Hormone Replacement Therapy, What Every Woman Needs to Know in 2026 | Dr. Heather Hirsch

13:51Dr. Gabrielle Lyon:The workout was the hard part, but the recovery doesn't have to be. Head to bodyhealth.com and use the code LION20 to get 20 % off your first order. That's bodyhealth.com and use the code LION20. It just, it seems like a huge blind spot.

14:11Dr. Heather Hirsch:Yep.

14:12Dr. Gabrielle Lyon:That there are a whole cohort of women that are not protected because they didn't have the ability to start hormone replacement. And when I say didn't have the ability, I remember. Yeah. So I finished fellowship 2015. Yeah. People weren't really talking about hormone replacement therapy. I had to learn it from those, quote, I don't even want to say underground physicians, but essentially the physicians that were still treating. You bring up a really good point. The physicians prior said it was amazing. The Women's Health Initiative comes out. People stop - Perscribing. Perscribing.

14:52Dr. Heather Hirsch:And stop teaching.

14:53Dr. Gabrielle Lyon:But the question becomes, how did that happen?

14:57Dr. Heather Hirsch:Yeah.

14:58Dr. Gabrielle Lyon:And do you think that the data was examined? It seems like just a huge miss.

15:04Dr. Heather Hirsch:Yeah. So from what I hear, one of my good friends and colleagues, actually Jim Simon, I'll credit him for this. He said, if they had done the Women's Health Initiative with progesterone and maybe a transdermal estrogen patch, and maybe women who are closer to the menopausal age, it could be a completely different world. Now, that's easy to say in retrospect, right? Or being a backseat driver. How could they have used this medication? Although that medication's not bad.

15:30Dr. Gabrielle Lyon:And are those medications used now?

15:32Dr. Heather Hirsch:You know, for example, those medications that we talk about, conjugated equine estrogen, I still use that medication because actually it has the most safety data. It is a part of one of the biggest randomized controlled trial, like we said, the WHI. Although most women these days really want bioidentical or a plant-based estrogen. So I don't have the opportunity to prescribe it too much. Prem Pro, I don't prescribe all that much actually. And so, you know, one of the things was we used a combination of oral synthetic hormones that we don't use now. And again, we used women who are slightly older, but when that study came out, it was a frenzy.

16:12Dr. Heather Hirsch:I mean, women were throwing their hormone therapy in the garbage, down the toilets. Physicians were calling their patients. We have to get off this. Right after it came out, it was like an explosion. And so my colleagues tell me it was one of the craziest days in medicine at that time.

16:29Dr. Gabrielle Lyon:Why was there not a challenge? Because you had mentioned relative risk and absolute risk.

16:34Dr. Heather Hirsch:Yeah.

16:35Dr. Gabrielle Lyon:I'm sure that people were examining if it was open to the public. I don't know if the data sets were open at the time, but one would think, okay, these are much older. Again, there's a difference between relative risk and absolute risk. I'm assuming that the data from that time hasn't changed. So where did the pendulum swing the other way? Because now people like yourself are really pushing for just education awareness. What happened? How come it went from this is terrible to now, okay, we're willing to reevaluate this?

17:12Dr. Heather Hirsch:I don't know. I think you're right. There were definitely clinicians at the time who actually, it's funny, read the study, right? Because I think the headlines were so drastic and everywhere. Everyone was covering it. Time Magazine and all the papers, which was like the social media at the time, right? They didn't have TikTok then, but imagine it was just your whole TikTok feed was this. and that really got into the psyche of clinicians and women. So then two things happened. Clinicians became scared and maybe they didn't read the studies, which is fair. If they're trying to do all these other things and physicians are really busy, they took the headlines for what they were.

17:50Dr. Heather Hirsch:And we can't really blame them, even though it's easy to sort of say, in hindsight, why didn't you read the study? Then you did have these group of clinicians. My mentor, her name is Dr. Thacker. She was my fellowship director at Cleveland Clinic. And so from 2014 to 2016, this was all I studied. And she was the one who really forced me to look line by line through the Women's Health Initiative. And what helped, I'll tell you this, is they did post-hoc analyses a couple years later. And what really solidified it for me was when they took the women who were within 10 years from menopause and really studied them.

18:23Dr. Heather Hirsch:That first came out, I think, around 2007. And so the Women's Health Initiative, the estrogen progesterone arm closed in 2002. the estrogen only group actually went like about two years later and then it just closed down for no reason but it wasn't a few years later until they had that post-hoc analysis and they really looked at the women who were age 50 to 60 or within 10 years of menopause and it's jarring how well they did how well they did reductions in heart disease reductions in all-cause mortality reductions in all cancer diagnoses better bones and of course better menopausal symptoms which you know, is really didn't even make the news here at this point.

19:03Dr. Heather Hirsch:Quality of life for women is a whole other topic we could talk about because we're not even considering that at this point. And that's what really solidified it. And then I think with social media building around 2016 and onwards and clinicians kind of finding each other digitally, as opposed to in, you know, universities or academic centers or private practices that really helped encourage other people to say, oh, you're right. Or, oh yeah, that's what this number means. Wow. Wait a second. When we read the studies, we were kind of duped.

19:35Dr. Gabrielle Lyon:What are the risks of hormone replacement therapy? And I want to break it down to estrogens, progesterone, progesterone, or progestins. Yeah.

19:48Dr. Heather Hirsch:We can talk about the difference too.

19:49Dr. Gabrielle Lyon:And testosterone.

19:50Dr. Heather Hirsch:Oh, I love this question because honestly, I'm going to answer you and it's not going to be all that significant. If we look at actually let's do estrogen last, because if we look at progesterone, progesterone does not have any major inherent risk of blood clots, cardiovascular disease and alone. although there's not terribly many studies on women taking just progesterone alone. And this time I'm talking about micronized natural progesterone or prometrium, the bioidentical, which is this lying term, but progesterone.

20:23Dr. Gabrielle Lyon:And bioidentical, just to pause, is just the same compound as what would be produced in the human body.

20:28Dr. Heather Hirsch:Exactly. Although it's still made in a lab, just like everything else. But it's a little bit more, it's more identical to what you would actually make versus a progestin, which is synthetic, often found in birth control pills. so we don't see any increased risk of breast cancer with that either just like i mentioned there was a study when they swapped the progestin for progesterone with estrogen and they said no increased risk of breast cancer progesterone is really safe and this is important because you may ask me during this show you know what if a woman can't take estrogen she could still potentially take progesterone which may help with sleep which may help with anxiety and other things same testosterone now my good friend and colleague dr kelly casperson will often say there's a Big data-free zone when it comes to testosterone in women.

