Ep. 508 Perimenopause Uncovered: From Heavy Periods to Stubborn Weight Gain – A Talk with Dr. Heather Hirsch

I am delighted to connect with a physician friend and colleague, Dr. Heather Hirsch, today. Dr. Hirsch is an entrepreneur and a board-certified internist by the American Board of Internal Medicine. She is also the Founder and CEO of Health by Heather Hirsch, and has a telemedicine practice offering best-in-class individualized care for perimenopause and menopause.

In our discussion, we explore heavy menstrual cycles and the benefits of journaling and shared decision-making. We discuss common and frustrating causes of weight loss resistance in middle age, the power of strength training and adequate protein intake, and estrogen as a metabolic regulator that is intricately linked to many physical systems, including digestion. We also examine how educating clinicians on shifts in estrogen, progesterone, and testosterone during perimenopause could prevent countless ER visits, and we tackle concerns surrounding contraception and pregnancy prevention in perimenopause, a biopsychosocial approach to low libido, and the often-overlooked silent symptoms Dr. Hirsch often sees in perimenopause and beyond.

Today’s conversation with Dr. Hirsch is truly invaluable. I highly recommend her Perimenopause Survival Guide, written by an internal medicine doctor extremely well-versed in perimenopause and menopause.

IN THIS EPISODE, YOU WILL LEARN:

• How hormonal fluctuations disrupt the body and create confusion in perimenopause

• The benefits of journaling 

• How hormonal and lifestyle shifts disrupt metabolism, weight, and insulin sensitivity during perimenopause

• Why body composition changes matter more than your weight

• How declining estrogen affects insulin resistance, metabolism, and diabetes risk

• The value of shared decision-making 

• How hormones, medications, sleep, relationships, and past trauma can cause changes in libido 

• How siloed healthcare often leaves perimenopause symptoms misunderstood 

• How irregular ovulation increases pregnancy risk and why hormone therapy is not a contraceptive

Bio: 

Dr. Heather Hirsch is a board-certified internist, entrepreneur, educator, and one of today's most trusted voices in women's midlife health. She is the Founder and CEO of The Collaborative, a concierge telemedicine practice delivering personalized, integrative care to women navigating perimenopause and menopause, as well as the Founder of The Heather Hirsch Academy, where she trains clinicians worldwide to confidently and compassionately care for women in midlife. 

After completing her internal medicine residency at Case Western Reserve University and advanced women's health fellowship training at the Cleveland Clinic, Dr. Hirsch founded the Menopause and Midlife Clinic at Brigham and Women's Hospital in 2020 and served as faculty at Harvard Medical School, where she championed innovation in women’s health education and care. Her decade-long focus on menopausal medicine has made her one of the most sought-after clinicians, consultants, and educators on all aspects of midlife healthcare. 

A Menopause Society Certified Practitioner (MSCP) and Fellow of the International Society for the Study of Women's Sexual Health (ISSWSH), Dr. Hirsch is also a contributing member of the North American Menopause Society. Her specialty practice focuses on menopausal hormone therapy, perimenopause, breast cancer survivorship, sexual dysfunction, bone health, and other conditions common to women in midlife. 

Dr. Hirsch is the author of the bestselling book Unlock Your Menopause Type: Personalized Treatments, the Last Word on Hormones, and Remedies That Work (June 2023), which helps readers cut through confusion and take charge of their symptoms by identifying their unique Menopause Type(s). Her second book, The Perimenopause Survival Guide, is available for preorder and debuts October 14 from Hachette’s Balance Publishing. It offers women practical strategies for navigating the often-overlooked years leading up to menopause, including what’s really driving one’s symptoms and how to decode them, proven FDA-approved treatment options, how to be an advocate for oneself and build a care plan, plus more. Details and ordering links for both books can be found on her website. 

A featured expert on Oprah Winfrey’s 2023 “The Life You Want” Series, Dr. Hirsch has also appeared in The New York Times, The Washington Post, The Drew Barrymore Show, Live with Kelly and Mark, Access Hollywood, and numerous other major media outlets. Through her clinical practice, social media presence, podcast, books, and national lectures, Dr. Hirsch is on a mission to fill the gaps in women's healthcare, destigmatize perimenopause and menopause, and ensure that no woman has to feel confused, dismissed, or stuck when it comes to her midlife health. 

Dr. Hirsch lives with her husband and three children in Rochester, New York.

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“Ditching the scale and divorcing the scale is a good idea because it is not the full picture of our health.”

– Dr. Heather Hirsch

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Connect with Cynthia Thurlow  

• Follow on⁠ X⁠,⁠ Instagram⁠ &⁠ LinkedIn⁠

• Check out Cynthia’s⁠ website⁠

• Submit your questions to ⁠support@cynthiathurlow.com⁠

Connect with Dr. Heather Hirsch

• On her website

• YouTube 

• Social media: @Heather Hirsch MD

Transcript:

Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives. 

[00:00:29] Today, I had the honor of connecting with physician, friend and colleague Dr. Heather Hirsch. This has been one of these interviews that I have been manifesting for a long time and I'm so grateful to be able to share her expertise with my community. She's an entrepreneur and an American Board of Internal Medicine Board-Certified Internist and CEO and founder of Health by Heather Hirsch. She's also has a telemedicine practice offering best in class individualized care for perimenopause and menopause. 

[00:00:59] Today, we spoke at length around concerns around heavy menstrual cycles, the impact of journaling and shared decision making, common and frustrating reasons for why we can become weight loss resistance in middle age, the value of strength training and proper protein intake, why estrogen is a metabolic regulator and how it is intricately related in many systems in the body, including digestion. How many ER visits can be prevented by educating all clinicians about the shifts in estrogen, progesterone and testosterone in perimenopause, concerns around contraception and preventing pregnancy in perimenopause, a biopsychosocial approach to low libido at this stage of life and last but not least, silent symptoms that Dr. Hirsch sees with some frequency in perimenopause and beyond. 

