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Hormone Replacement Therapy, What Every Woman Needs to Know in 2026 | Dr. Heather Hirsch
01:11:13
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- [00:00]
Dr. Heather Hirsch
The leading cause of death in women is heart disease. This, to me, is a huge reason to consider menopausal hormone therapy. So what estrogen does is it opens the blood vessels so you get better blood flow, and that is preventing cardiovascular disease. And they have improved cognitive function at the time at which they started.
- [00:19]
Dr. Peter Attia
There is an increased risk for dementia or other cognitive challenges when individuals are devoid of hormones.
- [00:26]
Dr. Heather Hirsch
They have all seen their parents struggle with cognitive decline, Alzheimer's and dementia. Something I actually going through in my own life.
- [00:38]
Dr. Peter Attia
What are women doing wrong?
- [00:40]
Dr. Heather Hirsch
As a society of women, we stay in the suffering period for far too long, and we've really normalized suffering, putting on a face and just getting the things done. However, sometimes that can be as a detriment to us.
- [00:52]
Dr. Peter Attia
I don't care how much you work out. I don't care how well that you eat. If we're talking about estrogen's impact or even testosterone, we have certain receptors that are only going to be affected by those hormones. The biggest concern I hear patients say is they're concerned about breast cancer with estrogen.
- [01:10]
Dr. Heather Hirsch
We've never actually proven that estrogen itself causes breast cancer. Sounds almost criminal to say out loud, but I'll say this idea that estrogen is dangerous and harmful truly came from.
- [01:34]
Dr. Peter Attia
Doctor Heather Hirsch. Dr. Lyon, you're a superstar, and I want to share with you where I first saw you live and in action.
- [01:42]
Dr. Heather Hirsch
Oh, where?
- [01:43]
Dr. Peter Attia
Fda. You were on an expert panel.
- [01:45]
Dr. Heather Hirsch
Yes.
- [01:45]
Dr. Peter Attia
Doing some extremely important work and really changing the perception of hormone replacement therapy.
- [01:51]
Dr. Heather Hirsch
Yeah, that was such an important moment. And actually, you know, I've been on stages before, but, like, I was not as nervous for anything else as I was before that camera panned to me because I knew that thousands of women were gonna be watching this panel, which was a group of expert clinicians coming together to speak with Commissioner Marty McCary about the safety of hormone therapy. Had a lot of stakes involved, and so I was also opening that. So I really wanted to kick it off and really make a nice impression and set the stage for the rest of my amazing colleagues to then do their work.
- [02:25]
Dr. Peter Attia
You did. You really did a fantastic job. And I recommend that anyone who is listening or viewing this, check out that it is available and we'll link it. Hormone replacement therapy for women.
- [02:35]
Dr. Heather Hirsch
Yeah. Huge topic.
- [02:38]
Dr. Peter Attia
What happened and where are we at right now?
- [02:40]
Dr. Heather Hirsch
You know, the story of hormone replacement therapy is an interesting one, and it's more a media frenzy and a little bit of myth than there is sort of an actual scientific story that kind of goes along with it. So in the late 1980s and early 1990s, the majority of women were on hormone replacement therapy. And actually, it's good to define what hormone replacement therapy is. Think that's always excellent to do. Typically it means an estrogen and then plus or minus a progestin or progesterone if a woman has an intact uterus, although you can take it even if you don't, and then plus or minus testosterone and then sometimes plus or minus vaginal estrogen. So menopausal hormone therapy can be a wide range of things. So most women were given estrogen as kind of the key component of hormone therapy in the 80s and 90s. And in 1992, the American College of Physicians, like, at their annual meeting, strongly advocated that most women take estrogen shortly after menopause. However, there was no randomized controlled trials yet. But prospectively, the clinicians were seeing that the women who were taking hormone therapy were living longer, having better bones, and having less heart disease. So they went to the NIH and said, we got to put together a randomized, controlled, double blinded study. So they enrolled thousands of women. Actually, it's one of the biggest randomized control trials we've ever had. You know, the NH spent billions of dollars over multiple sites. Now, inherent in that was they got women enrolled in the study who are closer to the age of 62 or 63. So on average 12.3 years later than the average age of menopause, which was 50. It's now 51. It's actually slightly creeping upwards. And they gave women one dose and one formulation of hormone therapy. So if you didn't have a uterus, you could take premarin, and that was conjugated equine estrogen, 0.625. And you took that alone without a progestin. And then if you did have a uterus, you were given Prempro, actually at the Same estrogen dose, 0.625 of conjugated equine estrogen and then medroxyprogesterone acetate. So this study sets the stage for what will happen in a few years. In 2002. In the summer of 2002, a press report, you know, was held where they said, hormone therapy is dangerous. And what they said is that it increased the risk of breast cancer. But it was only in the women on estrogen and progesterone. The women on the estrogen only were actually doing great. No safety threshold was crossed there, but they were noticing increased diagnoses of breast cancer. And the Media reported a 26% increased risk of invasive breast cancer. Now, if you.
- [05:26]
Dr. Peter Attia
26% increased risk.
- [05:29]
Dr. Heather Hirsch
Yes. Now, if you don't know the difference between relative risk, absolute risk. That sounds really scary. Yeah. That sounds like a quarter of the women were getting breast cancer. But the translation of that was two to four women out of a thousand over five years on oral PremPro at that dose. Two to four women out of a thousand over five years on that one dose and formulation. Now, later, they went on to find that even women who were in the placebo group who got breast cancer, comparatively, they had less mortality from breast cancer in the women who took the hormone therapy. We'll come back to that later when we talk about breast cancer myths. So hold that thought. They also then said, well, and it increased the risk of cardiovascular disease, strokes. And so that was kind of the end. The damage was done. Hormone therapy was considered kryptonite from 2002 onwards, although there's been so much data and evidence to the contrary to show how safe estrogen is, to debunk the myth about breast cancer risk and to show that once taken within 10 years, women do fantastic. They live longer, they do have less heart disease, they do have better bone health. The problem and the discrepancy really was that when they were looking at those prospective studies in the 80s and in the early 90s, women were given hormone therapy right around the time of menopause, whereas in the Women's Health Initiative, they were much older. In fact, the age range was 50 to 79. So you had women in their late 70s that were given hormone therapy for this trial. That really mixes up physiology. Right. You have different stages of life, women who maybe are not as healthy as they are today. And so that kind of landed us in this whole, like, is hormone therapy bad? So a plethora of data shows that it is good for us, and that's kind of why we're here today, is because we are still breaking down those myths and misconceptions.
- [07:33]
Dr. Peter Attia
In the 80s and 90s, the majority of women were put on hormone. And I think that you and some of your cohorts have. Instead of calling it hormone replacement therapy, do you not call it menopause hormone? Is it therapy? So what is it? It's. It's menopause hormone therapy.
- [07:49]
Dr. Heather Hirsch
Yeah, well, so, you know, the interesting thing about the names is that hormone replacement therapy, or HRT, is something that actually we use when we're physiologically replacing hormones in women who've had premature or early menopause, which would be 40. Yeah. Premature menopause is before age 40, and that could be from surgery or that could be from premature ovarian insufficiency. And then early menopause is if you have menopause under age 45. So then between 40 and 45, so you're supposed to physiologically replace their estrogen, almost like a diabetic, where you're physiologically replacing their insulin. So for women who experienced menopause at more of a natural age, 46 and up, it's kind of easier to call it menopausal hormone therapy, or mhd. But even, you know, us as, as experts, we kind of use them interchangeably all the time.
