Finding Support and Clinical Guidance

Hi guys and welcome back to my show, health by Heather Hirsch. I absolutely love doing this podcast. I feel like it's a place where I can just kind of like let loose and just say what's on my mind re pretty unscripted. So in this week's episode, we're going talk about what is a normal Hormone therapy journey like Because I hear from women all the time in my messages, in my emails, even my own patients. am I the only one experiencing X, Y or Z And if you don't know me, I'm a board certified internist and I wound up doing fellowship at Cleveland Clinic from twenty fourteen to twenty sixteen in basically menopause and perimenopause and HRT management And that's what I've been doing ever since then I worked at Ohio State and then I worked at Brgham and Women's Hospital in Boston. and then I started my own app practice, the collllaborative. And so over the last gosh, twelve to fifteen years, I've probably seen thousands of women and treated them through the perimenopausa menopause transition. So I feel like I really know a thing or two about what the journey looks like. And just like anything else, there's kind of different paths And I do want to make it clear up front, as I always do that there is no one right way to go through perimenopause or menopause. I really, really want to say this and make this very clear, even for everyone in the back Menopausal hormone theraapy or MHT kind of commonly referred to as hormone therapy or hormone replacement therapy or HRT does not have to be what you choose to do. But the reason I talk about it so much is because there's still so many myths Misconceptions and nuances That's what I'm really finding This is also why I love training clinicians. If you are a clinician, you're going to want to get in my main class how to prescribe and manage hormone therapy with ease and confidence because it's not rocket science, but it is very nuanced. And knowing what's normal for a woman to go through on this journey It can make you as a woman or you as a clinician feel more confident about how you're both handling the journey So let's talk about three main journeys, okay There is the superstar. There is also the tit tradating tweaker And then that sounds sort of funny, right? There's the tit tritor, right? orr the patient where we need a lot of adjustment And then there's a hypersensitive And I don't mean sensitive, We're all sensitive flowers, but I mean sensitive to hormones and medications So we're gonna to start with the second. We're gonna to start with the ty trader. okay? Now again, I'm making up these names on the flly, so just bear with me for a second here Because I would say that is the vast majority of women's experiences is the tit trader, the tweaker Now, what do I mean by this I mean that the journey kind of never ends So it may start like this. A patient comes to see me and she is experiencing symptoms for the last one to two years Very often, women also start to really think when they come and they talk about their symptoms And when we really start to dig into how long have they been going on for, they've often been going on for many years at this point. And that to me, again, just sort of nods to the fact that these hormonal shifts can start out very subtly. And then you can acclimate to them, not because you want to, but because of survival and because women are tough. We have so much on our plates so we start to acclimate. And so I do see this a lot. So when a patient comes to see me, typically we do your intake and we talk about What symptoms are bothering you the most? This is actually very helpful because a lot of women come in with many, many symptoms and lots and lots of notes and that is all gold. All of that information is so helpful But then I really like to sit down and say, what's the one thing that if we could fix maybe would help all the other things. And that often tends to be things like sleep. If we could sleep better, maybe my mood's better. my metabolism is better. My brain fog is better Okay Maybe it is vaginal dryness because it could be so bad that you feel like you have to I had a patient who would have to take a shower after she urinated every single time because she had so much burning and so much stinging. So all day all you can feel is a pain after urination or your partner looking at you and you know you don't want to be sexually active because it hurts so much and it's affecting your relationships. and then it's affecting your family. Maybe that's your biggest thing. If we could fix that, everything would be better. And that's where we typically tend to start So I've been saying over on my Instagram, I'm a Heather HMD. if you want to follow, I do lots of polls and fun things like that that even though you have a long list of symptoms, our goal is to start with maybe the one that's the most bothersome. and then, here's the key As someone who would consider herself a national expert, I'm going do my very best at your first plan. but this may not be perfect And this is what I've been saying is that even though I've seen thousands of patients and treated thousands of patients successfully, I may not get it right the first time. And this is what's really interesting. It's not so much in what happens at your first