Dhru Purohit Show - #1 Menopause Doctor: Biggest Myths On Weight Gain, Diet & Exercise For Women with Dr. Mary Claire Haver

Episode Date: April 1, 2024

This episode is brought to you by Lifeforce, LMNT, and AquaTru.  The transition to menopause has historically lacked comprehensive discussion and is often perceived as an abrupt occurrence without recourse. Our guest today has emerged as a vocal advocate, shedding light on the journey from perimenopause to menopause and providing empowering strategies for women navigating this transformative phase. Today, on the Dhru Purohit Show, Dhru sits down with menopause expert Dr. Mary Claire Haver. Dr. Haver guides us through the myths and misconceptions surrounding perimenopause and menopause. She sheds light on the misguided research and beliefs that contributed to a lack of awareness about this transition for women and the challenges women face during this time. This episode is a must-list for women of any age! Dr. Mary Claire Haver is board-certified in Obstetrics and Gynecology and is a Certified Culinary Medicine Specialist. In 2021 she opened Mary Claire Wellness, a clinic dedicated to caring for the menopausal patient. She developed the best-selling book and program called The Galveston Diet, a three-pronged lifestyle plan that encourages fuel refocusing, intermittent fasting, and anti-inflammatory nutrition to manage hormonal symptoms, stabilize weight, and revitalize the body as it ages to provide benefits that will last a lifetime. In this episode, Dhru and Dr. Haver dive into (audio version / Apple Subscriber version): Why women are living in poorer health later in life (0:00:28 / 0:00:28) The implications of lack of education about perimenopause and menopause (9:03 / 5:41) Surprising symptoms related to perimenopause (14:35 / 11:30) Hormonal changes that cause visceral fat (18:53 / 15:45) What habits can help women reduce visceral fat (34:11 /29:36) Protein and resistance training (40:05 / 35:02) A disruption in sleep quality and sleep apnea in women (43:51 / 38:00) The stress impact on women (50:50 /45:25) Gaslighting and lack of education: why women aren’t being heard (56:36 / 51:50) How menopause impacts gut health(1:01:12 / 56:25) Supplements to support perimenopause and menopause (1:03:58 / 58:59)  HRT: Who is it for, how much, and when? (1:15:40 / 1:10:56) Also mentioned in this episode: Dr. Haver’s new book, The New Menopause North American Menopause Society Right now, you can save $250 on your first diagnostic and get personalized suggestions. Optimize your longevity and track your progress go to mylifeforce.com/dhru!  Right now, LMNT is offering my listeners a free sample pack with any purchase. Head over to DrinkLMNT.com/dhru today. AquaTru is a countertop reverse osmosis purifier with a four-stage filtration system that removes 15x more contaminants than the bestselling water filters out there. Go to dhrupurohit.com/filter/ and get $100 off when you try AquaTru for yourself. Hosted on Acast. See acast.com/privacy for more information. Learn more about your ad choices. Visit megaphone.fm/adchoices

Dr. Mary, Claire, Haver, welcome to the podcast. You know, one of the most mind-blowing facts that you've been shouting from the rooftops that will surprise a lot of people when they hear it is that, yes, women are living longer. And there's a but, though, but they're not living as healthy as they could be, especially in the last one-third of their lives. Tell our audience what you mean about. this. You know that statistic? I learned about that actually fairly recently. I knew that, you know, we lived about six, four to six years longer than our male counterparts. But what I didn't realize the statistics would support is that 20% of our lives are lived in poor health than males. So men just kind of live and then die. We have this protracted period of progressive frailty,

dementia, you know, and we're much more likely to end up needing long-term care and then our male counterparts. And, you know, so my big focus now when I talk to my patients in clinic is they're looking at their mothers, their aunts, the women in their family and how they've aged. And they're like, a lot of them are really scared. And like, what can I do now? Nutrition, health, recommendations, whatever, so that I can limit my time of needing long-term care. We're going to jump around a little bit in this interview, but I want to get started at the beginning a little bit from part of the story that I'm starting at. Like a lot of women, you started to notice shifts in your body composition. And it was this moment where you started to notice a little bit more fat around the belly, some changes in sort of fat distribution, body composition distribution.

and that got you to a place where if I understand correctly, you felt that you wanted your husband to have the wife that he quote unquote deserved. I'm using your words at the time that you were sharing with him. So nobody canceled me. And that sets you on a journey. Tell us what journey that sets you on. Yeah. And how that led you to the topic of visceral fact, but even bigger than that, how that led

you to this topic that you are most known for talking about today. Menopause, yeah. So I was in menopause, and right at the time when I had stopped, I was on birth control pills for a long time, and I was very happy with them. I did well on them. I was being treated for a medical condition with them. And about 48 years old, I decided my practitioner and I decided I would come off and kind of see where I was and then, you know, make decisions moving forward. And right at the exact, that same time, I got the call that my brother had had a stroke. Now, he had been dealing with end-of-life HIV and hepatitis. And, you know, so I rushed home to do his end-of-life care and, you know, stayed home for about two weeks and went through, you know, we did his hospice at home,

my sister and I. And then, you know, the funeral, the burial and all that. And then came back and went to work right away. In that six-month period after his death, I was horribly depressed, really in a really dark place. And I wasn't sleeping. I was having all these, you know, kind of vague symptoms, and I was gaining weight. And so I would just had attributed all of it to grief. And certainly that was a part of it. But then as the grief kind of fall started to lift, I realized, when was my last period? Like, I haven't slept. I'm like having whirlable hot clashes. And I cannot get this weight off. And so what had been taught to me and what I had recommended my patients for years was work out. more, eat less. That's all I learned in medical school. And it stopped working for me. I would lose a

little bit of weight. I mean, I was getting really obsessive. And so my husband was leaving for this trip. He was going overseas for a couple weeks. And I said, when you get back, you're going to have the wife you deserve. You know, I was looking for self-motivation. And he just stopped me in my tracks and said, your daughters are watching. You're having some really concerning behaviors. You know, I was getting up in the middle of the night to pee because, you know, menopause. And I would weigh myself after I, every time I didn't do my bladder. And I mean, that's not healthy. And so he's like, I love you. You look amazing. But, you know, you're a scientist. Figure this out. This is what you tell your children. If what you're doing is not working, you must change the path. So that really