- [08:42]
Dr. Peter Attia
Help me understand the blind spot. Late 80s, early 90s, everybody is on hormone replacement therapy. Is that, Is that accurate to say
- [08:52]
Dr. Heather Hirsch
the data shows that about 50, sometimes 65% of women in certain studies were taking menopausal hormone therapy or an estrogen, and then an estrogen plus a progestin
- [09:03]
Dr. Peter Attia
in that time, is it as ubiquitous, or was it as ubiquitous as, say, birth control? And let me frame this up. Someone goes to their physician and says, a, maybe a young girl in their 20s, I'm PMS or I don't want to get pregnant. There is no second thoughts of giving someone birth control. Is it fair to say that potentially that is how it was in the 80s and 90s?
- [09:29]
Dr. Heather Hirsch
You know what I will say, because I wasn't there, you know, I was just a little kid at the time. But my colleagues will tell me, you know, they remember prescribing menopausal hormone therapy with like, this joy, like, oh, now you kind of have this. They would say things, you know, like, you know, fountain of youth or, you know, the vitamin D or sort of like the life hormone. I would hear them say all these different things. As I was talking about menopausal hormone therapy now, you know, 15 years after the Women's Health Initiative, they were like, you know, Heather, you weren't there. But it was so common, and we did it with such joy.
- [10:03]
Dr. Peter Attia
Prescribing hormone therapy at the time, were there health risks? Were people concerned about? Because right now, and still to this day, and I think for the last, easily the last 20 years, I get, you know, I'm still a practicing physician. I hear it almost every day. Is it safe?
- [10:20]
Dr. Heather Hirsch
Yep.
- [10:21]
Dr. Peter Attia
If I take estrogen, will I get breast cancer? Will it cause blood clotting, stroke? Talk to me about the safety profiles.
- [10:31]
Dr. Heather Hirsch
Yeah. So let's actually look at the data. Sometimes it's helpful to sort of, I always say, to My patients. Let's, let's do the logical and we'll keep the emotional aside because let's start with breast cancer. It is very emotional. I don't want any of my patients. We don't want any of our patients to get diagnosed with breast cancer. However, on the logical side, we know that about one in eight women will be diagnosed and then it's really common. And that luckily now that doesn't lead to mortality or death when it's caught early. What is actually the leading cause of death in women, as you and I both know, is heart disease. And there's, you know, so much, there's. There's so much still emotion around the breast cancer diagnosis. Diagnosis, even though heart disease or heart attack could kill you immediately. So in the studies, they found this 26% increased risk in breast cancer. That absolute risk is actually fairly small. Two to four women out of a thousand over five years. That's actually not statistically significant. What they also found was, as mentioned before, when you got breast cancer in the placebo group, those women actually had higher mortality or higher death rates. So it didn't mean you had a higher death rate. Now, here's the important point. Remember we talked about how they used a synthetic progestin, magoxyprogesterone acetate, in the Women's Health Initiative, but the women who didn't take the progestin because they didn't have their uterus, they could take estrogen only, they were actually showing less breast cancer than the placebo. So then the thought was maybe it was the progestin. So they do this study where then they replace that synthetic progestin with what we'd call bioidentical progesterone, which just means prometrium or progesterone, doesn't mean compounded, can be compounded, can be commercially available, and when they swapped the progestin for the progesterone, they saw no increased risk of breast cancer above a woman's baseline. That means that starting hormone therapy, if you're using bioidentical progesterone, and if you're using now more times, we use bioidentical estradiol and different formulations, we can talk about that. Pill versus patch gel, etc. If it's not going to increase your risk above baseline, and there's massive benefits like reducing heart disease, the leading cause of death in women, and improving bones so you don't have an osteoporotic fracture, which has a high morbidity and mortality rate. There is major benefits to considering hormone therapy.
- [13:07]
Dr. Peter Attia
You know that feeling after a really hard training session where the last thing you want to do is sit down
- [13:12]
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- [13:15]
Dr. Peter Attia
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- [13:28]
Dr. Peter Attia
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- [13:31]
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- [13:37]
Dr. Peter Attia
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- [13:43]
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- [13:59]
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- [14:03]
Dr. Peter Attia
That's a body health.com and use the code Lion 20. It just, it seems like a huge blind spot.
- [14:12]
Dr. Heather Hirsch
Yep.
- [14:13]
Dr. Peter Attia
That there are a whole cohort of women that are not protected because they didn't have the ability to start hormone replacement. And when I say didn't have the ability, I remember. So I finished fellowship 2015.
- [14:25]
Dr. Heather Hirsch
Yeah.
- [14:26]
Dr. Peter Attia
People weren't really talking about hormone replacement therapy. I had to learn it. Yeah, it's, you know, from those quote, I don't even want to say underground physicians, but.
- [14:34]
Dr. Heather Hirsch
Right.
- [14:35]
Dr. Peter Attia
Essentially the physicians that were still treating. Yeah, you bring up a really good point. The physicians prior said it was amazing. The Women's Health initiative comes out, people
- [14:49]
Dr. Heather Hirsch
stop prescribing and stop teaching.
- [14:54]
Dr. Peter Attia
But the question becomes how? How did that happen?
- [14:58]
Dr. Heather Hirsch
Yeah.
- [14:58]
Dr. Peter Attia
And do you think that the data was examined? It seems like just a huge miss.
- [15:04]
Dr. Heather Hirsch
Yeah. So from what I hear, one of my good friends and colleagues, actually, Jim Simon, I'll credit him for this. He said if they had done the Women's Health Initiative on, you know, with progesterone and maybe a transdermal estrogen patch and maybe women who are closer to the menopausal age. It could be a completely different world now. That's easy to say in retrospect. Right. Or being a backseat driver. How could they have used this medication? Although that medication smells bad. So.
- [15:31]
Dr. Peter Attia
And are those medications used now?
- [15:33]
Dr. Heather Hirsch
You know, for example, those medications that we talk about, conjugated equine estrogen. I still use that medication because actually it has the most safety data. It is a part of one of the biggest randomized controlled trial. Like we said, the whi. Although most women these days really want bioidentical or a plant based estrogen So I don't have the opportunity to prescribe it too much. Prempro. I don't prescribe all that much, actually. And so, you know, one of the things was we used a combination of oral synthetic hormones that we don't use now. And again, we used women who were slightly older. But when that study came out, it was a frenzy. I mean, women were throwing their hormone therapy in the garbage, down the toilets. Physicians were calling their patients, we have to get off this. Right after it came out, it was like an explosion. And so my colleagues tell me it was one of the craziest days in medicine at that time.
- [16:29]
Dr. Peter Attia
Why was there not a challenge? Because you had mentioned relative risk and absolute risk.
- [16:35]
Dr. Heather Hirsch
Yeah.
- [16:35]
Dr. Peter Attia
I'm sure that people were examining if it was open to the public. I don't know if the data. If the data sets were open at the time, but one would think, okay, these are much older. Again, there's a difference between relative risk and absolute risk.
- [16:50]
Dr. Heather Hirsch
Right.
- [16:52]
Dr. Peter Attia
I'm assuming that the data from that time hasn't changed. So where did the. The pendulum swing the other way? Because now people like yourself are really pushing for just education, awareness. What happened? How come it went from this is terrible right to now, okay, we're willing to reevaluate this?
