Perimenopause Starts Earlier Than You Think — What Every Mom Needs to Know Now

0:03I'm so excited to share today's conversation with you because I'm talking with Dr. Mary Claire Haver, who just published a book called The New Perimenopause. It is an evidence-based guide to surviving the zone of chaos and feeling like yourself again. And perimenopause happens a decade before menopause sometimes. There is so much going on in your brain and bodies that nobody has been talking to women about. And we sometimes just confuse with the season of just raising kids and the chaos of it all. I just wanted to gift you a conversation with Dr. Mary Claire Haver because we are covering what is happening with your body, what is happening with your brain, what is happening with your bones.

0:51and your sex drive and your sex life and your hormones and what you can do about it. I'm so excited to share this with you. I'm Dr. Elisa Pressman, and this is Raising Good Humans podcast.

1:09Okay. I am so excited that you have, first of all, that you're just here for us, generally speaking. And I was so lucky to meet you the millisecond. I started to notice anything going on with my body. I learned so much from you. Then I'm so excited you've written perimenopause because every time I see a young woman, a young mother, my brain wants to say like, there's other stuff coming and I want you to be prepared, but I also don't want to overwhelm anyone. So I want to ask you about this because it's really hard for me to understand, and I'm sure so many people, how to distinguish between what's going on in those years after you've had a baby when we have so many things that we attribute to having had a baby that may actually have to do with perimenopause because it starts so much earlier than we realize.

2:22How do people distinguish between those two things?

2:25Dr. Mary Claire Haver:We've now reached the point in time, I think New York Times published this, that now more women over 40 are having babies than under 20. Wow. And so women are on the regular going directly postpartum into perimenopause, or maybe they got pregnant in perimenopause. So it's like this season is layered with so many things. And then we're sandwiching, so we've got aging parents who didn't plan for this, right? So it is a lot. So when the patients come in, usually what I hear is this. I had it managed. I built this life. I was rolling with the punches. I could manage my stress. You know, typically the patients are like, I can't identify anything new, but I'm not able to manage the life I built.

3:22Dr. Mary Claire Haver:I've lost my resilience. Okay. We do a lot of blood work to rule out things that kind of look like perimenopause, like autoimmune disease, like inflammatory disorders, like nutritional deficiencies. You know, we're like looking under the hood, like what do we have? You know, what's going on? And then we don't have a great hormone test for perimenopause because it's a chaotic zone and like a one-time test isn't super definitive. You know, certainly if you're postmenopausal, we're super good at that. Yep. Right. The cows left the barn. You were fully menopausal. I can do that in two seconds with a blood test.

3:55Dr. Mary Claire Haver:But perimenopause is a lot harder. You have to really listen to the patient, help tease out what's going on. And we guess. And then we start treatment and we see what gets better. It's that simple. So I'm glad you mentioned blood tests because I know so many women who say, I'm not in perimenopause because my doctor did a blood test and said my hormone levels are fine. Can you address that? Well, God bless them. Or they're estrogen dominant, which is also perimenopause, right? Or polycystic avarian syndrome. So, you know, we, the blood tests are not definitive. I wish, I wish. I think we might be able to use AMH or this LDL, the small dense LDL-C.

4:35Dr. Mary Claire Haver:There's a certain cholesterol molecule that actually goes up only with menopause and not with aging. So we're getting there, but we don't have it yet. So really, it takes a doctor who listens to you, believes you, like runs the gauntlet with you. And like, just we start making interventions and we see what works. You know, it is a zone of chaos. And even with our best treatment, we can't stop the process, right? All we can do is kind of smooth out the edges until she transitions fully. And then after menopause, it's a lot easier because you flatline your hormones and I just give them back, you know.

5:11Dr. Mary Claire Haver:But treatment in perimenopause is literally pinning the tail on a moving donkey. But simply validating her, telling her, yep, this is what's happening. Yep, it's understandable. Yes, your stress, your anxiety, your sleep disruption, your weight gain, whatever is a biological consequence of what is happening with your hormones, that in and of itself is such a relief to the patients. I mean, that's why I wrote the book. No woman should traverse this without education and without understanding. First, I want to talk about symptoms because I will tell you, when I was in my early 40s, I got frozen shoulder.

5:51and nothing, no other, first of all, I did not know about perimenopause. Then at that point, nobody associated that in my life with perimenopause.

