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- [00:01]
Dr. Heather Hirsch
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- [00:29]
Dr. Kelly Casperson
Welcome to the you are not broken podcast. I'm your host, Dr. Kelly Casperson, a board certified urologist, thought leader, and conversation starter on midlife living, hormones, and sexuality. Enjoy the show.
- [00:43]
Hey, everybody. Welcome back to the you are not broken podcast. I have a good friend of mine, Dr. Heather Hirsch, on today, and before we go any deeper, I looked back because I can Google search me and my podcast. And first of all, Dr. Hirsch was on episode 290. That one was called the biggest gap in women's healthcare. That was way back. And then I was like, but Heather's been on my podcast more than that. You were on episodes 61 and 62, which was February of 2021.
- [01:12]
Dr. Heather Hirsch
Wow. Oh, my gosh. I remember recording that in my table in Boston.
- [01:18]
Dr. Kelly Casperson
Welcome back.
- [01:20]
Dr. Heather Hirsch
I'm so excited because you're such an inspiration. I love all the things that you do. I love all the. All the ways in which you speak about midlife, women's health, sexual health. And so it's so fun to get to talk with you and talk to your audience at the same time.
- [01:37]
Dr. Kelly Casperson
And that's the end of the podcast. I just had Heather on here to be kind to me. And we're done. So I remember listening to your podcast early on. You had on a very good friend of yours who was a urologist, and you said that she was your best friend. And I was like, oh, she's friendly to urologist. That's cool. And we connected via something we were doing and I came on your podcast and we talked about recurrent urinary tract infections, I think, or bladder leakage. It was a urology topic.
- [01:59]
Dr. Heather Hirsch
Now you know the truth about me. I must just love urologists because so many of my friends. Urologists.
- [02:07]
Dr. Kelly Casperson
I was in a meeting with Heather yesterday. There were three female urologists in this meeting that she had. So, like, she clearly attracts urologists. And you for people who missed the boat. Dr. Heather Hirsch is a internal medicine physician, which we need more of them in perimenopause and menopause because they actually understand things like cardiac disease. Dude, cardiac disease mystifies me sometimes. I'm like, why are we ordering all These tests when we don't have any data. And then people say we can't be on hormones because you got a calcium score and there's no data to support that. And telling women they can't be on transdermal hormones, so like cardiac disease mystifies me mostly because people just like throw tests at people.
- [02:45]
Dr. Heather Hirsch
Right. And actually we know, speaking specifically about this, that to me, I always say it's no coincidence that chronic diseases in women start at the same time as they start to lose their sex hormones. Estrogen is an anti inflammatory and vasodilator. When started, definitely within the 10 year window. But again, hopefully now we're changing the narrative so women are talking about this way earlier than they have have the 10 year window. But truthfully, I can't think of a better option for women who even have, you know, whatever you call heart disease. That's a very blanketed statement. But I actually think estrogen has more preventative benefits than statins. Now that is right off the bat, we're starting with a good one. Right? Right. Dr. Kasparson.
- [03:25]
Dr. Kelly Casperson
Yeah, there's the controversy starts. We're just saying it out loud. A lot of us think this, but there will never be a randomized control trial, transdermal estrogen patch versus a statin.
- [03:36]
Dr. Heather Hirsch
No, there won't, because nobody will fund it. And even if there was funding available, it will not get approved by IRBs. I will say that's not ethical to put women who could be, quote, harmed from hormone therapy. So there will never be.
- [03:49]
Dr. Kelly Casperson
Yeah. But we're here to talk about your upcoming book. Unlock your menopause type was your first one and now your second one. It's all about perimenopause and the survival guide that we need.
- [03:59]
Dr. Heather Hirsch
You know, writing a book, as we both talked about, because we both have books, it's a work of just love for all the things that you do because it's very difficult to do. But one of the reasons I wanted to write this is I have so many patients who told me they bought my first book and they were still kind of frazzled and things like that. And I realized, oh, you're in perimenopause. Of course, unlock your menopause type isn't really helpful for you yet because there's so many things happening to you. You're still bleeding, you're having good days and then bad days. You might have just had B baby and had IVF and you're postpartum and you don't know where you are. So I realized that when we grew perimenopause and menopause together, we're doing a big disservice to perimenopausal women. They're experiencing different things, different symptoms, and they're being told they have maybe different things. So that was one of the really reasons I wanted to labor over another book. But I'm really excited it's coming out soon.
