Menopause Masterclass: When "Normal Labs" Are Lying to You

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27:31Dr. Mary Claire Haver:All right, lab number four, the thyroid child. All right, what you should ask for. A TSH, a free T4, and the free T3, which is optional if the clinical picture really warrants one. So thyroid dysfunction, which 10 % of us at least have, it's probably higher, and perimenopause, which 100 % of us, if we live long enough, will go through, share almost every symptom. So how do we know the difference? Blood work, fatigue, brain fog, weight gain, hair loss, mood swings, depression, palpitations. If you do not rule out hypothyroidism, you cannot be confident that what you are treating is the hormonal picture of perimenopause rather than a completely separate and very treatable condition or both.

28:23Dr. Mary Claire Haver:TSH alone is often not sufficient. In most clinical labs, a TSH is the screening test and then they might do a reflex T4, which is the active thyroid hormone. It can be in range while the free T3 and free T4, the actual active hormones are low. So we send them on everyone. I don't want to miss a certain segment of the population. If your symptoms are persistent and your TSH is normal, asking for at least a free T4 is very reasonable next step with your clinician. So don't skip your thyroid testing. It is the other shoe that always needs to drop in a menopausal workup. You should not skip it. So lab number five, the iron and anemia panel.

29:05Dr. Mary Claire Haver:Iron anemia panel. Okay. What do you want to ask for? Your ferritin, that is the stored iron, okay? This is what you usually are missing. This is not included in the basic annual labs. They might get an iron level, maybe, if you're anemic. So, but here's what happens. Iron is stored typically in our bone marrow, and then we have iron floating around in our blood. Your body will steal from the bone marrow to keep the iron levels normal. While the storage is dropping, dropping, dropping, your iron levels will look normal and you will not become anemic. Once your ferritin levels get critically low, then your serum iron will drop, which will then lead to a microcytic anemia.

29:45Dr. Mary Claire Haver:So why wait until you're anemic? Why not check the ferritin level and see what your stores are doing? It's a way better way to determine who is running low on iron. Why do we run low on iron in perimenopause? Why would that happen? Maybe because you're not getting enough in your diet. That's a very important part, but usually that's not the problem. 90 % of us, 9-0, almost all, will develop dysfunctional uterine bleeding in perimenopause, especially late perimenopause. You've heard me talk about the zone of chaos. You've heard me talk ad nauseum about what the zone of chaos does to our brains, our mental health, our ability to sleep.

30:27Dr. Mary Claire Haver:The zone of chaos also wreaks havoc in our endometrial lining where the blood is made for our periods. Quite often, a huge percentage of us will develop heavy, irregular vaginal bleeding from the hormonal changes associated with perimenopause, which will then steal from our iron stores in the bone marrow, leading to a decreased ferritin. Here's what happened in the last few years. The deficient ferritin level used to be 15. They doubled it to 30. all of a sudden another like 45 million people in the world or whatever the numbers were became iron deficient from this ferritin level being doubled because they didn't understand the mechanics of it.

31:12Dr. Mary Claire Haver:So I love science because we learn more science changes. But if you know, you've never had a ferritin level checked and you're still at least if you're still having periods, especially if you have fatigue, you're not sleeping, your hair is falling out, you deserve to know what your ferritin levels are and if you have restless legs. So how do we correct a low ferritin? We give you ferritin and there's two ways to do it. We can give you an IV iron infusion, which is usually done in an infusion center. So there's not like a shot they can give you. It is something they actually have to do an IV into your bloodstream.

31:47Dr. Mary Claire Haver:I've had it done. I had low ferritin in perimenopause when my periods were getting out of control and I was having horrible fatigue. I couldn't climb the stairs at work without gasping. And I used to be a runner. I'm like, this was not normal for me. We checked iron. My ferritin had tanked. I got an iron transfusion and I felt like a normal person again for a very long time. It is something I think we're missing in a lot of women since this heavy bleeding is so common and is like the calling card of late perimenopause that we owe it to women to have this checked on a regular basis. You can also take oral iron.

32:23Dr. Mary Claire Haver:Now, that can be tricky for some women. It can cause constipation and some GI distress. Fortunately, we have options that are enterically coated and pass through the stomach without causing as much distress, something you really need to talk to your clinician about. But I often are recommending to patients to go back to their PCP and request an iron transfusion. An iron transfusion is something you can discuss with your doctor if you have low ferritin. And for most with regular insurance, it should be covered if your ferritin levels are critically low and it's worth pursuing. It works much faster than taking weeks and weeks and weeks of oral iron.

