What No One Ever Told Us About Menopause

27:51They're like, is that a thing? And I said, I don't know. I'm just going to try it and see what happens. And I'd always been employed. I've worked for a hospital system. I work for universities. And you just show up with your stethoscope. And they're like, here's your room. Go to work. Here's your computer. and so I had to like get the idiot's guide opening a medical practice, but it's been incredibly successful. And now I have a staff of, you know, seven clinicians, six clinicians and we're just, are you training them? Yeah. So you've developed like a rubric for how to, yeah. For our clinicians.

28:22Yeah. That's amazing.

28:29just going back to touch on sleep for a second is all sleep sort of not created equal like if you take melatonin or if you take great question i'm learning alongside you here and so i'm really leaning on like andrea matsumura who's like sleep goddess md she and i have known each other for years. And so she like got a fellowship in sleep medicine and it's so much more than just reading sleep apnea studies. You know, she's really focusing on teaching women how to sleep. And so when you take sedatives, they're fine for the short term. You've traveled in a different time zone. You know, you need a couple of days just to help readjust your schedule, but long-term they're not good, you know, to, to depend on a medication to make yourself fall asleep because you're not getting the same quality sleep when you take a sedative.

29:19Melatonin looks like long-term use of melatonin is associated with increased dementia. And so we wonder, is it the melatonin, which is something that's naturally produced in the body, or is it that sleep disruption leads to more dementia? I've read that quite a lot, actually, that sleep is the number one most important thing. Yeah, to restore your brain, to let your muscles grow, to protect your body. It's interesting. I've noticed I, when I, if I fly overnight, it's the only time I take something to sleep. That's I try to only do it then. And it's always the worst. Like my sleep scores on my aura ring are always the worst.

29:55If I take anything to sleep, I think it's really fascinating. It thinks I'm dead. It's like 56. I wear one as well. And same, we have a place in Colorado. And so when I go from sea level up to, you know, 10 ,000 feet and tell you, right, it thinks I'm dead for two days until I acclimate. So, but yeah, I, I love, you know, this tool because it has taught me so much about sleep hygiene and quality sleep and things that I do that affect my sleep. Yeah. I noticed personally, like if I, I'm so impacted if I don't, if I don't sleep now, I mean, whereas, you know, when you're younger, you can kind of bounce back really quickly from it.

30:38But one of my most viral memes, you know, funny videos I try to do was sleeping in a hotel in your twenties versus in your fifties. I used to just like fall in the bed with my clothes on from whatever adventure we'd been on versus like having my special sleep pajamas and like putting out all my, you know, my L-theanine and my progesterone and my, you know, extra estradiol in case I get up and my, you know, like all the things in the shaman and the sage, everything to spray. I put on my pillow, my mouth guard. I've seen that. That's so funny. I'm exactly this, but it's okay. So in other words, like L-theanine or.

31:14Yeah. The studies on L-theanine don't show any harm. The studies on magnesium so far, you know, and we have multiple types of magnesium do not show any harm. That's great. That's good to know. So in terms of nutrition, so it's, I think it's for a lot of people, very difficult to go, you know, to see a nutritionist or to understand where they're deficient. And I'm, I'm very heartened too. Cause there are a lot of like consumer kits that people are getting now too, but I, there's probably some pitfalls there too, for people at home, you know, who are get ordering their own labs. Gosh, you can go to quest now and order your own blood work.

31:51How do you feel about that? So I, I think about that a lot because I'm, that's one of the, like the business things in my mind that I consider. Would I, cause I'm doing the function health one as an experiment right now. And I went all in, I did the gallery. It's the Mark Hyman one. And I was like, let me do this as a consumer and see how this is. And would this be something I could develop? Of course, his is very high tech, but, you know, could I offer this to patients? Not really my patients, but like women who follow me who want to know, you know, in, in a very specific way. And those are the questions I I asked myself, like, what if they're abnormal?

32:26Who is their doctor? Right. Right. And so where do you go? It's one thing to have the lab test drawn and the Mark Hyman program, if he's not paying me to say this, actually gives you a beautiful output, like explains in such great detail why this test was done, what it means. And, you know, I've had no surprises on my blood work, thank God. But I like I did the gallery cancer test and, you know, I'm waiting on those results. So I lost I've lost two brothers to cancer. So I'm very interested, you know, in what that would mean. I think there's value, but I also worry, what if she has abnormals? Where does she go?

