Episode 12: Should I go on HRT? with Touseef Mirza

Dr. Sophia:
Hello everyone. Welcome to the Dr. Sophia Podcast. I'm an obgyn practicing for over 15 years in my native New York City. And I love to help women learn about their bodies, empower them, and embrace themselves. On this podcast, we will talk openly and with heart about all things affecting women from pregnancy, menopause periods, sexual health, fertility, and so much more. Disclaimer, this is general medical information based on my professional opinion and experience. For specific medical advice, please refer to your physician.

Hello everyone. It's me, Dr. Sophia, and we are here with Touseef Mirza. And I thought you guys would like to know this little fun fact. Touseef is not only one of my very good friends, but she's also my patient.

Touseef Mirza:
I am, we've known each other more as friends.

Dr. Sophia:
Yes, absolutely.

Touseef Mirza:
We've known each other as good friends for much longer. But then there was a point I was just like, why aren't you my obgyn, like, you know, everything else about me. So that's how that happened. One of the things that's come up is that I am in the age right now, I'm 51 and I am in the process right now of figuring out if I want to consider HRT, which is hormone replacement treatment because I'm almost done with menopause. I'm almost at the full year without any period.

And since this podcast is all about sharing and embracing our bodies and ourselves, I thought that it would be good to, instead of having a one-on-one with Dr. Sophia and asking her all the questions that I have on HRT is actually to just come here and share it with all of you as well. So this is literally what would be happening, like in her office. And I have all these questions. So, welcome to my world right now.

Dr. Sophia:
Welcome to my world right now.

Touseef Mirza:
Before we begin, let me just ask you if I would come into your office, and I would say, you know, I think I'm almost menopausal and I hear about HRT all the time. What is it exactly?

Dr. Sophia:
So I think, let's just take it back just a little bit. When we think about menopause, menopause is going through consecutive 12 months of no period and is usually attached to a lot of other symptoms that may be happening at the same time. And those symptoms can start way before you actually go through those 12 months of no period, and where we then consider you as being menopausal. So some of the symptoms include hot flashes, night sweats, you know, we've talked about this. I know you ladies and everyone else out there have all listened to our Menopause 101 Podcast.

But just as a quick review, some of the symptoms include hot flashes, insomnia, night sweats, energy changes, mood changes, weight gain, and mental fog, just to name a few. And so oftentimes women will come to me because they are concerned with some of those symptoms that they're experiencing and how, if anything, they can be doing in order to help them through those symptoms. And that's where the concept of HRT or hormone replacement therapy comes in. And just to be clear, it doesn't mean that everyone needs hormone replacement therapy and that the only way to mitigate some of the symptoms that women experience with going through the change called menopause is only possible through hormone replacement. Absolutely not. There are diet changes, there's exercise, there's meditation, there's so many other ways in which women can address some of those issues successfully, but it's individualized.

Touseef Mirza:
Thank you for that recap. So going back to me now, just to give a little bit of a background in terms of where I'm at in terms of health wise and, and everything. So like I said, I'm 51. I would say I'm not a person that has had too many hot flashes in my past, even in perimenopause, which is like before menopause, when you start to change your hormone levels already. I do have a little brain fog here and there and like four or five months ago I was feeling really tired and lethargic, but now I'm doing more exercise and I'm just feeling much more alert and not as drained anymore. So that's been going well. I've been able to mitigate certain aspects of that and I have gained a little bit of weight, not super substantial, but, a little bit of weight.

And even if I'm eating well and I'm working out, that's not really moving a lot. I also think it'd be good to talk a little bit about my medical past. I'm a healthy person. I haven't had any kids, like, just from a pregnancy standpoint and I haven't had any cancers. So I'm pretty healthy, knock on wood. I'm a pretty healthy gal. One thing I think is important to note just from a medical history perspective from my family, just two things is my father had Alzheimer's. So there is a disease of cognitive decline. And then, my mom does have some heart condition. So that's pretty much the whole medical aspect of things considering all these different factors, like do you think that HRT is something that would be good for me to consider?

Dr. Sophia:
So before we even talk about HRT, I really need to know a little bit more about what other symptoms you're experiencing. So you did say things like brain fog. You do feel like you've had a little bit of that and that you are not really experiencing bothersome hot flashes. You may get them, but it's certainly not something that's top of mind as being something that's bothering you. And it doesn't sound like you've really mentioned any of the other symptoms. I mean maybe a little bit of weight gain and then the energy you've been able to kind of, you know, like, or the fatigue maybe, which may be related definitely to menopause or, or being perimenopausal.

