Your new menopause toolkit with Dr. Mary Claire Haver & Dr. Sarah Berry

24:07From subcutaneous to intra-abdominal. Which is like from a healthy place around your hips all over to this unhealthy place around your... Yeah, the apple to the pear. The place where I saw my fat, as I've discovered in previous shows. Oh, Jonathan, you don't have any fat there. But yeah, it's shifting it from the pair, so around your hips. And estrogen actually directs the fat, funnily enough, to your hips. You lose estrogen and then it goes in a more male-like configuration, which is that apple around your tummy. But lots of people say, like Marie Claire said, well, hold on, that just happens when you age.

24:36And so what we looked at as well is we looked at males as they age in these risk factors, the blood pressure, the cholesterol, et cetera. And what you see is as you age each year, they go up a little bit. It's a longitudinal, yeah. And you get this kind of nice straight, pretty straight line, or as straight as you can get in human biology and science. When we looked at our females, we found all of the females for most of these risk factors are sitting nice and low. So we're doing a lot better than our male counterparts, hit the menopause or perimenopause. And suddenly, well, that line goes off the charts.

25:12And often in most of these risk factors even goes above. And we've got in our paper that we published on this some really lovely figures actually from our own real data showing that, which is really interesting. And, you know, it's not scientific, but when I posted about how shocked I was in my patient population looking at cholesterol levels and 80 % of my patients have hypercholesterolemia in their menopause journey. Meaning? Elevated levels of bad cholesterol. Their HDL drops and the low density go up in a negative health fashion. I think it had millions of views, comments of that. No one told me, you know, they just said I needed to change my diet.

25:53Well, I haven't changed it. And with no changes in diet and exercise, none. That menopausal status, estrogen deprivation, or the loss of our estrogen, the senescence of our ovaries, is a direct risk factor into these more likely to be associated with cardiac disease. And Sarah, can you explain for a minute? Next, I know this is, you know, your big area of expertise. What's going on in the way that these women are responding to food? Because that's really changing, isn't it? And that's what sort of explaining why these cholesterol levels are going higher and, you know, their responses to the blood sugar is changing.

26:25And I think you've, could you just explain that? Yeah, I mean, there's loads of changes going on everywhere from like our hunger receptors in our brain. And again, this is something that I think, you know, surprises everyone. And they're like, I'm eating exactly the same food, but I feel so hungry all the time. Oestrogen even impacts the hunger receptors. It impacts the release of fullness hormones. It impacts how we metabolize. So it's completely transforming the way that you engage with food and how you feel. Yeah. So first, it's impacting, yeah, people are hungrier because it's mucking up your hunger and your fullness signals, the release of those hormones.

27:00When you're eating those foods, it's also changing how you're processing those foods. And this was some really interesting findings from the zooprotic research and quite novel findings. And what we did is we looked at how people were processing the fat that they were eating from the meal and how they were processing the carbohydrates that they were eating. And we can measure this by measuring in the blood circulating blood glucose, or we also call blood sugar levels, which typically after a meal would rise, reaching a peak about 15 minutes, return to baseline about two hours. We can also measure how we respond and metabolize the fat in the meal by measuring something called triglycerides in the blood.

27:36And that's a slower, you know, reaches a peak about four hours, returns to baseline around eight hours. And what we found is when we gave our 1 ,100 participants standardized meals that contained exactly the same amount of fat, exactly the same amount of carbohydrate, the peri and post-menopausal women had what we would call unfavorable post-meal responses in this circulating fat, in this circulating blood sugar. So what was happening was is that the post - and perimenopausal women had significantly higher increase in circulating blood sugar, which we know if it's excessive repeated over long periods of time, increases our risk of chronic diseases, type 2 diabetes, cardiovascular disease, obesity, and so on.

28:17So that means basically you could be eating exactly the same food as you were eating five years before and your body was just fine with it. And now suddenly, like every time you're doing this each day, it's just this little bit of damage day after day after day. So it's like, it really is true. You are doing the same thing as before. And now you sort of can't cope with it in the way that you could before. The conventional thinking around this is that the patient is not being truthful. That's impossible. Like when you don't take into consideration the gut microbiome, you know, metabolism changes associated with the menopause transition.

