The Dr Louise Newson Podcast - 158 - Pushing against social and political constraints on women’s health with Dr Heather Hirsch

Episode Date: June 28, 2022

Dr Heather Hirsch makes a welcomed return to the podcast this week. Heather is an internal medicine physician, specialising in women’s health and menopause care at the Brigham and Women’s Hospital in Boston Massachusetts, USA. Her clinical work and research centres on inequalities or unanswered questions in the field of women’s health, specifically in menopause education. In this episode the menopause experts discuss the bigger picture of menopause care as a gender issue, women’s role in society and in the workplace, perceptions of women’s suffering and the menopause as a medical specialty. Louise and Heather share the challenges they each continue to face to educate and inform the public and healthcare professionals on the perimenopause and menopause and the benefits and safety of HRT. Heather’s 3 tips: Know what’s going on in your body by keeping a journal and tracking your symptoms. I recommend the free balance app to my patients for this. List your own priorities and what matters most to you, whether that is your sexual health, your hair or skin, your sleep and so on. Understand the three strands of menopause management: lifestyle changes, non-hormonal treatments and HRT, and know the pros and cons for all to realise what choices are best for you. Follow Heather at: Instagram @hormone.health.doc Website: heatherhirschmd.com YouTube: Health by Heather Hirsch Podcast: Women’s Health by Heather Hirsch

Hello, I'm Dr Louise Newsome and welcome to my podcast. I'm a GP and menopause specialist and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-Bron-Avon. I'm also the founder of the Menopause charity and the menopause support app called Balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause. So today in the studio, I'm delighted to reintroduce to you, Heather Hirsch, who came about a year ago to record a podcast with me. And she's recently recorded a fabulous podcast for any of you who want to listen to

for the News and Health Menopause Society. And now she's back again. So Heather is a menopause specialist doctor who works in Boston in USA. So, welcome Heather today. Oh, thank you so much. I'm so glad to be back. Oh, thank you. So you're doing a huge amount of work, obviously with your patients, but you're also doing a lot of education as well, aren't you, to really get menopause onto the map. Like we're trying to desperately over here, and we've talked at length and we will continue to talk at length, how hard it is actually to do something that's actually very easy medicine, isn't it? Oh, yes. You know, actually, this reminds me I was teaching at Harvard Medical School. That's the hospital that's affiliated with my institution. And I was teaching the medical students about menopause and how important it is. And one of the students raised her hand and she said, well, what special certification do you need to prescribe hormone therapy? And I said, none. She said, well, okay, you know, these are medical students. So she's like, why is it so hard? You know, what is it about it that makes it that so many doctors are so confused? And she just hit the nail right on.

the head. It's absolutely true, isn't it? Because, you know, those of you are listening know that the menopause is due to a lack of hormones. And if I said to you, Heather, you've got a lack of vitamin D, you'd say, well, give it to me then. I'll have it. Thanks very much. If you have a lack of iron, you take an iron supplement. It's just endocrinology, it's hormone medicine. If lack of any other hormones, you just replace. And that's the beauty of endocrinology, actually. It's a very nice subject because you get people better very easily. You know, we all know about diabetes. We all know about underactive thyroid glands. And this is just other hormones, isn't it? There's three hormones, estrogen, progesterone and testosterone that women need in different doses and different

types. Not all need all three. Some need one, some need two and some need three. But that's as hard as it gets, really, isn't it? It is. And whenever I'm talking to women as they're considering hormone therapy. I'll say, just like you kind of also mentioned, look, I bet you know someone who has hypothyroidism, right? And they say, oh, yeah. I say, well, we give them thyroid back, right? Yeah. And what if we only said they had a few years to take their thyroid medicine? And then we were going to take it away. And they're like, oh, yeah. And the pieces come together. And it isn't really rocket science. There is no special certification that you need to be able to prescribe these. And arguably, every and any internist, family doctor, OBJN should be able to freely know how to do this.

But as we've mentioned so many times, the invisibility of women in midlife has been thrust into the medical sphere as well because no one gets taught this. No one sees their mentors do this. And then, of course, because of the 2002 WHI, that was the last time sort of there was a turning point in terms of menopause care and hormone therapy. and we're still at a place where in the United States, about five to ten, let's just say 10, making it an aggressive estimate, 10% of women take hormone therapy when many, many, many, many more women would benefit. And it's the same.

