The HRT University® Podcast

Nico Misleh
  • 5.0 (11)
  • Medicine
  • Updated 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. 1d ago

    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

  2. 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

  3. 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

  4. 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

  5. Aug 10

    Low Testosterone and Depression: A First Responder’s Story

    This episode includes discussion of PTSD, suicidal ideation, and alcohol use. Garrett spent 18 years as a deputy sheriff and police officer, all of it on night shift. Over that career he was part of about a dozen calls involving dead children. He gave CPR to an eight week old and lost. He never took a day for any of it. There was no policy in his agency that offered one, and no version of asking that did not feel like a risk to his badge. It caught up with him when he had his own kids. He would hold his baby and start to come apart. He describes the thought that stayed with him: if a monster broke into my house I would destroy that monster, so what happens when you are the monster in the house. He says plainly that he was getting suicidal. His wife gave him an ultimatum, and he spent the next four years in therapy without telling his agency, his parents, or anyone but her. He refused psychiatric medication the whole way. Partly the fear of feeling like a zombie, partly that his dreams were already bad enough that he would not gamble on what a medication might do to them, and partly something prescribers rarely think about. He carried a firearm, and nobody could tell him what being on something would mean for a drug screen after a critical incident or a fitness for duty review. Somewhere in there his primary care ran a testosterone level and told him he was fine. Nobody mentioned there was a second number. Nobody drew a free testosterone. He closed that door and left it closed for years. When he and Nico Misleh, MSN, FNP-C finally met, the fuller workup came back with low vitamin D, very low B vitamins, and a testosterone level Nico described to him at the time as lower than a 75 year old man would carry. Nico walks his read of why. Years of head trauma from martial arts, football, car accidents with airbags, and the physical side of the job. Inflammation that started acute and became chronic. Eighteen years of nights. Sleep the PTSD was already wrecking, so no recovery anywhere in the system. His conclusion is that the signaling between the brain and the testicles had been degraded by all of it at once, which is exactly the picture a single total testosterone will not show you. Garrett is honest about the timeline. He expected to wake up a racehorse and the first weeks were quieter than that. What shifted first was not energy, it was the dreams. Four to five years on he says he has not had one of the bad ones in about a year, and he credits the testosterone, the vitamin repletion, and the therapy together, not any one alone. Nico is equally clear on the limits. This is a tool, not a cure, and he has watched it go the other direction in men who are not doing the work on the other side. Garrett has the plainest line in the episode, and it is aimed at providers. Most of these guys and girls are not trying to get jacked. They just want to be able to sleep at night. Male testosterone therapy is module two of the HRT University Master Course. The 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/

  6. Aug 3

    Testosterone for Women and Men: What Providers Should Order

    Testosterone is the hormone nobody checks in women. Nico Misleh, MSN, FNP-C sat in an OB-GYN office with his wife not long ago and watched it play out. Nobody ordered it. It did not come up. He checks it on every female patient he has, his students all check it, and inside that bubble it starts to feel like standard practice. It isn't. So the first half of this episode is women. Testosterone isn't a male hormone that women happen to carry a little of. They have it by design. It's doing work on lean body mass, on body composition, on cognition and mental clarity, on drive through a dopaminergic pathway, on libido. Bone too. It has effects on bone mineral density that don't run through estrogen, and progesterone does the same thing to bone, so this isn't a testosterone-only story. The woman on estradiol and progesterone can be a lot better and still not be all the way there. Her hot flashes eased and her sleep improved. Her libido is still flat, and she can't hold muscle no matter how hard she trains. That's frequently a testosterone story, and it stays unnamed. Testosterone did not come up once in his own NP program. Not for women, not for men. Androgenic side effects come up. They're real at supraphysiologic doses and uncommon at replacement doses handled carefully. The reference range is the harder problem. It was built on a population that includes symptomatic women, so it can tell you what's typical and it can't tell you what's optimal. His line: we're the cardiologists who never got taught how to use an EKG. Men get the second half. His position is that testosterone is still under-prescribed in men, and that where it does get prescribed, it's often done badly. Total testosterone is probably the least useful number on the panel. Free testosterone is what the cell can actually use. SHBG is the little protein he calls a Pac-Man, binding testosterone up and holding it hostage where tissue can't reach it, and in his opinion you can't interpret a testosterone level without it. He walks a case. Total of 5 or 600, SHBG north of 100, free testosterone nobody ordered. That man has low testosterone and it will never show up on paper, because the value that would have caught it was never drawn. Nico is plain about not having known what SHBG was either. In his words, we're all in this boat together. Then the hands-on stretch. Intramuscular versus subcutaneous and what the head-to-head data actually showed, needle gauge and length, post-injection pain and how to settle it, compounded creams and gels, why he isn't a fan of pellets in either sex, and the dosing philosophy he teaches. You aim for the maximum effective dose, not the smallest one that moves a lab value, because you're restoring a molecule the body already makes. Male testosterone therapy is module two of the HRT University® Master Course. Testosterone in women is the testosterone section of module three, the female module. SHBG runs through both. The 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/