motivated me. And type A kind of, you know, I called the nutrition scientist at the university I worked at. And I was like, what is going on in menopause? I'm going through this. All my patients are going through this. I can't lose the weight of what is happening in my belly. And they were the the PhD nutrition scientists who were doing all this work in the elderly and protein and who were showing me all these articles on inflammation, on menopause, the connection between the two. And then, you know, how nutrition really plays into this? I'm like, how did I not know this? So I just kind of start down this rabbit hole of how to get the weight off, what's going on with my belly, but it just blew up into this much bigger picture. And I'm like, I'm the doctor in

charge of these menopausal women. And I think I've been failing. You know, outside of a very, very, very tight conversation about possible hormone therapy, but you might get breast cancer, which turned out to be totally wrong, I really wasn't shepherding this women at all at this point in their life. So that really started my path. This episode is brought to you by Lifeforce, the diagnostic company I personally use every quarter. You know, I love learning about the latest longevity research. But ever since I turned 40, I'm even more interested in learning how to apply it to my life

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That's me to get your offer today. This deal is only available through my link. So you got to make sure you go to drink element. dot com slash d hr you picking up from there and zooming back out this really led to a much larger conversation around the changes the unique changes that women's bodies go through and one of the things that you talk about as a medical doctor is that so many women forget about men men are not taught about anything about women's bodies but even women themselves are not taught about this stage that happens in a woman's life where isn't just menopause is one thing that all of a sudden one day

you wake up and you're in menopause. It's actually this whole period that leads up to it. So describe this stage of life for women and all women will generally be going through this thing and more importantly describe the implications of the fact that society, medicine, and education has not properly educated the entire public or devoted scientific research to help people understand how to personalize and optimize this stage of life. So when we talk about medical education and menopause, for my own and when I pull doctors and health clinicians across the country, we might get an hour, maybe, of anything to do with menopause. And it's like your period stops and your estrogen declines. That's all.

And then in my OBGYN residency training, I think when I look back, I probably had about six hours of training. And I trained from 98 to 2002. Now, from about 2005 to about 2015, I was a residency program director in charge of the curriculum. So I got my orders from the American Board of OB-GEN. And I had to make sure that our learners, you know, our residents were covering all these basics. There was a very small menopause curriculum, but we didn't have required clinics. So I'm just trying to have your listeners understand. the lack of education and training. If you go right now to PubMed, which is Google search for doctors, you know, and clinicians, where we, it's a repository of a really good medical research. And you type in the word pregnancy, 1.1 million articles come up. And these are important. Back, pregnancy is very important, and we need to have healthy pregnancies. So, you know, but when you type in the word menopause, it's 94,000.

So that's greater than 10 to 1. And that's 10 to 1 of brainpower research funding. emphasis, education. And it made me think now that I'm in this phase of my life and I will be in this phase of my life for the rest of my life, why is menopause not important? Why is this part of my life not as important as when I was in my reproductive years? And that's what I think people need to understand how society thinks about the aging woman, how we think about it ourselves, we're not educating ourselves, we're not talking about our experiences because we're embarrassed and ashamed. And I think it's ridiculous. So let me educate your listeners as to what menopause actually is. And I don't

think most people understand. So number one, the difference between males and female. So if you're born with testicles or you're born with ovaries, you know, of course those organs are different. They both contain what medical we call germ cells, you know, and in the ovary, it's egg, and in the testicles, it becomes sperm. That's our genetic material. Men have the advantage of making their genetic material fresh every day pretty much from puberty till death. Okay? Females are born with all of their eggs. We reach our maximum eggs at five months in utero.

So think about it. You, you, Drew, were inside of your grandmother. You know, half of your DNA was inside of your grandmother. I mean, it's kind of amazing to think about it. That's how far back this goes. So when a female is born, she has about a male. million to two million eggs. Okay? By the time she's 30, she's down to roughly 10% of her egg supply. And by the time she's 40, she's down to 3% of her egg supply. Menopause represents the end

of the amount of genetic material we have available and that we can no longer ovulate because there are no more eggs. That is what the physiology of what menopause actually is. that is represented by less than 1% of our premenopausal estradial, the most important estrogen hormone in our body, less than 1% of our progesterone levels, and about a 50% decrease in our testosterone levels. Because our ovaries, that factory is shut down. Now, we lose the eggs because they're old. They decline. They're aging twice as fast as the rest of our body. And we lose about 11,000 each month trying to ovulate, trying to make that egg.

perimenopause is when, so each month when we're premenopausal, when we're a normal, healthy woman has a regular cycle roughly once a month. Our hormone levels and the stimulating hormone levels look like an EKG. We have rises and falls that are very predictable at certain times of the month and that repeats month after month after month. In perimenopause, because the egg quality and supply is getting so low, the signals in the brain are struggling to get the over to do its job. It takes longer. It takes more hormone to get it done. hormones have to be higher. So we see delays in ovulation and then we see these big surges of estrogen and big drops of estrogen. Progesterone takes a while to catch up and then we don't

have enough. So perimenopause begins the zone of hormonal chaos and that is when the symptoms begin. Postmenopause is no more eggs, no more estrogen, no more progester or no more estrogen, no more progesterone. That's clinic significant and much less testosterone. Let's talk a little bit about the hormones and the breakdown of them and tie that into this sentiment that you hear from so many women as they start to approach menopause, they're in perimenopause, and they're thinking about this and they're saying the same thing. All of a sudden, what was working for me before is no longer working for me anymore. So what's happening in the body that that's taking place and that's the story of so many women that are out there, including yourself?