I mean, in the UK, some figures say 14%, but I know areas of low social deprivation. It's only around 2% if that. It's shockingly, shockingly low. And there's a real resistance. There's a resistance for people to prescribe. And there's also a reluctance for women to consider taking it because of this misinformation. But, you know, I spend a lot of time trying to think about what can we do because I constantly think I'm not doing enough to really make a difference.

I am making a bit of a difference. But it's not enough and it's not fast enough as well. The suffering that I hear every day is absolutely traumatising to me. And I know it is to you as well because it's not necessarily. So I sometimes think about why is it happening so slowly. And, you know, I don't want to think it is a, because it's a female issue. But the more I get into this, Heather, the more I think it actually is. And I think there's something about people not wanting women to get as good as they can be. And I find that really quite distressing and uncomfortable even to say. But I've been on. a lot of meetings. I've personally have had a lot of bullying that is continuing, and I'm sure it's worse because I'm female. But actually, what is wrong with women asking to have their own hormones back? Why is that seen as such a terrible thing? And it's not just other men that I've heard

say it's women as well and women of quite high standing who are physicians. I've heard them say, it's outrageous. Women are now asking for their hormones back because of all this publicity about HRT. And why is that? Well, let's get into debate mode because I was a women studies major. I went to Syracuse University in upstate New York and graduated college in 2004, but I spent a lot of time studying, you know, feminist theory. And I could debate both sides and I'm happy to. But if we go on the side of women still being considered second-class citizens or women definitely being second-class citizens after men, women having much less rights in here in America,

much less medical rights. And as we know, those medical rights to early reproductive care are soon going to be flipped upside down. And so look, that is an obvious fact. We can see Roeb v. Wade coming undone. It is a clear fact that women's health, women's physical health, emotional and mental health, are clearly second tier.

And if we want to even extrapolate this debate a little bit farther, there's certainly a fear of the, you know, traditional white male dominated country that if we, maybe if women are feeling well and they're thriving and they're at the peaks of their career, they might outpace men. Now, that's always going to be hard because women do something men can't and that's child-wearing and then feeling those responsibilities for child-rearing.

We know there's still huge pay gaps here in the United States. So again, but these are all little clues that point to the fact that women are seen as second class citizens, at least here in the United States. And I'd love to see if you think that's similar. Yeah, you're absolutely right. And I think there are. And, you know, there's been a lot over the last 10, 20 years looking at gender pay gap. Absolutely so important. Looking at the lack of senior women in boards and everything else. And there's mean a lot of why is this happening? Why, why, why? And sometimes it's obviously because women are generally the caregivers. So if they've got children or relatives that they need to look after, absolutely understand. But now we're realizing more and more that a lot of it's to do with the menopause.

And, you know, 10, maybe 20% of women are giving up their jobs. We know from studies that we've done through my not-for-profit, women aren't going for promotion. They're not going for the jobs that maybe they should or they're going more part-time or leaving their jobs or changing. changing careers. So we know there's a reason and we know there's a treatment yet there's still this resistance. And I think you're right that there are men, but either and other women that are scared of this sort of new generation, this new power of women. And, you know, I look at my teenage children and how strong they are. And I was actually reading some of my old school reports. I didn't even know my mother had kept them yesterday. She'd give me a bag and they've all in there.

And I think, gosh, I was so naive as a 16, 17-year-old. I didn't have this sort of knowledge that children have got now. And that's partly because the internet wasn't around when I was young, I was sure. But I wasn't so aware. And there is this awareness. And I'm, you know, I often say to my 17-year-old, gosh, I'd be really scared if I was with you at school now. You're so, you know, you're that person that I would just be too scared to be with.

