Menopause Masterclass: Hormones, Brain Fog, Weight & Mental Health with Dr. Mary Claire Haver

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2:42The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. I'm Dr. Mary Claire Haver, a board-certified obstetrician, gynecologist, and certified menopause practitioner. I am also an adjunct professor of obstetrics and Gynecology at the University of Texas Medical Branch. Welcome to Unpause, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life.

3:22So welcome to my very first AMA or Ask Me Anything. We got so many questions when I solicited on Instagram. What do you guys want to know about? But I think we first really need to start with basic definitions. So what is menopause and how do we define it? Unfortunately, in medicine, we define menopause as one year after the last menstrual period. Now, what happens if you don't have regular periods? If you've had a hysterectomy or if you are having a Mirena IUD or some reason why you don't have a normal cycle, do you get left behind? And what if it's leap year? Do we go one extra day or 366 days?

4:00What menopause represents is the end of production of hormones from your ovaries. And why does this happen? human females are born with their entire egg supply. What I think every woman really, really needs to understand is why we go through menopause. So human females are different than human males on multiple levels. But from an endocrinological perspective, women are born with their entire egg supply. Men get to make their stuff fresh every day in the testicles until they die. So when we are in our mother's womb, so in medicine, we say in utero, when you're about five months along, your mother is pregnant, you're five months along, and the DNA, the genetic material for your children is inside of your grandmother, if you think about that.

4:50It's kind of fascinating. So you have several million eggs there, and they start deteriorating immediately while you're still in the womb. So that by the time you're born, you are down to already one to two million eggs at birth. You continue to lose them on a pretty steady state basis, and that is from a process called atresia. Atresia, I like to think of it as kind of survival of the fittest. You slowly tick off the less healthy eggs so that the most healthy and viable eggs will survive. By the time you start ovulating, you are down to about 120 ,000. And then by the time you are 30, you're down to 10 % of the original egg supply.

5:31And then by the time you are 40, you are down to 3 % of the original egg supply. Now, where do we go from here? Menopause is basically you run out of eggs. Now, let's talk about ovulation and how that happens. Before puberty, when we're children, there is kind of breaks put on the ovulation system. And that is to give your body a chance to grow and to get to some kind of an adult state. When that break comes off, we begin ovulating. So ovulation actually for us as women starts in the brain, not in the ovaries. The ovaries are sitting there just waiting for instructions to be told what to do. There's two glands in the brain that are important here.

6:12One is called the hypothalamus and the other is called the pituitary gland. So the hypothalamus is the master regulator of our sex hormones as females. So the hypothalamus has like, imagine a little finger in the blood supply, a little probe, and it is checking for estrogen levels. And in our natural cycle, when the estrogen levels get low at the end of the cycle, the brain says, hey, where's my estrogen? It sends a signal called GnRH to the pituitary gland that says, pituitary, we need estrogen. Send your signals down to the ovary. And that basically causes the ovulation. So we end up with this beautiful EKG-like ebb and flow of our hormones, FSH and LH from the pituitary gland, and then estradiol and progesterone from the ovaries.

6:59Mid-cycle, we see the surge of estrogen basically in preparation for a pregnancy. And then we have progesterone that rises in the second half of the cycle. And that beautiful process in a healthy female goes like clockwork month after month after month after month until she reaches our next definition, perimenopause. Perimenopause is you reach some critical egg threshold level, and it's different for every woman. Where the signals coming from the brain don't work. The ovaries become resistant. We don't have enough eggs to respond in the same manner that we used to. So signals come, the brain's like low estrogen, boom, starts sending that FSH and LH down to the ovary and the ovary's struggling to respond.

7:44The brain becomes agitated. The brain is, the hypothalamus is like, where's my estrogen? The pituitary is like, boss, I sent the signal. And the hypothalamus is like, send more. We've got to get this estrogen up. So what happens is the pituitary starts sending higher and higher levels of those stimulating hormones, the LH and the FSH, to the ovaries to force the ovulation. That creates chaos in the brain, and the brain hates chaos. So quite often, the first sign that we see in perimenopause is not cycle dysregulation. That is late in perimenopause. It is brain fog, mental health changes, and sometimes just feeling, I don't feel like myself.

8:26Something's not right. Clinically, when my patients come in and I think about the 20-ish years, 15 years that I practiced before I truly understood perimenopause and menopause and the whole multi-organ system effects that it could have. I knew that people had vaginal dryness. I knew that people would have hot flashes. I knew that their cycles would become irregular and then stop. But what I didn't really understand was what was happening in their brain. And for most patients, when you really look at the things starting in the brain, the fatigue, the sleep disruption, the mental health changes, the just not feeling something is wrong and you can't put your finger on it.

