HRT Side Effects & Troubleshooting

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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!

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  • Your Simplest Life – by Lisa Turner

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    We probably know how to declutter, and perhaps even do a “unnecessary financial expenditures” audit. So, what does this offer beyond that?

    A large portion of this book focuses on keeping our general life in a state of “flow”, and strategies include:

    • How to make sure you’re doing the right part of the 80:20 split on a daily basis
    • Knowing when to switch tasks, and when not to
    • Knowing how to plan time for tasks
    • No more reckless optimism, but also without falling foul of Parkinson’s Law (i.e. work expands to fill the time allotted to it)
    • Decluttering your head, too!

    When it comes to managing life responsibilities in general, Turner is very attuned to generational differences… Including the different challenges faced by each generation, what’s more often expected of us, what we’re used to, and how we probably initially learned to do it (or not).

    To this end, a lot of strategies are tailored with variations for each age group. Not often does an author take the time to address each part of their readership like that, and it’s really helpful that she does!

    All in all, a great book for simplifying your daily life.

    Click here to check out Your Simplest Life on Amazon today!

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  • Women and Minorities Bear the Brunt of Medical Misdiagnosis

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    Charity Watkins sensed something was deeply wrong when she experienced exhaustion after her daughter was born.

    At times, Watkins, then 30, had to stop on the stairway to catch her breath. Her obstetrician said postpartum depression likely caused the weakness and fatigue. When Watkins, who is Black, complained of a cough, her doctor blamed the flu.

    About eight weeks after delivery, Watkins thought she was having a heart attack, and her husband took her to the emergency room. After a 5½-hour wait in a North Carolina hospital, she returned home to nurse her baby without seeing a doctor.

    When a physician finally examined Watkins three days later, he immediately noticed her legs and stomach were swollen, a sign that her body was retaining fluid. After a chest X-ray, the doctor diagnosed her with heart failure, a serious condition in which the heart becomes too weak to adequately pump oxygen-rich blood to organs throughout the body. Watkins spent two weeks in intensive care.

    She said a cardiologist later told her, “We almost lost you.”

    Watkins is among 12 million adults misdiagnosed every year in the U.S.

    In a study published Jan. 8 in JAMA Internal Medicine, researchers found that nearly 1 in 4 hospital patients who died or were transferred to intensive care had experienced a diagnostic error. Nearly 18% of misdiagnosed patients were harmed or died.

    In all, an estimated 795,000 patients a year die or are permanently disabled because of misdiagnosis, according to a study published in July in the BMJ Quality & Safety periodical.

    Some patients are at higher risk than others.

    Women and racial and ethnic minorities are 20% to 30% more likely than white men to experience a misdiagnosis, said David Newman-Toker, a professor of neurology at Johns Hopkins School of Medicine and the lead author of the BMJ study. “That’s significant and inexcusable,” he said.

    Researchers call misdiagnosis an urgent public health problem. The study found that rates of misdiagnosis range from 1.5% of heart attacks to 17.5% of strokes and 22.5% of lung cancers.

    Weakening of the heart muscle — which led to Watkins’ heart failure — is the most common cause of maternal death one week to one year after delivery, and is more common among Black women.

    Heart failure “should have been No. 1 on the list of possible causes” for Watkins’ symptoms, said Ronald Wyatt, chief science and chief medical officer at the Society to Improve Diagnosis in Medicine, a nonprofit research and advocacy group.

    Maternal mortality for Black mothers has increased dramatically in recent years. The United States has the highest maternal mortality rate among developed countries. According to the Centers for Disease Control and Prevention, non-Hispanic Black mothers are 2.6 times as likely to die as non-Hispanic white moms. More than half of these deaths take place within a year after delivery.

    Research shows that Black women with childbirth-related heart failure are typically diagnosed later than white women, said Jennifer Lewey, co-director of the pregnancy and heart disease program at Penn Medicine. That can allow patients to further deteriorate, making Black women less likely to fully recover and more likely to suffer from weakened hearts for the rest of their lives.

    Watkins said the diagnosis changed her life. Doctors advised her “not to have another baby, or I might need a heart transplant,” she said. Being deprived of the chance to have another child, she said, “was devastating.”

    Racial and gender disparities are widespread.

    Women and minority patients suffering from heart attacks are more likely than others to be discharged without diagnosis or treatment.

    Black people with depression are more likely than others to be misdiagnosed with schizophrenia.

    Minorities are less likely than whites to be diagnosed early with dementia, depriving them of the opportunities to receive treatments that work best in the early stages of the disease.