Most healthy women can develop some type of homeostasis, meaning some kind of balance that they're able to maintain their health, they're outside of injury or illness. They're kind of maintaining their weight, their health, their mental health. Everything's kind of cruising along. Life's throwing them punches. They're dealing with it. Everything's going somewhere in their late 30s to 40s, their resilience starts changing. Now, why is that? Because what I talked about before, we're now entering perimenopause.

your body has estrogen and progesterone and sex hormone receptors in every single organ system, and it is used to working at certain levels in certain times of the month. And now that goes cattywampus. So all of a sudden, you may have mental health changes. We know we have an eightfold increase of depression across the menopause transition. All of a sudden, you're having brain fog. Your executive functioning, cognitive abilities begin to, you can't count on them anymore. all of a sudden our musculoskeletal system is affected we have joint pain estrogen is a powerful

anti-inflammatory hormone all of a sudden we're starting to have ringing in the ears because the way that the crystals form you know in the if i understood this better i'm not e-n-t so i'm um we knock off more crystals in our ear due to the declining estrogen levels all of a sudden we can have vertigo um again with the crystals in the ears all of a sudden we're having palpitations. The vasomotor symptoms can directly affect the sino atrial node and the lack of estrogen can cause inflammation around that node, which controls our heart rate. Our gut changes, our gut microbiome changes, our, you know, our genital urinary system changes. There is not an organ system. Our skin changes. I mean, I can go on and on and on. There is not an organ system that is not affected. So women, I have women all the time who say, I didn't have menopause. I didn't have any

symptoms. We're so used to only addressing the cliche symptoms of hot flashes and night sweats and period, you know, irregularity, though 90% of us will have dysfunctional uterine bleeding in perimenopause that we don't, we aren't taught or trained to be like, when I go, what's your cholesterol? And they're like, oh my God, it's shot up out of nowhere. I didn't change my diet, exercise anything. And all of a sudden, I have this massive increase in my cholesterol levels. I'm like, that's your perimenopause. They're like, yeah, my shoulder, I've got frozen shoulder. I've never had that before. It's not injured. I don't know what's going on, that's your pari menopause.

You know, going back to the frozen shoulder example, and you've shared this on a couple of the podcast, is that you're trying to help people understand that literally there are estrogen receptors all around the body. So even though this is thought of as just, and I'm using this in air quotes over here for the people that are not watching, just a female sex hormone. People are not understanding that really estrogen is in a way the hormone of youthfulness in the body. Is that a fair statement to say? You know, it's the hormone of low inflammation and where a female tends to, you know, if it's balanced with progesterone and enough testosterone, where she functions best. And then that level drops to less than 1%. So you can

absolutely be healthy without estrogen in your body, but it is a lot harder. You know, going back to that example, and we've done a few masterclasses on the topic of visceral fat, and again, primarily for its link to all sorts of chronic diseases and why we want to catch it early, how there's new advanced ways to be able to measure the visceral fat, things like MRI and other things like that. But one of the things that I did not know until I started following your content, and you've done a whole, you know, ebook on this topic. We'll make sure to link to it in the show notes below.

You have a whole series on Instagram that you've done a series of stories on this. So one of the things that I learned from your content is that for women who are going through this period of their life, they're going to this perimenopause period, their body's changing. And as the hormones are changing, they can see a massive uptick in visceral fat independent of other aspects that are there. So that there is this link. and why you're highlighting this as being so important for people to pay attention to, is that

so much of the advice as you've shared you've given to patients in the past too is, you know, eat less and exercise more is not keeping into consideration these shifts that are taking place hormonally. Can you expand upon that? Sure. So a woman premenopausal, so no changes in hormone levels yet. On average, has about 8% visceral fat. Okay, and that's pretty much a healthy level. We have to have some because it keeps the vessels from collapsing on each other in our momentum, right? When she goes through the menopause transition, that can triple. So we see 24, sometimes 30% visceral fat with no changes, no identifiable changes in diet and exercise. This is because the estrogen loss leads to

increasing inflammation, increasing insulin resistance. And as those insulin levels rise, we start getting a more pro-inflammatory state and driving more fat to the abdomen. So you end up in this vicious cycle. You're aging. That contributes, absolutely. But more than aging, your estrogen declines or your healthy sex hormones decline that are helping to keep you healthy, and which is increasing inflammation, increasing your blood sugar levels, increasing your insulin levels, which are then all of those things together are causing more fat to be deposited around the internal abdominal organs. And just having that fat creates more cytoklines. It's a very metabolically active fat, much more than subcutaneous fat. And it leads to increasing inflammation.

So really, you're just, it's really, really hard, you know, for a patient to like, what, what have I done wrong? So cosmetically, they see that their abdomen's expanding and that's concerning to them, and it should be. But more than just cosmetic curves, this fat represents something that is, is dangerous. And take that and extrapolate it a little bit further. If one continues, if a woman in this situation, without getting, you know, treatment, without getting attention, we're going to get into your protocol, your recommendation, questions that people should be asking their doctor a little bit later on in the episode.

But if that goes unattended and it continues to build up, what is the implication going back to the beginning of the podcast that women? are living longer, but in many ways they're living sicker than men, right? So what does that turn into? The higher the visceral fat, the more likely you are to have cardiovascular disease. So it increases all of the risk factors for cardiovascular disease and death from cardiovascular disease. You're also having increased risk of stroke and increased risk of diabetes and all metabolic disease, you know, all diseases that are metabolically linked. Now, when you were going through this research yourself, going back to your story, and you're learning about this. And you're talking

with the team at the hospital that you're at. And you're scratching your head. And I think you even mentioned before, like, asking yourself, like, why didn't anybody tell me about this? What were some of the answers that came to you genuinely of like, why weren't you being told about this? How come this wasn't part of your own education process? I don't think that medicine is up to speed on the clinical impact, the true clinical impact of menopause on females. They know it happens, right? But I don't think they realize how it accelerates our path to certain disease states

and that we can actually intervene, not just with hormone therapy, but with, you know, things specific to women that work in women so that we can decrease her risk of disease and she can improve her health span, not just her lifespan. You mentioned at the beginning of the podcast that when you would treat these patients that would come in, that you would generally be referring them to other individuals. You'd be sending them to other experts out there. And occasionally you'd bring up the topic of hormone replacement therapy with a big caveat that, hey, this probably won't work for everyone.

