Menopause and Heart Disease: What Every Woman Needs to Know with Dr. Jayne Morgan

22:45Dr. Mary Claire Haver:Yeah. That delay is the difference between not only life and death, but the difference between whether or not you can be restored back to full quality of life or whether you will have some deficits. We're going to talk about the numbers. So women are far more likely to be mismanaged in the emergency department when presenting with heart attack symptoms. One, because we're trained, chest pain, shortness of breath, you know, radiating down your left arm, where women are coming in with fatigue. Abdominal symptoms, you know, just very nonspecific, these atypical symptoms. One study found that women under 55, so younger than me, were seven times more likely than a man to be sent home from the ER while actively having a heart attack.

23:35Yeah. Yeah. Isn't that crazy? It's insane. And I'll tell you what's even more insane is that it's not that women don't recognize our symptoms. It's that the health system doesn't recognize them. It's not. I don't want to lay this at the - Yeah, we're not teaching women. We don't teach women and we don't even teach our doctors. So nobody knows. So the woman comes in after she's delayed, right? Her fatigue and nausea for a week or two. Finally, she can't take it anymore. She's done all of her home remedies. It's not working. Everybody's eating the same food. She doesn't know why she's nauseous, blah, blah, blah.

24:11She comes in and then you get to the health system. You think they're going to jump right on it. No, they're not. You're coming in with nausea. You probably will sit in the waiting room because for someone who's more critical and more acute. So it's a double-edged sword and we're getting it from both sides.

24:28Dr. Mary Claire Haver:One of the things I've learned in the last probably two and a half years, which was never taught to me, was these symptoms are different because where these blockages occur are different. So explain to our listeners the differences between where the blockages occur in men and where the blockages typically occur in women. Men, when we have these symptoms, this sudden onset of chest pain and shortness of breath, it's because there's a blockage in one of the main arteries that is feeding the heart. The widowmaker. And a widowmaker is very specific. But it can be at any of these arteries, but it blocks the artery.

25:04And therefore, it blocks oxygen immediately from reaching the heart muscle. And the muscle starts to die immediately. And you get these symptoms. Now, women, what happens to us? our arteries are a little bit smaller, and we generally don't get this one big blockage. Think of it like a big ball that comes through and just gets lodged. We end up with a studded pattern of plaques. So atherosclerosis, those are plaques, like fatty plaque deposits. And we just get them studded along the arteries. And so blood can still go through, but it's kind of meandering. And so over time, you have decreased blood supply, which means decreased oxygen supply, but it's not cut off entirely.

25:49So there are certain situations where you might feel worse, for instance, eating, where now blood is being driven more to the GI system, where you now will feel chest pain when you're eating because these blockages don't completely close off the artery. And blood is able to get through. And when I say blood, think about oxygen because oxygen is being carried in the blood. And so we get kind of these vaguer symptoms.

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27:59Dr. Mary Claire Haver:Tomorrow morning is knocking. Stock your fridge now. How about a creamy mocha frappuccino drink? or a sweet vanilla, smooth caramel maybe, or a white chocolate mocha. Whichever you choose, delicious coffee awaits. Find Starbucks Frappuccino drinks wherever you buy your groceries. So let's talk about diagnostics. I remember my dad had an MI, and so he had a stress test, and they put dye in his blood vessels to look at the blood flowing around the hearts. Is that really as effective in women? Like the way we diagnose heart attacks, would you change that to make it more inclusive of how women's heart disease progresses?

28:40Dr. Mary Claire Haver:A couple of things. I would say it's still an appropriate diagnostic workup for women. The stress test. The stress test. Okay. And so for our listeners, a stress test is we do something to stress the heart. Put you on a treadmill or give you a medication that'll stress out the heart. And the reason that I think it's still a very valid test is because of what I just described. We've got this studying in the arteries where the woman is not symptomatic all of the time, but when her system is under stress and even eating can be stressed because the blood can then be redeployed elsewhere. So when the body's under stress, then you get those symptoms.

29:12So a stress test would actually bring that out if you've got just kind of this studying. And if we do something that further decreases that blood supply, we'll be able to see a change. There's definitely still a place for stress testing there. and nuclear stress testing. Women also get something called, you know, microvascular disease, where we don't necessarily have blockages in these main arteries, right? And they're harder to find. That's right. They're much harder to find. These microvascular capillaries studded. And oftentimes, this is what we see in women who still have chest pain, who are still complaining of symptoms, who are still complaining of feeling unwell when all of their cardiac workup has been normal, but the cardiac workup is looking at these big vessels, and those big vessels are more often impacted by men.

30:03We have a long way to go. Because even microvascular disease is still poorly recognized.

30:08Dr. Mary Claire Haver:I've only heard of it in the last two years, in one of your talks. And I'm like, wait, what? We have diffuse microvascular disease instead of these big LADs or the larger arteries. We can have that, but we can't. We tend to trend that way. All right, so let's talk about these risk factors. What are they? So you have a woman coming to your office, and she's 50 years old and says, am I at risk for heart disease? So what are these risk factors we're gonna talk to her about? Yeah, so she's at risk for heart disease just based on her age. So let's start there, just at 50. And these are the conversations that women don't have.

30:44And oftentimes they come in, and maybe they, quote unquote, are feeling fine. You know how we always say that. If there's not something major going on with us, we say we're feeling fine. How are you feeling? I'm feeling fine. When really there are about 75 things going on with you that you haven't been able to figure out. And so what needs to happen is that doctors need to begin to probe women on any number of perimenopausal symptoms. The reason is not because it's bothering a woman to the point that maybe she wants to have some intervention. Every perimenopausal symptom, you know, is not intolerable.

31:22However, it gives an indicator and it's a marker of an increased risk of heart disease. And that's why the question should be answered. You certainly also want to provide relief if she's suffering and is uncomfortable. But the other reason to ask is to try to get a determination about where she is in her heart health risk. Because we know that prior to menopause, a woman's risk of heart disease is less than half that of a man. not half, it's less. And then once she reaches menopause, it equals that. And then by the time she's in her 70s, it actually surpasses. And so what is happening during this timeframe where we're completely ignoring women and the symptoms are good indicators of the fluctuations of the estrogen levels?

