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

The leading cause of death in women is heart disease. This, to me, is a huge reason to consider an apostle hormone therapy. So what estrogen does is it opens the blood vessels. So you get better blood flow and that is preventing cardiovascular disease. And they have improved cognitive function at the time at which they start it. There is an increased risk for dementia or other cognitive challenges when individuals are to believe a firm. They have all seen their parents struggle with cognitive decline. I was timers and dementia. Something I action going through in my own life. What are women doing wrong? As a society of women, we stay in the suffering period for far too long. And we've really normalized suffering, putting on a face and just getting the things done. However, sometimes that can be as a dead tremendous. I don't care how much you work out. I don't care how well that you eat. If we were talking about estrogen, they would be disaster. They have certain receptors that are only going to be affected by those hormones. The biggest concern I hear patients say is they're concerned about breast cancer with estrogen. We've never actually proven that estrogen itself causes breast cancer. Sounds almost criminal to say aloud, but it'll say this idea that estrogen is dangerous and harmful truly came from. [Music] Dr. Heather Hershey, Dr. Lyon. You're a superstar and I want to share with you where I first saw you live in an action. Oh, wait. FDA. We're on an expert panel, doing some extremely important work and really changing the perception of hormone replacement therapy. Yeah. That was such an important moment. Actually, you know, I've been on stages before, but I was not as nervous for anything else as I was before that camp or pan to me because I knew that thousands of women were going to be watching live. This panel, which was a group of expert clinicians coming together to speak with Commissioner Martin Carey about the safety of hormone therapy, had a lot of stakes involved. And so I was also opening that. So I really wanted to kick it off and really make a nice impression and set the stage for the rest of my amazing colleagues to then do their work. You did, you really did a fantastic job and I recommend that anyone who is listening or viewing this, check out that is available and we'll link it. Hormone replacement therapy for women. Yeah. Huge topic. What happened? Yeah. And where are we out right now? You know, the story of hormone replacement therapy is an interesting one. And it's more a media frenzy and a little bit of myth it than there is. Sort of an actual scientific story that kind of goes along with it. So in the late 1980s and early 1990s, the majority of women were on hormone replacement therapy. And actually it's good to define what hormone replacement therapy is. I think that's always excellent to do. Typically it means an estrogen and then plus or minus a progestin or pergesterone if a woman has an intact uterus. Although you can take it even if you don't. And then plus or minus testosterone. And then sometimes plus or minus vaginal estrogen. So, menopausal hormone therapy can be a wide range of things. So most women were given estrogen as kind of the key component of hormone therapy in the 80s and 90s. And in 1992, the American College of Physicians, like at their annual meetings, strongly advocated that most women take estrogen shortly after menopause. However, there was no randomized controlled trials yet, but prospectively, the clinicians were seeing that the women who were taking hormone therapy were living longer, having better bones and having less heart disease. So they went to the NIH and said, we got to put together a randomized controlled double-blinded study. So they enrolled thousands of women. Actually, it's one of the biggest randomized controlled trials we've ever had. You know, the NIH spent billions of dollars over multiple sites. Now inherent in that was they got women enrolled in the study who were closer to the age of 62 or 63. So on average, 12.3 years later than the average age of menopause, which was 50. It's now 51. It's actually slightly pretty big upwards. And they give women one dose and one formulation of hormone therapy. So if you didn't have a uterus, you could take Premerin and that was conjugated equine estrogen, 0.65 and you took that alone without a progestin. And then if you did have a uterus, you were given Prem Pro. Actually, at the same estrogen dose 0.65 of conjugated equine estrogen and then Medoxy progesterone acetate. So this study sets the stage for what will happen in a few years in 2002. In the summer of 2002, a press report was held where they said, hormone therapy is dangerous. And what they said is that it increased the risk of breast cancer, but it was only in the women on estrogen and progesterone. The women in the estrogen only were actually doing great. No safety threshold was crossed there, but they were noticing increased diagnoses of breast cancer. And the meter reported a 26% increased risk of invasive breast cancer. Now if you- 26% increased risk. Yes. Now if you don't know the difference between relative risk and absolute risk, that sounds really scary. That sounds like a quarter of the women were getting breast cancer. But the translation of that was 2 to 4 women out of a thousand over five years on oral Prem Pro-Ethept dose. 2 to 4 women out of a thousand over five years on that one dose and formulation. Now later they went on to find that even women who are in the placebo group who got breast cancer, comparatively, they had less mortality from breast cancer in the women who took the hormone therapy. We'll come back to that later when we talk about breast cancer myths. So hold that thought. They also then said, well, and it increased the risk of cardiovascular disease, strokes, and so that was kind of the end. You know, the damage was done. Hormone therapy was considered kryptonite from 2002 onwards. Although there's been so much data and evidence to the contrary, to show how safe estrogen is, to debunk the myths about breast cancer risk, and to show that when it's taken within 10 years, human-duffentastic, they live longer. They do have less heart disease. They do have better bone health. The problem and the discrepancy really was that when they were looking at those prospective studies in the 80s and in the early 90s, women were given hormone therapy right around the time of menopause, whereas in the Women's Health Initiative, they were much older. In fact, the age range was 50 to 79. So you had women in the early 70s that were given hormone therapy for this trial. That really mixes up physiology, right? You have different stages of life. Women who maybe are not as healthy as they are today. And so that kind of landed us in this hole like is hormone therapy bad. So a plethora of data shows that it is good for us. And that's kind of why we're here today. Is because we are still breaking down those myths and misconceptions. In the 80s and 90s, the majority of women were put on hormone. And I think that you and some of your cohorts have, instead of calling it hormone or replacement therapy, do you not call it menopause hormone? Is it therapy? So what is it? It's menopause hormone therapy. Yeah. Well, so the interesting thing about the names is that hormone replacement therapy or HRT is something that actually we use when they're physiologically replacing hormones in women who've had premature or early menopause. Which would be 40. Yeah, premature menopause is before age 40. And that could be from surgery or that could be from premature ovarian insufficiency. And then early menopause is if you have menopause under age 45. So then between 40 and 45. So you're supposed to physiologically replace their estrogen almost like a diabetic where you're physiologically replacing their insulin. So for women who experienced menopause at more of a natural age 46 and up, it's kind of easier to call it menopausal hormone therapy or MHT. But even, you know, us as experts, we kind of use that interchangeably all the time. How we understand the blind spot? Late 80s, early 90s, everybody is on hormone replacement therapies. Is that accurate to say? The data shows that about 50 sometimes 65% of women in certain studies were taking menopausal hormone therapy or an estrogen. And then an estrogen plus a progestin in that time. Is it as ubiquitous or was it as ubiquitous as safe birth control? And let me bring