visit. Your first visit is extremely important. You want to develop trust. You want to feel heard, you want to be listened to, and you want to be validated. But you're gonna to go off to the world after that plan that we thoughtfully wrote out for you and then come back to me or your clinician and talk about your experience. And then what we're going to do, tweak and titrate. Okaykay? Teak and titrate. So what I'll do with my patients is say, okay, we're having trouble with sleep is a trouble falling a sleep or staying asleep Sometimes trouble falling asleep is low progesterone. I had a patient just like this. She came in to see me and so we started her on progesterone. In about four weeks she came back and she said, it was horrible, Dr. Hurch. And I was like, o oh my gosh, you know. It was in that moment where actually I said, Okay, I've been here many, many times. I know exactly what we're going to do now. You had maybe a paradoxical response to the progesterone. Now we know that. Let's take that fact and we're going to shelf it for a second. Now let's try estrogen Typically progesterone is good for falling asleep, but not always. So she tried estrogen. She came back, four weeks later, I opened my laptop just crossing my fingers and she had this huge smile on her face and she said I feel so much better whatever you have I need more of Okay G, I said. So great. Sometimes you have to figure out what each woman's going to respond to. Each of us are so different. It could be in our proteins. It could be in how we absorb the medications. It could be in our epigenetics, which can dictate how we may express something or feel something. There wayay more that we don't know than we do know. And basically where we are right now is we're kind of going blind, meaning, I start by thinking about your symptoms and then we go from there. I don't have necessarily a perfect printout of everything about you and exactly how you're gonna respond to every single molecule dose rout and formulation So I have to do my very best And so when she came back, we talked about how the estrogen was very helpful. But she said to me, well, what about testosterone? When do we add the progesterone? Now that I don't do well in progesterone, what are we going to do? And so here is the key. It is now about the journey. In this case, what I said to my patient was, let's wait for a couple weeks. Let's just stay on the estrogen and let's just sit here. And let's just feel good for a moment. because it's been two years of really feeling this tumultuous Inomnia not sleeping well And then we are going to address all these other things. So what I'm already hearing from her is I might have progesterone intolerance How am I going to handle that? Now I have a whole podcast called Progesterone one hundred one. If you scroll back, it has all the information you could ever want on progesterone intolerance That is a lot of tweaking and a lot of tight trading You can start lower on the progesterone. We can try a different route of progesterone and we could try vaginal absorption versus oral absorption. We could try a synthetic progestin. There so many things that we are going to do together, but it is going to be a journey. And every time she tries something, it's either going to do One of three things, nothing at all, which can actually be a good thing. It's going to make her feel better or it's not gonna to make her feel better. And now we know. this is the most common scenario. and it can take months to years When I say that, I do want you to remember in this scenario, I feel like there's this very common. we get a big win And getting a big win is really helpful. So we alleviated one of her big symptoms, which was this trouble sleeping. Now with progesterine again but with estrogen in this case, but it still leaves us with lots of questions. Is this the optimal dose What happens when her periods really space out? Well, we need to change the dose again? That's what she asked me. And I said Probably, but we'll see and we'll go by your symptoms And then As I mentioned, she also is interested in testosterone. She's curious and she wants to see if that's going to help with libido. Now that she's sleeping, she's feeling better, but she also may not need it because she's sleeping and she feels better This is one of the most common scenarios with my patients. this journey of an ever ongoing sort of tweaking and changing And why? Because things change It could be that the stage of perimenopause or menopause that you're in changes. All of a sudden you could go from early perimenopause to late perum menopause where your period's really, really spacing out now and your estrogen drops even lower and we have to make an adjustment Ely menopause, the first three years of menopause and you may need a little bit more estrogen or you might start to get breast tenderness after a while. We need to drop your estrogen dose Anone else was part of the journey Shortages So you may be on a medication that all of a sudden iss not stocked in your pharmacy This is a topic for another podcast. Don't worry, I'm collecting my thoughts here on how we're going to fix this problem. But let's say something isn't covered or your pharmacy doesn't have something in stock Then you need to go to your trusted