Dr. Mary Claire Haver on Menopause: Recorded Live from LA with Dr. Rena Malik

26:54Dr. Mary Claire Haver:And we actually come out the other end that are problem solvers. It's not necessarily all negative, but the transition could be pretty harrowing. You know, women are leaving relationships, leaving jobs through this transition when they just need support while the brain kind of rewires for the next 30 years. Another thing that happens is how we utilize glucose changes. We rely, it's harder for glucose to get where it needs to get in the brain, especially in the amygdala that controls our emotions, our emotional, you know, response center, and in the frontal cortex where memories are stored. So you're more forgetful of things that used to just come so easy to you.

27:34Yeah. And so how can we support ourselves through that transition.

27:38Dr. Mary Claire Haver:So, you know, know that you're okay. You're going to be fine. That's, you know, you're not crazy and you're not, probably not developing Alzheimer's. So if it doesn't get better and the things we ask you to put in place. So there's nutritional things. Like when patients come to me, we're doing blood work, usually in perimenopause, not so much hormones because the levels fluctuate so much. A one-time blood, urine, saliva test for estrogen progesterone is usually not super diagnostic. So we actually have to listen to the patient and believe her. Yeah. Revolutionary, right? But I do do a lot of blood work, typically.

28:18Dr. Mary Claire Haver:I'm doing things like, you know, the basics, like you would get at a woman exam, a CBC, sorry, basic blood count, looking for anemia. But we're going a lot deeper. So we're doing not only your lipid panel, we're doing an LP little a, which is now recommended by the American Heart Association. LP little a. These are really specific markers for cardiovascular disease in an ApoB. So you guys should be looking at having that done. We're doing a deeper dive. We're not looking just for anemia. We're looking for iron stores, right? That's the first thing to go. So we're looking at ferritin levels. Is she low in iron?

28:51Dr. Mary Claire Haver:Is this something easy to fix? Everyone should know your vitamin D level, everybody in here. So vitamin D is one of the most common deficiencies we see. So there's low and then there's not optimal. So the way we measure in the US, most labs, typically a level of 30. Below 30 would be considered deficient. That's a crisis, right? If you're below 30. Vitamin D is hard to get enough in our diets. You know, it's super easy to supplement. So vitamin D, we're checking inflammation markers. I mean, I just want to make sure I'm not missing anything because so many things can be true at the same time. Does she have an autoimmune disease?

29:27Dr. Mary Claire Haver:Is it hypothyroidism? Like, I can't tell you how I've diagnosed lupus in my clinic. I've diagnosed so many things that women were kind of brushed themselves off, didn't know how to advocate for themselves at the doctor's office. Oh, your labs are normal. They weren't looking deep enough for us to be able to intervene. Yeah. So then we fix the deficiencies and we talk about possible hormone therapy and how that might be helpful for her. I think a lot of people are struggling with, in that perimenopausal transition, talking about hormone therapy. How do they bring it up with their doctors? and do they get pushback?

30:00Oh, you're not in menopause yet.

30:02Dr. Mary Claire Haver:Yeah. So a lot of, you know, if you can find a clinician who's willing to talk to you about hormone therapy, a lot of them are nervous in perimenopause because again, it's not their fault. It's lack of training, right? So if they haven't sought training outside of the traditional OBGYN, internal medicine, family medicine, it could be anybody, right? Then if they're not certified by Menopause Society, which isn't perfect, but it's a nice thing to have. You know, you really need a clinician who's informed. So a lot of you will hear, you have to wait until you've gone to your formerly menopausal, which is one year without a period.

30:38Dr. Mary Claire Haver:But actually, we know now that's not true. You know, when we look at the mental health data, women were treated with transdermal, usually estradiol patch for new onset mental health disorders, and they were responding better in perimenopause than with traditional SSRIs. Things like, you know, Prozac and things, you know, good drugs, but I think we're massively over-utilizing them rather than giving them some hormone support during this time. Yeah, absolutely. And so I think what you're getting at is get a second opinion if you feel like you're getting that pushback because it is an appropriate discussion to have.

31:14Dr. Mary Claire Haver:And, you know, it's not your clinician's fault. We're busy. You know, Most clinicians out there are forced to see patients in 10, 15-minute visits. Nobody wants to do that. That is being controlled by forces outside of them. And so another caveat is that this isn't your well-woman exam. Your well-woman exam is your screening for breast and cervical cancer, really. And so they might get some basic labs. But if you want to go in to talk about menopause or perimenopause, that should probably, if you're using insurance, that should be a problem visit. Schedule extra time. Let the staff know ahead of time why you're coming.

31:50Dr. Mary Claire Haver:Ask if they're comfortable talking about this. Do they treat women in perimenopause? Yeah. Before you hit the door. Save yourself some time and a copay. So you talked about inflammation. I want to read a passage from your book, page 253. It says, why inflammation increases in perimenopause. Estrogen is a powerful anti-inflammatory hormone. It downregulates the expression of pro-inflammatory cytokines like IL-6 and TNF-alpha. and helps maintain gut barrier integrity and vascular health. When estrogen begins, its unpredictable decline in perimenopause, this regulatory function falters. This is really powerful.

32:32Explain this to people. What's happening? What does it mean when they're having this inflammation increase?

32:39Dr. Mary Claire Haver:So female bodies work better with estrogen on board. There's no denying that, right? And when that goes away, why? Estrogen serves multiple functions in the body, not just for reproduction, which is an important part, but it is a powerful anti-inflammatory hormone. And when we remove that protection, we see inflammation increase. We see markers of inflammation in the blood go up with no changes in diet, no changes in exercise, no new chronic disease states. We see the rate of metabolic syndrome double across the menopause transition. That's increasing waist circumference, increasing blood pressure.