    Testosterone for Women and Men: What Providers Should Order

  7. Jul 27

    Progesterone for Men and Women: Why the Uterus Was Never the Point

    Progesterone gets filed under women's health, and inside that, under uterine health. Nico Misleh, MSN, FNP-C argues that both filings are too narrow and that a provider prescribing progesterone only for endometrial protection is working with roughly a quarter of the picture. The mechanism he builds the episode on is allopregnanolone. Progesterone converts through 5-alpha reductase into a neurosteroid that acts as a positive allosteric modulator at GABA-A receptors. GABA is the brake of the brain. When progesterone falls, that braking capacity falls with it, which is why anxiety, irritability, and fractured sleep tend to arrive in the same patient. He also separates progesterone from progestins, since medroxyprogesterone acetate is testosterone-derived, cannot convert to allopregnanolone, and binds androgen, glucocorticoid, and mineralocorticoid receptors, which is where its side effect profile comes from. Then he turns to men. Men make progesterone. Nico covers neuroprotection, sleep through that same pathway, cortisol buffering, and prostate tissue, along with the presentations where he reaches for it most: anxiety, traumatic brain injury, PTSD, and BPH. Male dosing is not female dosing, and he is candid that his own hesitation kept him from using it for years. If you have men with optimized testosterone and thyroid who still sleep badly and still feel wired, this is the variable worth adding to the picture. Progesterone is taught in depth across the advanced female and adjunct hormone modules of the HRT University Master Course. 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/ Nico's clinical email: https://nicomislehnp.kit.com/8050eeea5f Provider community: https://www.facebook.com/groups/1179376819949373/

    Progesterone for Men and Women: Why the Uterus Was Never the Point

  8. Jul 20

    Hair Loss and DHT, Why DHT Is Not the Real Problem

    DHT gets blamed for hair loss more than almost anything else, and Nico Misleh, MSN, FNP-C thinks that blame is misplaced. In this episode he makes the case that dihydrotestosterone is not the villain it has been made out to be. It is a necessary hormone that keeps doing real work long after puberty, and for a patient who is losing hair it is usually a downstream signal rather than the thing actually driving the problem. DHT does bind androgen-sensitive follicles and it does play a part in miniaturization. That piece is real. The question that almost never gets asked is why 5-alpha reductase, the enzyme that turns testosterone into DHT, is running high in the first place. That is where the clinical opportunity lives. Nico ties elevated 5-alpha reductase back to what he teaches inside the Big Five of metabolic dysfunction: insulin resistance and hyperinsulinemia, chronic inflammation, histamine, cortisol, and low thyroid function. Hair loss turns out to be one more way that same broken terrain shows itself. He also clears up something that often gets taught backward. Estrogen does not push 5-alpha reductase up on its own. In a healthy balance it holds it down. It is estrogen dominance, dragging progesterone lower and pushing blood sugar higher, that moves the needle. That is also why a serum DHT value can point you the wrong way, and why Nico leans on fasting insulin, free T3, cortisol, and a hard look at gut and metabolic health instead. Improve the terrain and DHT often settles on its own. Then he gets practical. Why he will not put a patient, man or woman, on oral finasteride or dutasteride after seeing what post-finasteride syndrome can do. Where low-dose topical finasteride and minoxidil honestly land, and where they fall short. And the pro-metabolic route he actually uses, including the compounded hair serum he built around progesterone, caffeine, melatonin, and thyroid to outcompete DHT at the follicle and calm the inflammation while supporting the energy a follicle needs to grow. It is slow work, so give it three to six months before you judge it. If you have a patient stuck getting the same block-DHT answer over and over, this episode hands you a better way to read the case. Hair loss is a symptom worth listening to, not just a part of getting older. Hair loss sits inside Nico's Big Five framework, the backbone of Module 1 in the HRT University Master Course. Read the full article: https://hrtuniversity.com/dht-causes-hair-loss/ More episodes: https://hrtuniversity.com/hrtu-podcast/ 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/ Nico's weekly clinical email: https://nicomislehnp.kit.com/8050eeea5f Provider community: https://www.facebook.com/groups/1179376819949373/

    Hair Loss and DHT, Why DHT Is Not the Real Problem
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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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