clinician and make a swab. So what is the equivalent of whatever you are on in another form? So right now, I'm having to change a lot of my patients from their patches to gels or to sprays or even to rings or to oral evenven injections if we need to We have to figure out sometimes because things change. You could go through a very, very stressful time And this is not uncommon because you've got houses and spouses, parents, kids So you could have a death in your family, you could have a child move away. You could have the loss of a Oh my gosh. And all of a sudden, this stress can change your physiology and your hormones may change. You may get a new diagnosis All of these things are possible. You may go off to Europe and forget your medications for a month. All of these things can happen. Then maybe you start bleeding, Then you come back and we need to decide, is this normal? Is it not? And so this sort of tweaking tight trading journey. is so, so common. For those of you who are clinicians, you know, this is one of the reasons I actually in my own practice, ended up moving to a membership model because I just felt whatever reason, you know for me, it really gave me a better depth and breadth into my patients and their lives. becausecause again, the first visit is not where this magic happens and we perfectly nail it about It can happen but M rare, it is always probably going to be part of the journey. And I get messages all the time, o, can I have one visit? C I do one conssole? And while I wish, I wish that would be helpful, but I also not going to sugarcoat it for you. It's probably not Because even just one visit isn't going to give you exactly what you need because I need to know how you experienced something and not just for a couple of weeks, but for years And that is really sort of the truth of the matter that if you find a good clinician where you can really go on this journey together is the best option Now I find for my patients that once they get through the later part of menopause, if they've been on menopausal hormone therapy the whole time, it does get a lot more stable. Now, if you are starting your menopausal hormone journey If it's been five, seven, ten, twelve years since spent a pause, then again, you're going need that time to go through the journey as well. So it's not really just what stage you're in, it's a combination of lots of different factors nuances, right That is the vast majority. I would say that's at least eighty percent of my patients. And they always feel as though they say, you know, Heather, I feel like am I the only one that's struggling. Am I the only one where it's taking this long? Absolutely not. eighty percent of my patients It is like, we get better, we go three steps ahead, and then maybe we take one step back and then three steps ahead and one step back. And all along the way, you are definitely feeling better, should be feeling better. But it is always a journey This episode is sponsored by Cozy Earth. One thing I talk about all the time is that midlife is not a season where you need to just push through your discomfort You're asleep Your temperature regulation, your rest and your comfort all matter. That's why I love cozy Eth Their Bamboo sheets are temperature regulating and moisture wicking. madeade from bamboo and designed to help you sleep several degrees cooler If you're dealing with night's sweats, hot flashes, or you just want a better night's rest, these are such a beautiful upgrade. I also love their bamboo pajama set. It's soft, lightweight and cozy without making you feel overheated, which is exactly what so many women need in this season of life. This isn't about fixing menopause, It's about supporting your body with comfort that adapts. toools and restores. Czy Earth also offers a one hundred night sleep trial and a ten year warranty so you can try it for yourself and feel confident in your purchase. Head to cozyarth. com and use code cozy Dr. Heather for twenty percent off and be sure to tell them Dr. Heather Hirsch sent you in the survey because the women who hold it all together deserve to feel supported comfortable and cared for too. Okay, now let's get to the other two buckets. We do have some high flyers. Let's talk about my high flyers. Just think you're just genetically lucky, perfect human. I would say this happens about five percent of the time, maybe last,be maybe somewhere around maybe at the most, one out of ten women. where the very first time we start your menopausal hormone therapy, boom, we get it right and you are off to the races. These are the success stories that you hear all the time But it's very, very rare. and I am telling you it is simply luck It is simply luck. They haven't done Anything different Now, in my very first book, Unlock Y your Menopause type, I have this great chapter on myths and misconceptions There is this idea that if I'm fit and I work out every single day and I eat clean and I avoid this and I avoid that and I have a great bedtime, I am just gonna sail through this That is untrue. I wish it were true I do wish it were true. and it doesn't mean that you should not do those things because those are going to increase your health span. Those are going to be the habits that you form that will take you through your