The HRT University® Podcast

Nico Misleh
  • 5.0 (11)
  • Medicine
  • Daily

Welcome to the HRT University® Podcast, where patient care meets the realities of building a thriving practice. Hosted by nurse practitioner and entrepreneur Nico Misleh, this podcast offers insights into hormone replacement therapy, cash-based clinics, and the business of wellness. Whether you're a provider navigating clinical care or an aspiring entrepreneur, Nico shares honest conversations, practical advice, and expert interviews to guide you. Tune in to redefine success for your patients and yourself. Learn more about Nico and becoming an expert in HRT: https://bit.ly/4twBb0D

  1. 57m ago

    Healthcare burnout: why a 30-patient day is a model problem

    On a good day she saw 30 patients. On a bad day, almost 40. She charted at home at night. A light day of 20 patients was the stressful one, because a string of them put her quarterly quota at risk. In this episode, Nico Misleh, MSN, FNP-C makes the case that burnout in a high-volume clinic is usually a model problem. He is talking to NPs, PAs and MDs alike. He goes back to NP school, when he split his clinical hours between two physicians. One worked in an insurance-based family practice owned by a large company. The other ran his own cash-based practice. They saw the same kinds of patients with the same complaints, and the second physician's patients were getting better results. The biggest difference was time. The cash-based physician had 20 or 30 minutes for a follow-up visit. She had maybe ten. A patient on levothyroxine asked her about desiccated thyroid. Afterward Nico asked why she did not prescribe it. She said it was a good question, and that she had never had the time to look into it. The volume model became the default because it is the only model most providers were ever shown. Better time management, earlier mornings and a scribe leave the structure underneath unchanged. Then the practical side. Nico is not asking anyone to quit a job. Almost every provider he knows who made the shift kept a day job. They built a practice on evenings and weekends, from 10 patients a week to 20 and then 50. Then the day job became the side work. A private-pay model runs on fewer patients, longer visits and deeper clinical work. Patients will drive hours for care that no clinic near them offers. If you have ever wondered whether the problem is you or the model, start with this episode. The clinical depth a private-pay practice runs on is what the HRT University Master Course teaches. The course is jointly accredited by ACCME, ACPE and ANCC. Pinnacle Conference, LLC is the accredited provider, and HRT University plans and implements the course. Providers earn 30 CE hours, including 12 hours of pharmacology. The Master Course is at https://bit.ly/4twBb0D Find more episodes at https://hrtuniversity.com/hrtu-podcast/ Read the Second Opinion newsletter at https://nicomislehnp.kit.com/8050eeea5f Join the provider community at https://www.facebook.com/groups/1179376819949373/

    Healthcare burnout: why a 30-patient day is a model problem

  2. Oct 26

    Clinical Reasoning in HRT: Why Principles Beat Protocols

    A patient sits down and tells you she is menopausal. She asks if you can help. You refer her out, because you are not sure you know this well enough. Then the voice in your head starts: maybe one more course. In this episode, Nico Misleh, MSN, FNP-C makes the case that another course rarely fixes prescribing uncertainty, because the gap is in the quality of what providers were taught and the clinical reasoning it never built. A year or two into learning hormone therapy, he compared programs that ran from $200 to $7,000. Most taught the same dosing charts, similar lab reference ranges and the same candidate criteria under a new name. He bought one and finished it still uncertain.   Nico explains why. Much of HRT education is modeled on algorithm-driven medical training. Algorithms work for standardized problems like an appendectomy. Hormones and chronic care are more complex, and a protocol stops helping the moment a patient does not fit it. Information without a framework has nowhere to go, so another conference or course adds to the confusion. A physiology-first framework gives each new study a place to land, where it confirms, refines or corrects what you already know. Progesterone is his example. Most courses teach how to dose it. Very few teach what it is, what it does across the lifespan in men and women, or how it connects to other hormones.   Then the practical side. Nico answers the busy clinician who says there is no time for deeper study. Once the reasoning is in your head, decisions take seconds instead of a search through references, and the patient outside the protocol stops being a fresh source of doubt. Competency comes first, and confidence follows it. Mastery is never the sum of every course you have taken.   If you have patients you send elsewhere because you are not sure you know this well enough, this episode is for you.   Nico teaches this framework inside the HRT University Master Course, starting with energy, function and metabolism. The course is jointly accredited by ACCME, ACPE, and ANCC. Pinnacle Conference, LLC is the accredited provider, and HRT University plans and implements the course, so providers earn 30 CE hours, including 12 hours of pharmacology.   Master Course: https://bit.ly/4twBb0D More episodes: https://hrtuniversity.com/hrtu-podcast/ Second Opinion newsletter: https://nicomislehnp.kit.com/8050eeea5f Provider community: https://www.facebook.com/groups/1179376819949373/