32:57Dr. Mary Claire Haver:So in general, low ferritin will cause fatigue. It can cause cognitive slowing. It can cause difficulty exercising. All of this happened to me. It can also cause hair thinning. Every one of those symptoms is also on the perimenopause symptom list. So we don't want to miss a nutritional deficiency and think that everything is not perimenopause, by the way. By listening to me, you may think that, but so many of these symptoms overlap that this is why we get all of this blood work because all of these things can be happening at the same time to a woman. Lab number six, hormones. So what to ask for?

33:33Dr. Mary Claire Haver:Estradiol. And there's a very specific estradiol. You want the high sensitivity. It's the LC slash MS. Okay. You don't want a plain estradiol. You really want the high sensitivity one, especially when the menstrual pattern is not available. So if you are over the age of 45 and you have not had a period for one year, that is the clinical definition of menopause. So who would I check an estradiol level on? Certainly if you've never had regular periods, and I can't say your period is gone for a year, therefore you're menopausal. I'm going to check it. If you have a Mirena or a progestin-containing IUD that has major periods go away, absolutely.

34:10Dr. Mary Claire Haver:If you have some kind of hypothalamic suppression or you're nursing, I might check it. If you've had a hysterectomy, uterus is gone or you were born without a uterus, I would check an estradiol level in order to help me understand the transition for you. Now, you've heard me talk earlier. If I have a patient who is postmenopausal on hormone therapy, especially on a transdermal hormone therapy like the gel or the spray or the patch, we have such variable levels of absorption of this particular medication. and I'm worried about, and you're worried about your bone density. For these patients, I am often recommending and checking an estradiol level just to see what their absorption is.

34:48Dr. Mary Claire Haver:Are they absorbing enough to protect her bones? Another hormone level you might want to consider is your testosterone level. Now, who would I check a testosterone level? I actually check it in everyone. It's part of the standard blood work that we do. Who do I treat if it's low? I am treating women with hypoactive sexual desire disorder, HSDD, or what lay people would call low libido. Now, we don't have a therapeutic range. No one has done that study to say, if your testosterone level is between 60 and 80, you should have perfect libido. That is not how libido works, okay? But for a big percentage of patients, you know, 50 % or greater, we will see improvement of their libido, especially in postmenopausal patients, with testosterone therapy.

35:37Dr. Mary Claire Haver:It's pretty awesome for patients. But if you're in perimenopause, what do we do? If you're in perimenopause, a single FSH or estradiol level is not going to be helpful in determining if you're in perimenopause. Remember the zone of chaos. We have talked about this multiple times on this podcast. Your hormones are fluctuating. LH, FSH, estradiol, and progesterone are no longer in a predictable pattern. The whole hallmark of perimenopause is the zone of chaos. So these one-time blood tests, saliva tests, urine tests are not diagnostic. If your doctor is treating you based on these, I want you to take a step back and say, hey, are these tests really necessary?

36:22Dr. Mary Claire Haver:Especially if they're asking for you to pay out of pocket hundreds of dollars for things like the Dutch test. We don't use them in our clinic. I can diagnose perimenopause without it very, very successfully. So buyer beware. Testosterone, on the flip side, doesn't fluctuate in perimenopause and doesn't crash in postmenopause. It is a more, just like men, a steady state, age-related decline. That is a hormone you can reliably check throughout a woman's life to give you an idea of the clinical picture. Lab number seven, and this is one of the more controversial ones, and we'll get into it. Your level of chronic inflammation.

36:59Dr. Mary Claire Haver:So you may want to consider asking for a high sensitivity C-reactive protein or an erythmosite sedimentation rate, ESR, which is optional. So estrogen, as it turns out, has tremendous anti-inflammatory properties throughout the body. And when estrogen declines, we know that most women will develop some type of chronic low-grade inflammation. And we can see this reflected in their high-sensitivity C-reactive protein. This is the most sensitive blood marker that we have of systemic inflammation. And, you know, this is a really easy and inexpensive blood test to follow. Here's the problem with the CRP.

37:38Dr. Mary Claire Haver:It's not specific, meaning I can't tell you why you're inflamed. It might be menopause from estrogen withdrawal. it might be from some other chronic inflammatory process going on in your body. So I can't get an elevated CRP, which, you know, high sensitivity CRP, which a lot of my patients have and say, oh, obviously this is from your liver or this is from gut health or this is from where I'm like, listen, something is inflaming. It might be menopause. Let's make these lifestyle changes. Let's make these diet changes. Let's do everything we can and, you know, get all this other blood work, see if we can rule out other inflammatory conditions like autoimmune disease, et cetera, and then we go from there.