21:12Dr. Heather Hirsch:And as you probably know and have studied, there is a hole in the use of androgens for women pre but post-menopausally as well. And we don't see, as for now, although we need more studies, we need more longer-term and more randomized control trials, but we don't see increased risks of clots, strokes, cancers, or breast cancers. Great. So that means that these two are options for women who maybe have risks from just estrogen. Okay, now let's go to estrogen. When we use estrogen, it depends if we're talking about transdermally or oral. So the risk of a blood clot on oral estrogen is very small, specifically postmenopausal oral estrogen, much smaller than the risk on birth control pills.

21:59Dr. Heather Hirsch:But again, like you already said, how ubiquitous is it to give young women

22:04Dr. Gabrielle Lyon:of reproductive age

22:05Dr. Heather Hirsch:who don't want an unintended pregnancy, birth control pills just rolls right off, right? So it's the women post-menopause who get, you know, kind of get vilified when they talk about estrogen or this risk for clots, even though many of these women have been on birth control, been pregnant, had surgeries, and do well. So there's a slight increased risk of a clot if you're on oral estrogen, but again, much smaller than if you were on birth control pills, much smaller than if you were pregnant or ever had surgery. if you use transdermal, which is a patch, spray, or gel, and there's a ring also, this set of trials called the ESTR trials or ESTR studies showed that the transdermal estrogen does not increase the risk of blood clot.

22:49Dr. Heather Hirsch:And so we're going to remove blood clots as a risk when you're using transdermal estrogen. So this is really wonderful. And then the breast cancer thing comes back up, right? And that really has to do with what are you pairing it with? Are you using progesterone or progestin. And also, even when it comes to is breast cancer a risk, it's really hard for me to say that estrogen directly causes a breast cancer. I think a lot of breast cancer is genetic. It's environmental. So if you have a really, really small tumor, because they take such a long time to actually develop so that you can actually see it, if it has an estrogen receptor on it, it may grow faster.

23:30Dr. Heather Hirsch:It may there cause it to show up earlier, but you may get treated faster, which is why the women in the placebo group back in the original WHI may have had higher death rates from breast cancer compared to the women with the hormone therapy in the WHI. So that's a mouthful. Yeah.

23:49Dr. Gabrielle Lyon:Well, I want to pause there. this is very important for the listener or for the viewer. The biggest concern I hear patients say is they're concerned about breast cancer with estrogen therapy. What I just heard you say is that let's say someone has undiagnosed breast cancer and potentially it's estrogen positive. The estrogen that one would take doesn't cause the cancer. It's not causal. Could it accelerate the growth of a tumor? Yes, but could it cause cancer? There's a big difference between something that's causative.

24:34Dr. Heather Hirsch:Right.

24:35Dr. Gabrielle Lyon:Something, you know, say an initiation factor. This is how we think about it in nutritional sciences, initiation factor versus something that would then perpetuate what is already in motion.

24:48Dr. Heather Hirsch:Right, exactly, exactly. So we've never actually proven that estrogen itself causes breast cancer. And so I think that's really important.

24:58Dr. Gabrielle Lyon:Where do we know?

25:00Dr. Heather Hirsch:I think this idea that estrogen is dangerous and harmful truly came from the press report that happened in the summer of 2002. too. And that media frenzy that there was a 26 % increase in breast cancer, it just switched people's minds to really, after that, find it really hard to disassociate estrogen from breast cancer. Even though, again, logically, when you look at it and we speak with just the logic and we take the emotional part out of it, it's really easy to see. And so this is a lot of what goes into counseling for women who want to start and take hormone therapy. But we have to then sometimes think this way too.

25:43Dr. Heather Hirsch:The risk of taking hormone therapy, again, we've called it, I like to call it an associated risk with breast cancer, but again - What do other people, what would other providers say? What other people sometimes say? There's still a lot of data. There's still clinicians that will say, you can only take hormone therapy for five years because at the five-year mark, I think that's when it could increase your risk of breast cancer. This though doesn't make any sense to me because breast cancer isn't like on a clock, for example. That may come from the WHI where they found that that increased risk started after five years.

26:21Dr. Heather Hirsch:But again, it just takes time for a tumor to develop and show up on a mammogram. So you'll hear sometimes clinicians still say, if you have a family history, I won't prescribe be hormone therapy. Is that reasonable?

26:33Dr. Gabrielle Lyon:You're at higher risk. Is there a kind of a hierarchy or decision-making tree that you go through that you feel confident and comfortable is safe and also not, on the contrary, overblown or overprotective? How do you think about that?

26:48Dr. Heather Hirsch:Well, look, I think this is a great time to say, what are the risks of you not taking hormone therapy?

26:54Dr. Gabrielle Lyon:And what are those?

26:55Dr. Heather Hirsch:Right. Accelerated aging. Although nobody wants to hear that, right? That sounds as though I have a bias and I don't feel as though women only have one option, but I really want them to know what happens to their body when they lose estrogen.

27:08Dr. Gabrielle Lyon:But wait, but there really isn't a replacement for estrogen. I don't care how much you work out. I don't care how well that you eat. If you are devoid of certain hormones, again, people can do whatever they want. But again, if we're being really transparent there, if we're talking about estrogen's impact or even testosterone, they have certain receptors that are only going to be affected by those hormones. And I do, I totally appreciate that it is absolutely a personal choice, but if you don't have it, it's, I mean, again, there is no replacement for what the body would be making.

27:48Dr. Heather Hirsch:Right. Exactly. And so, you know, you have accelerated bone loss at the time of menopause. And that is, I, you know, and I haven't seen any data.

27:56Dr. Gabrielle Lyon:I am so curious is the estrogen input versus if we know that there's a way to help with through training and nutrition. I mean, my guess is that it wouldn't be nearly as significant. I mean, it's critical. That would be a great trial. But it would be really interesting.

28:13Dr. Heather Hirsch:Yes. That would be a great trial. And you could probably do that where women just self-select which group they're in.

28:19Dr. Gabrielle Lyon:So accelerated bone aging. And how fast is that? So does a woman have to be completely through menopause once to actually have accelerated bone loss?