    Misdiagnosis isn’t new. Doctors have used autopsy studies to estimate the percentage of patients who died with undiagnosed diseases for more than a century. Although those studies show some improvement over time, life-threatening mistakes remain all too common, despite an array of sophisticated diagnostic tools, said Hardeep Singh, a professor at Baylor College of Medicine who studies ways to improve diagnosis.

    “The vast majority of diagnoses can be made by getting to know the patient’s story really well, asking follow-up questions, examining the patient, and ordering basic tests,” said Singh, who is also a researcher at Houston’s Michael E. DeBakey VA Medical Center. When talking to people who’ve been misdiagnosed, “one of the things we hear over and over is, ‘The doctor didn’t listen to me.’”

    Racial disparities in misdiagnosis are sometimes explained by noting that minority patients are less likely to be insured than white patients and often lack access to high-quality hospitals. But the picture is more complicated, said Monika Goyal, an emergency physician at Children’s National Hospital in Washington, D.C., who has documented racial bias in children’s health care.

    In a 2020 study, Goyal and her colleagues found that Black kids with appendicitis were less likely than their white peers to be correctly diagnosed, even when both groups of patients visited the same hospital.

    Although few doctors deliberately discriminate against women or minorities, Goyal said, many are biased without realizing it.

    “Racial bias is baked into our culture,” Goyal said. “It’s important for all of us to start recognizing that.”

    Demanding schedules, which prevent doctors from spending as much time with patients as they’d like, can contribute to diagnostic errors, said Karen Lutfey Spencer, a professor of health and behavioral sciences at the University of Colorado-Denver. “Doctors are more likely to make biased decisions when they are busy and overworked,” Spencer said. “There are some really smart, well-intentioned providers who are getting chewed up in a system that’s very unforgiving.”

    Doctors make better treatment decisions when they’re more confident of a diagnosis, Spencer said.

    In an experiment, researchers asked doctors to view videos of actors pretending to be patients with heart disease or depression, make a diagnosis, and recommend follow-up actions. Doctors felt far more certain diagnosing white men than Black patients or younger women.

    “If they were less certain, they were less likely to take action, such as ordering tests,” Spencer said. “If they were less certain, they might just wait to prescribe treatment.”

    It’s easy to see why doctors are more confident when diagnosing white men, Spencer said. For more than a century, medical textbooks have illustrated diseases with stereotypical images of white men. Only 4.5% of images in general medical textbooks feature patients with dark skin.

    That may help explain why patients with darker complexions are less likely to receive a timely diagnosis with conditions that affect the skin, from cancer to Lyme disease, which causes a red or pink rash in the earliest stage of infection. Black patients with Lyme disease are more likely to be diagnosed with more advanced disease, which can cause arthritis and damage the heart. Black people with melanoma are about three times as likely as whites to die within five years.

    The covid-19 pandemic helped raise awareness that pulse oximeters — the fingertip devices used to measure a patient’s pulse and oxygen levelsare less accurate for people with dark skin. The devices work by shining light through the skin; their failures have delayed critical care for many Black patients.

    Seven years after her misdiagnosis, Watkins is an assistant professor of social work at North Carolina Central University in Durham, where she studies the psychosocial effects experienced by Black mothers who survive severe childbirth complications.

    “Sharing my story is part of my healing,” said Watkins, who speaks to medical groups to help doctors improve their care. “It has helped me reclaim power in my life, just to be able to help others.”

    KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

    Subscribe to KFF Health News’ free Morning Briefing.

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  • Chocolate & Health

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    Chocolate & Health: Fact or Fiction?

    “Chocolate Is Good For The Heart”

    “When making chocolate chip cookies, you don’t measure using cups, you measure by heart”

    …but how good is chocolate when it comes to heart health?

    First, what is heart health?

    A healthy heart typically has a low resting pulse rate and a strong, steady beat. This is affected strongly by exercise habits, and diet plays only a support role (can’t exercise without energy from food!).

    It is also important to have blood pressure within a healthy range (with high blood pressure being a more common problem than low, so things that lower blood pressure are generally considered good).

    • Flavanols, flavonoids, and polyphenols in chocolate contribute to lower blood pressure
    • Dark chocolate is best for these, as milk chocolate contains much less cocoa solids and more unhelpful fats
    • White chocolate contains no cocoa solids and is useless for this
    • Some of the fats in most commercial chocolate can contribute to atherosclerosis which raises blood pressure and ultimately can cause heart attacks.
    • If you’re diabetic, you will probably not get the usual heart-related benefits from chocolate (sorry)

    The Verdict: dark chocolate, in moderation, can support good heart health.