And she's adorable. But I can see that sort of, there is this threat, isn't there? And I think, you know, women who are top of their game at multitask, they go home and they still carry on, they don't just go into their dark hole because they've had a busy day and escape, which is what generally a lot of men do. I can see it can be threatening. But actually, shouldn't it be really exciting as well that we're equals and we can challenge and we can do these things. And, you know, there's a lot of time and energy and effort and money that has been invested for. career women, yet they're just crumbling and they're hemorrhaging from the workplace and hemorrhaging from life, actually, and society. And I think we've got to acknowledge that

women underpin a lot, not just at work, but in general, they're propping up men and others and other women and children left, right and centre, but we're being ignored. We're not being listened to. It is so very true. In fact, today I uploaded a video. video to YouTube about menopause at work. And our good friend and colleague, Dr. Phil Sorrell, did a lot of studies looking at, you know, the indirect and direct cost to health care, women with untreated symptoms. And it's clearly higher. You're missing work. You're retiring earlier. And you're seeing more doctors. And so there's evidence to absolutely back up what we're both kind of echoing with each other. And then you add on top of that the fact that,

that women have the qualities of emotional intelligence. Not to say all men don't, but women really have developed so much emotional intelligence, social intelligence, social awareness as they've gone up the ladder, that to then have their job or their career crumble or their personal life or both, you know, there is such a big problem. And then to the flip side is also, is there at some point where women are hindering their own selves or our own gender because of, you know, there's always that theory of upper limit theory. And the upper limit theory is, you know, as you get close to the upper limit because you're either getting excited or you're scared, you tend to actually retract from that upper limit just when you're about to burst it. So certainly we hear several things,

friends telling other friends not to take hormone therapy or friends judging other friends for how they're going to treat their menopausal symptoms or women telling themselves, oh, no, I just, I obviously have to stick it out. I'm a failure if I need medical treatment. Those are also messages that women receive. But you put all those together. I mean, it is actually quite glaring how hard the problem is, even though hormone therapy prescribing hormone therapy isn't actually it,

because that part's easy. It's all the things leading up to getting to that visit. and making that decision, and then from there training other doctors to continue to do the same. Yeah, and I think also women are used to suffering a bit more than men, aren't they? I think, you know. Oh, right. Even every month women have to suffer, right? We all know the man cold. Yeah. So I think there is that whole thing is that that sort of expectation that, well, that's just our lot. That's our bank. That's what we have to put up with. And we do know, obviously, there's a lot of women who have very severe symptoms,

but the majority of people have symptoms which they probably don't think are severe, but it's not until they're better, they realize how bad they were. And so, and I hear this so much from women saying, well, I didn't want to give in and take HRT. I didn't think I should come and pester you because I'm really not as bad as my mother was who used to, you know, really struggle. I'm not so bad as my best friend who has no sleep. I have two hours a night.

I'm very lucky sort of thing. And I'm just like, listen to you talk. Of course, two hours of sleep is not normal. And it's that whole thing that it's sort of, well, that's just what life's given me. And that's what I need to accept. And it's how we change that narrative because like you say, you know, we have treatment that is cheap. It's cheaper for us in the UK than the USA, which should be a lot cheaper for you guys as well. Of course, we know that.

But it's safe. And it's being denied time and time and time again. And, you know, it's also very hard, and I know it's very hard to know how many symptoms are due to low hormones. And I'm sure you're the same. But in my clinic, I say to women, I have no idea how many of your symptoms are related. But I do know that a hormone deficiency is associated with health risks. And so let's reduce those health risks by replacing, optimizing your hormones and then seeing what's left. And time and time again, these women come back telling me that they're brain fog.

their joint pains, their headaches, their sleeplessness, their irritability, they're everything that they've put down to just being a woman at a certain stage of their life and not enjoying their jobs, they suddenly come back and go, wow, why didn't I start this before? And then they regret, and I've had a lot of people crying in my clinic saying, I wish I'd come back 10 years ago. Where were you? Five years ago is what they say. Yeah. And that's the first time it happened to me. I felt what I always feel sad, but I was really shocked. because someone came in and I do a questionnaire and I could see the questionnaire, the symptoms were so much better.

And then she burst into tears and I said, gosh, here's some tissues. Are you okay? And she said, no, because I realise the last 10 years of my life, I've actually wasted because I could have felt like this if I'd come and had seeked help earlier. And I think, gosh, this is such an injustice in so many ways. And that was six years ago when I've over my clinic and I thought things would have got better. But actually I think they've got worse, Heather, because more and more women are understanding what's going on.

So more and more women are now asking for their own hormones to come back or to be replaced. And more and more women are actually still being refused. And it's not just in the UK. I mean, it's globally as well, isn't it? Because I know, you know, you reach lots of people with your lovely work across the globe. And I do from all sorts of countries. And they're telling me that they refuse. They refuse.

