Menopause Masterclass: HRT Safety, Patch Absorption, Progesterone Intolerance, and Bone Density

27:05Dr. Mary Claire Haver:So if you start hormone therapy in the hopes your arthritis will get better or in the hopes your anxiety or insomnia, you know, or joint pain will get better and it doesn't, you know, we can do a couple of things. You know, I am always, when my patients come into clinic, I am not so interested in what their actual hormone, you know, other than testosterone, you know, and if I can't determine if she's fully menopausal or not yet, you know, we'll check hormone levels, but they're not as important as me ruling out other stuff. Hypothyroidism, looking for autoimmune thyroiditis, looking at autoimmune disease markers, looking at inflammation markers, looking at key nutrition labs.

27:44Dr. Mary Claire Haver:We do all of this for our patients because so much of this is intertwined. A lot of the, you know, in the columns of hypothyroidism and menopause, so many of the symptoms check off the same. So I need to rule out these other conditions or rule them in. All of this can be happening at the same time. So if you are on hormone therapy and certain parts of your presentation are not getting better, I check a level. What is your estradiol level doing? You know, if you're having persistent inflammation, I'm checking inflammation markers. I'm looking at your thyroid labs again. Like, did we miss something?

28:18Dr. Mary Claire Haver:So then we can go up on the dose. and see how you do, or we can start looking for other ways to treat those symptoms and conditions. Is this the best it will get, or do I need dose-forming timing changes, including testosterone? I want everyone to be living their best life, and I really think you can. I really think the last quarter of your life, the last third of your life, should be the best in your life. You have the most wisdom. You should be surrounded by the most love. You should be the most confident that you've ever, ever, ever been. You know, hormone therapy can go a long way to help restore balance when you've lost it, but it's not a miracle.

29:03Dr. Mary Claire Haver:You have to prioritize yourself. No one is coming to save you. You have to start putting yourself, your health, your life, your sanity first. Putting up boundaries, letting your grown ass children take care of themselves, letting your partners in life or whoever do their share of the domestic labor. Like this is the time for you to focus on you. So we are checking on our patients and she comes in and she's like, I am living my best life. I feel absolutely amazing. I have zero complaints today. Thank you for giving me my resilience back, you know, with whatever concoction we gave her. I'm not changing her dose based on some random mass lab marker.

29:44Dr. Mary Claire Haver:We're going to get her bone density. We're going to look for certain things. But like if she comes in saying she's doing amazing and all of her screening tests look good, we're keeping her on that dose. So it doesn't, you know, necessarily require adjustments at that point. Oh, this one's so good. Okay. Bleeding and uterine safety is the next caveat. Is spotting normal when starting or changing estrogen doses. Yes. Okay. Everybody gather around. 50 % of you will have unscheduled vaginal bleeding when you start hormone therapy. 50 % more with transdermal than with oral. Let me be clear. 50 % of you will have unscheduled vaginal bleeding.

30:27Dr. Mary Claire Haver:It is normal. It is expected and it is not pathologic. Your uterus is getting used to having hormones thrown at it again, and it tends to bleed. Now, good news, it usually goes away on its own with no treatment. You do not need a biopsy or a workup. And if any clinicians are listening, do not put these women through biopsies and hysteroscopies and DNCs until it's been six months and the bleeding has not resolved. You can go lower on the estrogen, go higher on the progestogen to get the bleeding. As long as you've determined you've done an exam and the bleeding is not coming from the vagina, it's coming from the endometrium, you can monitor her for a few months, change the doses around, see.

31:10Dr. Mary Claire Haver:Now, if the bleeding is persistent and you've done a workup and everything's normal, we have options. There is something called DuaVee or DuaVe. I don't even know how to pronounce it correctly. D-U-A-V-E-E. It is a combination of primarin plus basodoxyphine. Basodoxyphene is a serum similar to tamoxifen, okay, tamoxifen, but it binds, blocks, and downregulates the estrogen receptors only in the breast tissue and the uterus. So for my patients, our patients who are having persistent bleeding or very high risk for breast cancer, we are usually going with DUA-V for those patients to bind, block, and downregulate the estrogen receptors in the breast, and then they don't bleed.