28:30Dr. Heather Hirsch:So your peak bone mass is somewhere around like 20, 30, right? And then it will start to decline. But right around the time that we lose our estrogen in menopause, it's going to do like another big dive. And that's because estrogen helps keep those bones from breaking down. So So when you lose that protective benefit, they start to break down more rapidly than they're building up. And so what estrogen therefore is doing is really keeping you healthy in a way. Because if you have a fracture of your spine or your hip, that could be so detrimental for the rest of your life because you would spend a long time in bed.

29:04Dr. Heather Hirsch:You're going to atrophy. Your muscles are going to waste. And then you have to relearn so many things if you fracture, right? So it's so, so, so important.

29:11Dr. Gabrielle Lyon:Would you give it, when you think about it, if we talk about what are the benefits, and we know that estrogen is bone protective, does it matter the form? Does it matter if it is transdermal? Does it matter the kind? Does it need to be estradiol?

29:26Dr. Heather Hirsch:Yeah. So we don't really have enough data. So many data-free zones here, right? We don't have enough data to kind of put all the different kinds of estrogen in a row, and then see is one better for bone than others. or a lot of women will ask all the time, what is the serum level I need to ensure bone health? We have some data. What do you think it is?

29:45Dr. Gabrielle Lyon:Because I've asked Mo this as well by Kara, a colleague of mine. Do you have a framework for thinking about that?

29:54Dr. Heather Hirsch:You know, some data came out in the 90s that an estradiol level probably around even 40. So like not that high is really good for bones. And we have a ultra low dose patch called the Menastar patch. It's 0.14 weekly patch, which is even lower than our pretty standard patches or gels that usually start around 0.25 milligrams. But even that was shown to help with bones. So I have a hunch that you don't need much to help with bones. And I think you got to though add that with all the good things that you should be doing. Lifting weight and strength training and eating well and getting all your vitamin D and calcium.

30:35Dr. Heather Hirsch:So I'm not really sure. The biggest data set that we do have comes from, again, the WHI. And so this study is so crucial. And it's so funny, because I think I probably talk about this more than any other study, because it is where a lot of our safety data does come from. The decisions to start women on hormone therapy at what age they are, a lot of those will go back to the Women's Health Initiative. That's what I spend a lot of time teaching. But you see the massive benefit with conjugated equine estrogen because that was the oral premarone that they used in the study. Although again, clinically, because I've been treating patients for the last 10, 12 years, I see their bone densities improve on even small doses of the patch.

31:15Dr. Gabrielle Lyon:How long? Okay. One reason why someone would choose to go on estrogen would be for protection of bone loss. What else? Well, the symptoms. Oh, yes.

31:28Dr. Heather Hirsch:Yes. So I love how you have this preventative visual field, right? And I love that. And one of the reasons I enjoy the conversation about menopausal hormone therapy is so that women start to think about the preventative benefits of estrogen. And in the menopause world, in the hormone therapy world, that's even a little controversial, which - It is? No, no, really? Yes.

31:54Dr. Gabrielle Lyon:Okay.

31:54Dr. Heather Hirsch:And this is because hormone therapy is not FDA approved for prevention of anything, even though we do clearly see it in studies and particularly for women who start closer to menopause. Every year when the preventative task force services comes out with grades for medications for their preventative benefits, Hormone therapy always gets like an F. And everyone texts me like, can you believe it? Can you believe it? And I'm like, yeah, I can still believe it. But, you know, so the preventative benefits are something that a lot of women now are thinking about more than they were before. But I would say the majority of women come in with symptoms.

32:32Dr. Heather Hirsch:And they're like, oh, Dr. Hirsch, I'm not sleeping. I have terrible brain fog. I'm losing my hair. I'm losing my eyelashes. They'll say I have vaginal dryness, urinary tract infections. and those symptoms are what usually get them to start Googling or Instagramming or TikToking. And then, you know, there's a lot more information than there used to be. And so then they're asking more questions like what else can it help with? So symptoms. I like the osteoporosis aspect.

33:00Dr. Gabrielle Lyon:Yeah. Symptoms makes a lot of sense. And I definitely want to touch on the vasomotor symptoms.

33:06Dr. Heather Hirsch:Yes.

33:06Dr. Gabrielle Lyon:Because once hormone therapy got a bad rap, it seems as if people started to use a lot of SSRIs. Oh, SSRIs rose like 60%.

33:17Dr. Heather Hirsch:At the same time as they were pulling women off their hormone therapy, they had to do something because these women were experiencing terrible symptoms. You also had the rise of like compounded hormone therapy at the same time too, because some women were like, oh no, I got to solve this problem, right? Yes. So we have mistreatment for some of these symptoms.

33:36Dr. Gabrielle Lyon:When a woman is going through and thinking about hormone therapy, what about cardiovascular disease. Because again, and we've had Martha Gulati on the show. She's amazing. Female focused cardiologist, truly extraordinary. And we spoke a lot about estrogen, cardiovascular health. What is your perspective in terms of, again, I recognize that we don't use hormones for treatment.

34:02Dr. Heather Hirsch:Right. Well, that's what the WHI was supposed to do. They were like, well, great. Women are living longer and having less heart disease. Let's do this randomized control trial and see that estrogen prevents cardiovascular disease. Now, of course, then the study ended early and there were all these fears and you had women who were all these ages. But look, when we look at women within 10 years of menopause, we see clear reductions in cardiovascular disease, reductions in heart attacks. This is huge, huge. So what estrogen does is it's a vasodilator, releases nitric oxide. And so that opens the blood vessels.

34:36Dr. Heather Hirsch:So you get better blood flow. So think about that, right? You're getting better blood flow through your heart. You're, you know, those coronary arteries are working at their maximum. They're feeding the muscle around the heart and that is preventing cardiovascular disease. And so this to me is a huge reason to consider menopausal hormone therapy. And so that fits right alongside with the preventative benefits like bones, heart disease, and it also has been shown to increase health span. and there's no other medication. And how do we define that? Healthspan, different than lifespan, right?

35:12Dr. Gabrielle Lyon:And different than sex span, as Moe, I would say, and different, of course, than muscle span, as Matt Santiago, my producer would say. Oh, I need to learn about muscle span.

35:20Dr. Heather Hirsch:Okay, yes. I mean, healthspan, the way I define healthspan, is just how long you live a healthy life, right? So lifespan is just how long you live, but you can live with chronic disease and pain and poor quality of life. And that's not really what we want, right? We want to live healthy lives where we're doing what we love, playing the sports that we like, or we're using our brains in the way that make us feel like ourselves. We're working. We are engaging in communities. We're doing all the things that we want.

