GLP-1s, Hormones, and Why You Can't Calorie-Count Your Way Out of Menopause with Dr. Michelle Gordon

22:18Dr. Mary Claire Haver:They're definitely treating obesity as a chronic disease. Great. Yes. They are not stigmatizing patients with high fat levels nearly as much as I was kind of taught to do. But I think we have a whole generation of physicians still practicing who are struggling to get that message. Were you seeing this in your clinical practice? By the time my patients get to us, you know, and they're primarily coming for menopause, but many of them are struggling with weight. And so once we kind of tend to their menopause, then we'll start introducing GOP-1s into practice. So, I mean, women who come to me are women who have either been mismanaged or have gone to an online place and gotten medicine and then, you know, weren't really just kind of left to their...

23:04No body composition. Yeah, yeah. Yeah. And so when they come to me, most of them are usually on a GLP-1 and have been dieting since they were eight. So it's a much more difficult metabolic picture when I'm dealing with.

23:19Dr. Mary Claire Haver:Let's talk specifically about GLP-1 therapy. Okay. And I get this question all the time on social media. Is it okay, like they're asking for permission, for me to use a GLP-1 for my menopause weight gain? Depends. So who's a good candidate, who's not? So the guidelines are as follows. BMI, I know BMI is trash, but that's what we have, of 27 with a comorbidity. Comorbidity including high cholesterol, sleep apnea, high blood pressure, prediabetes, diabetes, for the most part. So that's BMI or BMI of 30 or higher. Okay. Those are all candidates for GLP-1. So 27 plus 1 or 30 plus? There are some guidelines to say 25 plus 1.

24:03For me, it really depends on the patient. Same. Let me tell you who GLP-1s are not for. Please. Okay. Be clear. They are not for someone who wants to lose 10 or 15 pounds for a wedding. They're not a temporary fix. Obesity is a chronic relapsing disease. There's no world where we would tell someone, hey, you know, you can take this asthma inhaler for two times and then you got to get off it. We got to get you off it. And so the biggest issue is changing the narrative around what obesity really is. and even even if it was behavior that caused it it's still there it's it's still active endocrine organ that is causing inflammation throughout your body and so what i love about glp1 is it makes it so that you're not hungry when you're trying to starve i mean you don't have to fight against your biology to get to a normal weight i'm a glp1 patient yeah yeah

25:00Dr. Mary Claire Haver:My patients talk about when they go on a GLP-1, something unlocks in their brain. Did you feel that? I don't know because I had been on a weight loss journey. I mean, at my highest, I was over 220. Okay. I'm five foot six. I gained weight with pregnancy, was never able to lose it. Right. So I gave birth in 1993. My son's going to be 33 next month. And I was never able to lose it. I would exercise my butt off and get down to maybe 15 pounds heavier than where I am now. But then I just couldn't maintain it because it was, you know, it was restrictive and so much exercise. And then I went into surgical residency, forget it.

25:41So for me, I was on a journey working with a coach, losing weight, doing great, tracking my food. And then I got bored in obesity medicine and started treating patients. Six months into treating patients, I went to Obesity Week. and one of the presenters said this about terzepatide specifically. It prevents diabetes. It prevents 10 types of obesity-related cancers. It prevents, we think, Alzheimer's. It has longevity benefits. And for me, that was the click. It's like, oh, I don't have to really fight with my body. I'm gonna try this. I'm gonna try it as an experiment and see. And so I started in December of 2024.

26:23I mean, I didn't lose that much. I also didn't go to the max dose. So I stayed at five milligrams for a long time and went up to maybe eight and a half, nine. But I got down. And this is semaglutide? No, terzepitide. 30-ish pounds. Okay. My pre-pregnancy weight. I haven't seen this weight since 1992. So for me, the biggest thing is I don't have to worry about what I eat. Yeah. Other than the protein. Like I got to make sure I get enough protein. You clear the brain space. Yeah. I mean, I still track.

26:50Dr. Mary Claire Haver:I still make sure I eat enough or don't eat too much. so you have a patient coming in decide she's a good candidate yeah you know for her glp1 walk us through what the options are what's available commercially right now for you to prescribe to a patient what are the differences in them how are they given okay what is currently available we have liraglutide i don't prescribe it it's a daily injection uh it's sexenda same same thing right It's GLP-1, but it's daily. Decent weight loss, 12 to 15%. Not bad, but it's a daily injection, and that will cause needle fatigue fast. We have semaglutide. Good drug, high side effect profile.

27:32Dr. Mary Claire Haver:For example, what are the side effects? Nausea, gastrointestinal. That's the biggest one. That's what we see in our clinical practice, too. Very, very high side effect profile. I do find, though, that men tolerate semaglutide better than women. You don't treat men, right? No. Yeah. So in the men, men, I will always start on somatolotide first. And then if they don't tolerate it, I'll switch them. But women don't tolerate it as well because we're different. We're not small men. Turns out, right? We just through trial and error have now pretty much exclusively do terzapatide. Yeah, yeah. For just to avoid the side effects.