32:59I think giving her data without giving her solutions, you know, or at least not being there to guide her through this abnormal finding, I'm worried, how do you navigate that? What does that look like? Especially because, you know, from what I understand, certain results can mean, you know, it can look like, Oh, you know, your, your vitamin B is low, but it might be that, you know, you have methylation issues or like things that need to be addressed before just like taking a supplement for it. Right. Like it's more complex than just there's an abnormal result. Right. And, you know, for example, my testosterone level looked a certain way, but then my binding globulin was another way.

33:41And like, that's a very nuanced conversation. So I think that there is benefit and especially if everything's normal and you just pack, yourself on the back and feel great. But where I'm worried is like, you know, and what would probably hold me from offering something like this without the doctor patient relationship is what if she has something abnormal and it leads to her making a decision that's not in her best interest, or there's no one to guide her through what to do. If there was an AI model that was able to maybe, but again, that's above my pay grade. I'm still seeing patients face to face.

34:13I spend an hour with my girls who come in. Do you really? Yeah. That's so nice. Yeah. You have to unpack a lot of menopause trauma. So I spend that time with the patient. Tell me more about that. What is the trauma when, when somebody comes in? There's a woman, I just read a statistic and I'm not shocked, but it is shocking as a doctor to see it is she goes to the doctor eight times before anybody realizes her constellation of symptoms could be menopause. That's eight doctor visits, eight copays, eight times off of work, eight times having to get a babysitter where you are dismissed, blown off or given some misdiagnosis.

34:48And that's a problem. And so my clinic is outside of insurance model because now I can take an hour. And so women are really motivated when they come to me and because they're paying out of pocket to see me. And so I want to give them that time to really kind of go through all of her issues because we're not just addressing her menopause symptoms. We are addressing her quality of life and trying to create a path forward so that she can feel like I do, you know, I'm so inspired by how you feel. Let's talk about your, the line where you said you're having the best sex of your life. I am. Okay. So there's a couple of things.

35:27Kids are out of the house. That's a huge one. So like just being naked is easier, you know, I love my husband. He, we've been together forever. So 30 plus 32, I lose track. We got together in 93. So whatever the math works out and he retired from his Chevron job. He was an oil executive in oil and gas. And I barely saw him. He was commuting all the time. He was traveling all over the world and whatever, you know, we great father, good, you know, good best friend, all that. But, you know, we were losing that connection, you know, just our lives were so busy. And my like menopause world was taking off and it was so foreign to him.

36:02And so he stepped in, he has an MBA and as things were kind of getting crazy with our supplement line, which was growing exponentially, I was struggling with contracts and having to deal with suppliers and, you know, and we grew it from the ground up. I have no VC, no funding, Mary Claire, you know, So he starts jumping in and he goes and meets with suppliers and he kind of gets involved in the business and he realizes, wow. And then he is retirement. Like he was able to retire. He had that magic number with the corporation where he could get full benefits of retirement. And I said, listen, I will have to pay someone your Chevron salary to do all the things you're doing now.

36:44Or you can just come work for me and not get paid. I'll pay you in blowjobs. He retired. So, so that put us in the house all the time together. And it's so awesome watching him kind of fly in this area and watching him do. And I have such an appreciation for him differently than just being really the world's greatest father, which he is, but, you know, and provider and all those things, but like we're partners in this and it's just really grown. So So on top of that, I started testosterone for muscle mass. So I'm lean like you are. And when I go and we have a scanner in my office, that's another thing where I can measure visceral fat, muscle mass and all that.

37:26So I can counsel my patients about protein and nutrition and all those things. So I was like, my muscle mass is low. It's always been low. I've always been a skinny girl. Okay. I want more muscle mass so I don't break my hip like my mom just did, you know, at 80. So I want to decrease that risk. There's no guarantees. and I was like, let me try testosterone. This would be off label for me, but I know that women with higher percentiles of testosterone have better muscle mass and bone strength and bone density. And so I said, let me just do it for that. I never complained of my libido. Like no one complained.

37:57We were fine. We were fine. Definitely. There's an uptick in the area. That's so great. And it's not chandelier ask. It's not, you know, but it's more than vacation sex. And so it is like, I'm a little more interested and maybe even initiate once in a blue moon, which had not happened in a very long time. So, you know, that's my end of one. That's just one person's experience, but my patients overall are pretty happy with it. Now, you know, it's proven for hypoactive sexual desire disorder, but who gets to define that? You know, if it's, if it's concerning to you, if it's, you know, hypoactive HSDD is if it causes her distress.

