How to Understand Your Symptoms, Personalize Your Care, and Finally Find Relief

All women aren’t the same, so why is our menopause treatment? When you understand your menopause type, it doesn’t have to be.

Join me for this unmissable conversation with internal medicine doctor Heather Hirsch about her groundbreaking approach to personalizing menopause care. She explains the six menopause types, hormonal and non-hormonal therapies, mission-critical lifestyle changes to make during menopause, the role of social support, and more.

Plus, you’ll learn about the telling symptoms you might be overlooking.

If you’re approaching or experiencing menopause, you do not want to miss this!


00:04:00 – How the menopause types came to be
00:07:06 – When do the types start to become relevant?
00:09:22 – Signs your Menopause Type is 1
00:10:10 – Menopause Type 2 & the care you need
00:13:36 – What are the risks of menopause at each age?
00:16:33 – The mind-altering menopause type
00:19:36 – Endocrine disruptions in menopause
00:21:09 – The seemingly-never ending menopause type
00:23:19 – My earliest sign of my hormones going sideways
00:29:36 – The silent menopause type
00:31:17 – When should women begin figuring this out?

Freebies From Today’s Episode 

Get Dr. Heather's FREE Menopause Guidebook PDF

Resources Mentioned in this episode

Subscribe to my podcast

Download my Anti-Aging From the Inside Out Cheat Sheet

Read my book, The Virgin Diet

Learn more about Dr. Heather Hirsch

Book: Unlock Your Menopause Type: Personalized Treatments, the Last Word on Hormones and Remedies That Work

Listen to the Health by Heather Hirsch podcast

Follow Dr. Hirsch on TikTok

Study: Scientific Reports: Oral micronized progesterone for perimenopausal night sweats and hot flushes a Phase III Canada-wide randomized placebo-controlled 4-month trial

Listen to Rethinking Breast Cancer Prevention with Dr. Felice Gersh

Listen to Beating Breast Cancer Statistics with Dr. Jenn Simmons

Study: Maturitas: Effect of Menopausal Hormone Therapy on Arterial Wall Echomorphology: Results from the Early versus Late Intervention Trial with Estradiol (ELITE) 

