Dr. Mary Claire Haver: How to Navigate Menopause & Perimenopause for Maximum Health & Vitality

26:40Again, she was 25 and it was not on radar and he never tested her for menopause and it took her you know 18 months to get the diagnosis. And so the longer your body is away from estrogen, the higher the risk factor. And it's been all over the news this week where we know that untreated premature ovarian insufficiency has a earlier death. So they have higher cardiovascular disease, diabetes, stroke, all because estrogen is so protective and they have to go so long without it. We can back negate most of those risks by giving her aggressive hormone therapy early. So she came in to make sure she was on the right dose because in premature ovarian failure we don't want to give them an apostle hormone therapy dose.

27:24They're too low. We want to get her more like she would have, which is three to four times the amount of estrogen as a reproductive -aged woman. And so, and she wanted to have a period so she would seem like her friends. It was an emotional thing for her, which I totally respect. So we were doing cyclical progesterone for her so that she would have a withdrawal bleed and feel like she was normal. Basic question, but I'm curious, I'll ask. Given that levels of estrogen change so much naturally during the course of the ovulation cycle, menstrual cycle. With estrogen therapy, is it a constant dose or it's modulated by how weak to weak for a day to day?

28:06Good question. There are some formulas. When we look at hormonal contraception, the biggest difference between contraceptive doses and menopause hormone therapy doses, they're both based in estrogen and progesterone mostly. The hormone therapy was developed to stop a hot flash for decades. The menopause was defined by the presence of the rubs. So severe menopause was defined by hot flashes or not. They didn't, nothing else. And so they developed the formulations with enough estrogen to stop hot flashes. Birth control was developed to stop ovulation. You don't ovulate, you don't get pregnant. And it's, but the difference between low dose birth control pill and higher dose menopause hormone therapy is not that far away.

28:53And so that a lot of people don't understand. Now, the types of estrogen we use in birth control are a little bit different. Most birth control is ethanol estradiol, which is one of the synthetics. We have literally millions and millions of women's year data on it. We know it's safety profile. I think we're not counseling patients adequately about birth control as far as what it does to their testosterone and what it can do to, you know, oh, it's fine. It's safe. I took it for years. But I think we need to do a better job as a specialty on counseling women. But I do think it's a good medication.

29:23And then on menopause hormone therapy, you know, So it's much lower dose. It does not suppress ovulation. So in parimenopause, it's a little bit of the wild west, which when we're going to use, how high do we want to go? Do we need to suppress our ovulation because she's got acne or horrible periods or cramps or something where I want to suppress that ovulation to help her? Or can I give her a menopause hormone therapy dose? Which in effect, think of the hypothalamus, I'm giving her just enough estrogen to calm the brain down and tell them everything's okay. We're not going to get those big peaks and drops.

29:52and if she still avulates, that's okay too. As many of you know, I've been taking AG1 for more than 10 years now, so I'm delighted that they're sponsoring this podcast. To be clear, I don't take AG1 because they're a sponsor, rather they are a sponsor because I take AG1. In fact, I take AG1 once and often twice every single day, and I've done that since starting way back in 2012. There is so much conflicting information out there nowadays about what proper nutrition is. But here's what there seems to be a general consensus on. Whether you're an omnivore, a carnivore, a vegetarian, or a vegan, I think it's generally agreed that you should get most of your food from unprocessed or minimally processed sources, which allows you to eat enough, but not overeat, get plenty of vitamins and minerals, probiotics, and micronutrients that we all need for physical and mental health.

30:40Now I personally am an omnivore, and I strive to get most of my food from unprocessed or minimally processed sources. But the reason I still take AG1 once and often twice every day is that it ensures I get all of those vitamins, minerals, probiotics, etc. But it also has adaptogens to help me cope with stress. It's basically a nutritional insurance policy meant to augment, not replace, quality food. So by drinking a serving of AG1 in the morning and again in the afternoon or evening, I cover all of my foundational nutritional needs. And I like so many other people that take AG1, report feeling much better in a number of important ways, such as energy levels, digestion, sleep, and more.

31:18So while many supplements out there are really directed towards obtaining one specific outcome, AG1 is foundational nutrition designed to support all aspects of well -being related to mental health and physical health. If you'd like to try AG1, you can go to drinkag1 .com slash huberman to claim a special offer. They'll give you five free travel packs with your order plus a year supply of vitamin D3K2. Again, that's drinkag1 .com slash Hubertman. As long as we're on the topic of birth control, earlier you mentioned that the IUD and presumably this is some form of the IUD, not necessarily copper IUD, can disrupt or stop a period.

31:59Maybe we could talk a little bit about the different forms of birth control. IUD, as the pill, quote unquote, old term, but I think most people know what we're referring to and say that the ring and on and on. What is your stance on these different forms of birth control as it relates to their safety? You know, it gets about a year and a half ago. I hosted a female physician guest on this podcast and both sides of the birth control issue were touched on it. One, the relationship to potential inhibition of certain forms of cancers, but then also the potential for certain side effects, maybe even cancers.

32:41And so, you know, it seems like it can play out both ways, and this is a very heated topic. Yeah. In fact, so much so that I learned that if one is going to post a clip of any of this on social media, it almost makes sense to have them in the same post because we actually did both of them. We did a post where it was about the pros of birth control and then the cons of birth control as stated through the words of this very same clinician. So we will be sure to, so for anyone listening, whichever answer comes first, stay tuned for the next answer because my understanding is that it's not a black and white issue.

33:18I think the best form of birth control is a vasectomy and so much of contraception is dumped in a female's lap, you know, in a committed relationship. And I can't tell you the comments I've heard when a patient comes to me and she wants to get X, Y, and Z simply for contraception, she's absolutely perfectly healthy. There's nothing wrong with her. She just doesn't want to be pregnant. And I'm like, okay, you're done. She's completed her family, she's out, you know. And I'm like, tell your partner to get a vasectomy, oh, he won't do that, you know. So now all of the risk and the onus goes on her.

33:53And so we go through the options of surgical, like, you know, tubal ligation, which is basically blocking the tube. So when I, you know, talk to my teenagers, I'm like, here's how you not get pregnant. A, you don't have sex. Well, if that's not an option, then we have to either block this sperm, stop the egg from coming out or stop the place where they communicate, which is the fallopian tube. And so when we look at the different forms of hormonal contraception, which are meant to stop population, suppress ovulation, because they're telling the brain, we have enough estrogen and progesterone on board, quiet down so it doesn't send those signals to the ovary, right?

34:27And so that can come in a pill form, a patch form, a ring form, and they each have their own pros, cons, risk benefits. You know, transdermal has less risk of blood clots versus oral has a higher risk of blood clot in any form of estrogen. So we talk about that. We look at their family history or if they have MTH or Fari, any of the clotting genes, means, you know, then we counsel directly versus the IUD, the IUDs create an inflammatory environment in the uterus that blocks and it creates a plug in the cervix so that the sperm can't get through. And then if any do get through, it's a toxic environment in the uterine cavity for the sperm.

35:06So that's really how those IUDs work. Some IUDs are coated with progesterone, a progestin, not progesterone, progestigen, and those end up decidualizing the endometrium, so thinning that lining from that constant progesterone to the point where you stop bleeding. So a lot of my patients really loved that option of being a menoriac, no periods, just for the convenience of it, but they were still ovulating in the background. So we're not suppressing their natural cycles, just their periods. I see. Is there any evidence that the use of any form of birth control can disrupt the timing or the availability of...

35:41I realize availability of eggs is a very clinically naive, biologically naive statement. But basically what I'm saying, can any of them accelerate the onset of perimenopause? Can they delay the onset of perimenopause? They will delay the onset a little bit. It's maybe a year if you use it for a long time from what the data shows. So women who suppress ovulation, we lose about 11 ,000 eggs each month with the ovulation process to get one out, 11 ,000 race to the finish line. and only one makes it, but we lose about 11 ,000 in the process. So women who are constantly, you know, for a long time suppressing ovulation will have a slightly older age of menopause had they not done that.

36:24When you say slightly older, what's the longest extension of the surgery? The best I could see in the data was maybe nine months. Okay, from nine months use of growth control. No, no, so maybe like five to ten year use. I have to look at the data again to be, you know, I'd have to look that one up. but it was several years. Got it. To gain an extra maybe nine months, maybe a year of a very in life. I see. And nowadays, at least if people have the means, there's some trend, if you will, toward freezing one's eggs. This might be a good opportunity to just state something that came up before when we had Dr.

37:04Natalie Crawford on the podcast to talk about the amount of fertility. I think surprising to many people was her statement that not because it's controversial, but because we just don't hear this often enough, that harvesting eggs for freezing or for IVF does not diminish the pool of eggs that one would have, meaning you're losing them each month. Right. Anyway. Yeah, and so they're only pulling out 10, 12 maybe in a cycle and when you're losing 11 ,000 with an ovulation So it really isn't going to affect when you go through menopause Such a crucial thing for people to hear Yeah, I think there were a number of comments when we posted that clip on social media and people women saying Wow, I didn't realize that harvesting eggs would not somehow shift the onset of menopause earlier.

38:01And so for the record, we are not saying that. We're saying it does not. And very interesting that the use of birth control, but I'm guessing only forms of birth control that suppress ovulation can delay the onset of paramanopause menopause by about nine months maximum. So things like the copper IUD, which prevent pregnancy by creating an unfavorable environment for the sperm rather than disrupting an ovulation. in any way will not presumably extend a permanent, a possible, okay, just want to make sure we're crystal clear for people. You're being very clear, but I want to make sure that I'm clear on it and then reiterate because this can be kind of tricky territory.

38:40There are a lot of assumptions about this stuff and there's a lot of lore out there. Why do you think that is? Is that because of the lack of solid research and communication in this area? I think so. Or is it something else? I think these are tricky topics for discussion often because is we hear all this stuff, like birth control pills, disrupt one's ability to get pregnant when they come off, or we just learn that it can delay the onset of pregnant opos, which by extension means there's a greater window for pregnancy if one thinks about it that way. But why do you think it's so such a tangled discussion out there?

39:18I think just the way that society views pregnancy and female health and you know at least you know I live on the internet now you know this new life has brought me life on the internet and this what the algorithms are showing me. It's a very friendly they everyone's a written out. Everyone loves you. It's a great lesson it's what you're doing is so important and I understand the statement behind that statement I think but it's so important because it people are getting the opportunity to learn about really critical public health and female health issues in a way that just was inaccessible before.

40:00Yeah, it is. And it's good and bad. There's a lot of lore and misinformation that's getting propagated. And I feel like as a specialty, as a woman's health specialist, we did this to ourselves. We have not properly educated ourselves. We have not spent the money, the research, really championed women after reproduction. When you look at the dollars and the research and where it goes in women's health, I mean, women's health just gets a little sliver of all the NIH funding. When you look at all NIH funding and what goes to menopause, it's .03%. Less than half a percent. This is one third of a woman's life.

