Listen Again: Build Strength, Live Longer: The Menopause Longevity Blueprint with Dr. Vonda Wright

24:53I order a DEXA on everybody. Same. I think, just like we get our mammograms at 40, I think we should have our screening test by 40. You should have a baseline. Let's just figure it out. Whether it's REMS, whether it's DEXA, just find one. In fact, we should probably do it at 35 when we have a little bit of estrogen still circulating. To see what your peak. Your baseline. And if you're already low, then you really got to get after it because you're still probably producing some estrogen.

25:23Dr. Mary Claire Haver:This podcast is sponsored by MidiHealth. You've heard me talk about my menopause toolkit. It consists of nutrition, exercise, hormone therapy, and other medications, stress reduction, sleep quality, and community connection. When you put those pieces together, they don't just ease symptoms. They support your long-term health. That's why I recommend MidiHealth. They put your toolkit to work for you. MIDI is a virtual clinic built by leaders in women's health with clinicians who understand the science of female aging and who take the time to understand you. Through one-on-one visits, they listen to your symptoms, your goals, and your concerns, then create a personalized care plan tailored specifically to you.

26:10Dr. Mary Claire Haver:And best of all, MIDI is covered by most major insurance plans, making expert, high-quality care accessible and affordable for every woman. All of which is why MIDI should be part of every woman's menopause toolkit. Book your virtual visit today at joinmidi.com. That's joinmidi.com.

26:36Dr. Mary Claire Haver:Walk us through bone loss over time. Like what is the process? What does bone do, right? So we're building peak bone density, if we're building peak bone density to 30, and then we stabilize for a while. Okay. And then just like men, we start to lose bone density about 1 % per year in a slow, steady decline. And men just continue like that. Men get osteoporosis, 2 million men in this country of osteoporosis, but they have this slow, steady decline. Nobody notices. For women in perimenopause, when estrogen walks out the door, as I like to say, and never looks back that girlfriend of ours, we start to rapidly lose bone density between two and 3 % a year, such that in the five to seven years surrounding the end of perimenopause to menopause, we can lose 15 to 20 % of our bone density.

27:29And most of us never know it. I have no idea. No idea. It's a shock when people, even women who are doing all the right things, will lose bone density because of the loss of estrogen. So that's what happens. So men and women do not age the same when it comes to bones.

27:47Dr. Mary Claire Haver:Now, what role, we talked about estrogen, does the other two hormones involved, you know, coming from the ovaries, progesterone and testosterone have any play in this? Yeah, testosterone has a bigger role than progesterone. I mean, and the reality is these things need to be worked out. We don't know all the answers, like how does progesterone affect it? How can we use the supplemental progesterone that some of us take at night? But because not enough research has been done. We know testosterone plays a big role in bone density in both men and women, but not as big as estrogen does. What is sarcopenia?

28:24Yes. So sarcopenia translated means a low muscle. Okay. Sarco muscle penia less like osteopenia, sarcopenia. But it is not just about your total pounds of muscle. It is a functional definition. You want to be 45 % muscle or more, actually. But it's functional, meaning can you sit to stand? How fast can you walk? Because the concept of sarcopenia has to do with function. Do we have enough muscle mass to function? Do we have enough strength in the muscle we have to get up off the floor or to walk fast enough to be safe. It's not running, but it's not the slow crawl we see some people do as they age.

29:09Dr. Mary Claire Haver:What is frozen shoulder? One of the most audible musculoskeletal symptoms of menopause has to do with our shoulders. And it's not because suddenly your shoulder is bad for you. Estrogen walks away. We become highly inflamed everywhere. The shoulder is very susceptible. So the shoulder on the inside, you see it on the outside with skin and and then muscle, and then inside of that, there's this layer called the capsule. The capsule will become so inflamed that overnight you wake up and your shoulder is killing you. And you didn't bump into the door, nothing happened. You're like, I don't know what happened.

29:45So like most women, you try to wait it out. You're like, I got this, I've suffered a little. And so women come to me in a relatively short amount of time and their arms will no longer move. they're excruciating and they can't get their arm up and they certainly can't hook their bra

30:01Dr. Mary Claire Haver:i shared one of your videos on frozen shoulder years ago now and it was absolutely viral the comments in the thousands and thousands of women oh my god no one's ever said this i can't i've had this and one of the hallmarks i see is that women struggle to put their you know we always left to take our group photos. Oh, right. Oh, can't put their arms around each other. They can't put their arms around. How would you know maybe if you had frozen shoulder? Like if someone is like sitting at home listening to this. Are you in your perimenopausal years, did your shoulders start hurting out of nowhere?

30:37Like you didn't hit it. There was no obvious injury. Can you suddenly not reach behind your back or reach out to the side? Those are the two motions that go first. And suddenly you can't put your bra on it from the back. You got to scoot it around in the front. Those are clues. This also happens in people with uncontrolled diabetes. So if you don't have diabetes, like where is this coming from? Here's the thing, though. The medical term is called adhesive capsulitis. We orthopods have known about this for centuries. In fact, it's sometimes described in the conclusions of papers tends to happen in middle-aged women with nobody then taking the next step to say, well, why could that be?

31:17What's a common? So bless their hearts, I have to say about my orthopedic peers, whom I love, I do, but most of them, 94 % of them were born without the benefit of ovaries. So they're never going to know what they don't experience. All they know is that women show up in midlife, their shoulders don't work, and then it's going to take two years to defrost.

31:39Dr. Mary Claire Haver:Oh, my gosh. Oh, my gosh. So you wrote a paper that changed my life called The Musculoskeletal Syndrome of Menopause. And I was so excited for this because I, as you probably in medical school, got one hour of menopause. Oh, I don't even remember. Maybe. And then in my OBGYN residency, which was four years of 100 plus hour weeks, I had six scheduled lectures on menopause. Six hours in four years. And I was taught hot flashes, vasomotor symptoms. I was taught some vaginal dryness, atrophy. I was taught the bones would begin to deteriorate and sucks to be a woman for that. And there's not much we can do about it.