    “Chocolate Is Good For The Brain”

    Chocolate has been considered a “brain food”… why?

    • The brain uses more calories than any other organ (chocolate has many calories)
    • The heart benefits we listed above mean improved blood flow—including to your brain
    • Chocolate contains phenylethylamine, a powerful chemical that has a similar effect to amphetamines… But it’s metabolized in digestion and never makes it to the central nervous system (so basically, this one’s a miss; we had a good run with the other two, though!)

    The Verdict: dark chocolate, in moderation, can support good brain health

    “Chocolate Is An Aphrodisiac”

    “If chocolate be the food of love, pass me that cocoa; I’m starving”

    Most excitingly, chocolate contains phenylethylamine, the “molecule of love” or, more accurately, lust. It has an effect similar to amphetamines, and while we can synthesize it in the body, we can also get it from certain foods. But…

    Our body is so keen to get it that most of it is metabolized directly during digestion and doesn’t make it to the brain. Also, chocolate is not as good a source as cabbage—do with that information what you will!

    However!

    Chocolate contains theobromine and small amounts of caffeine, both stimulants and both generally likely to improve mood; it also contains flavonoids which in turn stimulate production of nitric oxide, which is a relaxant. All in all, things that are convivial to having a good time.

    On the other hand…

    That relaxation comes specifically with a reduction in blood pressure—something typically considered good for the health for most people most of the time… but that means lowering blood pressure in all parts of your body, which could be the opposite of what you want in intimate moments.

    Chocolate also contains zinc, which is essential for hormonal health for most people—the body uses it to produce testosterone and estrogen, respectively. Zinc supplements are popularly sold to those wishing to have more energy in general and good hormonal health in particular, and rightly so. However…

    This approach requires long-term supplementation—you can’t just pop a zinc tablet / bar of chocolate / almond before bed and expect immediate results. And if your daily zinc supplementation takes the form of a 3.5oz (100g) bar of chocolate, then you may find it has more effects on your health, and not all of them good!

    The Verdict: dark chocolate, in moderation, may promote “the mood”, but could be a double-edged sword when it comes to “the ability”.

    “Chocolate Is Good During Menstruation”

    The popular wisdom goes that chocolate is rich in iron (of which more is needed during menstruation), and indeed, if you eat 7oz (150g) of dark chocolate made with 85% cocoa, you’ll get a daily a dose of iron (…and nearly 1,000 calories).

    More bang-for-buck dietary sources of iron include chickpeas and broccoli, but for some mysterious reason, these are not as commonly reported as popular cravings.

    The real explanation for chocolate cravings is more likely that eating chocolate—a food high in sugar and fat along with a chemical bombardment of more specialized “hey, it’s OK, you can relax now” molecules (flavanols/flavonoids, polyphenols, phenylamines, even phenylethylamine, etc) gives a simultaneous dopamine kick (the body’s main “reward” chemical) with a whole-body physiological relaxation… so, little wonder we might crave it in times of stress and discomfort!

    The Verdict: it helps, not because it serves a special nutritional purpose, but rather, because the experience of eating chocolate makes us feel good.

    Fun fact: Tiramisu (this writer’s favorite dessert) is literally Italian for “pick-me-up”

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  • Habits of a Happy Brain – by Dr. Loretta Graziano Breuning

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    There are lots of books on “happy chemicals” and “how to retrain your brain”, so what makes this one different?

    Firstly, it focuses on four “happy chemicals”, not just one:

    • Serotonin
    • Dopamine
    • Oxytocin
    • Endorphins

    It also looks at the role of cortisol, and how it caps off each of those just a little bit, to keep us just a little malcontent.

    Behavioral psychology tends to focus most on dopamine, while prescription pharmaceuticals for happiness (i.e., most antidepressants) tend to focus on serotonin. Here, Dr. Breuning helps us understand the complex interplay of all of the aforementioned chemicals.

    She also clears up many misconceptions, since a lot of people misattribute the functions of each of these.

    Common examples include “I’m doing this for the serotonin!” when the activity is dopaminergic not serotoninergic, or considering dopamine “the love molecule” when oxytocin, or even something else like phenylethylamine would be more appropriate.

    The above may seem like academic quibbles and not something of practical use, but if we want to biohack our brains, we need to do better than the equivalent of a chef who doesn’t know the difference between salt and sugar.