40:38And when you look at, God McKinsey and Company just published a report where they pulled 680 studies on chronic diseases, diabetes, hypertension, cardiovascular disease. And they looked at how they were women included in the studies, but how many presented the data for the different sexes? Like, what happened to men versus women? It was only 50 % of the articles actually did sex -specific differences and how this medication affected this process or whatever. And then of the ones that did, 30 % when women had poorer outcomes. And on the flip side, 10 % of men had poorer outcomes. And these things aren't just being brought to light.

41:17So the lack of recognition of sex -specific differences in chronic disease and how menopause kind of plays into all that I think is where the future needs to go. So we deserve as much good health as everyone else because yes We're living longer than men, but 20 to 25 % of that life is in poor health Well, that's a really significant statement. I mean, I think that the national institutes of health has been terrific in establishing new institutes within it They even have a complimentary health institute now. There's the National Eye Institute. There's a cancer here. Is there a plan or one would hope for a dedicated institute for women's health?

42:01Push. So there was one piece of legislation that got pushed through the Biden's signed it and it was $100 million for women's health and that got chopped up very quickly. I'm gonna pause, did get a little piece of it because we're also really struggling with intubitriosis and a lot of the female specific uterine diseases and PCOS and things. And so we need more funding there as well. And then there's another bill that's the one Hallibary was like on TV talking about another bill for $250 million. That bill includes language for education of providers. So we have whole generation of providers. I graduated my residency training the year the WHOI came out.

42:46So all we had very little like real clinically significant menopause education and then we knew about HRT and we were giving it in clinic if she was coming in with severe hot flashes, but that got taken off the table after the WHOI and then we have a whole general, like all menopause education basically stopped after that. So WHOI women's health initiative, HRT, no that's okay, just so that people are on board hormone replacement therapy. Yeah, it's a, well, we can encourage the expansion of research in these areas with this discussion. And certainly, I was on NIH panels for years as a regular member in the I Institute.

43:28And what I've noticed with NIH is that they are very responsive to the public call for growth of research in particular areas. You know, it can take time, it's government after all, and they need funding. There's a fine item out of funding. But I think that rarely do I ever get into legislature -based things. But if you are somebody who cares about more funding in a given area of research, it's actually very straightforward what to do. You call your congressman or senator, and you tell them, literally, you leave a message. I find this kind of interesting, And so it's a kind of like what we learned in social studies and In elementary school, but you call your you call your Senator or your governor and you leave a message and you say hey, you know, there's this issue that impacts a ton of people and it's really important and the next time it comes up when budgeting Comes up in Washington.

44:22It's really important and if you hear about a bill you can call and support a bill and believe it or not some of that stuff actually translates to more funding in a given area. In fact, the Brain Initiative, which unfortunately had its budget cut significantly recently, maybe put that funding back. But you know, a rose from the, I believe it was the child of two neuroscience professors up at University of Wisconsin. I'm probably going to get some details wrong, but so the Calioles are the professors, as I recall, and their son, overhood, all these conversations growing up about the importance of brain science and then eventually pushed through government channels for more money for brain research.

45:01And then we had a long phase of pretty substantial research and then it was cut. So these things, but it persists. And so these things really matter. Like you can impact it. So and maybe we should send them a clip of your statements on this podcast. Getting back to kind of things that people can control. So for people who are heading into parry menopause or who are in the parry menopause phase, Aside from the typical things that we hear about, fortunately, a lot these days, like getting adequate sleep, getting exercise, nutrition. Maybe we could touch a little bit on nutrition in a moment. You mentioned Mediterranean diet, Galveston diet, things that are going to promote overall health.

45:40Are there any things that people can do, maybe even take, that would improve their outcomes in this phase? Like, I've heard of people, and I have no bias here, or even knowledge of the research on this if there is any people taking, for instance, grape seed extract or people trying to do a number of things to reduce inflammation. You have general themes around self -care and wellness these days. But what are sort of the five or six that come to mind perhaps as like the things that can move the levers in the right direction? What I would tell my 35 year old self, you know, who just kind of went into this obliviously.

46:14And what I know now is your diet is probably one of the most important things that determines your level of inflammation. And then estrogen is a really powerful anti -inflammatory hormone and we lose that protection when we start losing it through the transition. So whatever you can do in the other areas, especially with nutrition, sleep, stress, reduction, we need to do it. So fiber, we are not getting enough fiber in our diet and the Western diet, I think it's most women are getting 10 to 12 grams per day and we need at least 25 and the health benefits 10 to max out around 30, 32 grams per day.

46:49So focusing on foods that are rich in fiber fibers feed in the gut microbiome slowing down glucose absorption You know glucose levels Sugar absorption into the bloodstream. It is slowing down the rate of you know certain parts of transit and pulling more water into the gut Like there's nothing bad about it, right? The foods that are rich in fiber have a lot of other stuff that's good for you to co -factors vitamins minerals Nutri you know just they're just so helpful And then anthocyan's you know just find things that crunch that are and get as many colors as you You can, you know, green, red, purple, yellow, every color represents a phytochemical that is going to be good for you in different areas of your body and try to keep it as very as possible.

47:29We're not getting enough protein and I have to thank Dr. Gabriel Lyon, you know, really helping me focus in on that. You know, when I first wrote Galveston diet to be honest and transparent, it was for weight loss. And, you know, I was frustrated with my weight gain and that was the pain point my patients had and that was my pain point, but I didn't realize it represented something much more than just the way I looked, you know, the visceral fat gain. And so learning about visceral fat and what it really means, and that is for your listeners, the fat that wraps around our internal organs, it's a very different fat than the subcutaneous fat.

48:01And, you know, a pre -menopausal woman's, we age -matched and looked at visceral fat levels, measuring it with the dexascanners. You have about 8 % of your fat as a visceral, as a pre -menopausal person, and then when you go through the transition, it's 23%. with no changes in diet and exercise. The visceral fat is not something that gets enough attention. Everyone thinks about subcutaneous fat because it's really... It's cosmetically distressing, but really, yeah. And one doesn't want too much of it for health reasons either, but it's the intravisceral fat that, at least by my understanding, is really the most problematic for health.

48:40It's a harbinger of chronic disease. So I read that weight gain is one of the primary symptoms of menopause itself. Yeah, so you have to be careful. You think about that when we when we plot weight gain versus age, it's a very straightforward linear curve and menopause does not seem to affect that. What is happening is a body composition change. We are losing muscle and we are gaining visceral fat. And so and you might be gaining some cus subcutaneous fat, but those are kind of the key things that are happening. And so that's really when I'm counseling patients what I'm focusing on because I have a body scanner in my office where I can tell them what their level of visceral fat is in their muscle mass.

49:22And so we bone and muscle, that musculoskeletal unit works together. And so we see this acceleration of muscle loss which controls our basal metabolic rate, which determines our resistance to insulin, which, you know, so it's just that's the organ of longevity. That's what I've learned from Dr. Lyon. And everything we can do to hang on to it and build is so important. So protein going back to the original point, protein intake is key and women by and large are getting 50 to 60 grams of protein per day. And we really probably need 80, 120, depending on our body composition. Yeah, thanks for mentioning Dr.

50:01Gabrielle Lines. She's doing what I, beautiful work in the world. Yeah, terrific work, really promoting women's health. And health generally, I know she's now, I believe, is exploring advanced training in in urology for males as well. So, you know, it's it's it's only fair to credit her with with really expanding into these different areas, but especially this idea that we need and women perhaps in particular from what I understand of she'll be on the podcast soon. So we get more of an understanding at least one gram of quality protein per pound of lean body mass maybe even per pound of body weight per day in order to optimize their health.

50:44Yeah, she's definitely on the higher end. The WHO are the Women's Health Initiative. Some of my favorite data, it's not all bad, it's data, and was looking at frailty scores and protein intake and women. And what they found was women who were having 1 .5 to 1 .7. So basically it was the higher their protein intake, the less likely they were to be frail the end. And it was, you know, they were reaching, it was kind of peaking out somewhere around 1 .5 to 1 .7 grams for kilogram of lean body mass. And most women are getting, you know, the FDA recommends 0 .8. Wow. And source of protein also important, high quality.

51:24Right, right. You need all the amino acids. Yeah. Very interesting. Now that's in menopause, but presumably also... So starting those habits in parry, just getting that laid down and getting those habits laid down are going to set you up for a much better postmenopause, a much healthier postmenopause. And we have to stop defining menopause by your hot flashes. You know, it may or may not make your hot flashes better. And we have great medications for that if it's disruptive. But I'm talking about your cardiometabolic disease risk. I meant to ask this earlier, so forgive me for leaping back briefly.

51:59But is there any Any value in knowing the age at which your mother went into menopause as a metric or a sensor rather for or a as a window into whether or not you will go into menopause at more or less the same age. Yes. There is a of course it's not one to one we at half of our DNA from our fathers. But I always ask and there is a you know the latest data that looked at it genetics is the biggest factor that determines when you're going to go through menopause. So knowing when your mother's your aunts went through and if there were any medical conditions associated with that is huge. Okay, so now we're talking not so much about parry menopause, but also menopause itself.

52:43What is the typical constellation of symptoms as one enters menopause, like right at the beginning and then does that constellation of symptoms change as one is a year or two years, three years into menopause? So it's almost 100 % with body composition changes, very, very, very close. You know, that visceral fat is tough to beat. It's beatable, but it takes a lot of work, you know. Do people know if they have visceral fat? I mean, there's their scanning approaches to look at it. So, gold, you know, of course the gold standard is a dexa or even an MRI, but no one can afford that. So, we have, like what I have in my office is the inbody scanner, so it's electrical impedance scanner and it's pretty good.

53:22So, you stand on the scale, hold the hand. I have the highest grade one for my patients. Most people doing what I do, utilizing a body scanner, use that one. But you can use the waist tip ratio. The waist tip ratio is a better measure of your risk of metabolic health than your weight or your BMI. It's so simple. You take a tape measure and a calculator. You can do it in your head, but you measure the smallest part of your waist. If you don't have a small waist, if it goes out, then just use your belly button. Just use something you can measure again. Are people sucking in or are they relaxed? You should be relaxed.

53:55And I tell my patients, you know, do it first thing in the morning when you're bladder is empty and you're not bloated and, you know, and then the widest part of your hips. It's not perfect, but it's better than your weight or your BMI. So widest part of the hips with people feet parallel, standing up straight. Yeah, I'm just saying it up straight. Because people are going to go try this, right? And so I only know the data for women, so forget me, but for a female, if it's less than 0 .7, then your chance of having clinically significant aberrations in visceral fat are low. And then if it's greater than one, you likely have higher levels of visceral fat.

54:33And so in clinic or when I was coaching online for Galveston diet, we were using the waste to ratio as one of the measures for their success. When measuring the waste, what's point along the waste? Is it red? Is it... It's just wherever you're smallest, so that's kind of different for different women. So I would just say look in the mirror wherever your hourglass goes in is where you want to kind of stick to. But if you don't have that kind of a waist and you have a wider waist, just pick the belly button because you always know you can go back to that level. You know, that's because we're tracking them over time.