32:23Dr. Mary Claire Haver:You know, until she's diagnosed with osteoporosis, then we give her all these meds. I was never taught estrogen's effects, the loss of estrogen's effects on the musculoskeletal systems. For our listeners, walk us through what the musculoskeletal syndrome of menopause is. The musculoskeletal syndrome of menopause, which affects about 70 to 80 % of all women. So think of all the women with hot flashes. Equal numbers have one of these, right? Every musculoskeletal tissue, muscle, tendon, ligament, bone, cartilage, which is the smoother, the nice lining of the end of the knee. Fat is a musculoskeletal tissue.

33:00We have stem cells. The discs in our back, all of those, which are cousins, have estrogen, alpha, and beta receptors on them. So I always hold up my hand like a little basket because estrogen fits in there. And then all the good things happen. Lack of estrogen in these tissues manifest as total body pain. It's called arthralgia. I think we throw every woman under the bus and call her fibromyalgia when actually it's untreated arthralgia of the musculoskeletal syndrome of menopause. So total body pain. I had this. I'm an athlete. It was disabling. I mean, not so much that I couldn't work, but I had trouble getting out of bed.

33:39Number one, frozen shoulder, both due to inflammation. We have tendonitis. How about tennis elbow, golfer's elbow, Achilles tendon, patellar tendon. All your tendons hurt for no reason. On the bottom of your foot, it hurts. Your plantar fascia hurts. Women have a rapid increase of arthritis, which is loss of cartilage, after 50. Before 50, men have more arthritis. after 50, women rapidly develop arthritis. I see this all the time in my clinic. It's because, again, estrogen alpha and beta receptors are critical for maintaining cartilage. The matrix, cartilage is a matrix. And without it, it just crumbles.

34:24And we wear down our cartilage, which is irreplaceable. We get one set for a lifetime. All of these things happen for the same reason. Estrogen decline.

34:35Dr. Mary Claire Haver:You often talk about meeting women for the first time in the emergency room when they're shattered, broken, fractured as an orthopedic surgeon. Where should they have met you first? The youngest, big fracture, life-changing fracture, not an ankle, not a wrist. The woman was 57. I write about her in my book. And I met her in the emergency room. And I had probably met her in the gym. We went to the same gym because she was doing everything she thought she could possibly do. She was because you know why her motivation was she was not going to age like her mother who was frail and overweight. And so she was doing everything she thought Dr.

35:15Google would want her to do. She was lifting, but she was starving because she still believed that she could only be this big. Right. So if we're going to work that hard, we need to feed ourselves that hard. But what I do, what you're referring to is when I meet women in the emergency room or on the floor because she has a hip fracture, it's the first time she's ever thought about her bones. And she's forced to because fractures are excruciating. Finally, these bones that you think are silent are screaming so painful that, you know, in hospitals how the beds are kind of slick because they're plastic.

35:51And people slide down to the end of the bed and they need to be pulled up in bed, but they won't let you touch them because it's too painful. So much pain. They're in so much pain. But here's the reality. And I've gotten not afraid to say these things out loud. You know that when I go to the bedside, she has been incontinent. And she's usually laying there, not because of bad nursing care, but because she's a constant incontinence. Because she's just lost her bladder control and we've done nothing about her pelvic floor or her prolapse bladder. And often when I'm trying to clear her for surgery, which we go through a certain procedure, do lab tests, she has a UTI.

36:29In fact, maybe she got dizzy and fell down because of her chronic UTIs, which we know is a thing. Then what happens now in the hospital is the medical doctor will come and clear her heart for surgery. It takes about 45 minutes to fix a hip, but the heart has to be healthy enough. but many women have not been treated with estrogen only four or five percent right so they have microvascular heart disease that they may not even know about and it's difficult to

36:59Dr. Mary Claire Haver:clear their hearts and then finally clear their hearts for surgery to prime their hearts for surgery that they're not they're going to survive the surgery they're going to survive anesthesia thank you for clarifying that because it's a stress to undergo surgery and anesthesia it's like running a race. You don't want somebody to have a heart attack on the table. But the other thing, Mary Claire, is that either the stress of the incident or they've already got early Alzheimer's. They're not cogent. Their brains are not functioning the way they would want them to. So we've got all these things that, frankly, my friend, we could have prevented had we gotten a hold of women when they were 35.

37:41Dr. Mary Claire Haver:So mama is 88. Yes. And she has never had a bone density scan in her life. And no one ever, ever, ever, ever talked to her about her bones. Her mother laid in a bed incontinent with severe dementia and had broken, not a hip, but broke ribs, broke shoulder, arm, you know, multiple falls and spent probably the last good three to five years in a bed, hallucinating, incontinent, yelling out, you know, not how she wanted to be. And my mother, no one ever talked to her about what mama could do to prevent that. Not even me. Now I tried to help her with vaginal estrogen. My mother's had struggles with incontinence since I was a child.

38:33Dr. Mary Claire Haver:Mama is now has Alzheimer's, is in a facilitated living facility. And on New Year's night, fell looking for my father who passed away six years ago, hallucinated, thought she heard his voice, fell, shattered her hip, got taken to the ER, passed clearance for heart, survived the surgery. Yes. It is eight months post-op and she is just now walking with a walker. She has been rolling around in a wheelchair, scooting herself around since that. And we finally got the right physical therapist in to really get her up and get her motivated. And no one is talking to these women. Nobody. About prevention, about this doesn't have to happen.