this up. Yeah. Someone goes to their physician and says, a maybe younger all in their 20s. I'm PMS or I don't want to get pregnant. There is no second thoughts of giving someone birth control. Is it fair to say that potentially that is how it was in the 80s and 90s? You know, what I will say because I wasn't there. I was just a little kid at the time. But my colleagues will tell me, you know, they remember prescribing menopausal hormone therapy. It's like this joy. Like, oh, now you kind of have this. They would say things, you know, like, you know, fountain of youth or, you know, the vitamin D or sort of like the life hormone. I would hear them say all these different things as I was talking about menopausal hormone therapy. Now, you know, 15 years after the women's health initiative, they were like, you know, Heather, you weren't there. But it was so common and we did it with such joy prescribing or month air fee. At the time, were there health risks where people concerned about? Because right now, and still to this day, and I think for the last, easily the last 20 years, I get, you know, I'm still a practicing physician. I shared almost every day. Is it safe? Yep. If I take estrogen, will I get breast cancer? Will it cause blood clotting stroke? Talk to me about the safety profiles. Yeah. So let's actually look at the data. Sometimes it's helpful to sort of, I always say to my patients, let's do the logical and we'll keep the emotional aside. Because let's start with breast cancer. It is very emotional. I don't want any of my patients, we don't want any of our patients to get diagnosed with breast cancer. However, on the logical side, we know that about one and eight women will be diagnosed and then it's really common. And that luckily now, that doesn't lead to mortality or death when it's caught early. What is actually the leading cause of death in women as you and I both know is heart disease. And there's, you know, so much, there's so much still emotion around the breast cancer diagnosis. Diagnosis, even though heart disease or heart attack could kill you immediately. So in the studies, they found this 26% increased risk in breast cancer. That absolute risk is actually fairly small. Two to four women out of a thousand over five years. That's actually not statistically significant. What they also found was, as mentioned before, when you got breast cancer in the placebo group, those women actually had higher mortality or higher death rate. So it didn't mean you had a higher death rate. Now, here's the important point. Remember we talked about how they used a synthetic progestin, a joxy progesterone acetate in the Women's Health Initiative. But the women who didn't take the progestin 'cause they didn't have their uterus, they could take estrogen only. They were actually showing less breast cancer than the placebo. So then the thought was maybe it was the progestin. So they do this study where then they replace that synthetic progestin with what would call bioidentical progesterone, which just means prometrium or progesterone. Doesn't mean compounded can be compounded, can be commercially available. And when they swapped the progestin for the progesterone, they saw no increased risk of breast cancer above a woman's baseline. That means that starting hormone therapy, if you're using bioidentical progesterone and if you're using now, more times we use bioidentical estradiol in different formulations, we can talk about that. Pill versus patch, gel, et cetera. If it's not gonna increase your risk above baseline and there's massive benefits like reducing heart disease, the leading cause of death in women and improving bones so you don't have an osteoporic fracture, which has a high morbidity and mortality rate. There is major benefits to considering hormone therapy. - You know that feeling after a really hard training session where the last thing you wanna do is sit down and eat a full meal, yeah, I get it. And I'm not about forcing down a stake when my body just isn't ready for it. But here's the thing, intense exercise and really all exercise is catabolic, meaning it increases muscle breakdown. So to protect my muscle and build new muscle and recover, I consume essential amino acids around my workout. This helps with the recovery. Body health, perfect amino helps me hit the protein threshold I need to stimulate muscle with minimal calories and not a huge digested burden like a large sink. The workout was the hard part, but the recovery doesn't have to be. Head to bodyhealth.com and use the code lion20 to get 20% off your first order. That's a bodyhealth.com and use the code lion20. - It just, it seems like a huge blind spot. - Yep. - That there are a whole cohort of women that are not protected because they didn't have the ability to start hormone replacement. And when I say didn't have the ability, I remember. So I finished fellowship 2015. People weren't really talking about hormone replacement therapy. I had to learn it. It's from those quote, I don't even want to say underground physicians, but essentially the physicians that were still treating. You bring up a really good point. The physicians prior said it was amazing. The women's health initiative comes out. People stop, - First cry ring. - First cry ring. - And stop teaching. - But the question becomes how, how did that happen? - Yeah. - And do you think that the data was examined? It seems like just a huge mess. - Yeah. So from what I hear, what are my good friends and colleagues actually Jim Simon, I'll put it in for this. He said, if they had done the women's health initiative on with progesterone and maybe a trans-normal estrogen patch, and maybe women who are closer to the menopausal age, it could be a completely different world. Now that's easy to say in retrospect, right? Or being a backsy driver. How could they have used this medication? Although that medication's not bad. So are those medications used now? You know, for example, those medications that we talked about conjugated equine estrogen, I still use that medication because actually, it has the most safety data. It is a part of one of the biggest randomized control trial, like we said, the WHOI. Although most women these days really want bio-identical or plant-based estrogen, so I don't have the opportunity to prescribe it too much. Prem Pro, I don't prescribe all that much actually. And so, you know, one of the things was we used a combination of oral synthetic hormones that we don't use now. And again, we used women who were slightly older, but when that study came out, it was a frenzy. I mean, women were throwing their hormone therapy in the garbage, down the toilets. Physicians were calling their patients. We have to get off this. Right after it came out, it was like an explosion. And so my colleagues tell me, it was one of the craziest days in medicine at that time. Why was there not a challenge? 'Cause you had mentioned relative risk and absolute risk. Yeah. I'm sure that people were examining if it was open to the public, was I don't know if the data, if the data sets were open at the time. Right. But one would think, okay, these are much older. Again, there was a difference between relative or risk and absolute risk. Right. I'm assuming that the data from that time hasn't changed. So where did the pendulum swing the other way? 