33:16Dr. Mary Claire Haver:So estrogen makes our blood vessels. It gives them more pliancy, more elasticity. And when we remove that, they become stiffer and blood pressure goes up. It's protective in the liver. So the way that we clear our LDL changes and so LDL levels rise. I mean, who's LDL rose? And you're like, wait a minute, I've done nothing different, right? So all of a sudden you have high cholesterol. all across. So we see about a 20 % increase in LDL across the menopause transition and LP little a goes up a smidge as well. So we used to think LP little a was just genetic and you check it once and you have it or you don't.

33:49Dr. Mary Claire Haver:But if you've had it in pre-menopause, you need to check it in post-menopause because it may creep up on you. So insulin resistance, that's another huge one. So we see, you know, we have diabetes, pre-diabetes, and then we have insulin resistance and we can measure that with something called the HOMA-IR score. It's a little algorithm we use where we look at a fasting insulin and fasting glucose level. And then we can plug those numbers. Basically, you can go online and get an app and plug those numbers in and it'll tell you what is your HOMA-IR score, H-O-M-A-I-R if you want to look it up. And you can do it yourself.

34:25Dr. Mary Claire Haver:And so if it's less than two, you're good. But if it's more than two, you are considered to be insulin resistant, meaning your body is using more insulin than a healthier person with the same glucose load, you know, to get that glucose into the cell. And high insulin levels, high glucose levels cause inflammation on their own. So we just kind of end up in this like traffic circle where everything's feeding towards inflammation and that's going to disrupt your sleep and drive more fat to the abdomen and your sleep's disrupted because your hormones are going crazy and it's 3 a.m., 3.17 and you're like, when I was in second grade, I took an apple from the teacher's desk and I really should have not done that.

35:06Dr. Mary Claire Haver:I need to, you know, confess and yeah. Yeah. It's just too relatable. So, you know, I think there's so much confusion about hormone therapy and a lot of that started with the Women's Health Initiative. And it really shaped, in a way a whole generation of women. Can you walk us through what happened and how we ended up here? So Women's Health Initiative was, there was a female director for the National Institutes of Health for the first time ever. And we had a ton of data on women and health and hormone therapy. So at the time of the Women's Health Initiative, about 40 % of menopausal women were on some form of hormone therapy.

35:49Dr. Mary Claire Haver:And back then, the most common form was Primrin or Primpro, which is conjugated equine estrogens plus medroxyprogesterone acetate. And no big deal, right? That's what people got. So they decided, and they knew that women who were on HRT tended to have less heart disease, okay? Well, did they tend to have less heart disease? Because this is observational data. This is not a randomized controlled trial. Did they really have lower heart disease, or it's just that these women were healthier, wealthier, had more access to healthcare, they tended to be Caucasian, you know, is this a real thing, a real finding?

36:24Dr. Mary Claire Haver:So we look at observational data to make these assumptions, and then we do randomized controlled trials to prove it, okay? So we were going to prove. So at the time, it was a billion-dollar study to study women's health. I mean, we were excited. I mean, I was like, yes, this is, you know, we know, we think estrogen's great, and women do so well on it. And, you know, it probably prevents heart disease, but we're going to get that proven. So they collect, God, I think over 30 ,000 women for the study. Because what they were looking for was heart attacks, right, heart disease, the average age of the study was 63 years old, really.

37:02Dr. Mary Claire Haver:You know, women have heart attacks in their 60s, 70s, 80s. So they couldn't start at the average age of menopause because it would be so expensive to study the women for that long, right? So they started with a little bit older population. And then they also measured breast cancer and other things. They had lots of... But that wasn't the end point of the study. And Dr. Blooming's here somewhere, and he tells the story way better than me because he was kind of there. But if you haven't read Estrogen Matters right now, download it, and this book is magical, and it changed my life. And so basically, there was a signal, meaning there were two arms.

37:40Dr. Mary Claire Haver:you got estrogen only if you'd had hysterectomy, or you got the combined if you still had a uterus, and they give everybody the meds, and off they go, and they start measuring. A couple years in, there's a signal in the estrogen progestin group that it's not statistically significant, but it was a slightly increased risk of breast cancer. It was very, very small, like four out of like a thousand. I mean, it was so small. But a press conference gets called. A paper gets written without, you know, there was, this was done at multiple centers, like over a dozen centers in the U.S. And just a couple of the researchers get together and they write a paper that says basically estrogen causes breast cancer, for lack of a better thing.

38:23Dr. Mary Claire Haver:And the estrogen only arm, by the way, did not show an increased risk, actually showed a decreased risk, the women who were just doing the permaran by itself. And the women who were on the combined were diagnosed at a lower stage and had a better survival rate than the women who were not on anything. So, you know, because we had a placebo arm, right? And nobody knew who got what, okay? They excluded women with hot flashes.

38:55Dr. Mary Claire Haver:Why? Because they'd know if they were on the medication or not. What was hormone therapy developed for? To stop a hot flash. So those women were out of the trial. Like, there were so many little, like, this makes no sense. But what happened was this thing went viral before there was viral. It was the number one medical news story of 2002. A genie got out of a bottle that took 23, 24, 25 years to get back in. So I was my chief year, the end of my chief year, and I remember the whispers in M &M, which is our like morbidity and mortality conference. You know, we have once a week where we review cases and all the faculty are in there.

39:34Dr. Mary Claire Haver:The faculty are all arguing in the back. And no one had, they couldn't, when they did the press announcement, no one had read the study. It wasn't even published yet. And so this was before the internet where I can go right now on PubMed and pull up whatever I want and read it. But like, you had to wait for the journal to be mailed and delivered to your house and then, you know, read it and then call your buddy and see what he thought. Like the internet's changed a lot of that now or a lot faster to disseminate information. But like just the verbiage around it and the way people felt about hormone therapy really, really changed.