28:51I've seen it in the literature when I was researching for the new menopause. this kind of paternalistic, well, women do tend to somaticize their symptoms. Women do tend to stop moving quite as much. And there may be some truth to that, and they are hungrier. We know that. But just believe the patient. She's telling you, I have not changed my diet and exercise, and all of these cardiometabolic risk factors have worsened for me. What's going on? You said, and again, coming back to these quickfire questions, you shouldn't necessarily expect your doctor to be supported, which is quite a strong thing to say.

29:28I mean, could you maybe start with that? Why is that? And then love to talk through, so how could you help a listener to be able to talk well to their doctor to get the right focus and treatment? It's really, you know, of course, for some people, it's a personality thing. They just have a checklist, and if you don't fit the checklist, you know, but if you're not trained and educated as to this basic biologic process. You don't know how to associate it with what's going on. So I think we have a huge problem across the world in how we train and educate our healthcare providers in as far as the far-reaching aspects of the menopause and the menopause transition.

30:11And so I think that's the first problem. So I arm my patients with lots of tools. I arm my followers with lots of tools to try to advocate for themselves. I'm like, there's no guarantee, but I give them research studies to print out. And, you know, these are big meta-analyses. These are big, big things, not little, small, you know. And so that they can, the American Heart Association wrote a beautiful study on the menopause transition and the risk of cardiovascular disease. I hand them that. You know, I give them things from the Menopause Society in the U.S. or the British Menopause Society in the U.K., you know, with tools to advocate for themselves because often they are educating their providers.

30:54I teach them the words to say to go in and ask for certain treatment options that might be available to them that the physician may not have realized could help them. I think the next generation of doctors, I hope, are going to be more aware. And I think, like, my daughter's in medical school. I think her generation forward were great. But it's going to be our generation to kind of retire the ones who are out, who aren't learning, don't have the time or inclination or care really to pick up this new information. The societies are not on board yet with menopause. So it really has to come from above.

31:31I mean, we just have so much. This is a big ship to course correct. And I do find it a bit surprising because one of the striking thing is how many doctors are women today, right? So that's definitely a shift from when I was a small child. We were trained in male medicine, male-centered medicine, that any female experience, whatever it was, was abnormal and different than the standard. The male patient was standard. And we have so much work to do around that as well. It's the same in research. Most scientific nutrition, biological research is undertaken on males because males are easier to study.

32:06You don't have to think of their menstrual cycle. you don't have to think of whether they're pre, peri or post. And I know I've often told you this, Jonathan, but Marie-Claire, before I started working with Zoe, I had conducted about 30 randomized control trials looking at the impact of diet on cardiometabolic disease. I had never recruited females into my trials because it meant it would triple the cost of running the study because I'd have to recruit more individuals to take into account all of the factors that I just said. And you can't get that funding. And so unfortunately, as a female, not only, you know, up until five, six years ago, I was only including males in my studies.

32:41Fortunately, at ZOE, you know, we're really kind of pioneers in terms of, you know, we're over-indexing on females in our research, which is fabulous, which is why we can produce all of these great, great findings. So coming back to this woman who's going in to see her doctor, so hopefully she sees a doctor who is completely informed, but that's great. But let's say they're worried that maybe their doctor isn't going to be completely up to date. What can they walk into that doctor's office with, or how can they approach this to try and make sure that they do get the best outcome for them? I'd say for her to educate herself as much as possible, because at this point, she knows her body better than anyone.

33:23To be very clear, like write down her symptoms, make sure she has her family history ready. In the U.S., we have something called the Well Woman Exam. That is not the time to talk about menopause symptoms. You have a 10-minute visit. Half of that's in stirrups, getting your breast cancer screening and your cervical cancer screening. Schedule a special visit, a problem visit, just to discuss the menopause. Call ahead and see if they are willing to discuss this. Do they feel comfortable? Would they have an open conversation with you? Because a lot of physicians, rightly so, know that they have a lack of education.

33:58They're very, very busy discussing this, you know, doing surgery and delivering babies. I mean, and it's really sad in the U.S. that this all gets dumped in the lap of the poor, busy OBGYN. And this really should be internal medicine and family medicine or GPs. And so taking the time, do your homework, go in prepared with questions, go in prepared with your history, go in with all your previous blood work and lab tests that you've had done so that you can create a clear picture for your physician to be able to help you. One of the starkest examples of where the focus and priority in women's health, there's two.