35:47Dr. Gabrielle Lyon:What about this idea that you're either in menopause or you're not? Because if we talk about the benefits of estrogen and we think about it, again, from bone, from heart, from cognitive function, which I would love to hear your perspective. Yeah. Typically from what I've seen is individuals will wait until they're in menopause to begin treatment.

36:14Dr. Heather Hirsch:I'm actually seeing, well, I love this question. Let's talk about this because you can biohack your way out of perimenopause and menopause. If you want to, you can start hormone therapy earlier. In fact, I talked a lot about that in my new book. And I started doing that myself. Right. So now luckily I kind of have a lot of information at my fingertips and I have some good resources and some good doctors. But you're right. Kind of this idea that let's wait until the symptoms are really severe, or I will still hear women say, you know, I can stick it out a little bit longer, or I know I only have a short window where I can use it.

36:51Dr. Heather Hirsch:So I want to put all those ears together. These are all myths that we kind of need to, you know, let go of. The idea is you can start low doses of estrogen or progesterone and or testosterone when you're still menstruating and you're having cycles. In fact, you can use them if you even have severe postpartum issues. We could talk about what that means if you're breastfeeding, but some of these options can be used postpartum. More popular though would be perimenopause and then leading into menopause. Because what we don't want is women who are saying, gosh, now I'm 65. Now I'm 75. I didn't get the chance to be counseled on hormone therapy.

37:32Dr. Heather Hirsch:Am I too old? Am I out of the window? We want to start women and have them think about this and trial it sooner rather than later.

37:38Dr. Gabrielle Lyon:Cooking is a major pain and convenience slays. And yes, I just said slays. Our place, one of the sponsors of the show makes the Wonder Oven. And by the way, it comes in amazing colors. It is a gorgeous little toaster oven and it's an all-in-one. It has an air fryer, an oven. It's made from stainless steel and glass. You're not just cooking your food in questionable coating type appliances. You are utilizing an appliance that is healthy and doesn't have PFAS and all these other chemicals that are in various pans. And Our Place takes a totally different approach. It is high performance, no PFAS.

38:19Dr. Gabrielle Lyon:The Wonder Oven, by the way, makes all of your breakfast meals like crisping salmon or reheating leftovers easy without sacrificing quality. It looks cute. Yes, it does look cute. Stop cooking and reheating with Toxic Cookware and upgrade to Our Place today. Visit fromourplace.com slash Dr. Lyon and use the code Dr. Lyon for 10 % off site-wide. And 100-day risk-free trial, free shipping and returns. You can also experience this, yes, gorgeous and cute type cookware. It is a game changer with zero risk. And when you begin to dose them, say perimenopause, like your new perimenopause survival guide, how do we think about dosing?

39:13Dr. Gabrielle Lyon:We have a lot of clinicians that listen to this and they have courses and you've got just amazing resources. But if somebody is listening to this thinking, okay, maybe my doctor doesn't have access to or hasn't yet taken your course, how do we begin to dose them?

39:29Dr. Heather Hirsch:Yeah. So I actually always start by symptoms that actually helps me because, you know, in the beginning of the show, we talked about menopausal hormone therapy or HRT is estrogen plus the progesterone, maybe plus or minus plus or minus testosterone plus or minus vaginal estrogen. And so kind of, if you think about it, like I was going to say Chipotle, which, but, you know, if you think about it, like sometimes you're kind of like, hmm, you could just get a bowl of chicken if you want and just be like, all I want is my protein. You can walk right out of Chipotle. There's nothing wrong with that.

39:58Dr. Heather Hirsch:You don't have to build the super massive, you know, bowls that everyone's doing. So if a woman has symptoms that sound more like low progesterone.

40:07Dr. Gabrielle Lyon:Which would be?

40:08Dr. Heather Hirsch:Anxiety or insomnia. Just feeling, you know, a little bit more overly thinking things or losing confidence in sometimes. These are subtle things. There's kind of an art to this science. And sometimes we'll try a woman on progesterone first. My usual go-to would be to start with low-dose prometrium or micronized progesterone, 100 milligrams. If you want to go lower, you have to compound it to, say, 50 or 25 milligrams because the lowest commercial available dose is 100 milligrams. And progesterone is a fun hormone to start because women will know in two days whether it helps them or it doesn't.

40:46Dr. Heather Hirsch:And if it helps them, they might feel it'll help them sleep. they kind of it's a nice anti-anxiety because of the way it increases GABA in the brain so yes it's it's really wonderful I've actually prescribed it for anxiety before just straight

41:01Dr. Gabrielle Lyon:up anxiety but it has to be taken at night it does it it causes drowsiness it definitely causes

41:07Dr. Heather Hirsch:drowsiness although I have some women that it does it so everyone's different you know all the patients say I've been taking it in the morning for years and I'm like wow you need a lot of coffee. Yeah. Yeah. I would definitely say that one's a good one to take before bed.

41:20Dr. Gabrielle Lyon:And nobody, there's no contraindication that we know of for progesterone. Is that correct?

41:24Dr. Heather Hirsch:Mostly. Although if you have an allergy to peanuts, since a lot of the commercially available progesterones are made or they're packaged with peanuts, you want to make sure if you have a peanut oil allergy that you actually are going to have to go the compounded route.

41:37Dr. Gabrielle Lyon:What about blood levels, blood markers of progesterone?

41:41Dr. Heather Hirsch:You know, this one's always challenging to me because here's kind of what my thoughts are. I have looked at my patients' labs for years. And what I will tell you is that symptoms will always trump lab work because, you know, a woman may, you know, certainly have actually progesterone intolerance, basically where the GABA is working way too well and they feel way too sedated or way too groggy. And so they just probably don't want to stay on maybe that progesterone formulation. And so whatever their labs are, actually, it's probably too much for them. So I always want to think about what is your clinical symptoms and then what do your labs look like as well?

42:19Dr. Heather Hirsch:You know, a lot of my, what we don't have clear correlations on is does progesterone in the bloodstream, is it getting to where we want it to go, which is really to get to your uterus to ensure that also, while it's treating your symptoms in your brain and you're sleeping and all those good things, is it also protecting your uterus if you're taking estrogen later on? And we don't really have a great way to correlate. if your blood level is two and a half, is that enough for uterine safety? Does it have to be higher? Can it be lower? So we're not really sure.

