Podcast Summary: You Are Not Broken, Ep. 338

Theme: Perimenopause – Rethinking Definitions, Care & Empowerment
Host: Dr. Kelly Casperson, MD
Guest: Dr. Heather Hirsch, Internal Medicine Physician
Air Date: October 5, 2025

Episode Overview

This episode features Dr. Heather Hirsch, a prominent perimenopause and menopause expert, in an in-depth discussion about perimenopause—how it differs from menopause, the problems with current medical definitions, challenges in diagnosis, symptom management, and the importance of proactively addressing this stage of life. Dr. Hirsch discusses her forthcoming book, “The Perimenopause Survival Guide,” and she and Dr. Casperson passionately call for a paradigm shift in how the medical community and society address perimenopause, emphasizing validation, symptom treatment, and prevention.

Key Discussion Points & Insights

1. Perimenopause vs. Menopause: Naming Matters

(04:53 – 11:08)

• The speakers highlight how the term “menopause” is both misleading and siloed, often relegating perimenopausal women and their symptoms to the sidelines.
  • Dr. Hirsch: “The word menopause does—it’s a very siloed word... it not meaning to, has siloed menopause as this separate thing... This huge transition that can span two decades into, like, one little corner.” [05:21]
• Perimenopause is an “irregularly irregular” hormonal time, much more than a simple loss of periods.
  • Dr. Hirsch likens perimenopause to atrial fibrillation—chaotic and unpredictable changes. [09:00]
• Both agree that using a period as the dividing line is arbitrary and exclusionary; symptoms and suffering occur both before and after periods stop.

2. Problems with Medical Definitions and Ageism

(06:17 – 11:08)

• The “you’re too young/old for menopause” cliché is called out as nonsensical:
  • Dr. Casperson: “This is not a driver’s license. This is not a legal document. But women get it all the time—you’re too young for, or you’re too old for.” [06:59]
• They highlight how medical terminology around menopause and perimenopause can alienate women and obscure real, significant symptoms.

3. Diagnosis: The Limits of Lab Work

(13:03 – 15:53)

• Both doctors agree: labs like FSH are only a small piece of the diagnostic puzzle, and patient symptoms/patterns matter more.
  • Dr. Hirsch: “Periods will always trump lab work... FSH is going to be screaming at those ovaries... but periods are only four months ago—she is clearly in perimenopausal range.” [13:19]
• Many women don’t have periods to track (due to IUD, hysterectomy, ablation) making diagnosis even more nuanced.

4. Why Definitions Matter: Pregnancy and Treatment Access

(15:53 – 16:51)

• The main practical use of differentiating perimenopause vs. menopause is pregnancy risk.
  • Dr. Casperson: “Can you pull the goalie from the hockey rink?...But what I see is women want to know: Can I take hormones, can I try to feel better?...Treat the symptoms, help the woman out, be mindful of pregnancy...It’s irrelevant!” [15:53]
• The artificial menopause/perimenopause line wrongly restricts access to hormone therapies.

5. Hormone Therapy in Perimenopause: Safety & Terminology

(16:51 – 19:51)

• Dr. Hirsch prescribes hormone therapy for women still having cycles, emphasizes evidence supports safety and efficacy, and challenges the idea that only postmenopausal women “qualify” for therapy.
  • Dr. Hirsch: “My entire career, for the last 12 years, I’ve been prescribing hormone therapy to women still having cycles...These women really are suffering.” [16:51]
• Both challenge the nomenclature—calling it “sex hormones” is misleading. Prefer “precision endocrine therapy” or just “estrogen, progesterone, testosterone,” to avoid exclusion and medical confusion.
  • Dr. Casperson: “Sex hormones diminishes their brain function, their bone function...I hate that they’re called sex hormones because it’s mislabeling.” [18:04]

6. Most Common Perimenopause Complaints in the Clinic

(19:51 – 22:22)

• Patients are often unsure if their symptoms are “perimenopause or something else” (anxiety, fibromyalgia, GI issues).
  • Dr. Hirsch: “The most common thing women in perimenopause ask me: Is it perimenopause or is it something else?” [20:32]
• Most frequent symptoms: fatigue, low libido, insomnia, anxiety, feeling “not like myself.”
  • Dr. Hirsch: “That’s really what is really interesting...when we’re using hormone therapy, I always teach go slow and start with one at a time in perimenopause, because that’s going to be the only way they can rule in or rule out what might be hormonal.” [22:22]

7. The “Horses, Not Zebras” Analogy

(24:17 – 26:26)

• Dr. Casperson uses the medical adage “when you hear hoofbeats, think horses, not zebras” to underscore that perimenopause is common and should be considered before rare diagnoses.
  • Dr. Casperson: “To help answer the question: treat the horse first. Every single person will have diminishing ovarian failure at some point...That’s the horse: think about it.” [24:17]