32:10It doesn't mean that your estrogen is just, you know, going straight downhill, but it could be fluctuating. And it's actually those fluctuations that are causing all of these different symptoms because... So what specific symptoms are you referring to? So any number of symptoms, and people may not know, and I'll tell you what mine were. Itchy ears. My ears just started to itch. Literally one day, my ears were itching. Now, I live in Georgia, big allergy person, so I assume that they were allergies. Didn't do anything other than all of a sudden now, every single morning, I have to take a Q-tip and scratch my ear.

32:45And at first you think your ear's dirty, but your ear is never dirty. The Q-tip is perfectly clean. You just have to scratch every morning and then it would go away. So that's sort of, this is a great example of, it just became a part of my morning routine. You don't think about it. It itches, you scratch it, it goes away. Yeah, most women, that's a viral video for me

33:03Dr. Mary Claire Haver:is talking about itchy ears in perimenopause and menopause. And for the listeners in menopause, we lose the ability, the transepidermal water loss. We lose a tremendous amount of fluid through the skin. We lose collagen. and we lose oil production. So that makes dry, itchy skin. And all of that kind of gets into the ear canal and it's unbearable. You can't scratch in there on a regular basis to relieve that itch. And so that is one of the signs. Talk to me specifically about hot flashes. And most women don't realize that is tied directly to cardiovascular risk. Yeah, and you know what's interesting is that at the American College of Cardiology Conference in 2024, they presented a paper looking at the number of hot flashes that a woman has.

33:48They looked at the number from one to six in a week. And I know some of your listeners are screaming, in a week, I have six in an hour. I'm just telling you how the research was set up. So they looked at hot flashes one to six in a week and they measured the carotid arteries. So the carotid arteries are the two big arteries on either side of your neck that feed the blood to the brain. They feed oxygen to the brain. And they looked at what we call CIMT, carotid intimal media thickness. That's a big term that basically just means we just were trying to see if the arteries were narrowing or not, whether they were getting narrower or not.

34:24And so when they looked at this and they looked at the women who were having the most hot flashes, so six per week, they actually had a greater narrowing of their carotid arteries, the lumen, the inside, than those who had one hot flash per week. And what that means, the interpretation for physicians is, as your carotid arteries narrow, your risk of stroke increases. So what inherently that paper was telling us was that women who had more hot flashes had a greater risk of stroke. And then we went on to talk about what that means for heart disease and the narrowing of our arteries as well with these numbers of hot flashes.

35:09And so it became clear that, as I often say, hot flashes are not just like, ha ha. We see people, we laugh, we give them a fan, we see them take off their jacket, everyone's sweating, it's funny. Oh, she's having a hot flash. Actually, what this woman is screaming at you is, my risk of heart disease is increasing. My risk of stroke is increasing. If you look at it that way, it's not ha ha. and women literally are sweating to tell you, please do something. My risk of heart disease is increasing. My risk of stroke is increasing. And so that's why it's incredibly important to continue to do this research to make certain that we understand, again, connecting the dots.

35:51It's not all about feeling comfortable. It's not the complaining woman. Women have had hot flashes for centuries. Why is it a problem for you? Well, here's why it's a problem for me. It's a problem for me because it increases my risk of heart disease and stroke. And I'll tell you something. When you talk about our ancestors in centuries, we didn't really live that long. Exactly. Mostly because we were dying of heart disease and stroke. And heart disease is still the number one killer of women. And heart and brain health are also closely interconnected. And so what's happening to my heart is happening to my brain.

36:22And what's happening to my brain is happening to my heart. Thank you very much. Yeah.

36:25Dr. Mary Claire Haver:Let's play a wishing game. Okay. You mentioned research. I've heard that the philanthropist Melinda Gates has committed$100 million to women's health research. So if I wrote you a check right now, what would you, you know, in particularly for areas like cardiovascular disease and menopause, what would you build? I would design a study probably looking at specific hormone levels and fluctuations and arterial disease. And not only the arteries of the heart, but also the vasculature of the body. And I think I would look to draw direct correlations between hormone windows, not necessarily what the actual level is, but the hormone windows because they can fluctuate and dark line towards increased risk of heart disease, increased risk of stroke, and what that means.

37:30And I think so far, that's what we are missing in sort of this whole cardiology, menopause, women's health world. And quite frankly, it's not our fault. The reason we're missing it is because we're not included in clinical trials. And since we're not included in clinical trials, we don't get therapy for the things that we need. and we just extrapolate data. And we really do harm, not only to women, we do harm to populations of color. We do these clinical trials, mostly on white men. The majority of research is done on them and we just extrapolate it to everybody else. So the only thing we really know is that the drugs and devices work in white men.

38:07That's the only thing we can absolutely say for sure. We don't know about anyone else. And you know, I just came from the European Society of Cardiology Conference in Madrid this year. fascinating and tragic paper presented looking at beta blockers. Now, beta blockers are a type of blood pressure medication that we've used for decades in cardiology to manage people after they've had a heart attack. It's supposed to prevent you from having another heart attack. All the trials have supported it. Of course, all the trials were done on men. Turns out now, in the paper that was presented, that when beta blockers, these same medications are given to women after they've had a heart attack, they're more likely to go on to a second heart attack, more likely to be admitted to hospitals for heart failure, and three times as likely to die.

39:01Yeah. That's why we need sex-specific, gender-specific research. Men and women are biologically different. And just like all of those women in my training where I knew something was going on, but I kept asking my professors and they assured me that I was insane. And no, this is what the books say. Follow me and I'm following the authority figures. Here's another great example of we just got it wrong and we've got to begin to do research with women in them because we're killing women in a well-meaning fashion. Right, no one's - We're simply applying information without knowing it. And I'm going to just defend my profession for just a moment.