28:06Dr. Mary Claire Haver:Our patients tolerate it better in general. There's a few that come in on it, want better management. They're happy with it. We keep them on it. But if we're doing a new start, we're pretty much doing terzapatite. Yeah, I really like terzapatite. I started with terzapatite. I never had any major side effects. I get a little bit of nausea. I'm very careful about constipation, as a surgeon especially. So my cocktail for constipation is magnesium oxide. Some people do better with magnesium citrate. But for the most part, if I have a patient who says that they're constipated, it's magnesium oxide.

28:41And it works. It's great. It might cause some diarrhea in the morning, but it's a lot better than being constipated, in my opinion. So semaglutide will come in 0.25 and now up to 7.2 milligrams. I haven't prescribed 7.2 yet, but it's like a huge jump. It's from 2.4 to 7.2, which I don't know how... I would never want to do that. I would want to step somebody up. Yeah, start slim. But I don't know. I haven't talked to Narva, so I don't know how to step somebody up to that. But I'm pretty sure you can go from 2.4 to 7.2, which seems scary to me. Wow. Yeah. What about terzepatide? How do you dose that?

29:18So terzepatide is 2.5 to 15 milligrams. Another big jump. Yeah. Yeah. But you dose it small and slow. I love using vials. So do we.

29:30Dr. Mary Claire Haver:Okay. I like having that ability to control the dose. Yeah. So there might be somebody who can't take a 2.5. They just get too sick from it. and we'll start them on a much lower dose. The Zet-bound vials come in 50 units per vial. And so we might start them on 20 units or 30 units instead and work that way. I have very few patients who are on max dose of terzapatide. It is never my goal to take somebody to the max dose. I want to get somebody to the dose that works, where they're feeling good, able to live their life and losing weight, of course, but we don't want to lose weight too fast. Right.

30:08Because the data tell us that if you lose weight too fast, you're at risk for, especially for women, more osteoporosis and muscle mass loss. I mean, we know that from bariatric studies that there's a lot more muscle mass loss in rapid weight loss. So we don't want that. And also with rapid weight loss, there's the gallbladder risk, gallstones, acute cholecystitis.

30:29Dr. Mary Claire Haver:So how do you counsel? You get these patients and we decide she's a good candidate. You pick the medication. You start her on the dose. what other counseling are you giving her? Oh, well, about the medicine specifically? Well, about lifestyle. Lifestyle. I'm your patient. Walk me through this. So we're going to talk. So I have my shots. I'm ready. Yeah. No, you don't have your shots yet. We're going to find out what your history is first. What is your relationship to food? What is your lifestyle like? Why is that important? Well, because if you're somebody who has always been afraid to eat a carb, we're going to talk about eating carbs.

31:01That's really important. I'm really big on understanding what somebody's relationship is to food. You know, I have some patients in my practice who won't step on a scale. They would just want to base it on how their clothes fit. That's fine. I think it's very important to meet patients where they are. We're going to talk about how your sleep is. What's your sex drive like? What's your mood and motivation? How willing are you to partner with me in helping you reach your goals, right? And then what are your goals? What do you want? And how fast do you want it? Because is it realistic to think that you're going to lose 20 pounds in a month?

31:35Those are really important things. So I need to get to know you. And we're going to talk about protein. The only thing you have to track is protein. That's all I care about to start.

31:44Dr. Mary Claire Haver:Okay. How much protein? The data say one gram per pound of ideal body weight. Almost nobody can get that. So yeah, like that's a lot. For example, if you're 120 pounds ideal body weight, 140 pounds, that's 140 grams of protein. Every single day. Most women are in reality eating 50 to 60. Yeah. Maybe. Yeah. And that is so like more than doubling. That is a lot of protein. It's a lot of protein. How do you teach them to scale or do you teach them to scale? Well, again, you have to start people where they are and we start finding high protein foods, right? The only thing I care about is getting 30 grams of protein in the morning.

32:18I don't care about timing, but I want you to get 30 grams of protein in the morning. Why? Because that's going to keep you full and it's going to fuel your brain and it's going to help you get through the day. That's the number one thing. And it's funny because when I have patients who start doing that, they're like, oh, I feel so much better during the day when I do that. Yeah. Right.

32:34Dr. Mary Claire Haver:And I've seen videos that you did where you like getting 50, 60 grams of protein first thing in the morning. I like efficiency and I'm a very busy girl. And so I've concocted this shake that I make that hits so many of my nutritional goals at once. So we tell patients to track their protein and their fiber, okay, for satiety and all the health benefits. So this shake has a scoop of protein powder, of course. It has Greek yogurt. I have no dairy. issues. And that gives me another 20 grams there. I have a like hemp chia flax, you know, mix that I throw in there for omega threes. The Greek yogurt also has probiotics.

33:12Dr. Mary Claire Haver:You know, I put an extra scoop of fiber and I do put a little collagen that's a specific for skin and bone, which we create. And so, you know, I put frozen berries for anthocyanins and, you know, vitamins, minerals, nutrients and fiber and shake that whole thing up and add a little water because the berries are frozen and it's delicious. It's probably 700 calories. It is 700 calories, but it has 50 grams of protein-ish and probably 20 grams of fiber. And it takes me three, four hours to get through it. So I take it down to the gym. I get my workout in and then I work on the treadmill on my walking desk and take all my Zoom calls for business there.