31:53Dr. Mary Claire Haver:They just don't bleed. It's a wonderful side effect of that particular formulation. The problem is there's no generic. It's one standard dose. It doesn't work for everyone. But I just want everyone to know that there is an option. Are vaginal or alternative progesterone routes better for endometrial protection? We don't really know if they're better for endometrial protection. When our patients are having progesterone intolerance, meaning they're having side effects. They feel dizzy. I was on crinone for fertility and I had horrible dizziness in the operating room. Like I was a resident doing all these fertility treatments and I used a certain progestogen and it made me loopy.

32:34Dr. Mary Claire Haver:So I get it. Some people have about, we think 10 to 15 % will have an adverse reaction to progesterone. So you can go vaginal progesterone and kind of skip that first pass effect in the liver and it gets absorbed straight into the bloodstream, you just take the regular oral estradiol pill that has a gel cap and you can put it in the vagina. Like when you go to bed, it will dissolve overnight. You'll be able to absorb your progesterone that way. Some patients do really, really well with that. So that is an option, but no one has measured like oral versus vaginal approach for endometrial protection.

33:07Dr. Mary Claire Haver:Common sense will tell you it's getting right to the uterus immediately. So none of us hesitate to use it and worry about endometrial protection. I've never had a patient who did it that way, who had any endometrial hyperplasia. What do I do if progesterone causes reflux, mood changes, or poor tolerance? You don't tolerate progesterone. Look for alternatives. Duovie is an option. Switching to a progestogen, something like CombiPatch. I was on CombiPatch for a couple of years. It's not a bad medication. Using one of the progesterone alternatives may be an option for you. Or doing a Mirena IUD or a Luleta.

33:42Dr. Mary Claire Haver:you know, one of the progestin-containing IUDs could be a great option for you. Are creams, pessaries, or other delivery methods effective and safe? Listen, so I think what you're really asking are compounded options as safe as FDA-approved option because we have creams, we have the rings or pessaries all available in FDA-approved options. Those have been tested, and I can tell you with confidence that they ran those through clinical trials and we know the safety efficacy of those types. But if you're getting them from a compounder, now I use compounding. I think it's a great option to have for a lot of things.

34:19Dr. Mary Claire Haver:But my go-to for HRT is the FDA approved options that you would pick up at CVS. When should testosterone be added? Good question. Okay. Definitely, if you have hypoactive sexual desire disorder, I'm going to have a conversation with you about testosterone. What is that? HSTD is just the easier way to say that big, long thing. Hypoactive, low activity of your sexual desire that causes distress. You need to, we, we, me, we all need to normalize when women don't ever want to have sex again. That's okay. That is totally up to you. HSTD is when it causes you distress. You had it, you miss it. If you don't ever care if you have sex again, that's okay.

35:08Dr. Mary Claire Haver:that is totally okay. That is not what I'm talking about here. We're not trying to magically induce a libido in you, okay? You don't owe sex to anybody. No one ever died because they didn't have sex or didn't have an orgasm. Truth. And a direct quote from Rachel Woodman, you should go watch that podcast that I did with her because she's fantastic and she's the best. But she says clearly, no one ever died because they didn't have an orgasm or they didn't have sex. You won't die. And if you don't want to want, that is okay. However, if you want to want, you miss it, you miss the intimacy, you miss whatever, you miss just all the things.

35:44Dr. Mary Claire Haver:We have options for you. We have testosterone, which works pretty well in most patients, is very well tolerated, and doesn't require super physiologic doses, like turning you into male, giving you male doses to work. There is anecdotal evidence. We have lots of evidence that suggests probably going to help you if you're working out, going to help you maintain your bone and muscle strength. There are testosterone receptors in our brain. We know from all the studies that were done in men that mental health and testosterone are related, that overall general health, well-being, quality of life and testosterone are related.

