Dr. Mary Claire Haver: How to Navigate Menopause & Perimenopause for Maximum Health & Vitality

welcome to the huberman Lab podcast where we discuss science and science-based tools for everyday [Music] life I'm Andrew huberman and I'm a professor of neurobiology and Opthalmology at Stanford School of Medicine my guest today is Dr Mary Clair Haver Dr Mary Clair Haver is a board-certified OBGYN and an expert in perim menopause menopause and all aspects of female specific health during today's episode Dr Haver explains exactly what per menopause and menopause represent in terms of their underlying psychology and biology and the specific actions that all women can and should take in order to navigate these

stages in Optimal Health she also describes the things that all women should know and do long before per menopause arrives in order to best navigate perimenopause and menopause once they arrive we discuss specific nutritional practices supplementation practices as well as conversations that you should have with your mother and with your physician in particular your OBGYN not just as per menopause and menopause approach but at every developmental stage a fair amount of our discussion centers around hormone replacement therapy not just for estrogen but for testosterone in women as well and the many misconceptions and controversies that

exist around hormone replacement therapy for menopause Dr Haver explains how the specific timing in which hormone therapy is initiated plays a key role in whether or not the hormone therapy is beneficial for women or not and of course today's discussion gets into ways to offset some of the more common difficulties associated with menopause including sleep issues hot flashes inflammation and more by the end of today's episode you will have a clear picture from Dr Marie Clare Haver about what per menopause and menopause actually represent the best way to approach perimenopause and menopause and the various

considerations around hormone therapy and lifestyle choices that can allow any woman to approach the years of Perry menopause and menopause and Beyond with the utmost vitality and wellness before we begin I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford it is however part of my desire and effort to bring zero cost to Consumer information about science and science related tools to the general public in keeping with that theme I'd like to thank the sponsors of today's podcast our first sponsor is arero press Aero press is like a

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again that's eights sleep.com huberman today's episode is also brought To Us by betterhelp better help offers Professional Therapy with a licensed therapist carried out completely online I've been going to therapy for over 30 years initially I didn't have a choice it was a condition of being allowed back in high school but soon I realized that quality therapy can be extremely valuable and I now consider doing therapy as important as getting regular exercise including cardiovascular exercise and resistance training which of course I also do every week therapy provided it's with a therapist with whom you have

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here and to learn about menopause and other aspects of women's health there's a lot happening in this area right now yeah and you are at the center of what I understand is a new direction for the understanding and treatment of menopause that's what we hope and related themes like per menopause yeah and the many important aspects of female Health that stem from it like cardiovascular disease osteoporosis right and so on so we will get into all of that today but just to kick things off how do we Define menopause so the medical definition of menopause

which I have a huge problem with is one year after the final menstrual period And the reason why I have a problem with it is not everyone has a menstrual period what if you've had a hysterctomy what if you have an IUD what if you've had an ablation or something that's suppressing your periods PCOS so for a lot of women and even clinicians they are struggling to like find that diagnosis because it doesn't fit everything what it represents is something much bigger menopause is also one day of your life it is that one day exactly

one year after your last period but it represents the end of your ovarian function some of us call it ovarian failure ovarian sence but basically what separates males and females is many things separate us but in my world um we are born with all of our eggs we have 1 to two million at Birth by the time we're 30 most of us are down to about 10% maybe 120,000 by the time we're 40 we're down to 3% of our egg supply and the quality is declining as well so menopause is when you have no more

eggs left and therefore no more sex hormone or very little sex hormone production from the ovaries so estradiol levels will decline less than 1% of your reproductive years your progesterone levels will decline as well testosterone declines for sure but we have other ways to produce it so it's somewhere 50% or less than your healthiest years so is it fair to say that we need a redefinition of what menopause is I think so I think defining it as the presence or absence of a period is a mistake is there any consensus about the quote unquote typical

age of onset for men and paws and is it changing you know I hear a lot about how the onset set of puberty is Shifting earlier in females and given that puberty at least by some definitions relates to the onset of menes uh one could imagine that menopause would be shifting earlier as well so the things that determine when we have puberty or not are different than the things that determine when we run out of eggs um right now in the US it's the average age of that one year after your cycle so menopause that

one day is about 51 to 52 years old however normal is still 45 to 55 and there's a big variation you know that curves pretty wide um Perry menopause begins 7 to 10 years before that last minstral period wow okay I say wow because um it's the first time I've ever heard a specific number tacked to this word per menopause maybe we could talk a little bit about per menopause since it sounds like it represents a transition phase into official menopause right um however one chooses to Define that what are some of the I don't

know if I should call them symptoms sure where I should uh just well let me let me do let me walk you through the endocrinology and then we can go through symptoms so you understand so in a normal healthy menstrual cycle before menopause ever becomes an issue the female hormone cycle is a very EKG like reproducible monthly rise and fall of estrogen progesterone and then the brain hormones LH FSH and then g& RH so the way it works is our brain in the hypothalamus um is sensing for has a little sensor in the blood looking

for estradiol levels and when they get low it sends G&R down to the pituitary saying hey tell the ovaries to start trying to ovulate so we can get more estrogen on board the process of ovulation is what drives up our estrogen levels okay so pituitary sends out the pulses of LH and FSH which then lead to ovulation when we reach in perimenopause the beginning of perimenopause that critical level of egg supply those signals don't work as well we start becoming resistant to the LH and FSH pulle surges so the brains like hey I told you

we need more estradiol and the pituitary is like I sent the signal and the brains like send more so we get much higher pulses of FSH and then finally the ovary kind of is able to get that egg out but sometimes it's delayed so we have the timing of that monthly predictable cycle goes arise sometimes the periods are closer together sometimes they're further apart but also the estrogen and progesterone levels start changing dramatically we see much higher surges of estradiol than we ever had in our pre productive years and then much lower levels underneath so

we end up with this very volatile curve and not predictable at all we call it in our world the zone of chaos so it is literal hormonal chaos what used to look like this you know every month is now just just insane and very very very unpredictable that is why we don't have a good blood test in per menopause to make the diagnosis those of us in the mense use symptoms usually to make the diagnosis and we rule out other conditions that might overlap so per menopause basically critical threshold it's a downward Trend overall of

estradiol but is a very chaotic you know race till you Flatline and bottom out I see so for those listening um your description of the um kind of the amplitude of the estrogen surge it gets much greater in this per menopause phase you also mentioned that follicle stimulating hormone which comes from the pituitary has to be or somehow is upregulated in this phase because I don't know is it that the recept for FSH are somehow not responsive at the level of the ovary do we know what's happening to the ovary is it obviously the signals

getting there it's not effective so then the brain is kicking out more FSH is it that the quality is poor and then around each germ cell is the tholian cells which is actually where the estradi the whole pathway going from you know actually testosterone's converted to estrad so that whole pathway you know it still will respond but the cells are just old you know is the way that it's been explained to me and from what I've read I think we need a lot more research in this area because that is how we're going to help

women I think longer term is understanding that process better but you know all I learned in school 25 years ago was it's the transition to menopause the end you know the whole endocrinological process I didn't learn till about two years ago and my guess is just based on my understanding of the only recent Trend toward emphasizing studies of both female and male even just mice in mouse models which is where generally this stuff originates and then it shifts into humans once certain targets are identified um only recently has the NIH insisted that there be uh

female uh mice in the studies of mice I mean it's it's been a few years now but that's a you know sex as a biological variable is is actually a requirement in most Grant applications unless of course there's a specific reason to study only one or the other um sex of mice so you can imagine that um the dir of research in this area is due to a a long um desert of um absence of studies into what is per menopause right so for women who are in the age range of per menopause or who

are thinking about this are there things that they can do in order to either upregulate the sensitivity of the ovary to FSH or to somehow prolong this period of per menopause um and I should also say what are some reasons why they would want to do that um you know obviously this is part of the um of the Arc of maturation of the female reproductive axis but of course that alone is not a reason to not try and um I guess we say optimize it for one's well-being so we don't know when you the best

way I can highlight why we don't know or or where the dollars are going for research you know we go to PubMed and you type in the word pregnancy 1.1 million articles come up type in the word menopause it's down to 97,000 really you type in the word per menopause and I checked this like 2 weeks ago and it was like 6,400 and something wow yeah that is surprising so or maybe it shouldn't be surprising given what we were just talking about in terms of so as far as like why those cells are becoming resistant

and what's happening at the level of the receptor I think we need a lot more research in this area I think it's starting to happen because women are realizing there's a demand now because the older you are when you go through menopause the healthier you are for cardi metabolic disease it's the loss of estrogen that accelerates our path to those diseases so are there clinical signs of perimenopause that either directly or indirectly relate to these bigger surges in FSH and these larger amplitude um estrogen uh surges the the two best documented and studied are mental

health changes um the brain does not like the chaos of and and the neurotransmitters are very very sensitive to estrogen and progesterone and even testosterone and so we see aberration in serotonin and orpine and and dopamine as the levels start becoming chaotic so we have at least a 40% increase of mental health disorders in and SSRI use doubles across the menopause transition across per menopause and now the data is showing that women who are given hormone therapy in their per menopause have a lower incidence of neonet depression and now the neuroscientists are saying hey for

these women who are developing depression in per menopause giving them estrogen is better than an SSRI they're going to have a better outcome I think most people don't realize how rich the brain and rest of the nervous system are with hormone receptors in particular I estrogen receptors and as you mentioned testosterone receptors as well Androgen receptors um and the often direct relationship between estrogen and the neuromodulators such as serotonin dopamine epinephrine aceto Gaba for for um progesterone yeah it's it's interesting during neural development which is where I started off which was um neural embryonic development

the hormones exert you know these widespread roles in defining even which neurons will Express certain neurotransmitters and then somehow the field of Neuroscience is only recently gotten on board the idea that um this intimate relationship between hormones and neurotransmitters is something to consider in essentially every aspect of of brain health right not just cognition but maintenance of neurons and um offsetting neurod degeneration and so on um I mentioned that only um so that people I think typically think of hormones as something sure there's a signal from the brain and but that hormones are mostly of

the body when in fact hormones play an absolutely crucial role within the brain yeah so you mentioned that during per menopause there there are symptoms that are I guess it's are mainly reflected as shifts in mental health so is this women suddenly feeling um kind of um less uh optimistic is it like what what's the sort of um constellation of of of psychological shifts that can occur so we see uh increasing anxiety we see definitely loss of executive functioning so new onset of add type symptoms um we see of course the cognitive you know what

we call brain fog and and lay terminology which is cognitive you know so they lose their words they're not able to do the calculations at work like their executive functioning ability in their jobs is huge like one in five women will quit their jobs because of menopause symptoms um that's that's an outrageous number yeah and the the economic impact is huge and so now companies are starting to get on board and this is a Time Of Our Lives when the kids are grown for a lot of us you know and we're trying we're ready to

lean into our positions and really get into leadership we have all this experience and now we can't REM you know and now all of a sudden these and their confidence is just wrecked so and then the depression and they're not sleeping and like it's this horrible feedback cycle that they end up in that we end up in yeah I wasn't aware that one in five is is striking that came out of the UK but they're starting to like crunch the numbers here in the US and it's looking very similar I know we're going to get

into actionable tools later as it relates to menopause but as long as we're discussing this phase of per menopause uh what are some of the basic things sure that women could a pay attention to we don't want to make people hypervigilant to the point of anxiety but but um certainly given the frequency and given the implications um it's important for them to pay attention to this phase and then some of the things that they can do to you know either behaviorally or perhaps through other tools offset um some of these changes uh dysfunctional uterine bleeding

um which is abnormal periods so and again nothing's off the table it could be heavy periods menaga too frequent too few skipping it's really really chaotic and but a lot of women are suffering horribly from really debilitating periods either through the volume of blood loss or they're having you know cramps and you know really and so 90% of us will have that as a symptom um fatigue is a huge one a lot of them the symptoms are kind of vague you know and can be attributed to a lot of other things in our in my