And maybe even for some people, it's going to be a little bit of the. roll of the dice of whether or not it's going to increase their risk of breast cancer. Let's talk about that for a second. There was a well-intentioned, very large study that happened many years ago that contributed to this idea. And this idea is still out there. A lot of women have avoided the topic of hormone replacement because there's still a sense that, hey, does this increase my risk?

risk of breast cancer. Let's talk about this study. Yeah, the fear of breast cancer is driving the majority of health care decisions for women at my age and older without any consideration of any other body part. And this is due to, so up until 2002, so that study was the Women's Health Initiative, the WHOH, it was National Institutes of Health. A.I.H. You know, finally we were going to study women. and they had a female director for the first time. Finally, you know, we knew from observational and anecdotal evidence that women who were on hormone therapy had lower cardiovascular disease. We knew this.

And lower death from cardiovascular disease and lower all-cause mortality, meaning death from any cause, versus women who were not. And so the study was designed to see, because that's observational. That's not proof in medicine. Proof is a randomized controlled study with a placebo, with equal groups of people, them monitoring them for disease improvement or not. So the WHOHI was designed to see if, if hormon therapy really, really did help decrease the risk of cardiovascular disease. And it wasn't some artifact, right, from healthier, wealthier patients being able to afford hormone therapy and

beyond it and whatever. But here was one flaw. They, because they were looking for heart disease and women don't get that until they're older and is very expensive to run these studies, the average age of the woman in the study was 62 years old. They excluded women with flashes. So that's 85% of the population. They excluded women with hot flashes because they would know if they were on placebo or not because their hot flashes would stop. So, and the women with flashes, you know, so that was two things. So they start the study and they have two arms. Women who have a hysterectomy, and so they get estrogen only or placebo. And then women who still have a uterus and they got estrogen and a progestogen plus and then placebo group. And they took

offering. They had women as old as 79 or 77 in the study, much older patients than we would usually consider starting hormone therapy. And they did have some in their 50s. They saw in the estrogen and progestogen arm what they thought at the time was an increased risk of breast cancer. They called a press conference at Watergate Hotel in Washington, D.C., they made a very elaborate announcement that estrogen causes breast cancer. And for that group of patients, it's an average age 63, it did not appear to decrease their risk of cardiovascular disease. And we've known for a while that older patients have a slightly increased risk of stroke with oral estrogen. So they didn't talk about the decreasing colorectal cancer or anything like that. So the study gets called off. They

kept the estrogen-only arm on for a while, and then they stopped that one because of the increased risk of stroke. So that one study and that announcement saying women will die for breast cancer if they take hormone therapy, that was the headlines. And what it actually was, there's a difference between relative risk and absolute risk. So relative risk is a statistical risk, you know, if your listeners don't understand this, that looks at populations. And so it basically was four out of a thousand was placebo and it went to five out of a thousand. the number's not exactly right for estrogen plus progesterum. So that is a 25% increased risk, okay? And, but that's relative risk. The absolute risk for a human being to take the estrogen, it was a 0.8% risk per year. And no increased risk in the first five years of therapy.

And so that's kind of what got misreported. You know, it was kind of the first viral misinformation thing in my mind. But that's what I remember. doctors weren't even allowed to review the study. They did this before the paper was actually published. And so the damage was done. 80% of women saw the headline, saw it was the number one news story in 2002. Stop their Mormon therapy. Through it in the trash.

I'm going to get breast cancer. And every woman who got breast cancer after that in the U.S., who had ever been, you know, had slept in a room close to a box of hormone therapy, was told that caused your, I'm being facetious. That caught, you know, so there was all of this talk, talk, talk, talk. that disrupted the health of women for the next generation. That was the year of the last year of my training. And I was terrified, terrified to prescribe hormone therapy.

Like I was doing something wrong. I couldn't convince her otherwise to do it. Now they've stratified the study. If you start hormone therapy within the first 10 years of your menopause, you have a 50% decrease risk of cardiovascular disease per year. Okay. the risk of breast cancer is statistical at best and not for the estrogen-only arm. You know, estrogen fees a breast cancer.

It's not carcinogenic. The highest of woman's estrogen levels ever are in pregnancy, and it's the extreme rarity that a patient will develop breast cancer during her pregnancy. So that's not the conversation. And all of the protective benefits of estrogen, it will always protect your bones. It will always protect your general urinary system. If you take it within five years, your menopause, you're going to have a decrease risk of dementia and Alzheimer's.

So we have a window of opportunity for protection from certain diseases, and we need to start having this conversation now. This episode is brought to you by Aquitru. I've talked to so many experts about the importance of clean water as a foundation for great help. And this makes total sense because our bodies are mostly made up of water. So if we don't get enough, they literally, our cells literally can't function right. But tap water is no longer an option.

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You know, we're incredibly thankful for therapeutics like hormone replacement therapy. And, you know, we'll get into some of the nuances. Not everyone's a good fit, but what you're really highlighting and what you and many other contemporaries of yours are saying is that. that a lot more, and probably even most women could benefit from it if it was applied at the right time and stage. That's not to say that lifestyle interventions are not of the most important, too. Those are very important. We're going to get to them as well. So we're so thankful for modern medicine and things like that. But zoom out a little bit more. Is this the way that things

have always been for women? Are there unique things that are going on in our world? the way that we live today, the environment that we're surrounded with that are contributing to a situation where both perimenopause and menopause are now, if we just look around, a very extremely tough time for many women that are out there. Has it always been this way? So I think that, you know, when we look at kind of how we got where we are today and why, you know, we have what's going on in society, how we view and judge aging women. what responsibilities we're taking on as females, you know, in this kind of age group. We are taking care of aging parents who, you know, who are not doing well.