34:35If you go into PubMed, which is Google for doctors, Google for medical scientists, and you type in the word pregnancy, 1.1 million articles come up. Then if you just type in the word menopause, we have 94 ,000 articles. And when you think of the money, the brain power, the lab space, that, you know, is the last third of our lives not worth us in, you know, once our reproduction ends, are we no longer only worth 10 % of the research funding and dollars? So you're basically saying there's 10 times as many sort of medical trials and studies and papers on pregnancy than on menopause. Yes. Well, in that PubMed search, if you then put nutrition and menopause, you get in the hundreds.

35:18And yet if you were to put nutrition... Quite a lot of those are yours. if you were to put you know nutrition and i don't know cholesterol you'd get in the hundreds of thousands and so it's crazy that is crazy well i think that's really um fantastic advice i'd love now to talk about well what's the advice that you know you can give today to our listeners whether it's for themselves or for um you know for loved ones and i know in your book mary claire you talk about sort of a toolkit of strategies. There's not like just one answer. We should probably start with medicine and, you know, talk about hormone replacement therapy.

35:58But I definitely want to make sure that we have time to talk about a lot of the other things because, of course, that's a conversation with your doctor. And I think for many of these other things are things that you can implement at home. So hormone replacement therapy is something I discuss with all of my patients. We talk about the risks and the benefits. We direct those risks as to what may apply to her. And we talk about the benefits for everyone. We talk about the cardiovascular benefits, the neuroprotective benefits, the osteoporosis prevention benefits, the general urinary preservation benefits.

36:33We talk about, yes, it will help you with your hot flashes. It will probably help with your brain fog. Could you talk for a minute just about those benefits around long-term health. Because again, I think it's often been presented as something that's very much around symptoms. But it's interesting that all those things you just started with were about sort of the long-term risks that Sarah was talking about earlier. So one of the meta-analyses that stopped me in my tracks and really changed my practice of medicine was in 2020 when the American Heart Association published a treatise on the menopause transition and cardiovascular risk changes.

37:11And they really were very, very clear that a woman's cholesterol dramatically moves towards an unfavorable profile through the menopause transition very, very quickly. Usually it's a slow process over time, like Sarah talked about. And then all of a sudden, it just, boom, accelerates, beginning in perimenopause. And they talked about looking back at the Women's Health Initiative study. if you started hormone therapy very early in your transition state, within the first 10 years or before the age of 60, there is a cardiovascular benefit to being on hormone therapy. So you're less likely to have a heart attack or a stroke.

37:49You're less likely to have a heart attack, not a stroke. Less likely to have death from a heart attack and less all-cause mortality. Which is just death. Death from anything. 50 % reduction of cardiovascular disease. And we see in our own data from our zoopiotic studies, some suggestions of why this is. And so when we looked at individuals who were taking HRT versus those not taking HRT, we found that those individuals taking HRT had significantly lower blood pressure. They had significantly lower cholesterol, particularly the bad cholesterol. They had significantly better insulin sensitivity, significantly lower visceral, so the tummy fat, and significantly lower inflammation.

38:32and it's this inflammation that's actually I think really interesting as well post-menopausally that we know chronic inflammation underpins many long you know chronic diseases like your type 2 diabetes cardiovascular disease etc even some cancers and the fact that HRT was reducing the increase that you see post-menopausally in inflammation was interesting but I think the problem with HRT there's been so much confusion and you mentioned about the women's health initiative and this is a landmark study that came out in the early 2000s, 2002, that had this, you know, big headline saying, they called a press conference to stop the study and share this incredible finding that not only was estrogen not cardioprotective, it was increasing your risk of breast cancer.

39:18And this is before they had actually completed all of the statistical analysis. I mean, you know, Jonathan, having just gone through the process of the papers we've done, and we've just finished and Marie Claire and a randomized control trial that everyone's blinded who's doing the analysis to actually the analysis that we're doing that we wouldn't even consider talking about it until you know it's gotten undergone lots of review processes so the whole way that these results were presented was not appropriate plus the type of HRT that was given to these individuals is was oral HRT so that was in the form of you know a tabernacle in the UK I know it's a little bit different in the US, but in the UK, we only prescribe transdermal HRT.

40:02So these are the patches or the gel. How you process the oral, the tablets versus the transdermal HRT is different. Very different. But also the evidence, and you mentioned this, didn't you, that the timing of taking it versus the risk is really important. And so in the Women's Health Initiative, women were being prescribed it later in their 60s. So they were in their 50s to 79 was the catch ages. And so the average age was 62, much older than the traditional patient would have been started on hormone therapy. But the outcome that they were measuring was cardiovascular disease. So I get that they start, you know, they wanted an older population because it takes a while to develop, you know, to get your outcome.