what we call the menopausia chat group you know we have a lot of theories about a lot of conditions like fibromyalgia and the irritable bladder syndromes and that probably just per menopausa menopause and doctors didn't know how to put you know make that diagnosis and so you know muscular skeletal system takes a huge hit through the transition so all of a sudden you have no injury and you're having hip pain joint pain back pain with you know you go to the doctor and you get an x-ray you do whatever work up and they can't find

anything wrong palpitations are huge it is a vasomotor symptom so along with hot flashes palpitation so a woman will walk into the emergency room sweating profusely horrible palpitation she's anxiety and they'll tell her she's having a panic attack you know um they'll work her up you know everything's negative and just say well it's panic attack go home and no one knew to connect the dots and figure out that this woman was in her menopause transition and this is how her body was expressing it it's complicated because we have sex hormone receptors as you do in

every organ system of our body and when these levels start going chaotic it can present in so many different ways and so when the patients come to me I'm doing blood work not a lot of hormone levels because they're not super helpful but I am doing thyroid workups and autoimmune workups and looking for nutritional deficiencies and anemia and different things because I don't want to miss those things and just pen everything on per menopause are there lifestyle factors that can offset some of this it's not a perfect correlation but the healthier you are so anti-inflammatory

diet you know Mediterranean s galison dietes you know nutrition pattern um regular exercise good sleep habits you know all the pillars of Health the healthier you are when you hit per menopause the better the course is going to be for you they're looking at extending the life of the ovary with pharmacology we know what can shut it down faster so we have kind of a genetic predetermined age of when you're going to lose all your eggs but we can speed that up so if you smoke you're going to go through menopause sooner than your twin

would have if she didn't smoke okay if you don't have children and you ovulate regularly then the more you OV the faster you run through your egg supply okay interesting I I wasn't aware of those data that's I I don't know that most people are aware of those if you have a hysterctomy and you leave your ovaries behind I didn't know I didn't never counsel my patients about this you lose four years off the life of your ovaries if you have a tubal liation you use lose a year and a half huge genetic disparities so

African-Americans tend to go through a year and a half sooner and then there's caucasians in the middle and then Asian family tend to go through later and they're not sure why you know a year or two years years so there are if you have chemotherapy if you have surgery if you have any inflammatory process in the abdomen irritable bowel or endometriosis you're going to lose some of the life of the ovary you mentioned smoking are there any data on vaping not yet I haven't seen any there might be out there I just haven't seen it

yet no I'm I'm guessing uh if they're out there they're not um prominent or you would have seen them I'm curious about vaping because a lot of people are vaping instead of smoking and hopefully people are neither vaping nor smoking because it seems that we had an expert on vaping on the podcast recently from Stanford and it seems that um there's nothing great about it right and there may be some things really bad about it but was just curious given that a number of young women and men for that matter are vaping nowadays who smoking

rates have gone way way down another 10 years before we'd be able to you know see when those women are going through menopause you know because vaping I think of vaping as younger the younger generation um like my kids they're they people in their 20s and 30s 10 V so we're you know we're 20 years out from seeing how it's going to affect them is there any evidence that alcohol can impact menopause I haven't seen any but I can't imagine that you know heavy use of alcohol would prolong the life of the ovary in any

way right so um and we know that any use of alcohol has some potential role in disrupting sleep and presumably like everything else uh if you disrupt sleep you disrupt things for the for the worse and got it so you mentioned um rough ages for onset of uh menopause um 51 but anywhere from 45 to 55 and the per menopause uh is defined as a period about seven years prior to that 7 to 10 okay um what's the earliest you've ever had a patient come in who entered menopause what's the latest you personal patient 27

and she came in just a couple months ago so she had a special condition we call premature ovarian failure and she had found me on social media and wanted to come just to make sure she was doing everything right and so early menopause is defined as between the ages of 40 and 45 and then premature menopause or pre premature ovarian insufficiency it's not a complete failure for most women but it is very very low is any time before the age of 40 so this patient kind of got kicked around for 2 years went to her

doctor no periods horrible hot flashes again she was 25 and it was not on his radar and he never tested her for menopause and it took her you know 18 months to get the diagnosis and so the longer your body is away from estrogen the higher the risk factor and it's been all over the news this week where we know that untreated premature ovarian insufficiency has a earlier death so they have higher cardiovascular disease diabetes stroke all because estrogen is so protective and they have to go so long without it we can back negate most

of those risks by giving her aggressive hormone therapy early so she came in to make sure she was on the right dose because in premature ovarian failure we don't want to give them menopause hormone therapy doses they're too low we want to get her more like she would have which is three to four times the amount of estrogen as a reproductive aged woman and so and she wanted to have a period so she would seem like her friends you know it was an emotional thing for her which I totally respect and so um so we

were doing cyclical progesterone for her so that she would have a withdrawal bleed and feel like she was normal basic question but I I'm curious all I'll ask um given that levels of estrogen change so much naturally during the course of the um ovulation cycle menstrual cycle um with estrogen therapy is it a constant dose or it's modulated by week to week day to day question so there are some formulas so and when we look at hormonal contraception so the the biggest difference between contraceptive Doses and menopause hormone therapy doses they're both based in estrogen

and progesterone mostly okay the hormone therapy was developed to stop a hot flash for decades menopause was defined by the presence or absence of you know severe menopause was defined by hot flashes or not they didn't didn't nothing else and so they developed the formulations with enough estrogen to stop hot flashes birth control was developed to stop ovulation you don't ovulate you don't get pregnant and it's but the difference between lowd dose birth control pill and higher dose menopause hormone therapy is not that far away and so um that a lot of people don't understand

now the types of estrogen we use in birth control are a little bit different most birth control is ethanol estradiol which is one of the synthetics we have literally millions and millions of women's year data on it we know it's safety profile I think we're not counseling patients adequately about birth control as far as what it does to their testosterone and what it can do to you know oh it's fine it's safe I took it for years but I think we need to do a better job as a specialty on counseling women but I do

think it's a good medication and then on menopause hormone therapy you know it's much lower dose it does not suppress ovulation so in per menopause it's a little bit of the Wild West which one we're going to use how high do we want to go do we need to suppress her ovulation because she's got acne or horrible periods or cramps or something where I want to suppress that ovulation to help her or can I give her menopause hormone therapy doses which in effect think of the hypothalamus I'm giving her just enough estrogen to calm the

brain down and tell them everything's okay we're not going to get those big Peaks and drops and if she still ovulates that's okay too as many of you know I've been taking ag1 for more than 10 years now so I'm delighted that they're sponsoring this podcast to be clear I don't take ag1 because they're a sponsor rather they are a sponsor because I take ag1 in fact I take ag1 once and often twice every single day and I've done that since starting way back in 2012 there is so much conflicting information out there nowadays about

what proper nutrition is but here's what there seems to be a general consensus on whether you're an omnivore a carnivore a vegetarian or a vegan I think it's generally agreed that you should get most of your food from unprocessed or minimally processed sources which allows you to eat enough but not overeat get plenty of vitamins and minerals probiotics and micronutrients that we all need for physical and mental health now I personally am an omnivore and I strive to get most of my food from unprocessed or minimally processed sources but the reason I still take ag1

once and often twice every day is that it ensures I get all of those vitamins minerals probiotics Etc but it also has adaptogens to help me cope with stress it's basically a nutritional insurance policy meant to augment not replace quality food so by drinking a serving of ag1 in the morning and again in the afternoon or evening I cover all of my foundational nutritional needs and I like so many other people that take ag1 report feeling much better in a number of important ways such as energy levels digestion sleep and more so while many supplements

out there are really directed towards obtaining one specific outcome ag1 is foundational nutrition designed to support all aspects of well-being related to mental health and physical health if you'd like to try ag1 you can go to drink a1.com huberman to claim a special offer they'll give you five free travel packs with your order plus a year supply of vitamin D3 K2 again that's drink a1.com huberman as long as we're on the topic of birth control earlier you mentioned that the IUD and presumably this is some form of the IUD not necessarily copper IUD can um

disrupt or stop a period a period um maybe we could talk a little bit about the different forms of birth control um IUD um as the pill quote unquote um old term but um uh I think most people know what we're referring to when we say that the ring um and and on and on um what is your stance on on these different forms of birth control as it relates to their safety um you know a guess about a year and a half ago I hosted a um a female physician guest on on this podcast

and both sides of the uh birth control issue were touched on one the relationship to um potential um inhibition of certain forms of cancers but then also the potential for certain side effects maybe even Cancers and so it you know it seems like it can play out both ways and this is a very heated topic yeah um in fact so much so that I learned that if one is going to post a clip of any of this on social media it almost makes sense to have them in the same post because we actually did both

of them we we we did a post where it was more about the the pros of birth control and then the cons of birth control as as stated through um the words of this very same clinician um so we will be sure to so for anyone listening would you ever answer comes first stay tuned for the next answer because um my understanding is that it's not a black and white issue I think the best form of birth control is a vasectomy and so much of contraception is dumped in a female's lap you know in a

committed relationship and I can't tell you the comments I've heard when a patient comes to me and she wants to get X Y and Z simply for contraception she's absolutely perfectly healthy there's nothing wrong with her she just doesn't want to be pregnant and I'm like okay you're done how you know she's completed her family she's out you know and I'm like tell your partner to get a vecto oh he won't do that you know so now all of the risk and the onus goes on her and so we we go through the options of

surgical like you know tub legation um which is basically blocking the tube so when I you know talk to my teenagers I'm like here's how you not get pregnant a you don't have sex well if that's not an option then we have to either block the sperm stop the egg from coming out or stop the place where they communicate which is the fallopian tube and so when we look at the different forms of hormonal contraception which are meant to stop ovulation suppress ovulation because they're telling the brain we have enough estrogen and progesterone on board

quiet down so it doesn't send those signals to the ovary right and so that can come in a pill form a patch form a ring form and they each have their own Pros cons risk benefits you know transdermal has less risk of blood clots versus oral has a higher risk of blood clot in any form of estrogen so so we talk about that we look at their family history or if they have MTHFR any of the clotting genes you know then we Council directly versus the IUD the iuds create an an inflammatory environment in the

uterus that blocks and it creates a plug in the servic so that the sperm can't get through and then if any do get through it's a toxic environment in the uterine cavity for the sperm so that's really how the those iuds work some iuds are coated with progesterone progestin not progesterone progestogen and those end up decidualizing the endometrium so thinning that lining from that constant progesterone to the point where you stop bleeding so a lot of my patients really loved that option of being aaric no periods just for the convenience of it but they were

still ovulating in the background so we're not suppressing their natural cycles just their periods I see and is there any evidence that the use of any form of birth control can disrupt the um timing or the uh availability of I realize availability of eggs is a very um clinically naive biologically naive statement but basically what I'm saying can it can any of them accelerate the onset of per menopause can they delay the onset of onset a little bit you know it's it's maybe a year if you use it for a long time from what the

data shows so women who suppress ovulation we lose about 11,000 eggs each month with the ovulation process to get one out 11,000 race to the Finish Line and only one makes it but we lose about 11,000 in the process so women who are constantly you know for a long time suppressing ovulation will have um a slightly older age of menopause had they not done that when you say slightly older what's the longest extension of of the best I could see in the data was maybe nine months okay from nine months use ofth control so so

maybe like 5 to 10 year use I have to look at the data again to be you know I'd have to look that one up but it was years got it um to to gain an extra maybe N9 months maybe a year of ovarian life I see and um nowadays uh at least if people have the means there's some um Trend if you will toward um freezing one's eggs um this might be a good opportunity to just State something that came up before when we had Dr Natalie Crawford on the podcast to talk about female

fertility um I think surprising to many people was her statement that not because it's controversial but because we just don't hear this often enough that harvesting eggs for freezing or for IVF does not diminish the pool of eggs that one would have meaning you're losing them each month right anyway yeah and so they're only pulling out I don't know 10 12 maybe in a cycle and when you're losing 11,000 with an ovulation so it really isn't going to to effect when you go through menopause such a crucial thing for people to hear um I think