40:07Dr. Mary Claire Haver:I was scared. I was very hesitant to prescribe it. I was doing anything and everything to prescribe other things before I would give hormone therapy because I was under the impression. And I think that carried for a lot of clinicians for a long time. It wasn't until I was sitting at a menopause conference four years ago, my first one, I was invited to speak on a panel about nutrition and menopause. But I sat in that audience and I watched Dr. Blooming and Dr. Tavris and Dr. Malone sit on that stage and break down what happened with the WHI. And I had tears in my eyes. How did I not know this? I was a good girl.

40:44Dr. Mary Claire Haver:I did all my CMEs. I read all my articles. I was a straight A student. I blew the top off my boards and no one had sat me down and prioritized menopause for me as an OBGYN. And I thought, what are we doing? Yeah. And it was that moment I decided to pivot. I'm like, nutrition is a huge part of what I preach, but like, I want, I need to talk about menopause. I need to talk about hormone therapy and I need to talk about brains and bones because all of the speakers at this conference were connecting the dots for me about the multi-organ system effects of menopause and how there's estrogen receptors everywhere.

41:22Yeah.

41:22Dr. Mary Claire Haver:And how women are suffering really needlessly and we need to change the way we educate our clinicians. It's amazing how the media can pick something up and transform it to something it's not and everyone believes it. Because very few people actually read the papers. Right. Very few people go. I didn't read the paper until 2021, 2022. Yeah. And it's, it's a real shame because a lot of women were told that they couldn't, we would be giving them cancer by giving them hormone therapy. So in 2022, the guidelines from the Menopause Society. So as an OBGYN board certified, I follow the American College of OBGYN.

42:04Dr. Mary Claire Haver:okay? You have a similar board, American, what is it? Urological Association. Yeah. So the AUA, we're ACOG, very complicated. And so ACOG guidelines for menopause hormone therapy have not changed since 2014. They still say the lowest dose for the shortest amount of time and only in post-menopause. No mention of perimenopause. Menopause Society was a rogue organization that formed from a bunch of docs, Wolf Udian, if I say it right, formed it. And it was just like some concerned people who wanted to like learn more and talk about menopause. It's not recognized by ACOG and their guidelines have not been picked up.

42:40Dr. Mary Claire Haver:So like if you're a board certified OBGYN and you, I'd never heard of the menopause society until I was at that first meeting. I didn't even know such a thing existed. Yeah. And as a urologist, we learn nothing about menopause, but I was shocked when I first found out that OBGYNs weren't managing it and they weren't taking care of it. And that's why I learned about menopause, because I was like, who's taking care of all the women? Right. Where are all the Viagra-laden penises going? Exactly. Exactly. Yeah.

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44:15Dr. Mary Claire Haver:One thing I talk about often during perimenopause and menopause is inflammation. And nutrition can play a major role there. Many women are getting far too many omega-6 fats and not enough omega-3s. But most people have no idea what their ratio actually looks like. That's one reason I personally trust Chronometer. It doesn't just track your food. It gives you detailed nutrient data, including your omega-3 intake and even your omega-3 to 6 ratio. That level of insight can help you become more intentional about the foods you're eating every day. Chronometer is accurate, easy to use, and far more comprehensive than many other nutrition apps.

44:59Dr. Mary Claire Haver:I love that I can look beyond calories and really evaluate nutrition quality, including protein, fiber, iron, and healthy fats. Especially during this stage of life, when nutrition becomes even more important. If you're ready to better understand your nutrition and make more informed choices, Download Chronometer for free today at chronometer.com. Can I tell you something? Back to school season isn't just for students. It's for anyone in healthcare who's continuing to learn, grow, and evolve. My daughter is in medical school right now, and watching her prepare for another year reminds me that in medicine, none of us ever really graduate.

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46:38yeah so absolutely well let's talk about sex okay so perimenopause changes sex for women it changes libido it changes their vulvar architecture let's talk about it so when i have a patient who comes

46:56Dr. Mary Claire Haver:to me in clinic and says dr dr haver they usually just call mary claire or whatever I'm not happy with my sex life it's this is not a band-aid right it's not a cookie cutter we start diving in there's kind of four to five areas and they could overlap but I'm like how's your relationship is this a relationship disorder right do you feel supported by your partner do you love your partner and they're like oh my god I hate him and I'm like well nothing in my toolkit is really going to help you you know so So, okay, so we ruled that out quickly. I have extensive, you know, questionnaires that patients come before they fill out before they come, and we do one for sexual health.

47:38Dr. Mary Claire Haver:And it's, are you having pain? So we have a pain disorder, right? And the majority of that pain, if it's new, is general urinary syndrome of menopause, right? The thinning, the loss of elasticity, the dryness, okay? That's a blood flow problem. That is a skin architecture problem. There's also arousal disorders. So again, another blood flow problem. That is what men tend to have. That is erectile dysfunction. That's our equivalent. You can't get the blood flow going. And that could be because of diabetes. You know, could be because of the arteries are narrowing from, you know, microscopic atherosclerotic disease in that area.

48:16Dr. Mary Claire Haver:I mean, there's lots of ways. And then there's desire disorder as well. So desire is what happens in the brain. And that is like, this is a good idea. and desire is complicated for a lot of people. And so my questions to the patients are, did you ever have good desire? Did you ever want to do this on a regular basis? Did you look forward to it? Was it fun? And now that's changed and do you miss it? We have to normalize that I've had patients tell me, I don't care if I never have desire again. And I'm like, okay. You know, you have to want it back. it has to be a problem, right? We don't want to pathologize what could be normal for some people.

