Best of The Body Pod: Should We Be Taking Estrogen, Progesterone, AND Testosterone with Dr. Heather Hirsch

0:00Hey, it's Hailey. If you're a woman in midlife who has done everything right and those stubborn pounds won't move, stay with me for a minute. You cut your calories, you've added more cardio, you try harder than anyone around you, and the scale just sat there while your energy crashed and the weight crept back on. In midlife, your hormones, sleep, muscle, and your bones all change the math. I want you to be the woman who knows exactly what her body needs now and can make a fat loss phase work for her lifestyle. Fat Loss Happens Education is seven weeks of evidence-based guidance from registered nutritionists, menopause doctors, and exercise physiologists with me right there alongside you.

0:43You learn how protein, training, hormones, and recovery work together in midlife and how to hold on to your results long after the course ends. We start the live course in September. To get first access in August, go to hayleyhappensfitness.com forward slash fatlosshappenseducation or grab the link in the show notes. Now back to the show. We're back with the best of the body pod episode, and this is one of the most requested episodes in the body pod history. Our conversation with Dr. Heather Hirsch, menopause specialist, founder of the Hirsch MD collaborative and creator of the Reclaiming Menopause Masterclass.

1:26If you've ever walked out of a doctor's appointment more confused than when you walked in or have been told your labs were normal when you knew something was off or felt like the hormone conversation was way too complicated to even start, this episode cuts through it all. Dr. Hirsch breaks down her Thrive method for navigating estrogen, progesterone, and testosterone, one hormone and one symptom at a time, debunks the myth that you have to wait until you're fully postmenopausal to start HRT, gives testosterone the full conversation it deserves, and makes a compelling case for why vaginal estrogen belongs in virtually every woman's future.

2:13You're going to finish this one feeling genuinely equipped, knowing what to ask, what to expect, and what you actually deserve from your care. Let's get into it. This is the best of the Body Pod.

2:31Dr. Heather Hirsch, we are thrilled to have you on. I have been counting down for this podcast. And I literally have just been perusing everything that you've ever written and your menopause course, the thrive method. I mean, I have been just diving deep into all of it. And I have to say, I was just at a conference last weekend with Kelly Kasperson, who's my favorite and, um, you know, Vonda Wright and everyone there was just amazing. But Kelly was like, she got asked a bunch of times people are like well what about you know a menopause course and she was like heather heather heather so incredible okay i'm going and buying it right now and and getting in there so thank you for being on oh i am so so excited this is my favorite topic

3:26Dr. Heather Hirsch:um and let yeah let's get into all the things yes okay so all right let's talk first of all about your menopause masterclass and why you, I mean, because it's available to any female. This isn't just like for trainers and coaches. And I love that because I feel like there's so much information that clients ask me and I'm like, I don't know. I'm not quite, I mean, I'm definitely perimenopausal, but you know, it was just a wealth of information. So tell us about how you came up with this course and what reclaiming menopause is. Yes. Okay. I was just telling my last patient that I saw that I love teaching so much.

4:16Dr. Heather Hirsch:And for so many years, especially when I worked at Harvard, I really felt like they really wanted me to become a researcher. And I tried and I tried and I tried to fit in and to fit the mold, But I loved teaching. I was just such a natural at it. And I really, really loved it. And so I really started to lean into it. And so during the pandemic, I started YouTubing, podcasting, making TikToks. And that turned into just so many women from all across the country asking me all these questions that I just felt like every woman should know what their body is going through in the perimenopause to menopause transition.

4:58Dr. Heather Hirsch:So from there, I came up with the concept of just making a course. I even went and took a really fancy course on how to make a course, which actually was really, really helpful. And so the Reclaiming Menopause Masterclass really was a way to get help with your own clinician. This was back when I worked at the Brigham and Women's Hospital in Boston, because I wanted all women to have access to this knowledge. and I knew that their clinicians also needed this knowledge. So then I went on to make a course for clinicians as well. And, you know, I hope that I can in some way, shape or form help women who maybe even never see me as their clinician per se, but get them to where they need to go with all that I've learned along the way.