9:04That is perimenopause. So remember our definition of menopause. One day after your last menstrual period. Remember one day. Just one. That is menopause. Everything after that, the next 30 to 40 to 50 years if we're lucky, is postmenopause. So postmenopause represents the entire lifespan that we have where we have to learn how to live without the hormones produced in our ovaries. So let's get into some questions. Which organ systems are affected by estrogen deprivation or menopause? Well, that's a really good question. I talked earlier about what I was taught would happen. So I knew genital urinary changes, the bladder, the vagina mostly.

9:50I knew about the period disruptions and I knew that our bones would begin to crumble, but I did not understand. No one taught me until three or four years ago about what happens in the brain, what happens in the heart, what happens in the bones, what happens in the musculoskeletal system, what happens in the liver, what happens in our joints. So one of the papers that truly changed my life was researchers mapped out where the estrogen receptors were in the body. And that took my breath away. I had no idea that so many organ systems could be affected, that symptoms like palpitation, like frozen shoulder, like elevated cholesterol, like insulin resistance, prediabetes are all having to do with menopause.

10:43The natural estrogen in our systems, while we're still ovulating and healthy, is very protective of the human body. It protects our joints. It protects our liver function. It protects the way we process glucose. It determines where and how we store fat. And that was mind-blowing to me. So let's talk about symptoms. When I was researching for the new menopause, I was trying to find as much medical evidence and papers that were written, and actually there's quite a few, that demonstrated from organ system to organ system what symptoms might be experienced by a woman going through perimenopause from the estrogen deprivation.

11:22And are you ready for this? Breast tenderness, brain fog, arthritis, acid reflux, body composition changes, belly fat, brittle nails, arthralgia, body odor, asthma, bloating, anxiety, depression, burning sensation in the mouth or tongue, autoimmune disease, new or worsening, dry skin, sleep disruption, chronic fatigue, dizzy spells, dry eyes, decreased desire or libido issues, dry mouth, eczema, fatigue, headaches, fibromyalgia, frozen shoulder, hot flashes, palpitations, incontinence, insulin resistance, bloating, gastrointestinal problems, electric shock sensations in the skin, irregular heartbeat, also known as palpitations, genital urinary syndrome, vaginal dryness, recurrent UTIs, difficulty concentrating, high cholesterol, high triglycerides, irritability, joint pain, itchy ears, itchy skin, kidney stones, memory issues, mental health disorder, migraines, and the list goes on and on.

12:09And I need to add heightened hearing because my husband chewing is absolutely intolerable to me at this point. Perimenopause begins 7 to 10 years before your period stops, at least. So remember, the average age of menopause is 51. Normal, meaning under the normal curve, is 46 to 55. Let's do math and back that up 7 to 10 years. It is completely reasonable and expected and predictable for a woman as young as 35 to 36 to begin having any or all of the symptoms that I listed before. So Dr. Haver, talk to me about weight gain and menopause. So when I talk about weight gain and menopause, you will see, I see it on social media all the time, a lot of the wellness crowd saying menopause does not cause weight gain.

13:03What that means is that when we look at age-matched patients, Menopause, regardless of their menopause status, they are all gaining weight. So it's hard to blame menopause on that. However, what we do see is body composition changes, loss of muscle. So muscle weighs more than fat, as we all know, but fat takes up more space. So we are seeing expansion of the body fat compartment, especially in what we call the viscera in medicine, which you would call belly fat. This is a very specific type of fat that wraps around our internal organs. And it acts very differently than subcutaneous fat. Subcutaneous fat is the fat under our skin.

13:43It's heavily tied to our genetics of how and where we store fat when we are younger. And subcutaneous fat is not inherently dangerous unless you have a critical mass that is causing wear and tear on your joints. It's not really metabolically active, not nearly to the degree that visceral fat is. Visceral fat expands dramatically across the menopause transition, and there is no denying this. So, for example, a premenopausal woman, on average, of her total body fat, about 8 % is visceral. Take her through the menopause transition, put her into menopause. We now go from 8 % to about 20 % to 23%. So almost tripling the amount of fat with not one single change in diet and exercise.

14:32So why does this belly fat happen? That's a great question. So when we take estrogen away and out of the system, several things start happening. Estrogen is a powerful anti-inflammatory hormone. So we see systemic inflammatory markers rise. things like interleukin, things like C-reactive protein, go up without estrogen there to kind of hold them back. When our body is more inflamed, we tend to drive fat to the visceral cavity, to the abdomen. When we have fat there, the more fat we have, that fat itself pumps out more inflammatory cytokines, these chemical messengers that raise our blood levels of inflammation.