39:18Dr. Mary Claire Haver:She's exactly walking the path my grandmother did. And I am refusing. I know. For this. I'm changing the legacy for my daughters. Yes, you are. There's no way you'll let that happen. So we're going to talk about what we can do about that. What part does inflammation play in all this? I'm so glad you asked that. Because it's not just one thing. It's not just menopause. It's not just calcium intake. The second chapter of the whole book is all about the science behind aging. Because I just don't want people to walk away thinking, just get on another exercise program or another diet. That is so not what you and I are talking about.

39:54One of the things we talk about is this concept of inflammaging. It is chronic inflammatory processes in your body that never stop. Now, let's clarify. Inflammation is a normal bodily process. When you twist your ankle and it gets hot and red and it swells up, protective. Because your body is rushing to the scene. It is dumping growth factor. It is creating inflammatory cytokines to heal and to clean up the mess so that you can return to life. When we do not turn off our inflammatory processes, either because we're chronically stressed, which increases our cortisol levels, and increases all these inflammatory cytokines that we just normally produce, they never get taken care of, we enter a state of inflammation, which is one of the motivators for all of our chronic disease, whether it's your heart disease, whether it's your diabetes, whether it's your sarcopenia and your bone density.

40:56because both bone and muscle are critically sensitive to inflammatory cytokines. When they are present all the time, they can increase loss of bone because they give osteoclasts, the bone-eating cells, the advantage. So high inflammation, more loss of bone. The same for muscle mass. High levels of these inflammatory cytokines make us weaker, make us recover from muscle injury slower, such that there are lots of studies that go way deep into the mechanisms of this. But we know that in some studies in women that when they measure these levels in the blood, they can correlate it to significant decreases in muscle mass and recovery.

41:49So this is not just theoretical. We know this happens. And so why do we become so inflamed? Because estrogen is a potent anti-inflammatory.

41:59Dr. Mary Claire Haver:I remember reading the data on blood inflammatory markers and some researchers, thank God, who were tracking them across the lifespan, specifically in women and seeing this dramatic uptick somewhere around 45 on average. And some other researchers said, hmm, I wonder if this is menopause. And they started looking at animal studies and then human studies and just how menopause itself, just from the loss of estrogen, changes in progesterone, you know, becomes a pro-inflammatory state. I was floored by that. Exactly right. When women say, oh, I didn't have menopause. I didn't have night sweats, brain fog.

42:39I didn't feel bad. Or, you know what, I just had it a little. Or, I'm done with all that. Oh, I'm done. Well, okay. That just comes from the fact that we need to educate women continually to say that you may not feel it, but it's happening. It's happening. It is happening.

42:56Dr. Mary Claire Haver:Yeah, that loss of estrogen will follow you in every organ system for the rest of your life. That's right. Okay, talk to me about vitamin D and calcium. We hear a lot about that on social media, and it's one of the things I was taught in residency. So, you know, we talk a lot about those things in terms of building bone density, but we forget that vitamin D is critical for brain health and immune function and gut absorption. Calcium supplements, and correct me if I'm wrong, have never been shown to decrease the risk of osteoporotic fracture. We need it from our food. It's not hard to accumulate 1 ,800 milligrams.

43:30Definitely not hard for 1 ,200. Because a cup of yogurt has about 300 milligrams of calcium. Salmon with bones in it. sardines but you know who wants to eat those but prunes and bok choy there's just so many choices that I'd rather people try to get it from their food the way I counsel my patients is these foods

43:50Dr. Mary Claire Haver:that are rich in calcium are also rich in so many other things that are wonderful for you great health so it's always better from food so earlier we talked about that one in two women after the age of 50 can expect to have an osteoporotic fracture. And that's our reality. However, in my clinic, I am recommending DEXA scan. So let's go get your bone density checked. Often insurance won't pay for it until the age of 65 or if she has some severe risk factor. But even in that setting, I feel like that is too late. When my patients are diagnosed with low bone density, they are devastated. They cannot believe it.

44:33Dr. Mary Claire Haver:How do you counsel those patients in your clinic? They feel disappointed, ashamed, frightened. And then we don't just leave the conversation there. I think a DEXA scan number alone is useless unless you give a patient or a woman a plan. And so we go through all the things we know that will help build better bone. and we know that we can stabilize or build better bone. What are those things? Every woman is a sentient being and gets to make her hormone decision, but I insist that she makes it based on facts, not fear. And so every day I recommend, well, I recommend your book. So I say, if you want all the world's data on the safety of your hormones, you're gonna read Estrogen Matters.

45:19If you wanna know what's about to happen to you, you read The New Menopause. If you know how good sex can be at this age, you read You Are Not Broken. And then, of course, I recommend Now Here's Your Plan Unbreakable. But as I explain to them, I say you must make your hormone decision. And then I explain the role of estrogen on bone. It's going to be harder to get in front of this if we don't. But if you don't want to, well, what else are we going to do? We are going to learn to lift heavy weights. We are going to put down the mamby-pamby five-pound weights that we lift 30 times to failure. And we are going to take the six or nine months to work up to lifting the hex bar that you lift when you deadlift, right?

46:02To lift heavy because it is that which is going to exert the most pulling force against your bone. We're going to jump around like a crazy person. I want people to jump 20 jumps a day, not just straight up and down, not landing lightly. I want you to thud on the floor because we need to generate four times body weight. You can do that. Walking generates about 1.2 times body weight, running two to three times, but we want a thud on the floor and that takes jumping from a height of about eight inches. If you cannot do that because your knees hurt too much, well, NASA uses rebounders or little trampolines.

46:42We can't use it as an excuse. We just have to do the best we can because lifting, jumping, plus or minus estrogen, plus nutrition high in protein can help you stabilize and rebuild bone. And so of those things, the best data is from estrogen and lifting. Women always ask me, especially online, but either I'm afraid or I have osteoporosis, I can't lift.