    Where things are of less practical use, she tends to skip over or at least streamline them. For example, she doesn’t really discuss the role of post-dopamine prolactin in men—but the discussion of post-happiness cortisol covers the same ground anyway, for practical purposes.

    Dr. Breuning also looks at where our evolved neurochemical responses go wrong, and lays out guidelines for such challenges as overcoming addiction, or embracing delayed gratification.

    Bottom line: this book is a great user-manual for the brain. If you’d like to be happier and more effective with fewer bad habits, this is the book for you.

    Click here to check out Habits of a Happy Brain, and get biohacking yours!

    Don’t Forget…

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  • Her Mental Health Treatment Was Helping. That’s Why Insurance Cut Off Her Coverage.

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    Reporting Highlights

    • Progress Denials: Insurers use a patient’s improvement to justify denying mental health coverage.
    • Providers Disagree: Therapists argue with insurers and the doctors they employ to continue covering treatment for their patients.
    • Patient Harm: Some patients backslid when insurers cut off coverage for treatment at key moments.

    These highlights were written by the reporters and editors who worked on this story.

    Geneva Moore’s therapist pulled out her spiral notebook. At the top of the page, she jotted down the date, Jan. 30, 2024, Moore’s initials and the name of the doctor from the insurance company to whom she’d be making her case.

    She had only one chance to persuade him, and by extension Blue Cross and Blue Shield of Texas, to continue covering intensive outpatient care for Moore, a patient she had come to know well over the past few months.

    The therapist, who spoke on the condition of anonymity out of fear of retaliation from insurers, spent the next three hours cramming, as if she were studying for a big exam. She combed through Moore’s weekly suicide and depression assessments, group therapy notes and write-ups from their past few sessions together.

    She filled two pages with her notes: Moore had suicidal thoughts almost every day and a plan for how she would take her own life. Even though she expressed a desire to stop cutting her wrists, she still did as often as three times a week to feel the release of pain. She only had a small group of family and friends to offer support. And she was just beginning to deal with her grief and trauma over sexual and emotional abuse, but she had no healthy coping skills.

    Less than two weeks earlier, the therapist’s supervisor had struck out with another BCBS doctor. During that call, the insurance company psychiatrist concluded Moore had shown enough improvement that she no longer needed intensive treatment. “You have made progress,” the denial letter from BCBS Texas read.

    When the therapist finally got on the phone with a second insurance company doctor, she spoke as fast as she could to get across as many of her points as possible.

    “The biggest concern was the abnormal thoughts — the suicidal ideation, self-harm urges — and extensive trauma history,” the therapist recalled in an interview with ProPublica. “I was really trying to emphasize that those urges were present, and they were consistent.”

    She told the company doctor that if Moore could continue on her treatment plan, she would likely be able to leave the program in 10 weeks. If not, her recovery could be derailed.

    The doctor wasn’t convinced. He told the therapist that he would be upholding the initial denial. Internal notes from the BCBS Texas doctors say that Moore exhibited “an absence of suicidal thoughts,” her symptoms had “stabilized” and she could “participate in a lower level of care.”

    The call lasted just seven minutes.

    Moore was sitting in her car during her lunch break when her therapist called to give her the news. She was shocked and had to pull herself together to resume her shift as a technician at a veterinary clinic.

    “The fact that it was effective immediately,” Moore said later, “I think that was the hardest blow of it all.”

    Many Americans must rely on insurers when they or family members are in need of higher-touch mental health treatment, such as intensive outpatient programs or round-the-clock care in a residential facility. The costs are high, and the stakes for patients often are, too. In 2019 alone, the U.S. spent more than $106.5 billion treating adults with mental illness, of which private insurance paid about a third. One 2024 study found that the average quoted cost for a month at a residential addiction treatment facility for adolescents was more than $26,000.

    Health insurers frequently review patients’ progress to see if they can be moved down to a lower — and almost always cheaper — level of care. That can cut both ways. They sometimes cite a lack of progress as a reason to deny coverage, labeling patients’ conditions as chronic and asserting that they have reached their baseline level of functioning. And if they make progress, which would normally be celebrated, insurers have used that against patients to argue they no longer need the care being provided.

    Their doctors are left to walk a tightrope trying to convince insurers that patients are making enough progress to stay in treatment as long as they actually need it, but not so much that the companies prematurely cut them off from care. And when insurers demand that providers spend their time justifying care, it takes them away from their patients.