- [17:12]
Dr. Heather Hirsch
I don't know. You know, I think you're right. There are. There were definitely clinicians at the time who actually, it's funny, read this study, right? Because I think the headlines were so drastic and everywhere, everyone was covering it. Time magazine and all the papers, which was like the social media at the time. Right. They didn't have TikTok then, but imagine it was just your whole TikTok feed was this. And that really got into the psyche of clinicians and women. So then two things happened. Clinicians became scared, and maybe they didn't read the studies, which is fair. If they're trying to do all these other things and physicians are really busy. They took the headlines for what they were, and we can't really blame them, even though it's easy to sort of say in hindsight, why didn't you read the study then? You did have these group of clinicians, my mentor, her name's Dr. Thacker, she was my fellowship director at Cleveland Clinic. And so from 2014 to 2016, this was all I studied. And she was the one who really forced me to look line by line through the Women's Health Initiative. And what helped, I'll tell you this, is they did post hoc analysis a couple years later, and what really solidified it for me was when they took the women who were within 10 years menopause and really studied them. That first came out, I think around 2007. And so the Women's Health Initiative, the estrogen progesterone arm, closed in 2002. The estrogen only group actually went like about two years later, and then it just closed down for no reason. But it wasn't a few years later until they had that post hock analysis and they really looked at the women who were age 50 to 60 or within 10 years of menopause. And it's jarring how well they did, how well they did. Reductions in heart disease, reductions in all cause mortality, reductions in all cancer diagnoses, better bones and of course, better menopausal symptoms, which, you know, is really didn't even make the news here at this point. Quality of life for women is a whole other topic we could talk about because we're not even considering that at this point. And that's what really solidified it. And then I think with social media building around 2016 and onwards and clinicians kind of finding each other digitally as opposed to in, you know, universities or academics centers or private practices that really helped encourage other people to say, oh, you're right, or oh, yeah, that's what this number means. Wow, wait a second. When we read the studies, we were kind of dupes.
- [19:36]
Dr. Peter Attia
What are the risks of hormone replacement therapy? And I want to break it down to estrogens.
- [19:43]
Dr. Heather Hirsch
Yeah. Progesterone, yes.
- [19:45]
Dr. Peter Attia
Progesterone, yes. Or progestins.
- [19:48]
Dr. Heather Hirsch
Yeah, we can talk about the difference too.
- [19:50]
Dr. Peter Attia
And testosterone.
- [19:51]
Dr. Heather Hirsch
Oh my. I love this question because honestly, I'm going to answer you. And it's not going to be all that significant if we look at. Actually, let's do estrogen last. Because if we look at progesterone. Progesterone does not have any major inherent risk of blood clots, cardiovascular disease, and alone. Although there's not terribly many studies on women taking just progesterone alone. And this time I'm talking about micronized natural progesterone or prometrium, the bioidentical, which is a slang term. But progesterone.
- [20:24]
Dr. Peter Attia
And bioidentical, just to pause, is just the same compound as what would be produced in the human body.
- [20:28]
Dr. Heather Hirsch
Exactly. Although it's still made in a lab, just like everything else. But it's a little bit more. It's more identical to what you would actually make versus a progestin, which is synthetic, often found in birth control pills. So we don't see any increased risk of breast cancer with that either. Just like I mentioned, there was a study when they swapped the progestin for progesterone with estrogen and they said no increased risk of breast cancer. Progesterone is really safe. And this is important because you may ask me during this show, you know what, if a woman can't take estrogen, she could still potentially take progesterone, which may help with sleep, which may help with anxiety and other things. Same with testosterone. Now, my good friend and colleague Dr. Kelly Casperson will often say there's a big data free zone when it comes to testosterone in women. And as you probably know and have studied, there is a hole in, you know, the use of androgens for women pre, but postmenopausally as well. And we don't see as for now, although we need more studies, we need more longer term and more randomized control tries, but we don't see increased risks of clot strokes, cancers or breast cancers. Great. So that means that these two are options for women who maybe have risks from just estrogen. Okay, now let's go to estrogen. When we use estrogen, it depends if we're talking about transdermally or oral. So the risk of a blood clot on oral estrogen is very small, specifically postmenopausal oral estrogen, much smaller than the risk on birth control pills. But again, like you already said, how ubiquitous is it to give young women of reproductive age who don't want an unintended pregnancy birth control pills? Just rolls right off. Right. So it's the women post menopause who get, you know, kind of get vilified when they talk about estrogen or this risk for clots. Even though many of these women have been on birth control, been pregnant, had surgeries and do well. So there's a slight increased risk of a, of a clot if you're on oral estrogen, but again, much smaller than if you were on birth control pills, much smaller than if you were pregnant or ever had surgery if you use transdermal, which is a patch, spray or gel, and there's a ring. Also, this set of trials called the ester trials or ester studies, showed that the transdermal estrogen does not increase the risk of blood clot. And so we're going to remove blood clots as a risk when you're using transdermal estrogen. So this is really wonderful. And then the breast cancer thing comes back up. Right. And that really has to do with what are you Pairing it with. Are you using progesterone or progestin? And also, even when it comes to. Is breast cancer a risk? It's really hard for me to say that estrogen directly causes a breast cancer. I think a lot of breast cancer is genetic. It's environmental. So if you have a really, really small tumor, because they take such a long time to actually develop so that you could actually see it, if it has an estrogen receptor on it, it may grow faster, it may there cause it to show up earlier, but you may get treated faster, which is why the women in the placebo group back in the original WHI may have had higher death rates from breast cancer compared to the women who took hormone therapy in the whi. So that's a mouthful. Yeah.
- [23:50]
Dr. Peter Attia
Well, I want to pause there. This is very important for the listener or for the viewer. The biggest concern I hear patients say is they're concerned about breast cancer with estrogen therapy. What I just heard you say is that let's say someone has undiagnosed breast cancer and potentially it's estrogen positive. The estrogen that one would take doesn't cause the cancer. It's not causal. Could it accelerate the growth of a tumor? Yes, but could it cause cancer? There's a big difference between something that's causative, something, say, an initiation factor. This is how we think about in nutritional sciences. Initiation factor versus something that would then perpetuate what is already in motion.
- [24:49]
Dr. Heather Hirsch
Exactly. Exactly. So we've never actually proven that estrogen itself causes breast cancer. And so I think that's really uncomfortable.
- [24:59]
Dr. Peter Attia
Do we. Do we know?
- [25:01]
Dr. Heather Hirsch
I think this idea that estrogen is dangerous and harmful truly came from the press report that happened in the summer of 2002. And that media frenzy that there was a 26% increase in breast cancer, it just switched people's minds to really, after that, find it really hard to disassociate estrogen from breast cancer. Even though, again, you know, logically, when you look at it and we speak with just the logic and we take the emotional part out of it, it's really easy to see. And so this is a lot of what goes into counseling for women who want to start intake hormone therapy. But, you know, we have to then sometimes think this way too. The. The risk of taking hormone therapy. Again, we've called it. I like to call it an associated risk with breast cancer.
- [25:52]
Dr. Peter Attia
But again, what do other people. What would other. What would other people say?
- [25:58]
Dr. Heather Hirsch
You know, there's still a lot of data, there's still clinicians that will say you can only take hormone therapy for five years because at the five year mark, I think that's when it could increase your risk of breast cancer. This still doesn't make any sense to me because breast cancer isn't like on a clock, for example, that may come from the WHI where they found that that increased risk started after five years. But again, it just takes time for a tumor to develop and show up on a mammogram. So you'll hear sometimes clinicians still say, if you have a family history, I won't prescribe you hormone therapy.
- [26:33]
Dr. Peter Attia
Is that reasonable? Is there a kind of a hierarchy or decision making tree that you go through that you feel confident and comfortable, is safe and also not, on the contrary, overblown or overprotective? How do you think about that?
- [26:49]
Dr. Heather Hirsch
Well, look, I think this is a great time to say what are the risks of you not taking hormone therapy?
- [26:54]
Dr. Peter Attia
And what are those.
- [26:55]
Dr. Heather Hirsch
Right. Accelerated aging. Although nobody wants to hear that. Right. That sounds as though I have a bias. And I don't feel as though women only have one option. But I really want them to know what happens to their body when they lose estrogen.
