Podcast Episode 8: Exploring the differences in approach to perimenopausal and menopausal treatment in the USA with Dr Heather Hirsch

Colloquially referred to as ‘cousins’, the UK and USA are known to institutionally share certain similarities. When it comes to drawing comparisons however, our healthcare systems are often identified as anything but familial. Yet how do these differences really manifest in practice? Moreover, how do they effect the people seeking treatment for perimenopausal and menopausal symptoms? Featured in this week’s episode and joining host Lauren Redfern to discuss the ever-evolving global landscape of perimenopausal and menopausal care is Dr Heather Hirsch. Based in Boston Massachusetts, Heather is a menopausal clinical expert committed to helping her patients become symptom-free, educated and empowered in order to thrive in their mid and later life. Between them, Heather and Lauren explore both the similarities and differences in approach to treating the perimenopause and menopause in the USA and beyond.

If you would like to learn more about the work Dr Heather Hirsch is undertaking, you can follow her on Instagram @heatherhirsch.md and find her on twitter @heatherhirschMD. Heather also hosts an excellent podcast titled Health by Heather Hirsch. You can listen by visiting her website.

Podcast Transcript:

Lauren Redfern [00:00:06] Welcome to the podcast for the Newson Health Menopause Society, a multidisciplinary collective of interested professionals passionate about improving hormone health across the world. The society exists to educate and inspire others to raise the standard of menopause care and access to treatment, to facilitate research collaborations across specialities and countries, and to provide expert advice and guidance to our associates. The ultimate aim of the Newson Health Menopause Society is to improve the lives and future health of women and all who experience the perimenopause and menopause. I’m Lauren Redfern. I’m a medical anthropologist, and I’ve been exploring the experiences of those using testosterone as part of their HRT treatment. In this podcast series, I’m going to be talking to guests from a variety of different disciplines in order to share knowledge and ultimately improve our understanding of the perimenopause and menopause.

Lauren Redfern [00:01:05] For the past two months, I’ve been recording this podcast in the US. Before making the decision to travel stateside, I’d given some thought to how attitudes toward hormonal therapies in the US may differ to those in the UK. Rather naively, perhaps, I had assumed that the use of HRT would be fairly commonplace amongst perimenopausal and menopausal persons in America. After all, as adjusting to the time difference would teach me, pharmaceutical drugs are regular features on TV ad breaks. As I’ve come to realise, however, approaches to menopausal care and treatment are in the US surprisingly cautious. One possible reason for this relates to something we’ve spoken about before in this podcast, which is the ways in which medical journalism and the media have largely misrepresented HRT as dangerous, particularly since the Women’s Health Initiative study was first publicised in 2002. The reach and impact of this in the US has been profound, and in conversations I’ve had with professionals based in the States, there appears to be concern regarding how both the US government and the media have impacted the health of perimenopausal and menopausal persons by convincing them that menopausal hormone therapy is dangerous.

Lauren Redfern [00:02:21] Here to chat with me today about the clinical approaches to menopausal care in the US is Dr Heather Hirsch. Heather is a physician who has specialised in internal medicine and gynaecology with a particular focus on menopausal hormone therapy, contraception and family planning. Breast health, sexual dysfunction and urinary incontinence. Heather also has a special interest in clinical research and leadership and in particular is interested in developing the women’s health curriculum.

Lauren Redfern [00:02:48] Hi, Heather, thank you so much for joining me today. I wondered if we might start by you introducing yourself to those listening and telling us a little bit more about the work that you do.

Dr Heather Hirsch [00:02:56] I would love to. So I am the clinical programme director of the Menopause and Midlife Clinic at the Brigham and Women’s Hospital and faculty at Harvard Medical School, and I live and work here in Boston, Massachusetts. And before I was at Boston, I had done my training at the Cleveland Clinic, where I was really shocked going into my fellowship training that women had no education around what happened to their bodies after they had children, if they even chose to have children. And I had an ‘aha!’ moment. I could not believe that women were flying from all over the country to come to Cleveland, and we dubbed the Cleveland ‘the mistake on the lake’. And that’s because it’s in this cold, snowy part of the country. And they were all questioning if they can have hormone therapy or what was wrong with them, or their doctor wouldn’t prescribe it for them. And I knew instantaneously that I wanted to be part of something bigger. I wanted to be a part of women’s lives, not just delivering their babies, but actually setting them up for success for long term health. And so that’s how I came to become a menopause doctor, and I worked in Cleveland for a couple of years, and then I was recruited to come out to Boston.