42:48Dr. Gabrielle Lyon:I'm definitely glad that you point that out because again, people shouldn't be taking estrogen alone.

42:53Dr. Heather Hirsch:Right, if they have a uterus and they're postmenopausal.

42:57Dr. Gabrielle Lyon:But we don't know exactly the right dose for a progesterone.

43:01Dr. Heather Hirsch:It's a little tough. Yeah, we have guidelines and standards so that based on if you're on both, you can always actually take more progesterone than estrogen, but not the other way around. So you don't want to be on too much estrogen and not enough progesterone. In the very rare case, that could increase the risk of uterine cancer. So we want to kind of use the standard guidelines that we have, but yes, another place for more data is how much progesterone do we need? Now, if you're a woman who does well on progesterone and makes you feel fantastic, this isn't going to be an issue for you because you're going to probably be taking your progesterone and it's protecting the uterus.

43:42Dr. Heather Hirsch:It's more of an issue for women who actually find side effects from the progesterone. They really want to know, gosh, how much do I really need? Because I feel so much better on the estrogen.

43:51Dr. Gabrielle Lyon:What do the side effects of progesterone look like?

43:54Dr. Heather Hirsch:Yeah. So I think that it may have been me, but I don't want to give myself credit where it's not due. But this idea of progesterone intolerance is something I started to see over the last decade. And what I see, and this is specifically for Prometrium, not so much for the synthetic progesterone, but for Prometrium, which I think has the most impact on the CNS, it really goes through that blood brain barrier. So you can really get these brain impacts. About a third of women love progesterone. They feel like it finally helps their insomnia and helps their anxiety and they feel so much better. About a third of women don't really have much of an effect from the progesterone.

44:33Dr. Heather Hirsch:And so they may take it just because they're adding an estrogen later on for their symptoms. For example, we're talking about how to use start hormone therapy and perimenopause, more of the hot and dry, hot flashes, night sweats, dry skin, all of those things. That's going to be more where you start a low dose estrogen. So for those third women who feel as though progesterone really kind of doesn't, is just neutral, they're taking their estrogen. Then about a third of women will have side effects. And actually I would break this down into a third, mild, moderate, severe. So mild progesterone intolerance feels just kind of like it makes you feel a little sedated and you might need a little bit more coffee the next day.

45:12Dr. Heather Hirsch:Sometimes they maybe feel a little bloating. I'll say my rings are a little tight, but nothing that they're like, this is bad. More of the moderate and into severe, you'll get really bad mood disorders, almost like if you're triggering low mood before your period or PMS, because actually So that's when progesterone would normally rise right before your period. So they may feel depressed. I've had women have suicidal thoughts on progesterone. And that's more in the severe category. Significant bloating, so much water retention. They'll put on five or 10 pounds from the progesterone.

45:44Dr. Gabrielle Lyon:How fast within a few days?

45:46Dr. Heather Hirsch:Yeah. I would say most women know within even just a few nights if they're either going to love it, kind of have no effects, or they're going to have some side effects. And sometimes you have to play around with dosing a little bit because it might be too high or maybe it's too low. But the interesting thing about progesterone is it will have an impact pretty soon. Whereas estrogen, I usually say it takes about two-ish, four weeks to know where you're feeling on estrogen. And I think testosterone can take even longer because it's slowly building up in your system. Whereas progesterone is the one that's like, I'll tell you in like two nights if you like it or not.

46:21Dr. Gabrielle Lyon:Fast in and also fast out. The half-life is really short.

46:24Dr. Heather Hirsch:Really short. So the good news is if you are going to not tolerate it, you're going to be one of those women that has side effects, it'll be gone pretty quickly.

46:32Dr. Gabrielle Lyon:Do you have to take a break? Is it something that has to be used cyclically?

46:36Dr. Heather Hirsch:Oh, great question. So you don't have to. And actually, one of the reasons women will do this is to take breaks is if they have a little bit of intolerance. For them, they'll say, you know, if I take it for 12 nights of the month, or if I take it every other night, it's not so bad. I'm not sure why that is. Maybe there is a little buildup in the system. So every other night, they sometimes feel better. So they'd rather do it cyclically. Some women will do that, will do cyclic if they're still having some breakthrough bleeding, especially if they're in that late perimenopause phase, or even if menopause was just a year or so ago, sometimes we'll do it cyclically so that they kind of have a bleed and that they don't have to have unpredictable bleeding.

47:19Dr. Heather Hirsch:That one is also just a pain because the one nice thing about menopause is you stop bleeding, right? Some women will just say, if I don't have to take it every night, I'll just take it 12 nights. But women will take it continuously because again, they'll fall into that. I really like the progesterone effects. I can't sleep without it. So they'll take it nightly. And I recommend they don't do it cyclically because then they just have trouble sleeping for half the month.

47:44Dr. Gabrielle Lyon:And if someone is already getting, or they're still getting their period, do you have them time progesterone for example if it's the day that she's supposed to have her period will you have her continue progesterone or will you have her stop that so again it's

47:59Dr. Heather Hirsch:going to depend on how they feel on progesterone so sometimes if we're first starting and we want to see if the progesterone will help the symptoms especially if they worsen right before her period we'll try that and then kind of have her stop as she starts bleeding one of the things i do with my patients, which sounds almost criminal to say out loud, but I'll say, go with what your body thinks. If you took it and you felt great and you want to try it day one, day two, if you're still bleeding, see what happens. Because I know what she's doing. And I also know that everyone's going to respond so differently.

48:32Dr. Gabrielle Lyon:Do we have an upper limit of how much one could take? For progesterone.

48:36Dr. Heather Hirsch:I would say you can certainly go up to 300. Some studies show that that's where sleep is actually impacted the best if you're going to use progesterone for insomnia, literally trouble falling asleep, but it's a pretty happy dose. Like you might be really kind of sedated the next day. I have a patient who takes 400 milligrams and it doesn't make her feel sedated at all. And that dose actually really helps her sleep. I don't probably have many people, if any, over 400 milligrams of commercially available progesterone.

49:07Dr. Gabrielle Lyon:Testosterone.

49:08Dr. Heather Hirsch:Yes. Let's do testosterone.

49:10Dr. Gabrielle Lyon:Talk to me about testosterone.