DEXA scan

Click Here To Read Transcript

ATHE_Transcript_Ep 607_Dr. Heather Hirsch
JJ Virgin: [00:00:00] I'm JJ Virgin, PhD dropout, sorry mom, turned four time New York Times best selling author. Yes, I'm a certified nutrition specialist, fitness hall of famer, and I speak at health conferences and trainings around the globe, but I'm driven by my insatiable curiosity and love of science to keep asking questions, digging for answers, and sharing the information I uncover with as many people as I can, and that's why I created the Well Beyond 40 To synthesize and simplify the science of health into actionable strategies to help you thrive.
In each episode, we'll talk about what's working in the world of wellness, from personalized nutrition and healing your metabolism to healthy aging and prescriptive fitness. Join me on the journey to better health so you can love how you look and feel right now and have the energy to play full out.
I'm a total sucker for quizzes, but quizzes that [00:01:00] actually give you actionable information that help you know more about yourself. Yes, please. And that is what we're going to be doing today. We're going to be talking to Dr. Heather Hirsch. She wrote the book. You're going to want it the minute you hear the name, Unlock Your Menopause.
And what she did was identified six different menopause types than what you need to do. And she did that from all of her years of practice and really looking at how can you personalize menopause care? So super cool. Let me tell you a little bit about Heather, who's a ton of fun too. You'll hear it in the interview.
She's a certified internal medicine doc and she practices in New York and she is helping women who are in menopause and perimenopause like really dig into is hormone therapy right for you? What else can you do and personalizing it based on these menopause types, which is super cool. And what's also cool is that she is providing us [00:02:00] with a guidebook that will give you the quiz so you can identify.
And I'm going to put all of that at And I also put the link to her book, Unlock Your Menopause Type. And I'm also going to put the link to her TikTok because she is blowing it up on TikTok and you'll see how fun she is. She's fun. She's brilliant. Someone who started off in
gynecology and obstetrics made the jump into internal medicine and has really gone deep into understanding postmenopause and hormones and all of that. And it answers a lot of these questions that I have had in my head wanting the answers to. She answers them and gives us all of the research, the evidence to back it up.
So you are going to love this. Stay tuned. I'll be right back with Dr. Heather Hirsch.
Dr. Heather Hirsch, welcome to the show.
Dr. Heather Hirsch: I'm so excited and thank you for having me.
JJ Virgin: Well, come on, you've got unlock your menopause type. How could I not have you? I would have hunted you down for this [00:03:00] information.
Dr. Heather Hirsch: I know. I think like, don't we all kind of want to know a little bit more about personalized recommendations, right?
That was supposed to be the tagline. The hook here is, what is your menopause type?
JJ Virgin: Yeah, I love that because we all have our menopause story, so it just makes so much sense to kind of put them into types to figure out what works best. You have six types here. I want to get into them and just for you listening, going, of course, you're going to want to know your type.
Don't worry. We actually have a quiz as part of a guide that Heather's giving you free, so you will be getting that. You know, I'm also the person that on Instagram is going to do, you know, what's my Sex and the City character? Like we love typing and quizzes, right? And this one actually will do something for you as opposed to the Sex and the City character doesn't really change your life much.
So, what I would love to start with is your origin story, because you got into this, you created [00:04:00] these types, how did this all come to be? Well,
Dr. Heather Hirsch: that is a loaded question, but in, in an effort to not be here all day with my story, I always wanted to take care of women. And I was a women's studies major in college, and as I went to medical school, I thought, well, the only way to take care of women is to deliver babies.
And still, this idea that women's health is. Contraception and obstetrics is still kind of embedded in our mind, but I didn't love being up in the middle of the night. I love delivering babies and I didn't love surgery. So I transferred to internal medicine from an OBGYN residency. And I love the intersection between women's health and obstetrics and internal medicine.
And then I ended up doing a fellowship in late reproductive care and menopausal midlife at Cleveland clinic in 2014. And. Truth be told, up until about 2000, 2014, I hadn't thought about menopause once, or perimenopause. Yeah, well how old were you? It just wasn't on my radar. Early 30s. And [00:05:00] I was watching women fly from all over the country to come to Cleveland, of all places, not like the most desirable city, complaining about…
All these different symptoms and was HRT safe? And my mentor was like, yes, HRT is safe. And here's the evidence behind it. And I just had my aha moment. I was like, oh my gosh, one, this is so fascinating of the intersection of into chronic disease development and you've got the biopsychosocial model.
