Hormone replacement therapy (HRT) for women in menopause serves as a driver for Dr. Heather Hirsch, who says it’s “the reason I get up every single day and do what I do.” To that end, she founded and helms a concierge clinic, The Collaborative, to bring science-based support to women in perimenopause and menopause, while advocating for better understanding of therapeutic options — including HRT.
Weeks after her talk at DOC 2025, the Food and Drug Administration took a significant step to support women by removing the black box labeling that gated the use of HRT for decades. Helping clinicians understand the potential benefits of this therapy — and how to craft a unique approach for each patient — remains a crucial mission for her.
“We have to train clinicians, we have to be able to scale, but we also have to personalize,” she says.
You can hear more from Dr. Hirsch in our video of her talk from DOC 2025’s “The Science of Women’s Health” session below or read our lightly edited transcript.
TRANSCRIPT:
Dr. Heather Hirsch
Thank you, everyone, for, inviting me. It’s such a privilege to be at this conference. So I never thought I was going to grow up and be a menopause doctor in fact, that was not really on my radar. I always wanted to take care of women. After I did my internal medicine residency, I did fellowship at Cleveland Clinic, I was really interested in long-acting contraception. I wanted to help women know more about their bodies, peri-, partum-, postpartum. But when I saw my mentor treat women who came to what we called, “the Mistake on the Lake,” Cleveland, for all these crazy symptoms that they didn’t know what was happening to them. They thought they had dementia. They thought they were never going to sleep again. They lost interest in things like sex and even decorating for the holidays. When she treated them with menopausal hormone therapy, I thought to myself, what is going on? Because they would come back full of life and reborn. I knew that that’s what I wanted to dedicate my career to, and that’s what I’ve been doing. That’s what I just love doing, teaching because I didn’t get any education on this when I was in training.
I want to ask you because this is important. So I need to ask a question. So I need a show of hands. Who here does know this recent study? 70,000 women were in a randomized, double-blind, placebo-controlled study that showed an intervention that increased women’s health span by 3.2 years.
Who knows that study? We’re going to talk about the forgotten longevity date. Nobody knows what study I’m referring to. Come on somebody. All right. The Women’s Health initiative. Great. So I want to start by talking about the forgotten longevity data.
In the 1980s, in the 1990s, in fact, the American College of Physicians in 1992 strongly advocated that women use hormone replacement therapy. Most women in menopause, early in menopause were given Premarin, a conjugated equine estrogen, and the clinician saw that it was increasing their lifespan, reducing heart disease and reducing fractures. Then they came up with a randomized control study called the Women’s Health Initiative. The Women’s Health Initiative changed the game in a good way. But unfortunately, we’re stuck somewhere deep in myths and misconceptions about what the science actually showed.
This study was 70,000 women randomized to placebo or menopausal hormone therapy. They found that women who took the menopausal hormone therapy lived on average 3.2 years longer. Name one medication that we know of that already does that. They also had less cardiovascular disease, the leading cause of death in women. They lived longer, they had less fractures, and they had amazing quality of life.
Now before we go any further, let me define what’s menopausal hormone therapy. We use this blanket statement. But it can mean so many things. Menopausal hormone therapy for most women is an estrogen replacement either in the form of patch pill, spray or gel. FDA-approved is what I strongly recommend, because it has the safety data to go along with this.
I have an ice cream cone theory about hormone therapy, where estrogen is the ice cream, it’s really the main ingredient. That’s what actually helped women have less heart disease. Live longer. If you have a uterus and you’re taking estrogen, you need to take some progesterone with it, and then some women will add some low dose transdermal testosterone. Some women will add low-dose vaginal estrogen. But it’s very personalized. That’s important because some women may be on just progesterone and testosterone. Some women may be on vaginal estrogen and progesterone. Some women may be on all four.
We have a medication that has improved health span for women in many different organs. The fact that we are not speaking about this every single day and helping women understand menopausal hormone therapy is absolutely wild to me, is the reason I get up every single day and do what I do, whether it’s teaching students, whether it’s seeing patients, and whether it’s going on social media, because this information is pure gold.