They're not allowed. And it's like, well, how? Is there any other area of medicine where you'll refuse treatment? I never understand how a clinician could say to a patient, I don't believe in that. They'll say, I ask my doctor for hormone therapy, but he said I don't believe in that. I said religion's not really a part of the protocol here.

And it's not evidence-based, and that shouldn't be part of the conversation. Not only does that set her up for needing to find another doctor, doctor, of course, but she's good a second guess, too, if that's the right thing because a doctor she's been seeing for 10, 20 years and saying he doesn't believe in something, even if she's read and followed you or me, it's always just another nail in the coffin is what it seems to be. And I agree. When you were talking, I thought also, too, if we really want to be, you know, feminist about this, there's something about the word hormones. You know, everyone always kind of

Pokes fun at women. Oh, she's on her period. Oh, she's PMSing. Oh, her hormones are over the place. Even women say that. So I had a big fight with my partner. It's just my hormones are all out of whack. It kind of actually almost minimizes what we do. Like we're just these little hormone doctors that are just playing with these silly female hormones. And I think that there is part of this cultural mythology here that our branch of medicine, preventing chronic diseases, helping women thrive. feeling well, keeping them at work, keeping them happy in their lives, that it's just this little silly side thing. And we are really trying to stand up to say, you know, menopause, whether you want to call it a symptom, a syndrome, a disease, it is a part of 100% of women go through this if they live to that age. And 80% of women have symptoms that last five to seven years. Why are we continuing to skirt around this? Then you further that with the fact that we're replacing as estrogen, the female hormone. So it's just already second class. If women are already second class, citizens, so is estrogen. Not that it should be, but it falls under that realm of,

oh, her hormones are just all over the place, right? We live in a society where that's kind of been brushed aside as every woman's issue when she's having a bad day, which is just another way to keep women small and to put women down. So I think then when we are talking on social media, we're raising awareness about menopause and we're talking about replacing hormones and exactly how to do it and the evidence behind it and what the women's health study shows. You know, for those who want to continue to make us small, it's very easy because they just weigh their little, oh, they're just talking about hormones wand. And this is just a female problem and it's natural. So there are so many reasons in the book why someone will have to wait five to seven years and then burst in

to tears because it's just this battle and it should never have to be. Yeah, it's very interesting. One of my first patients, I remember who I saw when I'd opened my clinic and she was a nurse and really lovely, lovely lady. And she's married to someone who, he worked in a factory and he was packed boxes for sardines, actually. And they had no money at all. And she was desperate to carry on nursing and she was menopausal, but she had this condition where she was born without a womb and she knew she could obviously never have children. But it was also the condition that was associated with kidney failure as well. It was very unusual genetic condition. So she had had had a kidney transplant which had failed a few years ago. So she was on dialysis waiting for another kidney

transplant. And meanwhile, her sister who'd had the same genetic condition, but more severe than her, had sadly died, but she had a child that she had adopted. So this patient of mine had inherited, if you like, a two-year-old boy, and she was awaiting a kidney transplant, and she was menopausal, and really, really struggling. And she came to see me and said, my kidney specialist said, I can't have HRT, and said, you need to go and see your GP. The GP said, oh, gosh, no, I don't know anything. You're on so many drugs. You wouldn't want HRT. And so she said, she had battled and battled and I was thinking, well, she hasn't got a womb. So what she needs is a bit of estrogen, maybe a bit of testosterone, but I'll start with just a bit of estrogen gel.

She's on so many drugs and drugs that stop her rejecting her kidneys. And as you know, some of them will increase the risk of osteoporosis and kidney disease increases the risk of osteoporosis. So I thought, well, she really needs actually some estrogen. So I gave it to her and I wrote a letter to her doctor and to the patient. And then she came back in floods of tears and she said, I had HRT for a month and I started to feel better. My kidney doctor said, no, no, no, absolutely not. And then when she read the letter, she said, she laughed. And she said, a menopause specialist.

Who on earth does she think she is? That's not a specialism. And it really shocked me, actually. And it's exactly what you're saying. They just think we're tinkering around with some lifestyle medicine. Yeah. And they don't realize the importance of estrogen and how important it is for chronic disease.