49:00Dr. Mary Claire Haver:Asexuality is a thing. And so they're like, I miss it. I want it back. So pain we fix first. I don't start going into desire until we get normal anatomy back, right? Most humans don't want to do things that hurt that are supposed to be pleasurable. There's a few. That's okay. Yeah, that's okay too. But so we treat vaginal estrogen. Is it vulvodynia? You know, the pain is not always GSM, but for a menopausal woman who never had pain before, it usually is that. So we go right into treatment with some kind of local estrogen in the vagina. Typically because of cost and ease of use, we're doing the vaginal estrogen cream.

49:47Dr. Mary Claire Haver:So we get the pain fixed. And sometimes they come back and they're like, we're all good. You know, it doesn't hurt anymore. My brain's like, yes, let's do this again. But sometimes they come back and they're like, still struggling. So then we start talking about how, you know, desire is a mood, right? And what do we know works for desire? Certainly if you are, if you had surgical menopause or premature menopause, testosterone is your friend. We know we have great data. That's the best data for testosterone. The data's decent for menopausal women. where we don't have data because no one cares about perimenopause or is in perimenopause, but I treat them anyway.

50:25Dr. Mary Claire Haver:So a trial of testosterone, or there are two FDA-approved medications. One does have an indication for perimenopause now, and one is called Addi, and the other is by Lisi. So Addi is filbasterin. Fibasterin. That one. And so I like to say Addi. It's easier. But it's a medication you take every day. It works by upregulating dopamine. Remember what's happening to dopamine in our brains? Dopamine is that hormone that's like, I want to have a good time. This is my reward, my fulfillment, my, you know. So, Vilesi also increases dopamine, but it is an injection that we would give a patient 30 to 45 minutes before the onset of intercourse, and it causes melanocortin to release, which then upregulates dopamine.

51:10Dr. Mary Claire Haver:And when it works, it works really well, and patients can like it. But a lot of my patients are hesitant to, like, do an injection with a potential praying mantis on the other end going, is it working? Is it working? Is it working? Where the Addy is just, you take it every day and it's just kind of there in the background. Yeah. I will say, I think from taking care of women with low desire, when you get your desire back, you feel like yourself again. You really do. And it's okay. I think we need to normalize wanting desire. It is okay to want that back. And it's important to talk to your doctors about it.

51:49Dr. Mary Claire Haver:Yeah. So my testosterone story, and my husband's not here, but he's heard me tell it in public, and God bless him. I have low muscle mass. I've always been thin. It's something I've struggled with, and I'm just doubling down at the gym and working so hard to get muscle so I don't die at 80. And I read studies that said women with naturally higher levels of testosterone have lower frailty scores, have better muscle mass. And I was like, you know, I'll try it. I'll, you know, I checked my levels. They were on the lower end for my age, you know, nothing crazy, but I'm like, I'll do a trial of this.

52:24Dr. Mary Claire Haver:And I would not have qualified because we have a scoring system for HSDD, hypoactive sexual desire disorder. We did it when we did it and it was fine. You know, nobody was complaining. However, I go on this med to, for my muscle mass and there's a little uptick in the area. Got better. And I would miss it if it was gone. And I didn't qualify to say this is a problem, but it just kind of put a little pep in my stuff, and everybody's happier in my house. I mean, sex is great. Orgasms are great. Yeah, orgasms are great. I want to talk about something that's really relevant right now. The black box warning was removed.

53:07Yay. Yay! A lot of hard work from a lot of people to get that removed.

53:13Dr. Mary Claire Haver:Yeah. Really important. But there is a shortage of estrogen patches. What can we do? Okay. There is a shortage of estrogen patches. There is also, I'm reading in some areas, and this is kind of how estrogen patches started, a shortage of vaginal estrogen, which scares me even more because our elder generation really needs it. So we have sprays. We have gels. We have other forms. We have oral, okay? Most people are great candidates for oral estradiol therapy. There's plenty of that. They're not going to run out of that. And it's$2 generic, okay? So don't be afraid to switch a formulation. Shop around.

53:52Dr. Mary Claire Haver:Call ahead. I am with Express Scripts. So far, they still have my patches. So you have to get a little creative about it. But we do have other options. There's plenty of estradiol out there. And compounding, you know, this might be a good stopgap until we can get the supply back up. If anybody wants to open an estradiol factory, I'm in. You've got your investors right here. Okay. So we've talked about mood. We've talked about sex. But hormones also prevent osteoporosis. What is the connection between estrogen and our bones? Okay. So our bones are constantly remodeling, like Pac-Man. So you have Pac-Man.

54:34Dr. Mary Claire Haver:That's why anybody ever broke a bone? Most of us have broken something. And so that, you know, if it's a non-commuted fracture, meaning the bones are still lined up, they just stick a cast on it and they heal all by themselves. Why? Because we're constantly chewing up old bone and pooping out. Lepec men are chewing and poop out bone. Okay, I'm very simplistic. Any orthopedic surgeons out there are dying. And so... No, they probably like it. Estrogen is very much in control of this process in women. and what key factor to remember is that men have estrogen too and when we go through menopause our estrogen levels drop lower than men's baseline okay so people are like well men don't have this I'm like you never lose your estrogen right you just have a slow steady state baseline so when a woman loses all of her estrogen the resorption rates increase we can't we're chewing up more bone than we can lay down behind it.

55:28Dr. Mary Claire Haver:And so, and we reach our peak bone density as women somewhere in our twenties, you know, maybe early thirties. And that's kind of the bank of your bone that you build. So this is the lesson I'm trying to give my kids is like, jump, lift, don't just do Pilates. I love Pilates. You know, just, just keep those bones as healthy as you can. Cause then the aging process and then menopause, you know, the fastest rate of bone loss is in perimenopause, two years before your period stops. So, you know, I think waiting till 65 is a mistake. Do not allow insurance to dictate your health care if you take nothing else from me today.