38:15Dr. Mary Claire Haver:And that works quite well in our clinic. So in plain language, back to the alarm system that we're trying to fix in someone's house, think of the high sensitivity C-reactive protein as your body's inflammation alarm. It doesn't tell you where the fire is, but it tells you that the smoke detector is going off and we need to go figure out what's going on in the body.

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42:18Dr. Mary Claire Haver:So again, these are very basic. We do more labs in our clinic, but I wanted you to have the seven basic labs that are super easy to discuss and not unreasonable for your clinician to offer. But this next section, I want to talk about what to do and what to say when you don't think you're being heard by your clinician or doctor. I want to walk you through 12 common dismissals and give you the exact language to respond. These are not confrontational scripts. These are things that you as my listeners, you as my social media followers have come to me and said, these are the things that my clinician has said to me when I voiced my concerns.

43:00Dr. Mary Claire Haver:So I wanted to give you language that you could use that might open their mind to the possibility that something else might be going on. Because remember, this is not one doctor out to get you. This is not one doctor who's a jerk or doesn't care. Or, you know, this is a system that is overwhelmed. a group of clinicians that are largely overworked, forced to fit you into a 10-minute slot while they're trying to take care of every health problem that you've got going on. I'm trying to give you the best shot that you have to get what you need out of this clinical visit. Remember also that you may not be able to get this all done at once.

43:36Dr. Mary Claire Haver:This may have to take more than one visit, and that's okay. So when your doctor says, you go in complaining of fatigue, or I can't sleep, or I'm gaining weight or I'm having muscle aches or joint pains. And they say, this is just a part of getting older. What do you say? Your response can be something like, I understand that aging brings changes, but what I'm experiencing is interfering with my daily life. I'd like to talk about where the hormone shifts might be contributing and what we can do to help me feel better. What do you do when the doctor says, this is probably just stress or lifestyle related.

44:18Dr. Mary Claire Haver:What can you say? All right, stress may play a role, but these symptoms feel that they might be hormonal. I'd like to look into whether perimenopause or menopause could be part of what's going on and discuss my options for managing it. What to do when you're told you're too young for perimenopause. Again, remember, menopause and perimenopause education is severely lacking. If your doctor comes at you with this response, most likely they have not been adequately educated in modern menopause medicine. And that's not their fault. That is the fault of the medical system leaving us behind and expecting us to behave like small men and not taking into account this like robust hormonal change that we go through.

45:07Your response, you're not old enough for menopause yet.

45:10Dr. Mary Claire Haver:Well, I've learned that perimenopause often starts in the 40s or sometimes younger. These symptoms line up and I'd like to take a closer look at where I am in the menopause transition. Here's another key. There is a validated perimenopausal scoring system called the Menopause Quiz. We have it on our website. It's 100 % free. You can go in, take the quiz. It's been absolutely validated. It will spit out your results that you can then take to your doctor with the list of symptoms and their severity and the chance that this constellation of symptoms is related to your menopause. One more tool for you to go in, help yourself feel validated and give talking points to your clinician to help get the process started for them to take you seriously and what's going on.

45:58Dr. Mary Claire Haver:What to say when regular periods are used to dismiss your symptoms. You're still having periods, so it can't be menopause. Your response, I know that hormone fluctuation can cause symptoms long before the periods stop. I'd like to talk about perimenopause and whether these changes could be playing a role in how I'm feeling. What to say when birth control is offered without a discussion. Now, let's be clear. I use birth control pills in certain situations. They are an important tool in the toolkit. Like it's a form of hormone therapy. Using that level of hormones, which is very different than menopause hormone therapy, think of menopause hormone therapy as a microdose compared to what we're giving you in a birth control pill.

46:46Dr. Mary Claire Haver:But if you need contraception in perimenopause or if you need cycle control, birth control pills can be magical for some of the hormonally related changes that are going on with your periods during perimenopause. It worked for me, great. So remember, they're not the devil, but it shouldn't, you know, if you're not having, if you don't need contraception, you're not having heavy periods, you might be a better candidate for just plain menopause, hormone therapy, and perimenopause. But again, lack of training, lack of education, most clinicians aren't comfortable doing that because they never learned about it.