49:12Dr. Heather Hirsch:Oh, you're a big fan of testosterone. And again, I say that sort of with this smile on my face of, you know, again, every woman is so different. I have had women take testosterone and even get to really good levels. And they'll say, I just don't know if it's doing anything for me. And I'll say, okay, do we want to stay off it? Or do we want to come, you know, do you want to just stay on it? And sometimes they'll say, I feel like, you know, I've done some research. It's probably doing some good things. Even though I don't like feel it. I'll stay on it. And some of them are like, well, it's one other thing to do.

49:43Dr. Heather Hirsch:And I don't really feel any different. So I'll just kind of stop it. You know? So again, I really just want to say for the record, in the middle of the show, again, I think all women, you know, are different. There's no right or wrong answer, but I don't want women to feel afraid, especially of trialing these medications. Because for a lot of women, you don't know how much it's going to help you until you literally try it on. Right.

50:03Dr. Gabrielle Lyon:And FDA approval.

50:05Dr. Heather Hirsch:Oh, gosh. You know, so So when it comes to what matters more to me is removing the DEA constriction around testosterone, right? So what that means is it's really hard for women to get because it's considered a controlled substance. So that means when I prescribe it, I have to constantly refill it because I can only do it for a month. Women are having to give out their licenses for it. And some of them feel like that's so uncomfortable. And I understand that. Some of them are like rolling their eyes thinking like, okay, this is what I have to do, right? And then an FDA approved medication would mean that we have something that's appropriately dosed for women, which because we don't have that, and you probably do this as well, we take the male dose and we dilute it, but it's really easy to screw it up.

50:52Dr. Heather Hirsch:right and even that even for me i feel like this would be very hard to do because you kind of have to guess if either you're using a gel or you're using a syringe sometimes you're going to get a little bit more sometimes a little bit less and so that's what an fda-approved product would hopefully do which i do think maybe that will be in our future um where women actually don't have to kind of guess their doses anymore that would be fantastic and removing the dea this is silly You know, this is saying that women are abusing testosterone and we have no proof of that. Most women don't want to abuse testosterone because they don't want to lose all their beautiful hair.

51:29Dr. Heather Hirsch:Like they don't want to abuse testosterone, right? And, you know, I think this is patriarchal and sexist. And so hopefully this will change at some point.

51:37Dr. Gabrielle Lyon:I believe that it will.

51:38Dr. Heather Hirsch:But let's talk about the benefits of testosterone. You know, I would say my women will see the 2019 Global Consensus Position Statement paper came out about the use of testosterone, which really kind of said it was endorsed by the Menopause Society, the British Menopause Society, the Endocrine Society, low doses of transdermal estrogen for postmenopausal women. We see the majority of benefits in that group for hypoactive sexual desire disorder, low libido. Okay, great. But I'm going to go out here and say my patients who use testosterone feel better mood, less brain fog, less exercise fatigue.

52:15Dr. Heather Hirsch:They feel as though they're seeing their physique. They're seeing their muscles when they're lifting, when they're using testosterone. And they kind of just feel like it was a cherry on top of their hormone therapy.

52:26Dr. Gabrielle Lyon:What about safety risks of testosterone?

52:29Dr. Heather Hirsch:Yeah. So, you know, we know that if testosterone is going to get too high, you want to check liver function tests. you want to check cholesterol. Sometimes I will see patients with really high levels, and you might see some liver dysregulation, some cholesterol dysfunction. And so those are important to watch. Testosterone to me is a tricky one. We're in this conundrum where women do benefit from these medications, but when we don't have enough clinicians who know how to prescribe them, we're getting women who are maybe getting over-treated, some women under-treated. And so What we want to do really truly is just train more clinicians, get the message out there so that women can safely get on their testosterone without judgment and be safely monitored, and we get more studies.

53:14Dr. Heather Hirsch:We don't yet see, again, we don't have the longest-term studies. We don't have randomized controlled trials that increase its cancer risk, cardiovascular disease, or stroke, the big things that scared women from estrogen 25 years ago. So testosterone really when used appropriately and those levels don't get too high because I think a lot of the side effects are correlated with levels. If it's done well, I don't see a lot of side effects from testosterone.

53:41Dr. Gabrielle Lyon:How do you look at their numbers? Do you say, okay, well, I would like to see testosterone or free testosterone here?

53:50Dr. Heather Hirsch:So again, this one is where I will sort of have discussed ranges for women. One of the things that I think that's difficult in this category is that I don't, can I say this? I don't really know that I trust the lab work because sometimes it just feels like it is all over the place. Like I just, I'm like, is this calibrated right? Is one lab different than this lab? because my patients sometimes will come in with their levels that look like they're flagged or they're high, but they don't have any side effects. They're otherwise doing well. They've been on this dose for a while. And so you're kind of trying to explain to your patient, even though this level is maybe 80 or a hundred, it's okay for you, right?

54:33Dr. Heather Hirsch:We'll keep monitoring you for a while. So they get a little nervous.

54:36Dr. Gabrielle Lyon:They get nervous.

54:37Dr. Heather Hirsch:I would say, I don't know that I have specific targets because I will also have women who will use a little bit of testin gel and they will feel so much better. And we'll look at their testosterone and it went from, you know, 14 to 30. And I don't have enough data to say like, let's keep going on that. Cause they're like, I feel good now. Okay. You know, and so you see such a wide range. I will say this, my younger women, my athletic women and women with polycystic ovarian syndrome tend to do better on higher testosterone levels. I think that's because their body's used to it. And so they might feel the impact of testosterone at 70 or 100 or 110 because they might have had those levels floating around in their body than women who didn't.

55:19Dr. Heather Hirsch:So again, that's younger women, especially if they had surgical menopause and they're 36 for a high risk of ovarian cancer. They need their androgens replaced. Women with PCOS tend to have higher circulating androgens. So their bodies are familiar with that and they're used to that. And then my athletes, I do see that they do feel better when their levels are higher, whatever that means.

55:43Dr. Gabrielle Lyon:Thank you to Manicora for sponsoring today's episode. Winter means more time indoors, more travel, and if you have kids, a new bug, cough, or sneeze every other day. I like keeping my routine simple, and Manicora has become something I reach for almost every morning. And why do I love it? It is rich and creamy. It tastes delicious. I either take it right from the spoon or I use these little packs, it coats my throat. Tastes amazing. Now, what makes Manakora special is where it comes from. Their beekeepers work in this remote forest of New Zealand where the bees collect nectar from the Manuka tea tree.