55:07Great, those are very useful recommendations and how often should people do that? Uh, you know, you should never wear yourself every day, you shouldn't do this every day. We were having patients do it or you know our followers do it once a month. So changes in body composition as measured by dexa or impedance or you don't have access to that, waste of hip ratio. What are some of the other symptoms of the pulse? Fatigue. Multiple causes for the fatigue. A lot of sleep disruption. Sleep disruption is another huge thing. So all of a sudden you're struggling to go to sleep or you're having middle of the night awakeings and not able to go back to bed.

55:44that are new and different from previous. New and different than before, right? I see. There was a recent study that came out, and most of my patients in hindsight say, I knew something wasn't right, or something was different, something had changed, but I couldn't put my finger on it. And they just had a study come out saying, something's, when they looked at what that means, what does, I'm not feeling like myself mean. And it was psychological changes. So you lose resilience. You're suddenly more irritable. you're suddenly not able to like go with the punches or do you know you're not adjusting as well to change that you used to you're snapping at your kids more your partner or you know you're you're getting frustrated at work you know it's just very kind of subtle and it takes going through it and then looking back to say yeah I really say maybe about 47 that something was changing and I just thought I was just stressed out or whatever and then now I can see that was the beginning of the pattern so And then the stroke changes as we talked about.

56:42You know, the big highlights, vertigo, tenetists, ringing in the ears. Skin changes, so dry skin, itchy skin, feeling like you're having crawling under the skin. Big gut changes, so nuance that bloating, you're kind of eating all the same things and your guts just not handling things like it used to. So the Zoey Nutrition Study took 1100 women and did stool samples through menopause, through the period of menopause transition and saw the changes in the gut microbiome from the loss of the sex hormones. And basically, we went from what a typical female microbiome to that of a male through the transition.

57:20Is there any direct evidence that supplementing the gut microbiome? And here I don't necessarily mean pills and powders. My understanding is that's getting enough fiber. Yeah. And low sugar fermented foods. can also support the gut microbiome. Things like sourcrow kimchi, can you feed me so? Plain yogurt, just straight up, nothing added. Yeah, so is there evidence that supporting the gut microbiome can make this stage of menopause more? I guess reduce some of the symptoms of menopause. So the best I could find was most of them are ardent with supplements, because those are easier to measure than handing someone a cup of yogurt.

58:01Right, and you know which bacteria you're promoting. So they did lactobacillus and looked and bifidobacterium, I think, and saw that women who were obese and hypertensive and menopausal, and they had visceral fat decreased in blood pressure improvements versus placebo. Also, it's hard to do placebo studies with food, you know, so. But they do, and then in the retrospective studies, they can look at dietary patterns, and women who ate rich foods fermented and lots of yogurt, you know, Mediterranean type diets have better symptoms overall. What's the difference between the Mediterranean diet and the Galveston diet?

58:39So when I got my culinary medicine certification, I was frustrated when I was working because I didn't know anything about nutrition and suddenly like everything I was trying to to tell my patients was based on the one lecture I got in medical school. Good nutrition was like porn. When you see it, the Supreme Court definition of pornography. The best I'd ever gotten was the gestational diabetic diet. It was the Xerox things. I was in Texas, so it had tortillas and stuff on it. It had been copied so many times you could barely read it anymore. That was the diet. That was the only nutrition I'd ever handed to a patient.

59:20I'm like, eat healthy. And so I'm like, I got to do better than this. I don't know enough. And so we had a guest speaker for Alpha Omega Alpha, which is the Honor Society for Medical School, and I was one of the advisors. So, and it was this guy, Tim Harlan, who had started this culinary medicine movement, and it was basically nutrition for doctors. And he developed this like online program, and I had to go to New Orleans for a lab, it's in a Tonyo for a lab, and work in kitchens, where you were learning how to counsel patients, how to cook, and also basically like getting a little minor in nutrition.

59:51So it was the best thing I've ever done. I learned to say very cool words. I mean, I learned about allergies and like all this stuff, you know, food allergies and things that I just did know and just basic nutritional principles, like what it takes to build a healthy body and what, you know, I knew about Quasher or Quarer in like severe deficiencies, but not good basic nutrition. And so, you know, they talked heavily about Mediterranean. They talked a lot about the FAD diets and stuff. But you know, the principles of the Mediterranean, I was like, I want to teach this to my patients, but they're not going to eat a lot of Greek yogurt, or they're probably not going to eat a lot of feta.

1:00:22Like, how can I kind of take these blocks and make it more Americanized? That was kind of like the brainchild for me around Galveston diet was, let me create something, and I really was into fasting at the time too. So I was like, let me put this fasting thing together with good nutritional anti -inflammatory principles and talk about the things we know, or probably you should not have a whole lot of processed foods and high sugars and stuff, and explain it in a way and how it's affecting their mental pause and like how can she approach her nutrition? And that's how Galison diet was born. It was for my patients.

1:00:51And then I gave it to my girlfriends and then they started sharing it. And I talked about it one day on Facebook and the world exploded. In the best way. In the best way. Yeah, it led me here. Right. Right. And we all benefit. What is the evidence that fasting can be beneficial or detrimental to paramanopause? Yeah. So the jury's kind of still out on that one. I was really liked the data that, you know, I think it was Mark Mattson had done on neurodegenerative disease and using fasting as a tool there and lowering inflammation level. So I was like, this is amazing, this is great because so much about menopause is a pro -inflammatory.

1:01:30You know? Is this intermittent fasting sometimes or significant? Yeah, so he was basically doing 68, you know, and, you know, very scheduled intermittent fasting. And so that was something I was coaching my followers about, you know, consider this, try this, this might be something to help lower inflammation. I pulled back on that because it's really hard to get enough protein in for a lot of women, especially if they came in at 60 and now I'm telling them to double their protein, you know, and then giving them an eight hour window to do it. They're like, I'm walking around, no, I'm on a chicken breast all day, you know.

1:02:00This is hard. Right. And metabolizing protein is its own work. Right. And so you have to spread it out throughout the day, you know, and a lot of that work was done at UTME where I did my under, I mean my residency and where I taught for years. And so I was friendly with the nutrition department there. I was getting all excited about everything. And they're like, you know, I went to several of their conferences and like talking about breaking up protein intake into nuggets throughout the day because most women have very little protein with breakfast, maybe weak gluten in their toast, and then have a little bit of lunch and then kind of stack their protein at night.

1:02:32And they're still not getting enough, but they're overdoing it and they're evening meal, that's their big protein meal. And so like teaching them to kind of, you know, what I was teaching in Galveston Diet was you need to have a healthy fat, a good healthy car and a protein with every meal and snack that you eat, you know. What do you think that protein has not been emphasized enough until recently? I think because we didn't understand it, you know, we didn't understand how important muscle was. And I mean, we knew that protein intake was important for muscle, but muscle was for bodybuilders and not for women.

1:03:07I lived my whole life up until about five years ago, eating to be thin and moving to be thin. That thin was the only measurement of health that I needed to worry about. And what I did was chip away at my bone and muscle strength. And thank God I don't have osteophenia yet. You know, I've hopefully have reversed whatever trend I was on and I'm naturally low muscle. So now it's just a battle to try to hang on to what little I have and build some And you and your resistance train? Yeah, yeah, yeah now Three days a week three days a week. Yeah, I'm resistance training much less cardio I was running marathons.

1:03:41I it was a great social thing with my girlfriends But you know everything I did was cardio I Taught step aerobics, you know the only weights I did were maybe in Zumba maybe one or two pounds You know so and that was good better than being on the couch I mean, I loved the community in doing that, but for me to stay out of the nursing home, which was my ultimate goal for as long as possible, I need to pick up some weights and heavy weights. So that's where my focus has changed. Isn't it interesting that it wasn't until recently that it was only bodybuilders and football players and people preparing for military or specific sport would resistance train.

1:04:17And now we are told that everybody, male, female, young, old should resistance train. Absolutely. I believe three times a week. Yeah. And the my generation is struggling because we don't know how to do it. And so I'm, you know, and I'm not a personal trainer. I don't pretend, you know, I hire one to help me develop a program so that I don't hurt myself and that I can get stronger, you know, progressive loads. So, you know, and again, Dr. Lyon's such a huge proponent of that. And so what I try to do publicly is show my workouts so that people, I normalize it and people see me doing it and they're like, well, she can do it, then I can do it.

1:04:52It's great, super inspiring and it really helps cross that threshold where people, as you said, they don't know how. It's scary. For people with resistance trained for a long time, they go into a gym, they know how all that stuff works. But for those that don't, it's... You're wandering around like, what does this one do? You know? Yeah, it's intimidating for a whole bunch of reasons. Well, thank you for putting that content out. Both the prescription, if you will, but also the example that one can go about it. So I'm guessing if you could go back 20 years, you would have started resistance training Yeah, yeah.

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1:06:38Again, that's InsideTracker .com slash Huberman to get 10 % off. So what are some other symptoms of menopause? You mentioned body composition changes. The one that we hear about the most for some reason, I don't know, is hot flashes. Yeah, so I think hot flashes. So in medicine, we call it a vasomotor symptoms. So we have a dysregulation of the thermoregulatory center in hypothalamus, and that, the thermoset gets reset basically. And so what happens is we have this vasodilation of it starts in the core typically from most women somewhere in the chest neck area and you feel this heat, you know, I can probably trigger one just by talking about it.

1:07:21And it goes up into the neck and out into the extremities and then you just start profusely sweating from all the blood vessels dilating and then it can last minutes to a second but for some women it's preceded by sometimes palpitations, sometimes by this intense feeling of dysphoria, you know, this intense sadness feeling, and then it just kind of passes. But you know, say you're, you know, wherever you are in your life, whatever you're doing, all of a sudden you're just like sweating profusely in the middle of some important area of your life worked, you know, whatever your jobs are in your life.

1:07:53And it's disruptive. If it happens at night, you don't sleep. And for some women, it's severe where they're having multiple ones a day. When any time you disrupt sleep, then daytime is far worse. Yeah. You usually differently. Yeah, you stress differently. You know, everything changes. And so when my patients come in, the first questions we ask are sleep. And that's the first thing we work on is, you know, what can we do to get your sleep better? What can be done for hot flashes aside from the things that you've already described to offset and then a pause. So the goal, absolute goal standard is hormone therapy.

1:08:27is giving your body back the estrogen, which will get your serotonin levels back to where they were and leave that thermo -regulatory center alone. So it's back to where it used to be. Let's talk about hormone therapy. It's a bit of a controversial topic. For no reason. Yeah, I was gonna say I don't know why. Yeah, it's demonized. It got such a bad rap and we need to, to, it's just some of the worst misinformation campaign in the history of medicine. Well, that's a bold statement, but I believe you, So the way I understand it is that there was this large scale hormone therapy trial and the interpretation of that trial was something different than we now believe as a medical issue.

