from what you've seen, what types of symptoms or what demographic of patient do you think is more likely to be a better fit for some types of HRT versus others?

[Dr. Heather Hirsch]

Yeah, let's start with local vaginal estrogen. And every time I talk about this on social media, I'm always surprised to know that women still, these definitions are confusing.

[Chelsea Clinton]

So please define it for us.

[Dr. Heather Hirsch]

Yeah, so local vaginal estrogen really means that this type of medication is going to just stay in the lower genital urinary tract and it won't travel throughout the rest of your body. So that means it's going to treat the genitourinary syndrome of menopause. And symptoms, symptoms of that include importantly recurrent urinary tract infections. Vaginal estrogen should be the first line treatment for any woman with recurrent urinary tract infections, which is typically defined as three or more than three or four in a year. But if you have a lot of UTIs, vaginal estrogen also dryness, pain with intercourse, this can even be pain with wiping or pain with urination. So, so these types of treatments include estrogen creams like either estrase cream or premarin cream, suppositories like little pills, Vagifem or Uva Femme. There's even a ring, it's called the E string. You can leave it in there for 90 days. And there is some inserts, there's invixi and progesterone. And these medications just treat those symptoms. So they won't treat hot flashes nights wise. Now, as Tamsen said, these medications, because they are not systemic, they have been shown in multiple studies to increase risk of breast cancer, breast cancer recurrence, meaning they can be safe for breast cancer survivors.

[Chelsea Clinton]

So even for people that are survivors, I think that's a really important point.

[Dr. Heather Hirsch]

Exactly. And actually by breast cancer survivors often have severe vaginal atrophy due to estrogen deprivation. And we want you to live a long, healthy quality of life as well. So. Exactly. Does not increase the risk of breast cancer, recurrence of breast cancer, nor does it increase the risk of strokes, heart attacks or dementia. So removing the box warning, the black box warning on vaginal estrogens is, is really great news because these medications really truly as a whole are so safe. Then you have systemic hormone therapy. So this means it is going to travel through your whole body. It's going to get to the. The bones, the heart, the brain, the skin, also the pelvic floor. And these include things either like oral estrogen, which could be estradiol, or this could be conjugated equine estrogen. There's also patches. These are mostly estradiol or only estradiol. So a lot of women just use generic patches. And these can be either twice or weekly. There's also gels. These gels are daily. And a lot of women like this because they can maybe apply a transdermal option at night, and that might help if night symptoms are, are more bothersome than daytime symptoms.

[Chelsea Clinton]

And Dr. Arch, could you explain what a transdermal is?

[Dr. Heather Hirsch]

Yes. Transdermal means that you're going to get the mechanism of this medication is going to be absorbed through your skin, and in that way, it's going to go right to the bloodstream, and it's going to avoid what we call first pass metabolism. So instead of taking it orally and going through the GI and then getting metabolized through the liver, it's going to directly go right into the bloodstream and then get absorbed and go to the organs where they need it. So a lot of women, I would say, prefer the transdermal options because they've been shown to not increase the risks of clots, which is a huge, a huge thing, because as we talked about when the black box warning came out, a lot of those medications or the medications that that was studied on were all oral. So transdermal is extremely safe for women who are concerned any risk of clot. There is also a spray called Eva mist. A lot of women like that as well. And there's even also a ring that's called the FEM ring. And this FEM ring is different than the E string. It is a ring that you place behind the cervix or vaginal cuff if a woman's had a hysterectomy and you can put it in for 90 days. So there's a lot of different ways to take hormone therapy.

[Chelsea Clinton]

There's a lot. I mean, Dr. Hirsch, I thought I knew a fair bit about this. And, and you just mentioned, you know, different options I was not yet familiar with. And also you, Tamsen, you referenced non hormonal therapies as well. And so wonder if, Dr. Hirsch, you could also share what else is in this kind of basket of possible ways to ameliorate perimenopause or postmenopausal symptoms.