33:50Dr. Mary Claire Haver:And, you know, that's my morning. That gets me till noon, one o 'clock. And that is how I start my day usually when I'm at home. That's great. I usually tell patients that, you know, they have to start tracking their protein. I do tell them 25 to 45 grams of fiber, but that's hard. It's hard to get more fiber in. It's hard if you've not done it. But you have to really ramp up the fiber slowly. Oh, yeah. If you ramp the fiber too fast, you're going to have the scoots. So we don't want that. But what I do is if they really have a hard time eating food and getting protein in from real food, then I say, let's find a powder.

34:26that you like. There's some clear protein powders you can put in water. There's, there's just, there's a lot of options out there.

34:33Dr. Mary Claire Haver:And there's more coming. Yeah. I like Greek yogurt. I like, I like the Oikos protein shots, the 10 grams of protein and 60 calories. I usually have a couple of those in the morning. And, uh, and I'm also a big sourdough bread fan. So I make my own sourdough. So I'll have that every morning. I'll have a slice of sourdough bread and some, and some like kefir kind of thing. And that'll get me to 25 or 30 grams of protein. Awesome. Okay. So what about, do you prescribe hormone therapy? Yeah. I do. Yeah. The combination seems to be magical for my patients, GLP-1 and HRT. And the data backs it up. There are good studies now showing both for semaglutide and terzapatide that the patients on HRT plus one or the other will lose more weight than on the medication alone.

35:21Well, yes. On a GLP-1 alone. And women lose more weight on a GLP-1 when they pulled a couple of metal analyses. And the data show us that women lose more weight than men on GLP-1s. Probably we're thinking because of estrogen. But yeah, I do prescribe them together. But not always. Some women come to me and just want to see if they feel better and see if they can lose weight on hormones. I think it's very important to meet patients where they are, like I said. And we have to know what their goals are, right? So part of evidence-based care is based on the patient's wishes. And if the patient isn't ready to start, that's fine.

35:58Yeah, we don't start them together.

36:00Dr. Mary Claire Haver:We almost always start hormones because we're a menopause clinic. And then see how they do. And there are a few patients who that's all they needed. And that with lifestyle, they're doing great. Why add something else? That leads me to the next question. This is all controversy, but I see it constantly on social media. microdosing, giving GLP-1s to patients who don't have a weight problem for the anti-inflammatory benefits. Where do you stand on that? Well, it's not something I practice. I think that it's an area of study. I think that there's a lot of benefit for people with, say, rheumatoid arthritis, for example, who would take a small dose, maybe a one milligram of terzepipide, and find that it really helps.

36:43It's like any other drug. Let's say you were going to take sermoralin, for example, right we have no data and and so i can't in good conscience and for our listeners morelin is the growth hormone and yeah it's a growth hormone analog that you can get at at you know functional medicine clinics and that sort of thing but there's a lot of untested peptides that that that are kind of getting hawked by people on social media bp-157 and the chu we don't we don't do any you that no no no i don't either i i i have worked for you know some big telehealth clinics that do sell that stuff and i won't prescribe it because i have not seen the data for it yeah there's just no data so why would i want to be a party to an experiment that isn't being controlled there's

37:31Dr. Mary Claire Haver:no human data there's none it's very very but to be clear glp1s are a peptide insulin is a peptide Like we use peptides that are studied in humans and show benefits. Absolutely. I'm not against peptides. I'm against unstudied peptides that haven't been FDA approved.

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39:29Dr. Mary Claire Haver:When your patients come to you, what labs are you running? Do you have a general panel? Do you wait till they get there? Yeah, I do, but I don't delay treatment for labs. I usually will meet with the patient. I'll see what their needs are. Again, remember, most of them are already on a GLP-1. Some of them may not be on hormones, but they're on a GLP-1. So I get baseline labs. So a good portion of my patients have had bariatric surgery and have had regain. And the problem with bariatric surgery is many patients forget that they had it and get lost to follow up. And anyone who's had bariatric surgery - It does not matter which kind, right?

40:05You had a VSG or you've had a RU-Y or a duodenal switch. You are at risk for iron, thiamin, all the Bs. And if you get tingling limbs, you probably have a B vitamin deficiency. And so it's really common for somebody who's had a regain to come to me and say, I want a GLP-1. And I'm like, but are you taking your bariatric multivitamin? And they're like, no. So that's important. So I test for micronutrients. I only do that once. I'll do cholesterol, you know, basic stuff. And then usually -

40:35Dr. Mary Claire Haver:CBC, so blood count, basic metabolic channel. Yeah, fasting insulin. The other thing I do is inflammatory markers. Which ones? CRP, HOMOIR, that kind of thing. And then we work on it. Yeah. And of course, DEXA, but I don't require, usually the labs and the DEXA - And so for our listeners, DEXA is a bone density scan, the DEXA scan. Yeah. Do you do any body composition measurements? in the office or i don't well you do a lot of virtual yeah so how do you do i just use it no i use dexa you use dexa excellent dexa is probably i think it's the gold standard standard yeah so i use dexa and that i do within three months now some patients that come to me have already had it and then we just follow and then i'll do one every three to six months depending on the patient we try to standardize it so they all come in fasting empty their bladder before you know we try to get them in eight hour fast they have a similar baseline status between between scans.