38:31Okay. It didn't, was not causing me distress, but I think if it got taken away, I would miss it. Well, it's an interesting thing to think about because I think, you know, our sexuality is such an important part of who we are and to worry that you're maybe, you know, losing that aspect of yourself or that it's harder to connect to that part of yourself. It feels quite demoralizing. You know, it feels like it's in concert with all these other life changes. And so it doesn't sort of why I asked you before, is it like circumstantial that we start to feel more depressed or is it chemical? Because I think it's all of it.

39:10Right. You know, it's a little bit of everything because we're complicated beings. Yes. Very. Ask our people around us. I have a question from a friend of mine who is having like very low feeling, low sexual feeling. Like sensation? Yes. Like don't touch. Okay. Yeah. During, and you know, she's going through perimenopause a little bit younger than I am, but never had that issue before. It's like delayed orgasm kind of thing. Just like not, she says it's like kind of a numb, like she doesn't feel that much. So a couple of things. As you know, the genital urinary area is highly, changes greatly.

39:56One of the parts of our bodies that change the most and the fastest. How so? When the estrogen, progesterone, testosterone. Well, testosterone declines our whole lives from 25, 30 down. So there's not like a cliff like happens with estrogen and progesterone. So testosterone kind of in the background is declining. Okay. And then estrogen and progesterone like fluctuate wildly like a roller coaster on their way down and out completely. blood flow is everything. You know, that's why Viagra works in a man. He doesn't have a desire issue. He has an arousal issue. And so women can have decreased arousal that, which is what sounds like, like the brain is there, but it's nothing's getting to where it's supposed to be.

40:35And they're not feeling so that's a blood flow. It can be blood flow. It can be nerve conduction disorder. So we have to, you know, we look for diabetes and, and different, you know, ways, but things that we know might help are things that would increase blood flow to the area. So topical estrogen, there's a medication called intra Rosa, which is a very specific, it's DHEA suppositories that you put in the vagina. And so they're like our breast cancer patients who are terrified of estrogen. The vaginal estrogen is safe for everyone, including a breast cancer patient. It just, you know, with all the hoopla and they're so scared, DHEA works beautifully for them.

41:09that DHEA gets converted to estrogen and testosterone on the vagina. So for patients in that situation, I'm able to get her estrogen and testosterone to the vaginal vault. It kind of makes its way out and gets onto the vulva and we're seeing improvements in, you know, that would be something I would try and some systemic testosterone as well. Interesting. So just another question on the sexual farm and then we can move off of it, but what is happening for you specifically that's making... I think I've... I... Part of my like menopause makeover is I'm taking care of me first for the first time in a very long time.

41:47And putting myself first has made me a better mother, a better partner, a better business person, a better, you know, putting my own... I'm giving myself permission because if I didn't do that, I would not be here. And how are you putting yourself first specifically? You know, well, it all coincided with empty nesting. So, you know, I'm not missing the gem. I'm saying what I'm thinking instead of, oh, I don't want to upset anyone. Or, you know, I'm putting up important boundaries, even with some family members. I love you, but I'm here. And this is a line I will never cross again, or I'll try not to.

42:21And really focusing on how do I want to live the next 30 years? What kind of relationship do I want to have with my husband and children? You know, and not taking that for granted. it. So really giving myself permission to do that work and get the therapy and write in the journals and do those things. And then there's like, would you describe it as like more of an overall integration with yourself? And I think so. You know, I always thought therapy was woo woo. And for the week, I kind of grew up in that generation and we were rewarded for working hard and falling in bed exhausted and, and all of our workouts were just to sweat a lot.

42:57And, and now it's, it's so different that I have to take care of me and be my caretaker. And that's just going to make me able to fill up my cup more so that I can give where it's important. What about like, if we have elevated, you know, toxic loads that we're carrying, obviously we live in a super toxic environment. There's plastic in all the things, even in our leggings and there's, you know, glyphosate all over and forever chemicals in our cells and everything. So do our toxic burdens impact menopause? That's a great question and no one's looked at it. Really? Yeah. So, you know, how would a tox-free life, whatever that looks like, impact the juncture of the menopause experience, the menopause symptomatology is this, you know, all of these exposures that we now have that endocrine disruptors, which are absolutely real, you know, where is that all playing into this?

43:56And, you know, a lot of people who don't like me will say, oh, women went through menopause, you know, for centuries and they never complained. Well, women were socialized not to complain. And if they did complain, they got thrown into mental institutions or left on the side of the road. So there's that, you know, women couldn't leave a marriage that they weren't happy with because there was no economic way for them to survive or their children. So we've, we've changed a lot of that, but we don't know. We don't know until we start studying these things. Yeah. I do wonder that, you know, I think it would be better, you know, as any better health choice will make most things better in your body.