  3. Oct 19

    Is HRT Safe? What to Tell Patients About Cancer and Clots

    Your patient is ready to start hormone therapy. Then she asks one question. My grandmother had breast cancer, so I can never take this, right? If the answer is not clear, she leaves. And she tells her family what she heard. In this episode, Nico Misleh, MSN, FNP-C makes a case. Most of the safety questions patients bring to an HRT or TRT consult come from old data. He also argues that providers who can answer them calmly keep patients who would otherwise walk out. He works through the questions that stumped him early in practice and still catch providers today. On the female side: why a family history of breast cancer is a risk factor to weigh. It is not a contraindication. Personal history and BRCA status matter more. Why the blood clot fear traces back to synthetic hormones, birth control pills and conjugated equine estrogen with progestins. Why a patient at 38 or 40 is not too young when symptoms and labs line up. Why waiting for 12 months without a period is a legacy rule. On the male side: why lifestyle optimization and testosterone replacement are different projects. What TRT does to LH, FSH and spermatogenesis, and how hCG or enclomiphene keep fertility on the table. What the 2023 traverse trial found for major adverse cardiovascular events. How the saturation model replaced the 1941 Huggins hypothesis on prostate cancer. Why you should expect a small, stable PSA rise in the first 3 to 6 months of TRT. Then the practical side. Nico reframes the question patients ask most: will I have to take this forever. His answer is replacement. It is not dependency. It sits in the same category as insulin or thyroid hormone. Stopping does not cause a rebound. Physiology returns to where it would have been without treatment. And he makes the case for answering these questions before the patient asks. Tell a man his PSA will rise before it does. Share the traverse data before his cardiologist raises it. Some of your patients stall at the consult. Others start therapy and then hear doubt from family, friends or another provider. This episode is for you. It gives you the framework and the words to answer. Nico teaches the physiology behind each of these answers inside the HRT University Master Course. The course is jointly accredited by ACCME, ACPE, and ANCC. Pinnacle Conference, LLC is the accredited provider, and HRT University plans and implements the course, so providers earn 30 CE hours, including 12 hours of pharmacology. Learn more about the Master Course at https://hrtuniversity.com/hrtcourse/ Hear more episodes at https://hrtuniversity.com/hrtu-podcast/ Read the Second Opinion newsletter at https://nicomislehnp.kit.com/8050eeea5f Join the provider community at https://www.facebook.com/groups/1179376819949373/

    Is HRT Safe? What to Tell Patients About Cancer and Clots

  4. Oct 12

    Leaving Your W-2 and What Year One Costs

    A W-2 feels safe. It is one client who can fire you. That client can cut your role, change your comp model or sell the company, and your income goes with it. Ownership is not safer. It is a different risk profile. In this episode, Nico Misleh, MSN, FNP-C makes the case that leaving a W-2 starts at home, long before the practice exists. He and Cherrell lived below their means, paid off every student loan, paid off their cars and drove them into the ground, and took no business loan. His rule is 12 months of household expenses in cash, kept separate from practice money. Months four through ten are usually the hard stretch. Patient volume runs slower than projected and the fixed costs keep coming. Every dollar of fixed monthly cost is a dollar of revenue you have to generate before you take any home. Then the practical side. Decide which clinical problems you will solve better than anyone in your market. Set up the legal structure with an accountant or attorney. Know your state's practice authority and collaboration rules. Get malpractice coverage. Nico prefers occurrence-based over claims-made if you can afford it. Choose an EMR built for a small practice and a payment processor that handles cash pay. A fully virtual practice can open for $3,500 to $5,000. Licensing across all 50 states runs closer to $15,000. A brick and mortar build-out with staff can run $50,000 to a quarter million, or more. At $200 a month, 20 to 50 patients on your panel is where it starts to work. Year one is not the freedom year. Expect more hours than your W-2, and build so the practice can run without you from day one. Be frugal without being cheap. If you are a prescriber weighing this move, start with your household numbers before you write a business plan. The HRT University Master Course is clinical and does not teach practice setup. Practice ownership lives here on the podcast and on the blog. The course is jointly accredited by ACCME, ACPE, and ANCC. Pinnacle Conference, LLC is the accredited provider, and HRT University plans and implements the course, so providers earn 30 CE hours, including 12 hours of pharmacology. See the clinical Master Course: https://hrtuniversity.com/hrtcourse/ Browse more episodes: https://hrtuniversity.com/hrtu-podcast/ Hear Cherrell's debt-free practice story in Ep 109: https://open.spotify.com/episode/2kS6UnxOpHDgWP7kY3KDBn Get the Second Opinion newsletter: https://nicomislehnp.kit.com/8050eeea5f Join the provider community: https://www.facebook.com/groups/1179376819949373/ Read more about practice ownership: https://hrtuniversity.com/hrt-blog/