- [27:08]
Dr. Peter Attia
But wait, but there really isn't a replacement for estrogen. I don't care how much you work out, I don't care how well that you eat. If you are devoid of certain hormones, again, people can do whatever they want. But again, if we're being really transparent, if we're talking about estrogen's impact or even testosterone, they have certain receptors that are only going to be affected by those hormones. And I do, I totally appreciate that it is absolutely a personal choice. But if you don't have it, it's.
- [27:42]
Dr. Heather Hirsch
Yeah.
- [27:42]
Dr. Peter Attia
I mean again, there is no replacement for what the body would be making.
- [27:48]
Dr. Heather Hirsch
Right, exactly. And so you know, you have accelerated bone loss at the time of menopause.
- [27:53]
Dr. Peter Attia
And that is. I, you know, and I haven't seen any data. I am so curious as the estrogen input versus if we know that there's a way to help with through training and nutrition. I mean my guess is that it wouldn't be nearly as significant. I mean it's critical.
- [28:11]
Dr. Heather Hirsch
That would be a great trial.
- [28:13]
Dr. Peter Attia
Really interesting.
- [28:13]
Dr. Heather Hirsch
Yes, that would be a great trial. And you could probably do that where women just self select which group they're in.
- [28:19]
Dr. Peter Attia
So accelerated bone aging.
- [28:21]
Dr. Heather Hirsch
Yeah.
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Dr. Peter Attia
And how fast is that? So it. Does a woman have to be completely through menopause once to actually have accelerated bone loss?
- [28:30]
Dr. Heather Hirsch
So you know your peak bone mass somewhere around like 20, 30. Right. And then it will start to decline. But right around the time that we lose our estrogen in menopause, it's going to like do like another big dive. And that's because estrogen helps keep those bones from breaking down. So when you lose that protective benefit, they start to break down more rapidly than they're building up. And so what estrogen therefore is doing is really keeping you, you know, healthy in a way. Because if you have a fracture of your spine or your hip that could be so detrimental for the rest of your life because you spend a long time in bed, you're going to atrophy, your muscles are going to waste, and then you have relearn so many things if you fracture. Right. So it's so, so, so important.
- [29:12]
Dr. Peter Attia
Would you give it. When you think about it, if we talk about the, what are the benefits and we know that estrogen is bone protective, does it matter the form, does it matter if it is transdermal, does it matter the kind does it need to be? Estradiol.
- [29:27]
Dr. Heather Hirsch
Yeah. So we don't really have enough data, so many data free zones here. Right. We don't have enough data to kind of put all the different kinds of estrogen in a row and then see, is one better for bone than others or a lot of women will ask all the time, what is the serum level I need to ensure bone health? We have.
- [29:45]
Dr. Peter Attia
So what do you think it is? Because I, I asked Modus as well.
- [29:49]
Dr. Heather Hirsch
Yeah.
- [29:50]
Dr. Peter Attia
A colleague of mine, how do you have a, a framework for thinking about that?
- [29:55]
Dr. Heather Hirsch
You know, I. Very early, very. Some data came out in the 90s that an estradiol level probably around even 40, so like not that high is really good for bones. And we have a ultra low patch called the menastar patch, it's 0.14 weekly patch, which is even lower than our pretty standard patches or gels that usually start around 0.25 milligrams. But even that was shown to help with bones. So I have a hunch that you don't need much to help with bones. And I think you got to though, add that with all the good things that you should be doing, lifting weights and strength training and eating well, getting all your vitamin D and calcium. So I'm not really sure the biggest data set that we do have comes from again, the whi. And so this study is so crucial and it's so funny because I think I probably talk about this more than any other study because it is where a lot of our safety data does come from the decisions to start women on hormone therapy, at what age they are, a lot of those will go back to the Women's Health Initiative. That's what I spend a lot of time teaching. But you see the massive benefit with conjugated equine estrogen, because that was the oral Premarin that they used in the study. Although, again, clinically, because I've been treating patients for the last 10, 12 years, I see their bone densities improve on even small doses of the patch.
- [31:16]
Dr. Peter Attia
How long?
- [31:17]
Sponsor/Advertisement Voice
Okay.
- [31:17]
Dr. Peter Attia
One reason why someone would choose to go on estrogen would be for protection of bone loss. What else?
- [31:26]
Dr. Heather Hirsch
Well, the symptoms. Oh, yes, yes. So, you know, I love how you're. You have this preventative visual field. Right. And I love that. And one of the reasons I enjoy the conversation about menopausal hormone therapy is so that women start to think about the preventative benefits of estrogen. And in the menopause world, in the hormone therapy world, that's even a little controversial, which it is.
- [31:52]
Dr. Peter Attia
No, no. Really?
- [31:54]
Dr. Heather Hirsch
Yes.
- [31:54]
Dr. Peter Attia
Okay.
- [31:55]
Dr. Heather Hirsch
And this is because hormone therapy is not FDA approved for prevention of anything, even though we do clearly see it in studies and particularly for women who start closer to menopause every year, when the, you know, the preventative task force services comes out with grades for medications for their preventative benefit, hormone therapy always gets, like, an F. And everyone texts me, like, can you believe it? Can you believe it? And I'm like, yeah, I can still believe it. But, you know, so the preventative benefits are something that a lot of women now are thinking about more than they were before. But I would say the majority of women come in with symptoms, and they're like, oh, Dr. Hirsch, I'm not sleeping. I have terrible brain fog. I'm losing my hair. I'm losing my eyelashes. They'll say, I'm. Vaginal dryness, urinary tract infections. And those symptoms are what usually get them to start Googling or Instagramming or Tiktoking. And then, you know, there's a lot more information than there used to be. And so then they're asking more questions, like, what else can it help with? So symptoms.
- [32:57]
Dr. Peter Attia
I like the osteoporosis aspect.
- [33:00]
Dr. Heather Hirsch
Yeah.
- [33:01]
Dr. Peter Attia
Symptoms makes a lot of sense. And I. I definitely want to touch on the vasomotor symptoms.
- [33:06]
Dr. Heather Hirsch
Yes.
- [33:07]
Dr. Peter Attia
Because once hormone therapy got a bad rep, it seems as if people started to use a lot of SSRIs.
- [33:14]
Dr. Heather Hirsch
Oh, SSRIs rose, like, 60%. At the same time, as they were pulling women off their hormone therapy, they had to do something, because these women were experiencing terrible symptoms. You also had the rise of, like, compounded hormone therapy at the same time, too, because some women were like, oh, no, I gotta solve this problem. Right? Yes. So we have mistreatment for some of these symptoms.
- [33:37]
Dr. Peter Attia
When a woman is going through and thinking about hormone therapy, what about cardiovascular disease? Because again, and I, we've had Martha Gulati on the show. She's amazing.
- [33:47]
Dr. Heather Hirsch
Yeah.
- [33:48]
Dr. Peter Attia
Female focused cardiologist, truly extraordinary. And we spoke a lot about estrogen cardiovascular health. What is your perspective in terms of. Again, I recognize that we don't use hormones for treatment.
- [34:03]
Dr. Heather Hirsch
Right. Well, that's what the WG was supposed to do. They were like, well, great. Women are living longer and having less heart disease. Let's do this randomized controlled trial and see that estrogen prevents cardiovascular disease. Now, of course, in the study ended early, and there were all these fears, and you had women who are all these ages. But look, when we look at women within 10 years of menopause, we see clear reductions in cardiovascular disease, reductions in heart attacks. This is huge. Huge. So what estrogen does is it's a vasodilator, releases nitric oxide, and so that opens the blood vessels, so you get better blood flow. So think about that.
- [34:38]
Dr. Peter Attia
Right?