44:33Yeah. Because if we know that there are certain compounds we store that have, you know, cause inflammation, I'm sure there's, I mean, I'm not sure because I'm not a doctor, but I would imagine. We are not taught a lot about that in medical school. You know, there's, there's toxicology as far as like poisons, but things that are, have been worked into our everyday environment and have, you know, considered to be safe ish, you know, that's really not part of the standard medical curriculum right now. Do you think that that's important going forward? I do, but I also think I do, but I think now that we have ways to rapidly get education out to the public through social media, medical information was gatekept for a long time into medical journals that a lot of people had no exposure to.

45:20Like even today, some of the best articles out there that I've learned so much from are behind paywalls and that the average person just can't get their hands on and probably would struggle to understand a lot of the scientific data. So that's what I like to do on social is break that stuff down for them. But I'm like, there's a lot of really smart people out there who could probably understand this to some level. And we are like totally putting this behind a wall that they're not going to get access to. And, you know, all these guidelines and decisions and things that have been made, we're in these very ivory towers.

45:50And now that we've democratized having access to information, when love or hate the new administration, like things are changing very, very rapidly on how we're funding research. So like Lisa Moscone, one of my favorite neural researchers in the world, she wrote the menopause brain plug to Lisa, just she's with Will Cornell, and she has stepped away from traditional funding through NIH, which is, it takes years to get, you're constantly under the gun to publish, publish, publish. Now she's working for a private, she's funded by a private institution. She's only focused on outcomes. She does not have to generate a single paper though.

46:26I know her, she will. And because she wants to share her findings, but she's on a fast track to discover the app, you know, what exactly do we know about menopause and hormone therapy and maybe a CIRM, which is a specific estrogen receptor modulator and decreasing the risk of Alzheimer's. Like her, she has a three-year job to only solve that. Wow. It's really amazing. And stepping away from traditional funding is allowing her to do that with a lot of ease. But presumably, you know, if it's happening, if it's being funded in the private sector, it's because there's a financial upside. Maybe, but someone has to pay.

47:00Yeah, absolutely. And who's going to do it? She can't work for free. So she's just excited to not have some of the things that become burdensome in the old system. I think it's great to be able to move a lot faster. Yeah. I think you make a really interesting point too around the democratization and access to information. And I think we've been patronized for such a long time. I agree. And, And, you know, now we are able to have visibility into some of this data. And I think that also inherently moves things. And I think for things like forever chemicals and toxins, you know, you have to realize that your health care provider most likely received little to no training on this.

47:38And so you're going to have to step outside of the box. And what I meant, you know, is and educate yourself and make those choices because you're the one buying these things. And so like in our home, you know, we're getting rid of the plastic and we're only using glass for food storage. You know, we're trying to, you know, make those changes in a responsible way, you know, for our own household. Yeah. Yeah. Yeah. Especially for somebody like me that genetically I don't detox well and I need to be slightly more careful without being, you know, overly paranoid. It is a mate. It's a balance. Yeah.

48:09And for so long, you know, I would drink water out of a plastic bottle. Same. You know, 100 degrees in the car for three hours while I, you know, like left in an appointment. or whatever, and definitely imbibing lots of microplastics along the way.

48:32So what about, you know, I also have some friends who don't want to take hormones. Some, some can't because they've had breast cancer, but some are like very into the wellness world and they just don't want to mess with it. What I tell the, and I have patients, same, you know, I am not here to convince anyone to take hormone therapy. I just want those decisions to be made on facts and not fear. So I might be just give walking them through the studies, what was walked back, what we absolutely know. But if you want to, and I joke, raw dog menopause and just go hormone free, fine. You can be healthy without, without hormone replacement.

49:16It is possible, but it's just a lot harder for, you know, depending on where your box is being checked, you know, you may never sleep the same. Okay. Then we have to figure out alternatives. And so you being on a nightly sedative is not going to be healthy, you know? And so we, we look at where they're struggling, where they're suffering. We try to find alternatives, you know, through lifestyle, through stress reduction, through pharmacology, through supplements, whatever it's going to take to have them function as healthy as possible. So it's absolutely possible. Right. So one of my very close friends who had breast cancer, she's on tamoxifen.

49:50Tamoxifen. Right. So she's been told that she can't take any hormones and she's really suffering through crazy hot flashes. I really, these poor patients, our breasties, we call them in our world are really getting left in the dust because these medications, which are needed to reduce their recurrence risk, absolutely needed, but no one's managing the fallout from that. No one's talking to them. Tamoxifen, you know, has a better safety profile as far as what's happening to your brain, what's happening to your heart, what's happening to, you know, your bones than the aromatase inhibitors. But again, you know, it's a balance between risk of recurrence versus quality of life.