But it seems like you're doing a good job of handling it in terms of exercise. So all of that is great because you're at the ideal age for starting hormone replacement. If it's even something that you're thinking about, then I actually would consider it from the standpoint of some of the benefits. Starting hormone replacement and like I said, it's not for everyone and it's just the sheer fact that you're thinking about it is what makes me think about it. So from a cognitive standpoint, as well as a heart disease standpoint,

And that's your family history, that's not your personal history. However, hormone replacement does decrease the risks of both cognitive decline as well as heart disease in women. And so if that is a big concern of yours, then it's, then it would be something that I would consider. And it's not because we're trying to say, oh, start hormone replacement therapy because this is somehow gonna be prophylactic. I don't just start hormone replacement therapy on women as a preventative measure. Right? But in someone like you where you're telling me, Hey, these are the things that are happening or have happened in my family as far as family history and moreover I am looking to see how, what else I could be doing to maintain my healthy status. And you do have a few of the symptoms that are associated with menopause and starting hormone replacement could certainly help with those symptoms. And so I think it's very reasonable to start you on hormone replacement. I think it's very reasonable for you to be on it for a long time.

Touseef Mirza:
So what is a long time, once you start, do you stay on it for the rest of your life? Do you get off it? I guess it depends the goal with HRT, but considering what we're talking about, how would you gauge that

Dr. Sophia:
Considering what we're talking about? I have to tell you, I'm definitely of the school of thought that if you start hormone replacement and it's working well for you, that there's no age time limit timeframe for which to stop. If you look at medical literature, and if you look at the way that most people practice in the sense of hormone replacement, many people will say that you should continue for up to five years and it definitely should be started within the first 10 years of menopause. So I definitely believe that the best time to start hormone replacement is definitely in that perimenopause, meno, early menopause time frame. However, how long you stay on it, I think women can be on it well into their eighties, even nineties. I have some women whom I know started hormone replacement back in the eighties who are clearly still on it and feel great.

Touseef Mirza:
So it's interesting you bring, bring this up. I was asking my mom, 'cause she's been on hormone replacement therapy since like 1988.

Dr. Sophia:
I'm not surprised.

Touseef Mirza:
And for her, it's just like, yeah, that's just what I've been taking all the time and that's just what it is. But then, you know, then I start to think why then do we have this bad rap?

Dr. Sophia:
Oh, the bad rap.

Touseef Mirza:
The bad rap of HRT and I think I'm also affected by that. This is why I am seriously thinking, well, you know, do I really need it? Do I not need it? Are my symptoms grave enough or am I, is my family history that severe that I have to do it? Or is it better not to do it because of the quote-unquote bad rap?

Dr. Sophia:
So the bad rap for HRT or hormone replacement really came from the Women's Health Initiative, a study that basically showed increased risks of different conditions such as stroke, such as breast cancer with hormone replacement. But those increases were so small actually. And one of the biggest parts of the study that just was not looked upon as a big deal is the fact that the average age of the women who were in the study and started hormone replacement were 63. So well after the time that most women who are seeking hormone replacement therapy would be, most women who are seeking to start hormone replacement are in their forties and fifties. And so at 63, where your average age of menopause is about 51, and these women were 13 years past menopause and only now initiating hormone replacement therapy. And so at that age, they actually already had a lot of the increased risks for all of those diseases in the first place.

Touseef Mirza:
Because they're older.

Dr. Sophia:
Because they're older, so-

Touseef Mirza:
Older, the risk is higher with age.

Dr. Sophia:
Exactly. So the risk of breast cancer is higher, the risk of coronary artery disease or heart disease is higher. And so what was interesting is that you actually have a lower risk, for example, of coronary heart disease or heart disease. If you start HRT younger, if you start HRT and the early signs of menopause or the early timeframe of when you're going through menopause. And that's just one thing and as one example.

Touseef Mirza:
So I feel like we have it all upside down then, then everything you're saying is that, you know, it's actually on the up and up versus everything that we've heard is more like, you know, you have to be skeptical about this. So let me ask you this. If I take HRT, what is it actually doing? Because I know my estrogen is going lower because of the phase that I am from a hormonal level in my body, my estrogen is going low. So is the HRT actually replenishing my estrogen levels? So the body continues to be in homos status? Like how does that work?

Dr. Sophia:
Yes, hormone replacement therapy is the combination of estrogen with a progestin or just estrogen alone depending on your personal situation. So in your case, it would be that you would be on both estrogen and progesterone or progestin. And the point of it would be to yes, basically prolong your exposure to estrogen in your body. And why is that? Because estrogen is protective. Estrogen is protective for your bones, your brain, your heart, your breasts.