- [34:39]
Dr. Heather Hirsch
You're getting better blood flow through your heart. Your, you know, those coronary arteries are working at their maximum. They're feeding the muscle around the heart, and that is preventing cardiovascular disease. And so this, to me, is a huge reason to consider menopausal hormone therapy. And so that fits right alongside with the preventative benefits like bones heart disease. And it also has been shown to increase health span, and there's no other medications.
- [35:09]
Dr. Peter Attia
And how do we define that health span?
- [35:11]
Dr. Heather Hirsch
Different than lifespan. Right.
- [35:12]
Dr. Peter Attia
And different than sex span, as Mo Akira would say, and then different, of course, in muscle span as well. Matt Santiago.
- [35:18]
Dr. Heather Hirsch
Oh, I need to learn about muscle span. Okay. Yes. I mean, health span. The way I define health span is just how long you leave, how long you live a healthy life. Right. So lifespan, just how long you live. But you can live with chronic disease and pain and poor quality of life. And that's not really what we want. Right. We want to live healthy lives where we're doing what we love, playing the sports that we like, or we're using our brains in the way that make us feel like ourselves. We're working, we are engaging in communities. We're doing all the things that we want.
- [35:48]
Dr. Peter Attia
What about this idea that you're either in menopause or you're not. Because if we talk about the benefits of estrogen and we think about it again from bone, from heart, from cognitive function, which I would love to hear your perspective, typically, from what I've seen, is individuals will wait until they're in menopause to begin treatment.
- [36:13]
Dr. Heather Hirsch
Mm. Mm. I'm actually seeing. Well, I love this question. Let's talk about this. Because you can biohack your way out of perimenopause and menopause, if you want to, you can start hormone therapy earlier. In fact, I talk a lot about that in my new book, and I started doing that myself. Right. So now, luckily, I kind of have a lot of information at my fingertips and I have some good resources and some good doctors. But you're right. Kind of this idea that let's wait until the symptoms are really severe or I will still hear women say, you know, I can stick it out a little bit longer, or I know I only have a short window where I can use it. So I want to put all those years together. These are all myths that we kind of need to, you know, let go of. The idea is you can start low doses of estrogen or progesterone and or testosterone when you're still menstruating and you're having cycles. In fact, you can use them if you, you know, even have severe postpartum issues. We could talk about what that means if you're breastfeeding. But some of these options can be used postpartum. More popular, though, would be perimenopause and then leading into menopause. Because what we don't want is women who are saying, gosh, now I'm 65, now I'm 75. I didn't get the chance to be counseled on hormone therapy. Am I too old? Am I out of the window? We want to start women and have them think about this and trial it sooner rather than later.
- [37:39]
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- [39:11]
Dr. Heather Hirsch
Yeah.
- [39:12]
Dr. Peter Attia
How do we think about dosing? We have a lot of clinicians that listen to this. I know they have courses and you've got just amazing resources.
- [39:19]
Dr. Heather Hirsch
Yeah.
- [39:19]
Dr. Peter Attia
But if somebody's listening to this thinking, okay, maybe my doctor doesn't have access to or hasn't yet taken your course. How do we begin to dose them?
- [39:29]
Dr. Heather Hirsch
Yeah, so I actually always start by symptoms. That actually helps me because you know, in the beginning of the show we talked about menopausal hormone therapy or HRT is estrogen plus the progesterone, maybe plus or minus, plus or minus testosterone, plus or minus vaginal estrogen. And so kind of if you think about it like I was going to say Chipotle, which but you know, if you think about it like sometimes you're kind of like, you could just get a bowl of chicken if you want and just be like, all I want is my protein. You can walk right out of Chipotle. There's nothing wrong with that. You don't have to build the super massive, you know, bowls that everyone's doing. So if a woman has symptoms that sound more like low progesterone, which would be anxiety or insomnia, just feeling, you know, a little bit more overly thinking things or losing confidence in sometimes these are subtle things. There's kind of an art to this science and sometimes we'll try a woman on progesterone first. My usual go to would be to start with low dose prometrium or micro progesterone, 100 milligrams. If you want to go lower, you have to compound it to say 50 or 25 milligrams because the lowest commercial available dose is 100 milligrams. And progesterone is fun hormone to start because women will know in two days whether it helps them or it doesn't. And if it helps them they might feel that it helped them sleep. They kind of. It's a nice anti anxiety because of the way it increases GABA in the brain now. Yes, it's. It's really wonderful. I've actually prescribed it for anxiety before. Just straight up anxiety.
- [41:03]
Dr. Peter Attia
But it has to be taken at night. It does it, it causes drowsiness.
- [41:07]
Dr. Heather Hirsch
It definitely causes drowsiness. Although I have some women that it does it. So everyone's different. You know, all the patients say I've been taking it in morning for years and I'm like, wow, a lot of coffee. Yeah. Yeah, I would definitely say that one's a good one to take before bed.
- [41:20]
Dr. Peter Attia
And nobody. There's no contraindication that we know for progesterone, is that correct?
- [41:25]
Dr. Heather Hirsch
Mostly. Although if you have an allergy to peanuts, since a lot of the, the commercially available progesterones are made or they're packaged with peanuts, you want to make sure if you have a peanut oil allergy that you actually are going to have to go the compounded route.
- [41:37]
Dr. Peter Attia
What about blood levels, blood markers?
- [41:40]
Dr. Heather Hirsch
Yeah, progesterone. You know, this one's always challenging to me because here's kind of what my thoughts are. I have looked at my patients labs for years and what I will tell you is that symptoms will always trump lab work because, you know, a woman may, you know, certainly have actually progesterone intolerant, basically where the gap is working way too well and they feel way too sedated or way too groggy. And so they just probably don't want to stay on maybe that progesterone formulation. And so whatever their labs are actually is. It's probably too much for them. So I always want to think about what is your clinical symptoms and then what do your labs look like as well? You know, a lot of my. What we don't have clear correlations on is does progesterone in the bloodstream, is it getting to where we want it to go? Which is really to get to your uterus to ensure that. Also while it's treating your symptoms in your brain and you're sleeping and all those good things, is it also protecting your uterus if you're taking estrogen later on and we don't really have a great way to correlate, if your blood level is two and a half, is that enough for uterine safety? Does that have to be higher? Can it be lower? So we're not really sure.
- [42:48]
Dr. Peter Attia
I'm definitely glad that you point that out because again, people shouldn't be taking Estrogen alone.
- [42:54]
Dr. Heather Hirsch
Right. If they have a uterus and they're
- [42:56]
Dr. Peter Attia
postmenopausal, but we don't know exactly the right dose for progesterone, it's a little tough.
- [43:03]
Dr. Heather Hirsch
Yeah. You know, we have guidelines and standards so that based on if you're on both, you can always actually take more progesterone than estrogen, but not the other way around. So you don't want to be on too much estrogen and not enough progesterone in the very rare case that could increase the risk of uterine cancer. So we want to kind of use the standard guidelines that we have. But yes, another place for more data is how much progesterone do we need? Now if you're a woman who does well on progesterone, it makes you feel fantastic. This isn't going to be an issue for you because you're going to probably be, you know, taking your progesterone and is protecting the uterus. It's more of an issue for women who actually find side effects from the progesterone. They really want to know, gosh, how much do I really need? Because I feel so much better.
- [43:50]
Dr. Peter Attia
Estrogen, what do the side effects of progesterone look like?