5:45Yes, I love it. So the Thrive Method, let's break that down because, again, all of these questions about when to take hormones, what hormones to take, I feel like everyone kind of gets into progesterone and estrogen, but then testosterone is kind of like, you know, the little sister that doesn't get invited to the party a lot of the times. When do we change those and when would we apply any and all of them?

6:18Dr. Heather Hirsch:Oh my goodness, yes. Well, so the Thrive Method really was my way of thinking through what I really do with my patients. So T stands for tracking. And that really helps us even know where to get started. We may know that there's these three sex hormones, estrogen, progesterone, testosterone, and they decline. So we're like, okay, we need to replace them. well, in what order, in what route, in what formulation, which one does what. And so you got to start with the basics, which is just tracking because what symptom might bother Laura may not bother her best friend. And so it could be that you're feeling hot and dry.

6:53Dr. Heather Hirsch:It could feel like a brain fog. It could feel as though you're gaining weight or your libido is dropping. And tracking them based on if you still are in perimenopause, your cycles, and if you're menopause, if there are certain, you know, times of day that things are worse or certain foods that trigger it. So it's tracking. The H stands for health history. So then what are you a good candidate for? You know, is there anything that's contraindicated for you? R stands for research. And this is where we dig into like specifically in my course, how safe hormone therapy is. And you got to remember, I made this course, I think in 2018 or 2019.

7:29Dr. Heather Hirsch:And that is like five years ago at this point, which seems like yesterday on one hand. And now there's a plethora of data really on the safety of hormone therapy. Oh, it's still really confusing. So we really want to go through the research so that we feel confident. Because my thing is, is that as a woman or as a patient myself, if I don't feel confident in my treatment, someone just says like, yeah, yeah, it's safe or yeah, yeah, that's what you need. I don't feel like that's enough. So I want to make sure everyone really knows their research. And then I will stay on the I. This is investigating.

8:04Dr. Heather Hirsch:And investigating is really where we say, okay, maybe your symptoms are more low progesterone. So let's trial progesterone. Let's investigate that. Maybe it's really low testosterone. You're very athletic. You've been athletic your entire life. You're used to a slightly higher testosterone. Maybe we investigate the testosterone. And then I kind of have this hormone stacking method because I like to do one thing at a time. I can tell you, I've seen so many women, they come to me on estrogen, progesterone, testosterone, they're still having cycles and they're like, I don't know what's doing what.

8:33Dr. Heather Hirsch:And I'm like, totally fair and totally fine. We're going to start from scratch so that you know what each one's doing. So that gets us up to the THRI where we really investigate. Cause I think while I went on a little bit of a long winded answer, the question of like, how do I even know where to start or what hormone to start with really taking it back to tracking? What are you a good candidate for? Feeling really confident about it and then investigating like probably one hormone at a time based on your most problematic symptom. So I have a question about how do people know if they are in perimenopause?

9:11What tests do you recommend? If someone comes to you, I don't know. Am I? Am I not? What do you do? Yeah.

9:19Dr. Heather Hirsch:Well, you know, I'm laughing because the answer is like you're going to hate the answer. And so will listeners. It's like if you're asking, you're probably in perimenopause. Or we have a joke like if you watch Saved by the Bell, you're probably in perimenopause. So there is no great test. And that's like the speaking point. Because for diabetes, we know it's an A1C or elevated glucose level. For blood pressure, we know it's like greater than 140 over 90. Whereas perimenopause, there's no one number or test that rules it in or rules it out. I hear so commonly, my doctor said my labs were normal and I'm too young, so everything must be fine.