You've got mental health concerns. You've got all these physical changes and it was just so fascinating to me. And I realized very quickly. That no one was really doing due diligence to this aspect in a woman's life. Not in the medical community, at least, not 10 years ago. And I knew this is what I wanted to do.
I loved counseling women. I loved helping them make, you know, what are seemingly difficult decisions or individualized decisions. And I loved it so much. And that's what I've been doing for the last decade. Nice.
JJ Virgin: Yeah, it is so interesting. Maybe 10 or 15 [00:06:00] years ago, I was eavesdropping on a group of women in the pool.
And they were all talking about going through menopause and getting prescribed Prozac and birth control pills. And I don't think we've moved much past that, which is so wild. I do think it takes women doing this because you've got to know what it feels. You aren't there yet, right? Where are you?
Dr. Heather Hirsch: What an interesting question.
I don't think anyone's asked me that lately.
JJ Virgin: You said everything was on the table, so here we go.
Dr. Heather Hirsch: Everything is. I'm probably in early perimenopause. And I know this because I get the most intense perimenopausal rage right before my period. I know when people tell me, I just want to like throw a lamp at my partner.
I'm like, oh yeah.
I'm most likely an early perimenopause, or could I be a little bit biased and just blaming my mood swings on that? You know, maybe a little bit of this, a little bit of that. That's probably where [00:07:00] I am in this wild transition. So you created
JJ Virgin: these six menopause types. Do these types start to come in at perimenopause?
Like where do they start to fit into the model?
Dr. Heather Hirsch: What a good question. The answer to that question is, when I wrote this book, I was almost thinking retrospectively, or like, if I could reverse engineer where you are in your menopause stage, what was that driving type? That, you know, therefore kind of led to these symptoms and truth be told, poor old little perimenopause was a little bit left out of the conversation.
So that may be something that I'm working on now because perimenopause, either fortunately or unfortunately, can be a totally different story than menopause. So to these types, I really do think of them more in terms of how menopause goes once your periods have really stopped. And it could or could not be different in perimenopause, the time leading up to that, which would be [00:08:00] anywhere from one to ten frickin years.
JJ Virgin: Alright, so let's dig into these types then. And first of all, how did you figure these out?
Dr. Heather Hirsch: Truth be told, when I was talking to my literary agent, she said to me, you know, Heather, You want to write a book about menopause? Great. There's a good amount of books about menopause. So, what's going to make you so different?
Why do people want to read your book? And I said, well, because I really take an individualized approach. And she's like, great. But you can't individualize a book for millions of women. So, go, you know, think on that and come back to me. And I was on a plane. Don't know where I was going. I cannot remember.
But they just came to me like a flood. Like these six different types of menopause. And that's really where they came from. Now, certainly, of course, that's from my long experience. In doing midlife and menopausal medicine and management, but they came to me on a plane and since then I looked at them and looked at them and looked at them and there they were.
They hadn't changed from the [00:09:00] day that I wrote them down on my notebook on the plane to the book that you're reading now.
JJ Virgin: That's so cool. Well, you know, you said they just kind of came out, but they were years in the making. You got it. Yeah. Right. So it wasn't just like, Oh, dream it up. So let's do a high level through each of these ones.
Dr. Heather Hirsch: Absolutely. I'll do a super, super high level so we don't have to get too much into the weeds. The first type is premature menopause. And what is crucial about this is that if your menopause was before age 40, that's called premature and before age 45 is early. And hormone replacement therapy And the gold standard of care, truthfully, the reason for your menopause, but that's because without hormone replacement therapy, women with premature and early menopause are at increased risk for cardiovascular disease, bone loss, probably also brain changes, and worsening quality of life.
And about 1 5 percent of the population will [00:10:00] have premature early menopause, and 5 percent is still, you know, couple million women every single year. And so that's really important that we recognize. The second is sudden and sudden often, but not always, is brought on by a pretty drastic diagnosis, cancer diagnosis.
You have to have chemo or you have to have your ovary surgically removed, or perhaps you had to go on Lupron, a medication that shuts down your ovaries for severe endometriosis, and it just suddenly puts you into menopause. And so you wake up one day making a bunch of hormones and the next day you're gone.
JJ Virgin: With that one. Is that also the standard of care is to do hormone replacement therapy?