41:30Dr. Mary Claire Haver:Sure. And we don't like hang a solid number on it. We're just looking for trends. What does informed consent look like? Well, I have a big contract I sent to the patients that I paid a lawyer to make, right? Yeah. I mean, we have to, right? But informed consent for GLP-1 specifically. So we talk about a few things. The number one thing I tell patients is that we're treating a chronic disease and that this chronic disease is something that we have to treat for life. So I look at GLP-1 as a forever medication. Not something that we're going to talk about coming off of. Not that I won't talk to you about it, but if you do decide you want to come off it, we're going to monitor very, very closely.

42:10It's not going to be like, you know, I'm going to let you come off and send you off into the void by yourself. But we talk about common side effects, nausea, vomiting, diarrhea, constipation, abdominal pain. It usually happens when you titrate too fast or if somebody's like a super responder and doesn't tolerate the starting dose, which can happen. Then there's some other things that we have to be careful about and explain. If somebody's had a history of pancreatitis, not gallstone pancreatitis, because usually gallstone pancreatitis is resolved after surgery. Yeah, I want you to get rid of the gallstones.

42:49But for somebody who's had an idiopathic pancreatitis, then we have to be cautious. somebody who's had gastroparesis, cautious, right? And then I do warn patients that if they get blurry vision to discontinue use and go see an ophthalmologist right away because there is a type of neuritis that's been linked. I'm not sure, but enough that I've had a couple of patients with blurry vision that I sent to ophthalmology. They were fine, but just to be careful. So those are the things I really talk about. Bowel obstruction is something else that can happen. And I haven't had a patient with any of the major side effects, but the rodent studies showed that bowel obstruction can happen.

43:34And then we have some absolute contraindications. Pregnancy, breastfeeding, absolute contraindications. We don't know what this does to a fetus.

43:44Dr. Mary Claire Haver:Yeah. Right? Right. So, I mean, I've had plenty of patients who got pregnant while they were on it, but it's not a fertility tool that I would recommend. We just don't have data. So we want to never do it. And if you're breastfeeding, it's a big no-no. If somebody wants to get pregnant, I tell them, stop two months before. It's got to be out of your system. Because the half-life is five days. That means it's still in your system 30 days later. Yeah. Right. So we want to make sure that it's discontinued. And then when you're done breastfeeding, if you want to get back on it, then come on back. Most of my patients are done having children.

44:18I mean, let's face it. Right. So are mine. Yeah. But then other absolute contraindications include family history of multiple endocrine neoplasia type 2. With that comes something called medullary thyroid carcinoma. Other thyroid carcinomas, not a contraindication. Okay. It's the medullary thyroid carcinoma. And that only showed in rat studies or rodent studies. We haven't seen in humans yet. We have not seen it in humans, but it's enough to make it. And MEN2 is really rare.

44:47Dr. Mary Claire Haver:Yeah. I've never seen a patient with it, but I've read about it. I know how to answer the question on the test. Right. That's why longitudinal care and having a relationship with a physician makes a huge difference. So somebody who's willing to look at the big picture and make sure that you're eating enough protein and that you're going to the gym. Or, you know, it doesn't necessarily happen. Some people hate lifting weights. And I've had some patients say, every time I go to the gym, I get angry, right? So we have to find something that you will like to do because the best exercise is one you'll do.

45:20If you hate it, you're not going to keep doing it.

45:22Dr. Mary Claire Haver:You're just going to be fighting yourself. Do you counsel someone differently if they have low bone density versus normal bone density? You know, it's not something I've had to treat yet. So I will say that, you know, somebody with low bone density, I mean, I usually send them off to a specialist. That's not my specialty. Rare, you know, sarcopenic obesity, I don't see a lot in my clinic because we do the body scans, but it's the thinner patients that are struggling because the heavier body that they had, that was actually protective because their bones and muscles were working harder for the heavier weight that they were carrying around.

45:53Dr. Mary Claire Haver:So I don't see so much of that in the obese patient. There's a few things you have to work on from a lifestyle perspective, right? You've got to work on the diet. You've got to work on the movement. You've got to work on the self-concept. Self-concept is huge when it comes to obesity. Remember, a lot of women will gain weight because they don't want to be noticed. And then what happens is they realize that it's not healthy anymore for them to do that, and they want to lose weight, but then they start to get noticed again. And if they've had any sort of trauma in their life, that can be triggering.

46:28So getting the self-concept, and usually I'll tell a woman who is at the beginning of her journey to get used to how you look in the mirror and start really loving who you are now. There's a lot to that, working with not hating the person in the mirror. It's a lot easier to get yourself to do something when you're not hating yourself.

46:51Dr. Mary Claire Haver:Yeah. The number one patient stop is gastrointestinal side effects. So we talked a little bit about constipation and magnesium oxide to help manage that. What are you backing off on dose? Like, how are you managing some of these other symptoms? Well, I use trisopatide, first of all. That's the number one thing. But I usually find that if somebody has a lot of nausea, that's usually a cue to back off on the dose a little bit. Most of the time, if it's really bad, we can give them Zofran. Just remember that Zofran is going to make any constipation worse. You've got to be careful. But also, ginger.