    “The issues that we grapple with are in the real world,” said Dr. Robert Trestman, the chair of psychiatry and behavioral medicine at the Virginia Tech Carilion School of Medicine and chair of the American Psychiatric Association’s Council on Healthcare Systems and Financing. “People are sicker with more complex conditions.”

    Mental health care can be particularly prone to these progress-based denials. While certain tests reveal when cancer cells are no longer present and X-rays show when bones have healed, psychiatrists say they have to determine whether someone has returned to a certain level of functioning before they can end or change their treatment. That can be particularly tricky when dealing with mental illness, which can be fluid, with a patient improving slightly one day only to worsen the next.

    Though there is no way to know how often coverage gets cut off mid-treatment, ProPublica has found scores of lawsuits over the past decade in which judges have sharply criticized insurance companies for citing a patient’s improvement to deny mental health coverage. In a number of those cases, federal courts ruled that the insurance companies had broken a federal law designed to provide protections for people who get health insurance through their jobs.

    Reporters reviewed thousands of pages of court documents and interviewed more than 50 insiders, lawyers, patients and providers. Over and over, people said these denials can lead to real — sometimes devastating — harm. An official at an Illinois facility with intensive mental health programs said that this past year, two patients who left before their clinicians felt they were ready due to insurance denials had attempted suicide.

    Dr. Eric Plakun, a Massachusetts psychiatrist with more than 40 years of experience in residential and intensive outpatient programs, and a former board member of the American Psychiatric Association, said the “proprietary standards” insurers use as a basis for denying coverage often simply stabilize patients in crisis and “shortcut real treatment.”

    Plakun offered an analogy: If someone’s house is on fire, he said, putting out the fire doesn’t restore the house. “I got a hole in the roof, and the windows have been smashed in, and all the furniture is charred, and nothing’s working electrically,” he said. “How do we achieve recovery? How do we get back to living in that home?”

    Unable to pay the $350-a-day out-of-pocket cost for additional intensive outpatient treatment, Moore left her program within a week of BCBS Texas’ denial. The insurer would only cover outpatient talk therapy.

    During her final day at the program, records show, Moore’s suicidal thoughts and intent to carry them out had escalated from a 7 to a 10 on a 1-to-10 scale. She was barely eating or sleeping.

    A few hours after the session, Moore drove herself to a hospital and was admitted to the emergency room, accelerating a downward spiral that would eventually cost the insurer tens of thousands of dollars, more than the cost of the treatment she initially requested.

    How Insurers Justify Denials

    Buried in the denial letters that insurance companies send patients are a variety of expressions that convey the same idea: Improvement is a reason to deny coverage.

    “You are better.” “Your child has made progress.” “You have improved.”

    In one instance, a doctor working for Regence Blue Cross and Blue Shield of Oregon wrote that a patient who had been diagnosed with major depression was “sufficiently stable,” even as her own doctors wrote that she “continued to display a pattern of severe impairment” and needed round-the-clock care. A judge ruled that “a preponderance of the evidence” demonstrated that the teen’s continued residential treatment was medically necessary. The insurer said it can’t comment on the case because it ended with a confidential settlement.

    In another, a doctor working for UnitedHealth Group wrote in 2019 that a teenage girl with a history of major depression who had been hospitalized after trying to take her own life by overdosing “was doing better.” The insurer denied ongoing coverage at a residential treatment facility. A judge ruled that the insurer’s determination “lacked any reasoning or citations” from the girl’s medical records and found that the insurer violated federal law. United did not comment on this case but previously argued that the girl no longer had “concerning medical issues” and didn’t need treatment in a 24-hour monitored setting.

    To justify denials, the insurers cite guidelines that they use to determine how well a patient is doing and, ultimately, whether to continue paying for care. Companies, including United, have said these guidelines are independent, widely accepted and evidence-based.

    Insurers most often turn to two sets: MCG (formerly known as Milliman Care Guidelines), developed by a division of the multibillion-dollar media and information company Hearst, and InterQual, produced by a unit of UnitedHealth’s mental health division, Optum. Insurers have also used guidelines they have developed themselves.

    MCG Health did not respond to multiple requests for comment. A spokesperson for the Optum division that works on the InterQual guidelines said that the criteria “is a collection of established scientific evidence and medical practice intended for use as a first level screening tool” and “helps to move patients safely and efficiently through the continuum of care.”