- [43:54]
Dr. Heather Hirsch
Yeah, so I think that it may have been me, but I don't want to give myself credit where credit's not do. But this idea of progesterone intolerance is something I started to see over the last decade. And what I see, and this is specifically for prometrium, not so much for the synthetic progestins, but for prometrium, which I think has the most impact on the cns. It really goes through that blood brain barrier. So you can really get these, these brain impacts. About a third of women love progesterone. They feel like it finally helps their insomnia and helps their anxiety and they feel so much better. About a third of women don't really have much of a effect from the progesterone. And so they take it just because they're adding an estrogen later on for their symptoms. For example, we're talking about how to use start hormone therapy and perimenopause, more of the hot and dry, hot flashes, night sweats, dry skin, all of those things that's going to be more where you start a low dose estrogen. So for those third women who feel as though progesterone really kind of doesn't is just neutral, they're taking as they're taking their estrogen, then about a third of women will have side effects. And actually I break this down into a third Mild, moderate, severe. So mild progesterone feel intolerance feels just kind of like it makes you feel a little like a little sedated and you might need a little bit more coffee the next day. Sometimes they maybe feel a little bloating. All the same, my rings are a little tight, but nothing that they're like, this is, this is bad. More of the moderate and into severe you'll get really bad mood disorders. Almost like if you're triggering, you know, low mood before your period or pms because actually that's when progesterone would normally rise right before your period. So they may feel depressed. Depressed. I've had women have suicidal thoughts and progesterone and that's more in the severe category. Significant bloating. So much water retention, they'll put on five or ten pounds from the progesterone
- [45:45]
Dr. Peter Attia
fast within a few days.
- [45:47]
Dr. Heather Hirsch
Yeah, I would say most women know within even just a few nights if they're either going to love it, kind of have no effects or they're going to have some side effects. And sometimes you have to play around with dosing a little bit because it might be too high or maybe it's too low. But the interesting thing about progesterone is it will have an impact pretty soon. Whereas estrogen, I usually say takes about 2 ish 4 weeks to know like where you're feeling on, on estrogen. And I think testosterone can take even longer because it's slowly building up in your system. Whereas progesterone is the one that's like, I'll tell you in like two nights if you like it or not.
- [46:22]
Dr. Peter Attia
Fast in and also fast out. The half life is really short, really short.
- [46:26]
Dr. Heather Hirsch
So the good news is if you are going to not tolerate it, you're going to be one of those women that has side effects. It'll be gone pretty quickly.
- [46:32]
Dr. Peter Attia
Do you have to take a break? Is it something that has to be used cyclically?
- [46:36]
Dr. Heather Hirsch
Oh, great question. So you don't have to. And actually one of the reasons women will do this is to take breaks is if they have a little bit of intolerance for them, they'll say, you know, if I take it for 12 nights of the month or if I take it every other night, it's not so bad. I'm not sure why that is. Maybe there is a little buildup in the system. So every other night they sometimes feel better. So they'd rather do it it cyclically. Some women will do that will do cyclic if they're still having some breakthrough bleeding, especially if they're in that late perimenopause phase, or even if menopause was just a year or so ago, sometimes we'll do it cyclically so that they kind of have a bleed and they don't have to have unpredictable bleeding. That one is also just a pain. Because the one nice thing about menopause is you stop bleeding, right? Some women will just say, if I don't have to take it every night, I'll just take it 12 nights. But, you know, women will take it continuously because again, they'll fall into that. I really like the progesterone effects. I can't sleep without it. So they'll take it nightly. And I recommend they don't do it cyclically because then they just have trouble sleeping for half the month.
- [47:44]
Dr. Peter Attia
And if someone is already getting or they're still getting their period, do you have them time progesterone, for example, if it's the day that she's supposed to have her period, will you have her continue progesterone or will you have her stop that?
- [47:58]
Dr. Heather Hirsch
So again, it's going to depend on how they feel on progesterone. So sometimes if we're first starting and we want to see if the progesterone will help the symptoms, especially if they worsen right before her period, we'll try that and then kind of have her stop as she starts bleeding. One of the things I do with my patients, which sounds almost criminal to say out loud, but I'll say go with what your body thinks. If you took it and you felt great and you want to try it day one, day two, if you're. If you're still bleeding, see what happens. Because I know what she's doing, and I also know that everyone's going to respond so differently.
- [48:33]
Dr. Peter Attia
Do we have an upper limit of how much one could take for progesterone?
- [48:37]
Dr. Heather Hirsch
You know, I would say you can certainly go up to 300. Some studies show that that's where sleep is actually impacted the best. If you're going to use progesterone for insomnia, literally trouble falling asleep, but it's a pretty heavy dose. Like you might be really kind of sedated the next day. I am a patient who takes 400 milligrams, and it doesn't make her feel sedated at all. And that dose actually really helps her sleep. I don't probably have many people, if any, over 400mg of commercially available progesterone, Testosterone. Yes, let's do testosterone.
- [49:11]
Dr. Peter Attia
Talk to me about testosterone.
- [49:12]
Dr. Heather Hirsch
Oh, you know, big fan of testosterone. And again, I say that sort of with this smile on my face of, you know, again, every woman is so different. I have had women take testosterone and even get to really good levels and they'll say, I just don't know if it's doing anything for me. And I'll say, okay, do we want to stay off it or do we want to come? You know, do you want to just stay on it? And sometimes they'll say, I feel like, you know, I've done some research, it's probably doing some good things. Even though I don't, like, feel it, I'll stay on it. And some of them are like, well, it's one other thing to do and I don't really feel any different, so I'll just kind of stop it, you know. So again, I really just want to say, for the record, in the middle of the show, again, I think all women, you know, are different. There's no right or wrong answer. But I don't want women to feel afraid, especially of trialing these medications, because for a lot of women, you don't know how much is going to help you until you literally try it on. Right.
- [50:04]
Dr. Peter Attia
And FDA approval. Testosterone.
- [50:07]
Dr. Heather Hirsch
Oh, gosh. You know, so when it comes to, what matters more to me is removing the DEA constriction around testosterone. Right? So what that means is it's really hard for women to get because it's considered a controlled substance. So that means when I prescribe it, I have to constantly refill it because I can only do it for a month. Women are having to give out their licenses for it. And some of them feel like that's so uncomfortable. And I understand that some of them are like rolling their eyes thinking like, okay, this is what I have to do. Right? And then an FDA approved medication would mean that we have something that's appropriately dosed for women, which, because we don't have that, and you probably do this as well, we take the male dose and we dilute it, but it's really easy to screw it up. Right? And even that, even for me, I feel like this would be very hard to do because you kind of have to guess if either you're using a gel or you're using a syringe. Sometimes you're going to get a little bit more, sometimes a little bit less. And so that's what an FDA approved product would hopefully do. Which I do think maybe that will be in our future where women actually don't have to kind of guess their doses anymore, that would be fantastic. And removing the dea. This is silly. You know, this is saying that women are abusing testosterone and we have no proof of that. Most women don't want to abuse testosterone because they don't want to lose all their beautiful hair. Like they don't want to abuse testosterone. Right. And, and you know, I think this is patriarchal and sexist. And so hopefully this will change at some point, but I believe that it will. Let's talk about the benefits of testosterone. You know, I would say my women will see the 2019 global consensus position statement paper came out about the use of testosterone, which really kind of said. It was endorsed by the Menopause Society, the British Menopause Society, the Endocrine Society, Low doses of transdermal estrogen for postmenopausal women. We see the majority of benefits in that group for hypoactive sexual desire disorder, low libido. Okay, great. But I'm gonna go out here and say my patients who use testosterone feel better mood, less brain fog, less exercise fatigue. They feel as though they're seeing their physique, they're seeing their muscles when they're lifting, when they're using testosterone, and they kind of just feel like it was a cherry on top of their hormone therapy.
- [52:27]
Dr. Peter Attia
What about safety risks of testosterone?