47:25Ginger works. It's the nausea, anti-nausea, natural. For nausea. And so I usually say, start with ginger. Let's see how you do. and kind of move from there. And when I was working for the big telehealth clinic, I probably had 15 ,000 some odd interactions and I wrote maybe 20 Zofran prescriptions.

47:42Dr. Mary Claire Haver:How often are you following up on your patients? Like how often are you monitoring? What does that look like? So that you get them started, off they go. When do you see them back? It's a medical partnership, right? So in the beginning, I see them a lot. Okay. About weekly. And then as things start to stabilize, it'll be every other week, but never less than once a month. So once they reach their goal weight, what do you do? Do you take them off? No, it's a chronic disease. Do you back up on the dose? It depends. My philosophy about these medications is they're a lever, right? If you're a woman who wants to gain muscle, then we got to back your dose off so you can eat.

48:20Because if you don't eat, you're not going to build muscle. It's really hard to build muscle when you're in a caloric deficit. That's almost impossible. It's really hard. And so I tell women, look, here's what we're going to do now. I'm going to drop you down to a lower dose. You're going to be hungry, or maybe, and you're going to lift heavy. And then once we've done that build phase, maybe three months, let's do a cut and we'll raise your dose and watch.

48:46Dr. Mary Claire Haver:This is exactly what bodybuilders do without it. Yeah, that's how they get ready for competition. Yeah. For patients who are not losing weight on a GLP-1, does that ever happen? It can. And about 20 % of patients lose less than 5%. Wow. That's what the data show. The thing is, is that that doesn't mean that it's not working, that it's not doing things behind the scenes to regulate blood sugar or even give you cardiovascular benefits. I mean, that was the biggest takeaway from the SELECT trial. But it's just what came to my mind is that regardless of weight loss, there's cardioprotective benefit.

49:20Dr. Mary Claire Haver:So you mentioned the SELECT trial. Tell us, tell our listeners in lay terms, please, a little bit about it and why it was important. Yeah. So they looked at cardiovascular benefits with semaglutide in particular. And I think the biggest takeaway is that cardiovascular benefits are there regardless of weight loss. Wow. That was my biggest takeaway from it. Cardioprotective, regardless of weight loss, patients in the trial with less than 5 % weight loss still benefited. Wow. That's huge. And what are those benefits? Like, what would that look like? Were they measuring, I don't know, cholesterol?

49:50No, 20 % lower major adverse cardiovascular events. Oh, so they were just looking for heart attacks. Yeah, but they only enrolled people who already had cardiovascular disease. Okay. So we don't know what it's going to be like in terms of cardioprotection.

50:02Dr. Mary Claire Haver:For someone who had had a heart attack or had died, you know. Yeah, anybody that already had it. And it was a 20 % reduction in major adverse cardiovascular events. And so because of this trial, this is when the American College of Cardiology said, we have to treat obesity first. That is what brought them around. That's amazing. That's what brought them around to saying that obesity is a chronic disease. Because before that, it was all, you know, bro science. But I think also it's really important, going back to Select, is that we don't know what all of the anti-inflammatory benefits are of this medication, right?

50:39I give you that. And so what we can say is that obesity is inflammatory disease, hypertension is an inflammatory disease, diabetes. So if we can mitigate that inflammation, we may see a decrease in chronic disease across the board. I agree. Okay. Let's talk about weight regain data.

50:58Dr. Mary Claire Haver:So people stop GLP once, they gain the weight back. They do. In the first year, it's two-thirds of the weight they lost. So that's why we don't stop. Just like any other medicine, what happens when you stop taking insulin when you're a diabetic and you're insulin dependent? The reason why I love this data is because it is the biggest evidence we have for obesity as a chronic disease, a chronic relapsing disease, that when you stop the stimulus, the weight comes back. And some people are able to stop and maintain. Yeah, I have, but not many. No, I don't know what the data are, but I can say that for the most part, the brain will take you back.

51:35Because GLP-1 works not just on the stomach, but it works on the brain.

51:40Dr. Mary Claire Haver:Let's talk about that because I think our listeners are really curious. How does this medicine work? Where in the brain is it working? It works on dopamine signaling. Okay. So there's this thing that can happen with it that's not truly a side effect because it hasn't been described enough called anhedonia. Have you seen that? A couple of times. Yeah. So I call it the I don't give a shits. Loss of joy in daily things. So like patients complain, you know, I've lost my libido. I don't want to go shopping. I'm not depressed, but things aren't making me happy anymore. This is where I think that there's a good amount of research potential in addiction for these medications, especially at higher doses, because of dopamine signaling.

52:26But if somebody gets all of their dopamine from food, and I was like that. So when I first started, I was like, why do I feel so crappy? Why do I just like, ugh? I don't know how else to explain. It was just very blah. And I realized that it was because I wasn't able to get that hit from food. I just had to change the story about it. And then I was okay. That was fine for me, but that's not going to work for everyone. I'm somebody who spends a lot of time constructing stories to make my life mean something. And so when I changed the meaning, because I knew the medicine was working, it had to work for me.