- [04:54]
Dr. Kelly Casperson
And I think this is where the menopause experts are going, is the menopause experts are saying, I want to say the word menopause less. And the reason is it's an art. We're using a period, literally a blood flow as a dividing line between people and putting them in different buckets when it's all ovarian decline, ovarian failure, ovarian senescence, whatever the term is, of living longer than your ovarian function. What are your thoughts on that?
- [05:22]
Dr. Heather Hirsch
Oh, my goodness. I couldn't agree more. I mean, what the word menopause does, it's very siloed word. We know that menopause is actually one day, and we use it a lot, very broadly. I even use it mistakenly. Often when I'm doing social media, I'll say menopause or menopause transition. But it means so much more than that. And for so many years, this word, I think, not meaning to, has siloed menopause as this separate thing. And when you talk about endocrine dysfunction or you talk about hypothyroidism, what comes to mind for clinicians is a whole host of organ systems that change because of hypothyroidism, hypothyroidism, or diabetes. But the word menopause, because it's about really means one year of no period has siloed this huge transition that can span two decades into, like, one little corner. And that's what's really led to a lot of problems. So I love this idea.
- [06:18]
Dr. Kelly Casperson
Yeah. I mean, it's almost like, hey, using the word menopause is not accurate because it's a symptom of what's the actual underlying problem. But it's almost like, harmful then, because it makes the perimenopause people disappear and it makes their symptoms not real because we're like, you're still the whole. Like, you're still having periods, so you can't be X, Y and Z. Right. And I think the other thing with perimenopause and menopause I see a lot is you're too young for or you're too old for. I see it all the Time in the perimenopause menopause world. And it's like, why is there a birthday involved? This is not a driver's license there. This is not a legal document. But women get it all the time. You're too young for, or you're too old for.
- [07:00]
Dr. Heather Hirsch
And we don't do that with other. Other endocrine, you know, pathologies. We don't say you're too young to have type 2 diabetes. We don't say that. We can't say, oh, gosh, no, this. This happens to people in their 50s. And also we now know, you know, again, there's different reasons why this type of endocrine dysfunction, type 2 diabetes, is happening in younger women, even in children. And we've accepted that. And if you look at other endocrine dysfunctions, again, there's so much more understanding and how that impacts the whole body, how it impacts lifestyle, et cetera. But this word, menopause, people think of it as hot flashes, and they don't realize that it is an increase in cardiovascular disease, a time when bone loss is happening, when brain changes are happening, when symptoms are affecting women's life for, I don't know, 10 years before, maybe 10 years after. And it's affecting their personal lives, how they might have, again, relations with their partner, their moods at home and their professional life, brain fog, things like that. I mean, I can't think of something that's more intertwined with a woman's every minute of her life, which is probably why I gravitated towards this. And I love it so much. And I never stop yakking about it, because you can come at it from so many different angles. So I agree, the word menopause alienates perimenopause. It alienates even women who are in their 60s and 70s, because I'll go to conferences and they'll say, oh, I already had menopause. And so it's cool that the dialogue is out there that we're talking about these things. The other thing I would say I've noticed when I've been talking about perimenopause, is that women in their 40s, a lot of them, not you, if you're listening to this, the show don't know what perimenopause is. So we're also using a medical word to describe something like, what the heck has happened to me in my 40s. And so I think these terms, while they're not necessarily meant to be harmful, they definitely can be. And they can be alienating.
- [08:55]
Dr. Kelly Casperson
What definition of perimenopause do you use and do you have an idea of what we should call it instead?
- [09:01]
Dr. Heather Hirsch
You know, I've heard all sorts of things. I think it's really the. Let's say your reproductive hormones, estrogen, progesterone, testosterone, they're kind of going rogue. And in menopause, they're low, they're stable because they're not necessarily even. You're not producing much of them anymore. So perimenopause is really this time of. In internal medicine, there's a condition called afib. And you probably know afib doctors call this. There's an irregular irregularity versus, like something that's regularly irregular. Afib is irregularly irregular. And the same thing with perimenopause. It's kind of like the afib of the woman's reproductive cycle. And not just cycle, meaning a month, but her life cycle. And it's when things become irregularly irregular. And that's really what typifies it for me. Estrogen is very volatile. It's lowering, but it's also being hijacked. Your progesterone's lowering and your testosterone is, you know, sometimes also spiking and sometimes declining. So. And everyone's is a little different. So for me, I feel like that it's that irregularly irregular that really typifies perimenopause.