50:29And then what's your path to cardiovascular disease. So, you know, if I have a patient who's, and I have several who are breast cancer survivors and they're coming in for, you know, hot flashes, We now have Vioza and we have clonidine patches, which work pretty well. Some of the SSRIs actually can work and to blunt the hot flash. Neurontin, which is a really medication that's been around forever. Neurontin is used in restless legs and can help with hot flash. So we do have options and she deserves that conversation. Just sadly, we have to kind of piecemeal her treatment depending on, you can go symptom by symptom when hormone therapy would kind of, you know, she has an absolute contraindication.

51:07She doesn't have to suffer. Right. And what about like black cohosh and red clover? Is there any veracity? Maybe. So red clover, black cohosh, I mean, any supplement like that, that weekly, but the way they work is they weekly bind their phytoestrogens and soy. Okay. Their phytoestrogens, meaning they look a lot like estrogen under the microscope, very, very similar. So they'll weekly bind to some of the receptors, which will lessen the symptoms. Interesting. The other thing with those patients is get an early bone density, you know, don't leave your bones to chance. And there's great research on, of course, you always see me on social with a weighted vest on.

51:46So the weighted vest, vibratory plates, box jumps, you know, all these things that we can do with nutrition, supplementation to help with bone strength. This is what I, there are two areas, this is great. We're getting into these areas that I want to touch on because, so you wear your weight vest. what is the calculus around how much weight for how much you weigh the whole weighted vest thing came about because i was like having patients who were osteopenic right which i am breast cancer patients and absolutely no no no no no for hormone therapy i'm like what can we do so i'm like literally going down pubmed pulling everything on what what has worked and i ran across two or three articles and they you know smaller studies but they're done in nursing homes so they call them in facilities and they were doing weight training, weighted vest, vibratory plates, like all these different things.

52:37And the collagen that, you know, that full disclosure, I do sell this particular collagen because I was so excited when I read the study, called my husband, I'm like, get this on her, you know? So for the weighted vest, this, the benefits began at 10 % of body weight. But when you think about who is in a nursing home, there's not a lot of obese people there. So, you know, it's putting that extra and because it's a vest, it's putting it right on the axial spine in the hips, which are the two biggest areas we target because the spinal compression fractures cause so much disability and, you know, and pain for women and then the hip fractures kill them.

53:13And so, you know, we want to, you know, particularly do the hand weights work. I'm like, you know, we have no studies showing that these will improve your bone density. They probably do a little bit, but you know, we really want to focus on the, and the distribution of weight in these vests. Front and back. So people like, Oh, I have a backpack. I'll put some weights in her. I got to go rock and all the boys. Sure. Rocking would be fine. And I've actually met the man who owns go rock and he's lovely, but I just, I go to the menopause studies and that's what I look at. And so they wore vests and the weight was equally distributed, roughly front to back.

53:45And these sweet little old ladies, they put them in the gym and they had better balance and they had improved bone density. What, just out of curiosity, what brand of like, Like, where do you find these? So I heard Aldi sell some. I found mine on Amazon and I'm actually in development talking to a company about, because the one I wear is fine, but it doesn't accommodate breasts. It was made for men. And so people are complaining of being smushed in the chest area. So we're working on a design that will like more fit the female form so that, you know, women with larger breasts will feel comfortable wearing it.

54:20And how often do you wear it? So the studies were done three times a week. So I tell my patients, listen, throw it on when you're going to walk the dog, when you go on your walks, just, this is just one extra thing. We have a very long seawall in Galveston and that's like the walking path for the whole town. And so now it's, we'll be walking down, you know, my girlfriends and I with our vest on, we'll see somebody else. We're like, Hey, you know, it's like a thing now. And I see him in Telluride too. You know, I'm like, you know, I'm starting a trend, but also when you're doing yoga or even balance training, you know, you want to have it tight because when you go upside down and do your inversions, you don't want it sliding all over the place, but the women saw better balance.

54:58So I'm like, stand on one foot, like do some good mornings so that you can really improve balance with that weighted vest on so that you decrease your risk of fall. Okay. And then do you also supplement with heavy weight training? I have now. So I didn't lift weights. I kind of like went all cardio running marathons with my friends, you know, and then started doing beach body, you know, picked up a few weights, lightweights doing beach body and was going to Zumba with my girlfriends, you know, really socializing and having fun. But once I got serious about hanging on to my bone density and building muscle, I need to work heavy.