- [52:30]
Dr. Heather Hirsch
Yeah. So, you know, we know that if testosterone is going to get too high, you want to check liver function tests, you want to check cholesterol. Sometimes I will see patients with really high levels and you might see some liver dysregulation, some cholesterol dysfunction. And so those are important to watch. Testosterone to me, is a tricky one. We're in this conundrum where women do benefit from these medications, but when we don't have enough clinicians who know how to prescribe them, we're getting women who are maybe getting over treated, some women under treated. And so what we want to do really truly is just train more clinicians, get the message out there so that women can safely get on their testosterone without judgment and be safely monitored. And we get more studies. So, you know, we don't yet see again, we don't have the longest term studies, we don't have randomized control trials that increases cancer risk, cardiovascular disease or stroke. The big things that scared women from estrogen 25 years ago. So testosterone really, when used appropriately, and those levels don't get too high because I think a lot of the side effects are correlated with levels if They're. If it's. If it's done well, I don't see a lot of side effects from testosterone.
- [53:42]
Dr. Peter Attia
How do you look at their numbers? Do you say, okay, well, the. I would like to see testosterone or free testosterone here year.
- [53:51]
Dr. Heather Hirsch
So again, this one is where I will sort of have discuss ranges for women. One of the things that I think that's difficult in this category is that I don't. Can I say this? I don't really know that I trust the lab work because sometimes it just feels like it is all over the place. Like, I just am like, is this calibrated right? Is one lab different than this lab? Because my patients. Patients sometimes will come in with their levels that, you know, look like they're flagged or they're high, but they don't have any side effects. They're otherwise doing well. They've been on this dose for a while. And so to, you know, you're kind of trying to explain to your patient, even though this level is maybe 80 or 100, it's. It's okay for you, right? We'll keep monitoring you for a while. So they get a little nervous.
- [54:37]
Dr. Peter Attia
They get nervous.
- [54:37]
Dr. Heather Hirsch
I would say, I don't know that I have specific targets because I will also have women who will use a little bit of test and gel, and they will feel so much better. And we'll look at their testosterone. And it went from, you know, 14 to 30. And I don't have enough data to say, like, let's keep going on that, because they're like, I feel. I feel good now. Okay. You know, and so you see such a wide range. I will say this. My younger women, my athletic women, and women with polycystic ovarian syndrome tend to do better on higher testosterone levels. I think that's because their body's used to it. And so they might feel the impact of testosterone at 70 or 100 or 110 because they might have had those levels floating around in their body than women who didn't. So again, that's younger women, especially if they had surgical menopause, and they're, you know, 36 for a high risk of, you know, ovarian cancer. They need their androgens replaced. Women with PCOS tend to have higher circulating, you know, androgens. And so their bodies are familiar with that and they're used to that. That. And then my athletes, I do see that they do feel better when their levels are higher, whatever that means.
- [55:44]
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- [56:22]
Dr. Heather Hirsch
Yeah.
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Dr. Peter Attia
So cool.
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- [57:24]
Dr. Peter Attia
And what I'm hearing you say is that we don't have a great number. We don't have a great number for bone production. We don't. Okay, so easily. Whether it is testosterone, estrogen or progesterone, we don't have great numbers as to where someone should. Is that true? As opposed to, we know that your luteinizing hormone is elevated or your follicle stimulating hormone is elevated. We know that the high number. Yeah, potentially also with no period, means you're in menopause. But we don't have a. Yeah. Because in my clinical practice, I really struggle with this because I want a target to shoot for. And I think a lot of the listeners, whether they're physicians or providers, are thinking, okay, well, for bone protection or for brain protection. Yeah, I would like my estrogen or estradiol. X, Y and Z.
- [58:09]
Dr. Heather Hirsch
Yes.
- [58:09]
Dr. Peter Attia
But we don't have those numbers.
- [58:10]
Dr. Heather Hirsch
It's really hard, right? And think about why. I can understand.
- [58:14]
Dr. Peter Attia
We're like, we want you to say something.
- [58:16]
Dr. Heather Hirsch
Wait, yeah.
- [58:17]
Dr. Peter Attia
Now, you know, as I'm thinking this, this. But for men, we have, you know, if it's less than 250, someone could say, well, you have low testosterone.
- [58:27]
Dr. Heather Hirsch
Right, Exactly.
- [58:28]
Dr. Peter Attia
But that's interesting because how does that work for.
- [58:31]
Dr. Heather Hirsch
For women?
- [58:32]
Dr. Peter Attia
Yeah.
- [58:33]
Dr. Heather Hirsch
Well, that's a different podcast of the different ways that we study men and women, I think, and how much historically men have, you know, gotten studied, how much we've looked more. I bet if we looked at numbers. More, more, more, more, more. If we looked at numbers. But we'd have to really look at numbers in this. So what level of estrogen helps your hot flashes? What level of estrogen helps your mood? What level of estrogen helps your bone health? I bet you it's actually different. It may not be the same and then the other part, but it's different for.
- [59:03]
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- [59:04]
Dr. Peter Attia
Meaning that at, say, 30 estrogen level, estradiol levels of 30 probably stops hot flashes. Yeah, I agree with you.
- [59:11]
Dr. Heather Hirsch
Does it help your bones? We don't know, Right? We think so. So we don't want to scare anyone either. This is all hypothetical. And what if you're younger? What if you're older? I think is actually a bigger story here when it comes to numbers. So this is what I teach for all the clinicians who take courses from me. Right. There's a lot of people, and we do like numbers. We want your A1C to be a certain number. We want your blood pressure to be a certain number. We want. So we like numbers, and they're objective and so, like, ha. We could just get to that number. Right. There's a little bit of an art to this. Right. Just like the woman who feels better when her testosterone is 35, and my other patient feels better when her testosterone is 110. And so there's probably completely different physiologies going on, and they're probably looking at different outcomes, and they're probably completely different genetically. And so I think there's a lot more to the numbers story. There are definitely clinicians who say, you know, I have a colleague who will really want the FSH number, which is high postmenopausal, to be lower than 25. And you can bring that FSH down by adding estrogen, by adding progesterone, by adding vitamin D. And. And in his research, he says when that FSH is lower, there's more optimization. Optimization. Kind of broad, but this is really what he kind of likes to target, too. I find that if I try to do that, I find that I'm pushing my patients into side effects from medications. If I'm trying to get to that number. So this is where that art and science comes from.
- [60:38]
Dr. Peter Attia
Okay, now I want to shift gears to cognitive function.
- [60:44]
Dr. Heather Hirsch
I know, I know. We wanted to talk about this.
- [60:47]
Dr. Peter Attia
I think it's really important because I did an AMA and I felt really comfortable saying that hormone replacement therapy. And I say hormone replacement therapy, you can use it however you want.
- [61:01]
Dr. Heather Hirsch
Yep.
- [61:01]
Dr. Peter Attia
Really? Estrogen, testosterone, there is some effect on cognitive health. Meaning I think that there is. Is an increased risk for dementia or other cognitive challenges when individuals are devoid of hormones. I don't have a randomized control trial, and I don't think any of us have randomized control trials.
- [61:24]
Dr. Heather Hirsch
We probably won't get one.
- [61:25]
Dr. Peter Attia
We will probably will not get one. But as a trained geriatrician, I can say when there's androgen deprivation therapy or when people are depriving individuals hormones, we have enough data that there is likely a negative outcome.
- [61:41]
Dr. Heather Hirsch
Yeah.
- [61:41]
Dr. Peter Attia
So I'm curious to what you would say when there's. And it's typically people that don't treat patients will say, you don't have randomized controlled trials to say this would help with the risk of dementia or cognitive impairment.