36:25Dr. Mary Claire Haver:We have more testosterone naturally in our bodies than we do estrogen. Be clear, ladies, okay? We don't have as much as men. We have about a tenth of what men have, but it is still in our healthy years, not postmenopausal, more than the estradiol we have. So it makes sense that, so most of my patients wanna go ahead and give testosterone a try. To be clear, there are two FDA-approved medications for libido, okay? One is Addi and the other is Vilisi. Addi is a pill you take every day. It works to stimulate dopamine production. Dopamine makes us happy, makes us want to do things that make us happy.

37:07Dr. Mary Claire Haver:And for some patients, it works very, very well. It also makes you a little bit sleepy. So it's great for sleep and you want to take it before you go to bed. Vilese is an injection that you have this massive release of melanocortin, which stimulates dopamine. You want to do that injection, I think it's 45 minutes before the onset of activity. Less popular with my patients. mostly because there seems to be a praying mantis situation on the other side of that injection, waiting for it to kick in. Like, is it working? Is it working? Is it working? So, but again, intimacy is intimacy. Whatever works for you.

37:41Dr. Mary Claire Haver:I'm so glad that we have options for our patients. So that is when we discuss testosterone with our patients. Can testosterone be used alone, especially in women with breast cancer or on CIRMs? Yeah, 100%, absolutely. What benefits and risks are supported by evidence? Definitely in a menopausal patient, the evidence is absolutely clear. The biggest risks seem to be hair growth where you don't want it and hair loss where you do want it here in the temple areas, like male pattern baldness. When really high doses, you can have things like clitoromegaly and enlarged clitoris or deepening of the voice that is non-reversible.

38:26Dr. Mary Claire Haver:So those of you who rely on your voice, if you're a voice actor, if you are a singer, if you sing in choir, you know, menopause already changes the vocal cords. And then if you end up running high on your testosterone level, you could have some hypertrophy in the area and change your voice into something that you may not like. And it is not considered to be reversible.

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43:12Dr. Mary Claire Haver:How can I protect bone if I can't lift or if I'm early post hysterectomy? So I interviewed Dr. Jocelyn Whitstein here on the podcast. She's an orthopedic surgeon, and she basically is the first clinician that we know of that made the connection and wrote the papers between frozen shoulder and menopause and frozen shoulder and breast cancer treatment. She is my hero. She does a ton of education on her page about osteoporosis prevention, including for those of you who can't do heavy lifting, who can't jump. She has lots and lots of alternatives. and she wrote the, and we'll put it in the show notes, the total body bone and joint plan.

43:51Dr. Mary Claire Haver:And they have recipes, exercises, pictures of her doing all these different exercises. So I would invest in her following her on Instagram. She is also a real doctor, board certified. She has like three or four certifications and she's board certified orthopedic surgeon and sports medicine and fellowships. And I mean, she's like one of the most highly regarded clinicians on the planet when it comes to women's health, sports medicine, orthopedic injuries, etc., and frozen shoulder, and how to keep your bones strong. Why do some women develop high blood pressure, bloating, or weight gain on HRT?

44:27Dr. Mary Claire Haver:Great question. So hypertension is usually more related to oral estradiol than transdermal. So if you're on oral and you've developed high blood pressure, you would want to ask to be switched to a non-oral form to see if your hypertension resolves. Your gut microbiome changes when you go through menopause. Okay. Your inflammation levels increase when you go through menopause. Fortunately, the weight gain on HRT, take testosterone, testosterone is an anabolic steroid. So anything anabolic can make you gain weight. So is your, are your bones growing? Are your muscles growing? That's weight gain.

45:05Dr. Mary Claire Haver:That's weight gain. Are you bloated because you have tons of gas, air, liquid? I mean, in your gut, that could make you look distended and very, very unhappy. When you're first starting on hormone therapy, your gut, especially if you're doing oral, your gut is going to have to adjust. And that may cause some bloating, some discomfort, but it's usually self-limited and goes away over time. Does sleep apnea, insulin resistance, or inflammation play a role? In menopause, abs, yes. Women see a dramatic increase in sleep apnea. And I had the incredible Dr. Andrea, Matsumura on the podcast, who is a sleep medicine specialist.