47:08Dr. Mary Claire Haver:I see a lot. Anytime I post about lifting exercises, the comments are always full with, but what if, but what if, you know, I have osteoporosis already, am I going to fracture? I have a herniated disc. I have arthritis. You know, a lot of women are already dealing with conditions that are going to make these things harder. But you know, the irony is, so Dr. Beck, who's from New Zealand, I believe, did a big study called the Lift More. And under supervision, we must be taught to lift heavy. we don't want to get hurt. In her protocol, you're lifting to failure in five reps times five sets. That is heavy.

47:47And nobody broke. And everybody built bones. No injuries. And so, yes, it can be done. And they all had osteoporosis. Oh, they were. That's entry to the study was osteoporosis. What the irony about what you just said is people think that they can't lift because they have arthritis or they can't jump because they have arthritis. When I get someone coming to me for arthritis, I don't start with the medical interventions. I start with we are going to make you strong as a bull because your butt, core, and hip strength will act as shock absorbers against the impact of your weight on your knees because regular activity exerts, you know, seven to nine times body weight on your joints.

48:29So if we don't want them to pound together, we have to build better muscle, right? People are so shocked when I say that we're going to make you strong first before we start doing all the medical stuff. But that's an approach that maybe they haven't heard at their standard doctors because you're right, we silo things. But the reality is if we want to treat the whole person, that person needs to be strong.

48:52Dr. Mary Claire Haver:Can you talk about some of the pharmaceuticals that have been developed to treat osteoporosis and when would you begin those? So there's several categories. The most common one that people are familiar with are the bisphosphonates, Fosamax. And then now there's a new category of monoclonal antibodies that work on, there's a receptor on the osteoclast that it blocks. Those medications are offered to women when they have the diagnosis of osteoporosis, which is a T-score of minus 2.5. But do you know, nearly to a woman that I see, they've all said to me, I have osteoporosis. My doctor wanted to put me on a bisphosphonate to rescue my bones, and I don't want it because of the side effects.

49:39Well, that's understandable because some of them are very terrifying sounding. But here's the reality, Mary Claire. We were talking about the women I treat and your own mama. If you get a hip fracture, 70 % of all hip fractures are in women, 30 % of the time you die in the first year from that moment, even after surgery, even after surgery from the complications, whether it's a UTI, sedentary living, bed sores, dementia, not being mobile, you lose 9 % of your muscle mass laying in bed for a week or more. These things add up in already frail people, right? 30%, you hit the floor. Those people who survive 50 % will never get to go back home because they can't get around, right?

50:26To live independently, you must be able to get up and down from a chair and do ADLs. This is why we care about fracture. Absolutely. No one would care unless the devastating outcomes of it.

50:39Dr. Mary Claire Haver:So what most women don't realize is most women are not offered any screening for osteoporosis currently. They just kind of get skipped. And most people are diagnosed with their osteoporosis at the time of fracture. You can buy a DEXA scan without a prescription. You can Google DEXA scan near me. If you don't want a DEXA scan, there's a new technology using ultrasound called a REM scanner, right? It's not as common in the United States as it is in the UK or Australia, but it's coming. And it uses ultrasound, not even x-rays to tell you bone quality because whether or not you fracture has more to do with the quality of your bone than how much mineral you have in it.

51:24Because what people don't know about bones either is that every time you take a step, if this is your femur, your leg bone, your thigh bone, it bends a little, it bends a little. And your body, knowing that, perceiving that, will build the strongest bone where you have the most bending. So the ultrasound type predictor will tell you the quality of your bone. But either one of these things, listen, can be purchased. So if you've got a clinician who just won't do it, then you can buy it yourself by saving up your Starbucks money. So do it just because we both told you to do it. But if that's not enough for you, think about these things.

52:04Is your mother shrinking? Yeah. Yeah. My mother has shrunk so much. She used to be my height. And now she's about down here, right? I can look over her head. Why are they shrinking? Because the vertebral bodies in our spine, our spinal cord is surrounded by an armor of bone. And they are like blocks, literally blocks. They sit one on top of each other. And as we lose bone, they collapse and shrink. So we lose height. So is your mother shrinking? Are you shrinking? Did you smoke when you were young because it was so cool? Smoking and nicotine is bone poison. Or did you have an illness when you were little, like asthma, where you had to take a lot of steroids chronically?

52:47Or do you have an autoimmune disease? All of these things, and many more, frankly, are risk factors for osteoporosis. Or how about this, Mary Claire? What if you're like me? You're a young athlete and you never had periods. Or maybe you had periods, but you were an athlete and never fed yourself. So all of these things could make you at risk for osteoporosis. And if you're identifying with any of these things, go get yourself a scan.

53:16Dr. Mary Claire Haver:So when should women begin to think about being proactive or just begin to be proactive about protecting their bones? How about during our fertility periods? I start talking about this and I have to be very careful with where I phrase this, but to build a baby, you are going to use at least 500 milligrams of calcium from your bones every single day. So, I mean, we're building a baby from ourselves, right? So either we're eating enough or we're taking it from ourselves. So there's a real entity called osteoporosis of pregnancy. Now, here's the good news. Our bodies are built to renew that, but only if you eat post-pregnancy.

53:55Many women are so focused on getting back in their genes that they don't eat or I may have used my breastfeeding period of life to get back to my original weight because I'm thinking, oh, I'm going to lose weight by doing this. Yeah, 500 calories a day out the breast. Yes, that was such bad thinking. Yeah, I didn't know at that point. Let's say you're breastfeeding. That requires about 500 milligrams of calcium, which we're going to take from our bones. Now hear me, audience, when I say it's not that I'm anti-breastfeeding. I breastfed for as long as my daughter would let me, right? Over a year.

54:31But unless you know that you're going to lose your bone, you can end up osteopenic or osteoporotic just from something so natural. So mothers and lactating mothers need to be really conscientious about getting enough of great nutrition to rebuild. Historically, women would have baby after baby after baby. And now what I see millennial women doing is because they're waiting a long time to have children. They're getting their babies done because before they become midlife, right? And then maybe you don't have enough time to rebuild. So it worries me that teenagers aren't building enough bone. It worries me that young mothers don't know that they need to rebuild their bones.