- [10:08]
Dr. Kelly Casperson
Yeah, I love that. And I think so many people, at least when they ask me about perimenopause, they want to know the years. How many years before menopause is a start? What year are you when it starts? Like, again, people really want to try to define this, and it really doesn't work that way, especially for the rare instances. But whatever we want to call it now, premature ovarian insufficiency, X, Y and Z. Like, it can be very, very young versus you can be having wild perimenopause stuff, and you're in your mid-50s. Right. So it's like, for people to try to give this like a timeline or an age. I understand they're trying to put constraints on something that's otherwise kind of intangible. Like, if you could look at your ovaries, that would be lovely, but they're not testicles. But people always want to be like, how young for. For the start of perimenopause. And it's like, it's kind of undef. I mean, we got the straw criteria medically to do research with, but other than that, like, there's no, again, too old or too young for the ovarian lifespan to start flickering.
- [11:08]
Dr. Heather Hirsch
This is exactly true. And a lot of women like myself, so I'll even put myself in this bucket. If one of the most helpful objective measures is your bleeding and your periods, a lot of women aren't having periods anymore. I've opted to not have periods because I have an intrauterine device. Women have had ablations or hysterectomies or they're on continuous birth control pills. And a lot of women are doing this to control the heavy bleeding that kicks up in the puberty. Puberty in reverse is another way to say it, which is not so much menopause, it's really perimenopause. And we could talk about this in a second because it takes about five to seven years for cycles to become regular at puberty. Same thing on the way out. Takes five to seven years for those to kind of change and go into menopause. Could be shorter, could be longer, but a lot of women don't have cycles anymore. And there's good reasons for that. It's too much heavy bleeding, it's inconvenient, whatever it might be. And so also this can make perimenopause really confusing for a large percent of women who don't bleed anymore because this can be a very helpful objective measure. And we don't have that anymore.
- [12:12]
Dr. Kelly Casperson
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- [13:04]
I think checking labs is validating to women. I just like a woman asks for labs, it's no skin off your back. Check some fricking labs. Ideally you know how to interpret them, but like how much of a shingle do you actually hang on an FSH or serial fshs in perimenopause?
- [13:20]
Dr. Heather Hirsch
Oh, I'll tell you a Great story about this. I agree with you as well. And I always. You share decision making with my patients. We were just talking about how the days of the weeks that we see patients and how much that keeps us really grounded in what we're doing. And when my patients do out lab work, I always share with them. It may not be terribly helpful, but let's just use it as more data to see. But I have a story about this. So I had a patient, she saw me and her other gynecologist, which happens my. In my practice, she hadn't had a period in four months. So clearly she's in perimenopause. If the definition of menopause is no period in a year or 12 months. So she goes to her other doctor, he draws some blood work, the nurse calls her and says, oh, hi, well, you're in menopause. And she's like, huh? I just. What? No, I can't be. I just. And, and, and she was relatively new to me, so she's confused. Why did I say peri and why did they say menopause? And you know, her FSH was 69. So she calls me and she says, I'm a little confused. Like you said, I was in Perry. My FSH is 69. Like, that's pretty high. The chart says that's menopause. And I said, yes, periods will always trump lab work. And when you go a couple of months without a period, your FSH is going to be screaming at those ovaries. It's going to be screaming and screaming, and that number is going to be higher and higher and higher. But those periods, which she was still getting because she wasn't on any form of contraception or birth control, that would change her periods because the period was only four months ago, she is clearly in perimenopausal range. Now, this one's kind of a little bit easier to distill because it was a clear, nice cut. Four months. But for example, if you've had an IUD like me, I haven't had bleeding in a while. That's kind of also my choice. And it works for me, doesn't work for everybody. But I don't know that I would trust my FSH all that much unless I was really tracking them for a much longer time. Because again, you could be just like my one patient and have an FSH of 69 and clearly still without a period four months ago. So you got to really take it into context. That's what I always tell my patients. So the context is really helpful. But labs can be a good surrogate marker if you don't get periods. And it's nice too. We're addicted to numbers and I get that. I love spreadsheets. I mean, I love it. I love looking at numbers, I love analyzing them. Everyone's got their aura rings and their whoops and their apple watches. So I agree with you. Let's get some numbers. But we have to make sure we're also really putting it into context. Because what's most important is actually I always tell my patients not what stage you're in, but how you feel on a day to day basis. So forget the numbers. Even if they're driving you crazy, let's make sure you feel like you're functioning well.