39:42Doctors like myself have no idea where these drugs come from, right? We train, we teach. Our job is to learn what the medications are, how they act, what their physiologic purpose is, any side effects, what their interactions are. It never occurs to us to say, hey, I wonder where this came from and how did the research even get started? And how many women were in the trial? How many people were in the trial? Nothing. Even for me, I didn't begin to think about that. I was definitely more of a mature doctor and had started doing research. And as I started to do research and we were enrolling in trials, that was the first time it occurred to me.

40:25Research now is big for students. But when I came along, we didn't really do research. Only the weird nerd who was getting the MD, PhD was doing research. The rest of us were studying clinical medicine. So in defense of my profession, we assume that when we get an FDA approved drug and they tell us that it can be used on men and women, that in fact, it can be used on men and women. But now we know that that is not true.

40:50Dr. Mary Claire Haver:It feels like the bad news keeps coming. Women are more likely than men to die after a first heart attack, more likely to develop heart failure after a heart attack and more likely to be disabled by stroke. And you talk about, we've tolerated this discrepancy for a long time. but I'm really excited to hear your voice, other voices really starting to point this out. I mean, and I live in the menoverse. Yes, you do. And so my social media shows me a lot of menopause content and I'm seeing more and more clinicians stepping forward to say, this is not okay. What changes do you see in your world and your social media?

41:28Dr. Mary Claire Haver:Like going to this conference and this paper being presented. So, so critically important. American Stroke Association, last year for the first time included menopause guidelines in the Stroke Association. Hello. We were so happy to hear that. That was just incredible. The American Heart Association this year has included for the first time pregnancy guidelines. And your listeners may say, what's the big deal about pregnancy guidelines? The big deal about pregnancy guidelines is that they showed up in the cardiology guidelines. That's what's the big deal. Yeah, so if you have preeclampsia or pregnancy-induced hypertension, you are at increased risk.

42:10Dr. Mary Claire Haver:And if you're not screening your patients for this, you're going to miss an early heart attack. That's right. Not only are you going to miss it, but the window of opportunity. We talked earlier about all of us trained in these silos. There needs to be cross-talk because pregnancy complications are risk factors for heart disease that handoff doesn't happen often. The integration of a cardiologist onto the team doesn't happen. Education to the patient doesn't happen. She has declared in her pregnancy that she has failed the stress test. And then for some reason, the system doesn't follow up on her failed stress test.

42:43She just goes off to have her heart attack. So that's why it's so exciting that for the first time, pregnancy is in a cardiology guideline. And here's what's going to be interesting. We are more immersed in this and we talk about it a lot. But most cardiologists will have never, ever heard of this. Why is pregnancy in the guidelines? What is this? But when they even finally get around to reading the guidelines. Because, you know, everybody's busy. So the academicians will learn of it first. They're reading, oh, what does this mean? But that's the scary part is that. How long it takes to propagate.

43:21How long it takes to get the information out. But getting it out and getting guidelines is at least the first step. And to see something that's considered obstetrics in the cardiology guidelines was just huge. So finally, hello, this is a cardiology issue. This is not just an obstetric gynecology issue. That's them over there in the happy land over in the LND. We should be involved and we need to understand what women's health is all about. It's not just reproduction.

43:53Dr. Mary Claire Haver:So let's talk about statins specifically in my clinic, and this holds in the data. And something I did not understand about menopause is the effect on cardiovascular risk factors, specifically lipids. So there's about a 20 % elevation of LDL and ApoBs, they're getting more data about it. So talk about all these patients are coming in. My doctor told me to get on a statin because my cholesterol is elevated. And I feel like there's a gap on the cardiology end because they don't understand where hormones are play, you know, what the play is here. How would you counsel that patient? A couple of things.

44:29I'm going to come at this so it's from a number of angles. I'm first going to start with statins. Statins are under-prescribed to women, underutilized, under-discussed, especially when we talk about men. Women don't get the same information on statins. Number two, we talk about statins. There's always been information that makes people wary of using them, and mostly because of a U-shaped curve where there is the lower dose is effective and you get to higher doses, it might be toxic. And then if you mix in menopause and nobody really understanding it or talking about it, doctors have no idea what's happening with the woman in front of them and not understanding that cholesterol levels are rising because estrogen levels are dropping.

45:18There's not a big comprehensive focus and picture on it. So statins aren't discussed. Estrogen is not discussed. Menopause is not discussed. It's just not discussed. And off she goes, you know, try to lose weight. You should exercise. Why don't you take a vacation? Right. The same old thing. Have an antidepressant. It's the same old thing. And yet there really are options. Now, other thing is I sit on the steering committee for LP little a therapy for Novartis. What is LP little a? So LP little a is a genetic type of cholesterol that is actually more deleterious than LDL, which is what we call now the bad cholesterol.

46:00I hate these labels bad and good, but the LDL, it's LP little a that drives a lot of the genetic components of heart disease because really 80 % of heart disease is preventable. There's only 20 % that's some genetic component to it, some congenital anomalies or LP little a. The rest really is all lifestyle, behavior, choices, lack of medical information, lack of medical curiosity. And so when you look at LP little a, when we talk about people with elevated cholesterol, it's something that women should measure. certainly if you are either black, African-American or Southeast Asian, but it's still actually fairly common in the white population as well.

46:44I do see it in our eyes. Check it on everyone. You should. And so when we look at LP little a, part of the reason that we haven't checked it in the past, and here's a little secret for medicine. The reason we haven't checked it is that there really isn't any therapy for it. There's nothing we can do about it. And so here's one of the little dark secrets of medicine. We don't really like checking for stuff that we can't treat. We can't fix it. So why look for it? Because what am I going to do about it later? But here's the thing. You actually can do something about it. We can aggressively intervene, driving your LDL down very, very low, trying to get your HDL, the good cholesterol up, making sure your blood pressure is at goal or below, working on your weight.