'Cause now people like yourself are really pushing for just education awareness. What happened? How come it went from this is terrible? Right. To now, okay, we're willing to re-evaluate this. I don't know. I think you're right. There were definitely clinicians at the time who actually, it's funny, read the study. Because I think the headlines were so drastic and everywhere. Everyone was covering it, time magazine, and all the papers, which was like the social media at the time, right? They didn't have tick, talk then, but imagine it was just your whole tick, talk feed was this. And that really got into the psyche of clinicians and women. So then two things happened. Clinicians became scared, and maybe they didn't read the studies, which is fair. If they're trying to do all these other things and physicians are really busy, they took the headlines from what they were. And we can't really blame them, even though it's easy to sort of say, in hindsight, why didn't you read the study? Then you did have these group of clinicians. My mentor, her name's Dr. Thacker. She was my fellowship director at Cleveland Clinic, and so from 2014 to 2016, this was all I studied. And she was the one who really forced me to look line by line through the Women's Health Initiative. And what helped, I'll tell you this, is they did post-talk analysis a couple years later. And what really solidified it for me was when they took the women who were within 10 years from an opus and really studied them. That first came out, I think, around 2007. And so the Women's Health Initiative, the estrogen, progesterone, arm closed in 2002, the estrogen only group, actually went about two years later, and then it just closed down for no reason. But it wasn't a few years later until they had that post-talk analysis. And they really looked at the women who were age 50 to 60, or within 10 years of menopause. And it's jarring how well they did, how well they did reductions in heart disease, reductions in all class mortality, reductions in all cancer diagnoses, better bones, and of course, better menopausal symptoms, which, you know, really didn't even make the news here at this point. Quality of life for women is a whole other topic we could talk about because we're not even considering that at this point. And that's what really solidified it. And then I think with social media, building around 2016 and onwards, and clinicians kind of finding each other digitally as opposed to in, you know, universities or academic centers or private practices, that really helped encourage other people to say, oh, you're right. Or oh yeah, that's what this number means. Wow, we did second. When we read the studies, we've kind of dooped. What are the risks of hormone replacement therapy? And I wanna break it down to estrogen, progesterone, progesterone, or progestins. Yeah, we can talk about the difference too. And testosterone. Oh, I love this question because honestly, I'm gonna answer you and it's not gonna be all that significant. If we look at, actually. let's do estrogen last because if we look at progesterone, progesterone does not have any major inherent risk of blood clots, cardiovascular disease, and alone, although there's not terribly many studies on women taking gestorgesterone alone, and this time I'm talking about micronized natural progesterone or permetrium, the bioidentical, which is a slang term, but progesterone. And bioidentical just to pause is just the same compound as what would be produced in a human body. Exactly, although it's still made in a lab, just like everything else, but it's a little bit more, it's more identical to what you would actually make versus a progestin, which is synthetic, often found in birth control films. So we don't see any increased risk of breast cancer with that either, just like I mentioned, there was a study when they swapped the progestin for progesterone with estrogen, and they said no increased risk of breast cancer. Progesterone is really safe, and this is important because you may ask me during this show, you know, what if a woman can't take estrogen, she could still potentially take progesterone, which may help with sleep, which may help with anxiety and other things. Same testosterone. Now my good friend and colleague Dr. Kelly Casperson will often say there's a big data free zone when it comes to test testosterone in women, and as you probably know and have studied, there is a hole in, you know, the use of androgens for women, pre-butt postmenopausal as well. And we don't see, as for now, although we need more studies, we need more longer term and more randomized controls, but we don't see increased risk of clot strokes, cancers or breast cancers. Great. So that means that these two are options for women who maybe have risks from just estrogen. Okay, now let's go to estrogen. When we use estrogen, it depends if we're talking about transdermally or oral. So the risk of a blood clot on oral estrogen is very small, specifically postmenopausal oral estrogen, much smaller than the risk on birth control pills. But again, like you already said, how ubiquitous is it to give young women a free productive age who don't want an unintended pregnancy, birth control pills? Just rolls right off, right? So it's the women postmenopause who get, you know, kind of get millified when they talk about estrogen or this risk for clots, even though many of these women have been on birth control, but pregnant had surgeries and do well. So there's a slight increased risk of a clot if you're on oral estrogen, but again, much smaller than if you're on birth control pills, much smaller than if you're pregnant or ever had surgery. If you use transdermal, which is a patch spray or gel, and there's a ring also, this set of trials called the astertrials or ester studies showed that the transdermal estrogen does not increase the risk of blood clot. And so we're going to remove blood clots as a risk when you're using transdermal estrogen. So this is really wonderful. And then the breast cancer thing comes back up, right? And that really has to do with what are you pairing it with? They're using progesterone or a progestin. And also, even when it comes to is breast cancer or risk, it's really hard for me to say that estrogen directly causes a breast cancer. I think a lot of breast cancer is genetic. It's environmental. So if you have a really, really small tumor because they take such a long time to actually develop so you could actually see it. If it has an estrogen receptor on it, it may grow faster. It may there cause it to show up earlier, but you may get treated faster, which is why the women in the placebo group back in the original WHO may have had higher death rates from breast cancer compared to the women with a hormone therapy in the WHO. So that's a mouthful. Yeah, well, I want to pause there. This is very important for the listener or for the viewer. The biggest concern I hear patients say is they're concerned about breast cancer with estrogen therapy? Yep. What I just heard you say is that let's say someone has undiagnosed breast cancer. And potentially it's estrogen positive. The estrogen that one would take doesn't cause the cancer. It's not causal. Could it accelerate the growth of a tumor? Yes, but could it cause cancer? There's a big difference between something that's causative, something, you know, say an initiation factor. This is how we think about it in nutritional sciences, initiation factor versus something that would then perpetuate what is already in motion. Right, exactly. Exactly. So we've never actually proven that estrogen itself causes breast cancer. And so I think that's really a concern. Where do we, do we know? I think this idea that estrogen is dangerous in the harmful truly came from the breast report that happened in the summer of 2002. And that media frenzy that there was a 26% increase in breast cancer. It just switched people's minds to really after that find it really hard to disassociate estrogen from breast cancer. Even though again, you know, logically when you look at it and we speak with just the logic and we take the emotional part out of it, it's really easy to see. And so this is a lot of what goes into counseling for women who want to start and take hormone therapy. But you know, we have to then sometimes think this way too. The risk of taking hormone therapy, again, we've called it, I like to call it an associated risk with breast cancer, but again, what do other people, what would other people say? You know, there's still a lot of data. There's still clinicians that will say, you can only take hormone therapy for five years because of the five year mark. I think that's when it could increase your risk of breast cancer. The zone doesn't make any sense to me because breast cancer isn't like on a clock, for example. That may come from the WGI, where they found that that increase was started after five years. But again, it just takes time for a tumor to develop and show up on a mammogram. So you'll hear sometimes clinicians still say, if you have a family history, I won't prescribe you hormone therapy because reasonable. You're at higher risk. Is there a kind of a hierarchy or decision-making tree that you go through, that you feel confident and comfortable is safe and also not on the contrary overblown or overprotective? How do you do that? Yeah. Well, look, I think this is a great time to say, what are the risks that you're not taking hormone therapy? And what are those? Right. Accelerated aging, although nobody wants to hear that, right? That sounds as though I have a biased and I don't feel as though women only have one option. But I really want them to know