40:42And the longer you run a study, as you know, the more expensive it is. So it turns out that estrogen is better at prevention than cure. and when you put estrogen on top of disease, sometimes it can make it worse. Whether it's oral or transdermal, estrogen can make platelets stickier and if you have issues in your cerebral blood vessels, you have an increased risk of clot. No increased risk in the first seven years of therapy and the WHI. 50 % reduction of cardiovascular disease. We see in our own data from our zoopedic studies some suggestions of why this is. And so when we looked at individuals who were taking HRT versus those not taking HRT, we found that those individuals taking HRT had significantly lower blood pressure.

41:31They had significantly lower cholesterol, particularly the bad cholesterol. They had significantly better insulin sensitivity, significantly lower visceral, so the tummy fat, and significantly lower inflammation. And it's this inflammation that's actually, I think, really interesting as well post-menopausally that we know chronic inflammation underpins many long you know chronic diseases like your type 2 diabetes cardiovascular disease etc even some cancers and the fact that HRT was reducing the increase that you see post-menopausally in inflammation was interesting but I think the problem with HRT there's been so much confusion and you mentioned about the women's health initiative and this is a landmark study that came out in the early 2000s, 2002, that had this, you know, big headline saying, they called a press conference to stop the study and share this incredible finding that not only was estrogen not cardioprotective, it was increasing your risk of breast cancer.

42:30And this is before they had actually completed all of the statistical analysis. I mean, you know, Jonathan, having just gone through the process of the papers we've done, and we've just finished Marie Claire and a randomized controlled trial that everyone's blinded who's doing the analysis to actually the analysis that we're doing that we wouldn't even consider talking about it until you know it's gotten undergone lots of review processes so no the whole way that these results were presented was not appropriate plus the type of hrt that was given to these individuals is was oral hrt so that was in the form of you know in the uk i know it's a little bit different in the us but in the uk okay, we only prescribe transdermal HRT, so these are the patches or the gel.

43:16How you process the oral, the tablets versus the transdermal HRT is different. Very different. But also the evidence, and you mentioned this, didn't you, that the timing of taking it versus the risk is really important. And so in the Women's Health Initiative, women were being prescribed it later in their 60s. Yeah, so they were in their 50s to 79 was the catch ages. And so the average age was 62. much older than the traditional patient would have been started on hormone therapy. But their outcome that they were measuring was cardiovascular disease. So I get that they start, you know, they wanted an older population because it takes a while to develop, you know, to get your outcome.

43:54And the longer you run a study, as you know, the more expensive it is. So it turns out that estrogen is better at prevention than cure. And when you put estrogen on top of disease, sometimes it can make it worse. Whether it's oral or transdermal, estrogen can make platelets stickier. And if you have issues in your cerebral blood vessels, you have an increased risk of clot. No increased risk in the first seven years of therapy in the WHI, but they did see a very slight increased risk. And what the data scientists think is that was probably they had pre-existing disease and then you added estrogen on top of it for the older patients.

44:32But clearly, the data is clear. When you start estrogen or you continue someone's estrogen, you know, who has no cardio, no clots, no plaques in her arteries, she's going to be fine. And so that means, I guess if I understand that right, it's not for everybody. But Mary-Claire, it sounds like if someone is coming into your clinic, quite a lot of those women end up taking hormone replacement. Is that? Yes. After we discuss, you know, the risks and benefits for her, most of them will decide to, yeah. Because there are some cases where there is increased risk. And it's important we mention that. Of course, yeah, there are contraindications.

45:08If you've had breast cancer, et cetera. So there will be some people that it isn't appropriate for. Exactly. Yeah. This is an individualized conversation with your doctor. But that's a big shift, isn't it? A big shift. Almost no one should take it to actually you're saying probably the majority of women who end up coming to see you at this point in their lives much earlier are. You know, clearly we know that when we lose our estrogen, we're less healthy on multiple ways to measure human health. And it's now looking very clear that the longer your body is exposed to estrogen, that was published in the BMJ, the British Medical Journal, looking at cognition.