1:09:11The initial, so it was really groundbreaking at the time. Aging women were finally being studied. We knew from observational data that women on hormone therapy, probably 40 % of the population of females eligible were on HRT. Okay, so very large amount. So the women who were given hormone therapy had lower incidence of cardiovascular disease, older ages of cardiovascular disease, lower death from cardiovascular disease. Some people argued that that was an artifact of healthier, wealthier women get HRT because they go to the doctor, okay? So this is just because they're healthier that they have less cardiovascular disease.

1:09:46So let's prove it. What do you do that with? A randomized control trial. So flaws in the study. So they take, I think there were 11 ,000ish women in the estrogen -only arm because they had hysterectomy. So for your listeners, if you have a uterus and you're getting estrogen, you must have a progestigen with it to protect the lining of the uterus from an ametial cancer. As long as you give an adequate progestin, you're fine, okay? But if you don't have a uterus, progesterone is not mandatory. So the women who had hysterectomy got estrogen -only or placebo. and the estrogen at the time was primarine, which was the number one prescription for HRT at the time.

1:10:23So nothing weird about that. So it's just synthetic ester dial. Actually, no. Primarine is, is primarine stands for pregnant, mare, urine. It is actually very natural. They take pregnant horses and extract the estrogens from their urine. Because they're pregnant and they're greeting a lot of it. And it was cheap and easy. And I have a lot of ethical issues about how they do that. But, and I don't prescribe it. But that's what was done at the time. So there's like there are Nate a lot there's dozens of Estrogens in that comp but the main one is Estardial so then there the other group who had uterus were given Prem Pro which is Premarin plus Provera and or placebo so off we go they recruit 11 ,000 and then I think 15 ,000 in the other arm huge study it's like a billion in dollar study.

1:11:14Like we're so excited this is happening. This started when I was in med school. And then they start recruiting patients and then everyone's taking their meds. They excluded women with hot flashes. What? Because if your hot flashes go away, you know that you didn't get the placebo. So they excluded women with hot flashes. Problem number one. Yeah, that's a big problem. Now, the end outcome, what they were trying to measure was cardiovascular disease. So they started with an older population. The average age was 63. Whereas the typical onset of menopause is 51. Wow. So these women had been menopausal, you know, on average, for 10, 12, 13 years.

1:11:55So time away from estrogen is when disease starts, accelerates, right? Okay. So put them on their meds, start measuring. In the estrogen plus progestin arm, they saw a non -stacistically significant increase risk of breast cancer. And it was this, the relative risk relative, now you know what this is, but your money or your listeners may not, was 25%. And I hope I get the numbers right. It was four out of a thousand women per year to five out of a thousand women per year. Okay. So placebo arm was four. So we have breasts, we are females, we get breast cancer, about four out of a thousand women per year.

1:12:35And that increased to five. In the estrogen and only arm, there was a 30 % decrease risk of breast cancer. Regardless of the average age. And they kept that arm going. Because it's randomized, so presumably the average age for the other group is roughly 61 as well. Yeah, they were matched. So in their 60s as well. So they call a press conference at the Watergate Hotel. The Watergate Hotel? Two announced the findings. They hadn't even published the date yet. No one had had a chance to read it. And the head researchers called this press conference and say estrogen causes breast cancer. Exogenous estrogen from these.

1:13:14Yes. Yes. And they said it's a 25 % increase risk. But the absolute risk was like 0 .8 % per year. But that didn't get that it's not a headline thing. So on every like ABC NBC CBS all the morning shows nightly news every major magazine it was the number one medical news story of 2002 that the estrogen was bad and it caused cancer and dead, the estrogen -only arm kept going and they found after a couple more years a slightly increased risk of stroke so they stopped the study. The effects on cardiovascular disease were neutral but there was lower colon cancer in both groups but no one talked about that.

1:13:52So the American Heart Association in 2020 went and looked at, they looked at ages. So there were younger women who were given HRT and what they found was if you started hormone therapy between Meaning the ages of 50 to 59, you had a 50 % decrease risk of cardiovascular disease and death from cardiovascular disease and all cause mortality. Wow. So age at which you start matters? Estrogen. So that's where there's something called the healthy cell hypothesis. And so basically estrogen is better at prevention than cure. And it's very protective, especially in the endoma of the coronary arteries. So taking that estrogen away, we lose that protection.

1:14:31Once the disease builds up, there's some worry that adding estrogen once you've developed after sclerosis or plaque might loosen the plaque, especially in that first year. So which led for some people maybe to have a slightly increased risk of stroke. So when my patients come in, we are talking about these differences. It doesn't mean that after 60 you might not have cardiovascular benefit, we start losing the benefit. So it's a timing hypothesis, it's key. And it's the years away from estrogen, that's the problem. It was a great study in the British Medical Journal. They looked at years of reproductive life plus HRT and looked at cognition scores and saw that the longer your body is exposed to estrogen in any form, like whether natural cycles or exogenous estrogen of any form, and it was estradiol in that study actually, then you you had higher cognition scores, healthier brains.

1:15:31Which at a just very top contour level makes total sense given that estrogen is neuroprotective. I realize it might not be neuroprotective in every instance and every neuron in the brain, but it's generally neuroprotective. Generally neuroprotective, yeah. And decline in estrogen is correlated with neurogeneration, which does not mean it's causal. I have to ask when they announce this study at the Watergate Hotel of all places, And the conclusion that they put forth was that estrogen therapies can increase rates of cancer. I have to wonder if that had something to do with what I understand is a sort of party line around cancers and breast cancers in particular, which is that you want to quote -unquote block the estrogen receptor.

1:16:15You want to get in there and put it give to moxophine or nowadays, I'm sure there are other drugs that are more effective to block the estrogen receptor. It all seems to pile up on the side of a story that says estrogen and estrogen binding to the estrogen receptor is pro -cancerous, which obviously I think you're telling us in an indirect and direct way now and we'll go further into is simply not the case. If you take a healthy breast cell and dump it at a peach reddish and then marinate it with some estrogen, it's not tyratogen. I mean, it's not carcinogenic. Estrogen is not carcinogenic. We live with it our whole lives.

1:16:47if it was in pregnancy for those of us who are ever pregnant, when our estrogen level skyrocket, we would see this into uptick in breast cancer and we don't. In fact, I think there's some evidence for the opposite that getting pregnant prior to age 40 is it true that that's protective against your relationship? That seems to be somewhat protective. For certain forms of breast cancer, yeah. We have this whole generation of physicians who really weren't taught much about menopause, don't understand the protective benefits of estrogen and menopause's effect on metabolic disease. And they have this mentality of estrogen is bad.

1:17:23And so a woman walks into her, today, 2023, they looked at the data. She goes into her doctor complaining of menopausal symptoms, which right now are still only recognizes generally urinary syndrome menopause, hot flashes, and nightswets, you know, the very cliché symptoms. Documents in the chart she's having whatever. However, only 10 % are offered any therapy and they're most likely 4 -1 to be offered and any depressant. That is where it stands today. That is what we are fighting against. Is not every woman will choose HRT, but every woman deserves an informed conversation about it and let her make her choice.

1:18:00If you believe the WHOI data, which there are some problems there, the risk is small. Okay? But did you talk to her about cardiovascular disease and diabetes and insulin resistance in her cholesterol? Because those things go up through the menopause transition with no changes in diet and exercise. And those are all, you know, even with the diagnosis of breast cancer, the most likely thing a woman is going to die from is cardiovascular disease. A heart attack or a stroke. So framing it like that, I think is where we need to head. And the other thing is, you know, I was a great OB -GYN in so many areas of what I did.

1:18:37Why should this all be dumped in the lap of the poor, busy OB -GYN, who's running around the hospital, doing pouts, who are trying to deliver babies, surgery, and all the things? Like, this should be required education for all everyone in medical school. We are females and we're not little men with breast and uteruses. We react differently to medications, disease, disease burden, you know, and that's not been studied adequately and that's where the push needs to go. It's bigger than just hot flashes. Do you think that one solution is to deepen the medical school curriculum? Absolutely. And I hate saying women's health, because everyone thinks breast and uterus, right?

1:19:17And reproduction, it's the health of women. And we're not addressing it differently than the health of a man. And we're different. We were, you know, and so that, I think, is where we need to head. given that it's half of the population. Yeah. One would imagine that the best thing to do is to make the core curriculum of medical students expand to include this as opposed to making it a specialty. I think so. Does that mean a 50 year of medical school? I'm not kidding. I mean, I guess... Maybe. I mean, people said, well, you'd have to extend the OB -GYN residency. I'm like, no. Any specialist who touches a female should understand how that female...

1:19:56I mean, the starkest example is cardiovascular disease. You know, how much longer we have to wait in the ED? How much more likely we are to die in the hospital setting from a heart attack? Because we don't present the same symptoms as men do, and it's just the default has always been how it happens to the basic, you know, really Caucasian male. And so, at least in the US. And so, because we respond differently, because we wait longer, because our symptoms are considered to be psychological, le -induced, less than biologically induced. And so women are dying at higher rates. When you look at the data on statins, you get high cholesterol.

1:20:34So 80 % of women will have abnormal cholesterol levels through the men and post -transition if they were normal before, okay? So elevated LDL. LDL and lowering HDL. So now they are at higher risk for cardiovascular disease. Automatically, a PCP will offer her a statin, okay? That is standard of care. Do you know that the American Heart Association published in 2020 that statins have never been shown to decrease their primary heart attack in a woman. Secondary yes, but no primary prevention and it does not decrease risk of death from cardiovascular disease. They're probably yeah. Yeah, where routine you know what does HRT if given in the right window of opportunity.

1:21:12How is HRT in this case estrogen HRT given? Is it a patch? Is it injection? Yeah, great question. All the above. So we have, I like to break it down into oral and non -oral forms. So everything oral we ingest goes into the gut, the liver, the hepatic system will pick up the portal vein, and take everything to the liver for processing. When that bump of estrogen hits the liver, we can see a slight increase in some of our clotting factors. So for that reason, I tend to go with the non -oral formulations to avoid that risk, especially if she has any family history of clotting or personal history of clotting, we're going to go with a nonoral form.

1:21:52These are things like elevations in factor five lightening. And THFR, if she's had a history of a blood clot, we are not going with an oral estrogen formulation. And for people that haven't had a history of a blood clot, my understanding, which admittedly is very sparse, is that you can do a genetic test just by blood draw to see whether or not you have two normal copies of the gene for factor five lightening. Some people are heterozygates, so they're more at risk of presumably bleeding in that case, right? But in other words, can people go into this knowing whether or not they're more or less at risk from taking estrogen form other...

1:22:31So I don't think that there's a high enough for that reason because we're not routinely screening for these things unless they have a family history. I'm going with non -oral estrogen as a primary product for my patients because I can just skip that worry. So a patch typically? So typically transdormals. So a patch, there's even mispray, there's FDA approved options of a patch, there's gels, there's a spring, and there's a vaginal ring which I love, love, love because you put it in for three months and it treats, you know, you get a two for one, you get a local treatment in the vagina as well as a systemic treatment as well.