- [61:53]
Dr. Heather Hirsch
Yeah. And actually, this kind of debate was really sparked when, you know, the. Around the same day is actually the box label warning was removed on hormone therapy. So then there was this idea that, you know, is, is there enough data to show that that hormone therapy reduces the risk of dementia? So here's what I'll tell you. I think and. And all the reasons why I think the same way as you. I think there absolutely has to be neurocognitive benefits in the same way that there's cardiovascular benefits. You have this vasodilation, and you see this when we prescribe menopausal hormone therapy for women, because we see less heart disease, even genital urinary syndrome of menopause, you're getting blood flow down to the pelvis. The pelvis doesn't die just because we went through menopause. Right. So the same thing's gonna happen in your brain. You're gonna get all this rich blood flow to the brain. It's gonna help remove all the toxins out of the. Out of the brains. Right. And while I'm not a neurologist, I can also definitely say that when my patients do start hormone therapy, initially, their cognitive function improves. Improved. I will be proof positive of this. If I forget my estrogen, I will have word finding difficulty the next day, and my entire team will say, did you forget your estrogen? Now, that is different. Because we're talking about something acute versus something long term. However, those early studies that they're doing now on the impacts of the brain and, and use of estrogen are extremely promising. And I have a. I have a. I have a, you know, idea of maybe what might happen. So one thing that we say, when it comes to hormone therapy and diabetes, this has been proven in so many studies, that women who take hormone therapy have less diabetes, but we don't say prevent diabetes. What is clinicians, the right thing to say is hormone therapy decreases the diagnosis of diabetes. Why? The word prevention, especially among absolutists and scientists and clinicians, means a lot to them. Like, you know, they don't want it thrown around. So I have a prediction that we will see improvements in brain health long term with the use of estrogen started around the time of menopause. And maybe we will be able to say estrogen decreases or delays the diagnosis of neurocognitive decline in women. Mark my words. I think that will be the next thing that we're able to say. And you're right. A randomized controlled trial would cause cost billions of dollars. And IRB boards that approve randomizing women to hormone therapy or not. And listen, these IRB boards are still biased and they still think that estrogen is dangerous. And so they're not going to maybe approve a randomized controlled trial to give women estrogen or not. And so we have to look at what we see clinically, which is that women live longer, they are sharper, and they have improved cognitive function at the time at which they start it, and then has to really work for something. Right? If you don't, don't use it, you lose it.
- [64:54]
Dr. Peter Attia
Isn't that the truth? And that goes for everything.
- [64:57]
Dr. Heather Hirsch
Everything. Speaking about, you know, earlier in the show, you kind of asked, what are women coming to you wanting to talk about hormone therapy for? You're like, all right, bone prevention, heart prevention. I was like, symptoms. And you're like, yes, symptoms, but this one is a huge one. They have all seen their parents struggle with cognitive decline, Alzheimer's and dementia. Something I actually going through in my own life.
- [65:21]
Dr. Peter Attia
So terrible. I'm sorry for that.
- [65:22]
Dr. Heather Hirsch
It's. Yeah, yeah. And. And they look at their parents and they think to themselves, because women are more affected than men, and they think to themselves, like, there has to be, like, what is happening here? There has to be something better. And then because women are smart and inquisitive and curious, they will do some research. And it's not that far of a Stretch. To think that that estrogen started at the time of menopause. It's good for your body, it's good for your heart. It helps you live longer. It's good for your pelvis. It's probably good for your brain, too.
- [65:54]
Dr. Peter Attia
Very, very well said. If you were to kind of boil it down to. And I know that you cover much of this in your book, but what are women doing wrong?
- [66:06]
Dr. Heather Hirsch
You know, I think that. I think that we, as a. As a society of women, we stay in the suffering period for far too long, and we've really normalized suffering. I mean, what is the period other than just, like, suffering? As soon as I figured out I could stop my periods, I was like, oh, I'm stopping those, right? And these are all things that are still, you know, clouded in mystery and fear. Well, I was at a dinner the other night, and the women said, are you sure it's safe to not have your period? And I'm thinking to myself, we've known this for a really long time, that you don't have to shed your lining every single month or have a period right now. Not that everyone has to do that either. But we also think about just all the things we joke about how when men get colds, you know, we call it man flu, right? Women are so used to not feeling great, but sticking through things and putting on a face and just getting the things done, because that's the way we are. We're productive and we're strong. Right? However, sometimes that can be as a detriment to us. We think, oh, well, this is natural. Like, you know, everyone else suffered through this. Like, I have to suffer through this. You know, they'll be told this could increase your risk of breast cancer. Like, well, I. I want to stay healthy, so I don't want to get cancer. Meanwhile, right? They're not getting the benefits of hormone therapy because they're trying to be strong or they're trying to stick things out. So I think that we, as women, stick things out a little bit longer than we need to. My patients will come to me and they'll say, I've had years of this. Actually, I look back, I think I've had a decade of this. I'm like, wow, we'll start on hormone therapy, and they'll come back and they'll say, this. This little sticker, this little patch, and everything's better. I say, I know.
- [67:53]
Dr. Peter Attia
And you said something else a decade, a decade ago. What are your thoughts on starting a woman on menopause therapy? Hormones. Ten Years out.
- [68:05]
Dr. Heather Hirsch
Yeah. For menopause. Yeah, yeah. I've done it for myself. Right. So I think that it is absolutely within a woman's right and you need a great clinician. So this is the other side of the problem. The other part of the equation is, you know, we want to help more clinicians be inspired and want to do this as a, their, as their job. It's so satisfying, it's so fun. So a woman deserves the right to kind of know, what are my options here at 35, at 38, at 42, if they, you know, are sort of feeling to themselves, I want to already prepare myself for this stage. I'm proactive, I'm healthy, I want to stay healthy. What are my options? And so there is no good reason that I am aware of at this moment in time where we couldn't start you on hormone therapy earlier than either you're having symptoms and, or therefore for prevention, or therefore to just skip perimenopause altogether. Right.
- [69:01]
Dr. Peter Attia
And then what about later? That was a really, that has been a heavy topic of conversation for all the women that have missed out.
- [69:08]
Dr. Heather Hirsch
Exactly. And again with the black box removal, this conversation really got amplified. I had my neighbors, you know, in their 70s messaging me like, well, can I started hormone therapy now? So here's what we know. 10 they so it, it depends if we think about again what all women can do. All women can do vaginal estrogen at any age. Doesn't matter how long you have been since menopause. A lot of women can probably also use testosterone and progesterone at any age. Now of course this is not direct medical advice and education, but when it
- [69:41]
Dr. Peter Attia
comes, they know that and we've got
- [69:42]
Dr. Heather Hirsch
that all covering when it comes to estrogen. You know, I have started women who are outside of 10 years of menopause routinely because at the point at which they are coming to me, they are healthy, they don't have any cardiovascular risks, maybe they don't have hypertension or diabetes. And so they're still good candidates to try transdermal estrogen. Because, and this is the rationale, that study that really showed the benefits of estrogen in the 10 year window was all on oral. And again, we didn't do that study on transdermal estrogens. And so if the biggest risk as you get out of that window is an increased risk for clot, but those ester studies or ester trials showed transdermal estrogen does not increase the risk of clot and a woman doesn't have any cardiovascular conditions now, Even if she's 65 or if she's 71, we can start really low dose transdermal estrogen, or I should paraphrase that, rephrase that, to say I am comfortable starting women on low dose estrogen, even if they've been out of the window, but they have a lot of other options, including progest testosterone and vaginal estrogens.
- [70:45]
Dr. Peter Attia
Dr. Heather Hirsch, you are just such a spitfire. And I really do believe we talked about this before. I believe that you and your colleagues are changing the landscape for women and really making things accessible to them, that a whole generation got skipped. So thank you for the work that you're doing.
- [71:04]
Dr. Heather Hirsch
Thank you for having me on.
- [71:10]
Dr. Peter Attia
Sa.