- [15:54]
Dr. Kelly Casperson
I love that. And I think I always try to go one level deeper with patients of like, why does it matter if you're in perimenopause or menopause? Why does it matter? And the only reason I can really think of mattering is can you pull the goalie from the hockey rink on, you're very unlikely to get pregnant, right? So I think that matters, you know, that said the woman who hasn't had a period in four months and her FSH is 69, you know, she might still get pregnant. It might be challenging, right? So I'm like the goalie in the hockey game is probably the reason why it really matters. But what I see is women want to know, can I take hormones, Can I try to feel better? And they use this again, artificial menopause perimenopause line, as you can take hormones or you can't take hormones. And I think what you and I are trying to teach the nation is it doesn't effing matter. Treat the symptoms, help the woman out, be mindful of pregnancy for those that have that. But otherwise it does not matter. It's irrelevant 1 million percent.
- [16:51]
Dr. Heather Hirsch
And that's the juicy part of my book. And I'm excited about this because I really walk through how I do menopausal hormone therapy in perimenopause and I really break it down. I break down the safety, which is based on the same studies that help us show the safety of menopausal hormones therapy or MHT for menopause. But again, I really also break through why I think birth control pills are also hormone therapy and why postmenopausal hormone therapy is often safer, more effective and easier to use, to be honest. And so I absolutely agree with you. My entire career for the last 12 years, I've been prescribing hormone therapy to women who are still having cycles. And what a wild ride it's been because perimenopause is still the evil little sister to menopause. And these women really are suffering, just like you said. They're looking for that. Can I just start HRT now? Now, a lot of my patients, I'm sure some of yours too, we've already kind of helped to educate them, but we can't see everybody. And so we have to really arm women with why they can take MHT and perimenopause and help their clinicians understand how the heck to do it.
- [18:05]
Dr. Kelly Casperson
Yeah, and I think that, you know, this is why, you know, we had that meeting of like, 20 menopause experts on a zoom a couple weeks ago. Mostly because I got feisty and I said, I'm effing sick of calling these sex hormones because I can't say sex on Instagram. Like, Instagram made me do it. So, like, I can't say sex on. I can't say sex on Instagram. These are called sex hormones. Sex hormones diminishes their brain function, their bone function, their heart function, their sexual function also. But, like, it denotes reproduction. So I'm like, so I hate that they're called sex hormones because it's mislabeling of these neurohormones. And so we had this meeting and 20 of us sat around and we're like, what should we call it? Because calling it MHT or HRT again draws a line in the sand that the perimenopausal people can't take these medications. And so I'm like, that's where we're like, pet therapy for progesterone, estrogen, testosterone, or precision endocrine therapy, if people want to use the acronym for that. But it's like, even just calling it menopause hormone therapy or hormone replacement therapy excludes the perimenopause people.
- [19:02]
Dr. Heather Hirsch
Right? And also it's medical dialogue and medical lingo that's outdated. So the medical lingo is absolutely outdated. And it's also boxing it again, just like you said, it is making some women feel dismissed and absent from this conversation. And it's also a mouthful. Menopausal hormone therapy, hormone replacement therapy, hormone therapy. And people are getting into silly, even, like, online fights about this. Like, we all know what it is. It's estrogen, you know, that's postmenopausal. It's not going to stop. Reproduction is with a progesterone. That's not going to Stop you from ovulating if you have a uterus. And it is plus or minus with a little bit of testosterone, so. Exactly. I see why thinking of just estrogen, progesterone, testosterone is just so much more streamlined and simpler. And it really just, you know, levels the playing field for hormone therapy.