Touseef Mirza:
Which was always there.

Dr. Sophia:
Which was always there.

Touseef Mirza:
That level of estrogen was always there before to do those things.

Dr. Sophia:
That is correct. It's the reason why women have a lower cardiovascular risk and their cardiovascular risk does not increase until after menopause. So as an example, all you've done is prolong your body's natural way of protecting itself by starting hormone replacement as well as mitigating some of the really unsightly and frustrating symptoms that come along with menopause

Touseef Mirza:
Such as hot flashes and-

Dr. Sophia:
Such as the hot flashes. Such as the insomnia, such as the fatigue, such as the mood changes, the anxiety, the depression, the paranoia that happens in the menopausal during the menopausal changes.

Touseef Mirza:
Let's say you have a certain level of estrogen in your body that's 10. Let's just say that as my normal level when in my twenties, in my thirties. Then when I hit perimenopause, menopause, my estrogen goes lower. Let's say it goes down to six. Okay? This is all hypothetical. Alright? And then am I going to continue to have lower and lower levels of estrogen as I age or can it stabilize or it can be either?

Dr. Sophia:
No. What happens after menopause is your estrogen levels go to the floor

Touseef Mirza:
Okay. So it keeps going down and down.

Dr. Sophia:
It just keeps going down.

Touseef Mirza:
Okay. And then hormone replacement therapy enables that estrogen number to go back up.

Dr. Sophia:
It goes back up to a baseline that is, we're trying to make it so that those estrogen receptors in your body, the ones that are in your brain, the ones that are in your heart and your bones okay, are still getting the effects of the estrogen, the beneficial effects of the estrogen.

Touseef Mirza:
Alright. So just to break it down, estrogen basically is something that affects all different parts of your body, and that's why we say estrogen receptors. Is that because a lot of different parts of our body uses estrogen in order to function.

Dr. Sophia:
Our skin, In order to function correctly, our skin is one of the organs that uses estrogen.

Touseef Mirza:
Okay. Then the question is, and by the way, I would've asked all these questions one on one. So, because I'm really trying to figure out if it's, if it's a good decision for me, the HRT in terms of the molecule that then goes in my body, how much does it mimic the real estrogen?

Dr. Sophia:
That is the whole point. It does. It's mimicking your body's natural estrogen. It's mimicking that.

Touseef Mirza:
Okay, let me ask you this. Is it, do you ingest a pill? Is it in pill form?

Dr. Sophia:
Yes.

Touseef Mirza:
So then when I'm taking that pill, it's full of estrogen.

Dr. Sophia:
Yes. It's a pill that has both estrogen and progesterone. And it doesn't always have to be in a pill. It could be in the form of a patch. It could be in the form of a gel, it could be in the, you know, so I don't want you to think about it just in terms of how you're taking it. I just want you to think of the replacement, the concept is here replacing these hormones. And when we say replacing hormones, it could be even where it could even be talking about like thyroid hormone. Thyroid hormone also goes down and thyroid hormone.

What's really is a very underutilized hormone. And you know, when we think about it, because it's the hormone that helps the rest of all of the other hormones work so well, it's kind of happening in the background in terms of what it does for us also helps us with mood and, and our brain function and our metabolism. And you know it's the concert of all of these hormones working in your body that all go in a decline as we age.

Touseef Mirza:
But HRT doesn't have-

Dr. Sophia:
Thyroid. But when we are typically thinking about HRT, yes we're really mostly talking about estrogen and progestin, but there are other hormones. There's like I said, thyroid hormone, and in some cases there may be, you know, replacement even of testosterone in women. You know. And so this is a very individualized conversation and I want women to feel they can embrace the concept if it's something that they're questioning, that they're going through all of the, the symptoms that are associated with menopause, having a better understanding of what some of the actual benefits are and some of the risks and who really is a good candidate and knowing that it's okay to want to be on hormone replacement therapy.

Touseef Mirza:
I think one of the things we need to say, even before saying it's okay to be on hormone replacement therapy, it's okay to want to be okay.

Dr. Sophia:
Yes. Right. It's definitely okay. You should, why not? If it's something that's gonna, your mom, let's just use your mom as an example. As a woman of a certain age at this point who has been on hormone replacement therapy for almost 30 years. Or more actually she's been on it for more than 30 years. At this point, it's a part of her vitality. And so it's a part of, like your mom, the benefits that she's reaping from this is lower risk of colorectal cancer, improved cardiovascular health, and even if she has cardiovascular disease, the concept, she's still on hormone replacement.