We are also still raising children. We are 50% divorce rate. You know, more women are entering the workforce and all of those responsibilities. So we can't negate the societal pressure that a woman's going through. But, you know, what my patients are telling me is that, you know what, I had it all handle. It suck. You know, it's hard. I have a lot of things in my life, but I was managing and now I can't.

And so I think the rugs getting pulled out from women who were otherwise productive and, you know, dealing with all of these things at this point of our lives and then go into their doctor. Look, something's not right. And the sad thing is because of the lack of education and awareness in the health care system is they're getting sidelined and dismissed and gaslit and told it's all in your head or, you know, or this is just part of aging. and just get over it. You're lucky to be alive. I want to come back to your story. As I mentioned in the beginning, we were going to jump around a little bit. Part of this and a huge part of this is, of course, raising awareness and helping women who previously felt that they didn't have community, that they didn't feel understood, that they were being

gaslit, that, hey, you're not alone. And so many women are also in the same boat. And it's time that society stops ignoring you. Right. So that's a huge part of this conversation here is the educational piece. Now, going back to your story is that after the education started to come in, you started to peel back the layers of the onion to see that there were many things in your control that could be supportive and helpful and not leave you in a place where the accumulation of visceral fat year over year in particular, but many other challenges, terrible sleep, pain in different parts of the body. you know, massive changes for the worst in the gut microbiome, that these things didn't have to be

completely inevitable. What did you start to see and what did you start to unpack as you started digging down that rabbit hole? So I started to realize that your best health in menopause is a kind of synergistic toolkit. And my first focus was visceral fat. I knew that this is a new thing. It's very specific to the menopause transition. You know, we just see this dramatic increase. And what studies have been done that have shown this is going to work for women or women who have these habits are going to naturally have less visceral fat. So that the, you know, biggest first foremost is nutrition and fiber. So, and I was like, fiber, I've never tracked five.

I counted calories. I don't know fiber. Women who consistently get 25 grams or more of fiber in their diet per day have less visceral. fat, which leads to less inflammation, which leads to lower blood sugar, which leads to, you know, fiber feeds the gut microbiome, moves the stool through quicker, decreases the rate of glucose absorption into the bloodstream. I mean, it works in so many different ways. And I was like, huh, okay, let me start talking to my patients about this, talking about it

on social media. Added sugars, I know through the keto movement, good and bad, that a lot of, there's a lot of demonization of sugars. Well, it turns out when you look at the nitty-gritty data, it's not sugars as much as added sugars. The sugar's added in cooking and processing. And so people who were kind of leaving fruits and vegetables behind are scared of them because they lost weight on keto, you know, we're really worried. I'm like, listen, those sugars are packaged around fiber and vitamins and minerals and nutrients. You know, a handful of berries is very different than a handful of candy, you know, even though they may have the same amount of cars.

And so, you know, looking at things nutritionally. So women who have less than 25 grams of added sugars in their diet per day have less fissural fat, have less inflammation, you know, all that stuff is measurable. Movement. So this goes across the board. But, you know, most women in my generation are pretty good about cardio. I was a cardio person. I, you know, I worked out to be thin.

And I equated my thinness with my health. even as a physician, and that is such a mistake, and that is a conversation I have with my daughters, my patients, anyone who will listen to me is strong over skinny. You know, we move our bodies to be strong. We do cardio for strong hearts. There needs to be a point, you know, but where we're failing, our generation is resistance training. I didn't pick up weight so I was in my 40s, not seriously, you know, and I am now doing progressive load weight training. I have a person helping me so I don't hurt myself, but my muscle mass is going to determine my resistance to frailty as I age. It's going to determine my resistance to insulin, you know, as I age. And so helping to reframe that for my patients

and my followers has been just key. That's incredible. I want to unpack some of the ones that you've shared, and then I have a couple questions on some other categories that are there, too. So fiber, you mentioned that women that have, I believe you said, 25 grams of fiber. or more a day are going to see less visceral fat based on the research that you had come across, just to contextualize that, depending on the age group, because it's different for different age groups that are there. But in America right now, I think that the average, although there's no average, but there's different subgroups that are there, but the closest that we could get to the average from what I've seen that's been shared is that many people are having less than

10 grams of fiber. And some people, I think it's the lower 30% of the population. And I'll fact-check this and put it inside the show notes afterwards. If I misspoke, my apologies, but it's a lower percentage of the population that's having less than five grams of fiber a day, which is kind of crazy. Like five grams is not a lot of fiber better there. Living in a food desert is tough. And having access to fiber-rich foods, which often have to be fresh or prepared from scratch, is really difficult when you're forced to rely on processed foods due to convenience or whatever, it really, really is difficult to get that amount of fiber in your diet for day. Yeah.

Is there a component of sort of naturally people hear about how protective something like fiber could be? And that's the one thing that they hear and they start running with it. Is there sort of a dose dependency here that you recommend to people that, you know, we just want to make sure we're getting good and adequate. amount of fiber that's there. It's not that we're asking people to necessarily get up to like a hundred grams of fiber. No, no. So there, when there was a recent study that came out that looked at fiber intake and cognition scores, and this is in patients in their 60s and 70s, and the people who had the highest amount of fiber up to about 32, 35 for women, it kind of tapped out, the benefit

tapped out there. So, you know, men started, like for us, it's 25 for females, males, it's You guys are bigger, you need more. I don't read a lot of studies done on men, just because that's not my jam. But I did cross that data. So in the cognition studies, it did tap out for females at about 35 grams. They were reaching their maximum benefit for cognition. Fantastic. So you talked about strength training and part of strength training and part of this conversation here is also the question about protein.