[00:01:55] This is a truly invaluable conversation. I highly recommend Dr. Hirsch’s The Perimenopause Survival Guide, which is written through the lens of internal medicine doctor who is incredibly well versed in not only perimenopause, but menopause as well. 

[00:02:15] Well, Dr. Hirsch, I'm so excited to introduce you to the podcast community. I know it's taken a while to make this happen and I'm really excited to share your expertise with everyone in Everyday Wellness. 

Dr. Heather Hirsch: [00:02:26] Yeah, I'm so excited to be here. I know we've been wanting to get together and do a show together for a long time, so thank you for having me. 

Cynthia Thurlow: [00:02:33] Absolutely. When I was reading your book, I was really reflecting on some of the biggest pain points that I think women in perimenopause experience. And without question, heavy menstrual bleeding is huge. I used to affectionately refer to it as crime scene periods and pray that my menstrual cycle would not start when I was rounding in the hospital because there was not enough tampons, pads, scrubs that could tolerate. You manage the amount of blood flow that I experienced. Let's talk about why this is happening and walk us through your process of how to evaluate patients when they come to you and they're reporting they're having a lot of heavy menstrual flow. 

Dr. Heather Hirsch: [00:03:12] Yeah. I'm actually really glad you, like, hit the ground running with this one, because there is lots of books about menopause but the difference between perimenopause and menopause is actually pretty big. They're completely different life stages, although they get lumped together all too often. Even I have lumped them together. But a huge difference is usually menopause, you're done bleeding. In perimenopause, you are actually at the, what we lovingly kind of call, puberty in reverse or menopause's little sister, or as my patients say, menopause's evil little sister. And it's because it's really confusing. You think menopause is still so far off or it's for your mom or it's for your grandmother. But this heavy bleeding is something that doesn't happen to everyone. 

[00:03:57] But actually, most women will report some change in their periods, and often it is not for the better, it's for the worse, so they can become heavier. So, there's a couple reasons this is happening, and I always break this into, there's hormonal reasons, and then there's anatomical reasons, and then there's probably a third category of other medical conditions. But let's go with the two hormonal and anatomical. So, one of the things that starts to happen in perimenopause, as you know, is we start to have a decline in our progesterone. And this hormone, I always like to say, is the orchestrator of the uterine line. It's the conductor, if you will, of the band. And so, it tells it when to build up and when to shed. 

[00:04:40] And as progesterone is declining, this can cause a lot of the spotting in between periods that women start to get. Well, they'll say, “Oh, my God, I had a period. And then two weeks later, I had a period.” So, there's some hormonal changes that are happening. Sometimes spikes in estrogen can cause a bigger lining, and then you can get all of this shedding. Next, you've got anatomical reasons, and that can be things like the development of fibroids or polyps, which can happen just simply with time. And I always like to explain a polyp or a fibroid. Particular fibroids is just like extra surface area. So, now you've just got more shedding, more lining that builds up, more shedding, more bleeding. And polyps can be really troublesome because they can have a lot of blood flow. 

[00:05:22] So, that means the pipes are there, they're bringing blood in and what goes up must come down. And so, you've got those two big changes. You've got hormonal reasons, you've got anatomical reasons. It can cause so much heavy bleeding and it can also cause more pain or cramping. So, again, you feel like a teenager. And this could because of things like adenomyosis or other conditions that again, just over time or with pregnancies or with instrumentation to the uterus, if someone's put something, you've had a D&C or we've had some procedures by this time that can actually cause the lining of the uterine wall, the muscular layer will invade it and therefore you can get more cramping where again, you're like, “I feel like I'm in sixth grade and I can't go to school with this happening.” And this is all really common in perimenopause. 

Cynthia Thurlow: [00:06:12] Yeah. I think for so many women, their symptoms are sometimes not addressed in a way that you just explained it. If you go to see your well-meaning provider, they may just say, “Hey, I know how to fix this.” I'm going to just dose some oral contraceptives or maybe we'll put in an IUD or perhaps we move to surgical options. And it's not to suggest that's not the right decision for listeners. It's just understanding. If we understood what was happening in our bodies could make a world of difference.

[00:06:43] I'd love to talk about endometriosis. It's a topic we have not unpacked here on the podcast much. And yet I think it's really underdiagnosed. And I think for many people they're under the assumption, “Oh well, you have to have really severe endometriosis to have all of these symptoms.” And I've come to find in talking to many GYNs and internists that it's far more common than we realize and in some instances can be an autoimmune condition. And I was like, oh my gosh, this makes so much more sense. But why it can be exacerbated as we're navigating this perimenopausal transition. 

Dr. Heather Hirsch: [00:07:18] I agree. I think most things with women are more of a spectrum. I would even talk about PCOS in the same way. It's like instead of do you have it, yes or no? It's where on this scale do you have it? Does it flare often? Does it flare only a little bit? Does it cause this much distress? Does it cause little distress? And I think the same thing with endometriosis. And you're so right that as women we are, we do not give ourselves enough credit for being so strong and so resilient and just packing it up and moving. We can do things that are unfathomable to the other sex, not to say that we're better, but we're different, we're wired differently. We can really handle a lot. 

[00:08:05] And so, I do think a lot of women have low-lying endometriosis that may not bother them or maybe they can take some nonsteroidals and they can move on. But in perimenopause, basically everything gets amplified, right? The bleeding gets amplified, your PMS gets amplified, your endometriosis can get amplified. And that's again, because we're feeling things more. There's more volatility in the hormones. And so instead of just the usual roller coaster that we normally have, now we just have like the one that goes like upside down and flips you and you look at it and you're like, “Yeah, no thank you.” You know, only if I'm triple strapped in. And you know, but again, I still wouldn't get on a roller coaster anymore. But I digress. 