55:10And then if they're like me, they go straight from postpartum to perimenopause. That is a lot. They never get a

55:17Dr. Mary Claire Haver:chance because we lose 20 % in perimenopause. So yeah, they never have that chance to rebound. Yeah. So conventional wisdom, conventional medical advice that my mother and likely my grandmother got was to always fight to be in a smaller body. What is this, you know, this constant workout, you know, cardio, eat less, cardio, eat less, because if you're this size, then you're healthy. how much of this epidemic and I believe that we are living in an epidemic of frailty right now sarcopenia and osteoporosis for our women in that last decade you know how much of can we lay at the feet of we've been telling women the wrong thing I think we need to redefine what healthy is because you say all my mom knew was little little skinny to this day with her dementia I walk in the room and she comments on my size.

56:11Dr. Mary Claire Haver:Does she? You're looking nice and thin today, honey. Thanks, mom. Well, you know what? That is what she was taught. I cannot get my 86-year-old father to only compliment how I look. In fact, I got a little nasty with him. Bless his heart. It's just I said, Daddy, I'm smart. But that is the generation they grew up in. So here's what I see happening. Tell me if you think so. Our really elderly, your parent, your mother, my parents, and the baby boomers, I don't know if we'll ever get it through their head that it's okay to take up space. The Xers like us, we were raised like that. I was raised like that, where it's an aesthetic.

56:56I mean, you got to ask yourself, were we taught that really because skinny is healthy? Or were we taught that? Because in the world we were raised, there's an aesthetic of attractiveness that has to do with your size. But I am very hopeful that the millennials or definitely the generation of my 17-year-old or your daughters older than my 17-year-old will value their strength versus their thinness.

57:24Dr. Mary Claire Haver:So when I think about my exercise patterns throughout my life, when I was younger, my daughter's age, I moved my body to be thin. Yeah. So I did it for aesthetics purely. Yeah. And I thought that was healthy. And then when my 30s and 40s, I moved my body for performance. I got into racing, marathons, triathlons with my girlfriends. It really was a social thing to do. And we were healthy and we looked good. Yeah, of course. Now, this morning, I'm in the gym and I am moving my body for longevity. Yeah, that's right. What is your vision of that? What is moving your body for longevity mean? When I think of longevity, when we talk about women's longevity, all of us that are working together towards this are trying to reframe the narrative.

58:15For men, longevity, living longer is longevity and glorified in every press. Women win. When we just talk about longevity. We win. We win. We lose being six years longer anyway. But we suffer longer because we've spent our life on anti-aging. The superficial, and it's not the inside out anti-aging. It's the superficial, do we look young enough? Are we little enough, right? So we're reframing that to women living longer. Well, how do you want to live longer? I talk about in Unbreakable, what it means to me is I want to do what I want, when I want it, how I want it. I want to only ask for help if I want to ask for help, not because I can't help myself.

59:02So if you want to be independent, if you want to have the kind of relationships that fill your soul when you're older, it takes daily work now on all the kinds of things. You know, you went to the gym at five o 'clock this morning. nutrition is a huge part of your practice in your life, right? There's the daily investment of your health. That's the only way to get there. Because what happens if we just leave time to itself? Well, we don't answer the time bombs of aging. We don't build the kinds of shields that you're building from a lifestyle. And we're going to become frail.

59:36Dr. Mary Claire Haver:I don't want to burden my children. They will step up. I know my girls. You know, if I need help, they're going to come in and do it or find a really nice nursing home for me, you know, if they can't take care of me. But God, I don't want to do that to them. You don't want to. I want to die like my grandfather. He drove a truck the day he died. Oh, my gosh. You know, he drove a truck, went out about his business in his 90s. He probably should not have been driving, by the way. But he lived out in the country on a farm. They all do it. He got home, had a massive heart attack, and it was over. Me, too.

1:00:07I want to die like Queen Elizabeth, who on Tuesday met the Prime Minister of Great Britain and on Thursday just didn't wake up. Yeah. That's what I mean if I get to choose. If I could pick.

1:00:19Dr. Mary Claire Haver:What about the difference between lifespan and healthspan? And I think, you know, all this talk about anti-aging longevity and all the wellness bros saying they want to live to 120. I do not want to live to 120. It wouldn't. If it means I'm not going to have my loved ones, you know, if they die before me, I am not interested in that. And I don't have a single patient who tells me I want to live forever. Yeah. They all say, well, fix my hot flashes. Give me my life back. Okay. Now, then we sit down and say, let's talk about your mom. Let's talk about your grandmother, the women in your family, how they age.

1:00:53Dr. Mary Claire Haver:What are we looking at in the next 30 years? If you're lucky enough, if you run the cancer gauntlet and, you know, we're going to decrease that risk too with all of the exact same changes, you know. and they're like, I don't want to be a burden. Women say that to me in my office and then I'm like, great, because here's the plan we're going to start and we start building a blueprint together and one of two things happens. Either they are all for it and they're like, tell me how to do this. Set me up with a trainer. Like they are all action or this is what happens. Okay, well, I can't give up my sugar.

1:01:29Okay, and so there becomes an excuse for everything. And to which I say two things. Number one, you can't out excuse me because I've been doing this 30 years. I have an answer for every excuse. And they kind of chuckle when I say that. But number two, if you don't want to burden your children, then you better get active right now. Because that's what's going to happen. Either they're going to have to make a hard financial decision about who's paying for the nursing home, which can cost$7 ,000,$15 ,000 a month. A month. Yeah, and eat up your life savings. Or you're going to move in with somebody like my parents do, which we made that choice, right?