1:23:08It's just really expensive and typically not covered by insurance on the first tier. So very few of my patients can afford it. There are some injectables which no one in the menopausee uses. They're menopausee. Yeah, they're also the menopausee. Those terms that you coined a lot of. I think I did. Great. You heard it here. So the menopausee is a group of healthcare professionals who are from multiple specialties. We have cardiologists at Orthopedic Surgeon, internal medicine, Dr. Lyon is a member, and we have a big group chat, and we all support each other. We support each other's books and research, and we send articles back and forth, and we support each other on social, but we also band it together to kind of negate one of the bigger publications on menopause that when the Lancet published, it's a whole nother discussion.

1:24:00But we are fighting for equity in menopause care and women's health. Right? Nothing succeeds like a group. Like the old menopause versus the new menopause. I love it. I love it. So hormone therapy to increase estrogen, how does it make women feel? Psychologically, physically, what are some of the positive changes that can occur? Aside from just offsetting some of the negative, and I want to make sure that I remember to ask, what if a woman has been in menopause for, you know, has passed that point? Because So they passed that point a year earlier, two years earlier, three years earlier, given the results of this first study, which as you explained it are problematic in their interpretation the way it was interpreted as opposed to.

1:24:49Initially, yeah. What's too long should, how long should you stay on and which are you staying on? Should there be in their 40s, just to smooth the transition? Maybe. We need more studies in this area. like, should we just, the minute we figure out, like, I would love, like, I wear a glucose monitor. I have insulin resistance. So I was listening. It just, it looks like a little button size sticker on the back of the. I would love to develop one to track estrogen levels, starting your 30s. Just see where you're at. You know, start seeing or you having aberrations in your cycle and we can start the period of menopause journey and talking about, should we begin supporting?

1:25:28I think there's a tremendous amount, opportunity for research in this area, but typically we are not starting patients until they're very symptomatic if they're parimenopausal or they're postmenopausal. So in general. So if a woman is in her, let's say late 30s, she is anticipating parimenopausal, maybe is in parimenopausal and wants to start low dose hormone replacement therapy. I think it's something worth mentioning that not all, you know, presumably the dosages are tailored and then blood. So a given dose is tried, blood is drawn, you measure estridile. So we're not, and we don't have established levels of like therapeutic ranges of estridile.

1:26:14What we found is that when we do that so far, I think we have some opportunity here. If on my levels 15, you're levels 50, I could feel like I'm on top of the world, my symptoms are gone. You still need more. So we are titrating from symptoms. I see. Yeah. Interesting. Similar to what is done, similar issue with testosterone replacement therapy, which these days, you know, I sort of have joke that the, you can change out the R in testosterone replacement because a lot of people are, a lot of men are taking testosterone not as a replacement. I mean, their levels are not lower than 300 ng per deciliter, which has a lower range.

1:26:51They're sort of low middle and they're trying to get higher range. But hormone replacement therapy, as I understand it, has never been strictly in men or women, strictly for people who are out of range, that in theory it can be to optimize, reduce symptoms and to optimize well -being. And I don't know if the medical establishment wants it used that way, but certainly in the case of testosterone replacement therapy in men, it's being used that way, quite often So we don't have established therapeutic ranges for estradiol. If she's POI, premature variant insufficiency, we know we want to get her to around 100 or higher in Pychograms for a desoleter.

1:27:36But in the menopausal patient, we're rarely checking levels, but I do think we have an opportunity to learn a lot more. Now that we're able to track, how does it affect your cholesterol? We need to look at those numbers. Like what's the optimal dose for cholesterol? What's the apple doves for cardiovascular disease? All these studies have looked at was was she on it or not? So that's where I think the opportunities can come. So if a woman goes on hormone replacement therapy, how often is she coming in for blood draws? Or are you just able to say? Well, it depends. Like testosterone, we tend to check more often.

1:28:08We don't have an FDA approved option for women for testosterone. And so no. So we either try to get her T -stem, or she's finding someone to insert a pellet or something and there's other issues with that. What I do in Texas is really hard. The pharmacists do not like to do the T -stem for patients and I've even... T -stem. T -stem is the gel, you know. And I end up compounding it in a cream and do a transdormal cream for the patients, but there's such variable absorption. We do tend to check more levels of that just to try to get her therapeutic. So what for women at peak dose is somewhere in a healthy female, you know, 35 to 70.

1:28:52And so I had a woman coming in with signs of hyperanternism. You know, she's, you know, deep voice, hair growth, whatever acne. And I'm going to check a level of it's above 90 for females. I need to look for a tumor. Like that's too high, okay? Or PCOS, it can get that high. Certainly above 200. That's outrageous. So I'm trying to get my patients, you know, 60, 50, 70, but if she's like 50 and her, she's got her libido back and she feels great and everything's wonderful, then I'm hold, you know, because the higher we go, the more likely you are to have side effects. So you're losing hair, you know, temporal hair loss, voice deepening, acne, new chin hair, you know, losing hair where you want it, gaining hair where you don't want it.

1:29:32This is how I explain it to patients. And so when you say 50 that's 50 nanograms per deciliter. I think many people include myself were surprised to learn That women actually have higher levels of testosterone than they do estrogen And absolute ranges. Yeah, right in absolute ranges And I can tell you right now your natural level of ester dial is higher than mine now I'm supplement, but you know like when I go through menopause your residual ester dial is now higher than a personal of other women. So this is the ester dial that I have because testosterone was aromatized into estrogen. Interesting.

1:30:08Interesting. So much is breaking down around the old stereotypes of testosterone. Right. The man, hormone, and that's true. And testosterone is a human hormone. Astrogens are human hormone. And they exist in both biological sexes. Yeah, it's sometimes unfortunate that compounds in the body get names like steroid hormones because then people hear steroids, and it has a gravitational pull toward anabolic steroid use. Or even the word fat, you know, it's like dietary fat versus subcutaneous fat versus... This will fall, yeah. It's a negative factor. We need better nomenclature to avoid a lot of the confusion that exists out there.

1:30:49What are some of the other hormones that can be reduced and can possibly be replaced by hormone therapy. Like, progestines, is there a role for adjusting things like prolactin? Is there a role for other hormones in that what sure is to be a multifactorial thing? I mean, I mean, I didn't manifest as a process, not an event. Hypogonatism for females, right? And so we know that, because the pituitary and hepatomas are involved and that GNRH, There's some cross -reactivity. So, for example, hypothyroidism. When I have a patient who's on her and doing well on hormone therapy for her thyroid, so she's on T3, T4, whatever she's on, I'm like, listen, we need to recheck your thyroid levels in six weeks because giving you back estrogen is gonna mess with a little bit of that feedback cycle.

1:31:42So we need to make sure you're still therapeutic. So I think we've got more work to do with some of the other hormones. But when we talk about replacement and menopause, we are mostly looking at your estrogens, your antrogens, and your progesterone. So the formulations can differ. But there's a lot of misunderstanding around what is bidoidentical versus synthetic. And I think a lot of cottage industries in this little bubble that we had for 23 years where doctors were afraid to prescribe hormone therapy. And then women were desperate for care. We had some little cottage industries of people. I think we're well -meaning and trying to help, but kind of develop terminology that really isn't medically specific, like estrogen dominance, you know, and what that really is.

1:32:27And so that is not a term that isn't any medical journal. It's kind of something coin, I think, from a well -meaning provider trying to explain what's happening in parimenopause that you're having more estrogen produced than progesterone than you used to have. So a PCO patient to do the same thing, there's multiple reasons for that to happen. So when we talk about, you know, in the miniverse of what we're trying to replace, we all agree that we stick pretty much with extra dial, we're just trying to give you back the water you were drinking. So I want to get as close to what your body used to make because that's what the receptors like.

1:33:00I'm trying to give you progesterone, you know, rather than a synthetic, not that they're all demonized, progesterone doesn't work for everyone. I'm glad I have options. And then for your Androgens, we pretty much just do testosterone and we do a transdermal again because the oral can be hepatotoxic unless it's undecanoid which isn't available in the US. But there's no FDA approved option for women so it's not covered by insurance. We know it works for hypoectubesctual desire disorder, what your follow was called libido. We think we know that testosterone. Women at the highest quartile of testosterone have better bone density and stronger muscles.

1:33:36So I'm using it off label for my patients who come in with osteoporosis, osteopenia or sarcopenia. I'm using it off label telling them. This is probably a home, it's not a Hill Mary, we think it works, but we don't have the, you know, it's not approved for that yet yet. We know it has receptors in the brain. My patients are saying that they're more clarity of thought, they're sleeping better, they really, really like the testosterone. So there's, you know, DHA, there's a great vaginal preparation for DHA called introsa, and then the receptors there will start converting it into both testosterone and estridate, you know, through the process.

1:34:09And so the sexual medicine docs really like introsa, especially for breast cancer patients, because they get that little boost of testosterone in the vulva. Introsa. Introsa is the brand name. I think it's prostarone, prostarone. And this is a prescription drug. Yeah, these are prescriptions. So introsa's prescription DHEA, which is... Specifically formulated for the vagina. Got it, which sits further upstream to the production of testosterone and estrogen. Right. And so fortunately, what's left in the vagina is able to plug that guy in and get it to produce both testosterone and estradiol, which testosterone is the immediate precursor.

1:34:46We have to romanticize it to make estradiol in females as well. These local effects on tissues are interesting. They may be perfect sentence if the highest concentration is at the site of release from the patch or the gel or whatever. However, the, you said intravaginal, what is it? It's like a capsule. I think the pressurone is a insert, like a little gel looking and not a gel, but I forget what the binding material is. But it's like a little insert you put in. Okay, so the local effects, because I guess it, you know, it's, it's a risk that the highest concentration can be at the side of the thing that's releasing the hormone.

1:35:23But then it also goes systemic by getting into the blood. Actually, so the local formulations, the pressurone and the itterosa, and as well as the estradiol formulated for the vagina, do not absorb systemically. They're so low dose, they have not been clinically significant tissue absorption. I have a formulation for my face as well. So it's a cream? A cream that I put on my face, it's estriol. And so there's some decent studies with estriol, but we lose 30 % of our collagen. It's a very big pain point for women when they get to the menopause that we lose so much collagen so quickly in the first five years of menopause.

1:35:57And so we can slow that process down. We can't stop it completely. We can slow it down by using a topical estrogen. And the topical really seems to help with the elastin concentrations as well. Interesting. So you will often prescribe a lot of local treatments for hormone. Yes, and really it's so safe. So we can take breast cancer off the table, all the discussion around blood clots and everything. Everyone can use vaginal estrogen and they should. And I'll tell you why. Starting at what age relative to menopause? The old menopause thoughts do not give vaginal estrogen until she's symptomatic.