45:44They looked at risk of dementia and how long, instead of saying, was she on HRT or not on HRT or is she menopausal and what stage is she in? And they simply looked at lifetime exposure to estrogen in any form, whether it was, you know, from the time you stop your periods, from the time you start, however many years that was, plus hormone therapy in the form of estrogen. And the more years you had estrogen on board, the lower your risk of cognitive deficits. Amazing. I would love to switch to some of the other things that people can actually do for themselves. there'll be a lot of listeners who like me to be honest sort of five years ago thought well you know can really nutrition have any impact on like this sort of catalog of really serious symptoms you know what does the data say sarah so the data shows that nutrition can have an impact on symptoms and what we certainly know is that it can have a huge impact on all the kind of disease risk factors that mary claire and i've been talking about so nutrition can help with the two problems of menopause, one the symptoms, but one the increased disease risk.

46:48Now, it might work better for some people than other people. And it's really important that we say that. What we found in our data is that when we look at people's overall diet quality, those people that have a higher overall diet quality have a significant reduction in symptom prevalence. So they have lower levels of sleep disturbances, they have lower levels of hot flushes, lower levels of anxiety, palpitations, etc. And for some of these, this is like 30, 40, 50 % lower, depending on the symptoms. And is this one of these nutrition studies on 20 people, Sarah? Of course not, Jonathan. It's our Zoe studies.

47:28So this data actually comes from the Zoe Health Studies research platform. So this was actually in hundreds of thousands of individuals, which is fantastic, because that gives us the power to delve even deeper, which we haven't done yet. So we need to do another podcast in about a year when we're next in New York with you to divulge these kind of details. But what we've started by looking at was just overall diet quality. What we're going to be doing next is looking at individual components of diet and looking, you know, how does it differ depending on clusters of symptoms or depending on, you know, other characteristics such as, you know, the age at which you might have started that kind of perimenopause transition.

48:08And, you know, a lot of women will say, okay, at least on my social media following, you know, I'm choosing not to take it or I have an absolute contraindication. What can I do? And then I say, we have to double down on all the other aspects of the toolkit, especially nutrition. America, if you are taking hormones, does that mean you can just forget about all the rest of this? Absolutely not. If you don't maximize your nutrition, hormone therapy is really only going to help your hot flashes. Yeah, nothing offsets a bad diet, Jonathan. And this is where the whole kind of, you know, the supplements, all of these other kind of silver bullets that people take, nothing offsets a bad diet.

48:48We need to make sure we are having, you know, that healthy, balanced diet. And I think for me, the icing on the cake in terms of the evidence for symptoms and diet is from some what we call longitudinal analysis and science. I know this is brand new and has not yet been peer-reviewed, right? Share with that proviso. It's some results we only got last week, so it's even quite new for you. So we followed people who were on the Zoe program. So this is where we're encouraging people to have the healthiest diet possible for them. And we took baseline measures prior to them starting the Zoe program where we looked at menopause symptoms and we looked at their diet.

49:27And then after 18 weeks, we collected added information about their menopause symptoms. Had they changed? What symptoms did they now have? Severity, etc. And I must say, I was really surprised by this. We found a huge reduction in the prevalence. So how many symptoms people were having and how many people had each symptom. So we were having up to about 70 % reduction in some of the symptoms. And this was after about four months, you're saying? This is after about four months. Pretty fast. Yes. And we checked, had you started HRT in this time? So we adjusted according to that as well. Are there lots of studies showing a particular diet intervention and its impact on menopause?

50:08There are some studies out there. So there are some cross-sectional studies. So the studies where at one point in time, look at what's your diet and what's your symptom prevalence. Those studies show that generally if you're following a Mediterranean style diet, which is a very kind of healthy, plant-rich diet, that you have less symptoms than those not following that kind of diet. Those following a Western style, as we call it in nutrition research diet with heavily processed foods, have more symptoms. There's a couple of randomized control trials, but not many looking at whole dietary patterns.

50:43So these are trials where they'll randomly allocate one group of people to follow a Mediterranean style diet and another group of people to follow like the typical US or UK diet, they also see improvements in symptoms if you're following that Mediterranean diet. Then there's hundreds of studies on individual supplements, on individual foods, on individual nutrients. And I think this is where we need to be a little bit careful that there's a lot of inconsistencies. Now, that's partly because there haven't been enough good studies on each individual nutrient, etc. But I think that this idea that you can have a silver bullet where you just take, I mean, I can't remember.

51:21A probiotic or turmeric. Yeah. Where it's like a single component. And, you know, you see some of the claims are made. We call, I don't know if you have this term here, we call it meno washing. It's getting here. So you stick meno in front of it. You double charge up to 10 times because you put menopause in front of it. And hey, you know, you're like rubbing your hands together and off on your yacht in the Mediterranean and retiring early. But there isn't enough evidence yet for that. There's some interesting evidence coming out around soy isoflavones. Isoflavones are a particular chemical that mimics estrogen.