56:07Dr. Mary Claire Haver:So, I think it is a worthy investment. It doesn't take much to get it covered by insurance at a younger age. You need one risk factor, okay? If you smoke, if you're low weight, if your mother, you know, was shrinking, if she has lost you a person, you know, throw those risk factors, and they're all in the book, Throw those risk factors out there and see if insurance will cover at a younger age. I get them in perimenopause on my patients. They want to know their baselines because the younger you are, the easier it is to grow more bone. You can grow bone at any age. Let me be clear. The studies were done in women well into their 70s and 80s.

56:39Dr. Mary Claire Haver:And just from lifting, they grew bone. So it is reversible, but it gets harder as we age, right? And so get your bone density. It's$99 in Houston if you want to pay out of pocket. I think that's a worthy investment in your health. Because why? Why do we care? Because 50 % of you right now, if things stay the way they are, are going to fracture before you die. And if you break your hip, 30 % of us will die in that first year with surgery. If you're not healthy enough or you can't afford the surgery, 79 % in that first year. And these are not good years. I know it because my mother's living it. She fractured her hip over a year ago.

57:17Dr. Mary Claire Haver:She has not walked since. She fell out of the bed almost exactly a year later and fractured her pelvis in three places. And she has Alzheimer's. This was preventable. She got bad advice. She did everything the doctor told her. She dieted. She tried to be thin. She drank too much. She didn't check her vitamin D, didn't know what her calcium intake was. She didn't do the things. She was told to be thin and you'll be fine. and not take hormone therapy because it would give her breast cancer. And now she's, you know, can't remember anything. She deserved better. She did. And you all deserve better.

57:58Yeah. You all deserve better. And yeah, you lose 1 % to 2%.

58:05You lose 1 % to 2 % of your bone every year. Yeah. Starting in perimenopause. Yeah. That's a lot. And it just chips away. Okay. So you've talked about what we can do, jumping, lifting.

58:18Dr. Mary Claire Haver:Yeah. So with my patients who come in with low bone density, it's a multifactorial approach, right? And not everybody with osteoporosis fractures, you know? Don't fall. How do you not fall? Balance. Work on your balance. Balance on one foot. You know, brush your teeth standing on one foot. Like, purposefully work on your balance. You know, yoga has a lot of great balance poses in there. Jumping, lots of studies done on jumping. All you need is eight inches. Jumping for like 10 minutes, a couple of times a week, three times a week, okay? I would not go out, rush out and buy a vibration plate. I don't, you know, there's way better ways to improve your bone.

59:01Dr. Mary Claire Haver:HRT will always protect your bones. Always, no matter what age you are, okay? And it doesn't take much. Adequate vitamin D intake. So low vitamin D levels are about 60 % of you If you're not supplementing with vitamin D, we'll have a low vitamin D level. Please get your level checked. Know where they're at. Such an easy thing to supplement. And adequate calcium intake. Calcium supplements don't prevent bone fractures, but diets rich in calcium do. There's a difference. So make sure you're getting your calcium from food. So we've talked about things that people can do. And lift heavy. Lift heavy.

59:35Yeah. Yes. Lift. Everyone should be lifting. So we've talked about what women can do to protect their bone. What about women in their 20s and 30s? What should they be doing now to set themselves up to ease this transition and to be as healthy as possible? Vote.

1:00:02Dr. Mary Claire Haver:Besides that, don't take your health for granted. I mean, I'm just trying to get my 22-year-old to wear sunscreen. so she likes to tan. Don't worry about being skinny. I know there's some young people out there. Your curves are genetic. Embrace that. Visceral fat, the intra-abdominal fat that causes increased inflammation is very different than rocking some curves back here. Bigger butts are more healthy. okay embrace it don't try to diet your way to look a certain way or to look like a 14 year old we're learning who gave us that mentality right from all what's happening in the world right now so the younger work to be stronger bones and muscles weigh a lot get a bigger body take up space use your voice yes yes Yes.

1:01:04Dr. Mary Claire Haver:You matter. All vaginas matter, but you know, and all vaginas need estrogen. Yes. Yes, they do. Welcome back to another MidiPause. I'm Dr. Mary Claire Haver, host of Unpaused. Let's talk about something so many women experience during menopause, but don't always connect to menopause, anxiety and depression. When people think about menopause, they usually think about hot flashes. But for a lot of women, the emotional and mental symptoms can be just as disruptive, sometimes even more. You might suddenly feel anxious for no obvious reason. You may wake up every night at 3 a.m. and not be able to fall back asleep.

1:01:49Dr. Mary Claire Haver:Or maybe you feel emotionally flat, overwhelmed, irritable, or just unlike yourself. And the important thing to know is this isn't all in your head. Hormonal shifts during menopause can directly impact mood, stress response, and sleep regulation. Changes in estrogen and progesterone can affect neurotransmitters like serotonin and dopamine, which play a huge role in emotional well-being and sleep quality. These symptoms are often the first signs of the hormonal shift known as perimenopause. But here's where so many women get frustrated. When they bring these symptoms up, they're either dismissed or immediately handed a quick fix without looking at the bigger picture.

1:02:32Dr. Mary Claire Haver:Managing your health at this stage of life can be complex, and every woman needs a menopause-trained clinician who's there to answer questions, discuss the risks and benefits of hormone therapy, and figure out the best way to help you thrive. That's why having access to specialized menopause care matters so much, and why MidiHealth is such an important resource. MIDI connects women with clinicians who actually understand the connection between menopause and mental health. Instead of treating symptoms in isolation, they take a more comprehensive approach, looking at hormones, lifestyle factors, stress, sleep quality, and overall health together.