10:08Dr. Heather Hirsch:If you've heard that and you don't think it in yourself, you're probably in perimenopause. So the real answer is it's really a clinical diagnosis, which means the clinician actually makes the call based on your good tracking. If you've been tracking irregular periods, if you're tracking symptoms of low estrogen, which is typically more hot and dry, hot flashes, night sweats, dry skin, low mood, and then low progesterone, which could be spotting in between periods, heavier periods, anxiety, insomnia. Those are the kind of things that a clinician is like, okay, this is perimenopause. There's just not enough of us.

10:50Dr. Heather Hirsch:And so, so many women, the frustration continues because they're like, I checked my lab. My doctor says it can't be that. And so, I know it's not the most satisfying answer. There are some labs that I do sometimes check, but we track them over time, and then we put them in context. So, there is no lab that's like, yes, you're in perimenopause. It's more of a, what is the context in which this is all happening over a persistent period of time? And being body aware, like you said, tracking and knowing that you are having brain fog, or you are having hair loss or different issues. Yeah, exactly. So tracking is like where I always take it back to.

11:36Dr. Heather Hirsch:Like if there's one actionable item, it's really starting with just tracking because that gives you so much knowledge. It also is a great starting point when you go to your own clinician to say, all right, the last six months you pull it out and you're like, I've noticed hot flashes before my period. My periods are only lasting two days. My hair is falling out in droves. Literally, here's pieces of mine. I'm having low libido and vaginal dryness. I've tried this, this, this, and this. And then the doctor's like, okay, I can't gaslight you. There's nothing else I can say. You've got all the information right at your fingertips.

12:14Yeah. Okay. So if we start on, if we're in perimenopause, which I think, well, Laura and myself both are because we're the same. And we watched Saved by the Bell. So you know who Tiffany Ambrithiason is. So if like, do you ever start women on hormones before they're completely menopausal?

12:44Dr. Heather Hirsch:Oh, every single day, every single day, every single day, every single day, every single day. And this is such a myth. I'd love to dig into this in terms of what you hear. But hormone therapy is something that can be used in perimenopause and is often extraordinarily effective. So when I was talking about that Thrive method, the I, where we kind of got stuck, I think there's a V and an E, which stands for victory. And then E is basically just how to use hormone therapy longer term. But if we stay at that I, a lot of women, what I do with them as their clinician is help them investigate if they're in perimenopause, the use of postmenopausal hormones in perimenopause to see how that really changes or alleviates their big symptoms.

13:39Dr. Heather Hirsch:So I do it every day. And this myth that you have to be one year of no periods before you can start hormone therapy is something that's very pervasive. I actually don't know where it came from. And this is probably based on my training because I never went to med school saying I was going to be a menopause doctor. I did a two fellowship training in midlife and menopause in 2014 at the Cleveland Clinic. And so I always just learned to prescribe HRT and perimenopause. So, you know, as more women were speaking out on social media, I learned that this myth is out there that they're, they hear we can't do hormone therapy until you're in menopause.

14:21Well, we got to get rid of that, that rumor, I guess. So when do we add in? Because again, testosterone, how many, what percentage would you say of women need testosterone or that you prescribe? Because it's not as, you know, everyone kind of does, if they're doing hormones, they get the estrogen progesterone, but why isn't testosterone? I know it's harder to get and that's its whole separate issue. But what percentage would you say?

14:55Dr. Heather Hirsch:So this is a fantastic question. And as Dr. Casperson coins in a class that she's now teaching, is that we kind of call testosterone a data-free zone where like, gosh, like how many women need it? I don't know the answer, but I'll start with in my practice. So I founded the Heather Hirsch MD Collaborative, which is a telemedicine practice in almost all 50 states. I have amazing clinicians that work with me. Yeah. They're just amazing. And because I couldn't see everyone and it's just been wonderful to expand. So there's so many amazing clinicians available in, again, almost every state. We're missing like three and we're trying to get there.

15:40Dr. Heather Hirsch:But about a third, maybe, I would say on any given day, about a third of my patients are on testosterone. So it's not everybody, but it's certainly not so few and far between that I'm counting them on my fingers. A lot of women will trial testosterone and see if they get benefits. Some women find that they're great when we just start estrogen and progesterone. They're like, hey, Heather, I feel perfect. I don't want to add anything else. I don't need anything else, a lot of women will find their testosterone is low and they may have the most common or the most well-studied indication, which is low desire.