    Leaving Your W-2 and What Year One Costs

  5. Oct 5

    Ferritin: The Iron Marker Nobody Reads Right

    A ferritin of 15 clears the reference range. The patient is still exhausted. She is shedding hair at the crown and the temples, her sleep is fine, and three providers have told her the CBC looks great. In this episode, Nico Misleh, MSN, FNP-C makes the case that ferritin is the most useful iron marker a provider can order and one of the most consistently misread. Labs build those reference ranges from populations that include plenty of symptomatic people. The bottom of the range marks what is common, not what is well. Serum iron is a snapshot. It moves with meals, time of day, and stress. TIBC and transferrin saturation tell you how many trucks are on the road and how full they are. Hemoglobin and hematocrit are the finished product, and by the time those two drop the deficiency has been running for months. The window Nico wants providers to catch is iron deficiency without anemia. Storage is falling, the CBC still looks clean, and the symptoms have already started. He walks the mechanism. Iron carries oxygen. It is a cofactor for thyroid peroxidase, so low iron blunts T4 to T3 conversion. Starve the cell of iron and it cannot run oxidative phosphorylation properly, so it drops toward inefficient glycolysis. That is why fatigue, air hunger, hair shedding, restless legs, and low mood show up together. It is also why providers file them under anxiety, low progesterone, or low testosterone instead. Then the practical side. The ferritin levels Nico treats to in women and in men. Why heavy cycles and blood donation outrun anything a diet can replace. How low stomach acid, PPIs, and chronic inflammation shut down absorption at the gut wall through hepcidin. Why patients abandon ferrous sulfate and stay on iron bisglycinate. What the current evidence says about alternate day dosing. And how to work up a ferritin of 300 without assuming overload. If you have patients on well dosed hormones who still report exhaustion, check iron before you change the dose. Hormones cannot do their work when the substrate is missing. Nico teaches ferritin in depth inside the HRT University Master Course. The course is jointly accredited through Pinnacle Conference, LLC, with ACCME, ACPE, and ANCC accreditation, and providers earn 30 CE hours, including 12 hours of pharmacology. Master Course: https://hrtuniversity.com/hrtcourse/ More episodes: https://hrtuniversity.com/hrtu-podcast/ Second Opinion newsletter: https://nicomislehnp.kit.com/8050eeea5f Provider community: https://www.facebook.com/groups/1179376819949373/

    Ferritin: The Iron Marker Nobody Reads Right

  6. Sep 28

    Postpartum Psychosis Is an Endocrine Event

    A labor and delivery nurse was prescribed 13 psychiatric medications over four months. This is the Lindsay Clancy case. This episode asks a hard question: could thyroid screening and a hormone-aware postpartum plan have caught something during those months of psychiatric prescribing, when no one addressed the underlying hormone shift? Postpartum psychosis affects 1 to 2 women per 1,000 births. Onset is fast: usually within the first two weeks, often within 72 hours. It looks nothing like the slower build of postpartum depression. Confusion, mania, disorganized thought, sometimes delusions. Risk is higher with a history of bipolar disorder, prior postpartum psychosis, a family history of bipolar disorder, or autoimmune disease, including thyroiditis. It remains a psychiatric emergency that requires hospitalization. Nico Misleh, MSN, FNP-C, walks through why current thyroid and hormone screening misses the shift that begins in the first 48 hours after delivery. Progesterone falls from roughly 100 to 150 ng/mL at term to near zero within 48 hours of delivery. Allopregnanolone, the progesterone metabolite that acts on GABA-A receptors, falls with it. The FDA has approved two drugs built on that mechanism for postpartum depression: brexanolone in 2019 (since withdrawn from the market) and zuranolone in 2023. Misleh frames progesterone to soften that crash in high-risk women, not to treat psychosis once it starts, as mechanism-based and off-label, with no controlled trials behind it yet. He also makes the case for a full postpartum thyroid panel: TSH, free T4, free T3, and TPO antibodies. A single TSH at six weeks misses the picture. Nico Misleh, MSN, FNP-C, hosts the HRT University Podcast. Recorded before the September 4, 2026 mistrial in the Clancy case.