- [19:51]
Dr. Kelly Casperson
So I think, you know, in the menopause, perimenopause, midlife women's space, the powerhouse people are the people who are still seeing patients in clinic, we call it, in the trenches. That's the medical lingo for it. Like, you're doing the work, you're listening to the stories, you're figuring out doses, you're adjusting them as needed. Like the actual, like, nitty gritty of practicing medicine and the expertise that comes with just putting in enough reps. So in your. And you've put in probably more reps with the perimenopausal women than most people who are public educators on this. What would you say is some of the most common symptoms that women talk about when they come to see you for perimenopause symptoms?
- [20:32]
Dr. Heather Hirsch
The most common thing, I would say that women in perimenopause ask me, is, is it perimenopause or is it something else? For example, is it perimenopause or is this a fibromyalgia flare? Is it perimenopause or am I just really freaking anxious? Is it perimenopause or do I have Crohn's disease because. Or, you know, is my IBS flaring up and is actually trying to figure out which thing has gone array? Is it the hormonal milieu or is it the inflammation, or is it just the mental health and trying to parse out what is what. Now, in truth, it's usually a little bit of both. It's usually a little bit of everything. Because all women will experience that zone of volatility, right, where the hormones are really changing very much day to day, week to week. And also that may be triggering more inflammation, that may be triggering more anxiety. So it's usually not just one or the other, but most women, yes, they have the same symptoms as menopause. It's fatigue, it's low libido. It's definitely insomnia and anxiety. Those I see a lot, a lot, a lot. That could be because sometimes it's the progesterone declining first. But really what it is is this kind of feeling of being stuck. It's like, I'm not a girl, I'm not yet a woman to quote Britney Spears, if you will. And so it's like, which one am I or where am I or am I crazy to think that this is hormonal because we've been conditioned to think that our fluctuating hormones is just totally normal. And that's, I think what is really interesting in this whole hormone therapy journey or perimenopausal journey is so oftentimes when we're using hormone therapy. That's why I always teach go slow and start with one at a time, especially in perimenopause, because that's going to be the only way they can rule in or rule out what might be hormonal.
- [22:23]
Dr. Kelly Casperson
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- [23:48]
And it's okay to try things?
- [23:50]
Dr. Heather Hirsch
Absolutely. It is a lot of trial and error in perimenopause, as you well know, because you're also seeing patients. And my patients always say, have you seen anyone that's more complicated than me? And I always say, I promise this is very common, that there's just so many things swirling, so many things that this could be. But we're just going to take it one step at a time and we're going to probably make a lot of adjustments and that's how we're going to either know if this is or if this isn't or if this partially is or partially isn't.
- [24:18]
Dr. Kelly Casperson
Yep. I learned an adage in, I think this was in residency. I don't think this was med school. The adage is, when you hear hoofbeats, think of horses, not zebras. If you live in America. Right, because there's not many zebras. And I think of this a lot in the perimenopause women because they're getting worked up for multiple sclerosis, they're getting worked up for rheumatoid arthritis, they're getting worked up for lupus. And some people have those things, but many people don't have those things. They have perimenopause. And so to me, to help answer the question of, like, treat the horse first is the most common thing, because every single person will have diminishing ovarian failure at some point in the female population. Right? So it's like, that's the horse. Think about it. And then, yes, yes, there's some zebras. And yes, some zoos have horses and zebras together. So that's how I like to explain it to people.
- [25:07]
Dr. Heather Hirsch
I think you need to go on a comedy tour after your book tour because you're just so. But, you know, yes, in med school, I learned this as common things happen commonly. And the other thing about perimenopause, let's say someone had. Does have a zebra, but she most likely also has the horse. And so often that means in this, in this analogy that we've gone down this zoo zoology, if the horse is perimenopause, you know, and she also has, let's say again, multiple sclerosis, with her not sleeping well with her, then having low mood with her feeling stressed or brain fog, it's going to worsen. The horse is going to worsen the zebra. And so there is almost never. Almost never. I never want to say anything with a, you know, absolutes on a podcast, but there's almost never something that really worsens that can't easily be resolved. But there's almost something never that worse. There's almost always a benefit to adding menopausal hormone therapy or doing a trial up. The worst things I can think of is sometimes it causes some bleeding or some bloating and those things will resolve. But it also, if anything, gives the patient the peace of mind. Maybe it is time to go to Mayo Clinic for this zebra thing. But there's almost no reason I could think of why you wouldn't start with treating the horse either at the same time or before you look for the zebras.