uh there were a number of comments when we posted that clip on social media of people uh women saying wow I didn't realize that harvesting eggs would not um somehow uh shift the onset of menopause earlier and so for the record we are not saying that we're saying that um it does not and um and very interesting that the use of of birth control but I'm guessing only forms of birth control that suppress ovulation can delay the onset of per menopause menopause by about 9 months maximum maximum um so things like the copper IUD that

right which um prevent pregnancy by creating a unfavorable environment for the sperm rather than disrupting ovulation in any way will not presumably extend par menopause menopause okay just want to make sure we're crystal clear for people you're being very clear but I I want to make sure that I'm clear on it and then reiterate because this can be um uh kind of tricky territory I think there are a lot of assumptions about this stuff and there's a lot of lore out there what why do you think that is is that because of the lack of

solid research and communication in this area I think so or or is it something else you know I I I think these are um tricky topics for for uh discussion often because we hear all this stuff like birth control pills disrupt one's ability to get pregnant when they come off or where it we just learn that it can delay the onset of per menopause which by extension means there's a greater window for pregnancy if one um thinks about it that way but uh why do you think it's it's so um such a tangled discussion out

there I think just the way that Society views pregnancy and female health and you know at least you know I live on the internet now you know this new life has brought me life on the internet and this what the algorithms are showing me yeah it's a very friendly everyone is super everyone loves you it's a listen it's what you're doing um is so important and uh I understand the the statement behind that statement I I think um but it's so important because it people are getting the opportunity to learn about really critical public health

and female health issues um in a way that just was inaccessible before yeah it is and I I it's good and bad you know there's a lot of lore and misinformation that's getting propagated and I feel like as a specialty you know as a women's health specialist we did this to ourselves you know we have not properly educated ourselves we have not spent the money the research really you know championed women after reproduction when you look at the dollars and and the research and where it goes in women's health I mean Women's Health just gets

a little sliver of all the NIH funding when you look at all NIH funding and what goes to menopause it's 0.03% unb less than half a percent this is onethird of a woman's life and when you look at McKenzie and Company just just published um a report where they pulled 680 studies on like chronic diseases diabetes hypertension cardiovascular disease and they looked at how they had they were women included in the studies but how many presented the data for the different Sexes like what happened to men versus what happened to women it was only 50%

of the Articles actually did Sex specific differences and how this medication affected this process or whatever and then the ones that did 30% of women had poorer outcomes and and the other and on the flip side 10% of men had poorer outcomes and these things aren't just being brought to light so the the lack of recognition of sex specific differences in chronic disease and how menopause kind of plays into all that I think is where the future needs to go so we deserve as much good health as everyone else because yes we're living longer than

men but 20 to 25% of that life is in poor health wow that's a a really significant statement I mean I think think that the National Institutes of Health has been terrific in establishing new institutes within it um they even have a complimentary Health Institute now there's the the national eye institute there's you know cancer here um is there a plan or one would hope for a dedicated Institute for Women's Health there push um so there was one piece of legislation that got pushed through the Biden signed it and it was a $100 million for

Women's Health and that that got chopped up very quickly and menopause did get a little piece of it because we're also really struggling with endometriosis and you know a lot of the female specific uterine diseases and and PCOS and things and so we need more funding there as well um and then there's another bill that just got that's the one hi Berry was like um on TV talking about another bill for $250 million that bill includes language for education of providers so we have a whole generation of providers ERS like I graduated my residency training

the year of the Whi came out so all we had very little like real clinically significant menopause education and then we knew about HRT and we were giving it in clinic um if she was coming in with severe hot flashes but that got taken off the table after the Whi and then we have a whole gener like all menopause education basically stopped after so Whi Women's Health Initiative HRT no that's that's okay just so that people are on board hormone replacement therapy um yeah it's um it's a Well we can encourage the uh expansion of

of uh research in these areas and with this discussion and um certainly uh I was on NH panels for years um as a regular member in the I institute and what I've noticed with um NIH is that they are very responsive uh to the public call for growth of research in particular areas you know it can take time it's government after all and they need funding there's a finite amount of funding but but I think that um R rarely do I ever get into legislature based things but if you are somebody who cares about um

more funding in a given area of research it's actually very straightforward what to do you call your Congressman or Senator and you tell them literally you leave a message I find this kind of interesting it's so it's kind of like what we learned in um social studies and uh in elementary school but you call your you call your um Senator or your governor and you leave a message and you say Hey you know there's this issue that impacts a ton of people and it's really important and um the next time it comes up uh when

budgeting uh comes up in Washington it's really important and if you hear about a bill you can call and support a bill and believe it or not some of that stuff actually translates to more funding in a given area in fact that the brain initiative which unfortunately had its budget cut significantly recently maybe put that funding back um but you know arose from the um I believe it was the child of two Neuroscience professors up at University of Wisconsin I'm probably going to get some details wrong but um so the khil are the are the

professors as I recall and their son over Hood all these conversations growing up about the importance of brain science and then eventually pushed through government channels for more money for brain research and then we had a a long phase of of um pretty pretty substantial research and then it was cut so these things um but it persists and so these things really matter can impact so and maybe we should send them a clip of of your statements on this podcast getting back to um kind of things that people can control so for people who are

heading into per menopause or who are in the perimenopause phase um aside from the the typical things that we hear about fortunately a lot these days like getting adequate sleep um getting exercise um nutrition maybe we could touch a little bit on nutrition in a moment you mentioned Mediterranean diet Galviston diet um things that are going to promote overall health right um are there any things that people can do maybe even take that would improve uh their outcomes in this phase like I I've heard of people and I have no bias here or even knowledge

of the research on this if there is any of people taking for instance grape seed extract or people trying to do a number of things to reduce inflammation kind of General themes around um self-care and wellness these days but what are sort of the five or six that come to mind um perhaps as like the things that can move the levers in the right direction what would tell my 35-year-old self you know who just kind of went into this obliviously and what I know now is your diet is probably one of the most important things

that determines your level of inflammation and then estrogen is a really powerful anti-inflammatory hormone and we lose that protection when we go through we start losing it through the transition so whatever you can do in the other areas especially with nutrition sleep stress reduction we need to do it so fiber we are not getting enough fiber in our diet in the western diet I think it's most women are getting 10 to 12 grams per day and we need at least 25 and the health benefits tend to max out around 30 32 grams per day so

focusing on foods that are rich in fiber Fiers is feeding the gut microbiome slowing down glucose absorption you know glucose levels of sugar absorption into the bloodstream it is slowing down the rate you know certain parts of Transit and pulling more water into the gut like there's nothing bad about it right the foods that are rich in fiber have a lot of other stuff that's good for you too co-actors vitamins minerals nutrient you know just they're just so healthful um and then ansans you know just find things that crunch that are and get as many

colors as you can you know green red purple yellow every color represents a phytochemical that is going to be good for you in different areas of your body and try to keep it as varied as possible um we're not getting enough protein and I have to thank Dr Gabrielle lion you know really helping me focus and on that you know when I first wrote galison diet to be honest and transparent it was for weight loss and you know I was frustrated with my weight gain and I that was the pain point my patients had and

that was my pain point but I didn't realize it represented something much more Sinister than than just the way I looked you know the visceral fat gain and so uh learning about visceral fat and what it really means and that is for your listeners the fat that wraps around our internal organs it's a very different fat than the subcutaneous fat and you know a premenopausal woman so we age matched and looked at visceral fat levels measuring it with the uh um dexus scanner you have about 8% of your fat as visceral as a premenopausal person

and then when you go through the transition it's 23% wow with no changes in diet and exercise the visceral fat is not something that gets enough attention I think everyone thinks about subcutaneous fat because it's relation cosmetically distressing but really yeah um and one doesn't want too much of it for health reasons e either but the it's the um intval fat that at least by my understanding is is really uh the most problematic for for for our health it's a harbinger of of chronic disease so I read that weight gain is one of the primary

symptoms of menopause itself yeah so it's you have to be careful how you think about that when we when we plot weight gain versus age it's a very straightforward linear curve and menopause does not seem to affect that what is happening is a body composition change we are losing muscle and we are gaining visceral fat and so and you might be gaining some subcutaneous fat but those are kind of the key things that are happening and so that's really when I'm counseling patients what I'm focusing on because I have a body scanner in my office

where I can tell them what their level of visceral fat is in their muscle mass and so we bone and muscle that muscular skeletal unit works together and so we see this acceleration of muscle loss which controls our basal metabolic rate which determines our resistance to insulin which you know so it's just that's the the organ of longevity that's what I I've learned from Dr lion you know and everything we can do to hang on to it and build is so important so protein going back to the original Point protein intake is key and women

by and large are getting 50 to 60 grams of protein per day and we really probably need 80 100 120 depending on our body composition yeah thanks for mentioning Dr Gabrielle L she's doing what I view world yeah terrific work really promoting Women's Health and health generally I know she's now I believe is exploring um Advanced Training in uh in urology for males as well and um so you know it's um it's it's only fair to to credit her with with really expanding into these different areas but especially this idea that we need and women

perhaps in particular from what I understand um she'll be on the podcast soon so we'll get more of a of an understanding at least one gram of quality protein per pound of lean body mass maybe even per pound of body weight per day in order to optimize their their health yeah she's she's definitely on the higher end you know the Whi the Women's Health Initiative some of the my favorite data you know it's not all bad it's data and was looking at Frailty scores and protein intake in women and what they found was women who

were having 1.5 to 1.7 so basically it was the higher their protein intake the less likely they were to be frail the end and it was you know they were reaching that was kind of peeking out somewhere around 1.5 to 1.7 gram per kilogram of lean body mass and most women are getting around you know the FDA recommends 08 wow and source of protein also important high quality right right you need all the amino acids yeah very interesting um now that's in menopause but presumably also so starting those habits in Perry just getting that laid

down and getting those habits laid down are going to set you up for a much better post-menopause a much healthier postmenopause and we have to stop defining menopause by your hot flashes you know it may or may not make your hot flashes better and we have great medications for that if it's disruptive but I'm talking about your your cardiometabolic disease risk I meant to ask this earlier so forgive me for for leaping back briefly but is there any value in knowing the age at which your mother went into menopause as a metric or a sensor

rather uh for or a as a window into whether or not you will go into menopause at more or less the same age yes there is a of course it's not one to one we get half of our DNA from our fathers so but I always ask and there's a you know the latest data that looked at it genetics is the biggest factor that determines when you're going to go through menopause so knowing when your mothers your aunts you know went through and if there were any medical conditions associated with that is huge okay so

now we're talking not so much about perimenopause but also menopause itself what is the typical constellation of symptoms as one enters menopause like right at the beginning and then does that constellation of symptoms change as one is you know a year two years three years into menopause so it's almost 100% with body composition changes like very very close you know that visceral fat is tough to beat it's beatable but it takes a lot of work you know do people know if they have visceral fat I mean there's their scanning approach gold you know of course

the gold standard is a DEA or even an MRI but no one can afford that so we have in like what I have um in my office is the inbody scanner so it's electrical impedance scanner and it's it's pretty good so you stand on the scale hold the hand I have a medical I have the highest grade one for my patients um and most people doing what I do you know utilizing a body scanner use that one um but you can use the waist tip ratio and so the waist tip ratio is a better measure

of your risk of metabolic Health than your weight or your BMI so it's so simple you take a tape measure and a calculator you can do it in your head but you measure the smallest part of your waist and if you don't have a small waist if it goes out then just use your belly button just use something you can measure again are people sucking in or are they relaxed you should be relaxed and I tell my patients you know do it first thing in the morning when your bladder's empty and you're not bloated and

you know um and then the widest part of your hips it's not perfect but it's better than your weight or your BMI so widest part of the hips with people feet feet people are going this and so um I only know the data for women so forgive me but um for a female if it's less than 0.7 then your chance of having clinically significant aberration in visceral fat are low and then if it's greater than one you likely have higher levels of visceral fat and so in clinic or when I was coaching online for galison