[00:08:50] And all of these lower lying or things that we can really manage maybe in our 20s or 30s, really as we get into our 40s. And this is just an estimate, not everyone's in their perimenopause in their 40s. But they really, really get amplified. And it's really time that we start using this maybe perimenopause gate to look back and think about endometriosis, PCOS, PMS or PMDD, because it's not fair that women have to wait until they're so severe that they're seeking care. And I do agree with you. Understanding why this is happening, how long it might be, what we could do, what all of our options are when it will be over, is so, so helpful. And that's really why I wanted to put it. Put it all in my book. 

Cynthia Thurlow: [00:09:35] Yeah. And I love in the book, you talk about reasons why we can have heavy menstrual cycles, medications that can exacerbate this. And then you walk people through. This is my process for how I evaluate it and then treatment modalities. And I think that this is helpful because a lot of women are offered surgical options before we even talk about more conservative care. Can we talk about that? Because a lot of questions came in with women saying, “I'm really not ready to have a surgical option like a hysterectomy or uterine artery embolization.” It seems a little bit severe to go that direction. Let's just pretend you have an otherwise healthy patient coming to you. What is your usual process that you do to evaluate for heavy menstrual bleeding, if they are indeed in that perimenopausal age range? 

Dr. Heather Hirsch: Yes. So, the first thing I like to do is see if they have a history. This is really helpful. So, if you're a listener, I always say the most actionable thing that you could do is start journaling and tracking. Now, we're talking about bleeding and periods and all that fun stuff. But if you also track your symptoms rather along with what your periods are doing, this can be so helpful because then your clinician can really look back and say, “When did things get worse? By how much? And how is it impacting your quality of life?” As you were saying, Cynthia, you were rounding at the hospital and just, like, hoping you didn't have to have a heavy period because it would interrupt your entire day. So that's all helpful. 

[00:11:08] The next thing I like to do is like, again, compare with what her normal menstrual cycle is and then maybe run some lab tests. So, there's anatomical reasons, there's hormonal reasons, and so those hormonal reasons sometimes will show up in blood work. So, maybe it's nice to always see if there's any anemia, because you can start to get anemic when you're bleeding that much. So, we want to look for your CBC, which is like, what are your red blood cells doing? Your iron, your ferritin, your total iron binding capacity. Those are just some iron studies that a doctor could check for you. We also want to check your thyroid. So, a TSH, T4, free T3, because, yes, you can start to develop as you mentioned sometimes these things can be autoimmune. 

Dr. Heather Hirsch: [00:11:51] And in our 40s we can start to develop autoimmune conditions. So, even something like thyroid. So, I would check your thyroid hormones sometimes while I'm there. Then I might also check your estrogen, your progesterone, your FSH. Now, why I don't want to spend too much time on this because I talk about it a lot in the book. Labs for perimenopause, when it comes to your hormones, aren't that helpful. They need to be taken in context. But at the same time, sometimes it might give us a little bit of information. I've found that some women are actually in different stages of menopause based on their FSH. I do a quick double check and that will change the entire picture for me. So, it's a good time. I know it could be controversial. Should you check labs? 

[00:12:31] Should you not remember perimenopause is never diagnosed by labs, but at this point it might be helpful. And then since I'm an internist at heart, sometimes I just check your A1c and a couple other of your metabolic panel and I start to look at what your labs are doing. If all of that looks normal, maybe it's time to just do an ultrasound. I'm looking to see if there's any of those anatomical things like a polyp or a fibroid that might have shown up. Now, endometrial lining is something a lot of women ask me about, but it is going to be dynamic in perimenopause. It is going to be dynamic. If you're bleeding, you should actually have. Sometimes, you have a thinner one because you've just bled, sometimes it's thicker. 

[00:13:10] Endometrial lining, when we're talking about what that means in perimenopause, is a black box of just who knows what. It is very dynamic. We're not going to get hung up on that, but we're going to take a look at all of those things, right? So, that's how we're going to maybe start this process of gathering information. Is it hormonal? Is it anatomical? Again, there's some other reasons that it could be, but they're much more rare. And those might be some other medications you're on, other medical conditions. And so, we're going to start by looking at your journaling and tracking what's changed. How much are you bleeding? How much is it bothering you? Address any of those? Maybe lab work or hormonal and then any anatomical. And after that and I'll come up for air, we'll talk about what your different options are. 

Cynthia Thurlow: [00:13:51] Well, and I love that you really emphasize this shared communication and decision making. You know absolutely about the journal and tracking because you're inviting your patients to be involved in their care proactively. And that I think is so important because you could have 10 women with these symptoms who might all want something very different. There may be one person who's like, “I just want it to end, I don't want to have more bleeding, just take my uterus out.” You may have someone else who's like, “Listen, I want to manage this as conservatively as possible and what are my options?” 

[00:14:23] And this is where I think that shared decision-making model of care is so critically important because as a woman who's now on the other side of things. When I was in the throes of perimenopause 10 years ago, I did not have these kinds of conversations, even though I had a great GYN and I'm by no means am I being critical, but I didn't even know what to expect, let alone-- the options I received were like surgical IUD, oral contraceptives, that's it. And like, here's your platter of options, and these are the only options you have. Recognizing now we know so much more and I think women are far more informed in terms of care options. So, pivoting from talking about heavy menstrual cycles, one of the other really big pain points that women report the most is weight loss resistance. And this is multifactorial. There's so many things that contribute to it. 

[00:15:17] From your perspective when you're working with your patients, what are some of the most common reasons women will start to struggle? Maybe it's someone who's never had problems with their weight before. Maybe it's someone who is super type A, probably used to doing all the things all the time, and now all of a sudden, they're completely full flummoxed with the fact that they're struggling with weight loss resistance. 

