This is Dr. Heather Hirsch. She’s a board-certified internist, and her clinical expertise focuses on women’s health, particularly in midlife and menopause, and its intersection with chronic diseases (ranging from things associated with sexual health, to things like osteoporosis and heart disease).

So, what does she want us to know?

HRT can be life-changingly positive, but it can be a shaky start

Hormone Replacement Therapy (HRT), and in this context she’s talking specifically about the most common kind, Menopausal Hormone Therapy (MHT), involves taking hormones that our body isn’t producing enough of.

If these are “bioidentical hormones” as used in most of the industrialized world and increasingly also in N. America, then this is by definition a supplement rather than a drug, for what it’s worth, whereas some non-bioidentical hormones (or hormone analogs, which by definition function similarly to hormones but aren’t the same thing) can function more like drugs.

We wrote a little about his previously:

Hormone Replacement Therapy: A Tale Of Two Approaches

For most people most of the time, bioidentical hormones are very much the best way to go, as they are not only more effective, but also have fewer side effects.

That said, even bioidentical hormones can have some undesired effects, so, how to deal with those?

Don’t worry; bleed happy

A reprise of (usually quite light) menstrual bleeding is the most common side effect of menopausal HRT.

This happens because estrogen affects* the uterus, leading to a build-up and shedding of the uterine lining.

*if you do not have a uterus, estrogen can effect uterine tissue. That’s not a typo—here we mean the verb “effect”, as in “cause to be”. It will not grow a new uterus, but it can cause some clumps of uterine tissue to appear; this means that it becomes possible to get endometriosis without having a uterus. This information should not be too shocking, as endometriosis is a matter of uterine tissue growing inconveniently, often in places where it shouldn’t, and sometimes quite far from the uterus (if present, or its usual location, if absent). However, the risk of this happening is far lower than if you actually have a uterus:

What you need to know about endometriosis

Back to “you have a uterus and it’s making you wish you didn’t”:

This bleeding should, however, be light. It’ll probably be oriented around a 28-day cycle even if you are taking your hormones at the same dose every day of the month, and the bleeding will probably taper off after about 6 months of this.

If the bleeding is heavier, all the time, or persists longer than 6 months, then speak to your gynecologist about it. Any of those three; it doesn’t have to be all three!

Bleeding outside of one’s normal cycle can be caused by anything from fibroids to cancer; statistically speaking it’s probably nothing too dire,but when your safety is in question, don’t bet on “probably”, and do get it checked out:

When A Period Is Very Late (i.e., Post-Menopause)

Dr. Hirsch recommends, as possible remedies to try (preferably under your gynecologist’s supervision):

• lowering your estrogen dose
• increasing your progesterone dose
• taking progesterone continuously instead of cyclically

And if you’re not taking progesterone, here’s why you might want to consider taking this important hormone that works with estrogen to do good things, and against estrogen to rein in some of estrogen’s less convenient things:

Progesterone Menopausal HRT: When, Why, And How To Benefit

(the above link contains, as well as textual information, an explanatory video from Dr. Hirsch herself)

Get the best of the breast

Calm your tits. Soothe your boobs. Destress your breasts. Hakuna your tatas. Undo the calamity beleaguering your mammaries.

Ok, more seriously…

Breast tenderness is another very common symptom when starting to take estrogen. It can worry a lot of people (à la “aagh, what is this and is it cancer!?”), but is usually nothing to worry about. But just to be sure, do also check out:

Keeping Abreast Of Your Cancer Risk: How To Triple Your Breast Cancer Survival Chances

Estrogen can cause feelings of breast fullness, soreness, nipple irritation, and sometimes lactation, but this later will be minimal—we’re talking a drop or two now and again, not anything that would feed a baby.

Basically, it happens when your body hasn’t been so accustomed to normal estrogen levels in a while, and suddenly wakes up with a jolt, saying to itself “Wait what are we doing puberty again now? I thought we did menopause? Are we pregnant? What’s going on? Ok, checking all systems!” and then may calm down not too long afterwards when it notes that everything is more or less as it should be already.

If this persists or is more than a minor inconvenience though, Dr. Hirsch recommends looking at the likely remedies of:

• Adjust estrogen (usually the cause)
• Adjust progesterone (less common)
• If it’s progesterone, changing the route of administration can ameliorate things

What if it’s not working? Is it just me?

Dr. Hirsch advises the most common reasons are simply:

• wrong formulation (e.g. animal-derived estrogen or hormone analog, instead of bioidentical)
• wrong dose (e.g. too low)
• wrong route of administration (e.g. oral vs transdermal; usually transdermal estradiol is most effective but many people do fine on oral; progesterone meanwhile is usually best as a pessary/suppository, but many people do fine on oral)

Writer’s example: in 2022 there was an estrogen shortage in my country, and while I had been on transdermal estradiol hemihydrate gel, I had to go onto oral estradiol valerate tablets for a few months, because that’s what was available. And the tablets simply did not work for me at all. I felt terrible and I have a good enough intuitive sense of my hormones to know when “something wrong is not right”, and a good enough knowledge of the pharmacology & physiology to know what’s probably happening (or not happening). And sure enough, when I got my blood test results, it was as though I’d been taking nothing. It was such a relief to get back on the gel once it became available again!

So, if something doesn’t seem to be working for you, speak up and get it fixed if at all possible.

See also: What You Should Have Been Told About Menopause Beforehand

Want to know more from Dr. Hirsch?

You might like this book of hers, which we haven’t reviewed yet, but present here for your interest:

Unlock Your Menopause Type: A Personalized Guide to Managing Your Menopausal Symptoms and Enhancing Your Health – by Dr. Heather Hirsch

Enjoy!