Lauren Redfern [00:04:16] Amazing. And I think it’s interesting, actually, when I was writing up the introduction today. Obviously, you talk about in the US, you refer to it as internal medicine. So for those listening to clarify, would that be the same in England as GP, general practice?

Dr Heather Hirsch [00:04:30] Probably. We don’t do children. So I have a couple of those and I do not know what is going on if they get a rash, but we really specialise in chronic diseases, shared decision making in adult patients.

Lauren Redfern [00:04:45] I thought, actually we could maybe start with a broad question or discussion, really, I guess, as to what I allude to in my introduction, which are the differences between the US and UK when it comes to approaches to menopausal care and treatment. And obviously, you mentioned you do have a broad experience, but you’ve come to specialise in mainly menopause and being a menopausal physician. So I wondered if you could talk us through a little about what that looks like for you on a daily basis?

Dr Heather Hirsch [00:05:12] Well, that’s a really great question, it’s something that I think about a lot, as I look at other countries and what they’re doing in terms of midlife, menopausal, women’s health, and there certainly are some significant differences. But actually, I’m going to start with some of the significant similarities, which is that the education for healthcare providers on the impact that menopause has on chronic diseases and disease development and how to prescribe and manage hormone therapy is severely lacking here in the United States. Now I actually went to medical school between 2006 and 2010 and then started my training after medical school in 2011, and that was after the Women’s Health Initiative had come out. And so I can only sort of speak from that perspective. But the training I received on menopause was almost nothing. I can tell you that the message I received in medical school was that hormone therapy is dangerous, and the message I received in my residency training was that if you really have to use hormone therapy – after you try every other option out there – that’s non hormonal, if they really still need it and really have to use it, well use the lowest dose for the shortest time possible. And then when I went to do my fellowship training, as I had mentioned, that’s when really actually, all of this that I had learnt up to that point from seemingly top notch institutions and training programmes was absolutely wrong and not evidence based. And I’m a self-proclaimed feminist. I was a biology and women’s studies major in college. I actually spent a year in OB-GYN and then actually transitioned to internal medicine. So you would think of all people I’d be really set up to understand women’s health after children, but in fact, even I didn’t. So the educational system is failing physicians and not just physicians, we can include that to nurse practitioners, physical therapists, pharmacists, social workers, etc. It takes a team and therefore it’s failing women. And that is a problem that is continuing to be a domino effect. And we’re seeing all sorts of options for women that are marketed as being ‘safer than hormone therapy’, which are actually more unsafe. Now, one of the big differences between the United States and, say, the UK is the healthcare system. Now, I don’t want to pretend I know everything about the UK healthcare system because I don’t, but I do know about the US healthcare system and that is that insurance companies are third party players and have a huge say in what medications can be prescribed or received for patients. So that’s one thing. And at the other hand, is that also physicians in the United States and because potentially if you’ve grown up in the United States, there is certainly this idea that we can all practise autonomously and that even though we know their practise guidelines and bulletin points, there’s protocols for things like diabetes and hypertension that most people tend to follow. But even those people can do a little bit differently, and that’s OK as long as they’re board certified. So if we go back two more steps, the fact that we don’t even have training for menopause education, for the healthcare providers in the United States, we are a long way from creating a type of protocol. And even if we had such a thing, would they follow that? So, you know, that’s kind of to say, in summary, the lack of education is similar and the fact that women are demanding more, is similar. But the two big problems here we have are insurance dictating what medications women can get or not get, and that there are no protocols for menopause management that include hormone therapy. And I think we are a long way off.

Lauren Redfern [00:09:04] Mhm. And I want to come back to the learning and education that you touched on there because I think it’s a very important point and also, I know something that you feel quite passionately about. But I just want to clarify that, so from an insurance-based system, for example, I know when I was doing my own research, the main HRT that women were using was sort of combination of a progesterone and an estrogen, usually topical. And so in the US, is that the case that even if a woman wanted to say, for example, use a topical estrogen and progesterone form for their HRT, they would only be able to if their insurance company allowed that and prescribed that?