Dr. Heather Hirsch: [00:15:42] Yes. This one is so frustrating for women. And I don't want to speak for all women, so, I'm only going to say what I hear from a lot of my patients. And they'll say, “Yeah, there's a little bit of vanity, but mostly I want to feel comfortable in my own clothes.” I want to feel like me. They don't want to lose more weight than maybe they just were in their 40s. And I completely understand this. You've heard this a million times. We've all heard this a million times. You guys listening can say it right along with me. “I haven't changed anything in my diet or exercise and I'm unable to maintain my weight.” 

[00:16:20] And sometimes it wasn't that they were actively trying to lose weight, it was that they just are having trouble now maintaining their weight. And I feel this so much as someone else, as someone who is going through perimenopause myself, you wake up in the morning and you're like, this should be my lightest of the day. Now I think ditching the scale and divorcing the scale is actually a really good idea because it is not the full picture of our health. But I do think for some women, it's a way to just gauge how is your body responding to some of the things that you're doing. So, there's so many reasons for this. I like to break things down in terms of, like, what they are. 

[00:16:57] So, there's the hormonal changes. Your body is going through so many hormonal changes. If the bleeding is any indication, just think about what's happening to the rest of your body, and when you're either bleeding or you're not sleeping, we will talk about that, I'm sure, or you're moody, or you're cranky, or you are binge eating or you're tossing and turning all night. All of these things are going to affect your metabolism. They just are. And at the same time, I do think we might not be moving as much as we think we are. I know it's a hard pill to swallow, but there's not kids to pick up for it maybe anymore, there's not toys on the ground, you're not running up and down the stairs because someone forgot a water bottle, this or that.

[00:17:41] And so even though we think we're eating the same and we think we're moving the same, we might not be. So, I think it's time to really help women understand what's happening to our bodies and how can we get back to our usual cells? Because for a lot of women, it's maybe not- There's a difference between struggling with my obesity for years. I want to get this under control. That is one thing. And then it's another where I'm up 10, 15 pounds. And this is this very stubborn feeling of now you're up one or two clothes sizes. This means a huge change for your wardrobe. How your pants feel when you're working all of these things and can't lose them. It's very, very frustrating. 

Cynthia Thurlow: [00:18:22] Yeah, it really can be. And I think that, we've grown up in a very toxic diet culture and so women have been taught that we need to live and die by the scale. And I think a lot of the work that I'm sure we're both doing is helping women understand. A lot of what's showing up on the scale are shifts in body composition. And, the more we can understand about whether it's fat free mass or like muscle mass and understanding how our habits play into shifts in these body composition, it's helping women understand like we want to try to maintain some muscle and how does that show up and how can that improve insulin sensitivity at the same time, helping them understand, like the scale is just one of many metrics, but it may not give us the big picture. 

[00:19:11] And to your point about these shifts in confidence like that, I think is what most women are upset about or frustrated with is that maybe they were feeling like incredibly confident. And now when they're feeling like their clothes don't fit or they're focused on the scale. And I still have some patients who weigh themselves every day, sometimes twice a day. And so, I always tell them I think we need to reacquaint ourselves with the scale or the scale concept so that we can better understand what's happening to our bodies. 

Dr. Heather Hirsch: [00:19:37] I think it's really important to think about how your clothes fit. And also, we'll talk about like things such as building muscle mass. But there is definitely, and you're probably living under rock if you haven't heard lift more, eat more protein. We're all hearing it, but the message is good. The message is correct. We need to build that muscle. That's our metabolic. You know, basically that's our metabolic means. And we really also need it for our bone strength to prevent fragility. There is so many benefits to lifting weights and ditching the-- like 90s which cardio has many benefits. Please don't not do any cardio, but please really maybe flip it where you do more of that weightlifting and you do cardio, you either walk or you do a brisk jog or you put cardio into your workouts and then eating more protein. 

[00:20:32] But I think it also behooves us to talk about the fact that estrogen may play a little role in our insulin resistance, which is like, why does estrogen get all of these roles? It's almost like one of the master hormone regulators of the body. And it's quite unfair that estrogen may leave the center left in our 40s or in our 50s. But we do know, and this is interesting, that in the Women's Health Initiative, one of the biggest studies about hormone therapy, arguably, also a little hot to debate about the WHI, but I always say it gave us a lot of information. We know about the safety of estrogen and hormone therapy. But women who took hormone therapy, compared to women in the placebo, gained less weight. But more importantly than the weight, because that might just be scale, had less diabetes, had less progression to diabetes. 

[00:21:23] So, I am very convinced, and I've actually even done a lot of research in some protein-omics and things like that a couple years ago when I was at Harvard, that estrogen and insulin really talk to each other and they have this nice symbiotic relationship. And then as estrogen starts to decline, then we get a little bit more insulin resistance. And that might also be the hormones playing a little bit of a role. We don't necessarily yet know exactly how it works. Testosterone may be involved in that. But this can also shift that stubborn weight gain that you feel like, “No, no, no guys. Cynthia, Heather, I'm doing all the things that you said.” 

[00:22:00] Now, not that hormone therapy necessarily is a weight loss drug, medication. I would not go so far as to say that. But there are many things that sometimes my patients feel like when they do add hormone therapy or menopausal hormone therapy or the estrogen, that helps almost like turn the keys. They still have to, of course, do the work and do all of the things as you are already doing. But we can't also deny that estrogen might play this significant role, which is why at the same time as our periods become crazy, where our progesterone is lowering, our estrogen is becoming really volatile and eventually is also going to drop. This is when this hormonal havoc is happening. And again, the more you know, the more you know, right, Cynthia?