what happens to their body when they lose estrogen. But wait, but there really isn't a replacement for estrogen. If you are devoid of certain hormones, again, people can do whatever they want. But again, if we're being really transparent, they're, yeah, if we're talking about estrogen's impact or even testosterone, they have certain receptors that are only going to be affected by those hormones. And, yeah, and I do, I totally appreciate that it is absolutely a personal choice. But if you don't have it, it's, yeah, I mean, again, there is no replacement for what the body would mean. Right. Exactly. And so you know, you have accelerated bone loss at the time of menopause. And that is I, you know, and I haven't seen any data. I am so curious as the estrogen input versus if we know that there's a way to help with through training and nutrition. I mean, my guess is that it wouldn't be nearly as significant. I mean, it's critical. That would be a great trial. It would be really interesting. Yes, that would be a great trial. And you could probably do that where women just self select which group they're in. So accelerated bone aging. Yeah. And how fast is that? So it doesn't want to be completely through manopause once to actually have accelerated bone loss. So, you know, your peak bone mass is somewhere around like 20, 30, right? And then it will start to decline. But right around the time that we lose our estrogen in menopause, it's going to like do like another big dive. And that's because estrogen helps keep those bones from breaking down. So when you lose that protective benefit, there's start to break down more rapidly than they're building up. And so what estrogen therefore is doing is really keeping you, you know, healthy in a way. Because if you have a fracture of your spine or your hip, that could be so detrimental for the rest of your life. Because you spend a long time in bed, you're going to atrophy, your muscles are going to waste. And then you have to relearn so many things if you fracture, right? So it's so, so, so important. Would you give it when you think about it, if we talk about the, what are the benefits? And we know that estrogen is bone protective. Does it matter the form? Does it matter if it is transdermal? Does it matter the kind? Does it need to be estradiol? Yeah. So we don't really have enough data. It's so many data free zones here, right? We don't have enough data to kind of put all the different kinds of estrogen in a row. And then C is one better for bone than others. Or a lot of women will ask all the time, what is the serum level I need to ensure bone health? We have so many things. Because I, I, I, the Asmode is as well, my car. Yeah. A colleague of mine. How do you have a, a framework for thinking about that? You know, I very early, a very, some day to came out in the 90s, then estrogen level probably around even 40. So like not that high is really good for bones and we have an ultra low dose patch called the Menestar patch. It's 0.14 weekly patch which is even lower than our pretty standard patches or gels that usually start around 0.25 milligrams. But even that was shown to help with bones. So I have a hunch that you don't need much to help with bones. And I think you got to though at that with all the good things that you should be doing. Of course, strict training and eating well and getting only for vitamin D and calcium. So I'm not really sure. The biggest data set that we do have comes from again, the WHOI. And so this study is so crucial and it's so funny because I think I probably talk about this more than any other study because it is where a lot of our safety data does come from. The decisions to start women on hormone therapy at what age they are. A lot of those will go back to the women's health initiative. That's what it's been a lot of time teaching. But you see the massive benefit with conjugated equine estrogen because that was the oral bramaran that they used in the study. Although again, clinically because I've been treating patients for the last 10, 12 years, I see their bone densities improve uneven small doses of the patch. How long? Okay, one reason why someone would choose to own estrogen would be for protection of bone loss. What else? Well, the symptoms. Oh yes. Yes. So you know, I love how you have this preventative visual field, right? And I love that. And one of the reasons I enjoy the conversation about menopausal hormone therapy is so that women start to think about the preventative benefits of estrogen. And in the menopausal world and hormone therapy world, that's even a little controversial. Which it is. You know, really? Yes. Okay. And this is because of hormone therapy is not FDA approved for prevention of anything. Even though we do clearly see it in studies and particularly for women who start closer to menopause. Every year when the, you know, the preventative task force services comes out with grades for medications for their preventative benefit, hormone therapy always gets like an F. And everyone text me like, can you believe it? Can you believe it? And I'm like, yeah, I can still believe it. But, you know, so the preventative benefits are something that a lot of women now are thinking about more than they were before. But I would say the majority of women come in with symptoms. And they're like, oh, Dr. Hersh, I'm not sleeping. I have terrible brain fog. I'm losing my hair. I'm losing my eyelashes. They'll say I'm vaginal dryness during a track infections. And those symptoms are what usually get them to start googling or Instagram and you're tick-tocking. And then, you know, there's a lot more information than there used to be. And so then they're asking more questions like, what else can it help with? So symptoms. I like the osteoporosis aspect. Yeah. Symptoms makes a lot of sense. And I, yep, I definitely want to touch on the vaso-mother symptoms. Yes. Because once hormone therapy got a bad rap, it seems as if people started to use a lot of SSR eyes. SSR eyes rose like 60%. At the same time as they were pulling women off their hormone therapy, they had to do something. Because these women were experiencing terrible symptoms. You also had the rise of compounded hormone therapy at the same time too. Because some women were like, oh no, I got to solve this problem. Right? Yes. So we have mistreatment for some of these symptoms. When, what is going through and thinking about a hormone therapy, what have put cardiovascular disease? Because again, we've had Martha Gulotti on the show. She's amazing. Female, focused, cardiologist, truly extraordinary. And we spoke a lot about estrogen, cardiovascular health. What is your perspective in terms of, again, I recognize that we don't use hormones for treatment. Right. Well, that's what the WTI was supposed to do. They were like, well, great women are living longer and having less heart disease. Let's do this randomized control child and see that estrogen prevents cardiovascular disease. Now, of course, in the study ended early and there were all these fears. And you had women who were all these ages. But look, when we look at women within 10 years of menopause, we see clear reductions in cardiovascular disease, reduction in heart attacks. This is huge, huge. So what estrogen does is it's a vasodilator, releases nitric oxide. And so that opens the blood vessels. So you get better blood flow. So think about that, right? You're getting better blood flow through your heart. You're, you know, those coronary arteries are working at their maximum. They're feeding the muscle around the heart. And that is preventing cardiovascular disease. And so this to me is a huge reason to consider menopausal hormone therapy. And so that fits right alongside with the preventative benefits, like bones, heart disease. And it also has been shown to increase health span. And there's no other medicine. And how do we define that? Health span, different than lifespan, right? And different than sex span as Moa, I was saying, and different person muscle span is, that's on T.R. Go. Oh, I need to learn about muscle span. Okay. Yes. I mean, health span the way I define how span is just how long you leave, how long you live a healthy life, right? So lifespan just how long you live, but you can live with chronic disease and pain and poor quality of life. And that's not really what we want, right? We want to live healthy lives where we're doing what we love, playing the sports that we like, or we're using our brains in the way that make