8. Prevention & Changing the Medical Paradigm

(26:26 – 29:04)

• Waiting for patients to be in “crisis mode” before treatment is criticized.
  • Dr. Hirsch: “This idea that you have to be sick...before we treat you is an absolute Western medicine disaster.” [26:40]
• Insurance and healthcare systems perpetuate the problem by not rewarding prevention and by denying coverage for proactive therapies.
  • Dr. Casperson: “Insurance doesn’t cover stuff to keep you healthy...the average person is on their insurance plan only four years.” [27:47]

9. Prevention: Bone Loss, Mental Health, and Earlier Intervention

(28:25 – 36:46)

• They discuss a 2018 RCT showing estradiol patch therapy halves the risk of depression in perimenopausal women:
  • Dr. Casperson: “We have a placebo-controlled randomized trial saying it cuts the risk of depression in a year by almost a half.” [28:25]
  • Dr. Hirsch: “This is a fantastic study. It demonstrates how much estrogen, progesterone, testosterone impacts the brain and impacts mental health.” [29:04]
• Bone loss is fastest in the two years before the final period—so prevention is key; don’t wait for osteoporosis to start.
  • Dr. Hirsch: “In my utopian world...by forty...you have your first perimenopause/menopause consult.” [33:57]

Notable Quotes & Memorable Moments

• On the Issue with “Menopause” Terminology:
  “When you talk about endocrine dysfunctions...what comes to mind is a whole host of organ systems that change, but with menopause...we’ve siloed this huge transition that can span two decades into one little corner.” – Dr. Heather Hirsch [05:21]

• Advocating for Precision and Inclusion:
  “Calling it menopause hormone therapy or hormone replacement therapy excludes the perimenopause people.” – Dr. Kelly Casperson [18:04]

• On Clinical Experience vs. Research Lag:
  “I see so many women for mood changes...it is not like a challenge for menopausal hormone therapy to improve their mood...why this isn’t known about more...they need to know about this as well because they’re seeing a lot of anxiety and depression.” – Dr. Heather Hirsch [29:04]

• Quality of Life as a Medical Priority:
  “You can’t measure feeling like yourself. How do I know Heather doesn’t feel like Heather? There’s no blood test, but not feeling like myself and the drastic improvement—there are not many more important things in medicine.” – Dr. Kelly Casperson [31:39]

• On Making Perimenopause Standard Care:
  “Why can’t we, you know, train enough doctors...once a woman turns forty she starts to think about this next transition...that we help each individual woman?” – Dr. Heather Hirsch [33:57]

Key Timestamps

• 00:43 – 02:45: Dr. Hirsch re-introduction, specialty backgrounds, discussion of cardiac disease and hormone therapy confusion.
• 04:53 – 11:08: Deconstruction of menopause/perimenopause definitions; why terminology matters.
• 13:03 – 15:53: Evaluating the usefulness and pitfalls of lab tests for diagnosis.
• 15:53 – 16:51: Pragmatic division: the only medical utility of defining menopause vs. perimenopause.
• 16:51 – 19:51: Hormone therapy for perimenopausal women—safety, terminology, and clinical practice.
• 19:51 – 22:22: Most common perimenopausal symptoms and patients’ confusion around diagnosis.
• 24:17 – 26:26: The “horses not zebras” approach & why common causes deserve attention first.
• 26:26 – 29:04: Prevention, pitfalls of current healthcare paradigms, and insurance limitations.
• 28:25 – 30:48: RCT evidence for estrogen patch’s mental health benefit in perimenopause.
• 33:57 – 36:46: Early intervention, prevention, and the concept of a “utopian” perimenopause care model.
• 37:00 – 38:19: Book release info; importance of education and preparation; normalizing experiences.

Takeaways & Calls to Action

• Language shapes care: We need more inclusive, accurate, and empowering language around this life stage.
• Diagnosis is contextual: Symptoms and experiences matter more than lab numbers—listen to patients.
• Prevention is key: Proactive education, intervention, and therapy can have profound impacts on physical and mental health.
• Access and equity: Normalize and expand access to perimenopause care, making it as routine as other midlife screenings.
• Education is empowerment: Read and share resources like Dr. Hirsch’s upcoming book to demystify and destigmatize perimenopause.

Upcoming Resource

• The Perimenopause Survival Guide by Dr. Heather Hirsch releases October 14, 2025. Suitable for women in their 30s–40s (and anyone who loves/supports them), it aims to validate, inform, and empower through this pivotal life stage.

Host sign-off:
“Remember, you are not broken.”