Touseef Mirza:
And the reason for that is because we say HRT. But the reason for that is because she has a level of estrogen in her body that enables her body to function as it's supposed to better than if there was no estrogen.

Dr. Sophia:
If she had no estrogen, her body would be functioning. How do I put this? Because I don't want people to take away from this that I'm simply trying to push HRT because that's not the case. I don't wanna be misunderstood. As a woman of a certain age, she's going to have age related risks or issues, health issues potentially. And by her continuing her hormone replacement, she is in a sense mitigating some of that. Now, of course she's still getting older, so there are still some things that are happening, but if we completely stopped her, she would probably not feel as great as she does. If I had to use a metaphor perhaps of the benefits or the reason why, one would be on HRT, I would say if we have a bouquet of flowers and we put water in a vase and we put, let's say some flower food now because we've put in the flower food, extended the life, the beauty of that bouquet. So instead of having a bouquet of flowers that's going to be beautiful, let's say for three or four days, I now have extended the beauty, the life of that bouquet, let's say to a week.

And so in those seven days, let's look at the bouquet of flowers over seven days. There's the one that had some flower food and the one that didn't, and they're both gonna be wilting, but one may wilt a little faster, one may progressively wilt and, and die eventually. And so the one with the flower food, it still is gonna eventually die. But the wilting process is long, you know, takes a lot longer to get there.

Touseef Mirza:
Because they have that extra-

Dr. Sophia:
Because they've gotten that little extra flower food. Is the same flower food that would've been, let's say in the soil before we even cut it? And so let's say menopause or going through menopause is having cut the flowers in the first place and all you've done by putting in the flour food is as if you've kept it in the soil.

Touseef Mirza:
So you're recreating that environment.

Dr. Sophia:
Environment exactly.

Touseef Mirza:
That it likes to thrive on.

Dr. Sophia:
Exactly. So yes, of course, it's still gonna go through the aging process. But it's gonna go through that process a little bit slower, a little bit more vital.

Touseef Mirza:
Would you say that there are, like, what are certain potential drawbacks aside from, you know, like the risks that we talk about depending on my health situation, but just in general, like smaller types of symptoms. Like does it give you headaches or does it give you any stomach issues? Like do you know if it has a tendency to do that?

Dr. Sophia:
So again, when we're dealing with hormones and hormone changes or adding and subtracting and, and that kind of thing, we have to get to a balance. We have to get to a point where it's good for you. And so in that process, in that timeframe, you may have things like nausea, you may have things like headache as you say, you may experience. I mean those are small side effects that may or may not happen and may only happen for a small amount of time. a little bit of potentially water weight. but again, these are things that over time go away. And so as you're more common, I would say side effects so to speak, when we're talking about risks specifically like contraindications and that kind of thing, I would say that any abnormal bleeding, then we would wanna investigate first why someone's having abnormal bleeding before starting them, let's say on a hormone period.

Touseef Mirza:
You're talking about like your period,

Dr. Sophia:
I'm talking about bleeding, not just not a period. That's exactly my point. That we're talking about bleeding that's happening. If you're menopausal, you should not be bleeding. Once you, once you've hit menopause then all bleeding stops. So if you have bleeding after menopause, then that should be investigated before starting any type of hormone replacement.

Touseef Mirza:
Does it happen that once a person starts to decrease the estrogen level when they're around my age, that eventually starts going back up?

Dr. Sophia:
No.

Touseef Mirza:
No. Okay. I'm just asking.

Dr. Sophia:
If it does, then something's wrong.

Touseef Mirza:
And something's wrong.

Dr. Sophia:
Yeah. If you are a menopausal woman and all of a sudden you start to have high levels of estrogen again, you might be feeling good, but you may also have some really serious medical issue happening such as an estrogen-secreting tumor, you know, and so that's a whole different conversation, you know, but the bottom line is no, once your estrogen is gone, it's gone for good.

Touseef Mirza:
So then when we say that, because I've heard that, you know, if you're, if you're having certain symptoms of, of perimenopause, menopause, if you do certain things like we talked about like exercise and proper diet and your sleeping, that it does help. So how does it help?