1:02:07All right. So it's one of those two things. So either stop making excuses, take the action you need, or just know you're going to burden somebody. When do you order a DEXA? Or when do you recommend DEXA? I order a DEXA on everybody. I think just like we get our mammograms at 40, I think we should have our screening test by 40. You should have a baseline. Let's just figure it out, whether it's REMS, whether it's DEXA, just find one. In fact, we should probably do it at 35 when we have a little bit of estrogen still circulating. To see what your peak. Your baseline. And if you're already low, then you really got to get after it because you're still probably producing some estrogen.

1:02:49Dr. Mary Claire Haver:Do you have another way to measure body composition? Like, do you have one of the impedance scales in your office? Yeah, I like, well, we have in bodies in our facility. Yeah. Yeah. I like those. I mean, I think, I don't, do you know the data? I don't know how accurate they are. I mean, they're close enough. They're close enough. Because we're actually looking for trends. Right. More than absolute numbers. Yeah. So, and for our listeners, when we talk about body composition, we're talking about not just their bone density, like we would get on a DEXA, but these scales in our office do not give us bone density.

1:03:19Dr. Mary Claire Haver:But what they do give us is they can tell us how much muscle, where the muscle is. So I can look at muscle mass, especially for my GLP-1 patients. I want to know their baseline and where we're heading throughout their treatment. It also tells us where the fat is, what type of fat. Is it visceral fat, which is around our organs? Or is it subcutaneous fat, which actually is not that harmful? No. So, yeah. Curves are good. Curves are healthy. Curves in a premenopausal woman, meaning subcutaneous fat under her skin, especially in the hips and thighs, is actually protective for your bones and cardiovascular disease because you have to carry around a little bit heavier body than someone like me who wasn't blessed with wonderful curves.

1:04:02Dr. Mary Claire Haver:Yes, there's benefits of all body types. Why is insurance company, and I think it's gatekeeping a little bit, is the decision to not have bone density. And this is based on, you know, it's not an insurance company making it independent. They're going off of guidelines. Where do you think the guidelines are wrong or, you know, are underserving women here? Well, if we're working in a disease care model, then you set the guideline for when you've got the highest probability of picking up the most disease. So it's 20 years postmenopausal, right? So it's 65. That's probably, I don't know how they were established, but probably that's what the thinking was.

1:04:39We're going to treat osteoporosis with drugs. And is their T-score likely to be low enough? Well, it's actually bad thinking. 65, right? Right. Or in Australia, 70, interestingly. Okay, if you're in a disease care model, okay, I can see why you did that. Although I know that 30-year-olds are osteoporotic, 40-year-olds. But if you're in a preventive care model like we are for breast cancer, you're going to do it much earlier because we know interventions, the longer you're preventing the less likely meaning the endocrine society data show that you need to be on estrogen optimization for 10 years to have the biggest effect on fracture risk not started at 65 when you have a bad dexas scan but it's better if you start earlier to give your bones all that runway.

1:05:38So that's why I think is is we're working in a disease care model. Let's got osteoporosis. We've got a drug for that. Let's give you the drug. We wouldn't give you the drug if you didn't have the diagnosis.

1:05:49Dr. Mary Claire Haver:So why check? And estrogen is FDA approved. And most women don't know this. Most doctors don't know this. Or the prevention of menopause. That's right. Yes, it's the only drug approved for the prevention of osteoporosis is estrogen. That's right. And the other reason I think women don't get them is, is it's not thought about in most medical circles. Right. In OBGYN, it is in our guidelines to discuss osteoporosis and to recommend like it was one of our little checkboxes. So I can say in mine, but most women stop coming to me when they're done having babies. You know, they when I was doing traditional general OBGYN gynae practice, they weren't they were like, I'm done having kids.

1:06:36Dr. Mary Claire Haver:I'm just going to go to my internist or my family medicine doctor. And I think we, as a medical specialty or, you know, all of medicine is really dropping the ball, especially for prevention in women. Well, the whole medical system is a disease care model. There's never the whole person care.

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1:10:01Let's pivot.

1:10:04Dr. Mary Claire Haver:I love that you're trained in orthopedic surgery because you were trained to treat both men and women. Yes. I don't have that privilege. I still do. So I only, the only penis I saw were baby boys at birth and I did a few circumcisions and then gave up on that practice. And then my husband's is the only one I have to tend to now. When I talk to orthopedic surgeons, especially females, when I talk to our female urology friends, people who came up through the system and treat both genders. It's shocking to them when they get out into practice and they realize the bias against women that is built into the system.

1:10:40Dr. Mary Claire Haver:So in my education, we had a term called WW or WWW, which was whiny women or whiny white women. And I talk about it in the book and I always give lectures on it. Basically, a woman in her 40s would come in with multiple vague complaints and we couldn't figure out what it was. Turns out it was probably perimenopause, some multi-system effect that she was having that we couldn't figure out. And the urologists, you know, our friends, our... Dr. Kasperson and Dr. Rubin. Dr. Rubin would say, hey, wait a minute. These patients are coming in with the same complaints. Sexual dysfunction, you know, things hurt or aren't working down there.

1:11:21Dr. Mary Claire Haver:And the men, you just go all in. You rush in to fix the problem and you give them the medication. And the women were getting pats on the head. And coconut oil or, you know, and just said, you got this, babe. Do you see the same thing? Yes, because, and I may have historically been guilty of it, because when a man comes in in midlife dragging around and multiple tendon issues, like everything hurts, multiple tendons or rupturing tendons, I test his testosterone. And then I send them off to get some testosterone, even because in men, the physiology is different. But obviously, I'm encouraging my millennial sons to get their testosterone checked in their youth.