Dr. Heather Hirsch: This one is really interesting because there can be an overlap here between premature and sudden, right? So what does that mean if you're 39? So it really depends for younger women, the ideology now in [00:11:00] 2023, going into 2024 is what is the real line where we can't give hormone therapy because if we've cured your cancer.
We might still put you at increased risk for cardiovascular disease, which is the leading cause of death in women. So it's a really fine balance. So you could have both sudden and premature, and that is a really high level conversation to have with your doctor.
JJ Virgin: Okay. I just want to point one thing out that you said, and I wrote it down on the premature.
You said, you know, we want to give them hormones because you're at increased risk for cardiovascular disease, for your bone health, for your brain health, but isn't that the case for any woman when they… Go through
Dr. Heather Hirsch: menopause? So this is a great question. The answer is yes, but the caveat is that for younger women, you talk about HRT.
So as we get into like full throttle, which is next, is an option for women. It's an option and that's absolutely true. And I think more women [00:12:00] should know how safe and effective hormone therapy is. But for my younger patients, it's almost like a hormone deficiency. So think of more like type 1 diabetics.
You've got type 1 diabetes. We've got to give you insulin. Because without it, you're drastically at increased risk because more and more time is going to elapse and you're going to feel so much older, you know, have more potentially chronic health conditions earlier on. So for the premature, it's really more thought of like the same you would treat.
Diabetes or hypothyroidism. You don't have this hormone. I've got to give it back to you. Versus yes, those risks are the same for someone who's also 53 or 54, but they're a little bit different in terms of how obvious the outcome is. And we still say to women, of course, you have a choice here. It's an
JJ Virgin: option.
I just wonder if it's just accepted at that age, these things are going to happen. And I'll tell you what happened that was so interesting for me seeing this [00:13:00] firsthand was I used to work out of a doctor's office, helping him with taking the labs and then giving them their nutritional recommendations and lifestyle recommendations.
And I could tell. With women who were post menopausal, I could tell who was on hormones and who wasn't purely by looking at it. I mean, it was so odd. Fascinating. It was like, Oh, you know, you could see it in their cholesterol panel, like boomf. Wow. Yeah. Crazy. So at any age, bones, brain, heart. All right. Let's dig into a full throttle.
Dr. Heather Hirsch: This is such a great question that you asked, and we'll incorporate what are the risks of menopause, you know, at each age. You know, I thought of my patient that just, like, had to tell, right? Losing hair, and brain fog, and irritability, and can't sleep, and hot flashes, and bachelor dryness, and low libido, and low energy, and everything, right?
Just kind of all hit you at once. That's really what I call full throttle. Speaking about hormone therapy, I really do often recommend hormone therapy with full throttle. It almost, the [00:14:00] name sounds like… I am on fire, right? You know, truthfully, we'll talk about how the benefits for the majority of women outweigh the risks when starting hormone therapy within 10 years from menopause.
And so that's kind of your classic full throttle. Is
JJ Virgin: there, for the full throttle, are there things that maybe diet and lifestyle, like someone who's more stressed, maybe someone with higher body fat, someone who's maybe smoking, are there things that would push people into full throttle?
Dr. Heather Hirsch: I thought you were going to ask that they could do that are lifestyles.
JJ Virgin: Yeah, like, yeah, smoking and drinking. No, it's like, you know, right.
Dr. Heather Hirsch: But when those things exacerbate it, someone coming in like massively stressed out and not sleeping well already because of the stress and not doing exercise and eating a high sugar, high fat processed food diet, et cetera. This is a great question because I can totally, I want to say, oh, of course.
Yes, yes, yes. But, I think the real answer is, I don't know to [00:15:00] what degree, of course, it's not going to help, but I always say to my patients, and like my listeners too, that menopause, especially something like a full throttle, There is a underlying physiologic process going on where your body's got all these receptors for estrogen and they're also screaming and yelling like, where's the estrogen?
And you just don't have it anymore. You're not making it. I say sometimes when your symptoms are really bad. You cannot out yoga your way out of it, you cannot exercise your way out of it. Now, to your question, working 12 hours a day and eating McDonalds or whatever fast food because you're so stressed, is that going to help?
I'm just wondering
JJ Virgin: if you saw any commonalities, like, with these people coming in, were they like total driven type A's? Or was it just luck of the draw? Maybe some genetics, like
Dr. Heather Hirsch: I feel like it was more luck of the draw. I really do. [00:16:00] Or unlucky luck. The draw, although that is really churning my brain a little bit and I wonder if there are lifestyle or like identifiers that we could look through in just what I'm seeing.