45:43Dr. Mary Claire Haver:And she goes into detail about all of this. It is so worth your listen, because here's what I learned. Sleep apnea is massively under diagnosed in women. We don't snore as much as men, so it's not recognized, but women are hypoxic. And one of the ways we are picking it up is that so many of us are wearing trackers of different types that are tracking our oxygen saturation. So if you're getting a pattern of low oxygen levels while you sleep, and if you're waking up from sleep, you know, in the middle of the night, and your blood sugar is fine, you're not having a hot flash, this is consistent, you deserve to be evaluated for sleep apnea because it is so common in women and we are missing it and they are suffering long-term because of it.

46:29Dr. Mary Claire Haver:Why do urgency and leaks persist despite vaginal estrogen? Great question. So why do we leak? Why do we leak urine? That's a great question. So I used to, I explained it to patients that there's anatomic reasons, meaning the anatomy. So we have our bladder. So if you're watching me on video, I'm trying to, my handout here is a bladder and then we have a urethra with the little tube that comes out, right? And then like that. And so when we're young and healthy, we have a sling that goes under the urethra. The tube that drains the bladder is called the urethra. There's a sling there that when we cough and laugh and sneeze and jump, the sling holds that urethra in place, okay?

47:08Dr. Mary Claire Haver:But after we have babies and we have obstetric injury and we get older, if you cough a lot, if you have poor collagen, if you're malnourished, if you're obese, that sling goes out, okay? You start losing that sling. And then you start, your ability to hold onto urine when you're stressed, when you physically go through a stress in the pelvic floor, like jumping, laughing, coughing, sneezing, that sling fails and you leak. That is called stress incontinence. Now, we have something called urge incontinence. It's very different with the same outcome, you leak. So it is an involuntary spasm of the bladder, meaning the bladder wall is full of muscle and it just starts spasming.

47:47Dr. Mary Claire Haver:Why does that happen? It can be because of inflammation. It could be because of aging. It could be because of signaling, bad signaling coming, you know, to the bladder itself from our nervous system. So urge incontinence, sometimes there's a trigger and you can like put a key in the lock and it triggers your bladder to spasm. You all of a sudden feel like you have to go and you start running to the bathroom and you leak usually on the way or you just can't make it. Now, everybody does that from time to time, unfortunately, but for others it's just a pattern and so fortunately this is treated this urge incontinence is treated with medication it's a parasympathetic action and it calms the bladder wall side effects of oxybutynin is usually one of the meds that we use or one of the long-acting forms and it can cause dry mouth dry eyes so again nuanced conversation with your doctor on how to treat that.

48:38Dr. Mary Claire Haver:So if it's just GSM, so general urinary syndrome of menopause, everything kind of acts better, acts more healthy in the presence of estrogen. So the first thing we usually do is give your general urinary system estrogen back and then see how the symptoms are. And if they persist, then we need further evaluation for stress incontinence. How do we treat that? Generally surgical. Okay. Some surgical way to lift that sling back up. There's also pessaries and some other things we can do. But if you're healthy and young and can tolerate surgery, It's a very minimally invasive procedure to have that sling repaired.

49:11Dr. Mary Claire Haver:And most patients do really, really well with it. That's typically done by a urogynecologist or a urologist with special training in female anatomy. But you should not be leaking. We should see no diapers for adults. We shouldn't. That makes me sad. Every time I see the diaper aisle, because I have to buy them for my mother. How do we let this happen? Why are we doing this to women? You know, when you look at the percentage of women that end up being incontinent versus men, it's really sad. Men get incontinence too. But, you know, when I see sex-based differences, it just makes me sad and wonder why.

49:46Dr. Mary Claire Haver:Why are we allowing this to happen? What else can help beyond hormones? Pelvic floor physical therapy. Pelvic floor physical therapy can change your life. I think it should be mandatory for every single woman who has a baby. Think about the stress we're putting on our pelvic floor, carrying a giant watermelon around at the end of pregnancy and then pushing such watermelon out of our pelvic floor. We are ripping and herring and shredding things that don't necessarily bounce back. And everyone should be evaluated, I think, for pelvic floor PT as a normal routine part of any genital surgery, any hysterectomy, anytime we're jacking with anything down there, especially after having a baby, even a C-section.