us feel like ourselves. We're working. We are engaging in communities. We're doing all the things that we want. What about this idea that you're either in menopause or you're not? Because if we talk about the benefits of estrogen, and we think about it again, from bone, from heart, from cognitive function, which I would love to hear your perspective. Yeah. Typically, from what I've seen, is individuals will wait until they're in menopause to begin treatment. Mm hmm. I'm actually seeing, well, I love this question. Let's talk about this. Because you can biohack your way out of pairing menopause and menopause if you want to, you can start hormone therapy earlier. In fact, I talked a lot about that in my new book. And I started doing that myself, right? So now, luckily, I kind of have a lot of information at my fingertips. And I have some good resources and some good doctors. But you're right. Kind of this idea that let's wait until the symptoms are really severe, or I will still hear women say, you know, I can stick it out a little bit longer, or I know I only have a short window where I can use it. So I want to put all those years together. These are all myths that we kind of need to, you know, let go of. The idea is you can start low doses of estrogen or progesterone and or testosterone when you're still menstruating and you're having cycles. In fact, you can use them if you, you know, even have severe postpartum issues. We could talk about what that means if you're breastfeeding, but some of these options can be used postpartum. More popular though would be parrymenopause and then leading into menopause because what we don't want is women who are saying, gosh, now I'm 65 now I'm 75. I didn't get the chance to be counseled on hormone therapy. Am I too old? Am I out of the window? You want to start women and have them think about this and trial it sooner rather than later. Cooking is a major pain and convenience slays and yes, I just said slays are placed. One of the sponsors of the show makes the wonder oven and by the way, it comes in amazing colors. It is a gorgeous little toaster oven and it's in all in one. It has an air fryer oven. It's made from stainless steel and glass. You're not just cooking your food in questionable coating type appliances. 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But somebody is listening to this thinking, okay, maybe my doctor doesn't have access to or hasn't yet taken your course. How do we begin to dose them? Yeah, so I actually always start by symptoms that actually helps me because in the beginning of the show we talked about menopause will hormone therapy or HRT is estrogen plus the progesterone, maybe plus or minus plus or minus testosterone plus or minus vaginal estrogen. And so kind of if you think about it, I was going to say Chipotle, which by, you know, if you think about it, sometimes you're kind of like, hmm, you could just get a bowl with chicken if you want and just be like, I'll always want my protein. You can walk right out to Chipotle. There's nothing wrong with that. You don't have to build the. super massive, you know, bulls that everyone's doing. So if a woman has symptoms that sound more like low progesterone, which would be anxiety or insomnia, just feeling, you know, a little bit more overly thinking things or losing confidence in sometimes. These are subtle things. There's kind of an art to this science. And sometimes we'll try a woman on progesterone first. My usual go-to would be to start with low dose per metrium or micro-insatial progesterone, 100 milligrams. If you want to go lower, you have to compound it to say 50 or 25 milligrams because the lowest commercial available dose is 100 milligrams. And progesterone's a fun hormone to start because women will know in two days whether it helps them or it doesn't. And if it helps them, they might feel that it helped them sleep. They kind of, it's a nice anti-anxiety because of the way it increases GABA in the brain. - Take GABA agonist is that? - Yes, it's really wonderful. I've actually prescribed it for anxiety before, just straight up anxiety. But it has to be taken at night. It causes drowsiness. It definitely causes drowsiness. Although I have some women that it does it. So everyone's different. You know, all the patients say, "I've been taking it in the morning for years." And I'm like, "Wow." But yes, a lot of coffee comes in. - Yeah, yeah. I would definitely say that one's a good one to take before that. - And nobody, there's no contraindication that we know for progesterone, is that correct? - Mostly. Although if you have an allergy to peanuts, since a lot of the commercially available progesterones are made or they're packaged with peanuts, you want to make sure if you have a peanut oil allergy that you actually are going to have to go the compounded route. - What about blood levels, blood markers, progesterone? You know, this one's always challenging to me because here's kind of what my thoughts are. I have looked at my patients' labs for years. And what I will tell you is that symptoms will always trump lab work because, you know, a woman may, you know, certainly have actually progesterone intolerance, basically where the gap is working way too well. And they feel way too sedated or way too groggy. And so they just probably don't want to stay on. Maybe that progesterone formulation. And so whatever their labs are actually, it's probably too much for them. So I always want to think about what is your clinical symptoms and then what do your labs look like as well? You know, a lot of my, what we don't have clear correlations on is does progesterone in the bloodstream is getting to where we want it to go, which is really to go to your uterus to ensure that also while it's treating your symptoms and your brain and you're sleeping and all those good things, is it also protecting your uterus if you're taking estrogen later on. And we don't really have a great way to correlate if your blood level is two and a half set enough for uterine safety, it's have to be higher, could be lower. So we're not really sure. I'm definitely glad that you point that out because again, people shouldn't be taking estrogen alone. Right. If they have a uterus and they're postmenopausal. But we don't know exactly the right dose for a progesterone. It's a little tough. Yeah. You know, we have guidelines and standards so that based on if you're on both, you can always actually take more progesterone than estrogen, but not the other way around. So you don't want to be on too much estrogen and on a progesterone in the very rare case that could increase the risk of uterine cancer. So we want to kind of use this standard guidelines that we have. But yes, another place for more data is how much progesterone do we need. Now, if you're a woman who does well on progesterone, it makes you feel fantastic. This isn't going to be an issue for you because you're going to probably be, you know, taking your progesterone and it's protecting uterus. It's more of an issue for women who actually find side effects from the progesterone. They really want to know, gosh, how much do I really need? Because why feel so much better in the estrogen? What do the side effects of progesterone look like? Yeah. So I think that it may have been me, but yeah, I don't want to give myself credit what I just not do. But this idea of progesterone intolerance is something I started to see over the last decade. And what I see in this is specifically for prometrium, not so much for the synthetic progesterone, but for prometrium, which I think has the most impact on the CNS, it really goes through that blood brain barriers, so you can really get these these brain impacts. About a third of women love progesterone. They feel like it finally helps their insomnia and helps their anxiety and they feel so much better. About a third of women don't really have much of an effect from the progesterone, and so they may take it just because they're adding an estrogen later on for their symptoms. For example, we're talking about how do you start hormone therapy and paramedicolids, more of the hot and dry hot flashes, night sweats, dry skin, all of those things. That's the more where you start aloe dos estrogen. So for those third of women who feel so progesterone really kind of doesn't, is just neutral. They're taking it's they're taking their estrogen. Then about a third of women love side effects and actually I'd break this down into a third, mild moderate severe. So mild