So I think that's fascinating question.
JJ Virgin: We'll, we'll revisit that on the next podcast, but you think about it and go, I would just pull one out, like stress. Yeah. I mean, that would be such an obvious one. Stress and insulin resistance, cortisol issues and insulin resistance have got to be contributors over here.
Dr. Heather Hirsch: They're probably not helping, but then actually we get into the mind altering menopause type to which stress also is no friend. And so the mind altering menopause type is a nod to something that I saw that was so common in my world. With it, some women didn't come in with the traditional hot flashes and nice wives, but just anhedonia, depression, lack of motivation, just not [00:17:00] even recognizing themselves.
Like they used to say, I had the big corporate job and a billion things to do. And I loved it. And now I wake up and I don't want to do any of it anymore. And I don't know who I am. And that mental health change. Was so obvious to me. I saw it all the time. And these women now in 2023, as we get into 2024, I think there's been much more awareness on the mental health changes about menopause.
Usually they had been to their doctor and a psychiatrist and a psychologist and a counselor and, you know, working so hard and then oftentimes. And not always, because I certainly don't want to, you know, give treatment advice, but let's say they had tried everything we try hormone therapy. Fascinating.
They would feel so much better. And there is a small research study that was done at the end of 2022 where it's a little different. It was giving women in late perimenopause estrogen [00:18:00] patches before their period and their mood really improved. So I think there's also. This aspect of menopause that really affects our mental status for some women and that's the driving factor.
And because we don't recognize that so much in society, they spend a lot of time looking for different clinicians only to realize that what if the mental health changes were from menopause?
JJ Virgin: Yeah. And you just missed the easiest way to fix it. I remember being at a conference and, you know, kind of a high level throwaway line.
They're like, testosterone for men and estrogen for women are like nature's Prozac for them. And I was like, ah, you can dance all around it, but what if it's just your estrogen dumped?
Dr. Heather Hirsch: I think this is the right place to say the fact that women lose estrogen, progesterone, and testosterone in the middle of their lives, right? Gone. And this fact hasn't [00:19:00] been interwoven into every single facet of women's lives is crazy, crazy to me, because the way it intersects with chronic health, mental health, we talked about that, talked a little bit or alluded to like sleep disruptions, about work productivity, about cardiac health, about bone health, about all of quality of life.
It is wild to me that this has been just really ignored.
JJ Virgin: Yeah. I actually don't know what it doesn't impact.
Dr. Heather Hirsch: I do. I honestly don't know either. I mean, there's estrogen receptors. From our hair to our toenail.
JJ Virgin: And then couple that with quite often thyroid issues start to precede it too. And then you've got like a just boom.
Dr. Heather Hirsch: Absolutely. Absolutely. Other endocrine disruptions play into that. How does estrogen affect insulin, affect adrenaline, affect leptin? We could go on and on, but you know, yeah, there's so many different facets of menopause. And the [00:20:00] highest group of age bracket for suicide among Caucasian women is women age 45 to 55.
JJ Virgin: Oh my gosh. Well, that says it all right there. Yeah, it does. Because if you think about it, now the kids are older. So if anything, generally your kids are older, things are starting to kind of settle down a little bit, except in my household. And it's like, it should be like this better time of life. And of course.
You're not there, but when you get to 50, there's a little magic switch that flips, and you just don't care about most of the stuff you ever cared about. You realize, like,
Dr. Heather Hirsch: it doesn't matter. I can't, I can't wait for that.
JJ Virgin: I always joke that I would turn, have turned 50 at 20 had I known, like, if someone had told me about it.
I know we're about to get into the, which I'm afraid of, the seemingly never ending menopause type, but I was just speaking at a conference yesterday and this gal waited till after and was sitting down with me. I was talking about powerful aging and body composition and what you need to do and how you need to eat and exercise.
And she goes, I have been doing all this. I've [00:21:00] been trying everything. You know, I'm post menopausal five years. I go, just go get hormones and stop it already. Like what? You know, it's like, come on. Anyway, let's talk. Seemingly never ending menopause type. Like, each of these, you're like, Oh, I don't want that.
I'm like, really don't want this one.
Dr. Heather Hirsch: Well, I have a feeling that won't be you. And I'll tell you why. There's two big reasons for this type. One, about 10 percent or so of women will have symptoms that do last the rest of their life. And we know this from long term research. And also this type, I think is very reminiscent of the woman that went through menopause, maybe 10, 15 years ago, was told there was never anything that she could do, always puts everyone in her life before her, as women usually do.