1:03:11Dr. Mary Claire Haver:And that personalized care can make a huge difference. For some women, that may mean hormone therapy. For others, it could mean sleep support, nutrition changes, stress management tools, or non-hormonal treatment options. The point is, there isn't a one-size-fits-all solution, and MIDI helps women figure out what works best for their body and their symptoms. And the convenience matters, too. Being able to access expert care virtually from home makes these conversations so much more approachable, especially for women who may have spent years feeling unheard or brushed off. Because menopause doesn't just affect you physically.

1:03:51Dr. Mary Claire Haver:It can affect your emotional health, your relationships, your confidence, and your quality of life. So if your anxiety feels higher lately, if your sleep has suddenly changed, or if you just don't feel like yourself, don't ignore it. Ask questions, seek support, and know that better menopause care and better understanding does exist. Go to joinmidi.com, join midi.com and connect with one of their clinicians today.

1:04:24All right, we are going to move to the questions you guys asked with the QR code. So first question, postmenopausal for 10 years with no symptoms, based on HRT benefits, is it still recommended? did.

1:04:39Dr. Mary Claire Haver:So when we look at benefits of HRT, right, it's always going to be beneficial for hot flashes, no matter your age. And we used to think that there was a, you know, the prevailing wisdom, which was absolutely wrong, was that, oh, you'll only have hot flashes for four years. Not true. Okay. If you're a woman of color, you're going to have hot flashes, I don't know, 28 years, who even knows. So it will always benefit you to decrease hot flashes. Hot flashes are a red flag for risk of cardiovascular disease are very sleep disruptive. Like sleep is gold. Sleep is everything. And so if your hot flashes are waking you up, it's always going to be helpful for that.

1:05:14Dr. Mary Claire Haver:There is a window of opportunity for cardiovascular disease, okay? Estrogen becomes a very preventative thing, but not so much curative. So women with estrogen on board have a delayed accumulation of plaques, delayed accumulation of atherosclerosis. But once those disease processes start, estrogen doesn't really help to, as far as we understand, doesn't really help to reverse that. So the further you are away from your menopause, you're losing the cardiovascular benefit. That's where the 60-year-old, 10-year thing came from. It doesn't mean you can't have it. You may have lost the majority of your cardiovascular benefit, but it's always going to help your bones forever.

1:05:55Dr. Mary Claire Haver:So if you start, and you can enjoy cardiovascular preventative protection for years and years and years. if you started early enough. But it doesn't mean you're not a candidate at a certain age. I mean, the 2022 guidelines, it doesn't say stop at 60 or stop at 65 or stop at a random age. If you're on it and you're happy and you're healthy and your bones are kicking and your brain is screaming and you're having lots of sex, stay on it. It's fine. Absolutely. And the bone thing is so critical. It is FDA approved for the prevention. Nothing is after you approved for the prevention of osteoporosis except hormone therapy.

1:06:32Dr. Mary Claire Haver:And if your clinician is like, oh, you don't have hot flashes, you don't need this, you deserve that conversation. Protect your bones. Next question. Perimenopause and menopause information is a hot topic at the moment. How do we vet the information and avoid being taken advantage of? Being sold things that are not useful or could be harmful. So, I mean, most of this is like swirling around social media. right? So if you're not on social media, you're probably fine. But look at credentials, you know, who's giving you this information? What are they? Who are they? If they say doctor in the title, but they don't fully qualify their, you know, if they're a DO, if they're an MD, if they're a chiropractor, if they're whatever, I mean, it doesn't matter.

1:07:19Dr. Mary Claire Haver:Like, where's this information coming from? What studies are they quoting? If it seems too good to be true, it probably is. And let me be clear, no supplement, and this is a doctor who sells supplements, is going to resuscitate the health of your ovaries. It doesn't happen. So if, and it's not going to bring back your sex life and it's not going to grow bone, you know, so you, buyer beware. If it seems too good to be true, it probably is. Look at the credentials of who this is. If they're leading you down a rabbit hole of, you know, click here and go over here and da, da, da, da, you know, just be careful.

1:07:52Dr. Mary Claire Haver:There are people who see this movement and are trying to capitalize on it not in a good way. Follow Estrogen Matters right now. Get out your phones. One of the best resources. If you're a breast cancer survivor, pre-vivor, Dr. Corinne Mann. You know, Dr. Sharon Malone, Dr. Rachel Rubin, Dr. Kelly Kasperzen, Dr. Suzanne Gilbert, who's here. There are so many, you know, Dr. Malik. There are so many great providers out there doing incredible medical education. and medical communication. So just follow them. Yeah. And I list them all in the book. If you look in the acknowledgements in the back, those are the people you want to follow.

1:08:32Yes. Yes. And look, she sells supplements, but you'll never see her talking about them on her platform. It is all education. And that's where you know her goal here is to talk about education. People who are trying to educate you without trying to lead you down some marketing rabbit hole, like that's a good sign. Yeah. We sell like vitamin D and fiber. So yeah.

1:08:55Dr. Mary Claire Haver:They're great. Not menopause cures. Believe me, I would sell it if we could figure out one. Yeah. And if someone tells you, oh, I got the secret and no one's telling you, trust me, if there was something we could do to make your life better, we would do it. Yeah, we would do it. Peptides don't cure menopause either. Sorry. Yeah. All right. What is up with these night sweats and how do we abate them? Okay, so night sweats. We lose control over our thermoregulatory center in our brain, specifically in the hypothalamus. There's a neurokinin receptor that goes catty freaking wampus when it loses estrogen, and it just starts firing at random times, usually at the most inconvenient times of your life.