1:12:11They're in their mid 30s, because that's how we know what to correct back to. because even if a guy in midlife rupturing all his tendons feels terrible moping around moody as heck has a testosterone that is between 250 and a thousand something which is normal if he used to be 800 in his youth and he's now 300 that's a big delta but we're sending that guy off to get some testosterone because god forbid we let anybody feel like that but when women come in and have multiple things going on, they're accused. It's all in their head. They get a psychiatric referral. Or maybe they're labeled with fibromyalgia.

1:12:57And I don't believe that everybody I say that comes in and wears that diagnosis has something like that. I think it's untreated perimenopause that affects the musculoskeletal system. So now there is parity in my clinic. But when I have queried my Instagram following, what have orthopedic surgeons said to you? What have they said? And it is appalling. It is appalling, the blaming, the dismissive, the you're just getting old. There's nothing wrong with you. It's in your head. Have you talked to your whoever about it? The musculoskeletal system is at least eight to ten, depending how granular you want to get.

1:13:40But whole organ systems, muscle, tendon, ligament, how can we just ignore that, right? So I'm this much encouraged, this much. You can even see the space here. Because I can't attract the attention of my own peers to publish these things in our own literature, to do grand rounds at our departments. Except I have to shout out Mount Sinai, which is led by a woman. We did this two years ago. The International Cartilage Research Society just called me to say, I think we're missing something. We need these researchers to learn about perimenopause. So we're sneaking in a talk to their whole assembly.

1:14:26It is a slow drip that needs to be a roaring conversation.

1:14:32Dr. Mary Claire Haver:Right. You and I both, and I'm back on as adjunct faculty, come from this academic world. And it's really, that's where the magic happens. That's where the guidelines happen. The guidelines are what insurance decides what they will and won't pay for. That's who gets screened for certain things. And I just want our listeners to understand from new research to a guideline changing on average right now is 17 years. Oh, my God. That is a generation of people. 17 years on average. Now that one of the beautiful things about the Internet, good and bad, is that now regular people, smart people, women who can make decisions for themselves actually have access to some of the medical journal articles.

1:15:19Dr. Mary Claire Haver:And they're coming in asking better questions. But, you know, we have this whole force of wonderful physicians who do care, who just weren't trained. Of course. And so where do you see, you know, what is a stopgap for this gen? These Gen Xers are not taking it. They're not having it. You know, my Gen X patients are like, absolutely not. I'm not going to live like this. Fix me. But I can't. You can't be the doctor for everyone. I can't be the doctor for everyone. Where can they go now? Like where can someone find better help? Yes. So I require women to be responsible for themselves. So they must become educated.

1:15:55So that's why I recommend the bevy of books that I discussed with you. You must get the information for yourself, number one. Number two, you can go the regular path. You can go to your primary care of your OB and have this educated discussion. And if they're not caught up with you, if they blow you off, it is okay to keep them as your disease care person. Yeah. But you must not stop there. There are so many women who write to me, they're like, my doctor said no, so I just stopped. That's not the answer. Seek out somebody who knows. So where do you find that person? Well, you're right. I can only see so many patients.

1:16:35You can only. There are many telehealth companies now that are staffed by legitimate clinicians who can expand the database. But in order to get in front of this, it has to start being taught in medical schools. So if you could design midlife care for women, what would that look like? Well, what it will look like is from the minute you, if you decide to have children or the minute you are done having children, you would automatically go into a holistic program. The whole woman preventive care model that includes education, that includes annual labs, that includes exercise teaching.

1:17:23Dr. Mary Claire Haver:So I think the takeaway here is we have to take our prevention into our own hands. We're responsible. Yeah. You can't count on the medical system. Nor should you. To, you know, be really an active partner in your prevention of disease. Right. Prevention is on us. How much protein do you shoot for in a day? Me? I shoot for 130 because that's a good weight for me. I'm short, but I'm really muscly. So that's what I need to take in a day. And it's not that much volume of food when you consider that a cup of Greek yogurt is 25 to 30. Your morning shake has 55 grams of protein, for God's sake, right?

1:18:05And you drink it. You try to knock it out. You do. So people think you have to eat this tremendous volume of food. You don't actually to get in that much.

1:18:13Dr. Mary Claire Haver:And I find when you're focusing on protein, when you're eating that much, the other stuff tends to just fall to the side. I mean, I'm eating complex carbohydrates. I'm eating plenty of healthy fats, you know, and I'm really focusing on protein and fiber are my top two goals. And I hear my daughter loves to make TikToks about meals she makes. And she's like, here's my high protein, high fiber. I'm like, I love that. You did the right thing. You did the right thing. And I know you focus on fiber. And I love to help people understand that I am not anti-carb. I am anti-simple carb and sugar because fiber often comes as carbs.

1:18:54Right. Right?

1:18:54Dr. Mary Claire Haver:Things rich in fiber are usually complex carbohydrates. That's right. So I'm not anti-carb. It's not a war against carbs. It's just who you let in. And it has to be high fiber. You have to be picky. What does an adequate workout program look like? How many days in the gym? How long should you be in the gym? So it's not about time. It's about time under tension, which means how many reps you're doing and how many sets you're doing. So no matter what kind of lifting you're doing, you need to lift to failure, meaning by the end of the set, you can't lift it anymore. So if you want to lift for endurance, you're going to lift a little tiny weight 30 times.

1:19:33That does not interest me in old age. If you want to build big muscles like bodybuilders, then you're going to lift medium reps for women. That's like 10 to 15 for four sets or so. And that's what's going to stimulate enough damage that you're going to build muscle. But in Midlife and Beyond, I teach people to lift for strength and power. Strength so that we can do what we want to do when we want to do it. And power, meaning lifting over time so that we don't fall down, that we can move quick enough to not have a fatal fall. So strength and power, take a different kind of lifting. Lifting for strength is lower reps, higher weights.