fifties, sixties, seventies, and beyond. Those are the things that are gonna allow you to play with your grandkids and get on the floor. Those are the things that are going allow you to play tennis into your eighties We're not going to not do those. But this is physiology and you cannot like out meditate if you're going to have severe symptoms of perimenopause. I know so many countless Fitness gurus, fitness influencers, whatever you want to call them. These are the girlies that you like, o, you just look up to. Oh my gosh, every day they're hitting the gym and they're living real lives and they're doing great things, but they are having terrible symoms. There's probably also fitness influencers and gurus and instructors who don't have symptoms. aboutbout ten percent of women do not have symptoms, okay? So the vast majority of women do So I wish those things helped. So for my like, you know, the ones that just fly, it doesn't have to do if they were picture perfect when they walked in. It is literally Just luck Sometimes we just find the right regimen and it is just It just works. They come back and they're like, I feel so much better Now This also tends to happen much more commonly for my menopausal women or women without periods, or who are not ovulating anymore. becausecause perimenopause is so much more complicated. When you talk about that tweaking and tit trading journey, that middle of the road, if you're in perimenopause, that's just going to be a given. That is just going to be you. because That is all part of perimenopause. Your hormones are still doing their own thing and we're giving you hormone therapy on top of that to alleviate it. but Your body will do what she wants. So these sort of lucky women tend to be menopized And you know, again, it really there's no specific. you might be like, well, which one do they use? Is it the patch? Is it the combined patch? Is Which one do they use where they just get this quick success? It really is a combination and I use every tool in my hormone therapy toolkit. I like to match the hormone therapy with the patient's lifestyle, with their goals, with, you know what their ideas are of health and what they ideas coming in on hormth therapy are. So it is Purely luck, I hate to tell you All right, now we're gonna to go to the last bucket. And the last bucket is my highly sensitive patients. okay? And I would say if I'm doing the math where now eighty percent of women are in the middle. five percent of women are like, got it right the first time, I'm great. And then about fifteen percent of my patients are very sensitive to hormone therapies. veryery, very sensitive. And these are the patients that come to me and say like everyone else around me is getting this right or everybody is getting success and I am not. Now On more research, I'm thinking about the fifteen percent of patients. And there again in lies a lot of things that we don't know One of my long term patients, dear patient of mine, we just had a great follow up visit. And she feels very strongly, as do I that she has real Not social media hype, but real Mass cell activation syndrome And mascle activation syndrome can cause a lot of different symptoms for people. It can be very subtle at first. It can involve you know, certainly symptoms that feel like allergies, but also just a lot of brain fog, a lot of food allergies. because There is a lot of histamine release in specific diet. And estrogen can hugely trigger this. And every time we tried vaginal estrogen or a little bit of estrogen gel, she felt worse So one of the things is that there might be in this fifteen percent of women who are ultr sensitive, not just that you're super ultr sensitive. But there may be an underlying diagnosis that we just don't know about yet We've also had patients with severe progesterone allergy. progesterone intolerant. whichich also probably has been something that's frustrated women and their clinicians for years, but progesterone allergy, or progesterone can cause rashes, hives, swelling, erythema, redness, puffiness, bloating, discomfort. And so these patients, not that they're just highly sensitive just because that's fun, Of course not, nobody that is not fun. But there is probably some underlying deep cellular, I'm talking like organic chemistry, cellular microbiology things going on that we do not have diagnosed yet And so for these women, we take things. Very low and very slow Because we are not trying to make you feel worse. We're trying to absolutely make you feel better Sometimes with my ultrasensitive patients, I even sometimes block certain hormones so they can specifically see what is estrogen causeed, what is progesterone cause And sometimes this is not three steps forward, one step back. This is sometimes Two steps back, one step forward And then two steps back, one step forward. Okay, now we're back to baseline. two step for backwards, one step forward. Now we're just slightly above, right? There can be a lot more trial and error that feels actually like it's sometimes even going in the wrong direction. And as a clinician and if you are a clinician, you can feel reallyally horrible because the patient's whole goal in seeing you and my whole goal in treating you is for you to feel better If we never trialed