53:00So I had to change that story. But there is that problem that some people just really feel crappy on it. And that to me is a signal that we just got to dial it down. And when it comes to weight loss, you didn't gain weight in three months. Why expect that you're going to lose all the weight you gained in three months? I think it's very important to remember that we are treating a chronic disease and we have to be patient. It all takes time.

53:30Dr. Mary Claire Haver:Let's move on to sleep. Okay. So my patients complain so much. And for me, I have to protect my sleep with my life. Sleep is important. With my life. I can't take it for granted. I can't expect to be able to have alcohol and sleep the same. And my little mean ring tells me, you know, like there are things like when I have caffeine, when I work out, like all of this will affect not just the hours I'm sleeping, but, you know, we had a couple of sleep medicine specialists on recently who really talk about the architecture of sleep. So what are you seeing in your clinical practice for sleep and your patients?

54:08Well, oftentimes I'll see patients who have not, you know, they're perimenopausal and they're not sleeping. And, you know, those patients are usually pretty easy to treat because we give them progesterone and they can sleep through the night, right? Again, it's increase in follicle stimulating hormone. And then the sex hormones decrease and the sleep architecture just gets all messed up. But, you know, again, one to 12 times per night, the sleep deprivation then leads to the brain fog where difficulty finding words and then cravings and then weight gain. And then it's all back to that whole cycle again.

54:38Yeah. Are you finding that GLP-1s are helping with sleep at all? Some patients find that they help with sleep, but some paradoxically find that they don't sleep well if they take it before bed.

54:49Dr. Mary Claire Haver:It's so individualized. Right. So if you have a patient coming in and her main complaint is brain fog, what are you thinking? like what's is she obese uh sure okay so we're gonna treat most are yeah so yeah yeah we're gonna treat the obesity with a glp1 and i'm gonna find out what other symptoms are going on okay you know she's she's 43 right she's waking up at 3 a.m progesterone all right progesterone and maybe even low dose estrogen depending on her mood true the data out of australia is clear you know So new onset mental health with anxiety, your transdermal estrogens are going to be. It's like a miracle.

55:30Your best bet. But also we've got to look at the thyroid. True. I mean, somebody with brain fog. That's standard on my panel. Like they get that before they even come through the door. I had one patient who had had a progesterone IUD placed and she was really tired, really tired, really tired. And I said, well, maybe it's that IUD. And then I looked at her TSH, which was 50. I was like, oh, we need to treat your thyroid. Let's do that first.

55:50Dr. Mary Claire Haver:So we talked about semaglutide. the main GLP-1 that's being used. Trisepatide is different because it's the GLP-1 plus. Yeah, it's got insulinotropic polypeptide. Yeah, and then there's something new on the horizon. Are you excited about it? I am so excited. Ritatratide. Ritatratide, okay. GLP-1, GIP, and glucagon. Okay, so it's like trisepatide plus glucagon. Plus glucagon. Basically. And glucagon. Why would that? Glucagon ups your fatty acid oxidation. Okay. So fatty acid oxidation with more muscle preservation. And the phase two trials look amazing. They're still enrolling for phase three. And what's really interesting for me, because I'm on Reddit, there's a subreddit called Retta.

56:32And the results that people are getting in this, it's amazing. So when you say results, is this just weight loss?

56:40Dr. Mary Claire Haver:What are we talking about? Weight loss, body composition, you know. Muscle preservation. But it's mostly men. And remember, if you're taking retatutide now, you're using something that is not FDA approved, that is gray market, that is... People are taking it? Oh, yeah. I had no idea. Oh, yeah. I'm just waiting for it to drop from the FDA. No, research grade is available. You can take it now, just like all the other peptides. I really want to use caution there because you don't know what's in it. No. You don't know what's in it. As opposed to my friends in the compounding world who will compound terzapatide and will compound semaglutide.

57:24And if you're using a reputable compounding pharmacy, then I don't necessarily have a problem with that as long as the pharmacy is good. And usually it's because of cost. But I haven't seen appreciable differences. In outcomes? Between the? Between the compound and the name brand. Right. I haven't.

57:44Dr. Mary Claire Haver:Okay. So I can't say anything bad about it. Injection barrier. What if a woman won't inject herself? Do you have patients? I don't. They will not get an IV. They will have a baby at home. But they will inject themselves with a G. That is how strong the pull to lose weight is. There's a greater conversation to be had about the standards of beauty for women. Like, what are they really based on? 14 year old 12 year old 10 year old not even post-adolescent I mean pubescent but I think I think it's important so we've got we've got strong social pull to be thin but at what cost and that's the problem and you know seeing some of the celebrities that are really emaciated now going back to that 90s heroin chic is scary so the question was needle fatigue right or being willing to give yourself a shot.

58:40I've had a couple patients who are really afraid. They'll find auto-injectors. So they'll get their compound or they'll get their vials from Eli Lilly and they'll use an auto-injector because they're just afraid to put a needle in themselves. I'm a surgeon and I'm afraid of needles. Man, when I needed to get a shot, I would run the other way. So I took Depo-Provera for a little while and my nurse was going to give it to me and I just ran to the other side. I'm just, I am afraid of needles, but I inject myself every week. It's slow. Now, what about the new oral therapies that are coming down the pipe right now?