progesterone feel intolerance feels just kind of like it makes you feel a little like a little sedated and you might need a little bit more coffee the next day. Sometimes they maybe feel a little bloating all the same. My rings are a little tight, but nothing that they're like this is this is bad. More of the moderate and into severe, you'll get really bad mood disorders. Almost like if you're triggering low mood before your period or PMS because actually that's when progesterone would normally rise right before your period. So they may feel depressed. I've had women have suicidal thoughts on progesterone and that's more in the severe category. Significant bloating, so much water retention, they'll put on five or 10 pounds from the progesterone. Fast within a few days. Yeah, I would say most women know within even just a few nights if they're either going to love it kind of have no effects or they're going to have some side effects. And sometimes you have to play along with dosing a little bit because it might be too high or maybe it's too low. But the interesting thing about progesterone is it will have an impact pretty soon. Whereas estrogen, I usually say takes about two-ish four weeks to know like where you're feeling on on estrogen. And I think testosterone can take even longer because it's slowly building up in your system. Where's progesterone? So the one that's like I'll tell you in like two nights if you like it or not. That's in and also fast out. The half is really short. Really short. So the good news is if you are going to not tolerate it, you're going to be one of those women that has side effects, it'll be gone pretty quickly. Do you have to take a break? Is it something that has to be used so cleanly? Oh great question. So you don't have to. And actually one of the reasons women will do this is to take breaks is if they have a little bit of intolerance. For them, they'll say, you know, if I take it for 12 nights of the month or if I take it every other night, it's not so bad. I'm not sure why that is. Maybe there is a little buildup in the system. So every other night, they sometimes feel better. So they'd rather do it cyclically. Some women will do that, will do cyclic. If they're still having some breakthrough bleeding, especially if they're in that late parimenopause phase, or even if menopause was just a year or so ago, sometimes they'll do it cyclically so that they kind of have a bleed and that they don't have to have unpredictable bleeding. That one is also just a pain because the one I think about menopause is you stop bleeding, right? Somewhere where I will just say if I don't have to take it every night, I'll just take it 12 nights, but you know, women will take it continuously because again, they'll fall into that. I really like to progesterone effects. I can't sleep without it. So they'll take it nightly and I recommend they don't do it cyclically because then they just have trouble sleeping for, you know, half the month. And if someone is already getting either still getting their period, do you have them time progesterone? For example, if it's the day that she's supposed to have her period, will you have her continued progesterone or will you have her stop that? So again, it's going to depend on how they feel on progesterone. So sometimes for first starting and we want to see if the progesterone will help the symptoms, especially if they worsen right before her period. We'll try that and then kind of have her stop as she starts bleeding. One of the things I do with my patients, which sounds almost criminal to say out loud, but I'll say go with what your body thinks. If you took it and you felt great and you want to try it day one, day two, if you're if you're still bleeding, see what happens because I know what she's doing. And I also know that everyone's going to respond so differently. Do we have an upper limit of how much one could take for progesterone? You know, I would say you can certainly go up to 300. Some studies show that that's where sleep is actually impacted the best if you're going to use progesterone for insomnia, literally trouble falling asleep. But it's a pretty happy dose. Like you might be really kind of sedated the next day. I am a patient who seeks 400 milligrams and it doesn't make her feel sedated at all. And that dose actually really helps her sleep. I don't probably have many people if any over 400 milligrams of commercially available progesterone. Tisosterone. Yes. Was it testosterone? Talk to me about testosterone. Oh, big fan of testosterone. And again, I say that sort of with this smile on my face of, you know, again, every woman is so different. I have had women take testosterone. I even get to really good levels and they'll say, I just don't know if it's doing anything for me. And I'll say, okay, do we want to stay off it or do we want to come, you know, do you want to just stay on it? And sometimes they'll say, I feel like, you know, I've done some research. It's probably doing some good things. Even though I don't like feeling I'll stay on it. And some of them are like, well, it's one of those things to do. And I don't really feel any different. So I'll just kind of stop it. You know, so again, I really just want to say for the record in the middle of the show. Again, I think all women, you know, are different. There's no right or wrong answer. But I don't want women to feel afraid, especially trialing these medications because a lot of women you don't know how much is going to help you until you literally try it on, right? And FDA approval. Yeah. Oh, gosh. You know, so when it comes to what matters more to me is we're moving the, uh, D E A, um, constriction around testosterone, right? So what that means is it's really hard for women to get because it's considered a controlled substance. So that means when I prescribe it, I have to constantly refill it because I can only do it for a month, women are having to give out their licenses for it. And some of them feel like that's so uncomfortable. And I understand that some of them are like rolling their eyes, thinking like, okay, this is what I have to do, right? And then an FDA approved medication would mean that we have something that's appropriately dosed for women, which because we don't have that, and you probably do this as well. We take the male dose and we dilute it, but it's really easy to screw it up, right? And even that even for me, I feel like this would be very hard to do because you kind of have to guess if either you're using a gel or you're using a so brine, sometimes you're going to get a little bit more, sometimes a little bit less. And so that's when FDA approved product would hopefully do, which I do think maybe that will be in our future. Um, we're when actually don't have to kind of guess their doses anymore. That would be fantastic. And we're moving the D E A. This is silly. You know, this is saying that women are abusing testosterone and we have no proof of that. Um, most women don't want to abuse testosterone because they don't want to lose other beautiful hair. Like they don't want to abuse testosterone, right? And you know, I think this is patriarchal in sexist. And so hopefully this will change at some point, but let's talk about the benefits of testosterone. You know, I would say my women will see the 2019 global consensus position statement paper came out about the use of testosterone, which really kind of said, um, it was endorsed by the menopause society, the British menopause society, the endocrine society, um, low doses of transdermal estrogen for postmenopausal women. We see the majority of benefits in that group for high blacked sexual desire disorder, low libido. Okay, great. But I'm going to go out here and say my patients who use testosterone feel better mood, less brain fog, less exercise fatigue. Um, they feel as though they're seeing their physique, they're seeing their muscles when they're lifting, when they're using testosterone. And they kind of just feel like it was a cherry on top of their hormone therapy. What about safety risks of testosterone? Yeah. So, you know, we know that if testosterone is going to get too high, you want to check liver function tests, you want to check cholesterol. Sometimes I will see patients with really high levels and you might see some liver dysregulation, some cholesterol dysfunction. And so those are important to watch testosterone to me as a tricky one. We're in this conundrum where women do benefit from these medications. But