50:27Dr. Mary Claire Haver:You deserve to have your pelvic floor evaluated and managed so that you can live your best life. Which supplements? Here we go. Okay. Full disclosure, Dr. Haver has a supplement company. So take everything I say with a grain of salt. Know that you do not have to buy from me and that the advice I give you is generic. I'm not even going to tell you what supplements I sell. Okay. You have to go to the website and look it up. She lists omega, magnesium, collagen, CoQ10, NAD, etc. Okay, I wish that no one needed a supplement. I wish you could put me out of business by just eating whole world foods all the time.

51:02Dr. Mary Claire Haver:Unfortunately, most people, it's just the way we live. We have food deserts. It's not always available. It's hard to meet all of those nutritional checkboxes with your diet alone. And that's where supplements should come in. Supplements should supplement a healthy diet. Now, that being said, what do we see in our clinics. We only take care of menopause patients. Most women, due to the aging process, due to different, the microbiome changing across menopause, due to the way we are protecting, rightly so, our skin against the sun so we don't get skin cancer. And if you don't believe sun causes skin cancer, you are listening to the wrong podcast.

51:41Dr. Mary Claire Haver:You need to move on. We are deficient in vitamin D. 80 % of my patients, when we surveyed the labs, are not just low, deficient in vitamin D. A deficiency means that you are not getting enough vitamin D to reach the basic minimum processes. Okay, that's different than optimal. Optimal means you're getting enough for everything to be working at an optimal level. There's a big gap between I am horribly deficient and I am at an optimal level. So you should know what your vitamin D level is. In our clinic, we try to make sure that our patients are reaching a level of 60 to about 100. okay? Deficiency starts at 30.

52:22Dr. Mary Claire Haver:The cutoff for deficiency in our labs is 30. But that's not enough. We don't want you to just be barely over the line. We want you to be at an optimal level. So all of our patients, we are checking a vitamin D level. If it is low, sometimes we have to give them a prescription amount, which is 50 ,000 IUs per day. We'll do that as a loading dose. And then we're recommending somewhere between 2 ,000 and 4 ,000 international units per day. When you talk to Lisa Moscone, another fantastic podcast that we did, and brain health, when you talk to Dr. Luisa Nicola, the two brain health specialists, all have tremendous amount of things to say about omega-3 fatty acids, okay?

53:01Dr. Mary Claire Haver:If you can get them in your diet, great. Hard to do. Hard to do. So you may want to consider supplementing somewhere around 2 ,000 milligrams of omega-3 fatty acids, which includes DHA and EPA, okay? If you are a vegan or vegetarian, that's gonna be a little tougher to do. You're gonna have to go higher on that level because you're gonna have to get like an algae-based, Nordic Naturals makes a really nice one for a vegan or vegetarian form of that omega-3 fatty acid. Fortunately, it's found in large amounts in fatty fish. So for our patients, we usually recommend a combo of vitamin D with omega-3 fatty acids and throw in some vitamin K in there for increased absorption.

53:43Dr. Mary Claire Haver:and it's a real tidy way to kind of hit those nutrients at once. You should know beyond the shadow of a doubt how much fiber you are getting per day. And here's the truth. Most women are getting 10 to 12 milligrams of fiber in their diet per day. And you need minimum of 25. Optimal for heart health is 35 for women. So am I suggesting you triple your fiber intake in one day? absolutely not. Your gut will not be happy. You will be bloated and you'll hate me and you'll say mean things about me. Okay. This is something you need to slowly introduce over time. The more variety of sources of fiber that you get in your diet, and that is things like nuts, seeds, legumes, vegetables, fruits, whole food.

54:32Dr. Mary Claire Haver:If you can get 35 grams a day from your food, avocado, I'm like an avocado a day-ish girl. And that helps me get a ton of fiber in my diet. Amazing. Go for it. If you can't, supplementing with fiber, it's basically harmless. It's not going to hurt you. It's usually pretty cheap. Using something with a base of psyllium husk, hopefully with some other nutrients added to it, would be a reasonable thing to do. And I supplement my own fiber. I use about an eight gram supplement on a daily basis. I think creatine is something. We don't measure creatine levels in humans, but the data is very clear on the benefits to women, the benefits to women in menopause, even if you're not lifting weights.