16:21Dr. Heather Hirsch:But they may also find that it gives them some other benefits like energy or cognition. We don't know. We think that it might also help bone. So there's a lot we don't know in this data-free zone. So I think the majority of women, if anything, could trial testosterone to see if it helps. Not all women stay on it for the long term, but I would say at any given time, about a third of my patients are on it, which gives you a good sense of how many women really do feel the benefits of testosterone. It's a conversation totally ripe for just a lot more discussion because, of course, if we hear testosterone.

16:59Dr. Heather Hirsch:We think, isn't that a guy thing? Isn't that a male thing? No, absolutely not. Women make testosterone and it's really an important hormone. Do we have data on what exactly it does in the female body? Of course not. Why would we have that, right? But as we are using it in clinical practice, a lot of us who are clinicians, not the researchers, I tried that. Nope, I'm a teacher and a clinician first. We see our patients often get a lot of benefit. And, you know, again, as a clinician, we want to make sure your levels are still safe. We're not putting you any long-term risks. You're not going to lose your hair or grow a mustache, et cetera.

17:36Dr. Heather Hirsch:I should end this by saying there's a small percent of women where testosterone can actually go up. And this is because it can be a stress response. The body is like, where's the estrogen? Where's the estrogen? Where's the estrogen? And the adrenal glands will start making cortisol and sometimes testosterone. So if you ever, you know, are like, why am I getting a chin hairs or a mustache? Like, what is this? It could actually be a stress response and you could actually be making testosterone. And so there are some women where actually we want to lower your testosterone. And you, I read and listened to one of your podcasts on testosterone.

18:11And I feel like it's great advice that people don't advise. Usually doctors don't advise using the pellet because it's hard to dose it correctly. So do you usually just prescribe the cream and you ever do an injection for someone who doesn't want to do a cream like they give it themselves a shot once a week or something?

18:38Dr. Heather Hirsch:Yes, I actually do both. The majority of my patients do use what we do and actually what the Menopause Society recommends. And what the there is in 2019, a position statement from both the Menopause Society, the Endocrine Society on testosterone use in women. And the recommendation was transdermal as first line. That way, it's really easy to control those levels. Because if you're putting a cream on every day, my patient, her levels were just kind of creeping up. And she was like, I'm getting some pimples, Dr. Hirsch. I said, all right, go to every other day. That's easy to then drop those levels.

19:22Dr. Heather Hirsch:With pellets, which lasts for about three months, and they're very, very popular. And I understand why they're popular. One, you feel amazing, but like, if it's too good to be true, there's probably a reason. And for a lot of women, you cannot adjust it, which is like as a hormone doctor, that's like my worst fear is someone calling me and saying, Heather, I'm having all this breast tenderness or my hair is falling out or I'm getting pimpled and not being able to just saying like, well, give it a few months, like they're going to reach through the phone. And, you know, so that's really the problem is they're so hard to adjust.

19:58Dr. Heather Hirsch:And some women metabolize them slow. Some women metabolize them fast. So you could put a long, a very long lasting medication like a three month injection. You don't know what you are literally experimenting with your body. It's crazy. Now, this is different. There are actually weekly injections of testosterone that can be done. And again, these are all what men use. So men have more solutions available to them than we do. We just dilute them. So even with the, I do have a handful of patients on the injections. They just found that the cream didn't do anything either. They were poor absorbers through the skin and they didn't get any benefits.

20:37Dr. Heather Hirsch:So then we'll go to the injection. Usually we're doing one a week because again, the longer you go, the more variation and loss of control you have over the dose. So you don't want to go like, let's do a high dose and make it last a month. that would give me anxiety. So we usually do a low injection about the 10th or an eighth of a male dose every week. And that's another way that could be done. That's great. If we move on to like vaginal, topical estrogen, how does like, how many women, because I feel like it's a no brainer, just go ahead and use it. As Kelly Kasperson says, it's skincare for the face, for skincare care for down there.