47:23If you have diabetes, getting it under strict, strict, strict control. If you're smoking, quitting. If you're drinking alcohol, stopping. All of these things to actually decrease your risk. And again, diet, diet, diet, diet. What kinds of foods are you eating? How are we going to adjust that? And then what's happening? So on Novartis, I'm on the steering committee of this. We are bringing forward a drug called Pellicarsin. It looks as if as we are rounding out our phase three trials. I just looked at this data. This will be the first therapy that comes to market that is a treatment for LP little a.

47:56Now, here's a couple of reasons why I bring that up. Speaking of women's health, we really don't know what's going on with LP little a either. Here's how we're taught. LP little a doesn't change in a lifetime, and you only need to draw it once. I'm challenging that personally, and I certainly have these discussions, because when we talk about women in menopause, you're making that statement without any information at all. And we have no idea if LP little a changes during perimenopause and menopause. And so we actually do need to draw it more than once in women. That's the world according to Dr.

48:31Jane Morgan. that women should have your LP little a drawn prior to menopause. And then it should also be drawn during perimenopause and maybe even a third time on the other side and get an idea of whether or not this value does change in women because the data that we have via which we make the recommendation that LP little a is a once in a lifetime blood draw was based on men. And we're just applying it to women.

49:02Dr. Mary Claire Haver:Ah, so let's talk about hormone therapy and cardiovascular disease. Has hormone therapy shown reductions in cardiovascular mortality in women? So when we look at, let's go all the way back to the Women's Health Initiative, and you know what was both interesting and tragic about this study is that there was a cohort of black women in the study, all of whom had had hysterectomies for any number of historical reasons that Black women are advised to have hysterectomies more often than white women. This group of women just was, they were not their own cohort. They were just in the trial. The whole Women's Health Initiative just kind of went off the rails.

49:43When we go back now and look at it and actually look at just the Black women, most of whom had had hysterectomies. And so - So they were on estrogen only. Only on estrogen. This cohort that had really been abused by the medical system, they were there with their hysterectomies, like so many black women, were just mixed in. No one bothered to look at them as a group. And it turns out this might be the most important group because when we look at the subgroup analysis, these women, since they didn't have hysterectomies, only got estrogen. They didn't get estrogen and progesterone. Remember, it was the estrogen and progesterone combinations that were so dangerous for breast cancer.

50:23They had a decreased rate of breast cancer. and a decreased rate of heart disease in these women. That was never published because nobody ever bothered to look. Nobody ever thought about it. But this actually may be the most significant group when we take a look at that and continue to look at what their indices are going forward with regard to what estrogen does in the body.

50:43Dr. Mary Claire Haver:The timing hypothesis, when they initially, the results were released and the world went crazy and so much of it has been walked back. But in the AHA published in Circulation in 2020, the El Cujadri big article. And then HOTUS, I believe, and Mac looked at the article about time and timing. So when they went back and looked at the data, specifically age, so women who were within 10 years of menopause or before the age of 60 and started on either arm, so estrogen, so the hysterectomy patients, largely African-American, and then the patients on both, it appeared that estrogen started early was protective.

51:28Dr. Mary Claire Haver:And I even saw in the article, they were showing pictures of the arteries and what happens through the menopause process with an acceleration of the calcification of the plaques. Whereas women on hormone therapy, you kind of just held at the plaque stage and didn't progress to the more aggressive calcified plaques. And - I don't think most physicians realize that. I certainly didn't. I would say almost no physician realizes that. How protective. You know, now once those plaques get calcified, estrogen is not helpful. You know, so it seems like it's better. We don't know. We don't know. What do we need?

52:01We don't know that. And I think the thought is changing. You know, I think about these cases and our work on protocols. You know, this, you know, the window of opportunity. Does that mean that women over the age of 60 should not be started on estrogen? Does it mean that women who have some established heart disease should not be started on estrogen? Currently, that answer is no, but it's maybe sliding. In the first year of starting estrogen, for women more than 10 years out than menopause, that you have an increased risk of a heart attack. Most of that risk is in the first four months. The question is, which is why we need studies, is the women who have some established heart disease, are they not the ones who actually could benefit the most from estrogen?

52:47What we really don't know, just like statins, One thing about statins is the, another positive thing about statins is statins are one of the only medications that actually have shown a regression of plaque lesions when you use them. I wonder if estrogen is another one that will show a regression of plaque lesions. I don't know that. I'm just saying there's a blind spot again. And now we are excluding women over the age of 60 because we've got this information and we don't, we don't really know.

53:28Dr. Mary Claire Haver:We'll see you next time.

53:51Dr. Mary Claire Haver:Know your sleep score with Apple Watch. iPhone 11 or later required.

54:20Dr. Mary Claire Haver:vary by state. At REI Co-op, we've got the gear that makes camp easy. A tent that sets up in seconds. A chair you could fall asleep in. A cooler that keeps things chill. So you can get to the good stuff. Late night laughs, endless stars, and stories you'll tell again and again. REI Co-op. Camp solved. Shop in store or at rei.com. Many of us in the menopause are, if they have risk factors and we don't have a history of established heart disease, we send them for the calcium cardiac score. Now explain to our listeners what that is and do you think it's really, is this something women should be doing?

55:08Yeah. So the calcium score looks at the amount of calcified plaques in your arteries. And the calcium score does not determine what your workup is. It is a risk predictor model of 10-year risk. So zero is your normal score. This is a test that you actually want to fail and get none of the questions correct. You want to get a zero. Zero means normal, no plaque at all. If your number is higher, let's say it's one or 10 or 14. How is it scored? Like to a thousand? It can be scored, yes. But even one is considered abnormal. But you're right. There are different ranges, right? So zero to 100 may mean one thing.

55:49As far as your risk, it is a risk predictor. It does not drive you on to other types of tests. It is a risk predictor. And it helps us guide and give advice on a woman's health. It is a tool. It's like a tool to give us a risk prediction of what this heart disease risk is in this woman. Do you have a cutoff where you're like, I'm not going to give her hormone therapy? So even though there's not really a cutoff, I would say definitely calcium score is over 100. So far, probably are excluded. Did you know I am waffling because I don't want to be a part of this whole thought that has harmed women over years.