59:13I haven't had to prescribe those yet. Me neither. So we have Wagovi now that's at 25 milligrams, 15 % body mass reduction. Okay. Wrapped in snack. Okay, don't ask me what that means, but it's wrapped in a special molecule so it won't get destroyed by the liver. In the gut. Yeah, that's proprietary. And I think it's very important that anyone who is offering a compounded version of oral wagobe, the coding is patented and you're not going to get that. And so what we found is that oral forms don't work, but this one does.

59:49Dr. Mary Claire Haver:Okay, because it's coded to basically make it through without being destroyed by the gastric juices. But then we have a couple of interesting ones coming down the pike, right? Orfor-Glipron and the R1. What is that? Orfor-glypron is really exciting because it has almost equal weight loss to semaglutide without having to worry about eating around it. So that's going to be an interesting one when it gets approved. We might see that a lot more frequently. And then the other one, what's that other one? Danu-glypron. Oh, more side effects, colorability challenges. These agents are really interesting because anything oral, you know, remember everything goes to the liver right everything gets destroyed by the liver and the stomach these these agents actually kind of permeate the barrier and go into the bloodstream that way so they're really interesting agents wow so they're kind of skipping that first class effect of the liver they're they're not peptides they're these small molecules that resist enzymatic degradation okay that's super cool well we'll see you know my patients are super happy on their injections and do not want to stop i haven't had anybody like ask for an or i mean they're like Like, it's working.

1:01:02Dr. Mary Claire Haver:I'm tolerating this. Like, why would I stop this? Exactly. You know, I'm very happy with my results and I don't want to switch to anything else. Giving myself an injection is not a problem. Now, if the cost came down significantly, that may tempt some patients. Well, cost is coming down. Semaglutide is off. Oh, since we've been prescribing it, it's down like 80%. Right. But also the patents are expired in Asia. Oh, wow. Let's say you go to India. You can get it for 30 bucks now. Amazing. Maybe 15. Okay. So, I mean, I'm not going to make a trip to India like every month, but I'm just saying it's going to get cheaper.

1:01:38Dr. Mary Claire Haver:So the studies were not powered to look at menopause, but we're doing it, you're doing it. You know, the whole menopause, most of them are prescribing it to some degree, HRT plus, and it's a game changer. I think it is, yeah. A total game changer on multiple levels, not just on what she weighs, but her inflammation, her sleep, her joint pain, her, you know, The combination really seems to be unlocking something and really giving her her life back. I agree. To me, I mean, my personal feeling when I started taking this, I write into my coach every week and say, this drug's a freaking miracle. Yeah.

1:02:14Because it really has helped me. And it helps my patients. And one time I did a 10-day fast because I was a surgeon. I had to fast people all the time. I was like, let me see what it feels like to fast. And I like to have experience. so that I can relate back to patients. And you know what happens after about five days without food? You start to feel really sad. And the reason I bring this up is that my experience with this medication, I understand. I struggled with obesity for 30 years plus. And understanding that it wasn't something broken in me, that I didn't have willpower, it was my metabolism that had changed, was a game changer.

1:02:57Dr. Mary Claire Haver:Yeah, giving you back at your best self. Do you see a future? I mean, I'm doing it now where GLP-1 and menopausal hormone therapy kind of go hand in hand for a menopausal patient? I do, but not yet. Probably, you know, we need more research money. We need more data. We need to find out what's actually happening. We need to understand why the ovaries fail. People are looking at that, but only from a fertility standpoint, you know, or extending the life of the overly simply so she can stay pregnant or get pregnant later. I just want enough estrogen to keep my bones strong, lower my risk of heart disease, you know, and do keep my cognition humming the way it should be.

1:03:40Dr. Mary Claire Haver:You know, keep my general urinary system on point and let me go live my life. Exactly. I would love to understand why it is. I mean, it's it can't just be because of fertility. there's got to be an evolutionary reason but i intentionally didn't have a period all throughout my through my residency but then when i stopped the pill i had i got a fibroid up to here and had to have a uterine artery ablation so it was it was crazy as i thought i thought well i want to lose weight now because i was perimenopausal didn't know i was perimenopausal and and so i stopped the pill and then all of a sudden i was like what is this mass in my house it's like oh my god i have cancer okay so so the question was more along the lines of is it going to be standard care probably but we need data and and for that for the society step up and make guidelines they they we're going to need the studies yeah we need to and i think that the studies need to be they need to be you know free of commercial bias true and you know the problem is is that there's no money in that so how you know how do you get it done yeah that's hard So let's talk about the system and the fix and social media.

1:04:48Dr. Mary Claire Haver:There is a very loud contingent out there on social telling women that GLP-1s are a crutch, the easy way out, that they're cheating and you just need to try harder. Let's say that about Viagra. What do you say to that? No, really. I mean, would you say that about Viagra? Because Viagra was intentionally, the first intention was to treat angina, right? GLP-1s were first intended for diabetes. We found another use for them to treat a chronic disease that wasn't a moral failing. The problem is that the residency system all by itself is broken. We destroy our doctors through residency. and it's almost like this same feeling when it comes to weight loss let's you know i had to suffer to lose weight so because of that so must you is it cheating not if you look at it as a chronic disease and you understand that it's chronic disease it's not for five pounds it's not for 10 pounds it's not to fit into a smaller clothes you have to understand we're looking at somebody who's had weight loss and weight regain and weight loss and weight regain over and over and over.