when we don't have enough clinicians who know how to prescribe them, we're getting women who are maybe getting overtreated, some women under treated. And so what we want to do really, truly is just train more clinicians, get the message out there so that women can safely get on their testosterone without judgment and be safely monitored and we get more studies. So, you know, we don't yet see again, we don't have the longest term studies. We don't have randomized control trials that increase cancer risk, cardiovascular disease or stroke, the big things that scared women from estrogen 25 years ago. So, testosterone really when used appropriately and those levels don't get too high because I think a lot of the side effects are correlated with levels. If it's, if it's done well, I don't see a lot of side effects from testosterone. How do you look at their numbers? Do you say, okay, well, I would like to see testosterone or free testosterone here. So, again, this one is where I will sort of have discussed ranges for women. One of the things that I think that's difficult in this category is I don't, can I say this? I don't really know that I trust the lab work because sometimes it just feels like it is all over the place. Like I just, like, is this calibrated right? Is one lab different than this lab? Because my patients sometimes will come in with their levels that, you know, look like they're flagged or they're high, but they don't have any side effects. They're otherwise doing well. They've been on this dose for a while. And so, to, you know, you're kind of trying to explain to your patient, even though this level is maybe 80 or 100, it's, it's okay for you, right? We'll keep monitoring you for a while. So, they get a little nervous. They get nervous. I would say, I don't know that I have specific targets because I will also have women who will use a little bit of test in gel and they will feel so much better. And we'll look at their testosterone and it went from, you know, 14 to 30. And I don't have enough data to say, like, let's keep going on that because they're like, I feel, I feel good now. Okay. You know, it's so you see such a wide range. I will say this, my younger women, my esolatic women and women with polycystic ovarian syndrome tend to do better on higher testosterone levels. I think that's because their body is used to it. And so they might feel the impact of testosterone at 70 or 100 or 100 time because they might have had those levels floating around in their body. It's then women who didn't so get next younger women, especially if they had surgical menopause and they're, you know, 36 for a high risk of, you know, ovarian cancer, they need their androgens replaced. Women with PCOS tend to have higher circulating, you know, androgens. And so their bodies are familiar with that and they're used to that. And then my athletes, I do see that they do feel better when their levels are higher, whatever that means. 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And all you need is one teaspoon to get the most out of these amazing bioactive ingredients in Manuka honey. And now it's easier than ever to try. Manacura honey had to manacura.com/doctorlion to save up to 31% plus $25 worth of this free starter kit, which is amazing. I have one. It comes with this massive jar of Manuka honey. That is go to M-A-N-U-K-O-R-A.com/doctorlion and save 31% plus $25 worth of free gifts. And what I'm hearing you say is that we don't have a great number. We don't have a great number for bone production. We don't. Okay, so be easily whether it is testosterone estrogen or progesterone. We don't have great numbers as to where someone is that true. As opposed to we know that your luteinizing hormone is elevated or your alpha stimulating hormone is elevated. We know that the high number, potentially also with no period means you're in menopause, but we don't have a. Yeah. Because in my critical practice, I really struggle with this because I want to target it to shoot for. And I think a lot of the listeners, whether they're physicians or providers, or thinking, "Well, for bone protection or for brain protection, yeah, I would like my estrogen or estrival at X, Y, and Z." Yeah. So we don't have those numbers. It's really hard, right? And think about why I can understand we're like, "Can we want you to say something? Wait." Yeah. Now, you know, as I'm thinking this, but for men, you know, if it's less than 250, someone could say, "Well, you have loteinis not wrong." Right. Exactly. But that's interesting because how does that work for women? Yeah. Well, that's a different podcast of the different ways that we study men and women. I think and how much historically men have, you know, gotten studied, how much we've looked more. I bet if we looked at numbers more and more and more and more, if we looked at numbers, but we'd have to really look at numbers in this way. So what level of estrogen helps your hot flashes? What level of estrogen helps your mood? What level of estrogen helps your bone health? I bet you it's actually different. It may not be the same. And then the other. But it's different for I bet you're right. Meaning that at say 30 estrogen level, estrogen levels of 30. How many stops hot flashes? Yeah. I agree. Do it. Does it help your bones? Right. We don't know. Right. We think so. So we don't want to scare anyone either. This is all hypothetical. And what if you're younger? What if you're older? I think it's actually a bigger story here when it comes to numbers. So this is what I teach for all the clinicians who take courses from me. Right. There's a lot of people and we do like numbers. We want your A1 C to be a certain number. We want your blood pressure to be a certain number. We like. So we like numbers and they're objective. And so we're like, we can just get to that number. Right. There's a little bit of an art to this. Right. Just like the woman who feels better when her testosterone is 35 and my other patient feels better when her testosterone is 110. And so there's probably completely different physiology going on. And they're probably looking at different outcomes. And they're probably completely different genetically. And so I think there's a. a lot more to the numbers story. There are definitely clinicians who say, you know, I have a colleague who will really want the FSH number, which is high postman, a puzzly, to be lower than 25. And you can bring that FSH down by adding estrogen, by adding progesterone, by adding vitamin D. And his research, you know, he says, when that FSH is lower, there's more optimization, optimization kind of brought. But this is really what he kind of likes to start new too. I find that if I try to do that, I find them in pushing my patients into side effects from medications, if I'm trying to get to that number. So this is where that art and science comes from. Okay. Now, I want to shift gears to cognitive function. I know. I know. We wanted to talk about this. I think it's really important because I did an AMA and I felt really comfortable saying that hormone replacement therapy. And I say hormone replacement therapy, you can use it however you want. Yep. Really estrogen to testosterone. There is some effect on cognitive health. Meaning, I think that there is an increased risk for dementia or other cognitive challenges when individuals are devoid of hormones. I don't have a randomized control trial. And I don't think any of us have randomized control trials. We probably won't get one. We will probably will not get one, but as a trained geriatrician, I can say when there's androgen deprivation therapy or when people are depriving individuals' hormones, we have enough data that there is likely a negative outcome. Yeah. So I'm curious to what you would say when there's and it's typically people that don't treat patients will say we have randomized control trials to say this would help with the risk of dementia or cognitive impairment. Yeah. And actually, this kind of debate was really sparked when the same day is actually the boxable warning was removed on hormone therapy. So then there was this idea that is there an updated show that hormone therapy reduces the risk of dementia. So here's what I'll tell you, I think, and and all the reasons why I think the same way as you. I think there absolutely has to be neuro-cognitive benefits. In the same way that there's cardiovascular benefits, you have this vasodilation. And you see this when we prescribe menopausal hormone therapy for