1:36:27Now, all of us will become symptomatic from GSM, so that's genital urinary syndrome of menopause. So from the pubic bone, all the way to the sacrum, all of that tissue is heavily tied to estrogen to testosterone. And when those levels decline, we see thinning of the tissue, loss of elasticity, loss of mucus production, as well as the health of the urethra. And so UTIs, like the best treatment for recurrent UTIs in a menopausal patient is vaginal estrogen. not recurrent antibiotics. And what about... So it's preventative. And we can probably keep 50 % of women out of the ER and out of ureosypsis.

1:37:01If we gave them all prophylactic vaginal estrogen, all these ladies in nursing homes should be on vaginal estrogen. So just to protect them from getting ureosypsis. Interesting. What about like urinary incontinence and some of these other symptoms that are associated with more elasticity? Yeah. is presumably more elasticity of tissue in that region. If you're early in us, so we have stress incontinence and then we have overactive bladder urgent incontinence. And so it definitely helps with urgent incontinence. It helps to relax and decrease the inflammation in the wall of the bladder. So that thumbs up there.

1:37:36So people are getting up at night and having that urge to go. But stress incontinence is an anatomical problem. We've lost the sling that holds up the urethra and the female fails from herniation and poor tissue health. We can build up that health and we, you know, there's physical therapy. There's lots of options and you know, no urogonicologist wants to take a woman to the OR to do a lift if she's not astronautized. They're all going to get vaginal estrogen, pre, you know, through healing and then forever to keep the tissue healthy. Everything that we've been talking about for about the last 15 or 20 minutes seems to go directly opposite this large scale study that was discussed at the Watergate hotel.

1:38:21Is your read that the medical establishment in particular the OBGYNs and the US and in other countries understand now that that study was flawed to some extent in its design or is what we're talking about here like really cutting edge. I mean we were to gather a room full of a thousand OBGYNs. I think Maybe 10 % maybe 10 % would have any idea. Here's why and I'm going to call out the American Board of Obi -GEN directly on this. We take our board certification exams every year and our specialty as every specialty does and they give us a set of articles of the cutting edge, newest research and it's divided into categories, obstetrics, office practice, gynecology, GY and surgery, pediatrics, on call, you know, there is no menopause category.

1:39:09Nothing. thing. So I went back over like 10 years of all my green journals and looked at how many articles were anything to do with menopause and it was less than 1%. So they were not systematically trying to put the latest menopause information in front of us. They don't even recognize the menopause society as a entity. Well, now they have to contend with the menopause. They do. And because they might, you might see me ban from the A -Bot, but you know what? No, no, no, but I'm so proud of what I learned. I learned amazing things. I am a boss, a delivering a baby, a taking care for pregnant patient.

1:39:48I am great at pediatric oncology. I was so good without a lesson where I failed and where this, I let the system let me fail was in the care of a woman after reproduction outside of surgery, outside of her surgical needs. Well, I have to imagine that given the medical profession is interested in the well -being of people and in, for sake of the discussion today, women that they will be grateful that now you have a microphone, many microphones in various contexts. So that is surprising to me, however, I would think that given the exciting findings around hormone replacement therapy and the, I'm kind of obvious, at least when you describe them to me, obvious flaws in these earlier studies of, you know, starting hormone replacement therapy when women are already 61 when they've already accumulated in many cases some health issues that it would be kind of obvious.

1:40:44You miss the ability to measure the protective benefits. So but fortunately we've got great studies coming out of like the Danish data, the Scandinavian data that are really looking at this again and showing the protective benefits. So is it generally the case that the studies out of Europe and and Scandinavia are more forward thinking? It depends. You know, some of the most forward thinking, shockingly, is come out of Asia, a lot out of China. And I asked my husband, he's worked there before. And he said, there's as many researchers in China that are female as male. It's not like they have a big stay at home culture.

1:41:23You know, they're not, women are expected to work. And they're getting PhDs. And they're doing the research. And so, and he thinks, in his, in of one, his humble opinion, and he's an engineer, You know that that's why I was like, what do you think you've worked over there? He goes I think because there's just as many women who are writing the papers as men Interesting take I like it It makes good sense What are the various things that people can do in terms of a non hormone replacement therapies that can support them through Really into and through parimenopause and menopause We talked about nutrition earlier.

1:42:00Maybe we could touch on that a little bit more. We talked about behaviors, resistance training, maintaining maybe even increasing muscle mass. There's no pressure to include them, but what about the very supplements that we hear about that can touch on, or we're year told, can touch on these hormone pathways. Things like dim, things like grape seed extracts. Things like, you know, evening primrose. I don't think they're harmful, but there's just not robust data to really support. So, menopause society went and looked at all of them, even soy and everything. And they just outside of cognitive behavioral therapy, which can be helpful, but it's not a menopause cure.

1:42:37They didn't find much in the supplement world that would stop. Remember, we're defining menopause as hot flashes in general, urinary syndrome of menopause. So, you know, when I'm recommending supplements to patients, I do think there's some okay data on turmeric for maybe hot flashes. but I'm not saying to take that instead of replacing the estrogen your body is missing greatly. I like the anti -inflammatory benefits of that supplement. I'm recommending fiber. 80 % of my patients are deficient in vitamin D and struggling to get it absorbed. I'm recommending creatine for muscle. I'm recommending there's a specific bioactive collagen that was studied in menopausal one with osteoporosis where they saw improvement in bone density.

1:43:23So I'm recommending a weighted vest, great studies, elderly women, but saw improvements in bone density. And I'm like, why do we wait until we're osteoporotic to make the diagnosis? Yeah, this is interesting. So weighted vest. Weighted vest. They looked at creatine, weighted vest, vibratory training in nursing home dwellings. So they were kind of a population where they couldn't go anywhere. Vibratory training is the shake plate. The shake plate. And so, you know, anything that stimulates that musculoskeletal unit will send the signal to get stronger. or what must women don't realize? I mean, they know about osteoporosis, right?

1:43:55And they don't want to have it, but they don't understand that your habits and your 30s and 40s are gonna put you on that path. And that your body's gonna fight to lose muscle and bone, naturally through the aging process and accelerated with menopause, it doesn't have to be that way, but you have to do the work. And there's some hacks. And so I love the way to vet's for a hack. I'm like, do the dishes with it on. Go walk the dog. You know, like. How heavy? So you want in the nursing home they started at 10 % of their body weight. So I'm like 10 pounds 12 pounds start with that So now my husband's obsessed and we have six of them and they go from 8 to 35 pounds You know, so I have different weights that I wear like if I'm doing leg day I'll put the heavier one on so I'll have to hold as heavy So you'll use a weight vest when you're doing leg day.

1:44:38Mm -hmm. Wow So I can't because I don't have great grip strength and you know, and so it'll help me be able to squat heavier But now I'm getting better. I've got the bar going, so I'm getting there. I'm telling my sister and my mom this. Yeah, and you know. And my sister got, yeah, doing some resistance training. It's been a good time. And it's just a cheat. So it's so cute on social because they'll post and tag me and they're walking their dog, they're doing whatever with their way to vest on. And now in Galveston where I live, you can't go, you see it all over the sea while everyone's walking with their way to vest.

1:45:07I love it. And it's hot down there a lot of the year. Yeah, it's warm. So no excuses, people outside of Texas or in Texas for that matter. But my experience is that people in Texas don't tend to make excuses. Anyway, that's said like a real Californian here. We were talking about this a little bit earlier and female specific weight vests. I would love to develop one because the ones were made for men and they're okay. But if you have larger breasts, it's hard with a snap. So I had to get it on right and I know there's a big trend with rucking. But that puts all the weight on your back and I really like the weighted vest because I feel and this is my opinion really.

1:45:42But that you know the reason why it's helping with their bone density is it's putting the weight on the entire axial skeleton rather than just The muscles on your back. So we're putting the force more evenly supported. Yeah And so but some of my followers have written in and said they're struggling because they have larger breasts and how to get this around I'm like I got to make one that's gonna accommodate you know have longer, you know to strap down here underneath the breast So yes, I want you to develop that you should develop that Not that you don't already have enough on your plate already I like rucking.

1:46:14It is sort of backloaded by definition. Some of the weight vests that are out there are evenly distributed in a way that makes them pretty comfortable. They're not all loaded up up front like a special operator or something would wear. So a positive effect of the weight vests would be increased bone density. You're doing a little more calories, right? You're doing more work. getting stronger, but I coached to it with my followers for this is part of my osteoporosis prevention pack. Are you willing to share a few other things that are in the prevention pack? Eating adequate protein, doing resistance training, wearing your weighted vest, creatine, five grams a day where most of the studies were done in the women.

1:46:55Created mono -hydrate. Monohydrate, yeah. And then that collagen, consider that collagen, full disclosure, I do sell that one, but really good investment, I think. Maybe we can talk about collagen for a moment. It's a complete protein? No. No, it's missing one, I think one or two amino acids. So it's not a complete protein. It's better than none. So I do include my collagen in my protein intake for the day because I eat all animal -based protein pretty much. So I figured I'm covered my basis to have 10 % of it coming, which is missing two amino acids. I think it's one valley. I have to look it up.

1:47:35And what are the specific effects of a quality collagen? So there's a lot of controversy there I've seen in the videos. It is broken down into its component amino acids through the digestion process. But the first ones I looked at were totally frivolity. I was trying on bathing suits with my daughter who was a little girl at the time and I was complaining about the appearance of my cellulite. Even thin people have cellulite. And so, oh, mommy, it doesn't look that bad. And I, you know, scientist in me was like, goes on PubMed and starts looking up articles on cellulite and how to decrease the appearance of it.

1:48:12And so I found these articles on something called Verisol. And it was a college in Made in Germany. And they'd studied, actually, done really high quality studies, like laser measuring wrinkles and cellulite. Germans are precise. And they, and it looked, they had positive outcomes. I'm like, well, it won't hurt me. So I ordered sign. Google, where do I find this Verisol College? I find this company out, order it, and then one day I talked about it on the internet. And the company called me and said, would you please let us know when you do that? Because they sold out of their supply for like three months.

1:48:42So the same like manufacturer of that particular verisol made this fortabone, did the studies five years doing bone density scans on these women. It was a small study, but they saw improvements. We know what happens to bone density if you do nothing. It goes down. These went up and I thought, okay, I want to do it. And I want to offer this to people. Like, if not them, me, this is a high quality product. I can rip, you know, and that's, so that's part of my what I offer to people or what I recommend. You can get it anywhere. Other people sell it, not just me. Great. So, I'm perplexed. This isn't a challenge, but I'm perplexed.

1:49:22What a protein that's not a complete protein. be beneficial for a body organ like skin, whereas the complete proteins don't seem to do it on their own. Nobody knows. Are they not studying the right thing? Are they not really looking at it? So, I don't know. That's great. When I hear, I don't know, the scientist in me says, great area for exploration. Great area for exploration. Because we don't really believe, in fact, we don't believe that amino acids that are derived from, are derived from a particular body part target that tissue. We've heard this argument before Dr. Lane Norton and I have both gone on record publicly saying there is basically zero, not basically delete the basically.