1:20:20I've been treating people for 30 years. I know people want very specific instructions. So my last lifting program, which is the one I published, was four reps, four sets. Okay. And that's all in the book. It's all in there. So what that means is when I'm doing a bench press, I can do four reps. I may be able to squeeze out five, but I'm not doing six without the bar coming down because I'm lifting to failure. And then I'm going to completely recover. I'm going to recover for two or three minutes before my next set. But this type of lifting will build our strength. And then once we're really good at it, and it might take us six months, nine months, a year, then we can add speed, meaning it'll take us three seconds to go down in a squat.

1:21:04And then we spring up in one second. That speed work helps us build the power we need to age without falling down. And so it sounds complex. It's not really once you learn this is a great time to hire a trainer for a short period of time. don't get another purse get a trainer that's what I say in the holidays but to get great benefit you can do it as little as twice a week I'd rather you do it four times a week and it doesn't take that long you can pound out a complex set in about half an hour I've seen you

1:21:39Dr. Mary Claire Haver:talk about certain tests certain milestones that women should meet and the gym bros love to talk about this. I posted a video of myself doing pushups. You sure did. When you talked about a woman should be able to do 11 pushups and I got, it went viral, not because I was doing 11 pushups because every personal trainer in America jumped in about my form, which needed some work, but okay. So we've got the 11 pushup test. Don't worry about it. Yes. Uh, what else is there? I want to clarify why we even do things like that. Because the response I got, whether it was the push-ups challenge or the sit-to-stand challenge, meaning can you get up and down off the ground without using your hands or your knees, or there's a pistol squat, anything, anything.

1:22:31The point is not, or I'll say it another way, more than 90 % of the time, women responded like you do. They're like, can I do this? I'm going to try to do this. I'm going to get better at this. Let's challenge ourselves. Let's be positive about the future. There were a small percentage of women and Jim Brose who came on and said things like, why are you shaming women? Why are you isolating and excluding people? To which I say, why do you expect so little from women? Why do you think that we can't do hard things? Because we birthed the babies in this world, right? We do hard things already. We figure it out.

1:23:12So when I do those kinds of challenges, it's aspirational because there is a line called the frailty line where your VO2 max, your fitness is so low, you can't get up from a chair by yourself. that is the day you have to be moved into assisted living whether it's with your kid or in a home because you can't get up from a chair yourself nobody wants to pass that line yeah and we can build that so that's the purpose of all these tests whether it's push-ups which tells you what your upper body strength is what your core is whether it's grip strength it's testing your grip strength online which we have all done is not about how strong your hand is and squeezing a tennis ball.

1:23:56It is a measure of your total body strength such that if you have a decrease in five kilograms of grip strength, it infers a increase in all-cause mortality of 16%. It's big. It's not about squeezing a tennis ball. It's about your total body strength. That's what those are for.

1:24:13Dr. Mary Claire Haver:Well, I've loved having you on today. Thank you so much. I have a few questions I kind of ask everyone um what is the best part of this stage of your life right now i may have come to this late in my life but this is the most authentic i've ever been people are surprised when they meet me they're like oh you're just the same as you are online i'm like there's only one me the most authentic the most confident because i think that we learn from the memory of our successes and I have figured out a lot of stuff in my life and I know I can figure anything out. I've said this to you before, because I am in a male field, I have more professional support now and I don't even know the right word to say, camaraderie, collegiate, whatever, than I have ever had.

1:25:09And from that, I mean, it's you, it's the extended group of people that we the menopause. It's the menopause. It's the five of us that talk every day. That enables me to go further, faster, harder. And I've never had that before.

1:25:26Dr. Mary Claire Haver:It's wonderful. What are your non-negotiables? Like, how do you take care of you? What does Vonda do? You know, we have a thing in the menopause is what would Vonda do? Oh my gosh, you guys. Because she's our touchstone. A lifestyle person. Like, none of us want to end up in a nursing home. So you are my nursing home prevention program. Oh my gosh. Well, if that's the truth, then you're going to be in bed at the same time every night and you're going to get up at the same time every day when you can because you are not going to compromise on your sleep, which is completely restorative. And that includes anything that might muck it up.

1:25:57Alcohol. Alcohol. Drama. Eating too late. Stress at night. I am not compromising on that, number one. Number two, at this point, eating the way I eat is just the way I eat. It's not a burden. It's not a diet. It's a lifestyle. With the protein, with the fiber, with the knowing what I'm eating, it doesn't mean that I don't occasionally have sugar. But it's not how I used to live, which was always having sugar, right? Non-negotiable. And then it's lifting weights. whether you know when I'm traveling it's very hard so sometimes it's just push-ups on the in the hotel room or anything I can fit in you know what I like people to remember as we've just laid out a bunch of things to do right do this do that and it can be overwhelming but we have to return to what do we value and why do we even want to do this but the number one reason has to be because you believe that you are worth it.

1:27:04You believe that you are worth the daily investment of your health, not because your children need you, not because something else, you as a person have value and worth and you are worth the work.

1:27:17Dr. Mary Claire Haver:What I'm finding in menopause and with my patients, with myself, with my girlfriends, is that they are, something about menopause kind of crystallizes that acknowledgement, that if I don't do this, no one's coming to save me. There's no hero. You have to be the hero of your own story. You have to be the CEO of your own healthcare. Thank you so much for joining me. I've told you this before, but you've changed my life. You've changed my patients' lives. You've changed the way I practice medicine. And I could not be more grateful for you joining us today on Unpaused and for your support through all of this.

1:27:59Dr. Mary Claire Haver:It's my privilege. As a reminder to our audience, her book Unbreakable is available now and listeners can also check out her podcast, Hot For Your Health, wherever they get their podcast and follow her on Instagram at Dr. Vonda Wright. 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 the honest, accurate information on health, fitness and navigating midlife at thepawslife.com. You can also find full episodes on YouTube at Dr. Mary Claire. Unpaused is presented by Odyssey in collaboration with Pod People. I'm your host, Dr.

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