While I know all the science behind this, and I only have a few seconds for this slide, hormone therapy-reduced osteoporotic fractures, of which one and two women will suffer from, of which more women will have an osteoporotic fracture than heart disease, breast cancer and strokes combined, costing trillions in health care. Women’s leading cause of death is cardiovascular disease. In the Women’s Health study, the women who took hormone therapy also had less cardiovascular incidences, MI’s and lived longer. They had less diabetes. Can you believe that? Women who took menopausal hormone therapy, this is science, this is not opinion, had less progression to the development or diagnosis of diabetes. They also had better brain function and improved their quality of life significantly.
How many women take menopausal hormone therapy knowing that? Two percent. The 2024 menopause position statement or menopause guide that came out said about 2%. Sometimes you hear 5%. Imagine if 80% of women were on hormone therapy. You may say, how many women are good candidates for hormone therapy? I would say the vast majority of women are good candidates for hormone therapy, especially when you’re thinking about the fact that menopausal hormone therapy could mean different things for different women.
Here’s a couple of myths that I’m going to debunk in about 40 seconds. We now use different formulations of FDA-approved hormone therapy than we did in the Women’s Health Initiative. So in the Women’s Health Initiative, it’s conjugated equine estrogen and progesterone acetate. Now we use FDA-approved estradiol and typically Prometrium. When we use Prometrium with an estradiol, we see no increased risk of breast cancer above a woman’s baseline. The biggest fear that women still have is that hormone therapy increases breast cancer risk. That’s because when the Women’s Health Study came out, training became extinct and physicians and women threw their hormone therapy in the garbage because they said there was a 26% increased risk of breast cancer. That is the big reason why we’re here, why only 2% of women take hormone therapy, not 80%.
It’s still this fear of breast cancer, and it’s the extinction of training. So clinicians have not learned how to prescribe menopausal hormone therapy. I said that the biggest fear that women have about breast cancer is actually debunked. We know that transdermal estrogen does not increase the risks of clots. We know that if women start within ten years, that’s when they get the most benefits. Although I believe all women should be counseled about menopausal hormone therapy, they can start in perimenopause. And there’s so many positives here. Not to mention the economic increase in women who are feeling well, not missing work, not seeing multiple clinicians as well as how much we would save in health care.
I believe in personalized hormone replacement therapy. What does this mean? Well, I’ve been doing this for the last 12 years, and I’ve found that not all women are going to need the same formula. It is really hard to protocolize hormone replacement therapy, which makes it hard to scale because it must be individualized. So we also want to think about not only do women need estrogen, progesterone and maybe a testosterone and maybe vaginal estrogen, but what order do they do this? That is something I call hormone stacking, which is really actually my way of thinking about precision medicine. Now I have to do this blindly. I don’t have enough data to know what are the genetics or epigenetics of someone who’s going to tolerate progesterone or not tolerate progesterone. Need a gel versus a patch of the patchwork stick? I don’t know yet, but what I know is a pattern that I see.
Metabolic monitoring is also really important in this menopause manual, which is that not all women must take hormone therapy. I want to make it clear there’s not one right answer, but all women and all clinicians should know the benefits of hormone therapy. We should be monitoring for their A1 C’s, for their lipids, as well as for brain markers, as well as for autoimmune and inflammatory conditions that start alongside menopause and lifestyle is
really important. We all know lifestyle. I’m not going to harp here for too long. But women who are in supportive communities also have improved health beyond 5 to 7 years longer than women who are not in supportive communities. I believe you have to start with personalization, which we’re going to use AI to help with.
Everything that I’ve either done, taught or recognized as a pattern, we’ve turned into a closed loop LLM, to help us be able to scale while also personalizing it. Because when you get it wrong, women do not like that. They’ve already had periods for a lot of years endometriosis, chronic pain, infertility, C-sections they didn’t want to happen. Then you get the hormone therapy wrong and the clinician and the women throw it in the garbage. It has to be personalized and we have to scale it.
Teaching is critical. We have a decade or two of clinicians who have never seen a clinician counsel and prescribe hormone replacement therapy. So this is really important. So what is the future here? I want all everyone here to know that menopausal hormone therapy is only used by 2% of women. It is something that 80%, if not more women are good candidates for.
It is the only thing that has shown to increase health span in women. We have the solution. We have to train clinicians, we have to be able to scale, but we also have to personalize. We have to use artificial intelligence for that. Thank you guys.