[Dr. Heather Hirsch]

I love this question because there are so many good options and so many tools we have in the toolbox. So it depends on the woman's major symptom that's affecting her quality of life. But if it's hot flashes, or if that's sometimes night sweats, which is essentially hot flashes at night sort of waking you up, we have a few non hormonal options. One is called Brizdell, which is in the selective serotonin reuptake inhibitor class, typically our antidepressants. But we find that a little bit of serotonin can decrease the severity or frequency of hot flashes. There's also a newer medication on the market that just came out a few years ago called Vioz. This can actually reduce core body temperature and help to reduce frequency and severity of hot flashes and can help with sleep. And a second medication just came out. So there's two now in that classification of medications. There's also medications for low libido. So there's a medication called Addi or Flibanserine, which helps to improve sexual desire. There's also an injectable medication that helps with desire. And of course, there's various medications for sleep or mood that clinicians have been using for many years. But when it comes to menopausal symptoms, it is helpful to know, you know, for women who don't want to use hormone therapy, can't, or choose not to, that there are other options here. And I think it's so important to say that, you know, we know that women who suffer with relentless hot flashes or a lot of sleepless nights, it's going to reduce your health span. And so suffering through menopausal symptoms really can derail your health. There's no kind of gold medal at the end. And so whether it's life's lifestyle or supplements which can help if those are still not working, it is really important that we train clinicians. We. We have women know as Tamson's been so good about advocating that women do talk to their clinicians, because suffering it out for decades or even for a few years can really hurt your overall health span.

[Chelsea Clinton]

It's so painful listening to you that we for so long have just expected women to suffer, often in silence for years or even decades. And while I think we've all referenced how thankfully we have begun to kind of move away from the stigma around menopause, around women's aging, there still is so much stigma and still, I think, quite a few misconceptions. And I wonder, Dr. Hirsch, I wonder, what are some of the misconceptions we haven't talked about as it relates to any phase of menopause.

[Dr. Heather Hirsch]

You know, I remember I gave grand rounds, my first ever grand rounds. I was just a baby doctor. I started my first attending job at Ohio State, and I was presenting on the data about menopausal hormone therapy. And one of the reasons I talk about it so much is exactly this, this clinician, this doctor in the back raised his hand and he said, you know, this is great, but women don't want hormone therapy. And I thought to myself at that very moment, women don't have the whole story. And we really want women to have the whole story to make the decision for them. And so those, I think, are things that I'm still very passionate about. And then again, I think there's still this idea about breast health, and I think, you know, a little bit of debunking on that could be helpful. And of course, it's, it's a complicated issue, and of course it's a very emotional issue. And you know, a lot of women are, are very, feel fearful about this and, and rightfully so. But what we know really is that, you know, when we use formulations of menopausal hormone therapy, particularly the formulation of progesterone called prometrium and maybe not medroxyprogestin acetate, which was what was used in the Women's Health Initiative, with either conjugated equine estrogen or an estradiol for women who still have a uterus. Actually, we don't see an increased risk of diagnosis above a woman's baseline. So the formulations really matter. And, and all women walking around do carry an inherent risk of breast cancer, be it genetic or environmental or otherwise. And so I think that's kind of one, one worry here. We also know from the Women's Health Study that women who took conjugated equine estrogen, or what we call Premarin alone had reductions in breast cancer. And that's actually really interesting, you know, and sort of. I think that the one thing I just kind of want to debunk here is I think that we still had this idea that estrogen causes breast cancer. And while it's much more complicated and nuanced than that, perhaps, actually what's more likely is that if is a slow growing breast tumor, which takes, you know, on average years or a decade to, to kind of start the estrogen can, yes, grow the tumor, which actually typically causes it to show up faster on a mammogram and get women treated faster. And actually in The Women's Health Study, the women randomized to the estrogen progesterone arm who did get breast cancer outlived women in the placebo group who got breast cancer, presumably because they caught it faster. And, you know, I think that, again, it's. It's an emotional top, but I think if we can sort of separate out the emotion and the logic, because a lot of women are still fearful of that, have family histories, as Tamsyn has already said. And I think that might even be a good place to ask Tamsyn how she kind of worked through her strong family history.

[Tamsen Fadal]

Yeah.

[Chelsea Clinton]

Tamsyn, please would love for you to answer Dr. Hirsch's question.

[Tamsen Fadal]

Yeah, thank you. Yeah, it really is the big fear out there. If you go into a room and just even ask, that is the one answer you will get constantly. I, you know, when I was offered hormone therapy, my mom had an estrogen positive breast cancer. And so 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. And I don't know if most women know where they've heard that. You know, it's kind of like, been there in the back of our minds. And I don't know that we all. I did certainly didn't at the time know that the 2002 Women's Health Initiative might have scared me, but I did go to a number of different doctors, and I was given hormone therapy. I let the progesterone, the little white pills, just kind of sit. Sit and congeal together in my medicine cabinet. You know, I didn't. I didn't put the patches on because I was petrified. And then I. I found a doctor that was really educated and really sat down and explained to me, like, you are suffering. You're not sleeping. You know, you're. You're all over the place in terms of your, you know, mind and your. My. I had tremendous brain fog to a point where I would. I used to read a teleprompter for a living. So I did the news, and I would look at a word, and I couldn't get it out of my mouth to a point where it got scary. It happened way too many times.