Yeah, exactly. And then, you know, it's kind of like, gosh, my symptoms are still bothering, looks at her watch and is like, Oh, it's been a decade. And we were told, especially when I, at the time of writing this book. You know, it's really the [00:22:00] boomers, women probably now in their 60s, that just, ugh, they should be so freaking mad because they were told hormone therapy is going to kill you, it's going to give you breast cancer, it's going to give you heart disease, there's nothing you can do, this is all going to go away.
And you know, now they're a little out of that 10 year window. Now I don't play by the, the door shuts at 10 years. I don't play that game. I, I do individual consults with women who are quote unquote out of that timing window. Which the Menopause Society recommends you start within 10 years of menopause.
But that generation really was, you know, kind of shut out from this conversation. And now they're in their 60s or mid 60s, maybe in their 70s. Or, again, women who have constantly just put everyone before them. Or maybe had the occasional hot flash or the vaginal dryness that has just never, ever, ever gone away.
So there's still plenty of things that you can do if you fall into that
JJ Virgin: category. That is great to know. And I would love to dig into. So I am the tail end of the boomers. Just turned 60 and tail end of the boomers. But I am very fortunate in that pretty [00:23:00] much all my best friends are gynecologists. Yes. My 50th birthday party was Dr.
Sarah Gottfried, Dr. Anna Kubetka, Dr. J, like it was very fun. I almost was probably over doctored, but like I've been on hormones since things went slightly awry. Which for anyone listening, my earliest sign of knowing something was going sideways was I could not recover at the gym. I would go in, I go, I'm like, not even doing as hard.
I could not recover. And then my gums started to bleed a little bit. Oh, bleeding gums. Yeah. And I went to the dentist. I'm like, what the hell is this? He goes, estrogen and I'm like, what? You know? So it is so important for us to look at all of these signs. And then find the person who's not going to tell us we're crazy, fire them.
Okay. So I do want to dig into, before we go to silent menopause type, because you brought up something that I think is so critical and I'm sure you've heard the story about the grandmother who always cut the end of the [00:24:00] roast and put it into the pan. And so the mother cut the end of the roast and put it in the pan.
And so the daughter started doing it and the daughter's like, why are we throwing away this part of the roast, put it in the pan? And turns out the great grandmother had a small pan. And, you know, I look at some of this stuff and go, where did this 10 year window come from? And was it one study where they only had funding for this amount of time?
Like, when I had a son who… was in the hospital for a traumatic brain injury, and I wanted to know about using progesterone. I found the guy who did the studies, and I'm like, would you start this after? And he goes, yeah, we just only had money for this length of time for the study. When I hear this, I go, why is this window, the door would magically shut at 10 years?
Why would that be? If it would last for 5 years, why wouldn't it last for 20 years? Why is there a door shutting? Yes,
Dr. Heather Hirsch: I got you on this one. Okay, because this is a great question. What is the origin of this story? Gosh, I could spend a whole hour on this, but I'm going to do my very best here to summarize before the biggest thing, which is Women's Health Initiative, in the [00:25:00] 70s and 80s, everyone got estrogen and menopause.
And just estrogen, no progesterone. That's a story for another day. And in the 70s and 80s, they saw that women were living longer and had less heart disease and felt great. And so in 1992, the American College of Physicians advocated strongly for the use of hormone therapy in post menopausal women. Well, the 90s is when they were like, well, we need randomized controlled trials.
Those are the best. Okay. So they did. And that's called the Women's Health Study. And the Women's Health Study is not that it was a bad or flawed study. It's just that the details of the study Can't be extrapolated in the way that they were and they were really globally. But anyways, what they found, of course, the study stopped in 2002, so the studies really started in the late nineties and went to 2002, and it stopped because of this apparent increased risk of breast cancer.
We, which was people al, it's total bss. That's another long story, but yeah,
JJ Virgin: we'll link, we actually did two [00:26:00] podcasts on the total BS of that with Dr. Felice Gersh and Dr. Jen Simmons debunking it. So wonderful,
Dr. Heather Hirsch: wonderful, wonderful. You know, and then essentially what they did from those women's health cohorts is every several years they would do what's called post hoc analysis.
So they'd re chop up the data. And in 2007 and then in 2013 and 2017, they really realized that the women who benefited actually had reductions in cardiovascular disease were the women within 10 years of menopause. Then, there was a study called the ELITE trial done by Dr. Howard Hodes in Southern California, and he looked at giving estrogen to women who had menopause greater than 7 years and then less than 4 years, so a little different.