Cynthia Thurlow: [00:22:41] Yeah, absolutely. I think that's this perfect Goldilocks effect that many people, and it's so personalized because there are some women that I know that are starting estrogen in their early to mid-40s. There are others that are waiting till they're in their latter 40s to start estrogen. And so, to your point about how important it is for metabolic health and really looking at the research to see what are the effects of estrogen. And I think that one thing that the weight loss or the weight and body composition piece is certainly important, but there's so much more to estrogen than just about body composition. 

[00:23:19] And so when I'm thinking about some of the less known effects about the role of estrogen, and you do such a great job in the book, you talk about the impact on digestion is one example, like, how many women are dealing with bloating, gas, constipation, diarrhea. And they don't realize that the effects of estrogen as well as progesterone on the digestive system can be what's exacerbating or magnifying their symptoms. 

Dr. Heather Hirsch: [00:23:47] Yeah, exactly. It plays a role from head to toe, and it can show up in all these different places. So, let's even use the bloating word. A lot of women will start to part more gas or more smelly farts. And let's just be honest. They'll say, “Oh, my gosh, nobody even wants to be around me.” I don't know if you've seen the meme on social media, but it's these women going on their fart walks, which I just found hilarious and cute because again, you're moving, you’re moving the bowels and things like that. But it goes to show that it plays a role in all these different organ systems. 

[00:24:23] And I'm really so excited for women to see, like, “Wow, it impacts my vision, it can impact my bones, it can impact my GI system, my pelvic floor.” And therefore, instead of maybe going to all the different clinicians and all the different specialists, because again, there exists this silo in medicine, maybe as we train the clinicians, as we help women really understand what's happening, instead of seeing the GI doctor for the bloating and then getting a colonoscopy and then the psychiatrist for the mental health and then a sleep study for the sleep, and then your nutritionist or dietitian, or getting started on a medication you don't maybe need, or the endocrinologist. And then your OB/GYN may be in a perfect world we can see that this could all be one thing, which is perimenopause. 

[00:25:10] Same thing happens in menopause. But perimenopause can be even more confusing because you're not thinking hormones, you're not thinking menopause. Like you're still getting your period. Clinician still have so many myths. It can't be your hormones, they are not connected to your GI system. It can't be your hormones you are too young. We have to stop this rhetoric and really see how these are so interrelated. And by doing so, we're just going to help millions of women feel better and not feel like all these piecemeal things are happening to them and they can really better thrive through perimenopause. 

Cynthia Thurlow: [00:25:44] Absolutely. And that's why I'm so truly grateful very transparently to share that your programs that you've written for clinicians are so important because we have so many women, it's 6,000 women a day that are transitioning into menopause and probably just as many that are on this trajectory of perimenopause and helping train clinicians so that they can better support women. Because to your point, traditional allopathic medicine, so many good things about this, but we are incredibly siloed. Like, if I was in cardiology clinic and I saw something that was not a cardiology focused symptom, my clinicians would always say, “Oh, Cynthia, they need to go back to GYN, internal medicine, or psychiatrist,” stay in your lane don't even go down that path. 

[00:26:31] And I'm like, but wouldn't it make more sense if we could actually address multiple systems at once so that women are being taken care of by providers that are perimenopause and menopause experts so that they're getting that kind of very comprehensive care. 

Dr. Heather Hirsch: [00:26:46] Exactly. This silo has really hurt women in particular. Again, I don't see men. So, I'm going to leave that as a no comment because I haven't seen men in like a decade. But women in particular, we are really connected. And you give so many good examples. I cannot tell you how many women will go to the cardiologist for benign palpitations. That could be perimenopause. And if we could teach the cardiologist even just a little bit so that they don't get completely dismissed or just told, this is normal. Go back here, say, “Oh, I wonder if this could be perimenopause.” And what I love about the course that I teach is there's a lot of different specialists who are in this class. And this is so good because it's helping to really really increase awareness. 

[00:27:33] And not that everyone needs to necessarily prescribe HRT perfectly, but really just to understand the basics, understand how these are connected. Who else really could learn about perimenopause and menopause, but particularly perimenopause emergency room clinicians.

Cynthia Thurlow: [00:27:50] Yes. 

Dr. Heather Hirsch: [00:27:49] How many women end up in the emergency room with the worst headache of their life? Maybe it's their very first migraine in perimenopause. A heart palpitation that scares them half to death. Maybe they faint, they pass out at work, they end up in the ER and it's just a benign palpitation. Panic attacks for the first time, a urinary tract infection even for the first time. If we could just get into the minds of emergency room or even urgent care clinicians, that could also be really helpful because perimenopause, it's funny, right? It's so hidden under this veil of what's the organ system that's being affected. Just like you said, we're so siloed into these organ systems and that can really leave women bewildered, confused, frustrated and mistreated. So that's the other thing. 

[00:28:37] Oh, maybe you need a beta-blocker for your heart palpitations, which is the medication that slows the heart rate a little bit. Well, beta-blockers are not benign medications. They have side effects as well. Oh, it's a urinary tract infection. Maybe your culture was normal, which means it really wasn't a urinary tract infection. [Cynthia laughs] Let's just give you antibiotic anyways. It could be genitourinary syndrome of menopause. Oh, you had your first migraine. Let's get you a triptan. Where it could be that maybe-- I know, we didn't even answer how do you treat endometriosis and heavy bleeding. So, at some point we'll circle back. Maybe you need something to help to keep the hormones a little bit more steadier. So, you don't have a migraine or so you don't have flares of your endometriosis and perimenopause. 

[00:29:19] Just think about how-- I'm sure I get goosebumps saying it. Because I'm like, yes, so many women would be really better supported if both they knew what was happening with their bodies but also the clinicians, it's a two-way street. 

Cynthia Thurlow: [00:29:32] Absolutely. And I sit here as someone who spent 16 years in clinical cardiology, both hospital and clinic management. My apologies to the women that had, what we would say, benign evaluations for palpitations, either with a Holter monitor, which is just for 24 hours, or an event monitor they might wear for a couple weeks. And of course, we're screening for pathologic or concerning-- [crosstalk] 

Dr. Heather Hirsch: [00:29:55] Scary stuff. 