Dr Heather Hirsch [00:09:39] Yes. And let me say that another way. When I see patients for consult at my clinic, as I’m reviewing their chart – and in my head, I’m kind of thinking about the options that they would be good candidates for – next I say, ‘OK, Nancy, let’s see what your insurance will cover’. And then I have to take kind of what I had in my mind and then I have to adjust for what their insurance will or won’t allow and it’s completely random. And when I say random, it depends on who their insurance provider is, it depends on what their deductible is. It depends on how much they might have already paid. And so there’s so many different factors that actually are different from person to person, even under the same insurance umbrella. So oftentimes I may have to tweak or tailor something that I really want to give them to something different. And actually, probably the more annoying fact is that’s not always the transdermal or it might be the formulation of the progesterone. For example, I like to prescribe micronised progesterone, which is also known as Prometrium, but that may not be covered under their insurance. Then I’m going to have to prescribe something different – maybe it’s a medroxyprogesterone acetate or whatever it may be. And that’s not – I’m not going to lose too much sleep over that small change, but it is annoying that what I want to prescribe and maybe has just a slightly better profile for them I can’t because of their insurance company.

Lauren Redfern [00:10:58] And I know that Louise has talked about this a lot, that I think that I don’t know if it’s the same, but there’s often a misconception when we think about risks associated with breast cancer. This kind of misconception that actually a lot of that is related to older forms of progesterone it has nothing to do with estrogen. So that does make a difference, you know, if you’re unable to prescribe a micronised progesterone that you feel may be safer for women or, you know, really mitigate that, that’s incredibly interesting and highly frustrating, I imagine, to practise in that.

Dr Heather Hirsch [00:11:24] It really is, especially because I’d like to spend the time going over the data with my patients, having them feel really comfortable for that. And then when we get to the end, it can be really a real sort of dealbreaker sometimes because then perhaps the formulation or the route they want isn’t covered.

Lauren Redfern [00:11:40] Yeah. And I mean, we spoke about this actually when we connected first of the, you were saying that sometimes you can sort of have this wording from insurance companies that comes through to say, ‘I just would like to make you aware that you are prescribing a dangerous sort of formulation to a patient’. And I was curious, does the patient themselves get that letter as well? Or does that only go to the physician?

Dr Heather Hirsch [00:11:59] I don’t know if it goes to the patient. That’s actually a really great question. And the reason I don’t know is because it changes a lot. I think that’s another thing is that, you know, we kind of get blindsided a lot by what insurance companies do. We don’t really have any say or very, very little. But yes, I get messages. And so many of the menopause experts here in the United States get these letters every single day saying, you know, ‘you’re prescribing a dangerous medication to your patient who is older, and it could include the risks of’ this, this and this, none of which we actually know are evidence based. In fact, both NAMS, the Menopause Society here in the United States, ACOG, the American College of OB-GYN, for example, now states that you don’t have to stop hormone therapy just because you have a certain birthday, just because you’re 60 or just because you’re 65. But those are all the letters that I get in the mail on a daily basis.

Lauren Redfern [00:12:49] And I mean, I think it comes into that next point that I wanted to really get your thoughts on is we talk a lot on this podcast about the barriers that women are facing accessing care and treatment. And it feels like in your responses to all of that, you’ve just named so many barriers that exist for women to actually access the care that they need. So I was curious to hear your thoughts on that.