55:15Dr. Mary Claire Haver:Definitely if you are lifting weights, you know, when we look at the studies done on creatine and strength training, it seems to be a synergistic thing with protein intake. So the studies for women were done showing benefits at three and benefits at five. And, you know, now that when you look at Abby Smith Ryan's work coming out of North Carolina, Dr. Smith Ryan. She is doing a lot of work on women in perimenopause and menopause and seeing benefits outside of just muscle and bone. We're seeing mental health, we're seeing cognition. So you wanna kind of ease into creatine, start with about three milligrams per day, and then you, a gram, sorry, and then you can increase.

55:52Dr. Mary Claire Haver:I, on a regular basis, do five, but when I'm traveling or stressed or didn't sleep well, and certainly on like heavy, heavy lifting days, I doubled that up to 10 per day. Let's see what else they ask about. CoQ10, really great studies actually done on menopausal women looking at potential heart benefits of CoQ10, something you should probably look into. I'm going to just stay out of the NAD conversation. Again, I think that's more with the wellness crowd. I haven't seen enough data done in menopausal women showing benefit for me to be excited about NAD or to recommend it in my clinic.

56:33Dr. Mary Claire Haver:Welcome back to another MidiPause. I'm Dr. Mary Claire Haver, host of Unpaused. When it comes to healthcare, there's no one-size-fits-all solution. When you face your symptoms with a tailored individual approach, you'll have a better chance of finding the solutions you need. MidiHealth is modern, evidence-based care, designed specifically for women in this stage of life. You get access to clinicians who understand what's happening in your body along with personalized treatment plans. Menopause is so much more than just hot flashes. What we're continuing to understand through both research and lived experience is that these hormonal shifts can ripple through nearly every system in the body.

57:16Dr. Mary Claire Haver:And they don't always present in obvious ways. For many women, it's a collection of symptoms that can feel disconnected at first. Joint discomfort, heart palpitations, brain fog, skin changes, even tingling sensation or a rise in anxiety. What makes this especially complex is just how often these experiences are dismissed. So many women are told it's just stress. But when you begin to view these changes through the lens of menopause, it can bring a completely different level of clarity. There's validation and understanding what's actually happening, and real empowerment in knowing there are effective ways to address it.

57:57Dr. Mary Claire Haver:Progress starts with a personal plan. Booking your first visit with MidiHealth takes less than 10 minutes. It's important to talk with an expert who understands what you're experiencing. That's personalized care. MidiHealth is setting a new standard for health care. As the nation's fastest-growing women's telehealth company, MIDI provides accessible insurance-covered services. MIDI fills the critical health gaps women face in perimenopause and menopause. If you want a clinician in your corner who understands what your body and brain need right now, MIDI is there for you. Go to joinmidi.com, join midi.com, and connect with one of their clinicians today.

58:43Dr. Mary Claire Haver:Can acupuncture or diet meaningly improve symptoms? Okay, so we have lots of lifestyle things that we know can improve your symptoms of menopause. You can improve your hot flashes, you can improve your joint pain, you can improve your weight gain, you can improve your insulin resistance, your gut health, all of the things. So when I talk about menopause care, I always do it in the framework in our clinics of a toolkit. Okay, this was the basis of my book, The New Menopause. It is the menopause toolkit. and it is looking at where do we, how can we optimize your nutrition? Where are the gaps? How much fiber are you getting?

59:17Dr. Mary Claire Haver:How much are you getting enough protein to maintain your bone and muscle mass? Or, you know, when we look at exercise, are you doing enough of the right kind of cardio to maintain your heart health? Are you doing, you know, enough lifting to keep your bones and muscles strong? What is that gonna look like for you? We're looking at stress reduction and I think it's important that I talk about this here now. I was doing a deep dive, you know, I think about a lot, a lot about longevity. And I don't want to get too political here. When we look at the longevity conversation and how it's being driven and given, you know, what's happened with the files that have been released recently and revelations about certain physicians, I think you have to be careful about worshiping at the altar of longevity.