21:22Yeah. So do you feel like you're always recommending that? Oh, yes. Relation with any of the systemic hormone doses.

21:33Dr. Heather Hirsch:Let's talk about this. It's it's a 40 percent of women who are on systemic or whole body estrogens, what systemic means also really need local vaginal estrogen because that tissue, whether it's external tissue like labia, clitoris, etc., those are like external tissue, it's just not going to absorb it and has the highest density in those receptors. So it just needs TLC. So 40%, which is pretty much close to half, half of the women that take systemic, which is recent reports say 2%, 3%, 5 % of women take systemic hormone therapy. So that's not even high to begin with, but 50 % of them also are on local vaginal estrogen.

22:18Dr. Heather Hirsch:And I hear so many myths about this. I hear patients say, well, my doctor wouldn't prescribe me vaginal estrogen because I'm already on systemic. And I'm like, what? Of course you can use it. And of course you probably need it. I also hear like a complete other myth that vaginal estrogen will help, you know, hot flashes and night sweats, of which it won't because it doesn't get absorbed systemically. So because it doesn't get absorbed systemically, that's why you can absolutely use both. They're not like adding to each other. And it's just, you know, so helpful. I absolutely wish it was over the counter.

22:50Dr. Heather Hirsch:It is so safe, despite the fact that the FDA still slaps a black box warning on it, that it doesn't apply to that medication. It came from the results of the Women's Health Initiative on oral Premarin and Prempro, which is nothing to do with using local vaginal esterase cream. So it's no wonder that we're podcasting about this for now and years to come because it's nonsensical. I'm like, vaginal estrogen is so safe. Most women need it, even when they're on systemic hormone therapy. It should be over the counter. You should get a tube of it when you go home after you've had a baby. You could use it after you've had or before your period when your estrogen drops or definitely in perimenopause.

23:33Dr. Heather Hirsch:And for every day until kingdom come once we're in menopause yet it's still so confusing nah it angers me just like getting all that out so everyone should be on vaginal estrogen i think so i guess the better question is like who shouldn't you know i mean it's great prevention um you know even if we're thinking it's not just the vagina it's the bladder and the urethra so it's the american urologic Association recommends it as first line for recurring area track infections. I don't know how many urologists are prescribing vaginal estrogen. They're probably prescribing antibiotics. It really is great preventative, even if you do it once a week to keep the tissue healthy.

24:16Dr. Heather Hirsch:So the only people that shouldn't, I do have a couple people where creams and anything in the vagina just causes recurrent itis, like yeast or BV or just something that irritates them more. If it irritates you more, then let's figure out something else. There's actually a couple of other options. Like there's an oral medication, actually, that's non-hormonal. But there's very few people who shouldn't use it. And even that's not harmful per se. It's more annoying. So, all right. We have estrogen receptors on the face. Yes? Yes. Okay. I know where you're going with this. is there a difference between what you would put on your face versus what you put in the vagina so amazing question i i you know i'm pretty known for telling my patients um that's no secret that they can use vaginal estrogen on their face of which many of them have and many of them do and it's funny because if they don't um as soon as i do a post or a podcast they all email me right away, hey, Heather, can you send me some vaginal?

25:24Dr. Heather Hirsch:Maybe they're on the suppository or maybe again, they felt like they didn't need it. So let's set the record straight. There's no FDA indication for any current estrogen product, be it compounded or esterase cream for your face. However, if we extrapolate its safety and if you're using a pea-sized amount, you know, maybe every day or every other day to your face of vaginal estrogen, the data from dermatologists does show that it is likely to be safe. And again, I want to be really careful about my words. I'm not saying it's 100 % proven. I am saying each to their own. Have I used? Yes. Okay. So, right.