6:07Dr. Mary Claire Haver:It's been five years the first time I heard of it. And I was like on the cutting edge of menopause, Right, right. And then I got it again on the other side right around when I actually met you and when I started hearing about perimenopause in the first place. And I was like, oh, so I, but, but I had no other noticeable symptoms. I'm wondering, in addition to frozen shoulder, which I'm, I would be thrilled for you to describe because I thought I had like a torn rotator cuff and was very confused because I do not do the kinds of things that would tear a rotator cuff. But, um, so it was a real, it was strange, but what are the symptoms that might not be so obvious?

6:56So perimenopause symptoms typically start in the

6:59Dr. Mary Claire Haver:brain. So ovulation is driven by signals coming from the hypothalamus and pituitary. So in our brain, we have glands, right? So the hypothalamus is kind of a master regulator of your thyroid, of your sex hormones, of lots of things, okay? And it's constantly sensing for thyroid hormone, for one, okay? It's also constantly sensing for estradiol. And when those estradiol levels dip in a normal healthy cycle, right, we peak at ovulation and then the estradiol levels kind of taper back down. The brain is like, wait, wait, wait, we really liked that estrogen level? Like we need it back? We want her back again?

7:39Dr. Mary Claire Haver:So it sends this GnRH down to the pituitary, which then produces LH and FSH, so lutealizing hormone and follicular stimulating hormone. Those hormones go from the brain down to the ovaries. So the ovaries actually don't act on their own unless there's a tumor, okay? They just wait for instructions from the brain. Then those LHNFSH start binding to the follicular cells. So around our eggs, we have these follicles, and then those cells will start producing estradiol, and then after ovulation, progesterone, okay? And about half of our body's testosterone, and testosterone is actually fairly steady state.

8:15Dr. Mary Claire Haver:We get a little bit of of a tenured fluctuation, but not nothing like estrogen and progesterone. So in perimenopause, so women are born with all of their eggs, females, right? If you're born with ovaries, you have a set egg supply, and there's a lot we can do to tip them off, right? We can smoke. We can have surgery, hysterectomies, inflammatory bowel process, trauma. There are sympathetic nerves going right to the ovary that just start knocking the eggs out. So it's really crazy that we can actually speed up the amount of eggs that we lose. So when you reach a critical egg threshold level somewhere in your late 30s to 40s, okay, and it's different for every woman, the signals coming from the brain, the ovaries become resistant.

8:57Dr. Mary Claire Haver:There's not enough eggs to give you the same response that you used to get like an EKG month after month after month, right? And so the brain's like, where's the estrogen? It's day 22. You know, it's day four. We should be building now. And the ovaries are like, I did what I could. So the brain gets mad and starts sending higher and higher levels of those stimulating hormones. So then you get these massive surges of ovulation, sometimes double, sometimes loop ovulations two in one month. And so we get much higher levels of estradiol than we ever had outside of a potential pregnancy. And then we have these crashes.

9:35Dr. Mary Claire Haver:Is that why periods get so heavy? Yes. Okay. And then what crashes and progesterone can't keep up to shed the lining. So that and that starts happening even when you before your periods become irregular, the brain is working double, triple time to try to force these ovulations. And our neurotransmitters, our glucose uptake, you know, in the brain, our the speed at which we transmit across the neurons. All of this is affected by our sex hormone levels. So it used to be predictable and EKG like now becomes a zone of chaos. like I threw spaghetti at the wall as you just run out of eggs. So that seven to 10 year transition is chaotic.

10:14Dr. Mary Claire Haver:And that is so sleep disruption, anxiety and depression and brain fog. Typically, for most women are the first symptoms they see. There was a beautiful paper Elisa done last year called I Just Don't Feel Like Myself. And they quantified it. And she spoke at the Menopause Society meeting last year. I'm like obsessed to get her on the podcast. and the first researcher who was like, all these women saying this can't be wrong. And so they quantified it and they're like, yes, this is the hallmark of perimenopause. I just don't feel like myself. And I can't put my finger on it. So pretty crazy. And what, because we know mothers in particular will put their health last.

10:58Yes. Especially during this time with, you know, raising young kids or even high school age kids, there's just no time for yourself. Can you sort of speak to the things that we should be doing to take time for ourselves now in perimenopause? I've raised children.