56:41Okay. On the other hand, I also don't want to harm women. Right. Yeah. So this is back where we're sort of in this dearth of information. Right. And we're trying to figure it out while we wait for trials to come forward.

56:54Dr. Mary Claire Haver:So what would you tell a patient who comes to your office and she's bypassed her, you know, menopause specialist? She comes to you first and she's symptomatic, late perimenopause, early menopause. No history of heart disease, but she's terrified of hormone therapy because of the WHI messaging around heart disease. How would you counsel her? Okay, she's symptomatic with heart symptoms. I'm thinking of my end of the world. She's the classic menopause symptoms. First of all, hormone therapy is not for everyone. Part of women's health is we have the autonomy to make decisions for ourselves. Decide for yourself.

57:27We are here to give you information. Now, the fear, I don't know what the fear would be of hormone therapy, but she sounds as if she's an ideal candidate for it. And so I think we began to counsel her about, you know, what's really bothering her. If her symptoms are very bothersome, she may want to consider taking it just for a period of time to relieve her symptoms, to see how she feels. It may be a way to start these conversations. But I think for me, the bigger conversation I like to have with women is heart disease risk. The life today that you want 20 years from now and looking out in your family and looking out in the women in your family.

58:07So it's not all about relieving your symptoms, but it's important to feel good to relieve your symptoms. But also think that it decreases your risk of dementia. It decreases your risk of heart disease. How are you going to think about estrogen therapy in that context? In the preventative context. Beyond OBGYN.

58:28Dr. Mary Claire Haver:So there's some pushback from people in charge, from the older messaging. We shouldn't be talking about prevention, even though it's FDA approved for hormone therapy for the prevention of osteoporosis. But whenever I talk about the preventative aspects in brain health and in heart health, You know, there's a little bit of pushback from the people who write some of the guidelines, not all. Do you feel like we're heading in that direction, that these guidelines will change? So I think the guidelines will change. Now, how quickly they will change. Just in the whole political arena that we find ourselves in where, you know, we're struggling to even use the word woman in research, which is just insane to me.

59:08Dr. Mary Claire Haver:We need gender-specific research. I'm sorry. Our women are going to continue to suffer. Literally, I had an editor write back because I had submitted a paper and was trying not to use the word woman because I thought that was the new rule. And I was trying to say, and the female, and literally they wrote back and I was happy to hear that. They said, woman is the appropriate term. And I thought, thank you. I'm struggling here. But people's research was slashed for using the word woman. So when you say, how long will it take? You know, I would like to say not long, but then there's a part of me that just says, this is just going to be a slog fest.

59:47Trying to kind of break through the patriarchy that knows best and has always known best. And in knowing best, we've gotten beta blockers that have killed us. You know, and we've gotten these terms that are killing us atypical and poor outcome.

1:00:05Dr. Mary Claire Haver:Yeah, if I had a twin brother, He has a 15 % higher chance of surviving a heart attack than I do. That's right. And that the system wasn't really built to serve us. That's right. But that's why education and us. Education is important. And I'm working on legislation as well in the state of Georgia just to see if we can even just start to teach it in medical schools. Teach it in internal medicine training. And I'm not even saying teach it at a deep level. Can we just say the word menopause? Have the students aware that, oh, this is something I need to be thinking about. So I'm just starting at the very, very, very basics.

1:00:39But my legislation is focused more on heart health and menopause, but it's also generally focused on, could we just have some teaching?

1:00:46Dr. Mary Claire Haver:The American Heart Association has called menopause a critical window for cardiovascular disease prevention, at least on paper. But most midlife women aren't hearing this from their doctors yet. I mean, should, let's reiterate this one more time. this should be central to everybody's education, which is your point? It should certainly be central to cardiology. And cardiology, in many ways, is the furthest away from menopause. I mean, we really... And there's such a tight link between the two. We really think of it as those people over there in labor and delivery. It's just a word that has no context to a cardiologist.

1:01:27Just baffling. why why even even if someone came to a cardiologist and was talking about menopause cardiologists would just be baffled as to why what is going on so there's even that level of just awareness and again if we can start to just at least get some of the words into our guidelines then someone has said them when we look up the guidelines they're going to come up on somebody's screen to say, wait, what is this? Let me refresh my screen. What is this?

1:01:58Dr. Mary Claire Haver:Let's talk about early menopause, premature ovarian, especially your surgical menopause or chemotherapy induced or radiation and the risk of heart disease. Right. And the risk of heart disease does increase the earlier menopause. And it's one of the things I talk about, especially with black women, because we tend to go into menopause earlier. 18 months. And, you know, weathering is a big reason for that. And for weathering, it's just the constancy of high effort coping in a society that's both gender conscious and race conscious. And what it's like to live in a society that is constantly aware of those two things.

1:02:38And you're constantly trying to push against it. Trying to validate your medical credentials. No matter how many times you walk into the room and introduce yourself as a doctor. they still are going to talk to the most junior person who's the white male or ask when the doctor is going to come into the room. So those kinds of things where it's just the socialization, the constancy of raising your children in this society, they have to be raised differently. You're cautioning them differently. Getting a driver's license is not such a fun time. You know, it's a celebratory, but now it's like all this other worry of you're going to be profiled, especially if you've got sons and Black women who are mothers of Black sons report the highest degree of stress and the highest degree of weathering.

1:03:24So most of my thought comes from this weathering process that drives an earlier menopause in women, in Black women, and drives a more accelerated path towards heart disease and a more accelerated path towards stroke. And so we know from that information on the weathering that early menopause does increase your risk.