1:09:36Dr. Mary Claire Haver:And that happens to about 85 % of us, right? So restoring Bringing estrogen back into your body at microdoses compared to what you made as a premenopausal woman helps most women get rid of the hot flashes. And if you don't have hot flashes, you sleep better, your bones are better, lots of things get better, right? Now, if you're not a candidate for estrogen or you're not interested, there are new neurokinin receptor antagonists that have come out that basically just bind to that receptor and kind of stabilize it. And they work pretty well. Before those were invented, and those just came out in the last couple of years, we were using.

1:10:09Dr. Mary Claire Haver:There's an SSRI that we use. There's a blood pressure medication. There's a few things that kind of stabilize it fairly well, but the gold standard is hormone replacement therapy. Yeah. And some of those other medications have lots of side effects, like the bladder medication. Yeah. Yeah. Okay. What is highly recommended for libido? We talked about this a little bit. Yeah. But I'll let you take it away. So testosterone, I usually lay out the menu to my patients. And they almost always pick testosterone to try first, probably because their friends are on it or they were curious about it. They read something about it.

1:10:44Dr. Mary Claire Haver:But it also has potentially some other benefits in the brain. We need more research on that. I'm not going to say, oh, it's going to improve your mood clearly, or it's going to do all these other things. But a lot of my patients are coming back and saying that they're having benefits outside of their desire. And so we just have an honest conversation about that. And if it doesn't help you in three months, then it's probably not going to help your desire. And we start looking at other options. And I would just add, you need to cultivate an environment of desire. And I think that we don't talk about that enough, but how are you supposed to go from working all day, taking care of your kids to now wanting to have sex?

1:11:21You need to put some work into cultivating a space where sex is fun and you're looking forward to it. It's exciting. And so I think, you know, you have to put some work in that with you and your partner and figuring out time and things that you can do that can be really fun. All right. What do we do if we're already on birth control, like an IUD or the pill? How do we determine if we have perimenopause symptoms or something else?

1:11:46Dr. Mary Claire Haver:So if you have an IUD, the progesterone in it, the progestin, it's not progesterone, acts locally, right? So for most women with that particular IUD, their periods will go away, right? It thins the lining of the uterus and we use it to treat heavy bleeding, off-label, and lots of other things. And it's great for contraception. But my patients are coming in and saying, I'm not sleeping. I'm having hot flashes. I'm having, you know, all the brain symptoms first. And so, you know, again, no great blood tests for any of this. Their cholesterol is creeping up. They're having all the signs and symptoms.

1:12:19Dr. Mary Claire Haver:So we'll just launch right into a treatment discussion at that point. And if they've had a hysterectomy, again, they're not going to have a period. The blood test will clearly tell us if she's post-menopausal, right? Because the estrogen flat lines and the FSH stays elevated forever, right? Unless you treat her. And so that's an easy diagnosis after hysterectomy. So I will check hormones in those patients just to see, did we miss full menopause. Somehow she got through peri without any symptoms. But if her levels aren't clear that she's postmenopausal, I'm going to assume she's peri if she's that age and she has this constellation of symptoms and all her other labs look okay.

1:12:57Yeah. And then for people who are already on oral contraceptives.

1:13:00Dr. Mary Claire Haver:So it will mask a lot of the symptoms. If you start noticing in your placebo week, especially if you're on a seven-day placebo, if you're starting to be symptomatic, especially with mental health or sleep disruption that week, that's it. I mean, And I'm like, you're there. Yeah. Speaking of hormone levels, how do you know what your own optimal hormone levels are other than being in the normal range and feeling okay? Good. So because our hormone levels fluctuate month to month and a normal healthy woman at a cycle, you know, we don't have like a baseline like your thyroid, right? To know at 23, my TSH was blah and my T4 was whatever.

1:13:36Dr. Mary Claire Haver:We don't have that, right? So we know that everything for symptomatic treatment for menopause was titrated to the presence or absence of a hot flash. But there is some decent data looking at when women were growing bone, like when they stopped their bone loss by looking at bone density scans. And so we have some numbers around that. And there's a brand new study that came out, well, it was now a couple of years, looking at a lot of women are doing transdermal therapy. And so we all absorb differently. and assuming you know that and we we found out that it takes less for most women to stop a hot flash than it does to fully protect our bones so in our clinic for the transdermal patients you know especially if she's not you know we're worried 20 of you are not going to be great absorbers turns out i was one of them so i'm a little sensitive here and um we are checking post-treatment levels to see what her absorption rates of and if bone density is important to her and she already has low bone density, we may up her dose based on that number and not the presence or absence of a hot flash so we can get her better bone protection.

1:14:45It's amazing to me that it took OBGYN so long to figure that out because we know for men, they don't absorb testosterone transdermally 20%. It's amazing. It's amazing.

1:14:59What is the known impact of HRT on GLP-1 users? can they coexist?

1:15:05Dr. Mary Claire Haver:Okay, there's one study that looked at women who were on GLP-1s, and they were postmenopausal, or on GLP-1 plus HRT. And the women who had the combination, and they only looked at their weight, so I don't love looking at weight for things. I like looking at body composition, right? But it's America, and they only care about the scale. So they had 30 % more weight loss when they were on combined HRT and GLP-1. So there's a synergism there. And it surprises none of us who do menopausal medicine, right? Because their inflammation is lower. Their gut microbiome is healthier. So many things are better when you're on HRT versus off.

1:15:48Dr. Mary Claire Haver:So it doesn't surprise me at all that women had a better weight loss outcome than when the combined was together. Yeah. I think the important thing for people on GLP-1s is to make sure that they are getting nutrition and weightlifting. Yeah. So our patients, we have an hour counseling session before they start a GLP-1. And we measure their body composition every two to three months while they're in the weight loss phase of it to make sure we're not losing muscle at a critical level. Yeah, absolutely. Next question is how to stop heart palpitations. So it turns out 45 % of women in menopause and perimenopause will have heart palpitations.