[Chelsea Clinton]

That is scary.

[Tamsen Fadal]

It is scary. It is. And so. And you never want to think the worst. And that's what I kept thinking. And so when I eventually got my diagnosis from a doctor who was kind of flippant about it and didn't have a conversation with me, I wound up looking for doctors and Finally, I found somebody that explained to me what was going on. And she said, you're hurting yourself more than helping yourself by not doing this and by suffering. And it's been years now of the hot flashes and the not sleeping and the. The weight shifting and the brain fog. And so I finally went on them, and it took me a long time, it took me about two years total to really get my head around whether yes or no. And it's the best decision I've made for myself in terms of my overall health, in terms of how I feel, in terms of how I sleep and, you know, and then to come now all these years later and really understand what I was. What I was doing was trying to get the goals gold medal. Like, I can do it without any. Without any help. But I'm always very aware that if my mom were here today, she might not be able to have that option of hormone therapy. And so then. Then what? And so I always. I want to make sure that we don't leave those women out of the conversation, because there are other options now out there, thankfully. And the more that we talk about it, and hopefully the more that we find funding to be invested in this and the more that we put women's health, you know, at the top, top where it should be, that we'll have more solutions for women. So nobody's left out of the conversation.

[Chelsea Clinton]

Doctor Hirsch, what are the questions? You think we still don't have enough clear data on, you know, where do you think we still need research? You know, really when it comes to menopause, you know, anything you'd like to share on women's health more broadly, but especially when it comes to menopause and all of the phases that you explained at the top of the conversation?

[Dr. Heather Hirsch]

Yeah, I. A lot of my patients, I would say a lot of the questions I get asked, I don't have clear answers to. For example? Well, Dr. Hirsch, what's better for my sleep? You know, should I do the patch or should I do the gel? We don't have head to head trials on hormone therapy, so that would be one. Because women really want to know what's the best. A lot of women also want to know what are the optimal levels. I get this question all the time. What's the optimal level? You know, we have things like an optimal hemoglobin A1C. We have optimal blood pressure, we have optimal cholesterol, even for something similar like hypothyroidism for women who have that condition, we know what the optimal TSH or Thyroid stimulating hormone should be, but we don't know what optimal levels are. Let's say to have healthy bones. If you use hormone therapy, we don't know what the optimal level is to treat hot flashes. Maybe it's different for hot flashes and then brain fog and then mood. So those are questions I get asked all the time that I don't have clear answers to. And now I use a lot of subjective data. And being that I've been doing this for, for many, many years, I, I can still help and guide my patients. But we don't have answers to these. Certainly women want to know, is this really good for my brain health? And there's a lot of misconceptions on social media about brain health and those studies are undergoing right now. And we, we, you know, are hopeful that maybe the use of hormone therapy closer to the age of menopause may delay the diagnosis or decrease the diagnosis of neurocognitive diseases. But we are answers and women really want them.

[Chelsea Clinton]

And so, Dr. Hirsch, I just have to ask, are we undertaking research to help answer those questions?

[Dr. Heather Hirsch]

You know, I actually think, as Tamsin said, potentially even just one of the benefits of this news last week, which is the removal of the black box, we may, you know, be able to get more large academic institutions, maybe the National Institutes of Health interested in undertaking these topics because one of the reasons this research is so hard to do, Chelsea, is because you have to get an IRB or institutional review board to, you know, say that these medications are safe enough for you to randomize women to them. And you know, this might help in that avenue. Right. So we still need women who would like to participate in these studies, which I think they would love to do. We need funding for these studies as well. And then we need, you know, reviews to get these studies through via those, those IRB boards.

[Chelsea Clinton]

You know, before we move on, on to kind of our last segment, we've talked about what's in the social media zeitgeist a few times and I imagine there's also quite a bit of fact and fiction there and so wonder kind of what advice each of you would have for someone listening who might be following the so called menopause influencers online or might see kind of their content and their feeds like pitching a certain supplement or pitching a certain lifestyle change or like how do you help people? People kind of think through sorting out kind of fact and fiction on social media, especially when it comes to everything around menopause.