    A separate spokesperson for Optum also said the company’s “priority is ensuring the people we serve receive safe and effective care for their individual needs.” A Regence spokesperson said that the company does “not make coverage decisions based on cost or length of stay,” and that its “number one priority is to ensure our members have access to the care they need when they need it.”

    In interviews, several current and former insurance employees from multiple companies said that they were required to prioritize the proprietary guidelines their company used, even if their own clinical judgment pointed in the opposite direction.

    “It’s very hard when you come up against all these rules that are kind of setting you up to fail the patient,” said Brittainy Lindsey, a licensed mental health counselor who worked at the Anthem subsidiary Beacon and at Humana for a total of six years before leaving the industry in 2022. In her role, Lindsey said, she would suggest approving or denying coverage, which — for the latter — required a staff doctor’s sign-off. She is now a mental health consultant for behavioral health businesses and clinicians.

    A spokesperson for Elevance Health, formerly known as Anthem, said Lindsey’s “recollection is inaccurate, both in terms of the processes that were in place when she was a Beacon employee, and how we operate today.” The spokesperson said “clinical judgment by a physician — which Ms. Lindsey was not — always takes precedence over guidelines.”

    In an emailed statement, a Humana spokesperson said the company’s clinician reviewers “are essential to evaluating the facts and circumstances of each case.” But, the spokesperson said, “having objective criteria is also important to provide checks and balances and consistently comply with” federal requirements.

    The guidelines are a pillar of the health insurance system known as utilization management, which paves the way for coverage denials. The process involves reviewing patients’ cases against relevant criteria every handful of days or so to assess if the company will continue paying for treatment, requiring providers and patients to repeatedly defend the need for ongoing care.

    Federal judges have criticized insurance company doctors for using such guidelines in cases where they were not actually relevant to the treatment being requested or for “solely” basing their decisions on them.

    Wit v. United Behavioral Health, a class-action lawsuit involving a subsidiary of UnitedHealth, has become one of the most consequential mental health cases of this century. In that case, a federal judge in California concluded that a number of United’s in-house guidelines did not adhere to generally accepted standards of care. The judge found that the guidelines allowed the company to wrongly deny coverage for certain mental health and substance use services the moment patients’ immediate problems improved. He ruled that the insurer would need to change its practices. United appealed the ruling on grounds other than the court’s findings about the defects in its guidelines, and a panel of judges partially upheld the decision. The case has been sent back to the district court for further proceedings.

    Largely in response to the Wit case, nine states have passed laws requiring health insurers to use guidelines that align with the leading standards of mental health care, like those developed by nonprofit professional organizations.

    Cigna has said that it “has chosen not to adopt private, proprietary medical necessity criteria” like MCG. But, according to a review of lawsuits, denial letters have continued to reference MCG. One federal judge in Utah called out the company, writing that Cigna doctors “reviewed the claims under medical necessity guidelines it had disavowed.” Cigna did not respond to specific questions about this.

    Timothy Stock, one of the BCBS doctors who denied Moore’s request to cover ongoing care, had cited MCG guidelines when determining she had improved enough — something judges noted he had done before. In 2016, Stock upheld a decision on appeal to deny continued coverage for a teenage girl who was in residential treatment for major depression, post-traumatic stress disorder and anxiety. Pointing to the guidelines, Stock concluded she had shown enough improvement.

    The patient’s family sued the insurer, alleging it had wrongly denied coverage. Blue Cross and Blue Shield of Illinois argued that there was evidence that showed the patient had been improving. But, a federal judge found the insurer misstated its significance. The judge partially ruled in the family’s favor, zeroing in on Stock and another BCBS doctor’s use of improvement to recommend denying additional care.

    “The mere incidence of some improvement does not mean treatment was no longer medically necessary,” the Illinois judge wrote.

    In another case, BCBS Illinois denied coverage for a girl with a long history of mental illness just a few weeks into her stay at a residential treatment facility, noting that she was “making progressive improvements.” Stock upheld the denial after an appeal.

    Less than two weeks after Stock’s decision, court records show, she cut herself on the arm and leg with a broken light bulb. The insurer defended the company’s reasoning by noting that the girl “consistently denied suicidal ideation,” but a judge wrote that medical records show the girl was “not forthcoming” with her doctors about her behaviors. The judge ruled against the insurer, writing that Stock and another BCBS doctor “unreasonably ignored the weight of the medical evidence” showing that the girl required residential treatment.

    Stock declined to comment. A spokesperson for BCBS said the company’s doctors who review requests for mental health coverage are board certified psychiatrists with multiple years of practice experience. The spokesperson added that the psychiatrists review all information received “from the provider, program and members to ensure members are receiving benefits for the right care, at the right place and at the right time.”