- [26:27]
Dr. Kelly Casperson
Yep. I love it. Let's talk about prevention, which is a complete paradigm shift in current medical practice. Because how many perimenopausal women come to you and say, my doctor said, come back when I'm more sick.
- [26:40]
Yes.
- [26:40]
Dr. Heather Hirsch
This happens a lot. And they know the patients that I luckily get to see sort of have already done a little bit of shifting through to realize how preventative thinking about menopausal hormone therapy or starting menopausal hormone therapy can be. But we have to be loud and loud and loud and loud and continue to get this message out there. Because this sort of idea that you have to be sick or you have to be in survival or you have to be in. Sorry, not survival mode, crisis mode. Right. Or you're trying to survive before we treat you is an absolute Western medicine disaster.
- [27:14]
Dr. Kelly Casperson
It's a thought error, really, for sure.
- [27:17]
Dr. Heather Hirsch
And it's also, not only is it a thinking and thought error, I mean, the way that doctors are rewarded has really separated this. It's made it worse. Right. Because doctors get rewarded unfairly for treating sick patients. Whether it's, you know, a big surgery because someone just had a heart attack or it's a cardiac catheterization or it's blah, blah, blah. I'm sure you can think of so many things. And they're also not rewarded for doing preventative medicine, which is arguably harder. And so that's another. You put those two together and it's just been a complete disaster.
- [27:47]
Dr. Kelly Casperson
Yeah. And I would add, just for. To pick on insurance companies, you can't get a blah, blah, blah, because you're not actually blah, blah, blah yet, like, insurance doesn't cover stuff to keep you healthy. It makes sense when you realize the average person is on their insurance plan for only four years.
- [28:02]
Dr. Heather Hirsch
Interesting. Because they are changing jobs more often.
- [28:05]
Dr. Kelly Casperson
Yep. And so, so then you're like, that's a completely money saving tactic for the insurance. Because they're like, you're not going to be on my insurance plan in five years. I don't need to keep you healthy. I just need to not have you spend money today.
- [28:17]
Dr. Heather Hirsch
Which is a really sad state of the world. That's what that means. For many reasons.
- [28:21]
Dr. Kelly Casperson
Yeah. No, but it's like, it's better to know that truth than to be like, why is it like this?
- [28:26]
Dr. Heather Hirsch
Like.
- [28:26]
Dr. Kelly Casperson
No, no, there's a reason why just the, you know, understand it. Okay, let's talk about. There's a randomized control trial in 2018 of estradiol patches in prevention of depression in perimenopause. 17.3% of women on hormone therapy, estrogen patch plus or minus progesterone, if you needed it, developed depressive symptoms at a year compared to 32.3% of women on the placebo. So we have a placebo controlled randomized trial in perimenopause saying it cuts the risk of depression in a year by almost a half.
- [29:00]
Dr. Heather Hirsch
This is a paramount study was this by Dr. Pauline Mackey and co. This is a fantastic study.
- [29:05]
Dr. Kelly Casperson
It's brilliant. When I read it, I was like, are you effing kidding me?
- [29:08]
Dr. Heather Hirsch
You know, it's interesting actually. I was doing a little bit of thinking through actually I created a new course for professionals who want to take the Menopause Society's exam. And I put this in there because I actually think it might even show up on the Menopause Society's exam because. But again, the menopause is a small wedge of professionals and also even amongst those professionals, we're not talking about it enough or the broader healthcare professionals in general. But this is absolutely significant. It demonstrates how much the estrogen, progesterone, testosterone impacts the brain and impacts mental health. We don't know exactly why or what it's doing there, but I see so many women for mood changes. It's almost always at least one of the top three symptoms and it is actually not like a challenge for menopausal hormone therapy to improve their mood. It does work in clinical, my clinical experience. So why this isn't known about more especially, you know, I, I think we maybe even have to go to the mental health providers, whether it's social workers, psychiatrists, therapists, they need to know about this as well because they're seeing a lot of anxiety and depression and they may not necessarily want to prescribe mhd, although it's again, it's not that hard. But yes, this immensely impactful. This is super exciting. You know, mood has always been something that I have really. I've lost two patients to suicide in menopause clinics and it is not lost on me how, how much mood changes. And this study is really paramount in showing there is positive results and we should keep doing this research 100% and.