    Postpartum Psychosis Is an Endocrine Event

  7. Sep 22

    TRT and Fertility: The Myth That Keeps Young Men Untreated

    Zach's testosterone came back at 302, in a range that runs from 300 to 1000, and his endocrinologist told him he was fine. He had brain fog, no energy, and no sex drive. In his words, she was judging him off an app. On this episode, Nico Misleh, MSN, FNP-C, talks with Zach, a patient and a friend. Zach gives the side of this story providers rarely hear firsthand. They talk about a belief that keeps young men out of care, the idea that testosterone ends fertility. Zach started treatment anyway. He came off testosterone before herniated disc surgery. He restarted his own production on Clomid, and his numbers were back within about 90 days. He has a 15 month old now, and another on the way. Nico explains why he moved away from Clomid. He also thinks that leaving a symptomatic man untreated for a decade causes more harm than treating him. Zach is just as clear about what testosterone did not fix. A hard stretch at work was a work problem, not a dose problem, and no amount of testosterone changed that. If you have young men asking about testosterone and fertility in the same visit, this conversation gives you the patient's side of it. Male testosterone therapy is module two of the HRT University Master Course. The course is jointly accredited through Pinnacle Conference, LLC, with ACCME, ACPE, and ANCC accreditation, and providers earn 30 CE hours, including 12 hours of pharmacology. The Master Course, the podcast archive, the Second Opinion newsletter, and the provider community are all linked below. Master Course: https://hrtuniversity.com/hrtcourse/ More episodes: https://hrtuniversity.com/hrtu-podcast/ Second Opinion newsletter: https://nicomislehnp.kit.com/8050eeea5f Provider community: https://www.facebook.com/groups/1179376819949373/

    TRT and Fertility: The Myth That Keeps Young Men Untreated

  8. Aug 24

    How to Start an HRT Clinic Debt Free: Savings First, Staff Later

    Nico Misleh sits down again with his wife, Cherrell, who runs the money and operations side of Apollo Health Optimization and HRT University, to talk about what it actually takes to build a business together without going into debt. They dive into how they opened their first clinic with savings instead of loans, why they waited to hire their first administrator until the revenue could cover her salary, and how they set a runway before Nico left his 1099 job. Cherrell shares her perspective on running the books, why she needed the five o'clock rule more than Nico did, and how they protect family time when the business starts asking for more. They also discuss why Nico believes a business acts like a member of your family whether you plan for it or not, why a spouse needs an honest picture of how the practice is doing, and what success looks like once the money question is settled. Whether you're getting ready to open your own clinic, already running one, or just curious how we divide it all up at home, this episode is an honest look at what has worked for us and what we've had to figure out along the way. If you have questions for Cherrell, come find us in the Facebook group! The HRT University® Master Course is jointly accredited through Pinnacle Conference, LLC (ACCME, ACPE, ANCC). Earn 30 CE hours, including 12 hours of pharmacology. Master Course: https://hrtuniversity.com/hrtcourse/ More episodes: https://hrtuniversity.com/hrtu-podcast/ The Second Opinion Newsletter: https://nicomislehnp.kit.com/8050eeea5f Provider community: https://www.facebook.com/groups/1179376819949373/

    How to Start an HRT Clinic Debt Free: Savings First, Staff Later
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Welcome to the HRT University® Podcast, where patient care meets the realities of building a thriving practice. Hosted by nurse practitioner and entrepreneur Nico Misleh, this podcast offers insights into hormone replacement therapy, cash-based clinics, and the business of wellness. Whether you're a provider navigating clinical care or an aspiring entrepreneur, Nico shares honest conversations, practical advice, and expert interviews to guide you. Tune in to redefine success for your patients and yourself. Learn more about Nico and becoming an expert in HRT: https://bit.ly/4twBb0D

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