15:10So we end up in this really crazy negative feedback cycle, more inflammation driving more fat to the abdomen, causing more inflammation. Second thing we also see is effects in the liver, how our body processes cholesterol. We see a dramatic increase in our LDL levels and a slight decrease in our HDL levels. And if you haven't learned this, LDL is the bad cholesterol, more likely to be related to cardiovascular disease, and HDL is the good and protective cholesterol. One final thing to remember is how your body processes glucose changes dramatically across the menopause transition. We see elevations in insulin resistance, pre-diabetes, and full diabetes.

15:55For example, a woman with pre-diabetes who is started on hormone therapy, not birth control pills, but menopausal hormone therapy in perimenopause, who is pre-diabetic, has a 50 % decreased risk of developing full diabetes versus a woman not on HRT.

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17:04Dr. Mary Claire Haver:Don't miss The Lady, streaming March 18th, only on BritBox. Watch with a free trial at BritBox.com. Perimenopause is not early menopause. It is its own distinct biological phase. And it has been largely ignored. My new book, The New Perimenopause, is about the 7 to 10 years before your period stopped. A transition that is anything but gentle. Hormones fluctuate wildly. And for many women, this is when the anxiety, brain fog, sleep disruption, weight changes, mood shifts, joint pain, and that unsettling feeling of, I don't feel like myself anymore, begin. Long before anyone says the word menopause.

17:50Dr. Mary Claire Haver:Perimenopause often starts quietly. It shows up in the brain first, then the body, then everywhere else. And too often, women are told nothing is wrong. I wrote the new perimenopause because you deserve answers before things spiral. You deserve care before burnout. And you deserve a clear roadmap for a transition that medicine has ignored for far too long. The new perimenopause is now available for pre-order everywhere books are sold. Learn more and pre-order your copy at thepawselife.com. Eczema is unpredictable. But you can flare less with EpGliss, a once-monthly treatment for moderate to severe eczema.

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19:02EBCLIS can be used with or without topical corticosteroids. Don't use if you're allergic to EBCLIS. Allergic reactions can occur that can be severe. Eye problems can occur. Tell your doctor if you have new or worsening eye problems. You should not receive a live vaccine when treated with EBCLIS. Before starting EBCLIS, tell your doctor if you have a parasitic infection. Ask your doctor about EBCLIS and visit EBCLIS.lily.com or call 1-800-LILY-RX or 1-800-545-5979. So Dr. Haver, talk to me about mental health changes across perimenopause and menopause. Why am I having increasing anxiety? That's a great question.

19:36There's a few things going on. The zone of chaos, increasing levels of inflammation in the brain. Also, estrogen and progesterone and likely testosterone all have direct effects on our neurotransmitters. And neurotransmitters are things like dopamine and serotonin. These are the chemical messengers that go from neuron to neuron in the brain. And when we're, for example, when we're treating depression, we are giving you medication that changes the level of these neurotransmitters between those neurons. So imagine all of a sudden your brain is very used to having certain amounts of hormones come and go throughout the month and you're doing great.

20:13Okay, or say you had a previous history of depression or anxiety that was well controlled on your medications. And all of a sudden you get to perimenopause. the brain's going through its hormonal chaos, your serotonin and norepinephrine and dopamine levels are starting to shift, and you are starting to have not only cognitive changes like brain fog, difficulty finding words, word salad, but you are also having a new onset of depression or anxiety or previously well-controlled medication is no longer giving you the symptom relief that you need. What we found when I was researching for the new perimenopause is that women who are treated with hormone therapy in perimenopause as a first-line therapy or an adjunct, if they're already on antidepressants, this is really the gold standard now.

21:03Not to start someone who was doing great in life, all of a sudden has new depression and anxiety in perimenopause. We want to stabilize from hormones with menopausal hormone therapy, and those patients are doing quite well. So first-line therapy should be hormone therapy, and then if needed, secondarily adding an antidepressant if needed. Should not be first-line therapy. It's also worth noting that we're doing a terrible job educating our clinicians about menopause and mental health. We're actually doing a terrible job educating them about menopause and anything. Recent survey done, only about 8 % of residents felt competent to treat menopause when they graduated from OB-GYN training programs, and only about 23 % admitted that they got any training in menopause at all.