- [30:49]
Dr. Kelly Casperson
We should stop saying we don't know. As far as like, I'm like, have you ever talked to a woman before and after being on hormones? This is really where clinical experience, experience plays in, I would say, especially with testosterone, because so many people only rely on data and not clinical experience with that one. But it's like, have you talked to these women? They will tell you. And then like even Instagram, right, Like Instagram will tell you how beneficial these hormones are on mood. I know that's not the gold standard trial, but it's like, it's there.
- [31:19]
Dr. Heather Hirsch
And you and I get to see this every single day. We get to see it every single day. And it's unfortunate that the research for. Because they, you know, you've got to find the money, you've got to get the stamp of approval that it's, quote, safe to study subjects, which I don't disagree with, but it lags decades behind clinical experience.
- [31:40]
Dr. Kelly Casperson
Yep, totally. It really. Again, downs play like you can't measure feeling like yourself. How do I know Heather doesn't feel like Heather? I can't measure that. There's no blood test. There isn't an X ray you like. You have to take Heather's word for it. But then not feeling like myself and the drastic improvements in feeling like myself, I. There's probably like several more important things in medicine, but not many more important things in medicine than helping a person feel like themselves. It's not objective data.
- [32:06]
Dr. Heather Hirsch
I think I always kind of want to call myself a quality of lifestyle or like, you know, an internist. I think this idea that we often don't consider quality of life, which is, does Heather feel like Heather? That's exactly what that is. It's quality. It's a measurement of quality of life. And this, for too often this has been brushed to the side because of the way medicine we've talked about is now done. It's sort of when we're in crisis mode, when patients are sick. And at that point, you know, quality of life is like a drop in the bucket. We got to keep you alive. But that's so unfair. And this idea of feeling like yourself is so crucial. And that's exactly to kind of circle back to what women in perimenopause often tell me. It's. I just feel like I'm slipping. Like it's the first time where they feel like I don't feel like myself anymore. And I don't know how study this. It's not objective. It is very subjective. But women are good at this. They can tell. And these objective measures, the way we do research on men is completely different than the way we should be doing research on women.
- [33:08]
Dr. Kelly Casperson
Yeah, totally. You know, I talking to a psychologist, a psychiatrist about this of the measurements, because these are standardized questionnaires Right. The standardized questionnaires we're using to show improvements in mood and cognition after hormone therapy are not even the best way. So it's like those studies are flawed sometimes and, like, you literally just have to talk to women and hear the story. I want to talk about one more preventative thing. The fact that your biggest rate of bone loss is in the two years leading up to your last period. How do you know when your last period is? You don't. Right. So pet therapy as bone protection in perimenopause is probably, by definition, the better way. Because why are we waiting for 6% of your bone loss to be gone before we start preventing it before. Why not start it while you still have bones to lose?
- [33:57]
Dr. Heather Hirsch
In my utopian world, by 40, and that's maybe even too late. But by 40, there's a. You know, how you get your mammogram at 40, or you get this, this, that. Like, that's when you have your first perimenopause, menopause, pet changing visit. Right? And women really start to map out what's important to them, what makes them feel good, what their health goals are like. Wouldn't this be a beautiful world? And y. We have these conversations, should you start menopausal hormone therapy? Should you start it when you know, this is a question I get all the time, is there symptoms? Just like we said, do they have to be that bad? Do you have to be in menopause? And we brush those all to the side and help each individual woman. Because I started myself at 42, the second I noticed, I realized my symptoms were perimenopausal. But even it took me a good six months to figure it out. And that's so unfair. And I can do that because I've got the resources, I've got the access. But what will it take if people always say, dream big, dream big, dream big. Like, how do I get to that utopian state? It really shouldn't be that hard where once a woman turns 40, you know, she starts to think about this next transition, right? Just like you would do. Not all women do consults for, say, fertility or for infertility. Not all women do that. All women usually will do some screening exams. It's like, why can't we, you know, train enough doctors, have, you know, better, some better research? But honestly, I don't even think that's the problem. It's just training the clinicians and then changing the healthcare system to accept that this is worthy of their money and their time. I mean, it's not that hard. But I love this point because it's going to be hard to say, hey, all doctors, we should start prescribing HRT, you know, because, well, Heather's 42. Her, you know, her mom was 49. Well, she could be early and like maybe then the two years and everyone's going to like have all this panic and twiddle their thumbs like this is, this is so crazy. You know, we should be able to help women map this out in a way that fits their goals, fits their individual health background and that we have more doctors who are competent and competent in doing this, you know, that we both care about this so much. And so like that point just made me mad because it's true. It seems like it'll be only the lucky ones, it seems right now. But we're going to change this.