diet we were using the waste ratio as one of the you know measures for their success when measuring the waist um which point along the waist is it right at Naval is it it's just wherever your smallest so that's kind of different for different women so I would just say look in the mirror wherever your hourglass goes in is where you want to kind of stick to but if you don't have that kind of a waist and you have a wider waist just pick the belly button because you always know you can go back to

that level you know that's because we're tracking them over time great those are um very useful um recommendations and how often should people do that I you know you should never weigh yourself every day you shouldn't do this every day we were having patients do it or you know our followers do it once a month so changes in body composition as measured by dexa or impedance or you don't have access that waste of hip ratio uh what are some of the other symptoms of menopause fatigue multiple causes for the fatigue um a lot of sleep

disruption um sleep disruption is another huge thing so all of a sudden you're struggling to go to sleep or you're having middle of the night Awakenings and not able to go back to bed that are new and different from prev new and different than before right I see there was a recent study that came out and most of my patients in hindsight say I knew something wasn't right or something was different something had changed but I couldn't put my finger on it and they just had a study come out saying something's then when they looked

at what that means what does I'm not feeling like myself mean and it was psychological changes so you lose resilience you're suddenly more irritable you're suddenly not able to like go with the punches or or do you know you're you're not adjusting as well to change that you used to you're snapping at your kids more your partner you're you know you're you're getting frustrated at work you know it's just very kind of subtle and it takes going through it and then looking back to say yeah I really say may maybe about 47 that something was

changing and I just thought I was just stressed out or whatever and then now I can see that was the beginning of the pattern so menstrual changes as we talked about um you know the big highlights vertigo tenus ringing in the ears um skin changes so dry skin itchy skin feeling like you're having crawling Under the Skin big gut changes so Nuance set bloating you're kind of eating all the same things and your guts just not handling things like it used to so the Zoe nutrition study took 1100 women and and did stool samples through

menopause through the per menopause menopause transition and saw the changes in the gut microbiome from the loss of the sex hormones and basically we went from what a typical female microbiome to that of a male through the transition is there any direct evidence that um supplementing the gut microbiome and here I don't necessarily mean pills and powders I mean um my understanding is that getting enough fiber and low sugar fermented foods can also support the gut microbiome things like um sauerkraut kimchi miso miso um plain yogurt just straight up nothing added yeah so is there

evidence that supporting the gut microbiome can um make this uh stage of menopause more I guess um reduce some of the symptoms of of menopause so the best I could find was most of them are are done with supplements because those are easier to measure than handing someone a cup of yogurt right and you know which bacteria you're provot so um they did lactobacillus and looked and bifido bacterium I think and saw that women who were obese and hypertensive in menopausal and they had visceral fat decrease and blood pressure improvements versus placebo um also it's

hard to do Placebo studies with food you know so right um but they do and then in the retrospective studies they can look at dietary patterns and women who ate rich foods fermented and lots of yogurt you know Mediterranean type diets um have better symptoms overall what's the difference between the Mediterranean diet and the Galviston diet so so um when I so I got my culinary medicine certification I was culinary medicine yeah so I was frustrated in when I was working because I didn't know anything about nutrition and suddenly like everything I was trying to

tell my patients was based on like the one lecture I got in medical school and you know good nutrition was like porn you know it when you see it you know the Supreme Court definition of pornography and so you know the best I'd ever gotten was the gational diabetic diet and it was this Xerox things with you know was in the Deep I was in Texas so it had like tortillas and stuff on it and and it had been copied so many times you could barely read it anymore and that was the diet we would

that was the only nutrition I'd ever like handed to a patient and so I'm like eat healthy and so I'm like I got to do better than this I don't know enough and so we had a guest speaker for a Alpha Omega Alpha which is the Honor Society for medical school and I was one of the advisers so and it was this guy Tim Harland who had started this culinary medicine movement and it was basically nutrition for doctors and he velop this like online program and I had to go to New Orleans for a lab

and San Antonio for a lab and work in kitchens where you were learning how to counsel patients how to cook and also basically like getting a little minor in nutrition um so it was the best thing I've ever done say very cool I mean I learned about allergies and like all this stuff you know food allergies and things that I just didn't know and just basic nutritional principles like what it takes to build a healthy body and and what you know I knew about quashi oror and like severe deficiencies but not good basic nutrition and

so you know they talked heavily about Mediterranean they talked a lot about The Fad diets and stuff but you know the principles of the Mediterranean I was like I want to teach this to my patients but they're not going to eat a lot of um Greek yogurt or they're probably not going to eat a lot of feta you know like how can I kind of take these blocks and make it more Americanized that was kind of like the brain child for me around galison diet was let me like create something and I really was into

fasting at the time too so I was like let me put this fasting thing together with you know good nutritional anti-inflammatory principles and talk about the things we know were probably you should you know not having a whole lot of you know processed foods and high sugars and stuff and and explaining in a way and how it's affecting their menopause and like how can she approach her nutrition and that's how Gallison diet was born it was for my patients and then I gave it to my girlfriends and then they started sharing it and I talked

about it one day on Facebook and the world exploded in the best way in the best way yeah it l me here right so right um and we all benefit what is the evidence that fasting can be beneficial or detrimental to um per menopause menopause so the jury's kind of still out on that one I was re really liked the data that you know uh I think it was Mark Matson had done on neurod degenerative disease and and using fasting as a tool there and lowering inflammation levels so I was like this is amazing this

is great because so much about menopause is pro-inflammatory you know is this intermittent fasting so Tim restri he was basically doing 168 you know and uh you know very scheduled intermittent fasting and so that was something I was coaching my followers about you know consider this try this this would might be something to help lower inflammation I pulled back on that because it's really hard to get enough protein in for a lot of of women especially if they came in at 60 and now I'm telling them to double their protein you know and then giving

them an eight hour window to do it they're like I'm walking around n on a chicken breast all day you know this is hard right and metabolizing protein is its own work right and so you have to spread it out throughout the day you know and a lot of that work was done at UTMB where I did my underground I mean my residency and where I taught for years and so I was friendly with the Nutrition department there I was getting all excited about everything and they're like you know I went to several of their

conferences and like talking about breaking up protein intake into nuggets throughout the day because most women have very little protein with breakfast maybe weak gluten in their toast and then have a little bit at lunch and then kind of Stack their protein at night and they're still not getting enough but they're overdoing it in their evening meal that's their big protein meal and so like teaching them to kind of you know what I was teaching in galison diet was you need to have a healthy fat a good healthy carb and a protein with every meal

in snack that you eat you know why do you think that protein has not been emphasized um enough until recently I think because we didn't understand it you know we didn't understand how important muscle was and I mean we knew that protein intake was important for muscle but muscle was for bodybuilders and not for women I lived my whole whole life up until about 5 years ago eating to be thin and moving to be thin that thin was the only measurement of Health that I needed to worry about and what I did was chip away

at my bone and muscle strength and thank God I don't have osteopenia yet you know i' I've hopefully have reversed whatever Trend I was on and I'm naturally low muscle so now it's just a battle to try to hang on to what little I have and build some resistance train yeah yeah yeah yeah now three days a three days a week three to four days a week yeah resistance training much less cardio I was running marathons I and it was a great social thing with my girlfriends but you know everything I did was cardio I

taught step aerobics you know the only weights I did were maybe in Zumba maybe one or two pounds you know so and that was better than being on the couch I mean I loved the community and doing that but you know for me to like stay out of the nursing home which was my ultimate goal for as long as possible I need to pick up some weights and heavy weights so that's where my focus has changed isn't it interesting that it wasn't until Rec Rec L that um it was only bodybuilders and football players and

people preparing for military or specific sport would resistance train and now we are told that everybody male female young old should resistance train absolutely probably three times a week yeah and the my generation is struggling because we don't know how to do it and so I'm you know and I'm not a personal trainer I don't pretend you know I hire one to help me develop a program so that I don't hurt myself and then I can get stronger you know Progressive loads so you know and again Dr lion such a huge proponent of that and

so what I try to do publicly is show my workouts so that people I normalize it and people see me doing it and they're like well she can do it then I can do it it's great super inspiring and it really helps uh cross that threshold where people as you said they don't know how it's scary right for people who resistance trained for a long time they go into a gym they they know how all that stuff works but uh for those that don't it's you're wandering around like what does this one do you know

it's intimidating for a whole bunch of reasons well thank you for putting that content out um both the uh prescription if you will but also the example that that one can go about it so I'm guessing if you could go back 20 years you would have started resistance training earlier and eating more stronger skinning nutrition over calories and and stop looking trying to look a certain way you know you're you're undermining your future health by doing that I'd like to take a quick break and acknowledge our sponsor insid tracker insid tracker is a personalized nutrition

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blood panels again that's insidetracker docomo to get 10% off so um what are some other symptoms of menopause you you mentioned body composition changes the one that we hear about the most for some reason I don't know is hot flashes yeah so think hot flashes um so in medicine we call it a Vaso motor symptom so we have a a disregulation of the thermo regulatory Center in the hypothalamus and that that the the thermostat gets reset basically and so what happens is we have this vasal dilation of it starts in the core typically for most

women somewhere in the chest neck area and you feel this heat yeah I can probably trigger one just by talking about it um and it it goes up into the neck and out into the extremities and then you just start profusely sweating from all the blood vessels dilating and then it can last minutes to a second but for some women it's preceded by sometimes palpitation sometimes by this intense feeling of of dis Foria you know this intense sadness feeling and then it and then it just kind of passes but you know say you're you know

wherever you are in your life whatever you're doing all of a sudden you're just like sweating profusely in the middle of some important area of your life work you know whatever your jobs are in your life and it's disruptive if it happens at night you don't sleep and for some women it's severe where they're having multiple ones a day and when any time you disrupt sleep Then daytime is far worse regulation you yeah you stress differently you you know everything changes and so when my patients come in the first questions we ask are sleep and

that's the first thing we work on is is you know what can we do to get your sleep better what can be done for hot flashes aside from the things that you've already described to offset menopause absolute goal standard is hormone therapy is like giving your body back the estrogen which will readjust get your serotonin levels back to where they were and leave that thermal regulatory Center alone so it's back to where it used to be let's talk about hor therapy it's a bit of a controversial topic for no reason yeah I I was going

to say I don't know why yeah it's demonized it it got such a bad rap and we need to to it's just some of the was the worst misinformation campaign in the history of medicine well that's a bold statement but I believe you the um the way I understand it is that there was this large scale hormone therapy trial um and the interpretation of that trial was something different than we now believe um as a medical ini so it was really groundbreaking at the time aging women were finally being studied we knew from observational data

that women on hormone therapy probably 40% of the population of females eligible were on HRT okay so very large amount so the women who were given hormone therapy had lower incidence of cardiovascular disease older ages of cardiovascular disease lower death from cardiovascular disease some people argued that that was an artifact of healthier wealthier women get HRT because they go to the doctor okay so this is just because they're healthier that they have less cardiovascular disease so let's prove it what do you do that with a randomized control trial so flaws in the study so they

take I think there were 11,000 is women in the estrogen only arm because they'd had hysterectomy so for your listeners if you have a uterus and you're getting estrogen you must have a progestogen with it to protect the lining of the uterus from minimal cancer as long as you give an adequate proest you're fine okay but if you don't have a uterus progesterone is not mandatory so the women who had had hysterectomy got estrogen only or Placebo and the estrogen at the time was primin which was the number one prescription for HRT at the time

so nothing weird about that so it's just um synthetic estrad actually no uh primin is is primin stands for pregnant mayor urine it is actually very natural they take pregnant horses and extract the estrogens from their urine because they're pregnant and they were screeing a lot of it and it was cheap and easy and I have a lot of ethical issues about how they do that but and I don't prescribe it but that's what was done at the time so I I've seen horses urinate they urinate a lot there's dozens of estrogens in that comp

but the main one is estrad so um then there the other group who had uteruses were given Prim Pro which is primin plus proa and or Placebo so off we go they recruit 11,000 and then I think 15,000 in the other arm huge study it was like a billion dollar study like we're so excited this is happening this started when I was in med school and then they start recruiting patients and then um you know everyone's taking their meds they excluded women with hot flashes what because if your hot flashes go away you know that