Dr Heather Hirsch [00:13:09] Oh my gosh, exactly. You know, in the first 10 minutes of recording this already, I mean, to find a knowledgeable physician who’s going to prescribe evidence-based medications, who’s going to be able to counsel you in depth on those risks and benefits, who’s going to be able to answer those lingering questions and then to be able to get it from your insurance company. That right there is so many barriers that most women cannot get through. So I have a great example of this. One of the prescriptions that I prescribe a lot ,and actually I would say that the majority of physicians across the country may feel comfortable with is something called Vagifem or Estrace. And these are forms of vaginal estrogens, and there is plenty of data showing the safety of vaginal estrogens. In 2016, Cochrane review showed vaginal estrogens do not increase the risk for heart attack, cancers, breast cancer in particular, strokes, blood clots and in The Lancet in 2019, I believe they even looked at the use of estrogen for breast cancer survivors, showing no increased recurrence of breast cancer. But when you still go get that vaginal estrogen here in the United States, there’s a black box warning on it. There’s a black box warning on it that says this is going to increase your risk for heart attacks, blood clots, strokes, cancer, breast cancer. Now NAMS, the North American Menopause Society has done a lot to try to lobby the US FDA, the Federal Drug Administration, to remove that black box warning, and that black box warning comes from data from the Women’s Health Study on World Prempo, which we actually now know isn’t necessarily true, especially when you look at timing hypotheses. But we have been unable to get that black box warning removed from vaginal estrogen. So even after they’ve gone through all those five steps I just mentioned previously and they go to get it, they might go home and then keep it in a drawer because they’re scared to death to use it if the provider doesn’t tell them all that. But that is just another layer of barriers that we have here in the United States.

Lauren Redfern [00:15:15] And I’m so interested that you used that example as well, because actually, I’ve done a number of podcasts now with physiotherapists, sex therapists and actually had a lot of discussion about how those symptoms of vaginal dryness, pain during sex can really be mitigated and improved by the use of localised estrogen in the vagina. And I think that’s what’s interesting is some women, even if they can’t access HRT, you know, there is still that use of a vaginal estrogen that will really help. So it’s incredibly sad, actually to know exactly as you say, that there are factors such as being too afraid to use something that could really improve quality of life.

Dr Heather Hirsch [00:15:52] Exactly. And even before we leave that topic, I always tell my patients that I would prescribe this to a nun. And a lot of people think vaginal estrogen is only for intercourse. And actually, you can use this quite preventatively for the entire pelvic floor, the pelvic floor muscles, you know, for the bladder, for the urethra, for the clitoris, for the labia, you don’t lose those parts just because we go into menopause. And so just also really to bring those other episodes together here. Vaginal estrogen is such an important medication for many vulva owners out there, and it’s a shame that it has to be so difficult. Now there are still women for whom they are really fearful that vaginal estrogen will increase the risks for chronic diseases and cancer. And that couldn’t be further from the truth. But again, it really demonstrates how far we have to go in educating other physicians and then the public.

Lauren Redfern [00:16:50] Yeah, it’s interesting actually, we were having a bit of a joke, but it’s not really a joke because it’s not that funny. But I was talking to Louise about it where she was saying that the irony is if this was happening to men, if we had sort of penises that were shrivelling up and, you know, really impacting quality of life, but we said there’s a medication that will help and really decrease that, but we’re not going to give it to you. So yeah, it just it wouldn’t happen. So there’s also, as you mentioned, those aspects in there that really are impacted by the gender politics. I think that exists within this.

Dr Heather Hirsch [00:17:18] You’re absolutely right. I think I put up a Tiktok on this and had I known we’re going to go here, I would have looked it up because I got a bajillion comments. You know I said, ‘What if menopause happened to men? What would happen?’ And they were all like, ‘Oh my gosh, this problem would have been solved a thousand years ago. It would be covered by insurance, they would have spent three times military budget to fix this’. And yet here we are as women.

Lauren Redfern [00:17:40] Yeah, exactly. So obviously, we’ve talked a bit about the barriers that exist there, and we obviously want to talk also about the positives out there, too. And I know that your background and your passion really does lie within teaching and learning. And I wondered if you could maybe talk us through a little bit what you feel could be done to improve the situation. Not only so women or persons experiencing perimenopause and menopausal symptoms are able to access the help that they need, but also so clinicians can feel empowered because it is a frightening domain also for new practising clinicians coming out if they are receiving that sort of learning where they are not being taught adequately how to care for, but also, you know, being told by insurance companies it’s a dangerous treatment.