51:59And there's some really interesting interaction with the microbiome related to this. And that's a fascinating area. And I really think like watch this space on that where there is, I think, enough evidence to say for many people supplementing with isoflavones may have an impact. All of these studies, even these hundreds of individual food item studies, their outcome is hot flushes. It's the easiest thing to measure. So basically your study is pretty much the first one ever to actually look at this full set of symptoms. Yeah, and I've never thought about that until, I mean, I've always been looking literally thinking, well, what about this and this symptom?

52:31But because of that misconception, anything to do with menopause, if it's not measuring a hot flash, it doesn't exist, you know. I'd love to talk about other actionable advice, Mary Claire. So we talked about sort of the hormones and the diet. If you were going to say to somebody here, here are like the three other things that you could really do that could make a difference, potentially on top of those others, what would they do? So again, you have to let go of the notion that menopause is hot flushes, right? So if I, like my big three are usually make sure you're getting a minimum of 25 grams of fiber in your diet per day.

53:09Most women on the Western diet are getting 12, and that's going to hit so many points in what you're dealing with. It's going to help with cholesterol. It's going to help with your blood glucose. It's going to help with your insulin levels. It's going to help with your gut motility. It's going to help with your microbiome, you know, and that should come from food. This is not your source of fiber. This is a little helper. You need to get this from food because those foods are also packed with micronutrients, minerals, vitamins, healthy fats, other things that will keep you healthy as part of a profile.

53:42Nutrition is a profile. It's not one thing. So one is fiber. The other is watching the amount of added sugars that you have. So not fruits and vegetables or dairy, but sugars added in cooking and processing and in alcohol. You need to limit those to less than 25 grams per day. Women who do that consistently have less visceral fat, less hot flashes. We have pretty decent data to show that you're healthier when you do that. And the keto movement really, so many of my patients who've done keto for years are really anxious when they see sugar levels and I try to talk to them about the difference between an added sugar and a sugar that's naturally found because it's sugar molecules, a sugar molecule, of course, you know, and but those naturally occurring sugars are wrapped in a package usually with fiber and vitamins and minerals and nutrients and have a very different impact on your health than a simple sugar that's through processing.

54:41And then to add in consistent resistance training, muscle training, Most women are doing cardio, and they didn't want to gain weight. They didn't want to be bulky, you know, and they didn't understand the impact of weight training and keeping strong muscles and bones. When I talked to my patients, when I talked to my followers, I did this questionnaire and said, what scares you the most about getting older? It shocked me because for me, it's cancer. I've lost two brothers to cancer, multiple aunts and uncles, you know. It's just my genetics, and it's okay. But I just, you know, you kind of come from your place of what you know, and it was overwhelmingly to not be able to think and to not be able to move.

55:23Basically, not be able to care for myself and be a burden on my family as I age. They want to limit that time as much as possible. And so what causes people to go into a long-term care facility or not be able to care for themselves is loss of being able to walk, move, break a hip, you know, whatever, or dementia, you know, whichever form of dementia. So, like, if we just look at frailty, what can we do to decrease that risk in muscle mass and bone strength? And that begins now in our 30s, 40s, 50s, you know. And they're not the same thing, are they? Like the bone strength and the muscle mass? Well, the musculoskeletal unit works as a unit.

55:56So, stronger muscles mean stronger bones. You're sending that signal that's going to slow down the rate of bone resorption that we see accelerate when we have our estrogen loss. And so, you know, that remodeling process slows down so that we can hang on to strong bones. And so what are you advising your patients to do? At least two days a week of resistance training with probably weights. I tell them there's, you know, YouTube videos now. There's lots of free resources. Start investing. And my favorite, like, hack is get a weighted vest. There's some beautiful studies, small, but they're there, done on women in their 70s and 80s wearing weighted vests.

56:36They were in long-term care facilities and looking at their improvements in their bone and their bone density and muscle strength. Now, this was combined, some with creatine, some with, they're all doing muscle training. But just wearing that weighted vest and also the vibration, the vibratory, which not everyone has access to, but wearing a weighted vest to like clean the house or walk on the treadmill or when you walk your dog, adding in that little bit of extra stress will send that chemical signal, you know, to the bones and muscles to be more resilient and to be stronger. So literally wear the weighted vest while either just walking around the house or something like that.