1:03:50Dr. Mary Claire Haver:So I was taught that this was pure biology, that people of color had increased risk of disease because their genes were different and they were just biologically programmed to do that. And that stress and lifestyle would compound that, but this is basically a biological difference. Right. Again, this is what I'm saying. We come through the system. You know, I was taught the same thing and I'm black. You know what I mean? You're just kind of like, oh, is that true? He said it's true. It doesn't sound true, but he's the professor. Is that true? And you just look, you know what I mean? You just, you get all these mixed things where inside you're like, I kind of don't think that's true, but he's the one with all the power, right?

1:04:32You're powerless. So you don't buck the system and you just think about these things.

1:04:36Dr. Mary Claire Haver:All right, let's talk about polycystic ovarian syndrome and the risk of heart disease. So it increases your risk, correct? It increases your risk long term. But when we look at polycystic ovarian syndrome, we have to think about all of the cardiometabolic components that come with that. And it's almost very similar to LP little a without therapy. You've got to drive all those risk factors down to almost being negligible. You've got to be able to focus on those risk factors. The 80 % you talked about that we can control. That's right. You can control that 80%. Now, I'm saying this. I want to be clear.

1:05:08I'm not saying it's easy. It's hard. It's an upward battle. And we ask women to do so many things. And now we're saying, hey, look, control your weight. Control your exercise. Make sure you're moving. Do your cholesterol. Sleep eight hours. Sleep eight hours. You know what I mean? I know you're probably listening to me going, lady, for crying out loud, I've got enough going on. But the fact of the matter is trying to control those indices as much as possible continues to mitigate your risk.

1:05:38Dr. Mary Claire Haver:So risk for heart disease for women, smoking, weight or visceral fat, blood pressure, lipids. So that's going to be cholesterol, specifically the LDL and the apobie and the LPD. And triglycerides. Triglycerides. Okay. When should we be screening for that? Like when should you go get your blood work done for lipids? When would you, for average woman? I think you should be screened at every physical exam. 25? 25 years of age. I agree. Because I totally agree. Men get their blood work done. Why don't we get our blood work done? We don't get EKGs. We don't get blood panels. We're just all. I have my daughters checked.

1:06:18That's right. So it should be a part of your annual physical exam, your battery of just standard blood tests that are being done. Routine screening. Routine screening. The reason that it's not done in women, I keep going back to this theme, is that women's health is considered to be all about reproduction. So you see your OBGYN and the OBGYN is focused on those things to keep you healthy in their reproductive system. So you don't get the battery of blood work where the man is over with the primary care physician having another focus. and we really should be seeing both doctors. And probably about 15 years ago, I started to preach that to say, women need a primary care physician and a gynecologist.

1:07:02We should be seeing both, which I know now it's two visits in a year. But the fact of the matter is, the two focus on two different things. And we should be doing that.

1:07:17Dr. Mary Claire Haver:Now for a MidiPause, sponsored by MidiHealth. If you're in midlife and feeling bloated, sluggish, or frustrated that the same diet you've always followed suddenly isn't working, you're not imagining it. As estrogen levels drop, we lose some of estrogen's protective effect on metabolism, heart health, and gut function. This shift can mean slower digestion, rising cholesterol, more insulin resistance, and potentially more belly fat. This is where getting enough fiber becomes critical. I recommend women get 25 to 30 grams of fiber per day, and it doesn't have to be complicated. Simply add a tablespoon or two of chia, flax, or hemp to your meals.

1:07:59Dr. Mary Claire Haver:Include lentils, beans, berries, avocados, whole grains, and other fruits and vegetables into your daily menu. If you fall short, don't worry. Supplement the gap with a high-quality fiber supplement. Remember, this isn't about dieting. It's about supporting your body's changing needs. Menopause is a biological transition, not a decline. When we understand how nutrition supports it, we can all thrive. Yeah, reproductive health is important. It is so important, but it's so often. It's the only doctor my patients are coming to see is their pap smear. And on a wing and a prayer that we're getting everything else they need for their routine screening.

1:08:39Even for me. I mean, listen, I'm a doctor in the system. I only saw OBGYNs. I never had a primary care. I had a pediatrician and I had an OBGYN for like 30 years. And sometimes I would just say, because I'm a doctor, I'd say, hey, could you draw my cholesterol? And it's never occurring to me that I'm sort of doing a one-off medicine. I'm getting these things done because I'm asking my buddy to draw them for me. But what's the average woman?

1:09:05Dr. Mary Claire Haver:And you've got 15 minutes for your well-woman exam and 10 of that is in stirrups. Right. You know, getting your specific kind of important stuff. Right. Okay, so we've talked about hot flashes or in medicine, we call vasomotor symptoms, but inflammatory markers, back to labs. Do you draw inflammatory markers? Do you find them helpful? So here's the answer to that. Most people, especially when you're looking at black women, have chronic inflammation. You can oftentimes look at people or take their history and know they've got chronic inflammation. I don't know if the markers are going to give me any more information.

1:09:38You just talk to the patient. You're just talking to the patient. Right. Just talk to the patient. And sometimes, you know, we do have to think about finances and what's going to be reimbursed and all those kinds of things.

1:09:49Dr. Mary Claire Haver:So also sleep disturbance and depression during menopause have all been linked to higher cardiovascular disease risk. Should we be treating this as a cardiovascular red flag rather than just a quality of life issue? And at least sleep is recognized by the American Heart Association. In fact, it's the duration of sleep. How much sleep? Five hours or less is a risk factor for heart disease. We need to get five hours or more. Now, I think we probably need more than five hours, but that was the cutoff for the study. And then what happens during menopause? Not only do we might get five hours, but it would be fractured.

1:10:23So it has to be five consecutive duration of five hours, not the fractured five hours of sleep that you might get. And you're in the bed for 10 hours, which you only really slept for five and you're waking up and you had insomnia. That actually is a risk factor still for heart disease.

1:10:37Dr. Mary Claire Haver:Okay. Talk to me about arterial stiffening. This is a new term for me and menopause. Because we have estrogen receptors on our arteries, we have them in our hearts, we have them in our arteries, we have them in our brains, we have them in our bones, we have them everywhere. Because we have them in our arteries, as we go through perimenopause and our estrogen levels begin to fluctuate and begin to decrease, we have less binding of estrogen to the receptors on our arteries, our arterial walls, so inside of those arteries. Now, what does estrogen do to the arteries? Estrogen creates something called compliance, meaning it allows the arteries to expand and contract.