21:55And that's just OB-GYN. That's not including family medicine and internal medicine, all of the people who are seeing women on the front line. So you hearing me say giving hormone therapy as first line for mental health changes in the perimenopause transition may be the first time your clinician hears any of this. Because even with CME, the continuing medical education, so once we get out of our training and our residencies, we are required to keep our board certification up by recertifying on usually a yearly basis, which means keeping up with the latest changes. but the boards are not selecting menopause-related articles to put in front of their clinicians.

22:37And many of them are using guidelines that are very, very dated. So you may have to educate your clinician or seek out a menopause-educated clinician to get the care that you need. One of the most popular topics that we were asked to cover was concerning changes to the vagina, the bladder, the vulva, something we lump together in my world called GSM, or genital urinary syndrome of menopause. That name is probably not the best because you can have general urinary changes from being postpartum, from being perimenopausal, from any time that your body is experiencing low estrogen. Our bodies, remember as we said earlier, have estrogen receptors everywhere, but really, really lots and lots and lots of them and are critical to the health of our bladder.

23:23our urethra which is the tube that drains the bladder out into the world the vulva you should know what a vulva is by now but if not it is the labia majora the labia minora all of the kind of outside skin in our pelvic area and the vagina when we take estrogen away or it begins to fluctuate and decline in perimenopause and then we take it away the skin the mucosa you know the inside skin is called mucosa the outside is just called skin becomes thinner we lose about 30 percent of all of our skin's collagen in the first five years of menopause, and I do not have to tell a woman that, she knows that, and we can talk about wrinkles on another podcast, we lose transepidomal water.

24:01So our ability to make mucus, the tissue thins, we lose elasticity. So the vagina becomes very easily damaged from regular intercourse, things that never hurt you before. We have recurrent UTIs because estrogen protects the microbiome, which protects the poop bugs from making it up into the urethra. And let me tell you, the number one treatment for the prevention of recurrent urinary tract infections is not antibiotics. You should not be on antibiotics as a first-line therapy. You should be on vaginal estrogen. Vaginal estrogen is local therapy. it is to quote Dr. Kelly Kaspersen, it is skin care for down there.

24:44It does not absorb systemically. So the warning labels and everything that applies to systemic estrogen does not count for vaginal estrogen. In my world, in the menopause, many of us believe that all women in perimenopause and beyond should be on prophylactic vaginal estrogen. Why would we wait until the vagina breaks before we decide to treat it? Why are we waiting for women to have a certain level of suffering before we offer them treatment? You actually should never suffer at all. Prophylactic vaginal estrogen is safe. Even if you have active breast cancer, you can use it. You know, it is probably the most undersung hero of the entire pelvic organ area, and I recommend it for everyone.

25:32So I did talk about this on a podcast with Corinne Mett, and you should go back and watch it. But in case you missed it, so here's my vaginal estrogen story. I had maybe six months between diagnosing menopause or figuring out it was menopausal and starting hormone therapy. Again, I started hormone therapy in the era where I was still afraid of it. I still believed the 2002 study. The American College of OB-GYN had not updated their guidelines. It still says for severe symptoms only for the lowest dose for the shortest amount of time. Now, the Menopause Society has updated their guidelines since 2022.

26:07And I follow those guidelines. But at the time, I didn't even know the Menopause Society existed. It kind of started as a rogue organization of a bunch of concerned physicians that the American College of OB-GYN was not addressing menopause adequately and they wanted to make their own society. But that's a whole political conversation we'll have later. However, I'm on reluctantly on hormone therapy and thought, I don't need vaginal estrogen. I'm covered. I'm on systemic estrogen. Why would I need it? And I was having no symptoms. So fast forward, no symptoms that I could recognize. I, about two years ago, I started noticing that I was struggling with orgasm.

26:46What used to take just a few minutes was taking longer and longer and longer. All the, you know, we were doing all the usual things to bring out this miraculous event. And it was just taking, it was so frustrating. I just remember being incredibly, incredibly frustrated. I wasn't having dryness. I was, and we always use lubricant though. so I wouldn't really know if I was having dryness. You know, I wasn't having any of the classic symptoms. And I myself, as a menopause expert, who talks about menopause all day on the internet, did not realize that my delayed orgasms could be and were a sign of genital urinary syndrome of menopause.

27:21I was probably having clitoral atrophy from not enough estrogen, making it through my bloodstream to get to the genital urinary tissues. And I was having poor blood flow to the area. So I'm on the phone with my bestie, my minnow bestie, Corinne Min, talking to her about this and how frustrating it is. And we were talking about vibrators at the time. And I was like, I don't know about this vibrator. It's not working. I'm taking forever. I don't know what's going on. And she's like, well, how much vaginal estrogen are you on? And I started laughing. And I was like calling myself out saying, none.