[Dr. Heather Hirsch]

Tamsen, I'd love to hear what you're gonna say, oh, I wanna hear from both of you. Yeah, it's actually really difficult. It really is difficult even for the very discerning lay women. You know, I joke that many of my patients by the time they see me have gotten a medical degree. They're just trying to, you know, download these studies and read them for themselves and learn epidemiology and statistics. And it, it is really, really hard. Like, I don't have a great answer. I wish I could say because, you know, certainly the answer here should be look at what the professional societies are also recommending. But I, I have to say, Tamsin, I want you to help me finish this one off because it is, it is hard to know what's right that, you know, sort of the pros and cons of social media.

[Tamsen Fadal]

It, it is. I agree with you, I agree on everything you said. It, it's very difficult. And, and I also think this. Most women don't have time to go to five doctors. And a lot of the things that, you know, I look at or read, even when I did the book, I was like, oh my gosh, these studies, like, you have to be really smart like Dr. Hirsch. I don't, you know, I didn't. It's very hard, you know, while you're working your job and taking care of the kids and taking care of your parents. I think this is one thing because we've had such a lack of education as women, you know, with doctors having it as well. We want something to fix us, right? Especially when we're feeling off. And I think that if somebody is promising you this one size fits all, this is a solution. This is going to solve all your symptoms, save your money. Because there is, as you can hear, you could hear all the different options, whether it's estrogen, progesterone, vaginal estrogen, testosterone, non hormonal lifestyle. There are a lot of different things out there. There is not one thing that's going to do that. There is not one blood test in perimenopause that's going to say like, this is it, here you go, here's your answer. So I think I would look at some of the lifestyle changes to incorporate first. If you're listening to somebody that's promising that they've got the answer, I can pretty much guarantee, guarantee that they don't. Because we have the best of the best all coming together, constantly trying to figure out what those answers are, which is why we need more money for research. And I would say that if you're on social media, and you feel overwhelmed and you feel like you've gotta make protein your full time job and you've gotta wear a vest and you've gotta, you know, find the right, you know, hormone. Give yourself a little bit of grace with all that because I, you know, you're not gonna be able to incorporate all those things at once. And I think that that can be very overwhelming if you can start bit by bit and maybe incorpor. Incorporate one thing and give it a little bit of time and then something else. I think that's what we've got to help women start doing. Because in the last six months to a year, my to do list has gotten so big I shut down. So I try to tell women, take it easy, take it a little bit at a time, and try to make sure that you're listening to a few people that you feel like are coming from a very science based background of it and not out there to scare you.

[Chelsea Clinton]

Yes, I think that point, Tamsen, is a particularly good one. You know, is what you're reading or listening to or consuming mainly motivating you to be afraid or motivating you to feel empowered and that you actually can do something.

[Dr. Heather Hirsch]

Yeah.

[Chelsea Clinton]

As I mentioned earlier, we like to end on a segment called Fact or Fiction. And so I'm going to go back and forth between the two of you, and you can say fact, fiction, or we don't know yet. All right, Tamsen, I'm going to start with you. You can hypnotize hot flashes away. Fact or fiction?

[Tamsen Fadal]

I think it's somewhat fact that hypnosis is involved in that. Isn't that right, Heather? Right. Hypnosis is one of the treatments for hot flashes. So fact.

[Dr. Heather Hirsch]

It's fact. I second that. Fact.

[Chelsea Clinton]

Right, fascinating. All right, Dr. Hirsch, food can change your hormones. Fact or fiction?

[Dr. Heather Hirsch]

You know. Oh, gosh, I think we don't know yet. I think when it comes to perimenopause and menopause, no, but I think some hormonal conditions, like maybe polycystic ovarian syndrome or severe pms, I do think food could be helpful in your hormonal status and how you feel.

[Chelsea Clinton]

Speaking about food, Tamsin, you invented something called the Hot girl menopause smoothie. Fact or fiction? Fact. Fact.

[Dr. Heather Hirsch]

What's in it?

[Tamsen Fadal]

I had to make it fun, you know, I had all these rules all the time, like have your vitamin D, have your protein, have your blah, blah. And I was like, oh, my gosh, I can't do this all day. So I threw it all into one thing. And I put berries, any kind of, kind of plant based milk protein. So you got your protein checked off for the morning. Vitamin D. K. Two little drops of it. It's got chia seeds for your fiber. It's got blueberries for antioxidants. It's got half a banana in it. And am I missing something in greens?

[Chelsea Clinton]

I mean, that sounds like that's probably healthy at any stage of life. Tamsen, picking up on the kind of protein train again. Women over 40 should be eating 90 to 120 grams of protein per day. Fact or fiction?

[Dr. Heather Hirsch]

Fact.

[Chelsea Clinton]

And Dr. Hirsch, why is that so important?