57:10And that's going to sort of do all this extra pounding on your bones and sort of muscle work. That will make a difference. Right. And just start at 10 % of your body weight. That's a very safe place to start. So we often talk about exercise snacking because I think if people haven't been used to either doing weights or any exercise, it's really daunting to suddenly do that. Right. Go into a gym. And so something we really advocate is do an exercise snack. And by this, it could mean do 10 squats, do a wall push-up. You know, you can do this when you're on the move. You use your own body weight as your weight.

57:43You only need 30 seconds. It can actually build up to doing quite a lot over the day if you're snacking on exercise in that way. And I think that's a really great way to start. I did want to pick up on one thing that you'd mentioned earlier. You talked about a frozen shoulder being quite common. And I at least hadn't heard about this before. I hadn't either. I'm imagining now that there will be a set of listeners who are suddenly going to be thinking, well, I've got that. I suspect some of them will not have associated this with menopause and may just be basically grinning and bearing this. Is there anything you can do if this is something that you're living with?

58:20So what it is is adhesive capsulitis. The capsule around the shoulder joint becomes adhesed and freezes. And so you start losing. The beginning stages, you have pain and loss of movement. You can't put your hand over your head. You can't put your bra on. You know, you can't reach behind your back. And it's very, very, very painful. And in the advanced stages, it could take a year or more of physiotherapy to get in that physical therapy to break down and regain your movement. And quite often, they'll have it on one side and they'll go to the other. So when I talked about it, so many people asked me on social media about frozen shoulder.

58:58Instead of saying, no, I've never heard of it, I'm curious. So I start digging in the literature. I find a study, recent study, coming out of Duke University where the head of the orthopedic surgery department, who was a woman, and the head of OB-GYN, who was a woman, got together and said, there's too many patients who are having this. Is there, and they're all menopausal, you know, is there a connection? And what they found in reviewing the literature is that we know the age at which you get, and it's definitely perimenopause and menopause, early menopause. And if you're on hormone therapy, the risk is significantly less that you will develop frozen shoulder.

59:35But say it's too late, you're not on hormone therapy, you know, so it's preventative. What can you do? Know early this might happen to you. When you start noticing, I can't quite reach, this is hurting or just feel stuck, immediately go to orthopedic surgery. Go get a referral for physical therapy. Go online and look at the exercises that you can do. Dr. Vonda Wright is an orthopedic surgeon and she does a lot of menopause care. She talks about this extensively. You know, things that you can do in the early stages to prevent having this severe adhesive capsulitis and then ending up needing surgery.

1:00:06I'd literally never heard of it. And I imagine there will be some people listening to this who are suddenly going to go out and speak to a doctor who didn't otherwise thank you. I would love to try and summarize what we've covered. We've covered a lot of things. And I know the two of you will correct me where I've got this wrong. So we actually started by talking about the fact that the symptoms of menopause are actually quite different from the way that many people understand them, including women going through it, including doctors and scientists. They're amazing. These hot flashes or hot flushes are only the fifth most common symptom, even though they're like the only one that people have historically used to decide whether or not someone's going through menopause.

1:00:42I think you said, for example, both bad sleep and anxiety, sort of 80 % of women are having it. And then there was a very long list of other symptoms you can have, both things like bone loss that are long term, joint pain, this frozen shoulder I've never heard of, forgetfulness. It's an amazing and very complex catalog of things. And this is part of the reason why often it's been hard to diagnose. You explained a bit about what's going on and the fact that we've historically thought about menopause as very much like it's at the point when you stop having eggs, but that actually we now understand that there's this long period, sort of seven to 10 years, I think you were saying before the point of your last egg, where there are suddenly not that many eggs left.

1:01:29And so instead of having this sort of constant amount of estradiol, did I get that right, which is this form of estrogen being produced, you have this hormonal chaos, I think you said, Sarah. So it's all over the place. And so actually sometimes the symptoms could be worse because it's not like it's just stopped. It's sort of up one day and down the other. But that also means the total period that you're experiencing, this is a lot longer than people have previously said because you might have seven to 10 years before menopause, maybe seven years afterwards. You said maybe 10 years if you're African-American.

1:01:58So like this really long period that could even start when you're 35 and might go on until you're 60. So this is a very big period of a woman's life. And it's made harder still because there is no test. Mary Claire, I cannot just go into your clinic and get like a single test that tells me you have perimenopause. We're great at postmenopause. Postmenopause is, I understand, quite straightforward. But for perimenopause, you don't know what's going on. And if we said like the first thing actually is just if you understand what's going on and that you may be going through perimenopause, that already might help with your stress reduction because suddenly at least you understand what's going on in this area.