1:00:04Dr. Mary Claire Haver:I think the conversation isn't relevant to women because I take care of women. I listen to women. I know what their needs and wants are. And I don't have very many, if any. A couple of people on social media have said, I want to live to 120. I can't think of a single one in our clinic who has walked in the door and said, I want to live as long as possible. I never want to die. I want dying to be optional. That does not come out of their mouths. Here's what they say to me. I want to be a benefactor and not a burden. I want to be with my loved ones for as long as possible. I want to enjoy those years.

1:00:38Dr. Mary Claire Haver:Because guess what? Women win the longevity race doing nothing. Right now, we live six-ish years longer than our male counterparts. Here's the problem. We are not as healthy. We are spending more of that life plagued with chronic conditions. We're twice as likely to require long-term nursing home admissions. we are twice as likely to lose our independence because we become so frail we can't take care of ourselves or women are three times more likely to develop alzheimer's and dementia than their male counterparts these diseases happen to men a woman can expect to have an 50 of us will have osteoporotic fracture before we die 50 okay the runway to decrease those risks starts as early as possible.

1:01:30Dr. Mary Claire Haver:However you are listening to me, it is never too late to change those statistics, but we have to work at it. When I look at the longevity literature and the books that have been written and all the bros talking online, here's one key thing they're not discussing.

1:01:49Trauma and sexual assault. When I looked at the data, a history of childhood sexual assault

1:01:57Dr. Mary Claire Haver:will decrease your longevity if untreated. And, you know, I don't want to not give hope here. It almost approaches smoking. Someone being assaulted as a child, sexually, when we look at the data, will decrease her longevity almost as much as smoking, as much as her being obese. Why? Cardiovascular disease. carrying that burden your whole life, living with that amount of stress and cortisol for unresolved trauma, is that dangerous. If we're serious about longevity, we must stop childhood sexual assault. We must protect our children from this possibility and stop protecting the people who are perpetuating these crimes.

1:02:55Dr. Mary Claire Haver:if you really want to be serious about women living as long and as healthy forever. I've talked to a couple of psychiatrists and people who specialize in post-traumatic, you know, people with, you know, high ACE scores, adverse childhood events, ACE. And ACE scores, you know, they go through a history and look at adverse childhood events, trauma, sexual abuse, physical abuse, mental abuse, et cetera, and you get a score. and those scores can play into how healthy you are as you age. You didn't cause this. You did nothing. However, there are resources. We can bring your risk down if you get help, if you go through counseling.

1:03:41Dr. Mary Claire Haver:So in the show notes, we are going to have a list of resources for you, books, websites, and how to find therapists out there because you deserve it. But I think that when we have this conversation about longevity and we are leaving out the elephant in the room, we are doing a disservice to every human on this planet who's ever been abused, especially children. And we are adding another layer of protection for the perpetrators that get away with this. how do i have evidence-based conversations when doctors dismiss symptoms won't adjust doses or want to just push pellets okay anytime you walk into a clinician's office and they are railroading you into one specific form of therapy and at least in texas it's usually a pellet why i don't want to demonize a pellet a pellet is just a way to get medication in your body and there have been FDA approved pellets in the past.

1:04:40Dr. Mary Claire Haver:The pellet industry, as it has developed over the last decade or so, is operating under a loophole of compounding and being sold as some miracle cure. Okay. The only way to get testosterone in your body, not a fan. You deserve all of your options. Okay. You deserve to know about oral. You deserve to know about transdermal patches, pills, creams, gels. But if they're like, nope, we just do pellets here, run. You deserve better. Now, if you go through all of your options and you and your clinician decide together, this is what I want to try. I want to try pellets. Okay, that's up to you. But you better damn be sure you are being monitored in physiologic ranges, okay?