- [36:09]
Dr. Kelly Casperson
Oh yeah. Health disparities are going to widen. It's going to be the haves and haves nots, the access and the not access. Whose insurance covers it and whose doesn't. Who gets the knowledge. It's an opt in at this point. But I'm like, listen, we tell people that periods are going to come. We tell them to buy pads because it might come. Like we prep people for puberty, we prep people for how to prevent a pregnancy. We've completely indoctrinated everybody that at age 50 you get a fiber optic tube up your anus. Like we've normalized colonoscopies after the AKA colonoscopy. I'm not downplaying it. I'm saying we've normalized preventative health care. It can be done because we're doing it.
- [36:46]
Dr. Heather Hirsch
It can be done. It's utopian. And it's funny because it's like it's not that hard. Train enough clinicians and make the payers understand how, how important this is. But it also is hard at the same time. There's a lot that we have to do to get there. But let's get there. Let's use that as our North Star.
- [37:01]
Dr. Kelly Casperson
I love it, dude. Thank you so much for coming on the podcast. We could talk for literally five podcasts, like one of five series books coming out. Tell us, tell us when the book comes out.
- [37:12]
Dr. Heather Hirsch
October 14th. I am so excited for the perimenopause survival guide. I really want women in their you-30s to read this book in their 40s. If you know you're a perimenopausal woman and your friend has no clue what you're talking about, grab her a copy or read it together or share it or whatever. You know, tell her the things. Because when women don't know, this is when they get misdiagnosed and they get mistreated, they get put on, you know, they get all the scans like we talked about. They see all the doctors, they get on antidepressants, and they are missing a massive horse. Right. The horse is perimenopause.
- [37:44]
Dr. Kelly Casperson
Yeah. If his hoof beats it, might be a horse, not a zebra. It's going to be a great resource for all of my perimenopause patients to normalize and validate the experience. So I'm very excited that the books are coming out about this because it's a huge. It's every woman. It's massive, and it's real.
- [38:05]
Dr. Heather Hirsch
Again, I've been doing this for many years, but when those symptoms actually started happening to me, I mean, wow, it is scary. It floors you. It's embarrassing, even if you're prepared for it. So there's just not enough talking about this and educating that we can do to help with women.
- [38:19]
Dr. Kelly Casperson
Totally. Thank you for joining me.
- [38:22]
Dr. Heather Hirsch
Oh, Kelly, thank you so much. You're such a great host. You really help to bring out the passion that one has, and I can't wait to have you on my show next.
- [38:31]
Dr. Kelly Casperson
Thank you for listening to this week's episode of youf Are Not Broken. If you want to dig deeper with me, sign up for my Adult Sex Education Masterclass where you learn adult things like communication skills, anatomy lessons and desire types, and how to talk to your doctor about sexual health concerns. If you want the Adult Sex Education Masterclass for free, join my monthly membership for more in depth, exclusive content, more time with yours truly. A private podcast, coaching and educational empowerment. And you can watch my interviews live and get them immediately without advertising. Head over to www.kellycaspersonmd.com for the membership and Adult Sex Ed Masterclass members. Get the masterclass for free. This podcast is presented solely for educational, entertainment and informational purposes only. I am a doctor, but not your doctor in this format and all of my platforms and guests, including on this podcast, are not giving individual medical advice or practicing medicine. See and consult with your own care team for your individual needs and concerns. This podcast is not intended as a substitute for the care and advice of a physician, therapist or other qualified professional. This podcast does not constitute the practice of medicine, in case you were curious about that. And no doctor patient relationship is formed. But I still love you. Using the information on this podcast or any of my platforms is at your own risk. Until next time. Remember, you are not broken.