And a lot of people, women included, were under-eating, as we're starting to understand and sort of pull from a lot of the new research that's out there, under-eating on protein and protein being an important part of the muscle synthesis aspect of our life and avoiding that frailty that unfortunately becomes inevitable for people who are under-eating, not working out. And then, of course, dealing with all these untreated issues when it comes to perimenopause, menopause, event. eventually. Is focusing on getting high quality protein a part of your protocol and program? Yes. So I have a body scanner. I have an electrical impedance scanner in my office. You know, DECS is probably, you know, MRI would be gold standard. I can't afford that for my patients. But, and the DX is the next best thing. Again, huge machine, very, very expensive. So this was the next best thing that I could afford from my office. And it's pretty good. And so I'm able to sit down and have a conversation around muscle mass and visceral fat with my patients to kind of guide, you know,

I give them nutritional goals based on that. But, you know, not to completely malign the women's health initiative. They followed those women for a long time, and we've got some really good data coming from that. One of the best things is they looked at frailty scores and protein intake in the women. And so the ones who had, so this is kilograms, this is in metrics. So the women who weight 1.5 to 1.7 grams of protein for every kilogram of her lean or ideal body mass had the lowest frailty scores, regardless of how much she looked out. And I thought that was huge because the FDA only recommends 0.8. I mean, that's enough to only keep you out of a severe quasi-oricorek or a deficiency stage. And so, but if you want a maximum, so when I'm talking to

patients, and I know that Gabrielle, Dr. Lyon, G. recommends two, you know, so I'm like, my most of my patients are coming in at 0.6 to 0.7.8 maybe when they hit the door because they've been dieting to be thin and they're frustrated and everything. I'm like, listen, this protein is going to be critical to you. And let's make our nutrition protein centric. Let's start with the protein goal. We're going to fill in our carbohydrates, our healthy carbs, and our healthy fats around that. But let's focus on protein and start doing some resistance training. And let's see what's going to happen with this muscle mass that you have, especially when they're coming in already, sarcopenic, you know, and showing signs of frailty. We're having a very direct conversation

around that. Fantastic. So we've got the exercise piece. We've gotten, you know, the fiber piece, which is a core pillar of something that you talk about. You've talked about protein a little bit. You also are helping a lot of your community, which is a very challenging thing because it's a little bit of chicken and egg situation. You're helping your community and the people that listen to you talk about the importance of prioritizing sleep and removing things that disrupt sleep quality. It's so challenging because a lot of women, I know my mother went through this. I know my older sister is going through this. You met at South by Southwest. Shout out to my older sister Herschel, who helps me with the podcast. They start to notice in this perimenopause period of their life

that their sleep quality starts to go down. And the same way that they were sleeping before, the same things that were making them feel recovered and feeling great the next. day, all of a sudden that routine doesn't work. So it's a little bit tough. You both want people to put emphasis on sleep, but you're also recommending them potential tools, tips, and mindset recommendations to help them with the struggling and the changing dynamic of their sleep. Can you chat about that? So the hormonal disruptions are huge for the majority of women. Sleep disruption is, now the sleep disruption could be hot flashes or waking. up, night sweats are waking you up, like the temperature of dysregulation. That's a big part of it.

But some women never have a hot flash and just wake up at 3.30 in the morning. So we begin the discussion around sleep hygiene, you know, are you cooling the room down enough at night? Are your partner snoring? Are you being, you know, having to get up to go to the bathroom? Like, we're trying to remove those obstacles that are waking her up. Alcohol is really sleep disruptive, especially for those of us, you know, the vast majority of us, you know, the vast majority of there's new research emerging on this, but it seems that we're not processing alcohol quite the same as we used to, and we're having different, you know, and so in my life, and with a lot of my patients, not all, if we choose to drink at night, you know, we have wine at dinner, and for

some it's one, two glasses, whatever, but there's this new limit that gets set. I can't have one glass of wine without knowing I'm going to wake up at 3 o'clock in the morning and maybe not be able to go back to sleep. So for me, it's a choice. I'm choosing to drink, or am I to sleep. And so framing it in that way has really helped me. Another thing I want your listeners to understand is sleep apnea is a much bigger problem than we realize in women because we don't snore as much. And our sleep apnea looks very, very different. So if you've done all the work and you're on hormone therapy and you're not getting up to pee, you're just really getting these gasping wakeups in the middle of the night, you're not having racing thoughts or anxiety,

you need a sleep study because you may have undiagnosed sleep apnea and this is very important because this needs to be addressed because sleep apnea leads to other health consequences that need to be addressed immediately. That's fantastic. And one of the best advancements that's happened in the last like five years, there's all these sleep study devices that your doctor can send you home with, right? And you don't have to go into a clinic and you can start to get a really good idea. generally, if you had to categorize some of the main root issues that are causing sleep apnea in women, who typically is not your standard sort of patient, that's a guy who's very overweight, who's snoring, as you had mentioned, what are some of the most common things that you've seen

out there with your friends or patients or other things that are at the root issue that's causing sleep apnea for them? So most women with sleep apnea are not morbidly obese. so we can't, and they're not having tremendous snoring. You know, mostly batmia is the architecture of where they process airflow is changing. And for whatever reason, we're seeing expansion in that palatal area without having obesity. And it's just another example in medicine how we are not little men and the same, you know, we suffer from the same diseases just in a different way. And medicine is just really struggling to keep up with all these new realization.

It's fantastic. Yeah, I know James Nestor in his book talks a little bit about the changing of the jaw structure and how that's led to some of the constriction and the constriction in the airways. But I digress. Coming back to the sleep topic, I literally before this interview, because I was checking out some of your content, there's starting to be a viral clip. And it's you talking on the Mel Robinson podcast. And it just the way you said it, and you said it here earlier, but I just want to pinpoint it because it was so great. You said, when I'm choosing to drink, I'm making a conscious decision that I'm not going to sleep well that night. And the comments on there are gangbusters. I'm sure you and your team have seen it. The way you said it, how you said it, it just resonated for so many people. It's like, wow, thank you so much. And I think there's a few layers. If I had to sort of embody some of the women that were commenting on there, number one, thank you for not lying to us about just how crucial, you know, sleep is, number one, right? Because so many people are feeling it.