these things, we won't know where that ultr sensitivity lies. And we won't know what we need to block and what we need to amplify. And so low and slow is the name of the game. And so this is something that happens more often than you would think because it is so much less likely if you're the five percenter where we get it right on the first try and you just sit on that regimen for a decade, that is even lower of a probability than you being in my ultra sensitive patient group, which is about fifteen percent And these patients, of course, do really well with close follow up. So these patients do great if they either have memberships or if they can see their doctor who may take insurance more frequently, like every four to six weeks. And specifically if you're in early perimenopause, this makes this even more challenging That can seem like Kind of a Debie D downowner situation, but it's really actually meant to say look There are many of you and you are out there And many of you right now are doing your own research and journaling and tracking and helping us clinicians these things together. So for a long time, I really found that progesterone allergy was u very nuanced and something very, very new. And it was a little bit easier to find than say an estrogen sensitivity because Typically if we prescribe Birth control in any form birth control pill or the nextplanon, which is systemic progesterone or the depo injection. These are big doses of progesterone and you can really see very quickly for someone who's ultr sensitive to progesterone, what might happen? Whereas estrogen's a little bit more like insidious because we're typically not giving you pretty big doses of estrogen unless maybe it's a birth control pill You can also look to like your pregnancies if your pregnancies were very difficult, if you were feeling just throughout your pregnancy doesn't mean that you're going to be ulr sensitive when it comes to periimenopause menopause and HRT You may also see that there is some connection there And that can really help you. And so what I want to say is if you feel like you're in that group, I again, I promise you're not alone. Slow and low is the way to go All right. So so far in this episode, I really wanted to break down for you what I see in terms of the patient journey. Now this is not everything. There are so many things in between. There's patients who start and who stop. There's patients for whom they have chronic com morbidities. They come in and hormone therapy help so much. There's patients that you have traveled internationally and then seen me and then traveled back and seen other dogs. I mean, there's so many scenarios of the patients's journeys But if I have to take a step back and really kind of give you sort of three common scenarios to see where you fall, at least you feel like you are not alone because ninety five percent of you are going to need a lot more than one, two, or even three visits to get your menopausal hormone therapy right And even when you get it right, I still think if you have either the resources or the bandwidth to have a meeting with your clinician every six months, this is so helpful because like I said, no matter what, things will change. The environment will change, or the pharmacy will change on you, or your insurance will change on you Or your dog might eat everything. I've seen everything. And so you need to know that this is a journey. This is not a one stop shop. I wish it was, but when have women ever been a one stop shop Never. So this is no different Okay If you're looking for a clinician, where can you go? I always recommend the Heather Harst directory. Why? This is a directory full of clinicians who have taken my flagship course. And inside my flagship course, we don't teach protocols. We teach philosophy. and this philosophy is right in all of their training. And every month, if you're a clinician and you want to join the class, we do these monthly lives and we have so many cases in there that again, it is really commonplace for clinicians in my courses to understand that this is a journey. And we have to use evidence based information FDA approved hormone therapy for the vast majority of the time, and sometimes we have to think outside the box, right And so if you are looking for a knowledgeable clinician, head to the Heatherherurstdirectory. com. If you would like to be a part of my practice, that is called the collollaborative, go to join thecollaborative. com. You can do a discovery call, you can meet with our team and really learn more if it's the right fit for you We would love to see you I am so proud of the collaborative, as a patient myself, as you know the CEO and founder to create something that I really love with our wellness partners who talk about nutrition and fitness. And hey, you can even work out with me. We have so much fun in our own community and our own discussions. and now sometimes our live events, So So amazing. so you can check that out as well. I hope you guys love this episode. I hope it made you feel a little bit less alone and a little bit more insight into what the journey is really like, you know, from someone who've seen thousands of women go through the transition Allright, guys, I will see you next week for a brand new episode. Bye