55:32And so I was doing some of the more aggressive programs on beach body again, and I was getting hurt. I was pulling things, my back would go out and I'm like, I'm not doing this right. So then I invested in a trainer, a woman I met in New York who has, she works in the Hamptons and has a place in New York and she makes a program for me and we'll kind of video each other and she's watching my form and, you know, to make sure I'm doing it right. So I've been working with her about a year and it's really been amazing. Have you done presumably on your scanner before and after? Yes. Yeah. So I've gained about four pounds of muscle, which on my frame is like amazing.

56:05That's great. So yeah, but it takes, it's a lot. It's like a full-time job, you know, with the eating enough protein and I know the protein. And that's a whole different mindset. I'm now eating to be stronger and not be thinner. Yeah. Yeah. That's what I'm trying to do too, is really make that switch. And, you know, I think in our generation, we really were totally raised. And, you know, as a doctor, I was like, Oh, I'm good. I'm thin, I'm healthy. And I was chipping away at my bones and muscles all those years. Right, right, right. Yeah. Yeah. I mean, I'm making a real concerted effort to do it.

56:39And, you know, I follow you and all the, all the doctors and have my doctors. I'm really, I'm really trying, but sometimes I'm like gagging down, you know, I can't, I'm like, it's tough. It's, it's hard. It really, it, and I know that, you know, it's necessary, but so on the subject of, you know, there are, and this is well documented, but the shapes of our bodies start to change in menopause right we're starting to sort of thicken out in the middle what the fuck yes mary claire yes so welcome to the body composition changes associated with menopause so when i first looked into this it just fucking pisses me off excuse my language you can bleep that out but like all the studies were like women just get lazier as they get older they just tend to gain weight there's nothing you can do but so So when you look at, so then I found this, I just reposted it the other day.

57:35I read a study that was written in 2019, but I didn't read it until like a year and a half ago. And it was looking at body composition changes. Now that we have tools like the in-body scanner, the DEXA scans that can measure muscle mass and measure visceral fat. And they looked at weight. So weight across the menopause transition, they looked at 1 ,200 patients is a steady state gain, okay, across. mass however muscle mass rapid descent decline in perimenopause and then it stabilizes in the first few years after menopause with a decline as we age so we have this like falling off the cliff the opposite for body fat they didn't look at visceral they just looked at total body fat and they see rapid expansion of fat accumulation which i don't have to tell you every woman who this happens to which is 98 of us knows it all of a sudden you're putting on fat in new places right?

58:25But what's with the new places part? Like, you know, it's so funny. When it falter, I was asking me this, like if I, everyone looks at you and like, she's perfect, but you're human, you know, definitely far from it and very human. But what, if I used to gain weight, it used to be sort of an equal distribution. And now it's like, yeah, from breast to hip bone. And okay, so what's happening there is as our estrogen levels decline, the liver takes a huge hit and we see cholesterol going up. So FSH goes up, estradiol goes up. They both have direct effects to the liver. So in the liver, we see the LDL cholesterol going up.

59:07So I'm sure your listeners are like, oh my God, I did nothing different. And all of a sudden my cholesterol numbers shot up. And then same here as well. And then your HDL kind of stabilizes and drops off a little bit. So your overall cholesterol goes up. LDL goes up in the bad LDL marker. LDL, apolipoprotein B goes up as well. So with not a single change in your diet and exercise. You're singing my song, girl. Okay. The other thing is that your insulin resistance goes up. So my, you know, we have the HOMA-IR score, which anyone can do. It's a, it's a ratio of fasting insulin to fasting glucose.

59:44and if it's below two and you can go on an online calculator you know someone can pull up their labs on quest or whatever and you can do this because it's not going to give you that result if it's less than two you're probably doing fine with insulin resistance but we become insulin resistant and then we become pre-diabetic and then we become diabetic so the diabetes measurement is typically done with the a1c yeah hemoglobin a1c so we see that trending up across the menopause transition as well. So when that insulin resistance marker goes up, we also see your high sensitivity, see reactive protein begins to increase, your homocysteine goes up and your sub rate goes up.

1:00:19And so we see these inflammatory markers going up. Estrogen is so freaking protective of our bodies. And when we lose it and when it starts going cattywampus and we lose it, like everything goes crazy. When those inflammatory markers go up, you start driving fat to the visceral cavity, to the intra-abdominal organs. So all of a sudden you get a belly where you never had one before. That's what it is. It's downstream impact of inflammation. Yeah. Directly related to estrogen loss. What do we know attenuates that? Okay. So this is like my, my, the belly fat challenge I've done and all the things.