Number two, thank you for being honest about the implications of alcohol and how it impacts sleep. And number three, thank you for also saying that, like, there might be a time in your life that you do choose to make that choice, but don't act like it's not making an impact on your body and on your life. So I just wanted to highlight that for a second. Yeah. I mean, I still drink on occasion, but I'm drinking less.

and it's probably helping in a lot of other people, too. And, but, you know, wearing, I do wear a sleep tracking device and try not to be obsessive about it. But, you know, it's really made me more cognizant about what these changes are with my, you know, my resting heart rate goes up and I don't sleep as deeply. And I'm up at three in the morning. One last item with sleep here that I just want to touch on. Everybody by now has heard about how blue light impacts us. but I just want to talk a little bit more about the emotional addiction that we all have with our phones.

And when we're watching stimulating content, especially closer to bedtime, when we're on our devices, have you seen that those things impact sleep quality? Absolutely. You know, I've read the studies. Of course, this pattern of behavior is within this last five, ten years, really since COVID, that we're seeing the scrolling, scrolling, scrolling. And so I'm telling my patients, you'll know if it's a problem because you'll find yourself on your phone. You know, I had to take my, I used to read on my Kindle, which was on my phone. And then the notifications pop up and everything.

It's like getting a separate device to read your book if you're going to read on electronic device. You know, what are we go? My, the whole, Kim Holderness was selling, she puts her phone in the bathroom to charge, you know. And for years, I had a job that disrupted my sleep because I was an obstetrician. and I work shift work at the hospital. And so, you know, that really took years off of my life. And I knew it. And I knew my gift to myself at 50 was to leave obstetrics behind to just focus on

gynecology and then menopause care. Then I'm like, I'm shooting myself in the foot. I did all this so I could sleep. And now I'm cheating my good sleep by playing on my phone, you know. And so, you know, having to learn to have the discipline to put that away and find other ways. I do like to read before that. So finding a different way either.

It's just I don't like to read with the book because the light and my husband is trying to sleep. So having a backlit kindle or something that's separate has been helpful. I want to come to the topic of stress and obviously sleep and stress are so deeply connected. But part of what I've heard you and some of your contemporaries in the space who have been on this podcast talk about is that women need to understand their sort of unique relationship with stress. Stress impacts everybody, right? And maybe you disagree with this comment. So I'll put it out there. But what I've heard, some of the people that I feel like you follow and are sympathetic

on your world is that stress when in its relationship with women and their relationship with stress is that their bodies are designed to actually feel more on purpose. Like the world is going to be more impactful to them in a good way. And that is something unique that if there's not a recovery process, There's not mindfulness. Men are the type that they'll feel stress all the time too, but then they'll ignore going to the doctor. They'll never deal with it. They'll shove it down.

And then one day they'll just have a heart attack at the gym and die, unfortunately. But women are meant to feel, not meant to. I don't want to get out of that. But women feel stress more than men. I don't know if that's true or accurate or how you feel about it. But let's talk about women and stress. Well, the female brain is definitely different than the male brain. And we process things differently.

And that's okay. And so I think most women are recognizing and, you know, society is socializing us that we are allowed to address our stress and try to do things to counteract it. Whereas you need to be a tough guy, you know, it's the emotional woman and the tough man, you know, kind of way that most societies kind of bring us up. But what I find is women are prior. No, they know they need to do it, but they're not doing it. And so, you know, myself, I really kind of hit this really critical point where I was menopausal and had a teenage daughter and, you know, my brother had died and like, I just got to the point where I could not function anymore and I was having to divorce or whatever.

And so I finally got therapy. It took that much. And, you know, my 23-year-old gets therapy just because, just in case, like, just wants to have it on backup. So in case she ever needs it. Like, that's the different mindset of this generation. And so I learned about mindfulness and journaling and, you know, things that will work for me. And so what I tell my patience is what work for me may not work for you, but you need to find the time and prioritize yourself to put your own oxygen mask on first. Because who is going to take care of you when you break?

Do you want your children to leave their jobs and their homes and their marriages to come home and take care of you or you move into their house and disrupt their life? So if you're not able to get this under control and figure out ways to balance, we can't stop the stress coming at us, but how we react to it has to change. That is going to contribute to you not, you know, breaking early. So it all, you know, it's all part of the synergistic thing of if we don't address how our body reacts to the stresses in our lives and how we manage that, that's going to, you're going to end up in the nursing home sooner. Well said. And I just want to say, you know, my audience who knows me well knows that if I sounded like I was fumbling on that last question, I probably was. I was trying to figure out the right way to ask it. But really the larger context of it is going back to this thing that you said earlier is that women are not little men. And as, you know, contemporary viewers and a friend, I think Dr. Lisa Moscone says, we cannot be practicing bikini medicine. We have to be treating men and women differently for their unique biological needs. Of course, stress impacts. everyone. We want to mitigate it. We want to reduce the amount of stress that's there. And there's this component where we're going to have to contextualize it. Of course, based on people, every person

is different just because somebody's one gender and somebody's another, there's going to be differences that are there. But largely because women's health has not gotten the attention that it's deserved, they've gotten ushered into this thing of, well, we're just going to treat them as little men, as you've mentioned. We were excluded from studies from 1983 to like 96 because we had hormones. And they didn't want to disrupt them. I mean, it came out of the thalidomide study where there were some birth defects. They were horrific. And so that scared everyone. So they said no one of reproductive age could be in a study just in case we would have this thing happen again. I think that was a very reactive response to something terrible that happened. But what it did is it left females out

of studies, clinical studies, for a significant period of time. So most of the cardiovascular drugs that are on the market now, all of that was really never tested significantly in women. And one of the most shocking examples of this that I can tell you is, you know, we all know that women present differently than men with heart attacks. It takes longer for them to get diagnosed in the ER and all those things. So when a woman has high cholesterol, she is routinely recommended a statin today. Okay. When you go back and look at the cardiovascular literature, and this is published in the American Heart Association Circulation Magazine, there is not a single study that shows a benefit to women to take a statin to prevent a heart attack or death from a heart attack primary.

Okay, they're a secondary. But we recommend it all the time. Turns out, biolacid sequestrants might be a little bit better. We have other options, but they are automatically put on a statin, even though it's never been shown to protect her. You know what protects her? Hormone therapy, if given when she's young enough. Much more than a statin to protect her from a heart attack. When I heard you first share that example, I had never heard of that.