And I do, I know, push boundaries, but I often think even if women have no symptoms, there's some really good evidence that it reduces risk of disease, more than giving a statin, for example, for reduction of heart disease, but, you know, people are pushing back about dementia, but of course it makes sense that estrogen works in our brain,

so it reduces risk of dementia and inflammation in the body. And so why can't it be taken as seriously as other hormones? And in the UK, a lot of endocrinologists, so specialists who specialize in hormones, they actually miss out female hormones. I don't know about what it's like in the States, but they're very good at fiddling with all the other hormones, but not with estrogen and testosterone. And I just don't know why. Exactly.

Again, it's part of that invisibility of those don't really matter. or historically they haven't really, well, even that argument's kind of hard because in the 80 to 90s, kind of the golden era when most women got hormone therapy, actually oftentimes without a progesterone because they didn't even know that it could increase the risk of uterine cancer. You know, again, endocrinologist here do the same thing. They're so great with insulin. They're so great with parathyroid hormone, adrenal insufficiency. But when it comes to a little bit of menopause, or even,

perimenopause. They really feel as though that's not their area. And so if no one's owning it, if no one's doing it, herein lies the problem. And in medicine, at least in the United States, we have become so specialized. You could easily argue there should be more or just as many menopause specialists as there are cardiologists, right? Absolutely. But there's, I believe, in the United States, I think there's a hundred or so nambosalists. certified MDs. Now, there's lots of NPs and physical therapists and pharmacists and they're wonderful. We need a whole team. But when it comes to prescribing medications, we need those MDs and or those PAs and NPs. And, you know, to your last point, I agree. And I will say, as the menopause

expert who is about to turn 40, I will take hormone therapy for preventative measures. And many people might roll over in their grave or that might, you know, really irk them. But when you are a clinician who reads this every day, who prescribes and sees patients before your eyes every single day, it is no far stretch to realize how important estrogen is and how it's not just a silly thing that we're placing just because she's sweating. It's more than that. Absolutely. And it's just been so neglected. And actually I was lecturing last week to a whole group of psychiatrists, and I'm doing some work with the Royal College of Psychiatrists over here. And a lot of drugs that are prescribed for quite bad depression and bipolar, as you know, they affect prolactin. So they affect

part of our brain and means that the prolactin levels increase. And when people have high prolactin, it actually can switch off our lutanizing hormone and our follicular stimulating hormones so reduces our estrogen and testosterone and it's very clear pathways. Endocrinology is all about lovely pathways and you can see how the hormones interact but the psychiatrists

usually measure prolactic levels every year on women and men on these drugs. But when I put the slides showing the pathway of how estrogen and testosterone reduces, it was just news to a lot of people and in fact a few psychiatrists have emailed me since to say, goodness, your talk really resonated and we're now looking at our female patients

quite differently. But it just hasn't been thought of before. It's very common and we know that people on some of these antipsychotic medication have raised cholesterol, they have raised blood pressure, they put on weight, they have this blunted affect. And I've known it for years as well, but then I never thought about it when I was doing psychiatry 20 years ago. Well, actually, these women are all menopausal and the men are probably hypogonadol. But we're just saying, oh, it's because of their mental illness. But why aren't we giving them add back hormones? It's crazy, isn't it? It really is. It's absolutely another level of where now we're going past symptoms into the textbook and still it's this medical mystery. It is eye-opening. It is

shocking when we kind of get this time and space to use this episode to kind of think through, you know, what are the social and political things that are keeping women small or not feeling well and not treated equally as the same way as a man would be? One time I put this on TikTok, I said, what would happen if men went through menopause? And I think the comments were off the are, you know, tons and tons of comments of this would already be solved by now if this was a male issue, twice the military budget, three times the military budget, NIH funding until it was solved, right? And so it is no secret that I think those women who do realize that there is treatment and they do get treatment. And then they say to you, oh my gosh, like, I can't believe

this little patch helped all these things. Like, why don't more people know about this? Dr. Hirsch and Dr. Newsom, and you're like, I know, back to the drawing board. That's what I have been doing and my spare time is yelling it from the rooftop. And so the cycle continues. Yeah, but I think the most important thing for me is educating, obviously educating healthcare professionals, but it is educating women so they are allowed to choose. And I strongly, strongly feel as a position that patients are allowed to choose. And we're not here saying that every patient has to have evidence-based medicine actually. I remember when I very first learned about consent and I'm sure you've done the same as a student and you learn about informed consent. So this is for any treatment.