What he found is that, what explains the hypothesis is that when it's been, we're gonna say 7 years, 10 years, or probably longer since your last menstrual period, your body just has not seen your good old friend estrogen in a while. [00:27:00] And if you have some plaque buildup on your arteries, and it's been a decade since you've last seen estrogen, estrogen at that point may be, may is the key word, it depends on how healthy are you, a little bit pro inflammatory can flick off one of those little pieces of plaque that can go on to cause a clot.
Now compare that to if you start within 10 years of menopause, now I know I just said seven, but. Give it 10. I'm just using some of these years here to paint this picture. Your body has seen tons and tons of estrogen. Estrogen releases nitric oxide. Nitric oxide is a nice vasodilator, dilates all the vessels around your heart.
That's why there was less heart disease. And so your body's released estrogen, estrogen's really anti inflammatory. But the more time that goes by and the more health risks that you have at the time, do you already have dyslipidemia? Yeah, I do already have. You know, diabetes, bup, bup, bup, bup, bup, ideally, you know, earlier is better.
Now, if there weren't so many fricking [00:28:00] biases and misconceptions and myths about HRT, nobody would want to wait till they were having 12 years of symptoms. So how come you're doing a lot to encourage women to be better educated about whether HRT is right for them sooner rather than later? And also, that's why, because I might have a perfectly healthy 62 year old, so she may be out of the window if menopause was 50, but if she really is otherwise healthy and no hypercardiovascular risk disease, et cetera, et cetera, et cetera, I still use transdermal estrogen, because also, too, in those studies, just to your point, which was like, what's the information that we're missing?
A lot of it was on oral estrodiol.
JJ Virgin: Oh my gosh, come on! Then you would have clotting and issues and… Yeah, that's, that's ridiculous.
Dr. Heather Hirsch: Right. When I have patients who are quote unquote outside the window, what I'm doing is I'm looking at, you know, how healthy is this person in front of me, how bad is their quality of life, how much have they been suffering, what is their bone status, blah, blah, blah, blah, blah.[00:29:00]
And then, you know, seeing if they can still do hormone therapy, and oftentimes they can. But you know, if you want to follow it to be kind of a least evidence based and you got to look at all of those things. And also I hope that explained a little bit about like where that window even
JJ Virgin: is for you. I mean, I hear that and go, all right, well, why wouldn't you just evaluate
Dr. Heather Hirsch: plaque?
Exactly. And a lot of times that we do, I see a lot of times women come to me for a second opinion. This doctor said, absolutely not because. My period was 10 years ago and I say, okay, come on in, come to
JJ Virgin: me. I love that you're looking beyond the thing. That is fantastic. Okay, let's dig into silent menopause type.
Dr. Heather Hirsch: And then silent really goes back to exactly what you said, you know, earlier on. This is about how does our heart change? How does our cholesterol change? How do our bones change? How does our brain change? How does the pelvic floor change? And so what I love about the silent type, and I think that interestingly, it kind of became the type that After, [00:30:00] you know, doing all the podcasts and talking to people, this was actually the one I thought was gonna be the most boring, actually the most interesting to people, because if you never have a hot flash, good for you.
But our, how does our body change inside, you know, and if you are one of those lucky women who doesn't have hot flashes, sometimes I think you're actually even less likely to even think about menopause or think about hormone therapy. Now, it's not really indicated, FDA approved, unless you have symptoms, but again, I really like to have all my patients have the facts and then help them make a decision.
And what I think is really important here is that our body changes drastically. And if you don't have a hot flash, don't forget about it.
JJ Virgin: And I think what we really need to look for, what I would also call symptoms, your LDL just shot up, the things that you wouldn't think about as a symptom, cause you're just thinking of the everyday, I hot flash, I can't sleep.
My gums are bleeding. But what about the things like going and getting a DEXA and seeing [00:31:00] your bone mineral density? Like, what are those things? What happens if your blood sugar starts to ride up a little bit? So there's other things that you wouldn't be overt symptoms, those silent ones that should be, to me, part of that whole evaluation, which it sounds like you're doing, which is so awesome.
Dr. Heather Hirsch: You got it. You nailed it.
JJ Virgin: When does someone start to look at this and at what point does hormone replacement therapy come into
Dr. Heather Hirsch: play? Another excellent question, I do hormone replacement therapy, well actually, and just to clarify, I say HRT all the time, HRT, the R actually stands for replacement, and it's really actually meant to be for women with premature menopause, the hormone replacement therapy, and hormone therapy is, HT is supposed to be, we, we interchange these terms all the time, but I had to get that off my chest so I didn't worry about it later.