[Dr. Heather Hirsch]

You know, that's one. It's gonna keep you feeling fuller, longer and it's gonna keep you from eating, you know, the Trader Joe's graham crackers or whatever carbohydrates you're addicted to.

[Chelsea Clinton]

Is that, was that a personal confession to you?

[Tamsen Fadal]

Too specific?

[Dr. Heather Hirsch]

I don't know. My kids just love them. So it's gonna keep you satiated, it's gonna keep you fuller, longer. It's gonna, you know, keep you from dropping so that you get those spikes. It's gonna keep you hopefully feeling nice and stable during the day. And, you know, certainly another trick I have is before bed if you are hungry, you know, that's really, I think also two o', clock, I would say three o'.

[Chelsea Clinton]

Clock.

[Dr. Heather Hirsch]

And then before bed, these kind of carb cravings for carbs can come up. It's just another good time to kind of keep a little protein snack around you so that you can keep yourself nice and stable. Because again, a lot of waking up at night could be these dips in blood sugars. And so it's really, really important to maintain good protein levels throughout the day.

[Chelsea Clinton]

You know, Dr. Hirsch, people can't do hormone therapy if they're on GLP1 inhibitors. Fact or fiction?

[Dr. Heather Hirsch]

Oh, that is actually fiction. In fact, I have a lot of patients who are on both GLP1 medications as well as menopausal hormone therapy. And this is another area where more research needs to be done because we have a lot of women who will or may require both of these. And of the limited data that we have, we have if a woman is on using menopausal hormone therapy, particularly probably the estrogen, with a lower dose of GLP1, they may actually have more efficacy in losing weight, even a lower dose. Yeah. And so it's really quite interesting to see and I could talk about this topic forever. We see that estrogen may, I really want to say, may help stabilize Insulin. And we do know from the Women's Health Study that women on hormone therapy had less progression to the diagnosis of diabetes. And so it's interesting to sort of think about how do these hormones play a role in metabolic health, which is so crucial considering the leading cause of death in women is heart disease. Even though, of course, we still spend some time on this show talking about the fears of breast cancer. So I thank you for this question. Cause, you know, this is an important one that is on top of mind for women right now.

[Chelsea Clinton]

You know, Dr. Hirsch, a large majority of medical residents and doctors say they don't feel comfortable treating menopause. Fact or fiction?

[Dr. Heather Hirsch]

This is a harrowing fact. It, it's actually, you know, it's, it's, it's staggering when we see that the majority of residents in OB GYN and then even more so in internal medicine and family medicine, who, you know, of course see women long term. Right. Do not feel comfortable or prepared talking about menopause, prescribing or counseling for menopausal hormone therapy. So, you know, I think this right here is my mission for the next of couple, couple of years.

[Chelsea Clinton]

Well, Dr. Hirsch, Heather Tamsen, thank you both for all you're doing to help educate us and empower us to be better stewards of our health, to ask more personal questions to our doctors so that hopefully we each can get the treatment and support that we need at every phase of life. We certainly have more work to do, more research that needs to be undertaken, but 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. So thank you so much for your time today and all you're doing.

[Tamsen Fadal]

Thank you so much.

[Dr. Heather Hirsch]

Yeah, thank you, Chelsea. This is an honor to chat with you and Tamsen about this topic.

[Chelsea Clinton]

You too. You can learn more about Dr. Heather Hirsch eatherhirshmd on Instagram and TikTok. Her new book is called the Perimenopause Survival Guide. Tamsen Fadal is Amsin Fadel on Instagram and TikTok, and her latest book is called how to Menopause. Thanks for listening. Talk to you next week. That Can't Be True is a production of Limonada Media and the Clinton Foundation. The show is produced by Katherine Barnes Mix in sound design by Ivan Koraev. Kristin Lepore is senior Director of New content, and Jackie Danziger is VP of Narrative and production. Maggie Kralshore is our managing director of Partnerships Executive producers are Jessica Cordova Kramer, Stephanie Whittles, Wax, and me, Chelsea Clinton. Special thanks to Erica Goodmanson, Sarah Horowitz, Francesca Ernst Kahn, Caroline Lewis, Sage Falter, Barry Lurie Westerberg, Emily Young, and the entire team at the Clinton Foundation. You can help others find our show by leaving us a rating and writing a review. And if you can think of someone who might benefit from today's episode, please go ahead and share it with them. There's more of that can't be true with Lemonada. Premium subscribers get exclusive access to bonus content when you subscribe on Apple Podcasts. You can also listen ad free on Amazon Music with your prime membership. Thanks so much for listening and see you next week.

[Tamsen Fadal]

Sam.