1:16:32Dr. Mary Claire Haver:It's a lot. Yeah. It is a common, common, common symptom of menopause. Again, there are estrogen receptors on the sinoatrial node that controls our heart rate. And when you take the estrogen away, it goes, it stops not working right. And you have palpitations. And so AHA has not, the cardiologists have not said, let's give everybody a trial of hormone therapy and see if their palpitations get better. But on our end of the world, they are. And so you still deserve a workup. Not all palpitations are due to menopause, but a whole lot are, 43%. And so, you know, for us, I think cardiology's making leaps and bounds right now, recognizing menopause.

1:17:14Dr. Mary Claire Haver:They've just added menopause as a risk factor for cardiovascular disease. That's huge. Like the scoring systems never, you know, the cardiovascular scoring systems until this year never considered menopause as a risk factor. And we know it is. And so, you know, we're getting there, I think. So, you know, one of the, so beta blockers are typically what women get for, you know, persistent palpitations that are life disruptive. But I think, you know, in our clinic, if they're not responding right away to HRT, we're making sure they're getting into cardiology. Yeah, absolutely. How can we prevent crepey skin?

1:17:52Does HRT help?

1:17:55Dr. Mary Claire Haver:So newsflash, you're going to lose 30 % of your collagen in the first five years of menopause.

1:18:04Dr. Mary Claire Haver:So it's not just cosmetics. That's skin health, how you heal wounds, you know, when our skin breaks, you know, and yes, my neck. I know. I feel you, girls. So topical estrogen can slow that down. You know, we are aging. This is, you know, we need to normalize aging skin. But it does go very, very quickly across the menopause transition. So we can slow it down a bit with some topical estrogen. It's not FDA approved for that. You have to use it off-label. So you can take your vaginal estrogen. I wouldn't do that now because we really need it for vaginas and we're running out. so you know vanity aside there are companies that can compound estriol which is a weaker form of you know of an estrogen that does work it's been studied and it works for skin but yeah you will lose 30 percent of your college and typically untreated in the first five years of menopause the sad realities of aging what if someone's on a vaginal estrogen and still having issues.

1:19:11And I think we should do -

1:19:12Dr. Mary Claire Haver:You need to see a gynecologist right away. Like not all issues are GSM. We have multiple other vulvar disorders that it could be. And so, you know, don't just assume if you're a doctor, you know, some of you may go and see someone who's not a trained gynecologist. And so I think it's a reasonable first try to give you vaginal estrogen. But if you're not responding quickly, like within six weeks, it's time to get in to see someone who knows how to look at the vulva and make the right diagnosis. And you might even need a biopsy. Yeah, and I would tell a lot of women, because I see a lot of women for this, recurrent urinary tract infections are often due to lack of estrogen in the vulva and in the vagina.

1:19:49So please, if you are suffering with recurrent UTIs, talk to your doctor about vaginal estrogen, because it will prevent and it will cure you. When should women start preparing for menopause? And is there anything teenage girls should start paying attention to early on?

1:20:09Dr. Mary Claire Haver:So, I mean, my children are living proof. You can survive your mother constantly talking about menopause and get into your 20s. I think normalizing the conversation. This is a normal part of life. We're all going to go through it. We don't want to hide it. We don't want to minimize it. We don't want to pathologize it. You know, just this should be a normal conversation, and they should be something that they expect. I mean, I'm on the other end of perimenopause. I mean, I'm 57. I'll be 58 in a couple months. I am literally living my best life. like and it should not like your period should never stop your life right you shouldn't have to not go to an activity the pain shouldn't be so bad that you can't participate in something or you're planning around your side menopause should be the same way right and that we we just this is so manageable this is so doable this is you know a change in our health trajectory but it doesn't have to be so bad.

1:21:06Dr. Mary Claire Haver:And you shouldn't quit your job, end your marriage, unless you really need to get out of that marriage, or quit that job. But you know, like, you can be this incredibly, like, I am in my wisdom. This is the best time of my life. My children, thank God, are healthy and thriving. You know, I've been with the same partner for 33 years, and God bless them for putting up with me. And, you know, but like, like I am so looking forward to my next 30 years. And I am refusing what happened to my mother and my grandmother to be the future for my children. Yeah. I'm not going to allow it. And don't live in fear.

1:21:42I think a lot of this social media noise makes people really scared about what's to come. The good news is you can get through this. You will get through this and you have wonderful support like the new perimenopause and so much education out there that you didn't have access to. Yeah, no. Yeah. All right. I want to end with, if you could leave every woman in this room with one empowering message about perimenopause, what would it be?

1:22:08Dr. Mary Claire Haver:I mean, it's inevitable, but suffering is not, right? We have tools to help you. There's lots of things out there. There's a community out there and talk about it. Don't hide it. Let's normalize it. Let's just make it a part of a normal everyday conversation. Absolutely.

1:22:28Dr. Mary Claire Haver:Will y 'all take a picture with us? Yes. Okay, let's get the music going. All right. I want to get a picture with everybody in the audience. Come on, Juan. All right. We're putting the lights up. Smile pretty. Okay.

1:22:50Dr. Mary Claire Haver:Thanks, everybody.

1:22:54Dr. Mary Claire Haver:You can find full episodes of Unpaused on YouTube at Dr. Mary Claire. Also, you can find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at thepausedlife.com. Unpaused is presented by Odyssey in conjunction with Good Roommate Media and Longwave Digital.

1:23:17Dr. Mary Claire Haver:This episode was sponsored by MidiHealth. the first virtual clinic created for women by women for the treatment of menopause. Don't let anyone tell you menopause is something you have to suffer through alone. Mitty can help. Visit JoinMitty.com to learn more.