you didn't get the placebo ah so they excluded one with hot flashes problem number one yeah that's a big problem this the end outcome the what they were trying to measure was cardiovascular disease so they started with an older population the average age was 63 whereas the typical onset of menopause is 51 wow so these women had been menopausal you know on average for 10 12 13 years so time away from estrogen is when disease starts accelerates right okay so put them on their meds start measuring in the estrogen plus progestin arm they saw a

non-statistically significant increased risk of breast cancer and it was this the relative risk relative now you know what this is but your Mone your listeners may not was 25% and and I hope I get the numbers right it was four out of a thousand women per year to five out of a thousand women per year okay so Placebo arm was four so we have breasts we are females we get breast cancer about four out of a th women per year and that increased to five and the estrogen only arm there was a 30% decrease risk

of of breast cancer regardless of the of the average age M and they kept that arm going right because it's randomized so presumably the average age for the other group is roughly 61 as well they were match so in their 60s as well so they call a press conference at the Watergate Hotel the Watergate Hotel announce the findings they hadn't even published the data yet no one had had a chance to read it and these the head researchers called this press conference and say estrogen causes breast cancer exogenous estrogen from these yeah yes and they

said it's a 25% increased risk but the absolute risk was like 8% per year but that didn't get that that's not a headline thing so on every like ABC NBC CBS all the morning shows Nightly News every major magazine it was the number one medical news story of 2002 that that estrogen was bad and it caused cancer and da d da the estrogen only arm kept going and they found after a couple more years a slightly increased risk of stroke so they stopped the study the effects on cardiovascular disease were neutral but there was lower

um colon cancer in both groups but no one talked about that so the American Heart Association in 2020 went and looked at they looked at ages so there were younger women who were given HRT and what they found was if you started hormone therapy between the ages of 50 to 59 you had a 50% decreased risk of cardiovascular disease and death from cardiovascular disease and all cause mortality wow so age at which you start matters estrogen so that's where there's something called the healthy cell hypothesis or and so basically estrogen is better at prevention than

cure and it's very protective especially in the Tima of the coronary arteries so taking that estrogen away we lose that protection once the disease builds up there's some worry that adding estrogen once you've developed a sclerosis or a plaque might loosen the plaque especially in that first year so which led for some people maybe to have a slightly increased risk of stroke so when my patients come in we are talking about these differences it doesn't mean that after 60 you might not have cardiovascular benefit we start losing the benefit so it's the timing hypothesis is

key and it's the years away from estrogen that's the problem there's a great study in the British medical journal they looked at years years of reproductive life plus HRT and looked at cognition scores and saw that the longer your body is exposed to estrogen in any form like whether natural cycles or exogenous estrogen of any form and it was estradi in that study actually then you had higher cognition scores healthier brains which had a just very you know top Contour level makes total sense given that estrogen is neuroprotective I realize my not be neuroprotective in

every instance in every neuron in the brain but it's generally neur neur protective and decline in estrogen is correlated with neur degeneration which does not mean it's causal I have to ask when they announced this study at the Watergate Hotel of all places um and the conclusion that they put forth was that estrogen therapies can um increase rates of cancer um I have to wonder if that had something to do with what I understand is a sort of party line around Cancers and breast cancers in particular which is that you want to quote unquote block

the estrogen receptor you want to get in there and put give tamoxifen or nowadays I'm sure there are other drugs that are more effective to block the estrogen receptor it all seems to um pile up on the side of a story that says you know estrogen and estrogen binding to the estrogen receptor is proc cancerous which obviously I think you're telling us um in a in a indirect and direct way now and we'll go further into is simply not the case if you take a healthy breast cell and dump it at a petri dish and

then marinate it with some estrogen it's not teratogen I it's not carcinogenic estrogen is not carcinogenic we live with it our whole lives if it was in pregnancy for those of us who are ever pregnant when our estrogen levels Skyrocket we would see this into uptic in breast cancer and we don't in fact I think there's some evidence uh for the opposite that getting pregnant prior to age 40 is is it true that that's protective against C be somewhat protect for certain forms of breast cancer yeah so we have this whole generation of Physicians who

really weren't taught much about menopause don't understand the protective benefits of estrogen and and and menopausa effect on metabolic disease and they have this me this mentality of estrogen is bad and so a woman walks into her today 2023 they looked at the data she goes into her doctor complaining of menopausal symptoms which right now are still only recognized as genit urinary syndrome menopause hot flashes night sweats you know the very cliche symptoms documents in the chart she's having whatever only 10% are offered any therapy and they're most likely four to1 to be offered an

anti-depressant that is where it stands today that is what we are fighting against is not every woman will choose HRT but every woman deserves an informed conversation about it and let her make her choice you know if you believe the Whi data which there are some problems there the risk is small okay but did you talk to her about about cardiovascular disease and diabetes and insulin resistance and her cholesterol because those things go up through the menopause transition with no changes in diet and exercise and those are all you know you're more even with the

diagnosis of breast cancer the most likely thing a woman is going to die from is cardiovascular disease a heart attack or a stroke so framing it like that I think is where we need to head and the other thing is you know I was a great Oben in so many areas of what I did why should this all be dumped in the lap of the poor busy OB Jen who's running around the hospital doing pops smar trying to deliver babies surgery and all the things like this should be required education for all everyone in medical

school we are females and we're not little men with breast and uteruses we react differently to medications disease disease burden you know and that's not been studied adequately and that's where the the push needs to go it's bigger than just half flashes do you think that one solution is to deepen in the medical school curriculum absolutely and more and and I hate saying women's health because everyone thinks breast and uterus right and reproduction it's the health of women and we're not addressing it differently than the health of a man and we're different we you know

and so that I think is where we need to head given that it's half of the population yeah um one would imagine that the best thing to do is to make the Core Curriculum of medical students expand to include this as opposed to making it a specialty I think so does that mean a fifth year of medical school I'm not kidding I mean I I guess maybe I mean people said well you'd have to extend the the OBG in residency I'm like no any any specialist who touches a female should understand how that female I

mean the starkest example is cardiovascular disease you know how much longer we have to wait in the Ed how much more likely we are to die in the hospital setting from a heart attack because we don't present the same symptoms as men do and it's just the default has always been how it happens to the basic you know really Caucasian male and so at least in the US and so because we respond differently because we wait longer because our symptoms are considered to be psychologically induced less than biologically induced and so women are dying at

higher rates when you look at the data on Statin you get high cholesterol so 80% of women will have abnormal cholesterol levels through the minum PO transition if they were normal before okay so elevated LDL LDL and lowering HDL so now they are at higher risk for cardiovascular disease automatically a PCP will offer her a Statin okay that is standard of care do you know that the American Heart Association published in 2020 that statins have never been shown to decrease their primary heart attack in a woman secondary yes but no primary prevention and it does

not decrease risk of death from cardiovascular disease they're know that yeah yet we're routine you know what does HRT if given in the right window of opportunity how is HRT um in this case estrogen HRT given is it a patch is it injections is it great question all the above so we have I like to break it down into oral and non-oral forms so everything oral we ingest goes into the gut the liver the hepatic system will pick up the portal vein and take everything to the liver for processing when that bump of estrogen hits

the liver we can see a slight increase in some of our clotting factors so for that reason I tend to go with the non-oral formulations to avoid that risk especially if she has any family history of clotting or personal history of clotting you know we're going to go with a non-oral form so these are things like elevations in Factor 5 lighten MFR if she's had a history of a blood clot we are not going with an oral estrogen formulation and for people that haven't had a history of a blood clop my understanding which admittedly is

is very um sparse is that you can do a genetic test just by blood draw to see whether or not you have U two normal copies of the of the gene for Factor 5 lien um some people are heterozygotes so they're more at risk of presumably bleeding in that case right um but in other words can people go into this knowing whether or not um they're more or less at risk from taking estrogen so I don't think that there's a high enough for that reason because we're not routin L screening for these things unless they

have a family history I'm going with non-oral estrogen as a primary product for my patients because I can just skip that worry so a patch typically so typically transdermal so a patch there's even miss spray there's FDA approved options of a patch there's gels there's a ring there's a um spray and um there is a vaginal ring which I love love love because it's so you put it in for three months and it treats you know you get a two for one you get a local treatment in the vagina as well as a systemic treat

treatment as well um it's just really expensive and typically not covered by insurance on the first tier so very few of my patients can afford it um there are um some injectables which no no one in the menop posi uses um there the menop yeah great there are also mention the mene and the menop posi are those terms that you coined I love it um I think I did yeah great all right you heard it here so the menasi is a a group of healthcare professionals who are from multiple Specialties we have card ologist orthopedic

surgeon um Internal Medicine you Dr lion is a member and we have a big group chat and we all support each other we support each other's books and research and and we send articles back and forth and we support each other on social but we also band it together to kind of negate one of the bigger Publications on menopause that when the lanet published it's a whole another discussion um but you know we are fighting for equity in menopause care and and Fe and Women's Health great nothing succeeds like a group it's like the old

menopause versus the new menopause I love it love it um so hormone therapy to increase estrogen how does it make women feel um psychologically physically what are some of the positive changes that can OCC aside from just offsetting some of the negative and I want to make sure that I remember to ask what if a woman has been in menopause for you know uh has passed that point because as you said it's a day so they passed that point um a year earlier 2 years earlier 3 years earlier um given the results of this first

study um which as you explained it are uh problematic and their interpretation the way it was interpreted as opposed to initially yeah yeah um what's too long should um women should wom starten therapy in their 40s just in just to you know smooth the transition maybe we need more studies in this area like should we just the minute we figure out like I would love like I would glucose monitor I have um insulin resistance so for those listening there's just it looks like a little button sized um sticker on the back of the arm I

would love to develop one to track estrogen levels starting your 30s just see where you're at you know start seeing are you having aberations in your cycle and we can start the per menopause journey and talking about should we begin supporting I think there's a tremendous amount opportunity for research in this area um but typically we are not starting patients until they're very symptomatic if they're per menopausal or they're postmenopausal so in general so if a woman is um in her let's say late 30s um she is anticipating perimenopause maybe is in per menopause and

wants to start lowd dose um hormone replacement therapy I think it's something um worth mentioned that not all you know presumably the dosages are tailored and then blood so a given dose is tried blood is drawn you measure estradi so we're not um we don't have established levels of like therapeutic ranges of estradi what we found is that when we do that so far I think we have some opportunity here if my level's 50 and your level's 50 I could feel like I'm on top of the world my symptoms are gone you still need more

so we are titrating from symptoms I see yeah interesting that's similar to what is done similarish with um testosterone replacement therapy which these days um you know I sort of have joke that the you can uh change out the r in testosterone replacement because a lot of people are a lot of men are taking testosterone not as a replacement meaning their levels are not lower than 300 n per deciliter which is kind of lower range um they're sort of low middle and they're trying to get high you know higher range but hormone replacement therapy as

I understand it has never been um strictly in men or women strictly for people who are out of range that it in in theory it can be to optimize reduce symptoms right and to optimize well-being right um and I don't know if the medical establishment wants it used that way but certainly in the case of testosterone replacement therapy in men it's being used that way quite often in fact so the we don't have established therapeutic ranges for estrad if she's POI premature Varian insufficiency we know we want to get her to 100 or around 100

or higher in picograms per deciliter um and but in the menopausal patient we're rarely checking levels but I do think we have an opportunity to learn a lot more now that we're able to track how is it how does it affecting your cholesterol we need to look at those numbers like what's the optimal dose for cholesterol what's the optimal dose for cardiovascular disease all we all these Studies have looked at was was she on it or not so that's where I think the opportunities can come so if a woman goes on hormone replacement therapy how

often is she coming in for blood draws or are you just you know well depend testosterone we tend check more often there's we don't have an FDA approved option for women for testosterone and so no so we either try to get her t- stem mhm um or she's finding someone to insert a pellet or something and there's there's other issues with that um what I do in Te Texas it's really hard the pharmacists do not like to do the t- stem for patients and I've even T t- stem is the gel you know um and