1:50:06There is zero evidence that when you ingest heart, let's say you like eating liver or heart or skeletal muscle that somehow the amino acids are selectively traffic to the organ of the heart or the liver or the skeletal muscle, there's no evidence of that whatsoever. Certainly not in humans. If there is evidence, I'm sure the less known the comment section on YouTube and let us know. But yeah, it's perplexing why collagen would have a selectively beneficial effect on skin. And they didn't study it versus a steak. They just looked at bone density if they took this product every day for five years and what happened.

1:50:42And they weren't having tremendous cardiometabolic disease. They weren't on bone building medications. They weren't on HRT. So they did a pretty clean, so there's not a huge study, but it was interesting and I thought, okay, you know, I don't want to break, because if I break my hip, well 50 % of women will have an osteoporotic fracture before they die. 50%. What about men, do we know? Just by way of comparison. I think it's 25. But don't quote me on that. I need to look at one up. So it's about half, okay? And then hip fracture, if you break that hip, if over the age of 65, you have your one -year mortality with surgical repair is 30%.

1:51:23If you're not healthy enough to have the repair, you can't afford to have it. It's 79. Goodness. So that's what we're trying to avoid is that. And the tremendous, if you've seen the women who have tremendous osteoporosis in their spine and just how their lives are so hard, how much pain they live in every single day. A lot of this is avoidable with aggressive, of being aggressive and an intentional about this. And HRT can be a huge part of that as well. What I'm about to ask is a little bit outside the box, but I feel fair asking it's given that, I'm not a clinician, but I have some background and certainly understanding of neuro -generative conditions of the eye and vision.

1:52:09Have you ever observed in your patients that when they get on hormone replacement therapy for menopause, that things that are typically associated with aging like diminished visual function, hearing, you mentioned tinnitus, also called tinnitus, I understand, but tinnitus, I think it's... Right, I can't. Yeah, yeah. We'll do both, tinnitus tonight, it's a lot of... And EG correct, we can't do that. ...tinnitus tonight, it's a lot of... ...tinnitus tonight. We'll do both. We'll do both. Here, that they report seeing better, hearing better, and any kind of sensory improvement or offset of sensory loss.

1:52:39So we know the data is clear on dry eye and how that can affect, but how it affects like the optic nerve, you know, we know that estrogen is anti -inflammatory. So any kind of like inflammatory condition in and around the eye does tend to get better, but we need, you know, probably more data in this area. For hearing, most of the research is around tenetists in vertigo. So the rate of which the crystals break off in that your accelerates in menopause and people on HRT have less vertigo, new vertigo than they would have had before. And I forget what the path of physiology, there are a rhodota in the book, but I can't think of it right now.

1:53:18What the physiology was behind why tenetists increases in menopause, but it's due to the estrogen levels declining. You mentioned dry eye. A lot of people might hear dry eye and think, oh no big deal, but actually dry eye is one of the most frustrating things to have. And it's a, I believe, a many billions of dollars of your industry to find treatments for dry eye. So does estrogen replacement therapy improve dry eye? It does seem to. They have less incidence. Most of the studies are just retroactive, and they're looking at the incidence of those things on women on HRT for other reasons or not.

1:53:55And they just see, especially like frozen shoulders, the best data there, I think. And what they see is a decreased risk of occurrence. And then if they do have it, they have a shorter duration and easier course, easier to treat if they're on HRT. Fantastic. So, what are some of the cases where a woman can't or shouldn't do hormone replacement therapy? And here where using hormone replacement therapy is kind of a proxy for estrogen therapy. Yes, so any hormone -sensitive cancer, one of the things a lot of women don't understand, if you have dysfunctional uterine bleeding that has not been evaluated, you should not start hormone therapy because we don't know if it's cancer.

1:54:34So if you're having, really have, especially if they're heavy bleeding, clots out of nowhere where something unusual about the volume or the frequency of your bleeding, you need to go see a gynecologist and get that evaluated before you start hormone therapy. It may not be anything cancerous or tumors, it might just be the hormone changes, but that needs to be evaluated. If known breast cancer, no, if you're actively having a blood clot that you're being treated for, they're saying, let's hold off until that therapy is over. Even if you've had a hormone sensitive cancer, including breast cancer, depending on the stage, the type, and it's a very nuanced conversation, does not mean that you are automatically disqualified for hormone therapy after your treatment.

1:55:16So that is one of the biggest misconceptions out there. If you have really severe liver disease, I'm not talking about mild fatty liver disease, lots of menopausal women have that, and it does tend to get better with HRT. If you have severe liver disease, that is where estrogen begins to be metabolized, and so you could have abnormal metabolism, you don't want that. So that year that's gonna keep you from being a candidate. Why do you think we're seeing or at least hearing about in my case PCOS, polycystic ovarian syndrome so much more? Is it because people are aware? Is it because I think two reasons one the obesity epidemic had led to more PCOS that is definitely a risk factor for you know insulin resistance is usually the the main path of physiologic cause behind PCOS and And I'm a PCOS, then PCOS suffer.

1:56:07So I had it my whole reproductive life. But you're not obese at all. No, no, they missed it forever. I was just stressed out medical student. Which can potentially cause PCOS? With acne. Yeah, I mean, you can have, PCOS is a symptom of something biologically apparent. Turns out I'm insulin resistant, which is why I, you know, even though I'm thin. And so we've had higher increasing levels of obesity, which is a risk factor for that. That also people are talking about it and writing books about a care and tang just published. It's not hysteria. It's not hysteria. And she's a gynecologic surgeon, does a lot of work around endometriosis.

1:56:47So she has like huge chapters on PCOS and how to advocate for yourself and all about the disease process so people understand. Interesting. What are some of the primary treatments for PCOS? Is it going to be blocking endrogens? So, yes. And so for me, you know, in all my training, it was always put them on birth control because it was, it, it will suppress ovulation and suppress the overproduction of androgens in their system. So I was a very happy birth control patient because I was thin. For the obese patients, if we can help them lose weight, it does tend to, they start ovulating again. And so, So now with the new GOP1s, a lot of PCOS will probably resolve itself.

1:57:30And they'll start ovulating again and go back to normal cycles. That's the pregnancies that are happening from GOP1s. I see. So GOP1 associated pregnancy. GOP1 babies. Yeah. We saw a surge of that when all the patients, the OV patients, were getting the gastric bypasses, then they get pregnant. And so we were advising them to not be pregnant until their weight was stable for a year after surgery because of the medical implications of nutrition and pregnancy. But they were so excited and cute and now they're libido's up and they're getting pregnant and never really needed contraception before and just assume they'd still have trouble.

1:58:06And so now they're ovulating and getting pregnant and we're seeing the same thing with GOP1. So, anyone listening out there who's prescribing a GOP1, please talk to your female patients about contraception if they don't want to be pregnant. Very interesting and admittedly unforeseen implications of GOP1. As long as we're there, what are your thoughts on a Zempoch Moncharo? I think that they can be a really important tool for a lot of patients. I don't think they're for everyone. I don't think people are being counseled adequately. A lot of them. In my area outside of Galveston where I live, there are med spots giving out GOP1s.

1:58:42As far as I can tell, they're just giving them the meds and sending them out the door. I've had patients coming in on it who were never counseled about the potential for muscle loss. So, when I look at a patient's health, I look at a 30 -year plan, right? And so, they come in with a lifelong history usually of having a weight problem and a fat problem. And here's this medication that's going to take the food noise away and help them focus on the habits that are going to keep them healthy longer. So I do have patients that I've prescribed it to. We have a very long discussion about adequate protein intake, resistance training.

1:59:13You know, I have a way to measure their muscle mass. We are tracking that every month for them every month to six weeks While they're you know on the medication. So women who are on HRT with the GOP one have a 30 % increased weight loss Yeah, yeah, I appreciate that you mentioned that The use of ozemic mojaro is not mutually exclusive with resistance training and improved nutrition No, I think it shows up on social media sort of like people assume well Well, you know, you gotta take great care of yourself and exercise well, great, but there are also a number of people that are carrying access weight to the point where they are at risk of injury when they exercise.

1:59:52I mean, everyone's at risk of injury when they exercise. But what I'm hearing is that you basically take the view whatever can get people in a kind of forward center of mass around management of blood insulin levels et cetera, because it wasn't that the original FDA approval was for, it was a type II diabetes. Type II diabetes. And there's also some data as I recall that ozambic mongaro can reduce alcohol cravings. So yeah, the rewards center in the brain are the noise. So they're looking now, I guess, my friends who are obesity medicine specialists and are all reading every study that comes out.

2:00:25Any kind of impulsive behavior or reward seeking behavior, gaming, gambling, alcohol, you know, people are tending to do less of those behaviors because whatever's being blocked in the brain and you know more of us than I do, seems to help with that. Those drives. That's interesting that the hypothalamus is chocoblockful of neurons associated with all sorts of drives. And temperature regulation, you mentioned earlier, you know, the preoptic area of the hypothalamus involved in temperature regulation. And we've always viewed those as somewhat separate, but they're actually quite interconnected.

2:01:02And so I'm not entirely surprised that a drug that would reduce cravings for food might also reduce cravings for other things. It's going to be really interesting to see what the science and the animal models in human shows us over time. Over time. It's definitely happening. I mean, has it hit a trillion dollar industry yet? It's probably hundreds of billions of dollars. I know that the majority of big research and funding is being funneled into this. Maybe not all for the right reasons, but the obesity medicine specialist who are kind of who I turn to for how do I do this? How do I do it right?

2:01:35How do I not hurt someone just to get them to lose weight? And are very excited because these new levels, they say it's like the iPhone 12, the iPhone 13, like they're just gonna get better and better with lower side effects, better profiles, as time goes on. That we're gonna look back at the Monjaro and these earlier meds and be like, oh my God, what were we doing? Because of the side effects. If nothing else, they're very interesting to pay attention to because it's clearly in the cultural zeitgeist right now. So, every once in a while, when a guest for whom the topic is of immense interest, coming on the podcast, I'll put out a call on social media for questions.

2:02:17And so, if you're willing, I'd like to just ask you a few of the audience questions. And we can treat these as rapid fire or as much depth as you like. First off, many of the questions you've already answered, things like what is the role for testosterone replacement therapy and women as opposed to just estrogen replacement therapy. But one of the more common questions in here that we've touched on, but I think could deserve a bit more attention, is, you know, if a woman is in her 60s and has already gone through menopause, is it appropriate for her to consider or at least just talk to her doctor about hormone replacement therapy or is she putting herself at risk?