Dr. Sophia:
So it helps because let's talk about exercise for example. Yes. And let's talk about some of the other symptoms of menopause. So exercise generates dopamine. Dopamine helps with mood, dopamine helps with sleep, dopamine helps. It just overall helps with so many other things. And the exercise itself is going to help you in terms of cardiac or you know, the benefits that it has on your body, on your heart, et cetera, on your bones, on your muscles and that kind of a thing. Now exercise is not bringing up your estrogen. Those are two different things. But exercise has the overall benefit on your health and it helps with certain symptoms of menopause that are not only gonna get better just because of estrogen for example.

That's what I mean when I say that there are other ways, if we're only thinking about symptoms, that there are some ways in which to mitigate some of those symptoms. And exercise doesn't help everybody. Some women can exercise five hours a day and they are still suffering from hot flashes. And hot flashes we know come from the jagged up and down part of perimenopause in terms of estrogen. And then of course the complete decline of estrogen.

Touseef Mirza:
I think this is so important what we're saying because I think by understanding really how estrogen works and when we say, you know, yes, if you exercise, if you sleep, because I think sometimes if a woman feels like she's doing all of that and still she's having a lot of menopausal symptoms, she might say, well what am I doing wrong? Or that is, so maybe I'm not doing it right. So, sure. Or maybe, I'm not doing it enough.

But actually since that is actually not affecting the, as actual estrogen level that is correct. That it might be two completely different things that we're talking about. So I think that is a place where there's confusion because we sometimes link exercise and sleep with menopause. And so we think that we can control it in certain conditions. It can help like you're explaining, but in certain conditions for certain people, it doesn't matter how much you do it.

Dr. Sophia:
That's right. You can exercise until you're blue in the face and still have 10 hot flashes a day, which is disruptive to your day. You know, or have night sweats or have brain fog, you know, granted exercise also helps with the brain function, but you may still be having bothersome symptoms that are menopausal symptoms that will really only get better once you start hormone replacement.

Touseef Mirza:
So let's say that I start HRT and then, I'm feeling better, but I wanna see maybe, I don't know, after six months or a year, I'm just like, I just wanna see if I would stop how my body would be.

Dr. Sophia:
Women do that all the time. As a matter of fact, I would say that probably most women stop taking HRT after, you know, a few years.

Touseef Mirza:
Okay.

Dr. Sophia:
Just because they're like, do I really still need this? And sometimes they don't because the bigger symptoms that they were taking it for have really diminished and, and they're basically at a baseline that they feel comfortable with.

Touseef Mirza:
But you can only know that once you stop it.

Dr. Sophia:
A lot of times though, there are women who do stop. And their symptoms return and they're like, oh no. We're not, I'm not doing that.

Touseef Mirza:
I mean I will be honest, like there was a point where I was feeling lethargic and really tired and it lasted for a while. So much so to the point that when I woke up one day and I was feeling fine, I had forgotten, oh yeah, this is how I used to feel. Like, you know, you just get so used to it and you know, I think as women also, you know, some, you know, when we had our periods we're just like, well, I guess that's just the pain it is. So we'll just deal with it. Just push through. We just push through. And I think even for me at 51, like, you know, I'm trying to not make it a default but actually see it and, and try to address it and not just think of it, oh well that's just my body so I'll just go and do it. This actually goes back a little bit to our previous episode of, to Endure, not Endure. So if you haven't listened to that, I mean, we literally talk all about this in terms of how we-

Dr. Sophia:
Push through as women.

Touseef Mirza:
Yes. And why do we do that? But I think we just don't have enough conversations about menopause and HRT in terms of really understanding all these nuances. And once you start looking at these nuances, I'm not saying right now that I'm a hundred percent going HRT, but I have a much better understanding and I'm gonna think about it some more. And, I think we would like to continue and talk about it. I'm totally fine talking about my journey and, and seeing where that goes. What, regardless of whether I move forward with it, or not.

Dr. Sophia:
Well I hope what you've really gotten out of this is that you should have some grace with yourself and if you feel like you would like to start HRT for whatever reason in terms of symptoms, in terms of just vitality and longevity, I think that that is completely reasonable. And at the same time, if you decided not to start HRT, that is equally as purposeful for you. And so I love the fact that we've gone through this discussion because the point of this is just so that you feel like you've gotten the information and that you feel like this is a decision that we can come to together and you can continue to have questions and we can continue to talk about it.

Touseef Mirza:
Awesome. Thank you so much for all of your openness in going all different directions. because God knows, I know I always have tons of questions. So, thank you for that.

Dr. Sophia:
You're very, very welcome. And as always, thank you for being here and joining me on the Dr. Sophia podcast. Bye bye. This is General Medical Information based on my professional opinion and experience. For specific medical advice, please refer to your physician. Until next time, embrace your body. Embrace yourself.