1:05:23Dr. Mary Claire Haver:And physiologic range of testosterone for a female should not go above, much above 100. Not to say that there's a few patients who might do well at that dose, but that is not where you start. And you should never be above 200. Let me explain this in clear language. If you were not given exogenous testosterone, if you were not on any testosterone therapy and you came in complaining of hair loss or whatever which would prompt me to check a testosterone level thinking you might have a tumor, that is a level above 90. If you come in with a spontaneous testosterone level above 90 to 100, I am obligated.

1:05:58Dr. Mary Claire Haver:It is malpractice if I don't investigate why you have that. Now, it might be PCOS. If it's above 200 and I don't draw and I don't go look for a tumor, I could lose my license for malpractice. So why would I take that patient and run her over 200, you know? Buyer beware. How do you find? Okay, so this is a great question. And we do have options. On our website at thepawselife.com, we have lists and lists and lists of testimonials given by you guys, people who took it in their hearts. I have a great doctor. I've had a wonderful experience. They go and they fill out a questionnaire from us. Where's the doctor address?

1:06:39Dr. Mary Claire Haver:And then they write their testimonial. We just organize them by state and city. So you can go to that list and see if there's someone, we just vet them that they're actually doctors and they see patients. Okay. We don't, I don't know these people. I don't know these doctors, but like, I was just trying to be helpful. Word of mouth is a great place to start, but it is unreasonable currently and probably for the next 20 years that you walk into your doctor's office and expect to have an educated conversation. They need extra training and they can get that training from Rachel Rubin has an awesome course, Heather Hirsch has an amazing course, or be certified by the Menopause Society.

1:07:16Dr. Mary Claire Haver:So the Menopause Society, menopause.org has a list of certified providers on their website that you can find. Finally, there are some great telemedicine options out there. They are listed on our website. You can go and compare and check and see. Things like Alloy Health, Midi Health are great places to start. But again, do your research. Midi does take insurance. Alloy does not, but the prices seem to be pretty reasonable. I know acquaintances who've used both services and have been very, very happy with them. How is the new perimenopause book different than the new menopause book? Great question.

1:07:56Dr. Mary Claire Haver:Perimenopause is not early menopause. It's its own distinct biological phase, and it deserved its own book. The new menopause is about life after the ovaries stop producing hormones and teaches you how to protect your brain, your bones, your heart, your muscles, and your metabolism in postmenopause. The new perimenopause is about the 7 to 10-year transition before your periods stop. This is not a gentle decline. Hormones fluctuate wildly. This is when many women first experience anxiety, brain fog, sleep disruption, weight changes, mood shifts, joint pain, loss of resilience, and that unsettling feeling of, I just don't feel like myself anymore, long before anyone ever says the word menopause.

1:08:48Dr. Mary Claire Haver:Perimenopause often starts quietly. It shows up in the brain first, then the body, then everywhere else. Most women are never taught to recognize it and 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 roadmap for a transition medicine has ignored for far too long. If you thought, why didn't anyone warn me? This book is for you. That is all of the questions I have for today. Thank you so much for joining me today. I absolutely love to be of service to you. I love answering your questions.

1:09:28Dr. Mary Claire Haver:I love reading. I love researching. I love providing evidence. So if you would love for me to do another AMA with your questions, please in the comments after the episode today, drop your questions. We will monitor them and try to get them answered for you. You can find full episodes of Unpaused on YouTube at Dr. Mary Claire. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at thepauselife.com. My new book, The New Perimenopause, is available everywhere you buy books.

1:10:10Dr. Mary Claire Haver:If you're loving this podcast, I have an important request. Please take a moment to follow Unpaused on your favorite podcast app. Following and listening is what pushes this information to more women who need it. So if this podcast has helped you feel seen, understood, or supported, hit follow right now so you never miss an episode. Thank you for being here with me. Let's keep going Unpaused. Unpaused is presented by Odyssey in conjunction with Pod People. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only.

1:10:55Dr. Mary Claire Haver:No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. This episode was sponsored by MidiHealth, the first virtual clinic created for women by women for the treatment of menopause. Don't let anyone tell you menopause is something you have to suffer through alone. Midi can help. Visit JoinMidi.com to learn more.

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