Cynthia Thurlow: [00:29:56] The scary stuff. And I would say to my patients, okay, stay hydrated, avoid caffeine. If you feel like you're really symptomatic, here's a beta-blocker which some of those are fairly benign, but they also don't have side effects. And so, I sit here very humbly now, better understanding that the fluctuations in estrogen could be provoking some of these symptoms. And so again I sit and apologize along with all the menopausal female that were on chronic low-dose antibiotic therapy. And I would say to them in the hospital, “Why are you on these antibiotics?” Oh, if I don't take them, I get a UTI. Now understanding, this is now retrospectively, oh, well, it's because you had genitourinary syndrome of menopause and what you really needed was vaginal estrogen to help with your symptoms. It's like now everything, life comes full circle. So, I say with profound humility and appreciation for those patients, thank you for teaching me what I didn't know. 

Dr. Heather Hirsch: [00:30:53] And so many of us on the clinician side feel the same way and I've heard so many clinicians say, “I've had so much grief over the misdiagnosis that maybe I did five years ago or 10 years ago. And we are just working to get better every single day. And it really is not one's fault. Again for listeners too, it's the way the human body is taught, the way we're taught in medical school, nursing school, PA school, pharmacy school, physical therapy. Physical therapists always tell me all the time that the default is really the male physiology or the male body. And what a time to really be here because we are all working together to change the narrative. It's a wonderful, wonderful time. 

[00:31:43] And that's something I would love to do is just to change the way we're taught, because that's really where it all starts. And, I am really convinced that the female physiology was never fully studied, never really understood in the way that it's starting to become now. One of the things that I think is so amazing, people ask me all the time, why do you think there's sort of interest in menopause and perimenopause? And I say it's because of the women. The women like you listening to the podcast, thinking to yourselves, “No, no, this can't be right.” Like, I'm not depressed. I'll have patients tell me all the time, “I've been clinically depressed before. This low mood, it's different.”

[00:32:27] And you've demanded more and you've demanded better. And I think now the healthcare professionals are really rising to the occasion and really excited about this, and all of us are benefiting because as clinicians, we feel like we're so much better addressing what's happening. And women, you're feeling like you're really being seen and heard and validated, and it's like a wonderful time. 

Cynthia Thurlow: [00:32:48]. It's a watershed moment. And I think that the concept of know better, do better. Like, every clinician out there reminds themselves that we're meant to evolve, shift and change throughout our trajectory of our careers. And that's why I think it's so exciting that this generation of clinicians and women are like, “Hey, we want things to be more transparent.” We want more options. We want to have an open dialogue, have a discussion. One thing I want to tie in, because so many questions came in around, what do I do about contraception for those who are not yet menopausal but aren't in a position where they are looking to become pregnant, maybe their partner has not had a vasectomy as another option. I know for many women that's usually-- that can be, for some people, the right decision. This unpredictable ovulation, why does it put us at greater risk for getting pregnant in some instances? 

Dr. Heather Hirsch: [00:33:38] Yeah, this is a great question, and again, very individualized. But if a woman is using family planning or natural planning as contraception, which we may not necessarily think that we're doing, but we're doing. So, women might know in the middle of their cycle when they're regular, that's probably when you're ovulating. So, that's maybe the time to either avoid intercourse or to be like extra careful because there could be a pregnancy. The eggs release 14 days backwards from when you start bleeding. And this all works really well when your periods are pretty regular. And regular can be any between 25 and 31 days or even a little bit more window.

[00:34:18] But anything that comes at a more regular frequency, that means 14 days prior to the bleeding or going backwards, I guess that's when you're ovulating and that's your highest chance of pregnancy. And most women, I think even if we're not using that as our contraception, we're kind of, we know it. So, what happens in perimenopause is this just goes out the window girls, like, there's just no rhyme or reason for periods can become very irregular. You can start ovulating just more irregular. I was going to say randomly, just eggs are flying around, no. [Cynthia laughs] That's probably not what's happening. But it is. It's the wild west of ovulation, if you will. And so, you could not be expecting to be ovulating. 

[00:34:58] And, there is many, many surprise babies born to women in their 40s. And this could be one reason why. So, you need to think about if you need a form of birth control and menopausal hormone therapy is not a form of contraception. It's not that it can't be used in conjunction with a form of contraception, but if an unintended pregnancy is something that you really don't want, then we also need to think about adding. And again, that's the key. You can add contraception to a menopausal hormone therapy. We can even think about there are newer forms of “I despise the term birth control.” [Cynthia laughs] There is no two words put together that make me cringe more. I cannot think of a way to describe a medication that is just disturbing than it is helpful. 

[00:35:46] So, I like to call some things perimenopausal pills. For example, sometimes I'll put a progesterone only birth control with maybe a postmenopausal estrogen. And there's ways that we cannot have pregnancy and help to treat symptoms. Now chances of pregnancy are still lower just because we are getting older. But again, it's not zero. So, if you're one of those, I have patients, this is a personal decision. Say, well, if it were to happen, that would be wild, but it would be God's choice. And I'm like, “Okay,” [unintelligible [00:36:15]. But there are some women that say, absolutely not, that I want to take no chances. And it makes them very worried. It can also then therefore roll into their sexual life and their sexual function is something they're worried about. 

[00:36:27] So, we've got to address it, especially in perimenopause. And we can do it in ways. And I write about this in my book too. There are ways to do it that are different from the ways we prevented pregnancy in our 20s. Sometimes they're the same, but doses are different, formulations are different, ways that we use it might be different. This combination of using a form of contraception but also relieving symptoms are new to you. So, there's lots of things that we can do. 