Dr Heather Hirsch [00:18:20] Right? So then a young clinician or a clinician, let’s say, who has been practising ten years and kind of fell in that sweet spot where they really never saw hormone therapy be prescribed as a resident or in training. You know, they don’t have a ton of motivation to go back and relearn these because they’re already busy as heck, dealing with insurance companies for many, many other things. And as we’re expanding healthcare, which is a good thing, it is putting a lot of stress and demands on our internists and our family practitioners and even our gynaecologists. I have plenty of gynaecology colleagues who come to me all the time for assistance or help or advice on how to prescribe hormone therapy. So I’ve thought about this and thought about this and thought about this, and I actually think that there’s two parallel but separate lanes. I think that the one lane is educating the healthcare providers and the other lane is educating the army of women and activating the army of women. And I’m going to kind of talk about this in two separate things because there’s really different ways and reasons why I think we need to do both, but simultaneously, at least here in the US when it comes to educating physicians, this can definitely be very powerful because while I can educate lay women, one physician, if I can educate one physician and teach him or her how to do this, she or he can help then hundreds of women. So I can have a big impact for every physician that I can educate. And so that’s really exciting. But again, the difficulty with that is how do I make it interesting to them and how do I get them motivated when they have a trillion demands already placed upon them? So that’s sort of a challenge. And we have a couple of organisations here in the US that are trying to help that. In the United States we have the North American Menopause Society, or NAMS, which I am proud to be a part of and really help to teach clinicians evidence-based information and education around all things menopause. There’s also the Endocrine Society, they do a good job of teaching about things like testosterone replacement for women and how to do that safely. And I’m even attempting actually hopefully getting the ball rolling on creating a new course through Harvard on how to prescribe and manage hormone therapy. Now the benefits of also educating lay women and being active on social media and following in the footsteps of, you know, wonderful folks who are so active like Louise is, that we can create this army of women who are going to demand change and they are going to say to their provider, who doesn’t maybe provide them with enough information, ‘I demand more. I want to see a specialist or I read this article. I read the position statement on hormone therapy. You can read it too’. In fact, I love doing that and I have people reach out to me on social media all the time saying, just by watching your videos, I realised that this was going to be safe for me and I could have a conversation with my doctor. And for those doctors who feel uncomfortable and I hear their sad stories, what may actually be happening behind the scenes is they may be going to their managers and saying, ‘Look, I need more senior education on menopause because all these women are asking me’, and so activating the army of women is really, really powerful because as they start to put pressure on physicians to be able to know more, we can actually maybe get things done. So I think about them actually in parallel. And I try to work on both sides of the fence here as we all actually are trying to do.

Lauren Redfern [00:21:49] And I mean, I think that’s such an important thing that you touch on is the empowerment of, I guess, patients advocating for the care that they need and want when actually, I think that can be quite complex in the healthcare system itself where we’ve sort of been taught and told, you know, ‘don’t answer back, take that treatment that you get prescribed’, you know, sort of the hierarchy status that exists that can make it challenging for people to do exactly, as you say, to advocate for the care that they feel they need.

Dr Heather Hirsch [00:22:15] Yeah. However, at the heels of that, I think that this generation of women who’ve got more knowledge about contraception and got more knowledge about pregnancy, got more knowledge about postpartum care, as they’re getting into their forties and starting to experience perimenopause and the menopause, I think that they’re starting to demand more, and I think this generation who can watch all this social media and watch all this stuff unfold is sort of ripe to actually push back a wee bit. And, you know, I could be wrong, I’m optimistic on this, but I hope those aspects, all those hours spent on the phone, it might come back to be really helpful in this movement.

Lauren Redfern [00:22:56] Yeah, I completely agree with you. And I think what you’re really touching on there and I don’t think is optimistic, I think it’s, you know, where we need to be is actually demonstrating that, you know, we do have the tools available to us to start advocating and speaking up for what we need and pushing the envelope that bit. And I think that’s what’s really amazingly happening, actually. You know, also by physicians like yourself who are so personable and articulate, but also approachable because I think, you know, when I first started researching this topic, on the one hand, I’ve had conversations with people where they’ve said it’s very straightforward to the treatment you know, it’s this and this, but actually is highly complex, the arena of tweaking and changing and working with your body to know what’s going to work for you. You know, I was trying to explain this the other day, to say whilst it may be the same approach in treatment, you know, one person who might need three pumps of oestrogel, another person might need only one. And that’s where it’s sort of finding that confidence to know it’s still not quite right – I need a bit more, I need a bit less. And I think as you spoke about earlier, you know, knowing the facts, the evidence base that exists here with this, because I mean, I think it is fascinating that we tend to talk about the risks, but not really the benefits. You know that there are benefits for cardiovascular health, there are benefits for bone health. There are lots of things that will benefit in this. So really kind of making sure that we’re keeping that evidence base at the forefront of the work that we’re doing and empowering women to know that it’s OK.