47:19Dr. Mary Claire Haver:Okay, what do you say? I'm open to discussing different approaches, but I'd like to understand the difference between hormonal contraception and hormone therapy for perimenopause and which option might best address my symptoms and long-term health. When hormone therapy is refused automatically, I would say run here, but I'm gonna give you some words. Doctor says, hormones are too risky. I don't recommend them. Your response, I've read the current research and know that hormone therapy is safe and effective for most women when started at the right time. I'd like to go over whether it might be a good option for me based on my personal risk factors.

48:00Dr. Mary Claire Haver:Pro tip here, you can download the Menopause Society guidelines that were updated in 2022 for menopause hormone therapy and hand them to your doctor. That might be the first time they've ever seen them in their lives. Remember, the Menopause Society is an elective society. The American College of OB-GYN does not recognize the Menopause Society or their guidelines yet. So I am a board-certified obstetrician gynecologist. I'm very proud of my training. But I did recognize as I became a menopausal person that there was a humongous gap in my knowledge and education. I sought out my own education through the Menopause Society.

48:37Dr. Mary Claire Haver:That's not common. So you can actually provide a source of education for your doctor and hand those guidelines over and hopefully teach them something and make them feel more comfortable in offering this to you. When mood symptoms are labeled as just garden variety depression with no hormonal component, okay? Doctor, this sounds like anxiety or depression. Let's try an antidepressant. Not 100 % unreasonable. But what we know now is that the mood changes associated, this is mostly in perimenopause. The chaos of the hormone changes in perimenopause are directly related to anxiety and depression.

49:16Dr. Mary Claire Haver:And there's some very recent studies that are excellent that have shown that giving these women menopause hormone therapy and these women were given transdermal options. they saw better improvement in their mental health than with an SSRI. Now, these were new diagnoses of anxiety and depression in perimenopause, or there were women who were previously well-controlled on an SSRI. Their symptoms were absolutely controlled. They were on medication. And rather than upping their medication or adding a second agent in that same family, they were given menopause hormone therapy, transdermal, and they did beautifully, beautifully well.

49:51Dr. Mary Claire Haver:So your response. I'm open to addressing mood changes, but I'd like to explore whether shifting hormones might be contributing. Can we look at the bigger picture, including hormone levels and perimenopause, before we start there? When your symptoms are called normal. This one drives me crazy. Okay. Normal means common. Not that it's not pathologic. Not that it's acceptable. I mean, presbyopia as we age is normal. You know, being farsighted becomes normal. We can't see the menus anymore at a restaurant. We struggle to read. This is a normal change. Normal meaning it's so, so, so common and happens to most people.

50:28Dr. Mary Claire Haver:Normal does not mean there's nothing to do. So the doctor says, every woman goes through this. It's just a part of life. Your response? I know menopause is universal, but it doesn't mean that I have to suffer through it. These symptoms are affecting my quality of life, and I'd like support in exploring what can be done. When a bone density scan is refused, you don't need a bone scan. and yet you're too young, you say. I understand the standard recommendation is to start at 65, but I know that bone loss can begin during perimenopause, rapid acceleration of my bone loss. With my age, my symptoms, and my risk factors, I'd like to proactively assess my bone health now rather than wait for a fracture.

51:15Dr. Mary Claire Haver:When symptoms are dismissed as not menopause, from your doctor, that's not really a menopause symptom. Again, this is a function of a lack in training of education. The only three areas I was taught, and I was taught nothing in medical school. The only areas I was taught that menopause could possibly affect. Your periods would stop. Your bones will disintegrate. Your general urinary system will suffer. That's it. Nothing about the musculoskeletal system, the metabolic system, brain health, mental health. Nothing, nothing, nothing. We're still struggling to teach that, okay? Again, not an individual doctor's fault.

51:54Dr. Mary Claire Haver:This is a systemic problem. So what do you say? From what I've read, perimenopause and menopause can affect multiple systems, including sleep, cognition, metabolism, and joints. I'd like to consider whether my symptoms might be connected to hormonal changes. And then when weight gain gets the diet talk. You probably just need to eat less and move more. And those words, sadly, came out of my mouth to women in perimenopause and menopause more times than I could count. It is what we standardly teach our students. I think understanding around obesity has improved. I know my daughter is not being taught that.

52:32Dr. Mary Claire Haver:She's a third-year medical student. She has taught about the multifactorial causation of obesity and weight gain amongst women, amongst all patients, and that it's much more complicated than just a simple calories in, calories out. But a lot of doctors who are older in training only got the message of this is a moral problem. This is a laziness problem. This is a you're just not moving enough and you're eating too much problem. And your response can be, I've made lifestyle changes and I'm still struggling. I've read that perimenopause can impact metabolism, insulin resistance, and body composition.