I end up compounding it in a cream and do a transdermal PR for the patients but there's such variable absorption we do tend to check more levels of that just to may try to get her therapeutic so what for women at Peak dose is somewhere in a healthy female you know 35 to 70 and it's so so I had a woman coming in with signs of hyperandrogenism you know she's you know deep voice hair growth whatever acne and I'm going to check a level if it's above 90 for females I need to look for a

tumor like that's too high okay or PCOS it can get that high certainly 200 that's that's outrageous so I'm trying to get my patients you know 60 50 70 but if she's like 50 and her she's got her libido back and she feels great and everything's wonderful then I'm hold you know because the higher we go the more likely you are to have side effects so you're losing hair you know temporal hair loss voice steepening acne new chin hair you know losing hair where you want it gaining here where you don't want it is how

I explain it to patients and so when you say 50 that's 50 nanograms per de I think um many people including myself were surprised to learn um that women actually have higher levels of testosterone than they do estrogen um outside absolute ranges right in absolute ranges and I can tell you right now your natural level of estradiol is higher than mine now I'm I supplement but you know like when I go through menopause your residual estradi is now higher than a postmenopause a woman so this is the uh estrad that I have because testosterone was

aromatized into into EST yeah interesting interesting uh so much uh is breaking down around the uh the old stereotypes female hor like testosterone is a human hormone right estrogen's a human hormone and they exist in in both U biological Sexes yeah it's um it it's sometimes unfortunate that compounds in the body get names like steroid hormones because then people hear steroids and then it has a gravitational pull toward um anabolic steroid use um or uh even the word fat you know it's like you know dietary fat versus subcutaneous fat versus fat we need better nomenclature

um to avoid a lot of the confusion that exists out there what are some of the other hormones that um can be reduced and can possibly be replaced by hormone therapy like progestins um you know are there is there a role for um you know adjusting things like prolactin or is there a is there a role for other hormones in that what sure is to be a multifactorial thing I mean I think menopause is a process not an event hypogonadism for females right and so we know that you know because the pituitary and hypothalmus are

involved and that G&R you know there's some cross reactivity so for example hypothyroidism when I have a patient who's on her and doing well on hormone therapy for her thyroid so she's on T3 T4 whatever she's on I'm like listen you know we need to recheck your thyroid levels in six weeks because giving you back estrogen is going to mess with a little bit of that feedback cycle so we need to make sure you're still therapeutic so I think we've got more work to do with some of the other hormones um but when we talk

about replacement and menopause we are mostly looking at your estrogens your androgens and your progesterone so the formulations can differ um when we you know there's a lot of misunderstanding around what is bioidentical versus synthetic and I think a lot of cottage Industries in this little bubble that we had for 23 years where doctors were afraid to prescribe hormone therapy and then women were desperate for care we had some little cottage industries of people I think were well meaning and trying to help but kind of developed terminology that really isn't medically specific like estrogen dominance

you know and what that really is and so that is not a term that is in any medical journal it's kind of something coined I think from a well-meaning provider trying to explain what's happening in per menopause that you're having more produced than progesterone than you used to have so PCO patients do the same thing you know there's multiple reasons for that to happen um so when we talk about you know in the miniverse of what we're trying to replace we all agree that we stick pretty much with estradiol we're just trying to give you

back the water you were drinking so I want to be get as close to what your body used to make because that's what the receptor like I'm trying to give you progesterone you know rather than a synthetic not that they're all demonized progesterone doesn't work for everyone I'm glad I have option and then for your androgens we pretty much just do testosterone and we do a transdermal again because the oral can be hepatotoxic unless it's uno8 which isn't um available in the US so but in there's no FDA approved option for women so it's not

covered by insurance we know it works for hypoactive sexual desire disorder what your followers would would call libido um we think we know testosterone women at the highest quartile of testosterone have better bone density and stronger muscles so I'm using off label for my patients who come in with osteoporosis osteopenia or sarcopenia I'm using it off label telling them this is a probably a hel it's not a h Mar we think it works but we don't have the you know it's not approved for that yet yet um we know it has receptors in the brain

my patients are saying that they're more clarity of thought they're sleeping better they really really like the testosterone um so there's you know DHEA there's a great vaginal preparation for DHEA called inosa and then the receptors there will start converting it into to both testosterone and estradi you know through the process and so um the sexual medicine docs really like in Roa especially for breast cancer patients because they get that little boost of testosterone in the vulva intr Roa intr Roa is the brand name I think it's prostone and this is a prescription drug yeah

these are prescriptions so intr roa's prescription DHEA was specifically formulated for the vagina got it which sits further Upstream to the production of testosterone and estrogen right and so fortunately the what's left in the vagina is able to you know plug that guy in and get it to produce both testosterone and estrad which testosterone is the immediate precursor we have to aromatize it right to make estradi in females as well these local effects on tissues um are interesting um I they make perfect sense if the highest concentration is at the site of release from the

from the patch or the gel or the whatever the um the the you said intravaginal what is it it's like a capsule uh I think the Prestone is a um insert like a little gel looking not a gel but a um I forget what The Binding material is but it's like a little insert you put in okay so the local effects because I guess you know it stands to reason that the highest concentrations can be at the sight of the thing that's releasing the hormone but then it also goes systemic by getting into the blood

actually so the the local formulations e the prostone and the um the inosa and as well as the estradi formulated for the vagina do not absorb Sy ically they're so low dose there's not been clinically significant tissue absorption I have a formulation for my face as well so it's a cream a cream that I put on my face it's estriol and so there's some decent studies with estriol but we lose 30% of our collagen it's a very big pain Point for women when they go through menopause that we lose so much collagen so quickly in

the first five years of menopause and so we can slow that process down we can't stop it completely we can slow it down by using a topical estrogen and the topical really seems to help with the elastin concentrations as well interesting so you you will often prescribe a lot of local treatments for hormone it's so safe so we can take breast cancer off the table all the discussion around blood clots and everything everyone can use vaginal estrogen and they should and I'll tell you why starting at what age relative toop the old menopause thoughts is

do not give adinal estrogen until she's symptomatic now all of us will become symptomatic from GSM so that's genital urinary syndrome of menopause so from the pubic bone all the way to the sacrum all of that tissue is heavily you know tied to estrogen testosterone and when those levels decline we see thinning of the tissue loss of elasticity loss of mu mucous production as well as the health of the urethra and so UTI like the best treatment for recurrent u in a menopausal patient is vaginal estrogen interesting not recurrent antibiotics and what about um so

it's preventative we can probably keep 50% of women out of the ER and out of urosepsis if we gave them all prophylactic vaginal estrogen all these ladies in nursing homes should be on vaginal estrogen so just to protect them from getting Euros sepsis interesting what about um like urinary incontinence and some of these other symptoms that are associated with more elasticity presumably more elasticity of of tissue in that region if you're early in a so we have stress incontinence and then we have um overactive bladder urge incontinence and so it definitely helps with urgent condet

it rela you know it helps to relax and decrease the inflammation in the wall of the bladder so thumbs up there so people are getting up at night and having that urge to go um but stress incontinence is an anatomical problem we've lost you know the the sling that holds up the urethra and the female fails right from herniation and and poor tissue Health we can build up that health and we you know there's Physical Therapy there's lots of options and you you know no Euro gynecologist wants to take a woman to the o to

do a lift if she's not estrogenized they're all going to get vaginal estrogen pre you know through healing and forever to keep the tissue healthy everything that we've been talking about for about the last 15 or 20 minutes seems to go directly opposite this large scale study that was discussed at the Watergate Hotel um is your read that the medical establishment in particular the OBGYNs in the US and in other countries understand now that that study was um flawed to some extent in its design no or is what we're talking about here like really cutting

edge I mean if we were to gather a room full of a thousand OBGYN trained in various decades and put there 10% would have any idea here's why and I'm going to call out the American Board of Oben directly on this we take our board certification exams every year in our specialty as every specialty does and they give us a set of Articles of The Cutting Edge newest research and it's divided into categories obstetrics office practice Gynecology GYN surgery Pediatrics onc you know there is no menopause category nothing so I went back over like 10

years of all my green journals and looked at how many articles were anything to do with menopause and it was less than 1% so they were not systematically trying to put the latest menopause information in front of us they don't even recognize the menopause society as a like entity well now they have to contend with the menop posi they do and because and they might you might see me banned from the a but you know what no no no but I'm so proud of what I learned I learned amazing things I am a boss at

delivering a baby of taking care of a pregnant patient I am great at pediatric Gynecology I was so good with adolescence where I failed and where this I let the system let me fail was in the care of a woman after reproduction outside of surgery outside of her surgical needs well I have to imagine that given the medical profession is interested in the well-being of people and in uh for sake of the discussion today women that um they will be grateful that uh now you you have a microphone um many microphones uh in various contexts

so uh that is surprising to me however I would think that given the exciting findings around hormone replacement therapy and the I'm kind of obvious at least when you describe them to me obvious flaws in these earlier studies of you know starting hormone replacement therapy when women are already 61 when they've already accumulated um in many cases um some health health issues that uh it would be kind of you miss miss the ability to to measure the protective benefits so but fortunately we've got great studies coming out of like the Danish data the Scandinavian data

that are really looking at this again and showing the protective benefits so is it generally the case that the studies out of Europe and Scandinavia are more forward W thinking it depends you know some of the most Forward Thinking shockingly is um come out of Asia a lot out of China and I asked my husband he's worked there before and he said there's as many researchers in China that are female as male it's not like they have a big stay-at-home culture you know they're they're not um women are expected to work and they're getting phds

and they're they're doing the research and so and he thinks at Le in his in of one you know his humble opinion and he's an engineer you know that that's I was like why do you think you've worked over there he goes I think because there's just as many women who are writing the papers as men interesting take I like it um it makes good sense what are the various things that people can do in terms of a non hormone replacement therapies that can support them through really into and through perimenopause and menopause we talked

about nutrition earlier maybe we could touch on that a little bit more we talked about behaviors resistance training maintaining maybe even increasing muscle mass um there's no pressure to uh include them but what about the very supplements that we hear about that can touch on or we we are told can touch on these hormone Pathways things like dim things like grape seed extracts things like um evening primrose I I don't think they're harmful but there's just not robust data to really support so um menopause Society went and looked at all of them even soy and

everything and they just outside of cognitive behavioral therapy which can be helpful but is not a menopause cure um they didn't find much in the supplement world that would stop remember we're defining menopause as hot flashes and general urinary syndrome of menopause so you know when I'm recommending supplements to patients I do think there's some okay data on turmeric for maybe hot flashes but I'm not saying to take that instead of replacing the estrogen your body is is missing greatly um I like the anti-inflammatory benefits of of you know of that supplement I'm recommending F

80% of my patients are deficient in vitamin D and struggling to get it absorbed you know um I'm recommending creatine for muscle I'm recommending um there's a specific bioactive collagen that was studied in menopausa one with osteoporosis where they saw Improvement in bone density so I'm recommending a weighted vest great studies elderly women but saw improvements in bone density and I'm like why do we wait until we're osteoporotic to make the diagnosis yeah this is interesting so weighted vest a weighted vest they looked at creatine weighted vest vibratory training in nursing home dwelling so they

were kind of a population where they couldn't go anywhere vibratory training is the shake plate uh the shake plate and so you know anything that stimulates that muscular skeletal unit will will send the signal to get stronger you know what most women don't realize I mean they know about osteoporosis right and they don't want to have it but they don't understand that like your habits in your 30s and 40s are going to put you on that path and that your body is going to fight to lose muscle and bone naturally through the aging process and

accelerated with menopause it doesn't have to be that way but you have to do the work you know and and there's some hacks and so I love the way to vest for a hack I'm like do the dishes with it on go walk the dog you know like like how heavy so you want in the nursing home they started at 10% of their body weight so I'm like 10 lb 12 PBS start with that so now my husband's obsessed and we have six of them and they go from 8 to 35 lbs you know so