1:00:56So I looked, I looked in all the studies. What do we know that menopausal visceral fat gain, which is belly fat in your, in your world, what works HRT will attenuate it. Okay. Nothing's better than your 25 year old ovaries. And sadly, you know, none of us took them out and preserve them and put them back in at 50. So, okay. Maybe for our kids, you know, that'll be a thing or some artificial ovary, but you know, for now we just have HRT. It's not perfect. You know, it's a lot of trial and error, not the same formulation does the same thing. You know, oral is very different than transdermal and each has its benefits and risks, but any form of menopause hormone therapy containing estrogen will attenuate the visceral fat gain.

1:01:33High fiber diets, which is why I talk about fiber all the time. So for cardiovascular, we're looking at 35 grams or more per day. Most women get 10, 10. And so women who get 25 or more have much less visceral fat accumulation. Also their insulin resistance goes down at, you know, So fiber, keeping that gut microbiome happy, decent studies looking at probiotic supplementation, either eating something rich in probiotics every day. But if you can't do that, say you're most U.S. it's dairy, you know, they're getting it from yogurt. But if you can't do that because of an intolerance, a supplement by might be the right thing for you to decrease that risk movement, you know, zone two cardio seems to be really beneficial for visceral fat accumulation.

1:02:17So I'd go through and then stress reduction, adequate sleep, all the things, all the things.

1:02:28is it possible to sort of get your old shape back or do should we just like relax and not care and accept our new when i do the body scans on patients you know we look at total body fat and then we look at visceral fat and i'm just focusing on the visceral fat number i don't care what the scale says those are curves the subcutaneous fat i don't care right i don't care, but getting them to undo that lifetime of shame and lifetime of drive to get to the least amount of subcutaneous fat ever, except now my kids' generation is more about, they like their curves. So I'm super happy we can celebrate that with them, but not me.

1:03:06I mean, that was not at all how I grew up. Me too. Yeah. I really do like that the, I mean, look, we're still objectifying ourselves and other women, so that's not great. But I, I do like that it's trending in a more self-accepting way. Right. And it's healthy. Yeah. So I don't, I try it. And I can't tell you the tears of some women, like, especially my athletes who've been told they were obese, you know, the Alona Meyer type people who is just a freaking machine of health and has more slabs of muscle on her. And absolutely, she was going to live forever, you know? And so versus some little frail, you know, was dieted her whole life and is now in a nursing home incontinent with broken hip and, you know, dementia.

1:03:54So is there a correlation between muscle mass and longevity? Yes. A hundred percent, especially for women muscles. So when we look at geroprotection, that's a word. Okay. Geroprotection means protecting yourself in your geriatric years, which is 65 or older. And that is just around the corner for me. The ovary, which goes away is protective. The most protective are the muscle and the ovary. And so we can artificial back our ovary with hormone therapy, but you have to fight. So if you do nothing and don't lift weights and don't stimulate that muscle, you will lose seven to 10 % per decade until about 70.

1:04:32And then it goes up to 25 % of your muscle mass per year. And why is it that people who are on GLP ones, which seem kind of miraculous for certain people. Yeah. So there is concern there and I think it's legitimate, but I think it's poor counseling and it's not the medication. Okay. So it, it itself does not. If any of us took enough GLP one, we wouldn't eat at all. Okay. And when we starve, you know, when you severely calorically restrict about 50 % of the weight you lose is muscle and 50 % is fat muscle determines our basal metabolic protein. You're not eating enough and you're not eating enough protein.

1:05:09Sorry, your total caloric restriction is down. So you're going to chew up any and everything to, you know, and your muscle is like muscle and bone are constantly remodeling. And a lot of women don't realize that the bones you have today are not the bones you had 10 years ago, because we're constantly chewing up bone and laying down new bone. Same with muscle and with aging. So there's an aging factor, which we can't undo. And then there's a menopause factor. Those accelerate across the menopause transition. Okay. So it's not that it inherently makes us lose muscle at a more rapid rate. It's just that overall we're eating less protein, less calories.

1:05:44Right. There's, we don't see yet. I mean, again, more studies, but I, there's no, as far as I can have seen in the data, no direct effect to the muscles. It's more of, you are not giving your muscles enough to maintain and you're losing and you're so happy with the scale, which is completely understandable. So when our patients come in and we determine they're a good candidate for GLP-1, you know, pre-diabetic or whatever their issue is. We had another hour of counseling about how important, and we have the body scanner doing their body scans to track their muscle mass throughout the process, adjusting the dose so that they can, you know, because we do live in an obesogenic society and I would love to go back to 50 years ago when so few people had pre-diabetes and were obese, you know, even the way we define it now, which is not with the BMI, but we can't ignore the fact in this country, we have a chronic health problem, you know, and now the debate is how do we solve it?