Dr Heather Hirsch [00:24:16] Absolutely. I couldn’t agree more. In fact, in 2017, there was a wonderful study done here in the US, and the study was interviewing internal medicine physicians and OB-GYN physicians and the hypothesis was, if you were more knowledgeable about the large clinical trials on hormone therapy, you were more likely to prescribe hormone therapy. And they interviewed 500 physicians and asked them nine true or false questions about those large studies and also some vignettes you know, ‘would you prescribe hormone therapy to this person’, whatever. And their hypothesis was correct; if you were more knowledgeable about the large clinical trials – and that includes the Women’s Health study, the post hoc analysis data from the Women’s Health Study, the DOPs trial, which is the Danish Osteoporosis Prevention trial, the KEEPS trial, the Kronos Early Estrogen Prevention trial and others, you are actually much more likely to prescribe hormone therapy. And the nine evidence-based questions, the internists scored on average two out of nine, and our gynaecology colleagues didn’t do much better, scoring a five out of nine, I think it was a 4.5 out of nine. So there’s a lot of work to be done. And the interesting thing is that we have all the evidence-based data right in front of us. It just doesn’t get looked at, talked about and put into practise, put in a motion like, for example, research on the best statin cholesterol lowering medication. And I think that’s what’s so fascinating. You know, so I think this all kind of goes back to actually how I became a menopause clinician myself was that when I was at the Cleveland Clinic doing my fellowship training, I could not believe that all the evidence based information had been before me the entire time, but was truly made invisible. And it wasn’t till I really got to read it and practise it and see it that it all came together. Now every physician can’t have all of that knowledge. They can’t all have years of experience prescribing hormone therapy like me or certain experts. But that’s why we have experts in diabetes for complicated cases. But most GPs know how to treat diabetes, and it would be great if we could get to that kind of system here in the United States, where there could be some types of protocols that a lot of physicians start to feel more comfortable, and they understand the benefits of prescribing hormone therapy, the safety of hormone therapy, and that if there are extremely complicated cases, sending them to those experts who exist. Because right now, the experts of which I believe experts is hard to say, we don’t have specific boards for that, but there’s probably maybe a few hundred of us in the entire country. Right now, we’re seeing everyone when really we should be seeing the complex. Patients and those providers who are their primary care doctor should be able to prescribe and manage hormone therapy.

Lauren Redfern [00:27:06] I like that you bring that in of the, you said earlier, it takes everyone, you know, you mentioned, it takes your physiotherapist, it takes your nurse practitioner, it takes your doctor, it takes, you know, I think that’s really what we’re hoping to do in the development of the Newson Health Menopause Society is really think about it in that way connected up in that way, but also as a global project where we can work together, you know, worldwide to improve knowledge and understanding

Dr Heather Hirsch [00:27:29] it would be so exciting. It definitely is a team, a team effort because you need all the different healthcare players, including over the insurance providers. But really, the insurance isn’t going to go away, probably anytime soon in the United States. But, you know, even if we could walk them through the data that shows that women who take hormone therapy actually have less chronic conditions and therefore need less medications, you know, they might be more interested in that. But we’re kind of a long way off from that right? You know, we’re still thinking about the two parallel lanes of educating physicians and educating lay women, educating insurance companies pretty far off. But it takes a team effort and it is a global thing, right? Oftentimes, I know I’m spending time thinking about how I can make Massachusetts better or the United States better. But just two days ago, I received a DM from a lady in Jamaica crying to me. And you know, I don’t really usually go through my DMs. I get so many, but something compelled me to listen to this, and I was just thinking, ‘You know, it is a small world and we have a lot of work to do’. So I am excited to be part of the society and excited to see what we can all do together.

Lauren Redfern [00:28:37] Yeah, and I wanted to just very briefly, on your website you do talk about that your research centres on inequalities and unanswered questions in the field of women’s health and specifically in menopause, its role in chronic disease development and evaluating the harms of over-screening for chronic diseases, which you just mentioned there. And I just wondered if you could talk us through a little bit of what that really means for you and the work that you’re doing there?