I have different weights that I wear like if I'm doing leg day I'll put the heavier one on so I don't have to hold as heavy so you'll use a a weight vest when you're doing leg day mhm wow so I can't cuz I don't have great grip strength and you know and so it'll help me be able to squat heavier you know but now I'm getting better I'm got the bar going so I'm I'm getting there you know I'm want to tell my sister and my mom this yeah and you know I've got my

sister yeah doing some resistance training it's been and it's just a cheat I'm so it's so cute on social because they'll post and tag me and they're walking their dog and they're doing whatever with their way to vest on and now in galvaston where I live you can't go you see it all over the sea wall everyone's walking with their weighted best on I love it and it's hot down there a lot of the year so no excuses people outside of Texas or in Texas for that matter but my experience is that people in Texas

don't tend to make excuses anyway that's said like a real Californian here um we were talking about this a little bit earlier in uh female specific weight vests I would love to develop one because the ones were made for men and they're okay but if you have larger breasts it's hard where the Snaps are to get it on right and I know there's a big Trend with Wrecking but that puts all the weight on your back and I really like the weighted vest because I feel and this is my opinion really but that you know

the reason why it's helping with your bone density is it's putting the weight on the entire axial skeleton rather than just the muscles on your back so we're putting the force more evenly supported yeah um and so but some of my uh followers have written in and said they're struggling because they have larger breasts and how to get this around I'm like I got to make one that's going to accommodate you know have longer you know dist strap down here underneath the breast so that's yeah someone should develop that you should develop that um not

that you don't already have enough on your plate already uh along the top I like rucking it is sort of backloaded you know by definition um some of the weight vests that are out there are little um are evenly distributed in a way that makes them pretty comfortable they're not all loaded up up front like like a a special operator or something would wear so I positive effects of of the weight vest would be increased bone density you you're doing more burning a little more calories getting stronger but I'm I'm I coach to it you

know with my followers for this is part of my osteoporosis prevention pack love it are you willing to share a few other things that are in the prevention pack uh you know eating adequate protein doing resistance training wearing your weighted vest creatine five grams a day where most of the studies were done in in the women creatine monohydrate monohydrate yeah and then um the that cagen consider that uh collagen full disclosure I do sell that one but um really good investment I think maybe we could talk about collagen for a moment um it it's a

complete protein no no no it's missing one I think one or two amino acids so it's not a complete protein um it's better than none so I do like include my collagen in my protein intake for the day because I eat all animal-based protein pretty much um so I figure I'm I'm covered my bases to have you know 10% of it coming with just missing two amino acids or I think it's one valine I have to look it up so and what are the specific effects of a quality collagen so you know there's a lot

of controversy there I've seen the videos it is broken down into its component amino acids you know through the digestion process but the first ones I looked at were totally for vanity I was changing bathing I was trying on bathing suits with my daughter who was a little girl at the time and I was complaining about the appearance of my cellulite even then people have cellulite and oh mommy it doesn't look that bad and I you know scientist in me was like goes on PubMed and starts looking up articles on on cellulite and how to

decrease the appearance of it and so I found these articles on something called verisol and it was a college in made in Germany and they'd studied actually done like really high quality studies like laser measuring wrinkles and cellular ger are precise and uh they and it looked they had positive outcomes I'm like well it won't hurt me so I ordered some I Googled where do I find this verisol collagen I find this company I order it and then one day I talked about it on the internet and the company called me and said would you

please let us know when you do that cuz they sold out of their supply for like 3 months so the same like manufacturer of that particular verosol made this forone did the studies five years doing bone density scans on these women it was a small study but they saw improvements we know what happens to bone density if you do nothing it goes down these went up and I thought okay I want to do and I want to offer this to people like if not then me this is a high quality product I can rep you

know and that so that's part of my um what I offer to people or what I recommend you can get it anywhere other people sell it not just me great um so I'm perplexed this isn't a challenge but I'm perplexed how would a protein that's not a complete protein um be beneficial for a body organ like skin whereas the complete proteins don't seem to do it on their own nobody knows okay I don't know interesting are they studying the right thing or they're not really looking at it so I don't know there great when I

hear I don't know the know the scientist in me says great area for for exploration because we don't really believe in fact we don't believe um that amino acids um that are derived are derived from a particular body part Target that tissue we've heard this argument before um Dr Lane Norton and I have both gone on record publicly saying there is basically zero not basic delete the basically there is zero evidence that when you ingest heart uh let's say you you like eating liver or heart or skeletal muscle that somehow the amino acids are selectively

trafficed to the organ uh of the heart or the liver or the skeletal muscle there's no evidence of that whatsoever certainly not in humans if there is evidence um I'm sure they'll let us know in the comment section on YouTube and let let us know but yeah it's it's it's perplexing why collagen would have a selectively beneficial effect on skin they didn't study it versus a steak you know they just they just looked at bone density if they took this product every day for 5 years and what happened and they weren't you know they weren't

having tremendous cardi metabolic disease they weren't on bone building medications they weren't on HRT so you know they they did a pretty clean so there's you know not a huge study but it was interesting and I thought okay you know I don't want to break because if I break my hip well 50% of women will have an osteoporotic fracture before they die 50% 5050 what about men do we know just by way of comparison I think it's 25 wow but don't quote me on that I need to look that one up so it's it's about

half okay and then hip fracture if you if you break that hip if over the age of 65 you have a your one-year mortality with surgical repair is 30% if you if you're not healthy enough to have the repair you can't afford to have it it's 79 goodness so that's what we're trying to avoid is that you know and the tremendous if you've seen the women who have tremendous osteoporosis in their spine and just how their lives are so hard and how much pain they live in every single day you know this a lot of

this is avoidable with aggressive you know being aggressive and and intentional about this and HRT can be a huge part of that as well what I'm about to ask is a little bit outside the box but I feel um Fair asking given that um you know I'm not a clinician but I have some background and certainly understanding of neurod degenerative uh conditions of the eye and vision have you ever observed in your patients that when they get on hormone replacement therapy for menopause that things that are typically associated with aging like diminished visual function um

hearing you mentioned tenus also called tentis I understand but tenus I think we'll do both tenus cored and said tenus we'll do both um here that that they um they report seeing better hearing better and any kind of sensory Improvement or offset of sensory loss so we know the data is clear on dry eye and how that can affect um but how it affects like the optic nerve you know we know that estrogen is anti-inflammatory so any kind of like inflammatory condition in and around the eye does tend to get better but we need you

know probably more data in this area for hearing most of the research is around tenus and vertigo so the the the rate of which the crystals break off in the ear accelerates in menopause and people on HRT have less vertigo new vertigo than they would have had before and I forget what the pathophysiology I wrote it in the book but I can't think of it right now um what the physiology was behind why tenus increases in um menopause but it's due to the estrogen levels declining you mentioned dry eye a lot of people might hear

dryeee and think oh no big deal but actually dry eye is one one of the most frustrating things um to have and it's a uh I believe a many billions of dollars of a year industry to find treatments for for dry eye um so does estrogen replacement therapy improve dry eye it does seem to they have less incidents most of the studies are just retroactive and they're looking at the incident of those things on women HR on HRT for other reasons are not and they just see especially like frozen shoulders the best data there I

think and um what they see is a decreased risk of occurrence and then if they do have it they have a shorter duration and easier cour you know easier to treat if they're on HRT fantastic so um what are some of the cases where uh a woman can't or shouldn't do hormone replacement therapy and here we're using hormone replacement therapy is kind of a proxy for for estrogen therapy yeah so any hormone sensitive cancer a one of the things a lot of women don't understand if you have dysfunctional uterine bleeding that has not been evaluated

you should not start hormone therapy because we don't know if it's cancer so if you're having really heav especially if they're heavy bleeding clots out of nowhere you know something unusual about the volume or the the frequency of your bleeding you need to go see a gynecologist and get that evaluated before you start hormone therapy okay it may not be anything cancerous or tumorous it might just be the hormone changes but that needs to be evaluated um if known breast cancer no if you're actively having a blood clot that you're being treated for they're saying

let's hold off until that therapy is over um even if you've had a hormone sensitive cancer including breast cancer depending on the stage the type and and it's a very nuanced conversation does not mean that you automatically disqualified for hormone therapy after your treatment so that is one of the biggest misconceptions out there if you have really severe liver disease I'm not talking about mild fatty liver disease lots of menopausal women have that and it does tend to get better with HRT if you have severe liver disease that is where estrogen begins to be metabolized

and so you could have abnormal metabolism you don't want that so that you're that's going to keep you from being a candidate why do you think we're seeing or at least hearing about in my case uh PCOS polycystic ovarian syndrome so much more is it because people are aware is it because I think two reasons one the Obesity epidemic had led to more PCOS that is definitely a risk factor for for you know insulin resistance is usually the the main pathophysiologic cause behind PCOS and I a PCOS then PCOS sufferer so I had it my

whole reproductive life um both but you're not obese at all no no they missed it forever I was just stressed out medical student which can potentially cause PCOS with acne yeah I mean you you can have PCOS is a symptom of something biologically a barent turns out I'm insulin resistant which is why you know even though I'm thin and so we've had higher increasing levels of obesity which is a risk factor for that also people are talking about about it and that writing books about it Karen Tang just published um it's not Hyster wait hysteria

it's uh it's not hysteria and she's a gynecologic surgeon does a lot of work around enetri so she has like huge chapters on PCOS and how to advocate for yourself and you know all about the disease process so people understand interesting what what are some of the primary treatments for PCOS is it going to be blocking androgens so yes and so for me you know in all my training it was always put them on birth control because it w it it will suppress ovulation and suppress the over production of androgens in their system so I

was a very happy birth control patient because I was thin for the obese patients if we can help them lose weight it does tend to they start ovulating again and so now with the new go 1s a lot of PCOS will probably resolve itself and they'll start ovulating again and go back to normal Cycles that's the pregnancies that are happening from G ones I see so glp1 associated1 babies yeah gp1 we saw a surge of that when all the patients the obese patients were getting the gastric bypasses then they get pregnant and so we were

advising them to not be pregnant until their weight was stable for a year after surgery because of the medical implications of nutrition and pregnancy but they were going to you know they were so excited and CED and now their libido's up and and they're you know getting pregnant and um never really needed contraception before and just assum they'd still have trouble and so now they're ovulating and getting pregnant and we're seeing the same thing with gop1 so I'm anyone listening out there who's prescribing a gop1 please talk to your female patients about contraception if they

don't want to be pregnant very interesting and um admittedly uh unforeseen uh implications of glp1 as long as we're there um what are your thoughts onic monjaro um I think that they can be a really important tool for a lot of patients I don't think they're for everyone I don't think people are being counseled adequately a lot of them I mean in my area outside of galvaston where I live there are Med Spas giving out GOP ons and as far as I can tell they're just giving them the meds and sending them out the door