1:11:16Think of it that way, kind of like a balloon or stretchy or rubber man. And that compliance allows us to regulate your blood pressure. The arteries kind of expand and contract. When we have less estrogen binding to the receptors, the arteries then become stiffer. They become more like tubes, rigid. And your blood pressure then starts to creep up. And that's important because you won't feel it. You feel the same. There is no symptom for high blood pressure for the most part. When it's very high, you might have headaches or vision issues. If you have headaches or high blood pressure, you need to go to the ER.

1:11:58But for the most part, high blood pressure as well as high cholesterol are silent. You don't necessarily feel them until you have an event. And in cardiology, when we say an event, we mean a heart attack or a stroke. You don't want to have an event. But that's what happens during perimenopause. And oftentimes, women are unaware of it because their whole lives they've had normal blood pressure. And it literally can happen in between the one year that you last saw your physician and your next physician. And I'll tell you what happened to me. Again, I'm just another cog in the wheel of the system.

1:12:32Like, I have all of this information and all of these degrees and training. And literally, I didn't know what was happening. My doctors didn't know what was happening. So I go to my doctor one year, my blood pressure's high. And she says, oh, your blood pressure's high. And I go, oh, that's weird. She says, oh, that ear's weird. You're probably rushing. And we went on with the physical exam and off I go. That's it. That was it. Like, yeah, you're rushing. That can't be right. Your blood pressure's been normal your whole life. Didn't see her again for another year. Next year I came in, she says, blood pressure's up.

1:13:02She's like, oh, you know what? It was up last year. Why don't you sit and let's just take a few breaths. You're just doing so much. I see you now. You're busy. So I stopped. We took the breaths, blah, blah, blah. Pressure came down a little bit, but it didn't come down that much. She said, you know what? I think you just are coming in here and rushing in. Just go back home. And then next week or so, take your blood pressure somewhere and send me the reading or whatever. And of course, you know, I never did that. And even me, not only have I had normal blood pressure, my blood pressure ran low.

1:13:34So that can't be right. How old were you? Oh my gosh. Was I 50? Okay. Now we're in the third year, right? I'm just living my life. Third year coming in for my physical exam. Blood pressure's up again. And she says, I don't know. Should I prescribe something for you? She says, you know what? I'm going to let you decide. She prescribed medication. I'm going to let you decide. And if you want to take it, take it. If you don't, don't. And I didn't want to take it. I was like, why would I take blood pressure? I have normal blood pressure. I think I'm just running around when I come in here. Another year goes by, right?

1:14:06But I have a prescription now. I've got a prescription. You're in year four now. Nobody's talking about perimenopause. Nobody's talking about, all they're talking about is, your blood pressure's always been low. This must just be some aberration for you. Nobody knows anything about menopause. So then I come in on year five and now it's higher. And we both decide, let's just take it for a while and see how it goes. And I've been on blood pressure ever since. It took five years to diagnose high blood pressure in me because it had always been normal and no one knew anything, including myself, about perimenopause or menopause.

1:14:43Dr. Mary Claire Haver:I've said those exact words to patients because I didn't know that there was a connection between hypertension and menopause in most of my career. I mean, I've admitted freely I was a horrible menopause doctor for probably 20 years. And those exact words, let's just recheck it. Blood pressure is a silent killer. So it's just insane that I'm in the system and I can't even get care. I don't even understand it. I didn't understand my itchy ears. I didn't understand that my blood pressure was going up. I developed vertigo, went to a neurologist. Nobody could find anything. You know what they told me?

1:15:20And eventually I thought it worked. I'm a big Pilates instructor, big Pilates enthusiast. They said, oh, you know, that's right. You're going to invert doing Pilates. Just, you know, I said, oh my God, I'm going to fall over. No, but try to hold the pose as long as you can before you fall over. And over time, you'll reset your cochlear, your vestibular nucleus, and you'll get over there. But we can't find anything wrong. And so there I am in downward dog and Pilates trying not to fall on my head and have a cervical fracture. So, I mean, insane. Yeah, even you, the most educated, the most. Insane.

1:15:55Now, eventually, my vertigo went away, and I credited Pilates with it.

1:16:02Dr. Mary Claire Haver:You've heard me talk about the care gap in menopause. How women's symptoms are often dismissed or left untreated. I see it all the time in my practice. There are many women struggling for answers, unsure where to turn, and too often not getting the support they need. That's why I'm so excited to tell you about MidiHealth. MidiHealth is a telehealth clinic focused exclusively on women in midlife. Led by trusted medical leaders and clinicians, the team is committed to evidence-based whole person care. They're also the only national women's health teleclinic covered by major insurance, making expert care accessible and affordable.

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1:17:18Dr. Mary Claire Haver:All right, I would be, before we wrap up, talk to me about GLP-1s and the intersection between the use of this and cardiovascular disease? GLP-1s definitely have a place in cardiology. And certainly we've seen the data. And by GLP-1s, we mean the Sozempic, Wagovi. They definitely have a place in cardiology as we have seen data showing that they decrease heart failure over time. You know, what's also interesting about them is when we're talking about women in menopause, when we're talking about visceral fat and weight gain and cholesterol and hypertension and all those things kind of go together.

1:17:57Like where you see one, you see the other. But it's not only, it's sort of like bedfellows. They just hang out together. If you can really intervene on one, the others also benefit. Right. So if you can help a woman lose weight, she also has less visceral fat. Her blood pressure also decreases. Cholesterol also drops. So all of these things are actually great outcomes. So what is the caveat? The caveat to that is that there seems to be no way to come off of them permanently. The patients who are on them either regain the weight or have to have some level of GLP-1 as a lifetime maintenance. And that is a choice that people will just have to make with regard to what they want to do with them.