1:05:57And by the time somebody's come to me, they've tried and failed, tried and failed, tried and failed 20, 30, 40 times. This time it's going to be different. This time it's going to be different. And then inevitably it all comes back.

1:06:10Dr. Mary Claire Haver:If there's a clinician out there listening, you have this really unique background of, you know, 15 years as a practicing general surgeon and then, you know, several years now, lifestyle, obesity medicine, totally just, you know, bringing women back their game medically, psychologically, you know, you're part-time therapist probably as well. But if there's a clinician out there who is traditionally trained the way we were trained, right, and hasn't is hearing all this noise right now about how women are different than men, what actually menopause is doing, what message do you want them to hear?

1:06:45Well, I think it's important that you understand that women navigate hormonal chaos from puberty to pregnancy. And then through the perimenopause and menopause transitions. Our hormones are never stable. Men have stable hormones for the most part. You know, they'll lose a little testosterone and give it back to them, right? Our hormones fluctuate because we 3D print humans. It's very important to remember that. We have this magical ability to create life. It's really cool. Doctors don't understand that women are not small men. And I think that's an important fact. Any woman who is presented to the doctor for weight loss has tried calories in, calories out, eat less, move more.

1:07:29They've really exhausted that. and a woman who continues to come back to the doctor in a system where she's been dismissed is persistent because she wants help and I think that's important and that woman who's sitting across from you as as the person who hasn't you know maybe hasn't studied menopause or starting to understand you know she's starved herself she's counted her calories she's exercised into oblivion. And she's probably being explained something by a man that she already knows more times than she's tried those things. So it's important that you meet her where she is and meet her with compassion and curiosity.

1:08:13Dr. Mary Claire Haver:Is there anything else you want to let to the women listening out there who just feel like they've just been gaslit, dismissed, and they're giving up. You know, this is what it is. What do you want to say to her? You're not broken. Midlife changes everything. Everything changes. It's your biology. No one told you it was coming either. Yeah. I mean, how many women have you spoken to that said, what the hell is happening to me? Thousands. Right? All of a sudden, I'm embarrassed, but I'm not embarrassed. It's a hot flash, right? But weight gain in midlife women is physiological and predictable. We know this now.

1:08:51The burn rate goes down and you can't out calorie count yourself out of it. It's going to happen. It's predictable. We can work on it. Resistance training. I mean, that's the number one longevity hack and sleep and fiber. You don't have to white knuckle through it. If you start gaining weight and you rapid rapidly the weight comes on and all you're doing is thinking about food and you're craving food we have medication that can help now and the other thing I want to say to the women is that if if your doctor dismisses you go get another doctor there's a million doctors in this country you don't have to go to a doctor that makes you feel like crap yeah

1:09:32Dr. Mary Claire Haver:it's okay to fire them and find someone else absolutely so if someone's starting a new start for GLP-1 and say she gets it from someone who hasn't given her a lot of information. What are your top three tips for her? So first one is don't go up too fast. Okay. It's not something that you want to race to the top. It's never a race to the top. It's a race to effectiveness, first of all. So when your appetite and your cravings are managed, then stay at that dose as long as you can. Let's milk as much out of it as we possibly can. And then we'll step it up slowly. Good advice. Eat protein. Eat more protein than you think you can tolerate.

1:10:09It's the magic sauce for menopause and midlife. It's very important.

1:10:14Dr. Mary Claire Haver:One of the most important to me findings from the Women's Health Initiative, because they followed these women off they were off hormones for decades, right? And we're still collecting data. Was when they looked at frailty scores, amount of protein in their diet was the most predictive measure. Wow. Of her chance of being frail was how much protein. So the women in the highest quartile of protein intake had the lowest frailty scores. Well then. Regardless of their weight. Even more reason to eat more protein. Gram of protein per pound of ideal body weight. And that's the start. That's really the start.

1:10:50And there's a lot you can learn from bodybuilders. Not the guys who are like doing tea, but they do understand weight loss. They do. The problem is that most of them don't understand female biology. Yeah. So we have to take the good with the bad. But the third tip I would say is it's got to be a slow process. You didn't get here overnight. You're not going to get there overnight. Enjoy every second of this journey and love yourself through it because no one shamed themselves into weight loss and felt good about it.

1:11:23Dr. Mary Claire Haver:Awesome. Well, Dr. Michelle Gordon, thank you for coming on Unpaused. Thanks for having me. you can find dr gordon through her website at drmichelle gordon.com or on instagram at dr michelle gordon i'd love to hear from you about this topic and anything else that's on your mind you can find me on instagram at dr mary claire and get honest and accurate information on health fitness and navigating midlife at thepawslife.com my new book the new perimenopause is available now everywhere and anywhere you buy books and through our website. If you're loving this podcast, be sure to click follow on your favorite podcast app so you never miss an episode.

1:12:03Dr. Mary Claire Haver:While you're there, leave us a review and be sure to share the show with the women you love. We would be so grateful. You can also find full episodes on YouTube at Dr. Mary Claire. Unpaused is presented by Odyssey in conjunction with Pod People. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment.