Special cases

Dr Sam's happy space

This is my happy space – the “complex” patients. I dislike the word complex. But I use it here with care, because what it really means to me is time. Time to sit with a patient for an hour or two (yes, I know that’s a luxury). Time to go deep, ask the right questions, and really understand.

💙 A note from Dr Sam

Over time, I’ve realised that many of these so-called “complex” cases—the ones other health professionals might quietly call heart-sink patients—are actually special hormonal stories. Not always obvious. Not always linear. But always worth it.

Because when we bring hormones into the picture, something shifts. People feel seen. Patterns emerge. And sometimes—yes, really—symptoms improve.

These patients have taught me more than I could ever have imagined. They’ve reminded me that dreams do come true—especially when we stop assuming and start listening.

What these patients have shown me

This is where I’ve learned how I practice.
Where I’ve been challenged.
Where the science finally makes sense.
Where textbook theory gives way to real human lives—and why that matters more than anything.

It’s in:

🩵 The validation of an autistic woman who felt like she was losing her mind every three weeks—until she removed her estrogen patch and felt relief. (Patches often peak and stabilise around that time.)

🩵 The woman who went into menopause suddenly after surgery to remove her ovaries (surgical menopause). She was on high-dose estrogen and felt better—but not quite right. We realised patches were causing her big peaks and troughs.

🩵 The 20-year-old with Primary Ovarian Insufficiency (POI)—early loss of ovarian function—who bled continuously and couldn’t tolerate progestins, desperate for anything to stop the bleeding.

🩵 Or the other 20-year-old who just wanted to feel like her friends, and the pill gave her that.

🩵 The woman with a history of breast cancer, spiralling into suicidal depression. She had tried everything else. MHT gave her life back. Her husband said he had her back. She became a vibrant grandmother again, spending summers with her moko.

🩵 The 35-year-old who’d been on Depo Provera for a decade—leading to low estrogen. Causing chronic dry eyes, vaginal dryness, and with multiple specialists involved, no one had considered estrogen deficiency.

🩵 The 24-year-old with endometriosis on 9-weekly Depo Provera injections. Her estradiol levels looked “fine” but her symptoms told the truth: vulval fissures, thin red vaginal walls, signs of tissue thinning (atrophy). She needed local estrogen and topical steroids—not just suppression, but restoration.

🩵 The 59-year-old grandmother who started HRT for “typical” symptoms, felt amazing for 6 months, and then stopped. Yet she still gets up and down off the floor to play with her grandchildren. That’s her win.

What every patient teaches me

Every patient shows me that when I return to the foundations—listening to the person, understanding their whānau, and mapping the hormonal timeline—we find solutions. We make educated guesses that aren’t stabs in the dark, but deeply informed starting points.

Sometimes the surprises are in the details: women who become more anxious or develop insomnia with progesterone, even though 98% of others feel calm and sleepy. Hormones are complicated—and that’s okay.

Because patients know their bodies. My role as a doctor is to ask the right questions, listen to what they already know, and bring science and skill into the room so we can figure it out—together. Especially in perimenopause, where the baseline keeps shifting. Sometimes we go back to the drawing board. That’s not failure—it’s part of the process.

Patterns I often see

One common pattern I see is someone starts MHT and they feel incredible. Then it fades. Maybe it’s receptor saturation. When hormones fall again, it feels worse—because now they know what “better” felt like.

But here’s the gift, they now have reference points. They can recognise the signs earlier. They can advocate for themselves. And if they stumble again (because sometimes life makes sure we all do), they know it’s not forever.

Most importantly, people learn it’s not just hormones. But when hormones are part of the story? We figure it out. Together.