women because we see less heart disease, even genatoyourinacinstream of menopause. You're getting blood flow down to the pelvis, the pelvis doesn't die just because we went through menopause, right? So this seems going to happen in your brain. You're going to get all this rich blood flow to the brain. It's going to help remove all the toxins out of the out of the brains, right? And while I'm not a neurologist, I can also definitely say that when my patients do start hormone therapy, initially their cognitive function improves. I will be proof positive of this. If I forget my estrogen, I will have word finding difficulty the next day. And my entire team will say, "Did you forget your estrogen?" Now, that is different because we're talking about something acute versus something long-term. However, those early studies that they're doing now on the impacts of the brain and use of estrogen are extremely promising. And I have a, I have a, you know, an idea of maybe what might happen. So one thing that we say when it comes to hormone therapy and diabetes, this has been proven into so many studies that men who take hormone therapy have less diabetes. But we don't say prevents diabetes. What is clinicians, the right thing to say is, hormone therapy decreases the diagnosis of diabetes. Why the word prevention, especially among absolutists and scientists and clinicians, means a lot to them. Like, you know, they don't want it thrown around. So I have a prediction that we will see improvements in brain health long term with the use of estrogen started around the time of menopause. And maybe we will be able to say, estrogen decreases or delays the diagnosis of neurocognitive decline in women. My words, I think that will be the next thing that we're able to say. And you're right, a randomized controlled trial would cost billions of dollars. And IRB boards that approve randomizing women to hormone therapy or not. And listen, these IRB boards are still biased. And they still think that estrogen is dangerous. And so they're not going to maybe approve a randomized controlled trial to give women estrogen or not. And so we have to look at what we see clinically, which is that women live longer. They are sharper. And they have improved cognitive function at the time at which they started and then has to really work for something, right? If you don't use it, you lose it. Isn't that the truth? And that goes for everything. Everything. Speaking about, you know, early in the show, you kind of asked what are women coming to you wanting to talk about hormone therapy for? You're like, all right, bone prevention, heart prevention. I was like symptoms and you're like, yes, symptoms. But this one is a huge one. They have all seen their parents struggle with cognitive decline, Alzheimer's and dementia, something I action going through in my own life. Oh, so terrible. I'm sorry for that. Yeah. And they look at their parents and they think to themselves because women are more affected than men. And they think to themselves like, there has to be like, what's happening here? There has to be something better. And then because women are smart and inquisitive and curious, they will do some research. And it's not that far of a stretch to think that estrogen started at the time of menopause. It's good for your body. It's good for your heart. It helps you live longer. It's good for your pelvis. It's probably good for your brain too. Very, very well said. If you were to kind of boil it down to, and I know that you cover much of this in your book, but what are women doing wrong? You know, I think that I think that we as a as a society of women, we stay in the suffering period for far too long. And we've really normalized suffering. I mean, what is the period other than just like suffering? As soon as I figured out, I could stop my periods as I go, I'm stopping those, right? And these are all things that are still, you know, clouded in mystery and fear. Well, I was at a dinner the other night. And the women said, do you sure it's safe to not have your period? And I'm thinking, my son, we've known this for a really long time that you don't have to shed your lining every single month or have a period, right? Now, not that everyone has to do that either. But we also think about just all the things we joke about how would men get colds, you know, we call it man flu, right? Women are so used to not feeling great, but sticking through things and putting on a face and just getting the things done because that's the way we are. We're productive and we're strong, right? We think, oh, well, this is natural. Like, you know, everyone else suffering through this, like, I have to suffer through this, you know, they'll be told, this could increase your risk of breast cancer. Like, well, I want to stay healthy. So I don't want to get cancer. Meanwhile, right, they're not getting the benefits of hormone therapy because they're trying to be strong or they're trying to stick things out. So I think that we as women stick things out a little bit longer than we need to. My patients will come to me and they'll say, I've had years of this. Actually, I look back, I think it had a decade of this. I'm like, wow, we'll start on hormone therapy and they'll come back and they'll say, this, this little sticker, this little patch and everything's better. I say, I know. And you said something else, a decade, a decade ago. What are your thoughts on starting a woman on menopause therapy hormones 10 years out? Yeah, from menopause. Yeah. Yeah, I've done it for myself, right? So I think that it is absolutely within a woman's right. And you need a great clinician. So this is the other set problem. The other part of the equation is, you know, we want to help more clinicians be inspired and want to do this as their job. It's so satisfying. It's so fun. So a woman deserves the right to kind of know, what are my options here at 30 to 5 at 38 at 42? If they, you know, are sort of feeling to themselves, I want to already prepare myself for this stage. I'm proactive. I'm healthy. I want to stay healthy. What are my options? And so there is no good reason that I am aware of at this moment in time, where we couldn't start you on hormone therapy earlier than either you're having symptoms up and or therefore for prevention or therefore to just get parryment upon all together, right? And what about later? That was a really, that has been a heavy topic of conversation for all the women that have missed out exactly. And again, with the black box removal, this conversation really got amplified. I had my neighbors, you know, in their 70s messaging me like, well, can I start an hormone therapy now? So here's what we know. No, 10. So it depends. If we think about again, what all women can do, all women can do vaginal estrogen at any age, as a matter of how long you have been since menopause, a lot of women can probably also use testosterone and progesterone at any age. Now, of course, this is not direct medical advice and education, but when it comes to you now that we've got that. When it comes to estrogen, you know, I have started women who are outside of 10 years of menopause routinely because at the point in which they are coming to me, they are healthy. They don't have any cardiovascular risks. Maybe they don't have hypertension or diabetes. And so they're still good candidates to try Trans. in Serumal estrogen. Because, and this is the rationale, that study that really showed the benefits of estrogen in the 10 year window was all on oral. And again, we didn't do that study on Serumal estrogen. And so if the biggest risk as you get out of that window is an increased risk for clot, but those ester studies or ester trials showed Serumal estrogen does not increase the risk of clot. And a woman doesn't have any cardiovascular conditions now even if she's 65 or if she's 71, we can start really low dose transfer on estrogen or I should paraphrase that, or rephrase that to say, I am comfortable starting women on low dose estrogen even if they've been out of the window. But they have a lot of other options, including progesterone, testosterone, and vaginal estrogens. - Dr. Heather Hirsch, you are just such a spitfire. And I really believe that we talked about this before. I believe that you and your colleagues are changing the landscape for women and really making things accessible to them that a whole generation got skipped. So thank you for the work that you're doing. - Thank you for having me, Ellen. (upbeat music)