    The BCBS spokesperson did not address specific questions related to Moore or Stock. The spokesperson said that the examples ProPublica asked about “are not indicative of the experience of the vast majority of our members,” and that it is committed to providing “access to quality, cost-effective physical and behavioral health care.”

    A Lifelong Struggle

    A former contemporary dancer with a bright smile and infectious laugh, Moore’s love of animals is eclipsed only by her affinity for plants. She moved from Indiana to Austin, Texas, about six years ago and started as a receptionist at a clinic before working her way up to technician.

    Moore’s depression has been a constant in her life. It began as a child, when, she said, she was sexually and emotionally abused. She was able to manage as she grew up, getting through high school and attending Indiana University. But, she said, she fell back into a deep sadness after she learned in 2022 that the church she found comfort in as a college student turned out to be what she and others deemed a cult. In September of last year, she began an intensive outpatient program, which included multiple group and individual therapy sessions every week.

    Moore, 32, had spent much of the past eight months in treatment for severe depression, post-traumatic stress disorder and anxiety when BCBS said it would no longer pay for the program in January.

    The denial had come to her without warning.

    “I was starting to get to the point where I did have some hope, and I was like, maybe I can see an actual end to this,” Moore said. “And it was just cut off prematurely.”

    At the Austin emergency room where she drove herself after her treatment stopped, her heart raced. She was given medication as a sedative for her anxiety. According to hospital records she provided to ProPublica, Moore’s symptoms were brought on after “insurance said they would no longer pay.”

    A hospital social worker frantically tried to get her back into the intensive outpatient program.

    “That’s the sad thing,” said Kandyce Walker, the program’s director of nursing and chief operating officer, who initially argued Moore’s case with BCBS Texas. “To have her go from doing a little bit better to ‘I’m going to kill myself.’ It is so frustrating, and it’s heartbreaking.”

    After the denial and her brief admission to the hospital emergency department in January, Moore began slicing her wrists more frequently, sometimes twice a day. She began to down six to seven glasses of wine a night.

    “I really had thought and hoped that with the amount of work I’d put in, that I at least would have had some fumes to run on,” she said.

    She felt embarrassed when she realized she had nothing to show for months of treatment. The skills she’d just begun to practice seemed to disappear under the weight of her despair. She considered going into debt to cover the cost of ongoing treatment but began to think that she’d rather end her life.

    “In my mind,” she said, “that was the most practical thing to do.”

    Whenever the thought crossed her mind — and it usually did multiple times a day — she remembered that she had promised her therapist that she wouldn’t.

    Moore’s therapist encouraged her to continue calling BCBS Texas to try to restore coverage for more intensive treatment. In late February, about five weeks after Stock’s denial, records show that the company approved a request that sent her back to the same facility and at the same level of care as before.

    But by that time, her condition had deteriorated so severely that it wasn’t enough.

    Eight days later, Moore was admitted to a psychiatric hospital about half an hour from Austin. Medical records paint a harrowing picture of her condition. She had a plan to overdose and the medicine to do it. The doctor wrote that she required monitoring and had “substantial ongoing suicidality.” The denial continued to torment her. She told her doctor that her condition worsened after “insurance stopped covering” her treatment.

    Her few weeks stay at the psychiatric hospital cost $38,945.06. The remaining 10 weeks of treatment at the intensive outpatient program — the treatment BCBS denied — would have cost about $10,000.

    Moore was discharged from the hospital in March and went back into the program Stock had initially said she no longer needed.

    It marked the third time she was admitted to the intensive outpatient program.

    A few months later, as Moore picked at her lunch, her oversized glasses sliding down the bridge of her nose every so often, she wrestled with another painful realization. Had the BCBS doctors not issued the denial, she probably would have completed her treatment by now.

    “I was really looking forward to that,” Moore said softly. As she spoke, she played with the thick stack of bracelets hiding the scars on her wrists.

    A few weeks later, that small facility closed in part because of delays and denials from insurance companies, according to staff and billing records. Moore found herself calling around to treatment facilities to see which ones would accept her insurance. She finally found one, but in October, her depression had become so severe that she needed to be stepped up to a higher level of care.

    Moore was able to get a leave of absence from work to attend treatment, which she worried would affect the promotion she had been working toward. To tide her over until she could go back to work, she used up the money her mother sent for her 30th birthday.