I've had patients coming in on it who were never counseled about the potential for muscle loss so when I look at a patient's health I look at a 30-year plan right and so they come in with a lifelong history usually of of having a weight problem and a fat problem and and here's this medication that's going to take the food noise away and help them focus on the habits that are going to keep them healthy longer so I do have patients that I've prescribed it to we have a very long discussion about adequate protein intake

resistance training you know I have a a way to measure their muscle mass we are tracking that every month for them every month to six weeks while they're you know on the medication so women who are on HRT with the glp1 have a 30% increased weight loss wow yeah yeah I appreciate that you mentioned that the use of OIC monjaro is not mutually exclusive with resistance training and improved nutrition the way it shows up on social media sort of like people assume well you know you gotta take great care of yourself and exercise well great

but there are also a number of people that are carrying excess weight to the point where um they are at risk of injury when they exercise um I mean everyone's at risk of injury when they exercise but what I'm hearing is that you basically take the view whatever can get people in a kind of forward Center of mass around management of blood insulin levels Etc cuz wasn't that the original FDA approval diabetes diabetes um and there's also some datas I recall that OIC monjaro can reduce alcohol cravings that so yeah the reward center in the

brain are the the noise so they're looking now I guess that my friends who are like obesity Medicine Specialists and are all like reading every study that comes out any kind of impulsive behavior or reward-seeking behavior gaming gambling alcohol you know people are tending to do less of those behaviors because whatever the whatever is being blocked in the brain and you know more about this than I do seems to help with that those drives that's interesting that the hypothalamus is uh choca block full of neurons associated with all sorts of drives and temperature regulation you

mentioned earlier you know the preoptic area of the of the hypothalamus involved in temperature regulation and we've always viewed those as somewhat separate but they're actually um quite interconnected and and so I'm not entirely surprised that uh a drug that would reduce cravings for food might also reduce cravings for other things it's going to be really interesting to see um what the science and the animal models and human shows us over time it's definitely happening I mean this is has it hit a trillion dollar industry yet it's probably hundreds of billions of dollar know the

majority of big F research and funding is is being funneled into this um maybe not all for the right reasons but the the Obesity Medicine Specialists who are kind of who I turned to for how do how do I do this how do I do it right um how do I not hurt someone just to get them to lose weight you know and are very excited because these new levels they say it's like the iPhone 12 the iPhone 13 like they're just going to get better and better with Lower Side Effects better profiles you know

as time goes on that we're going to look back at the Muro and these earlier meds and be like oh my God what were we doing you know because of the side effects well if nothing else there very interesting to pay attention to because it's uh clearly uh in the cultural Zeitgeist right now so every once in a while when a guest for whom the topic is of immense interest coming on the podcast I'll put out a call on social media for questions and so uh if you're willing I'd like to just ask you a

few of the audience questions um and we can treat these as rapid fire or um as much depth as you like um first off that many of the questions you've already answered things like um what the role for testosterone replacement therapy in women um as opposed to just estrogen replacement therapy but one of the more common questions in here that uh We've touched on but I think could um uh deserve a bit more attention is you know if a woman is in her 60s and has already gone through menopause is it appropriate for her to

consider or at least just talk to her doctor about hormone replacement therapy or she putting herself at risk there's definitely worth the conversation so if I have a patient who comes in and she she's she's more than 10 years P her menopause or over the age of 60 and has not been on HRT then we start looking at risk factors for cardiovascular disease or stroke and so we're looking at her blood pressure her lipids her you know cholesterol and triglycerides and looking for things that are going to put her at higher risk she's lost probably

the maximum cardiovascular benefit but we don't want to put estrogen on top of severe atherosclerotic disease so if she has abnormal cholesterol I'm going to send her for a calcium cardiac score I want to see if there's calcified plaques around her heart I may even if if stroke is a risk we may even Cent her for an ultrasound you know looking at the intimal thickness um of the kateed so if those are normal or lowrisk then we will talk about the benefits of what what would the benefits be for her after the age of 60

will we probably lost the best of the cardiovascular protection but it will always protect her bones it will always protect her genital urinary system it will always protect her skin I mean there's things that estrogen will do for us forever and so and then let her make the decision certainly if she's still symptomatic meaning hot flashes or things we can easily identify that we know estrogen will help with but you know that first tenear window is kind of critical for the preventative benefits but it doesn't mean she's not going to benefit forever now when do

we stop used to be doctors make up numbers three 10 years whatever if she's been on it since early in her menopause and has not developed any of these diseases and she wants to keep going we're going to keep her on I will probably die with my estradiol patch on if I don't develop a reason to take it off because I know it's protecting me in so many levels and I want to keep that going in so many ways it sounds very similar to testosterone replacement therapy and Men the ideas that people go on why

you stop at 70 why would you do that right you know if you didn't develop a contraindication to it very clear and um potentially very actionable answer thank you um a number of the questions related to um the relationship between menopause hormone therapy and mental health mental well-being um but let's just keep it simple for now and ask what are the things that women can do in order to um optimize or their mental health in per menopause and menopause and that they can do to offset any mental health issues that might arise during per menopause

and menopause and there's a reason why I asked about those two things separately one is just to very different than menopause for mental health so a great question so I just went to a menop posium menopause conference in Chicago and uh there was a whole section on mental health and it was uh neuroscientist psychiatrists and and menopause Specialists all up there discussing the latest data it was so f fascinating and so there really is a big difference as far as mental health for what's happening in per menopause and what's happening postmenopause and as we talked

about earlier in per menopause we have that hormonal zone of chaos and we see this you know in the Australian data it's a four times risk of mental health disorders especially depression and then in postmenopause a lot of these things tend to stabilize or get better probably because just the estrogen is bottomed out and the brain is not having to deal with these fluctuations so we think that the data is looking like the best treatment for the mental health issues in per menopause is going to be estrogen for stabilization and not the traditional ssris snris

you know the anti-depressants and the anxiety meds not incidentally uh one of the more common questions was um in this case very specifically worded I've been on HRT for 5 years and I'm 61 I feel great but how long as it quote unquote okay to be on them seems like I hear conflicting opinions well we just heard a very straightforward opinion from you so thank you for that as long as you want to be as long as you're still healthy how can I stop waking up in the middle of the night this is a problem

since entering menopause MH so we see sleep disruptions definitely from not only from the vasomotor symptoms which will wake you up okay if we can get those under control you know your sleep function should not be affected by that what we're seeing though is people even with HRT even with estrogen are still having middle of the night Awakenings or racing thoughts or having they get up to pee or something in the middle of the night and they can't go back to bed usually because their brain is is going on what we found is that progestin

probably through the effects of Gaba is very effective at settling your brain down and allowing for sleep so I'm having my patients take their progesterone Orly at night before they go to bed and we're seeing better sleep with that and that was also something covered in detail I was so excited by the neuroscientist that's part of her area of research that they are showing clearly and she can point to the neuro receptors of where that's happening that progesterone seems to be really protective for our sleep now take hormones off the table sleep hygiene is still

hugely important and I need to see the studies to prove it but I'm telling you we do not tolerate alcohol like we did Prem menopausal women are in at least 90% every time I post about it online I see thousands of comments of I quit I had to give it up I cannot sleep and even in my own life if I choose socially to have more than a glass of wine I am giving up sleep like it is a choice I'm choosing not to sleep that night I will wake up 2:23 3:35 whatever time in

the morning sweating and I'm like you know too much champagne at New Year's or whatever so you know that is a choice and it's something I councel my patients about like you probably can't tolerate alcohol like you used to aging is a factor here our body composition changes and there's probably something hormonally that's going on we don't understand yet but like you choose this you're going to choose not to sleep more than likely interesting I wonder whether or not um estrogen modulates the alcohol dehydrogenase enzyme but uh time hav't seen the data yet but I'm

sure it's coming here's an interesting One how can men help their female loved ones navigate these stages yeah you get that question a lot my and it's it's great and it always comes on the when I'm being interviewed by a male you know when I'm interviewed by a female they're wonderful but they they have their own experience and they have to talk about it and that's fine that's my job you know is women have to unpack their menopause trauma to me but the men are just so curious and just have so many questions and then

how can I support a partner and or my mom or whomever in my life who's who's dealing with this one is is acknowledge that this is happening and and try to educate yourself there's my book other books there's lots of information now on the internet about the subject but she is going through a transition that is in her world more than likely and is affecting her brain her bones her heart her kidneys her skin her ability to relate her ability to tolerate it's probably going to affect your relationship in some way go there with her

go to the appointments with her be there to advocate for her you know be a partner through this with her because you will get her back but it's going to take you know changing the way that you address things a couple of questions about quote how to rekindle libido oh yeah this person in particular says it's packed bags and moved out since I started menopause they're reporting their individual experience but um you touched on testosterone therapy earlier any woman in her menopause Journey at any time there's a 50% sexual dysfunction rate meaning she's not happy

with whatever is going on now when we look at the buckets where sexual function fall into we have orgasmic disorder now in menopause when we lose blood flow to the area people can have delayed orgasms or less um the peak of the orgasm is lower you know less vibrant orgasms for lack of a better word um they have decreased blood flow to the area they lose elasticity so pain is another bucket you know it hurts the skin gets torn it's very fragile it's very Frable so vaginal estrogen therapy can help there there is arousal disorders

where you want to do it but the blood's not getting where it needs to go so you're not having all the arousal type symptoms so sometimes Viagra selenophile topical selenophile can be helpful there there and but the most common thing that women have is hsd or of course relationship disorder you don't love your partner you don't feel supported it's going to be hard to you know relationship disorder official the official term so but then hsdd is hypoactive sexual desire disorder that's in the brain and so first thing I ask is did you use to have

a good libido or a drive yes you know and you have a good relationship with your partner it doesn't hurt you we have to rule out the other things that's where testosterone comes into play that that is those patients it does tend to help there are two FDA approved medications for libido one is VII it's an injection you give yourself and actually works for men as well about 30 minutes before it's in the alpha melany stimulating hormone path mordon and then there is um Addie addyi works at the level I think of dopamine in the

brain so it's more in the family of ssris that you know so it affects neurotransmitter and so you take that every day um and it works it was only studied in premenopausal women but it does you know it's modest but it does seem to have an effect so but most of my patients because testosterone has so many other benefits you and then the the cost the to get it compounded in Texas is maybe 30 bucks a month so it's really reasonable um and the V and the atti can be very expensive and usually not covered

by insurance so because of cost and and potential other effects most of my patients choose testosterone if it's hsdd I see this is a question about the um side effects associated with estrad hormone replacement therapy in this particular instance um the person says um what are the best alternatives to estrad I've tried tiny amounts and the side effects in this case um skin rashes and hives are what they are describing so I wonder if it's the patch so um there's a certain percentage of patients who it's not the estradiol it's actually the adhesive in the

patch they will have a reaction to it so one is try an alternative form another thing that one of the members on my team saw in her her chat group is they get the flon so corticon nasal spray over the counter and they spray it on and let it dry then they put the patch on and it decreases the risk of the reaction to the glue um I don't know how if that lasts forever but I thought that was a cool thing to know about and um but what I typically do for my patients is

change them to an alternative form interesting um thank you for that they went on to ask about um trying a new supplement called equil EQ u e l e about that one again I don't know what's an equil um but again not really robust studies but most of these things are not harmful but you may just it may be a little snake oil you know throwing your money away really the thing that's going to fix the problem for most women is restoring your estr yeah because there were other questions about you know wild yam and

and things more in the supplement um space um as well as things like acupuncture and herbal medicine so um acupuncture can really be helpful um but again it's it's hard to access and can be expensive for a lot of patients and it's not treating the root CA but it definitely can help you deal with some of the symptoms and make you more comfortable and then um last question um how best to attack and here I'm quoting attack the fat distribution problem at this time yeah uh you need a multifactoral approach to visceral fat so nutrition

exercise women on HRT have less visceral fat you know um those are kind of the key things and and the way you approach your nutrition with the exercise with the stress reduction getting those cortisol leveled down are going to make you healthier in every other way as well great well Dr Mary CLA um thank you so much for giving us just a wealth of knowledge about per menopause menopause really explaining what those are clearly um for the first time on this podcast and really illustrating the things that people can do to think about these stages

of life and to to I don't know if I should say tackle or to dance with the stage of Life whatever um term one prefers in order to offset the negative effects and it sounds like in fact it's very clear based on what you've told us that there are real levers of control yeah including hormone replacement therapy but other things as well nutrition exercise um sounds like when we put all these together there's almost like a mindset around per menopause and menopause that you are um promoting um which is one of of real agency that

this is not something that is um going to bury us mentally and physically that's something that really can be worked with and I just want to say on behalf of myself because I've learned so much from you here and uh the listeners and and viewers of the podcast thank you for the information today thank you for your clinical work um thank you for your ongoing Research into this area for attending these conferences and learning so much about it so you can bring us the latest and thanks for your public education efforts because they are really

really making a tremendous difference thank you thank you for joining me for today's discussion with Dr Mary CLA Haver to learn more about her work please see the link to her website in the show note caption as well as the link to her terrific book the new menopause navigating your path through hormonal change with purpose power and the facts if you're learning from Andor enjoying this podcast please subscribe to our YouTube channel and follow us on both Spotify and apple that's a terrific zeroc cost way to support us in addition you can leave us up

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