1:18:47I am not against them. I think they certainly have a place in cardiology. They have a place in menopause as well. They have a place in health. We are seeing data about decreased cancer rates as well. But, you know, I can imagine we'll start to see data on the other side of the coin at some point. The concern, if it's a concern, I guess the consideration is maybe a better term is when you start this, think about it almost like blood pressure pills. It's something you need to think about for the rest of your life currently because there is nothing else. And if you become dependent on the GLP-1s to control your weight and control your indices and your blood pressure, that's fine.

1:19:25You will still continue to have to use it from time to time. You'll have to have kind of like these little touch-ups. You'll have to keep using it.

1:19:32Dr. Mary Claire Haver:To wrap it up for our listeners, what are the specific steps that women can take to decrease their risk of cardiovascular disease and stroke? So if a woman is coming to me at midlife, I'm going to first ask about all kinds of perimenopausal symptoms. and they are like, depending on what you read, 35 to 60. I mean, I'm 70. I've got about 70. And I'm going to skew towards the high end. I've seen 35 to 60. I'm going to say 60. But now Mary Claire says 70. I'm going to agree with her 70 because I think it's probably 200, but we're still naming them. And so having any number of symptoms related to perimenopause, I'm going to begin to talk with her about her cardiovascular risk.

1:20:09That conversation is going to include not only the control of symptoms for comfort, but what are we going to do to actually decrease that cardiovascular risk? And oftentimes, that's going to include a discussion about hormone therapy. It's going to include a discussion about estrogen and progesterone. Now, we no longer give oral estrogen. By the way, that's what the Women's Health Initiative was, oral doses of estrogen, meaning by mouth. So, we're going to talk about other formulations, generally, usually the patch or a gel or a cream and make a determination about where you are. So, you know, every therapy is not right for every person, even if I think it's right for you.

1:20:52Part of women's health is also making the best decision for yourself with the most informed information, not with misinformation. Yeah. And so that's something that I really want to talk with patients about. and that is utilizing hormone therapy to begin to control, mitigate the risk of heart disease as you are going through this transitional period. The upside is that you'll have better control of all those vasomotor symptoms, so the hot flashes. So I think people like to take it because they want to control the hot flashes. They want to control the night sweats. I actually think - I was created.

1:21:35Right. But I actually think the upside is that you want to mitigate your heart disease risk. And the benefit is you get all of these basal motor symptoms that end up being under control as well. So I really want to focus on heart health. I also really want to focus on brain health because heart attacks and strokes are so intertwined. Dementia and heart disease, so intertwined and where you see one, you generally see the other. And that's just another area where we've got to begin to think about these two things together. And what about lifestyle? Lifestyle is always important. So we're talking about that 80%, right?

1:22:1380 % of people can do something about heart disease. That's not inevitable. So lifestyle is important. The human body is made to move. We don't move anymore. And I often liken it to a car, a car that you love. You love it so much you don't even drive it. And then when you go to drive it, what happens? It has a hard time starting if it starts at all because it hasn't been utilized. Cars, in order for them to work optimally, actually have to be driven. The body also has to be used. So you've got to be able to move. Now, I'm in digital health, and part of what I do in digital health and artificial intelligence is make your life easier so you don't have to move.

1:22:54So this is an oxymoron, right? So this is the age in which we're living. We don't move anymore just with our activities of daily living. We used to get dressed and make your breakfast and walk out to the car and have to open the car door, close the car door, put on your seatbelt, drive to work, get out of the car, walk into the office. And then you generally maybe joined a group of people. You walked down the street to lunch. You came back. You walked to meetings. So think about all of that activity. It was just built into non-exercise. You weren't even exercising. You're just at work. What'd you do today?

1:23:29I was just at work. And then you might come and exercise on the weekends. We don't even get that anymore. And so the body was made to move. Movement is probably the key index that I try to talk with people about all of the time. If there's one thing that you can do, I'd like for people to move. It's the second thing you can do. If you're prescribed medications, please take them. Don't be like me or my doctor on year four or whatever. We did prescribe it, and I still didn't take it for another year because I still didn't believe that I had blood pressure.

1:23:59Dr. Mary Claire Haver:So menopause often feels like society wants us to hit pause. What have you decided to unpause for yourself in your personal journey, and what did that open up in your life? I have decided to unpause societal limitations. I have decided to stop showing up the way society wants me to be. I love this. The good girl, the compliant person, always doing the right thing, the good minority. Don't be afraid of me. Don't be intimidated. Don't be threatened. Let me do twice as much work for you so you can continue to be dismissive of me. Because the more I do, actually, the less you respect me, not the more that you respect me.

1:24:46I have decided to stop making people feel comfortable with my presence. I love that. That's what I have decided to stop doing. I love that.

1:24:52Dr. Mary Claire Haver:I love that. And women are benefiting from it. So because you are standing up for them in the rooms and at the tables that they don't have access to. Yeah. So thank you for that. Thank you. I really appreciate you coming. I think our listeners are going to learn so much from this and be so motivated and keep educated themselves and keep fighting for their own heart health and brain health. Uncovered windows can make your home feel up to 20 degrees hotter. Stay cool and save up to 50 % off custom window treatments during the 4th of July mega sale at blinds.com. From outdoor shades to room darkening blinds, finding the perfect fit is easy.

1:25:28Dr. Mary Claire Haver:Get free samples, expert design help, and professional measure and install services. Or DIY with confidence and support every step of the way. Shop up to 50 % off site-wide, plus huge savings on doorbusters right now during the 4th of July mega sale at blinds.com. As a reminder to our audience, you can follow Dr. Morgan on social media, on Instagram, TikTok, YouTube, Facebook at Dr. Jane Morgan, J-A-Y-N-E and on LinkedIn at Jane Morgan, M-D. 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, accurate information on health, fitness and navigating midlife at thepauzelife.com.

1:26:14Dr. Mary Claire Haver:If you're loving this podcast, be sure to click follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and give us a like 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 the 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.