    She smiles less than she did even a few months ago. When her roommates ask her to hang out downstairs, she usually declines. She has taken some steps forward, though. She stopped drinking and cutting her wrists, allowing scar tissue to cover her wounds.

    But she’s still grieving what the denial took from her.

    “I believed I could get better,” she said recently, her voice shaking. “With just a little more time, I could discharge, and I could live life finally.”

    Kirsten Berg contributed research.

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    Woman Petitions Health Insurer After Company Approves — Then Rejects — Her Infusions

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    When KFF Health News published an article in August about the “prior authorization hell” Sally Nix said she went through to secure approval from her insurance company for the expensive monthly infusions she needs, we thought her story had a happy ending.

    That’s because, after KFF Health News sent questions to Nix’s insurance company, Blue Cross Blue Shield of Illinois, it retroactively approved $36,000 worth of treatments she thought she owed. Even better, she also learned she would qualify for the infusions moving forward.

    Good news all around — except it didn’t last for long. After all, this is the U.S. health care system, where even patients with good insurance aren’t guaranteed affordable care.

    To recap: For more than a decade, Nix, of Statesville, North Carolina, has suffered from autoimmune diseases, chronic pain, and fatigue, as well as a condition called trigeminal neuralgia, which is marked by bouts of electric shock-like pain that’s so intense it’s commonly known as the “suicide disease.”

    “It is a pain that sends me to my knees,” Nix said in October. “My entire family’s life is controlled by the betrayal of my body. We haven’t lived normally in 10 years.”

    Late in 2022, Nix started receiving intravenous immunoglobulin infusions to treat her diseases. She started walking two miles a day with her service dog. She could picture herself celebrating, free from pain, at her daughter’s summer 2024 wedding.

    “I was so hopeful,” she said.

    But a few months after starting those infusions, she found out that her insurance company wouldn’t cover their cost anymore. That’s when she started “raising Cain about it” on Instagram and Facebook.

    You probably know someone like Sally Nix — someone with a chronic or life-threatening illness whose doctor says they need a drug, procedure, or scan, and whose insurance company has replied: No.

    Prior authorization was conceived decades ago to rein in health care costs by eliminating duplicative and ineffective treatment. Not only does overtreatment waste billions of dollars every year, but doctors acknowledge it also potentially harms patients.

    However, critics worry that prior authorization has now become a way for health insurance companies to save money, sometimes at the expense of patients’ lives. KFF Health News has heard from hundreds of people in the past year relating their prior authorization horror stories.

    When we first met Nix, she was battling her insurance company to regain authorization for her infusions. She’d been forced to pause her treatments, unable to afford $13,000 out-of-pocket for each infusion.

    Finally, it seemed like months of her hard work had paid off. In July, Nix was told by staff at both her doctor’s office and her hospital that Blue Cross Blue Shield of Illinois would allow her to restart treatment. Her balance was marked “paid” and disappeared from the insurer’s online portal.

    But the day after the KFF Health News story was published, Nix said, she learned the message had changed. After restarting treatment, she received a letter from the insurer saying her diagnoses didn’t actually qualify her for the infusions. It felt like health insurance whiplash.

    “They’re robbing me of my life,” she said. “They’re robbing me of so much, all because of profit.”

    Dave Van de Walle, a spokesperson for Blue Cross Blue Shield of Illinois, said the company would not discuss individual patients’ cases.

    “Prior authorization is often a requirement for certain treatments,” Van de Walle said in a written statement, “and BCBSIL administers benefits according to medical policy and the employer’s benefit.”

    But Nix is a Southern woman of the “Steel Magnolia” variety. In other words, she’s not going down without a fight.

    In September, she called out her insurance company’s tactics in a http://change.org/ campaign that has garnered more than 21,000 signatures. She has also filed complaints against her insurance company with the U.S. Department of Health and Human Services, U.S. Department of Labor, Illinois Department of Insurance, and Illinois attorney general.

    Even so, Nix said, she feels defeated.

    Not only is she still waiting for prior authorization to restart her immunoglobulin infusions, but her insurance company recently required Nix to secure preapproval for another treatment — routine numbing injections she has received for nearly 10 years to treat the nerve pain caused by trigeminal neuralgia.

    “It is reprehensible what they’re doing. But they’re not only doing it to me,” said Nix, who is now reluctantly taking prescription opioids to ease her pain. “They’re doing it to other patients. And it’s got to stop.”

    Do you have an experience with prior authorization you’d like to share? Click here to tell your story.

    KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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