56:22Dr. Gabrielle Lyon:Yeah, so cool. And this plant is naturally rich in bioactive ingredients. So basically, the honey that you have ends up with three times more antioxidants and prebiotics than regular honey. And because it contains MGO, which is a rare antibacterial compound, Manuka honey has benefits that you don't get from other honeys. And all you need is one teaspoon to get the most out of these amazing bioactive ingredients in Manuka honey. And now it's easier than ever to try Manukura honey. Head to Manukura.com slash Dr. Lion to save up to 31 % plus$25 worth of this free starter kit, which is amazing. I have one.

57:07Dr. Gabrielle Lyon:It comes with this massive jar of Manuka honey. That is go to manukora.com slash Dr. Lion and save 31 % plus$25 worth of free gifts. And what I'm hearing you say is that we don't have a great number. We don't have a great number for bone production. We don't, okay. So be easily, whether it is testosterone, estrogen, or progesterone, we don't have great numbers as to where someone should, is that true? As opposed to, we know that your luteinizing hormone is elevated or your follicle stimulating hormone is elevated.

57:45Dr. Heather Hirsch:We know that the high number potentially also with no period means you're in menopause, but we don't have a, because in my clinical practice, I really struggle with this

57:55Dr. Gabrielle Lyon:because I want a target to shoot for. And I think a lot of the listeners, whether they're physicians or providers, are thinking, okay, well, for bone protection or for brain protection, I would like my estrogen or estradiol at X, Y, and Z. But we don't have those numbers.

58:10Dr. Heather Hirsch:It's really hard, right? And think about why I can understand. We're like, can we want to say something?

58:15Dr. Gabrielle Lyon:Wait. Now, as I'm thinking this, but for men, we have you know if it's less than 250 someone could say well you have low testosterone right exactly but that's interesting because how does that work for for women yeah well that's a

58:34Dr. Heather Hirsch:different podcast of the different ways that we study men and women i think and how much historically men have you know gotten studied how much we've looked more i bet if we looked at numbers more more more more more if we looked at numbers but we'd have to really look at numbers in this way. So what level of estrogen helps your hot flashes? What level of estrogen helps your mood? What level of estrogen helps your bone health? I bet you it's actually different. It may not be the same. And then the other part here -

59:02Dr. Gabrielle Lyon:But it's different. I bet you're right. Meaning that at say 30 estrogen level, estradiol levels of 30 -

59:08Dr. Heather Hirsch:It probably stops hot flashes.

59:09Dr. Gabrielle Lyon:Yeah. I agree with you.

59:10Dr. Heather Hirsch:Does it help your bones? We don't know. We think so. So we don't want to scare anyone either. This it's all hypothetical. And what if you're younger? What if you're older? I think it's actually a bigger story here when it comes to numbers. So this is what I teach for all the clinicians who take courses for me, right? There's a lot of people, and we do like numbers. We want your A1C to be a certain number. We want your blood pressure to be a certain number. So we like numbers and they're objective. And so we're like, ha, we could just get to that number, right? There's a little bit of an art to this, right?

59:41Dr. Heather Hirsch:Just like the woman who feels better when her testosterone is 35 and my other patient feels better when her testosterone is 110. And so there's probably completely different physiologies going on and they're probably looking at different outcomes and they're probably completely different genetically. And so I think there's a lot more to the numbers story. There are definitely clinicians who say, you know, I have a colleague who will really want the FSH number, which is high postmenopausally to be lower than 25. And you can bring that FSH down by adding estrogen, by adding progesterone, by adding vitamin D.

1:00:18Dr. Heather Hirsch:And in his research, you know, he says when that FSH is lower, there's more optimization. Optimization kind of broad, but this is really what he kind of likes to target too. I find that if I try to do that, I find that I'm pushing my patients into side effects from medications if I'm trying to get to that number. So this is where that art and science comes from.

1:00:38Dr. Gabrielle Lyon:Okay. Now I want to shift gears to cognitive function.

1:00:44Dr. Heather Hirsch:I know. I know. We wanted to talk about this. I think it's really important because I did an AMA and I felt really comfortable saying that

1:00:56Dr. Gabrielle Lyon:hormone replacement therapy, and I say hormone replacement therapy, you can use it however you want. Really estrogen, testosterone, there is some effect on cognitive health. Meaning I think that there is an increased risk for dementia or other cognitive challenges when individuals are devoid of hormones. I don't have a randomized control trial, and I don't think any of us have randomized control trials.

1:01:23Dr. Heather Hirsch:We probably won't get one.

1:01:24Dr. Gabrielle Lyon:We probably will not get one, but as a trained geriatrician, I can say when there's androgen deprivation therapy or when people are depriving individuals hormones, we have enough data that there is likely a negative outcome. Yeah. So I'm curious to what you would say when there's, and it's typically people that don't treat patients will say, but you don't have randomized controlled trials to say this would help with the risk of dementia or cognitive impairment.

1:01:52Dr. Heather Hirsch:Yeah. And actually this kind of debate was really sparked when, you know, around the same day is actually the box label warning was removed on hormone therapy. So then there was this idea that, you know, is there enough data to show that hormone therapy reduces the risk of dementia? So here's what I'll tell you, I think, and all the reasons why. I think the same way as you. I think there absolutely has to be neurocognitive benefits. In the same way that there's cardiovascular benefits, you have this vasodilation. And you see this when we prescribe menopausal hormone therapy for women because we see less heart disease, even genitourinary syndrome of menopause.

1:02:35Dr. Heather Hirsch:You're getting blood flow down to the pelvis. The pelvis doesn't die just because we went through menopause, right?

1:02:40Dr. Gabrielle Lyon:So the same thing is going to happen in your brain.

1:02:43Dr. Heather Hirsch:You're going to get all this rich blood flow to the brain. It's going to help remove all the toxins out of the brains, right? And while I'm not a neurologist, I can also definitely say that when my patients do start hormone therapy, initially their cognitive function improves. I will be proof positive of this. If I forget my estrogen, I will have word finding difficulty the next day. And my entire team will say, did you forget your estrogen? Now, that is different because we're talking about something acute versus something long term. However, those early studies that they're doing now on the impacts of the brain and use of estrogen are extremely promising.