11:18Dr. Mary Claire Haver:My kids are 22 and 25. I've been through it. I get it. But what I would tell her at 35, what I would tell Mary Claire at 35 is this is coming. I knew nothing about perimenopause. It was a definition that I had to check on a checklist. It was not anything I treated. And you're an OBGYN. Yes. I didn't treat it. I didn't put it as a diagnosis. I didn't. Nothing. Nothing. Certainly, like, some of the symptoms we would treat, oh, she has hot flashes, but she's still having periods. Oh, she's got heavy periods. That's never connecting the dots. And all of this was due to this. I didn't even know about the zone of chaos until three years ago.

11:53Wow.

11:54Dr. Mary Claire Haver:So, like, mind-blowing. So I would tell her, educate yourself, which is why I wrote the book. Like this is coming and it could infect your body in multiple ways. We have estrogen, progesterone receptors throughout our body. You need to be prepared for this. You don't feel crazy. Okay. Number two, prioritize your sleep. Prioritize your stress reduction. Get into therapy now. Don't wait until you're in a crisis. Like start putting up boundaries, protect, you know, stop saying yes to every single thing. You know, like this is a storm you're going to weather and it's going to affect multiple, And so you can't be everything to everybody at all times.

12:31Dr. Mary Claire Haver:You must, must, must put your health first. Your kids can make a sandwich. Your kids can get their homework started. Your husband can pick up the slack. So like me trying to be all the things to all the people at all times, like I was drowning, drowning. And so I would go back and be so kind to her and say, you must. Like, since I've done all those things, like, at 57, I am literally living my best life. Like, I want all your 30-year-olds to be me at 57. Like, healthy, happy kids. A 30-year relationship that's still going strong. The best sex I've ever had in my life. The best boundaries I've ever put in my life.

13:12Dr. Mary Claire Haver:The best time. I say no all the time. You know, like, no, no, no, no, no. And I'm living, like, my dream job. Like, I created this job. I, you know, just felt so called. I went with my calling, right? And I had a beautiful career and I risked it all to do this. And, you know, I want that for everyone. And had I not learned how to navigate this and get the toolbox going and maximize my nutrition, my exercise, my stress reduction, my sleep, and like really not feel selfish about putting me first so that I could be the best version of myself for everyone else, that's everything. What I want to tell you is the things that you talk about in terms of nutrition and physical health and bone density that, again, just don't occur to someone in their 30s and 40s.

14:07What really matters? Because I now care about bone density and it's a little late.

14:12Dr. Mary Claire Haver:So, gosh, we've reached our maximum natural bone density. Not that we can't affect it, but like your maximum bone strength and muscle abilities are somewhere in our 20s to 30s, you know. And that was the time when I was not getting enough sleep, running around the hospital, trying to raise a toddler in medical school. You know, like God only knows what I decimated in order to, you know, meet my goals for education. But then as I've taken care of my grandmother and my mother, you know, and watching how my aunts who most of my aunts had cancer and died before the frailty and before the dementia.

14:52Dr. Mary Claire Haver:But if they run the cancer gauntlet, right, this is on both sides of my family. My mother and my grandmother didn't get cancer, but and they don't have heart disease. They didn't have heart disease. They had horrible frailty, like loss of independence requiring long term care because they could not take care of themselves. this was not what they wanted. They did not want to go down this way. And my grandmother and my mother, my mother right now is in a memory care unit, completely frail, has fractured multiple bones and lives in constant pain and can't remember my children's names. And so when I think about that and how I do not want that, and I don't want to scare your younger listeners, but like, they're probably going through some of this with their grandparents or whatever.

15:36Dr. Mary Claire Haver:I'm like, this doesn't have to be your biologic reality. And so what works? What do we know works? Muscle is everything. I never understood this. Muscle controls your blood glucose. Muscle is what protects you against aging. You know, muscle, muscle, muscle, and muscle weighs a lot. So all those years I spent chasing the scale, chasing being thin, and I had thin privilege, and I would feel this joy when I got on the scale and I was down two pounds and my scrubs were loose And, you know, and I'm like, you're an idiot. That was not helping you. Like, what really matters? And so something kind of magical happened across the menopause transition where I stopped caring about being thin and realizing that being strong was absolutely what I had to focus on in order to avoid the fate that my mother and my grandmother went through.