2:03:00There's definitely worth the conversation. So if I have a patient who comes in and she's more than 10 years past her menopause or over the age of 60 and has not been on HRT, then we start looking at risk factors for cardiovascular disease or stroke. And so we're looking at her blood pressure, her lipids, her cholesterol and triglycerides and looking for things that are going to put her at higher risk. She's lost probably the maximum cardiovascular benefit, but we don't want to put extra on top of severe atherosclerotic disease. So if she has abnormal cholesterol, I'm going to center for a calcium cardiac score.

2:03:40I want to see if there's calcified plaques around her heart. I may even, if stroke is a risk, we may even center for an ultrasound, you know, looking at the intimal thickness of the carotid. So if those are normal or low risk, then we will talk about the benefits of what would the benefits be for her after the age of 60, where we probably lost the best of the cardiovascular protection, but it will always protect her bones. It will always protect her general urinary system. It will always protect her skin. I mean, there's things that estrogen will do for us forever. And so, and then let her make the decision.

2:04:15Certainly, if she's still symptomatic, meaning hot flashes or things, we can easily identify that we know estrogen will help with. But, you know, that first 10 -year window is kind of critical for the preventative benefits, but it doesn't mean she's not going to benefit forever. Now, when do we stop? Doctors make up numbers, three, ten years, whatever. If she's been on it since early in her menopause and has not developed any of these diseases, and she wants to keep going, we're going to keep her on. I will probably die with my estradiol patch on, if I don't develop a reason to take it off, because I know it's protecting me in so many levels, and I want to keep that going.

2:04:55In so many ways, it sounds very similar to testosterone replacement therapy in men, the idea is that people go on and don't - Yeah, but why would you stop at 70? Why would you do that? Right. You know, if you didn't develop a contraindication to it. Very clear and potentially very actionable answer. Thank you. A number of the questions related to the relationship between menopause, hormone therapy, and mental health, mental well -being. But let's just keep it simple for now and ask what are the things that women can do in order to optimize or their mental health in parimenopause and menopause and that they can do to offset any mental health issues that might arise during parimenopause and menopause.

2:05:40There's a reason why I asked about those two things separately. One is just to try and be a fucking pregnant menopause. for mental health. So, a great question. So, I just went to a menopause conference in Chicago. And there was a whole section on mental health, and it was neuroscientist, psychiatrist, and menopause specialist. All up there, discussing the latest data. It was so fascinating. And so, there really is a big difference as far as mental health for what's happening in parimenopause, and what's happening postmenopause. And as we talked about earlier, in parimenopause, because we have that hormonal zone of chaos.

2:06:17And we see this, you know, in the Australian data, it's a four times risk of mental health disorders, especially depression. And then in post -menopause, a lot of these things tend to stabilize or get better, probably because just the estrogen is bottomed out and the brain is not having to deal with these fluctuations. So we think that the data is looking like the best treatment for the mental health issues whose impairment opause is going to be estrogen for stabilization and not the traditional SSRIs SNRIs, you know, the antidepressants and the anxiety meds. Not incidentally, one of the more common questions was, in this case, very specifically worded, I've been on HRT for five years and I'm 61, I feel great, but how long is it, quote, unquote, okay to be on them?

2:07:06Seems like I hear conflicting opinions. Well, we just heard a very straightforward opinion. Yeah. So thank you for that. as long as you want to be, as long as you're still healthy. How can I stop waking up in the middle of the night? This is a problem since entering menopause. So we see sleep disruptions definitely from, not only from the vasomotor symptoms, which will wake you up. Okay, if we can get those under control, you know, your sleep function should not be affected by that. What we're seeing though is people, even with HRT, even with estrogen, or still having middle of the night awakenings or racing thoughts or having, they get up to pee or something in the middle of the night and they can't go back to bed, usually because their brain is going on.

2:07:48What we found is that progestin, probably through the effects of GABA, is very effective at settling your brain down and allowing for sleep. So I'm having my patients take their progesterone orally at night before they go to bed and we're seeing better sleep with that. And that was also something covered in detail. I was so excited by the neuroscientists as part of her area of research that they are showing clearly and she can point to the neurosceptors of where that's happening. That progesterone seems to be really protected for us. Now, take hormones off the table. Sleep hygiene is still hugely important.

2:08:25And I need to see the studies to prove it, but I'm telling you, we do not tolerate alcohol like we did pre -menopausal. Women are in at least 90 % every time I post about it online, I see thousands of comments of I quit I had to give it up I cannot sleep and even in my own life if I choose socially to have more than a glass of wine I am giving up sleep like it is a choice. I'm choosing not to sleep that night I will wake up to 233 335 whatever time in the morning sweating and I'm like You know Too much champagne at New Year's or whatever so you know that is a choice and it's something I counsel my patients about like You probably can't tolerate alcohol like you used to ageings a factor here your body composition changes and there's probably something hormonally that's going on we don't understand yet.

2:09:10But like you choose this, you're going to choose not to sleep more than likely. Interesting. I wonder whether or not estrogen modulates the alcohol dehydrogenase enzyme, but time will tell. We haven't seen the data yet, but I'm sure it's coming. Here's an interesting one. How can men help their female loved ones navigate these stages? Yeah. You get that question a lot. My, and it's great. And it always comes on the, when I'm being interviewed by a male, you know, when I'm interviewed by a female, they're wonderful, but they have their own experience and they have to talk about it. And that's fine.

2:09:41That's my job, you know, is women have to unpack their menopause trauma to me. But the men are just so curious and just have so many questions and then how can I support a partner and or my mom or whomever in my life who's dealing with this. One is is acknowledge that this is happening and try to educate yourself. There's my book, other books. There's lots of information now on the internet about the subject, but she is going through a transition that is rocking her world more than likely and is affecting her brain, her bones, her heart, her kidneys, her skin, her ability to relate, her ability to tolerate, it's probably going to affect your relationship in some way.

2:10:15Go there with her. Go to the appointments with her. Be there to advocate for her. Be a partner through this with her because you will get her back, but it's going to take changing the way that you address things. A couple of questions about, quote, how to rekindle libido. Oh, yeah. This person in particular says it's packed its bags and moved out since they started menopause. They're reporting their individual experience, but you touched on testosterone therapy earlier. Any woman in her menopause journey at any time, there's a 50 % sexual dysfunction rate, meaning she's not happy with whatever's going on.

2:10:53Now, when we look at the buckets where sexual function fall into, we have orgasmic disorder. Now, in menopause, when we lose blood flow to the area, people can have delayed orgasms or the peak of the orgasm is lower, less vibrant orgasms for lack of a better word. They have decreased blood flow to the area, they lose elasticity. So pain is another bucket. It hurts, the skin gets torn, it's very fragile, it's very friable. So vaginal estrogen therapy can help there. There is arousal disorders where you want to do it, but the blood's not getting where it needs to go. So you're not having all the arousal type symptoms.

2:11:32So sometimes, the viagras, the identify, the topical identify, can be helpful there. But the most common thing that women have is HSD or of course, relationship disorder. You don't love your partner, you don't feel supported. It's going to be hard to... Relationship disorder. Yeah, relationship disorder. The official term. But then HSDD is hyperactive sexual desire disorder. That's in the brain. And so first thing I ask is, did you use to have a good libido or a drive? Yes. You know, and you have a good relationship with your partner. It doesn't hurt. You know, with your rule out the other things That's where testosterone comes into play.

2:12:04That is those patients. It does tend to help There are two FDA -approved medications for libido. One is Vilecee. It's an injection You give yourself and actually works for men as well about 30 minutes before It's in the alpha melanocyte stimulating hormone path. Yeah, so melanocore And then there is Adi ADDY eye works at the level I think of dopamine in the brain So it's more in the family of SSRIs, you know, so it affects neurotransmitter. And so you take that every day. And it works. It was only studied in pre -minopausal women. But it does, you know, it's modest, but it does seem to have an effect.

2:12:38So, but most of my patients, because testosterone has so many other benefits, you and the cost, to get it compounded in Texas, this may be 30 bucks a month. So it's really reasonable. and the vitally seen that adi can be very expensive and usually not covered by insurance. So because of cost and potential other effects, most of my patients choose to stosterone if it's HSDD. Let's see. This is a question about the side effects associated with estradiol hormone replacement therapy. Yeah, yeah. In this particular instance, the person says, what are the best alternatives to estradiol? I've tried tiny amounts and the side effects, in this case, skin rashes and hives are what they are describing.

2:13:19So I wonder if it's the patch. So there's a certain percentage of patients who it's not the extra dial. It's actually the adhesive in the patch. They will have a reaction to it. So one is try and alternative form. Another thing that one of the members on my team saw in her chat group is they get the flonesa, a corticone nasal spray, over the counter and they spray it on and let it dry. Then they put the patch on and it decreases the risk of the reaction to the glue. I don't know if that lasts forever, but I thought that was a cool thing to know about. What I typically do for my patients is change them to an alternative form.

2:13:54Interesting. Thank you for that. They went on to ask about trying a new supplement called EQEL. EQULE. I think I read about that one. Again, I don't know what's in EQEL, but again, not really robust studies. Most of these things are not harmful, but you may just, it may be a little snake oil you know, throw anybody away. Really, the thing that's gonna fix the problem for most women is restoring your estradiol. Yeah, because there were other questions about, you know, wild yam and things more in the supplement space, as well as things like acupuncture and herbal medicine. So acupuncture can really be helpful, but again, it's hard to access and can be expensive for a lot of patients and it's not treating the root cause.

2:14:40But it definitely can help you deal with some of the symptoms and make you more comfortable. And then last question, how best to attack, and here I'm quoting, attack the fat distribution problem at this time? Yeah, you need a multi -factorial approach to visceral fat. So nutrition, exercise, women on HRT have less visceral fat. Those are kind of the key things. And the way you approach your nutrition with the exercise, with the stress reduction, getting those quarters all level down, are going to make you healthier in every other way as well. Great. Well, Dr. Mary Claire, thank you so much for giving us just a wealth of knowledge about paramanopause, menopause, really explaining what those are clearly for the first time on this podcast and really illustrating the things that people can do to think about these stages of life and to, I don't know if I should say tackle or to dance with the stage of life, whatever term one prefers in in order to offset the negative effects.

2:15:43And it sounds like, in fact, it's very clear based on what you've told us that there are real levers of control. Including hormone replacement therapy, but other things as well, nutrition, exercise. Sounds like when we put all these together, there's almost like a mindset around perimenopause and menopause that you are promoting, which is one of real agency. That this is not something that is going to bury us mentally and physically that's something that really can be worked with. And I just want to say on behalf of myself, because I've learned so much from you here and the listeners and viewers of the podcast.

2:16:18Thank you for the information today. Thank you for your clinical work. Thank you for your ongoing research into this area for attending these conferences and learning so much about it. So you can bring us the latest. And thanks for your public education efforts, because they are really making a tremendous difference. Thank you. Thank you for joining me for today's discussion with Dr. Mary Claire Haver. To learn more about her work, please see the link to her website in the show note caption, as well as the link to her terrific book, The New Menopause, Navigating Your Path Through Hormonal Change with Purpose, Power, and the Facts.

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