Cynthia Thurlow: [00:36:52] Yeah, and I love that you take such a personalized approach, because I think for a lot of women, they're given two or three options and they're told that's all that the options are. And what I'm hearing from you is the integration of, for some instances, some people need a little bit of replenishment of hormones in addition to higher doses hormones to prevent pregnancy. Because again, let me bring it back to one of the statements you made. Hormonal replacement therapy is not the same as contraception. It's important for people to understand it's differing doses. It's used differently. I think for a lot of people-- I have had patients that come to me and they're like, “Oh, I finally got put on hormone replacement therapy and they're in perimenopause and they're really excited.” And then they share with me what they're on. And they're on an oral contraceptive pill. And I'm like, “Okay, well, it's helping your symptoms. But let's make sure that we're really being fully transparent about what we're doing here.”

[00:37:47] Again, another big pain point that a lot of questions came in. Low libido, multifactorial, caused by a lot of things. What is your approach when you're working with a patient who is tracking their symptoms, coming to you, really looking for shared decision making. How do you approach low libido in perimenopause? 

Dr. Heather Hirsch: [00:38:06] For me, I think there is and a lot of amazing clinicians. So, I am not the only one who takes what we call a biopsychosocial approach But we think about, okay, what's going on biologically. It would be like your hormones, but also not just your hormones. What's going on with your other hormones? What's going on with your physiology? Are you on new or other medications that could block your libido? How is your sleep? And then we're getting into sort of the social. How is your relationship? How is this strain? Does it bother you or does it bother your partner? And it's okay if it bothers your partner that it bothers you. But what about the libido? What's your normal. 

[00:38:39] And then there's the social part, which is-- all my friends have the best sex of their lives and I'm feeling left out or I'm feeling pressured or have you had trauma in the past? Because for women, a lot of sexual trauma will come back in perimenopause. Maybe it's the first-time sex hurts again. Maybe it's the first time they feel dryness. Maybe it's the first time they do not want to be touched. [laughs] And it can bring back some of the sexual trauma, whether that's small ‘t’ or that's big ‘T’. There's a lot of different things that can come up for women. So, it is important to take this approach. I would say this is really common.

[00:39:13] Ladies, if you are thinking you are the only one in your friend group that's not having the best sex of your life, that's not having sex at all, that finds it painful, that loves your partner, finds him or her incredibly attractive, but would rather just cuddle like you are by far the norm, right? There's lots of societal pressures on sex, but sex is also a really important part of our relationship. Like there is a [unintelligible 00:39:34]. I'm going to tell you, quite frankly, the first thing I tend to do with patients is just help them feel better. And usually there's something else that's going on. Maybe the sleep is up, is not good. Maybe they're bleeding so much. 

[00:39:48] Like, who wants to have sex [Cynthia laughs] when you're constantly bleeding or you're cramping or you're worried that sex is going to trigger bleeding, like that happens to a lot of women. A lot of women will have bleeding during sex, even if they're not on their period, wondering, like, “What? It's so embarrassing.” That can be a hamper, right? Maybe it's the weight gain. And for whatever reason that makes them not feel sexy. There's so many things, but usually the libido is kind of- unless it's a make it or break it moment where they're like, “Heather, everything in my life's great, except for the libido.” That happens, but less frequently. There is often other things that are going on. 

[00:40:25] And so, I really want to help my patients first, clear some of those things, treat some of those things, get some quick wins. If there is a medical quick win. Sometimes there is, sometimes there isn't. And then once they start to feel better again, that's a good time to then go back and look at some of the hormones. Let's look at your testosterone levels. Let's see if supplementation is something that works for you that we want to do. But I would really kind of just say anyone who has like a quick fix or a band-aid or a pellet, where they're going to put lots of testosterone in your booty, this is going to miss some very crucial things that are happening to you and I promise will otherwise catch up to you if we don't address them now. 

[00:41:04] So, perimenopause is a great time. Again, for a lot of women, it's the first time where, I've had so many patients say, I was always so sexual. I loved sex. I never thought, never in a million years that I wouldn't want to do it. And it's the first time it's happened to them, could be in perimenopause.

Cynthia Thurlow: [00:41:22] Yeah. I think it's so helpful that you have this very comprehensive approach. Are there medications that you see clinically that are lending itself to diminishing libido? Because I think it goes without saying that sometimes it could be perimenopause plus or minus the addition of certain medications, which I sometimes think maybe when a patient's being prescribed one of these drugs, they may not be also told, “Oh, by the way, like, as an example, when I worked in cardiology, I would tell my male patients, especially my young ones, I'm putting you on low pressor or I'm putting you on Coreg. I'm putting you on a beta-blocker, which may make you depressed and may contribute to erectile dysfunction. So, if that happens, please let me know.” 

[00:42:05] And of course, my docs were always like, “What are you doing?” I'm like, I just want-- [crosstalk]

Dr. Heather Hirsch: [00:42:08] What the hell are you-- [crosstalk] 

Cynthia Thurlow: [00:42:10], Let them know, like, if you have experience, this is common to see. It's not just a conversation we should not have with our opposite gender patients. 

Dr. Heather Hirsch: [00:42:20] Quite frankly I would say, it's a little extremist to say, but I wouldn’t go so far as to say any new medication could change your libido. But you're right. What is physiologically-- sex is basically a neurologic, your brain, hormonal and then cardiovascular. It's your blood vessels dilating. It's all these things talking to each other. And a lot of these medications, because chronic diseases start around perimenopause and menopause. That's when we can be put on a new medication. Maybe you're on too much Synthroid. Maybe you just started a beta-blocker. Maybe you just started something, any of those medications that affect. Those are massive, right? Your neurologic wiring, your hormone levels and your cardiovascular system. There's a lot of medications. 