1:02:29I think you shared some great examples where even when you're as educated about this as you are through your work, like as an individual experiencing it, it can still be a shock because it's not so obvious to just this one symptom. You then went and said, not only are there all these symptoms, but actually it really is having a big impact on your long-term health. And that this is something that has not been well understood, but that suddenly a woman's risks of many long-term diseases. And we talked a lot about sort of cardiovascular, gastric, sort of heart-related diseases, but they're just in general, the risks to your bones, all these sorts of things start to shoot up.

1:03:05And I think explain that this is because there are these little receptors for this estrogen, like everywhere in your body. And so sort of every part of your body is changing. And I actually have for the first time that we now know you get hungrier, for example, but that also the way you process the food that you were always eating no longer works the same way. So suddenly you're eating the same food that you were eating five years ago, before you were fine with it, and now actually it's starting to cause you this harm. And so you're seeing the raised cholesterol and all these other things, more inflammation, weight moving towards your stomach, which is more dangerous.

1:03:38So suddenly you need to change things around your diet as well as everything else that before you're okay with. And then we talked about, okay, so what can you do about it? We talked about hormone replacement and that there's really been a big shift in understanding the benefits and the risks, that the way that you get this now is different from in the past. So that's a conversation with your doctor, but that in general, you are now prescribing this to a lot of the patients who are coming to you versus a situation where it might have been viewed as like, you know, for 5 % appointment. I think in the past, we were overemphasizing the risks unnecessarily, and we were dramatically under-emphasizing the benefits.

1:04:15And we're really understanding the benefits a lot more now. So I think that's really interesting. Then we talked about nutrition, Sarah, you said, some sort of amazing new data, some of which has not even yet been released. And that's very hard, by the way. So I'm quite pleased that Sarah must be very convinced about it. We wanted to share it before it's peer-reviewed. That not only do you see that diet is correlated with big differences in symptoms, and I know that's already been published, but also this new data about members of ZOE who are following their individual guidance, getting this retest.

1:04:48and actually seen amazing this. I think you said 70 % of people saw their symptoms decrease in just four months, so in a very short period of time and across this whole cluster of symptoms, which I know Sarah is very excited about, and I'm sure we'll be talking a lot more about that soon. Mary-Claire, you gave some great, really practical tips about what you could do. So first was like fiber within food, double it. So this is like all those healthy plants that support you in many ways and that you see that as really important. Watching the amount of added sugar you have. So not worrying about the fruit, but worrying about, you know, all the things that are in there, drinks and the cakes and all of these sorts of things.

1:05:24And then you talked about how important consistent resistance training. So which you were saying, you're trying to advise your patients at least two days a week to be working with weights. And that might well not be what they've been thinking about before. But now because of all these risks to do with bone loss, but also the strength that's going to allow you to continue to stay in your home, that's really important to ensure they can do what they almost all want to do right which is to stay at home for as long as possible not break a hip but also not get um dementia and you have this brilliant um tip that i hadn't heard before uh get a weighted vest you can start at just 10 percent of your body weight you could just wear that while you're doing some activities around the house and that alone could really make a difference which i love because i think we have a lot of listeners talk to us about the idea of going to the gym is really scary um and so i think we often talk about what are ways to sort of start to make those changes.

1:06:17And finally, I mustn't forget this frozen shoulder thing. So there will be a bunch of people listening to this, either listening to themselves or thinking about their wife who's been sort of complaining about this for some time, but doesn't want to make a fuss, is really busy. And so if you have got sort of part of this frozen shoulder, you should go and get that checked out because that is now sort of being identified as a real menopause symptom and it sounds like it gets very serious if you aren't taking it seriously. So it's something you should go and have checked out. Absolutely. We need to add that to our list of symptoms that we ask in the ZOVI app.

1:06:51I feel like we'll be coming back next year and there'll be even more symptoms on this. I've got, I think, 70 listed in the new book. Wow. That's amazing. Mary Claire, thank you so much for coming and joining us today. Thanks for having me. I thought that was fantastic. I hope you learned something today and enjoyed the episode. If you listen to the show regularly, you probably already believe that you can transform your health by changing what you eat. But now, there's only so much you can learn from general advice on a weekly podcast. If you want to feel much better and live many more healthy years, you need something more.

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