1:06:41Right. You know, and so I'm just one doctor, I have one clinic with, you know, a bunch of practitioners and we are all united in this. It's a tool. It can be a really helpful tool, but in the wrong hands or without the proper counseling, we may do more harm than good because of other side effects. Well, side effects are one. if she can't tolerate it, she can't tolerate it. Now with their new like terzepatide is way better on the GI system than semaglutide, at least with our patients. So we're actually starting with terzepatide because we just don't have to deal with as much nausea and diarrhea.

1:07:15And does it have the same anti-inflammatory effects? Yes. So far. What is it about these drugs that lower inflammation? So they're looking into that. First people said, well, they're just the diet. I've never seen my patients so motivated to really eat clean and stick to, you know, by removing the food noise and that constant, you know, I've never had it, but I've had enough patients talk to me about it to understand. And the food noise, you know, what we're seeing across the spectrum is not only is it food noise, it's gambling noise, it's alcohol noise, it's all those drives. So there are receptors in the brain that are, when you take that stress away, I think it's anti-inflammatory because it removes, it lowers your cortisol levels because you're constantly battling that internal demon of I need to shop, I need to drink, I need to gamble, I need to eat, you know.

1:08:05Wow. Is it because it's addressing some sort of like pleasure feedback loop? So one of the side effects that we saw when we started using semaglutide in the clinic was anhedonia, which is loss of pleasure. And they weren't depressed, but they just kind of couldn't, their get up and go was gone. They didn't want to go out to eat. They didn't want to go to a movie. They didn't want to have sex, you know, and I have that. So I'm fat, but it seems that we're having a much better time with Ters Appetite for that fascinating article in the New York Times just came out that talked about how marriages are changing when one partner gets on.

1:08:45And I was like, okay, cause you know, I'm on one half of that side. Cause I treat only women. And And I'm like, I think she has some important points here. The way you feel about your body changes because the way you look and the way the world's reacting to you changes. The things you socialized around, eating and drinking and whatever, change. And if both partners aren't doing it together, you know, in the story they gave the example, the partner was normal weight. He didn't, it wouldn't benefit him at all. But like the whole way that they connected and socialized really changed and it was really affecting their marriage.

1:09:15So that is now something I incorporate into our counseling as, you know, think about these things as you move forward, how you socialize with your husband. You're going to maybe have to find some new creative ways to connect. So interesting. I mean, I can't remember a class of drugs that's had this kind of medical, social, sociological, emotional. So many. It's wild. Yeah. It's wild. I would love to talk just one last question about your forthcoming book about perimenopause. First of all, thank you for taking the time to research and do some investigation here because as we were talking about earlier, it's a black hole.

1:09:53It's a black hole. There was not one single large scale research study on the treatment of perimenopause. It is literally the menopause think tank. What are you doing? What are you doing? What's working? How are you helping? I mean, okay, I have a patient and we have these little office hours, not office hours, but like we're just throwing out complicated patients or how would you manage this? it's really a beautiful thing, but we are crowdsourcing with our little group of perimenopause care and figuring it out. So what data set are you using to write the book? Good, good question. So there's really good data on that now, and this is all really recent data coming out, looking at cardiovascular risk factors across the menopause transition.

1:10:37So circulation magazine, which is American college of cardiology's like journal has published a few, Like, you know, you have to dig coming out of Australia, incredible research on mental health changes and what seems to be working. And it turns out that giving a woman stabilizing her estrogen with hormone therapy is more effective and probably more appropriate than giving her an antidepressant. Right. In perimenopause. Amazing. Well, I can't wait to read it. For a new onset, right? Right. So I'm so, I can't wait to read it. Yeah. Hopefully I will be out of perimenopause by that time. By that time.

1:11:112026. I think we just set the date, April 26th. Okay, great. That'll be released. You'll have to come back on. I would love to. Thank you so much for being here with me today. Thank you for having me. You're so amazing. Aw.

1:11:27Thank you so much for tuning in to today's episode of the Goop Podcast. I hope this conversation empowers you to take charge of your health, ask the right questions, and approach this phase with confidence and curiosity. because the more we talk about menopause, the more we can reshape the narrative around women's health and the better prepared we're all to navigate it. Thanks for listening and see you next time. This has been a presentation of Cadence 13 Studios. I hope you'll listen, follow, rate, and review all of our episodes, which are available for free on Apple Podcasts, Spotify, Odyssey, or wherever you get your podcasts.