[00:43:08] And in the book, I think, like, I had to be like the top medications, they're most commonly used medications that can change libido. There's a whole page I believe. And so, a lot of medications can. So, just as you said, Cynthia, like, you always probably had this in you, before social media and all of that, patients deserved better. They deserved to know what was happening to them. Despite the fact that they won't go take their low pressor, but, hopefully they did and they're all doing well. But there's so many things that can really change libido. So, it's such a huge category. It's just other medications. 

Cynthia Thurlow: [00:43:46] Absolutely. And you, again, you do such a beautiful job. And I think about this intricate relationship between estrogen and nitric oxide production and how less estrogen endogenously can contribute to less nitric oxide production, which can impact climaxing and orgasms. And I just think these are the kinds of things that are important for people to understand because I have a lot of patients that will say, before I went into perimenopause or before I was in menopause, I used to be able to have an orgasm with my partner or by myself, and now I can't. And so, we'll physiologically talk about what's happening and why estrogen is so important. There is so many reasons why estrogen is important. But helping them understand, like, this is not-- You are suddenly not attracted to your partner. There's so many physiologic changes that are ongoing that are contributing to shifts in libido and ability to have orgasm, etc. 

Dr. Heather Hirsch: [00:44:37] Exactly. I couldn't agree with you more. And sometimes, it's helpful to know why. Sometimes, I think the men are excited to also learn more why, because that's a whole other topic. But then you partner who feel like maybe they're doing something wrong, it's very sensitive, it's very intimate. But again, for the female, there's so many things that are changing, and sometimes, again, it's just nice to know why or what's happening to your body. So, I agree with you. 

Cynthia Thurlow: [00:45:08] Yeah. And just to round out the conversation today, what are some of the most surprising symptoms that patients will report to you? Obviously, this is your zone of genius, but the less common quirky things, like suddenly developing ringing in your ears, tinnitus, or some of the less common things that patients will report, and you're like, “Oh, that actually is a byproduct of shifts in estrogen.”

Dr. Heather Hirsch: [00:45:32] I will tell you. Like, this itchy ear thing, I don't know, it seems to be so benign. But I remember and this must have been two years ago, I said something about it on Instagram and I got flooded. Like, I don't get flooded with the ums that much-- flooded with people being like, “Yes, me too. Yes, me too. Yes, me too.” And it's so benign. It's probably just due to maybe, you know, it's just dry. It might just be a little dry. [Cynthia laughs] We don't really think about our ears, right? Those organs we totally take for granted, right? I would say a lot of women, I think we hit the major things. 

[00:46:12] I think the bloating and the gas is something that a lot of women have routinely sought out GI for. And so now that they're starting to mention it to me, I'm really putting that together. There's got to be a change in the microbiome in the gut at perimenopause. And I know that you probably could speak more on that. Connecting that is something that I think is huge. And I think that's less of a menopausal issue than a perimenopausal issue. Once the hormones stay low, at least they're low and steady, I think the volatility changes the microbiome in the gut significantly. For a lot of women also, it's also a new or the first time they've had a migraine before. 

[00:46:50] And again, this is historically going to send you into the ER because your doctor going to make sure it's not aneurysm, which is a very, very life-threatening emergency. And then you're going to go to the neurologist. And so even though these aren't like totally quirkiest things, they're definitely things that I think seemed so far from having a hormonal cause. And now we're like, “Oh, it's so obvious. How did we not see that before?” Women will report zinging sensation maybe down their leg, which is maybe some neurological changes that they're experiencing. Restless leg starts to start a lot in perimenopause. But we now know what these things are. And so, acne, this is another one. 

[00:47:31] Sometimes actually, I think for some women, they might get a spike in testosterone very transiently, almost as if the hormones from the brain are like telling the ovaries, like, “Come on, squeeze out anything that you got.” [Cynthia laughs] And they're getting all this estrogen. I had the worst breast tenderness yesterday. I just wanted to strap ice into my bra because I felt like, a 12-year-old just-- But you get all this volatility and so acne can also happen. And you're thinking to yourself, what? So where do you go? The dermatologist, right? So again, I think what I'm really excited about this book and to help women because menopause is different and we've really defined that now. 

[00:48:13] But perimenopause, there are millions upon millions of women, not your listeners, but who've never heard this term, who've never heard this word, who are going to seek a bunch of different doctors, start to feel like lost and depressed and confused. But we can break down those silos, talk about it and help women see how actually everything is connected. 

Cynthia Thurlow: [00:48:33] So, yeah, it absolutely is. And it's work like yours that is helping to shift the narrative around this. I so enjoyed connecting with you, reading your book. We will have it out around your publication dates. Please let listeners know how to connect with you outside of this podcast. How to access to your work if they've been living in a vacuum and they are not aware of you across social media. You do such a great job with education. Also, for my clinicians that are listening, you definitely, if you're interested in learning more about hormone replacement therapy. And I've also done Dr. Vonda Wright's course through you as well. You have lots of excellent clinicians, many of whom have been guests on the podcast. Please let them know how to connect with you. 

Dr. Heather Hirsch: [00:49:14] I would love to connect with you. I think community and connection is everything. So, thank you so much for having me on. You can follow me on my socials. I'm @heatherhirschmd pretty much everywhere. If you're interested in any of my-- I have a YouTube channel, lots of stuff for free, tons of free resources. I'd love for you to start cruising through because I really want women to start to feel like what they're going through is normal. If you would like to see me or my team as a patient, my practice is jointhecollaborative.com. So, it's the collaborative. And if you'd like to take a course, if you are a clinician, I mean, I almost always want to say, like, you have to take this class, right? Join this class. It's not just a class, it's really a community. And that's at heatherhirschacademy.com and again, thank you so much for bringing me on to talk about this topic that I love and to talk about my new book. 

Cynthia Thurlow: [00:50:07] Absolutely. Thank you again.

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