Patients have to be on board and they have to decide. And I remember learning that if people have all the knowledge, they can refuse treatment even if that means they're going to have harm. So for example, if someone needed a life-saving operation, but they said no, I don't want it. And they knew the risks of refusing it, they were allowed to say that. And that's really big stuff. And most people obviously wouldn't to refuse life-saving operations, but we have to respect our patients. And I feel this whole issue of consent and shared decision-making is so pivotal when we talk about this, because we've been fed all the time about risks, risks, risks of HRT, and we could spend hours discussing the potential risks.

But we can spend seconds commenting and discussing about the benefits. But we can spend even less time when we think about each individual patient what they want. And this is where I guess my anger comes in because the patients, i.e. all women, 51% of the population, are not being listened to in this. And this is where I feel our energy has to continue. And I'm sure you agree. I 100% agree. And I resonate with that story about the nephrologists who said absolutely not because why is it that the

nephrologist or the oncologist just says, why are they the last stop? Why is it that if they say no, the answers no? Or where do they even think that they can say no? If a patient has consented, a doctor is prescribed a medication, they can do a quick search to see, even with kidney disease, there are no contradictions there that are obvious, especially if you're using it. something transchrimal. So why is it that patients are overridden when they've already consented? And I agree that the idea of consent goes both ways. I was doing a talk to clinicians about hormone therapy and menopause management. And I always say, look, I'm going to spend 80% of this talk talking about hormone therapy because that's what most of you don't know about. So this doctor raises

his hand and he stands up and he says, Dr. Hirsch, this is great and all, but my patients don't want hormone therapy. And I said, it's just because they don't know. No one's told them about it. And they don't know what they don't know. So they're not really giving consent because no one has really given them both sides of the coin. Now, I think what's happening is that's what you and I are doing for those people who are lucky enough to stumble upon our stuff, et cetera, we're trying to fill that void. But then when you get someone gets into a clinician that says, oh, absolutely not, that's where both you and I feel very frustrated and sort of stuck on this issue. Well, now what do we do? Yeah. So we've just got to keep going. Yep. Yep. And we will. Indeed, we will. We're not going to stop. So it's been absolutely

great talking to you again and getting all fired up, which is really good because I know both of us at times for it exhausted and want to stop what we're doing, but we can support and prop each other up. So before I end, Heather, just to have three take-home messages, I'd really like. I'd really like to hear from you three ways that women can empower themselves even more to get what they want from their healthcare professional. Three tips. I think one thing that you could do that's a really easy win is just to start journaling and tracking so you know when your last period was what your symptoms are and maybe what your triggers are and I'm going to totally plug the balance app because I use it for my

patients and you can use the balance app to start tracking because you can listen to all this information that we're giving you online, but knowing what's going on with your body is number one. Second, then list your priorities. Your priorities may be different from your friends. Maybe your priority is sexual health. Maybe it's your hair or your skin and that's okay. Maybe it's your sleep. Whatever your priorities are, list your own without asking for others. And then third, I think if you briefly understand what your main options are and they're going to fall in three buckets. Lifestyle changes, non-hormonal medications and hormone therapy, as long as you know those three, and you actually really do, especially when we're talking about the hormone therapy bucket,

know both the pros and the cons, mostly there are pros, you're going to feel ready and prepared to realize what you need and what's best for you. And if you're listening to this show, it's likely that you are interested in hormone therapy. You've considered hormone therapy. So as you're doing that, my three takeaways are know what's going on with your body. And then list your own priorities so that you can get set up to get the best treatment for you. Excellent. So being prepared is the most important thing. Absolutely. I totally agree. And knowing that you can change your mind as well is really important. So nothing that anyone decides today has to be there tomorrow. And making sure that women are completely in control of their bodies is the most

important thing. So then women can rule the world and make a big difference. So as we should. Thank you so much, Heather. It's been great. Thank you. It was wonderful to be back on the show. Thank you so much for having me. For more information about the perimenopause and menopause, please visit my website, balance hyphen menopause.com, or you can download the free balance app, which is available to download from the app store or from Google Play.