Dr Heather Hirsch [00:29:02] Yeah, you know, I think that what I learnt, especially in my training, the little bit that I did before I got to my fellowship training was that menopause exists in the silo. Menopause is this singular event. It’s the last day that you menstruate and that couldn’t be further from the truth. It’s so integrated into chronic diseases. One of the projects I did was a Metabolomics Project, looking at the metabolomics of women in the Women’s Health study between those who took hormone therapy and those who didn’t. And the reason we looked at those metabolomics was because women who took hormone therapy, particularly actually the estrogen plus progesterone, had less progression to diabetes than women who didn’t. And this is huge because as an internist and a GP, I’m using them now interchangeably. You know, a lot of times we start to see the A1C level with a prediabetes start to go up while they’re going into menopause. And I don’t think that that’s a surprise. I think their mood is starting to change. Maybe they’re binge eating. Maybe they’re not eating the right things. Maybe they’re craving more sugar, they’re not sleeping, their metabolic rate’s just going all haywire because of the menopausal symptoms, a change in the hormone levels. Well, now we know, you know, and there’s plenty of Kaiser data as well a big bank we have of information here to show that women who take hormone therapy have less progression to diabetes is really significant. We also know that as we already mentioned in the WHI, there showed less progression to chronic cardiovascular diseases. So these are really so important. And so I really like to look at these and sort of really show how chronic diseases start to rise at the time of menopause, particularly in women who are untreated. So menopause is not a silo. It’s just not a silo.

Lauren Redfern [00:30:44] It’s fascinating, and I think I have 100 other questions I could ask you. And unfortunately, we’re at that point of running out of time. For everyone listening as well, on top of all of the hard work that Heather does, she also produces her own podcast, and you will definitely have to go and check that out. We’ll put a link to that so you can go and listen. I mean, you can tell from hearing Heather here she’s incredibly knowledgeable, and her approach to talking about this topic is just very accessible, so I would 100% recommend that. I wondered though if we could Heather maybe end by – I’ve started asking people if they have any take-home messages for those listening from today’s discussion or any points you’d like to emphasise or stress from the things we’ve talked about.

Dr Heather Hirsch [00:31:24] I think that my take-home message would probably be this idea of the two parallel lanes. The physician lane and the Army of Women Lane. Sometimes when I get really flustered or I feel as though everything I’ve done, I still haven’t made a dent. I like to kind of take a step back and remind myself of these two parallel lines. And it gives me some wiggle room to go between one and the other. So if I’m frustrated that my message isn’t getting out on social media, I can take a step back and I can focus and concentrate on maybe my next lecture. Making it really impressive or working on my CME course, all these moments that have led up to hopefully being able to impact change or if I’m feeling stuck there, I can mobilise the army of women. And I think these two separate lanes, unfortunately at this point, they’re not really meeting yet. Maybe they are. Maybe I’m just not seeing it, but it’s really the way I kind of like to keep it in my mind. And so if we’re all doing that together, eventually there should hopefully be this big bridge where we can, you know, really kind of help to actually really solve this. We have a long way to go, but I think that would be my take home message.

Lauren Redfern [00:32:34] Amazing. Well, thank you so much, Heather, and I hope you’ll come back and join us again because like I said, there are so many different questions I could ask you.

Dr Heather Hirsch [00:32:41] Any time I’m so honoured to be able to speak on the podcast. I know so many women listening in are so interested in this topic. And if I could provide any type of information, ideas, spread awareness, spread just sisterhood in this mission, I am delighted I got the chance to do so.

Lauren Redfern [00:32:58] Great. Well, thanks so much, Heather.

Dr Heather Hirsch [00:33:00] Alright. Bye, everyone.

Lauren Redfern [00:33:04] We would love for you to join our collective of professionals passionate about the menopause visit NHMenopauseSociety.org to become an associate. You’ll receive regular webinars and advice from our experts, as well as opportunities to network and connect with the latest research from around the world. You can follow us on Twitter @NHMenoSociety. And don’t forget to tell your colleagues about the Newson Health Menopause Society.

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