But anyways, I really take a really individualized approach to this. So I have many patients in perimenopause, we start postmenopausal HRT, much to the chagrin of a [00:32:00] lot of clinicians who were not trained on, you know, they'll say to my patients, you have to go a year of having no period. That's not true.
JJ Virgin: You just suffer a year? What would be the reason? I mean, I started it before my periods ended. Exactly.
Dr. Heather Hirsch: Yep. Me too. I put that down, so I don't run around with the rage yet. I don't know. I think that of course, education and training on perimenopause and menopause is wildly inadequate. And there may be some doctors who feel uneasy prescribing.
HRT to women who are still having periods. And to be quite honest, I really don't know why because I'm not one of those clinicians. I'm not even sure. I really can't even guess why. But I was just, you know, when I was at my fellowship, my mentor, Dr. Thacker, trained me on how to prescribe postmenopausal estrogen and prometrium to women who are perimenopausal and it works wonders.
So, I start all the way from perimenopause all the way up to that 65 year old woman who comes to [00:33:00] me crying and says, you know, Heather, I've been watching TikTok and I'm looking at the calendar here and like, can I still take HRT? So I got the full spectrum going on.
JJ Virgin: Nice. I love it. I know you're killing it on TikTok.
Dr. Heather Hirsch: Oh, yeah. Well, thank you. I mean, I, I love TikTok as a user. Like I do scroll every single night. I love it. And it's like, I feel like I want to buy an Airbnb and then make Halloween cookies and then clean out my basement and then learn something about lupus. Like I love it. Right. So I, I love TikTok as a user and I just have a lot of fun learning how to do it.
And we absolutely underestimate women in midlife. Everyone told me at the time, Oh, midlife menopausal women aren't on TikTok. Oh, yes,
JJ Virgin: they are. Clearly they are. And clearly they are, because my girlfriend Natalie Jill's on there too, with midlife conversations. Yes, yes. You know, Natalie,
Dr. Heather Hirsch: I follow her.
JJ Virgin: Oh, you should know Natalie.
You're going to get in our family here. [00:34:00] I'm making notes of people intro to you too. Here's the thing. We are going to link to your TikTok. We are also going to link, you did a super cool quiz and guide. Now this guide is not a substitute for the book. You got to get the book too. We'll link to that. The unlock your menopause type.
Obviously you want to grab the guide, do the quiz, get the book. So we'll have all of this in the show notes. And that of course is underneath the podcast player, but you can also go to so that you can figure this out. You probably are listening and identifying, but you know, the quiz will give you the true notes and then you'll also have what to do about it, which is of course the most important thing.
No point finding out something if you can't do anything about it. So I love the fact that you put in nutrition, And exercise and all of this, you know, of course, I love the fact put in exercise, old exercise physiologist. This is all fantastic. I super appreciate you like letting me just go rogue with questions.
Dr. Heather Hirsch: I love it. And you [00:35:00] asked me some of the best questions. I really have a running list of some things that you've really inspired me to take into, you know, what things could maybe bring on full throttle menopause. Just some great questions and I love this dialogue. I love this conversation. It's fantastic.
JJ Virgin: Thank you. This is a subject that is near and dear to my heart. And also, I was so fortunate As I started to go through this, my son was in a near fatal accident. Literally, I had doctors, like Dr. Prudence Hall, came to the hospital and helped me. Because, you know, if anything's going to throw your hormones off quickly, it's seeing your son in the ICU on a ventilator, right?
And so I just, I've been so fortunate to have access to this information and to not have to suffer. And so that is my big goal is to bring these brilliant minds out into the world because I feel like most people now they can't have the access. 10 years ago, like it was very difficult. Now [00:36:00] the access is out there, but access without taking action is not useful.
So make sure that as you're listening to this again, take the quiz. Get the book, get in action. You don't need to suffer. And thank you so much, Heather. I super appreciate you.
Dr. Heather Hirsch: You're welcome. Virtual hug. I mean, it's just been my pleasure to meet with you and hear your incredible attitude and your outlook and your story and that message.
It's so refreshing to be around. So thank you. Yay!
JJ Virgin: Thank you. Be sure to join me next time for more tools, tips, and techniques you can incorporate into everyday life to ensure you look and feel great. And more importantly, that you're built to last. And check me out on Instagram, Facebook, YouTube, and my website, jjvirgin. com. And make sure to follow my podcast so you don't miss a single episode at See you next time.[00:37:00]
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