16:31And so we can, when we are thinking about taking time for yourself, it's one of the most crucial protective factors is caring about bone, like muscles and bones. Bone and muscle, because they go together.

16:46Dr. Mary Claire Haver:The musculoskeletal unit works together. So strong muscles mean strong bones. When you pull on that tendon at the end of the bone, you are stimulating the bone to get stronger. So in a nutshell, that's how it works. also vibration and jumping. And there's fluid inside of the osteocytes that when you shake them up, that'll stimulate it too. So you'll see vibratory plates. I'm like, I'd rather you jump if you can. If you can't jump, a vibration plate is probably your next best thing. So, you know, lots of what we do, adequate protein, adequate vitamin D. I mean, it's very, very basic, you know, but not focusing so much on cardio.

17:20Dr. Mary Claire Haver:Cardio is important. And I love Pilates for many things, but it is probably not your best bet. Like if you want to be the most efficient at protecting your bone and muscle strength, you are going to need to lift heavy weights. My children have told me I'm an almond. I was an almond mom for most of their lives. Like I would like put the noodles on the side for the spaghetti and like eat the sauce, you know. Oh my God. I did all the things to try to stay thin. It worked, but I was really probably sacrificing. Now, my bone density has improved. I'm not on medication for that. I am on hormone therapy, which is FDA approved for the prevention of osteoporosis.

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20:05Dr. Mary Claire Haver:Meritbeauty.com. Okay. So I want to spend a little bit of time on hormone replacement therapy and the specific hormones, because I think there's just still misinformation out there. Okay. So when we're talking about bone density and prevention of Alzheimer's and all of the symptoms that start to creep up, when does hormone replacement therapy even become a conversation? Sure. when is it helpful? When is it overkill? Go. So bone density specifically. I have better evidence for bone density than for dementia. So let me be clear. And brain fog is very different than dementia, right? And we'll talk about the difference.

20:49Yes.

20:50Dr. Mary Claire Haver:So for bone density, the most rapid rate of bone loss is in perimenopause. Okay. We don't have a, no one studied perimenopause yet, by the way. We don't have a large scale study on the treatment of perimenopause in the history of the world. And so, yeah, so a lot of it is anecdotal. The menopause doc's getting together. What does the menopause society say? And we know that in perimenopause, we know for mental health, hormone therapy is more effective than SSRIs. For a new diagnosis of anxiety or depression and you're perimenopausal, you should try hormone therapy first, not to say you won't need an SSRI.

21:26Dr. Mary Claire Haver:There's no reason to get off your SSRI if you're on it and you're doing well. I'm not saying that. But, you know, we are starting those patients on menopause hormone therapy, not birth control pills. Very, very different. If you need contraception, if you are having heavy bleeding that is disrupting your life, birth control pills can be really helpful short term for that type of thing. But if, you know, your husband had a vasectomy, your cycles are still, you know, not bothering you, you know, and you're having sleep disruption, you're having hot flashes, you're having mental health changes, we're starting, we're doing menopause hormone therapy, which is estrogen plus or minus progesterone.

22:02Dr. Mary Claire Haver:Progesterone turns out is great for sleep. So for bone health, we know for a postmenopausal woman, it's protective of your bones for as long as you take it forever. Okay. Forever. And the earlier you start, the better. We don't have a study saying, okay, if you start in perimenopause, but it makes sense. So I just tell patients like most likely we're protecting your bones. And I'm encouraging patients to get a bone density as soon as you realize you're perimenopausal. You need to know what your baseline is. Insurance probably won't cover it that young. Out of pocket, most places you can get it for around$100.

22:34Dr. Mary Claire Haver:And I feel like it's worth the investment so that you know. I've never seen a woman more motivated when she sees if she's got osteopenia or osteoporosis. All of a sudden, her habits kick in. She's like, holy shit. I didn't see this coming. And you can still get out of osteopenia, but not osteoporosis? Oh, yeah. Oh, I get patients out all the time or improve their bone density. I mean, when you lock and load and do the habits, I mean, the studies are clear. The Lift More trial looked at osteopenia, osteoporosis. These women in their 60s and 70s, and they did weight training, you know, squats. They would jump up to a pull-up and let go and bounce.