53:06Dr. Mary Claire Haver:I'd like to explore what else can be contributing. And when you're told, this is my favorite, there's nothing we can do. This too shall pass. Your response. I understand that these changes are part of a transition, but that doesn't mean that I have to go through this unsupported. I'd like to work together on ways to improve how I feel right now. So these scripts are also available on the checklist. Don't worry. You can take them into your doctor's office and then you can just run your finger down to the responses and pick out the one that makes the most sense to you at the time. I'm not expecting you to memorize these or to have them be scribbling them down after the podcast, we are gonna have these available to you.

53:49Dr. Mary Claire Haver:Of course, they're on our website at thepawslife.com under the lab checklist, and they're gonna be linked in the show notes as well. So here's what I really want you to take from this episode. These labs exist. The science behind them exists. The clinical knowledge to interpret them exists. What has not always existed is the woman in the room who knew how to ask, or the medical system that recognizes menopause's impact outside of the reproductive system. This is you now, okay? Print out the checklist. Go to the website, download it. Go to the show notes, download it. Bring it to your next appointment.

54:30Dr. Mary Claire Haver:Go through it with your clinician. Push back a little bit if you need to. Use the scripts. And if your provider will not engage with you on these questions, that is important information too. And there are menopause-informed practitioners who will. How do you find them? How do you find someone who is educated in how to take care of a menopausal patient? On our website, we have a clinicians list. This is a list of clinicians that you guys, my followers, my supporters, you know, our email list has through their good graces gone and written testimonials on clinicians that they have found locally.

55:06Dr. Mary Claire Haver:We've organized them, and there's over a thousand. We've organized them by city and state, so hopefully that will be of some benefit to you. Second resource, the Menopause Society has a list of certified providers. So if you join the Menopause Society, you get on a big list. But if you pass the test, which I think is important, you want to find someone who is certified by the Menopause Society. So you not only are a member, but you've actually studied and took the test. Also, Dr. Heather Hirsch and Dr. Rachel Rubin have excellent clinical courses to teach people how to take care of menopausal patients and how to prescribe.

55:37Dr. Mary Claire Haver:There are other resources out there as well. And then there is also telehealth. There are some really great telehealth options. We do have those listed on our website as well. And these are telehealth companies that were built to just serve menopausal women. They saw a gap, they saw a need, and they decided to build a system around it to help support women in perimenopause and menopause. So menopause is inevitable, okay? If we are lucky to live long enough, you are going to go through menopause, perimenopause and then menopause. More women will go through menopause than get pregnant and bear children.

56:11Dr. Mary Claire Haver:Suffering through menopause uninformed and unsupported is no longer acceptable. We're done accepting this. You deserve the full clinical picture of your own body. So go get it. And here's what I want to leave you on with a note of hope. I am post-menopausal. I've been fully menopausal for at least 10 years. You want my life. I am living my best life. I've never had better relationships. I've never had better boundaries. I've never been healthier, okay? I have better muscle strength, better bone density that I've had in 10 years, and a better outlook on life. I've gotten therapy when I need it.

56:47Dr. Mary Claire Haver:I've totally changed my nutrition. I've totally changed my exercise habits. I'm having better sex. Like, I'm gonna say it out loud. I'm having way better sex. And there's multiple layers to that. Yes, I'm on testosterone. That definitely helped. But I'm also thinking about it differently. Like, thinking about putting me first. Like, the best thing about my life is I've lost my filter. I am simply putting myself first and taking care of Mary Claire first. I am able to take so much better care of everyone in my world around me. I've also learned to put up boundaries on people I don't need to be taken care of, who can take care of themselves.

57:19Dr. Mary Claire Haver:So all of this is possible. And there is light at the end of the tunnel. I don't want anyone to be scared of menopause or afraid or feel like it's something to fear. It is absolutely not. But you deserve to be educated and supported through it. so you can come out of this with flying colors and feel like I do every day. So thank you for spending time with me. I really, really hope this episode is useful and that these resources are going to help you. Please, if you found this helpful, send it to a woman who needs it. That could be your sister, your best friend, a cousin, a coworker. By sharing these episodes, we can share the education and knowledge so that we can all take menopause out of the closet, out of the dark and into the light where it belongs.

58:03Dr. Mary Claire Haver: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 thepauslife.com. My new book, The New Perimenopause, is available wherever you buy books. Unpaused is presented by Odyssey in conjunction with Pod People.

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