1:03:24Dr. Heather Hirsch:And I have an idea of maybe what might happen. So one thing that we say when it comes to hormone therapy and diabetes, this has been proven in so many studies that women who take hormone therapy have less diabetes, but we don't say prevent diabetes. What is clinicians? The right thing to say is hormone therapy decreases the diagnosis of diabetes. Why the word prevention, especially among absolutists and scientists and clinicians, means a lot to them. Like, you know, they don't want it thrown around. So I have a prediction that we will see improvements in brain health long term with the use of estrogen started around the time of menopause.

1:04:07Dr. Heather Hirsch:and maybe we will be able to say estrogen decreases or delays the diagnosis of neurocognitive decline in women. My words, I think that will be the next thing that we're able to say. And you're right. A randomized controlled trial would cost billions of dollars and IRB boards that approve randomizing women to hormone therapy or not. And listen, these IRB boards are still biased and they still think that estrogen is dangerous. And so they're not going to maybe approve a randomized controlled trial to give women estrogen or not. And so we have to look at what we see clinically, which is that women live longer, they are sharper, and they have improved cognitive function at the time at which they started.

1:04:48Dr. Heather Hirsch:And that has to really work for something, right? If you don't use it, you lose it.

1:04:53Dr. Gabrielle Lyon:Isn't that the truth? And that goes for everything.

1:04:58Dr. Heather Hirsch:Speaking about, you know, earlier in the show, you kind of asked what are women coming to you wanting to talk about hormone therapy for. You're like, all right, bone prevention, heart prevention. I was like, symptoms. And you're like, yes, symptoms. But this one is a huge one. They have all seen their parents struggle with cognitive decline, Alzheimer's and dementia, something I actually am going through in my own life. So terrible.

1:05:21Dr. Gabrielle Lyon:I'm sorry for that.

1:05:23Dr. Heather Hirsch:Yeah. And they look at their parents and they think to themselves, because women are more affected than men. And they think to themselves, like, there has to be like, what's happening here? There has to be something better. And then because women are smart and inquisitive and curious, they will do some research. And it's not that far of a stretch to think that estrogen started at the time of menopause is good for your body. It's good for your heart. It helps you live longer. It's good for your pelvis. It's probably good for your brain too.

1:05:53Dr. Gabrielle Lyon:Very, very well said. If you were to kind of boil it down to, and I know that you cover much of this in your book, but what are women doing wrong? You know, I think that we as a society of women, we stay in the suffering period for far too long.

1:06:16Dr. Heather Hirsch:And we've really normalized suffering. I mean, what is a period other than just like suffering? As soon as I figured out I could stop my periods, I was like, oh, I'm stopping those, right? And these are all things that are still clouded in mystery and fear. Well, I was at a dinner the other night and the woman said, are you sure it's safe to not have your period? And I'm thinking to myself, we've known this for a really long time that you don't have to shed your lining every single month or have a period, right? Now, not that everyone has to do that either. but we also think about just all the things we joke about how when men get colds you know we call it man flu right women are so used to not feeling great but sticking through things and putting on a face and just getting the things done because that's the way we are we're productive and we're strong right however sometimes that can be as a detriment to us we think oh well this is natural like you know everyone else suffered through this like i have to suffer through this You know, they'll be told this could increase your risk of breast cancer.

1:07:19Dr. Heather Hirsch:Like, well, I want to stay healthy. So I don't want to get cancer. Meanwhile, right, they're not getting the benefits of hormone therapy because they're trying to be strong or they're trying to stick things out. So I think that we as women stick things out a little bit longer than we need to. My patients will come to me and they'll say, I've had years of this. Actually, I look back. I think I've had a decade of this. I'm like, wow, we'll start on hormone therapy and they'll come back and they'll say this, this little sticker, this little patch and everything's better. I say, I know.

1:07:52Dr. Gabrielle Lyon:And you said something else a decade, a decade ago. What are your thoughts on starting a woman on menopause therapy, hormones 10 years out?

1:08:04Dr. Heather Hirsch:Yeah. For menopause? Yeah. Yeah. I've done it for myself, right? So I think that it is absolutely within a woman's right. And you need a great clinician. So this is the other side of the problem. The other part of the equation is, you know, we want to help more clinicians be inspired and want to do this as their job. It's so satisfying. It's so fun. So a woman deserves the right to kind of know, what are my options here at 35, at 38, at 42, if they are sort of feeling to themselves, I want to already prepare myself for this stage. I'm proactive. I'm healthy. I want to stay healthy. What are my options?

1:08:44Dr. Heather Hirsch:And so there is no good reason that I am aware of at this moment in time where we couldn't start you on hormone therapy earlier than either you're having symptoms and or therefore for prevention or therefore to just skip perimenopause altogether, right? And then what about later?

1:09:02Dr. Gabrielle Lyon:That was a really, that has been a heavy topic of conversation for all the women that have missed out.

1:09:08Dr. Heather Hirsch:Exactly. And again, with the black box removal, this conversation really got amplified. I had my neighbors, you know, in their 70s messaging me like, well, can I start on hormone therapy now? So here's what we know. Pretend they? So it depends. If we think about, again, what all women can do, all women can do vaginal estrogen at any age, doesn't matter how long you have been since menopause. A lot of women can probably also use testosterone and progesterone at any age. Now, of course, this is not direct medical advice and education, but when it comes to estrogen, you know, I have started women who are outside of 10 years of menopause routinely because at the point at which they're coming to me, they are healthy.

1:09:54Dr. Heather Hirsch:They don't have any cardiovascular risks. Maybe they don't have hypertension or diabetes. And so there's still good candidates to try transdermal estrogen because, and this is the rationale, that study that really showed the benefits of estrogen in the 10-year window was all on oral. And again, we didn't do that study on transdermal estrogens. And so if the biggest risk as you get out of that window is an increased risk for clot, but those ESTR studies or ESTR trials showed transdermal estrogen does not increase the risk of clot. And a woman doesn't have any cardiovascular conditions now, even if she's 65 or if she's 71, we can start really low-dose transhermal estrogen.

1:10:31Dr. Heather Hirsch:Or I should paraphrase that or rephrase that to say, I am comfortable starting women on low-dose estrogen, even if they've been out of the window. But they have a lot of other options, including progesterone, testosterone, and vaginal estrogens.

1:10:44Dr. Gabrielle Lyon:Dr. Heather Hirsch, you are just such a spitfire. And I really do believe that we talked about this before. I believe that you and your colleagues are changing the landscape for women and really making things accessible to them that a whole generation got skipped. So thank you for the work that you're doing.

1:11:04Dr. Heather Hirsch:Thank you for having me on.