And I just thought, wow, this is crazy that even somebody like me who's not a clinician, not a researcher, but I consider myself a health, I consider myself a professional amateur. You know, I think about health a lot. I get to interview incredible experts like yourself. I'm reading books all the time. And I had not heard that. And it just made me think, oh, my gosh, what the hell else have we all not heard? Which is obviously why we're so excited to have you on the podcast today. You know, I want to pause for a second on the protocol. We're going to come back to because we still have a few other areas that we want to cover, including some of the ways that supplementation can be benefited. on top of all the lifestyle recommendations that you had. And I want to go to this story that I

heard you tell. And it was the idea of a WW. And let's talk about that. What's a WW? And tell us and tell us audience this story. So when I was in my training program, so I'm done with medical school and I'm a brand new intern and I've got my long white coat for the first time. And we're doing our gynecology rotation. So we have multiple years of training. Okay, and it's very high up a fourth, third, second. So I'm a first year. So we get to gynecology clinic, and this is back when we had paper charts. And so there's stacks of charts and the upper levels, the fourth and third years, run to the charts and they start pulling the surgery cases. They want to operate. They have to get numbers. They're cowboys. They love to, you know, break and fix things. And that leaves everybody else

left for us, the interns. And so one of these long, tall cowboy, you know, boot wearing, Great guy, but he said, hey. And he looked at the chart and he said, you got a WW in room 13. Good luck with that. And I was like, so one of my coworkers said, that's a whiny woman, a whiny woman. And basically, I didn't know what that meant. And I just thought women were whiny. I mean, for my entire life, most of my medical training, that women, and that was kind of like beat into us from the medical

system. No one wrote it in the chart. No professor ever said that to me. It was just this kind of lore that was passed down that women get to a certain age. They have multiple vague complaints. It's just this time in their lives. Just pat her on the knee and tell her it's going to be okay. And this is normal. And it's like headaches and weight gain and not sleeping well. And she's a little bit depressed. And it, you know, and it took me like reading through. And one day I'm sitting at my desk writing the new book. And I was like, oh my God. Like, I, that was menopause. Like, that was very menopause. And it took me years to get that out of my head. I mean, to this day, when I have a patient with multiple vague complaints, I have to pull myself back.

And like, mantra, believe her, believe her, believe her, don't automatically dismiss, you know, no matter how complicated or confusing or dramatic she seems, this is a real person with real complaints. And so, and if she was Caucasian, it was a W. WW, a whiny white woman. So I asked other docs across the U.S. So they're called whiny-guinies in other area. I mean, it's a thing. So in my generation. Now, my daughter would never stand for that. She was raised very differently than I was. She is, you know, she's a first-year medical student, which is why I say, you know, and this upcoming generation of new physicians is not going to ever stand for that kind of stuff. But I was, I had imposter syndrome. I didn't know any, but I'm so embarrassed to even tell the story, but I think it's important because it explains and as, as shocking as it is

and as horrible as it makes me feel, I want people to understand where we came from and, and what we have to undo in order to get women to be believed and listened to and treat it appropriately. Yeah, when I heard that story, there was a few layers that I took away from it. Number one, I always appreciate the honesty because you're simply describing what was going on. And if you look at some of those layers that were there, one of the layers were from the outside, from a doctor's perspective, it did look like these women might be whining because in a way the doctor was not educated about just how much of a change was going on in a woman's life and all the underlining physiological components that were contributing to it. So it's easier to say, hey,

it's all in this patient's head because nobody ever told me. And I've gone through medical school, you know, these doctors saying both men and women, of course. So the easiest thing is to say, this is in this person's head because nobody has told us, you know, otherwise. And, you know, we were never taught how to connect the dots of these. So what's happening today is women and I was I was a terrible menopause provider, total honesty for probably 15 years. You, okay, you've got headaches. let's go see neurology. Oh, you've got palpitations. Let's go see cardiology. Oh, you've got, and we just weren't taught that all of these things together. Rule out the big stuff. But then let's talk about menopause and give her a trial of therapy before we go down this wild goose chase

and spend tens of thousands, millions of dollars on workouts she doesn't need. You know, you were talking about all the different ways that the body changes when estrogen and the loss of estrogen takes place. One of the ones that actually, again, another thing that I learned from you that blew my mind. You talked about the loss of estrogen will change a woman's gut microbiome. What did you find out about that space and what are some of the implications of that change? So the Zoe predict study, which is still ongoing, they were really the first ones where they had been following women and following the gut and getting stool samples and trapped women from pre through Perry and post and saw that the gut microbiome approaches that of a

man. And so we have a very female gut microbiome specific, you know, heavier, you know, very diverse, heavier in certain micro-lectivacillus and other, you know, specific microbes. And then it starts shifting and changing through the menopause process to one that is less healthy. You know, we are enjoying a certain amount of health benefit with estrogen and being female until we go through menopause and then we catch up with men and pass them up in our health span. You know, on these shifting changes, again, I'm highlighting out. This is not to steal your punchline. I just want to make sure that all the punchlines that I took away from all your content,

your incredible Instagram, which if everybody's not following you, please make sure you follow. I have the link in the show notes below. You have great content on there. But, okay, another thing that I learned is that there's a reason why hot flashes became the defining sort of symptom when it came to menopause. Can you explain that? Because you can't blame it on anything else. So there's nothing else that causes hot flashes except for maybe tuberculosis or really high

fever. And you can rule that stuff out quickly. And so, and 85% of women will have them. they'll have them in menopause. So it became the defining, you know, and it became, hormone therapy was developed to stop a hot flash, the dosages, whatever, it was not developed to stop a heart attack. It was not developed to keep your bones strong. It was developed to stop vasomotor symptoms, which are not the only medical indication for, you know, and so it's just fascinating to me that immediately a physician, if they don't know better, will dismiss

nine out of ten of her changes as something else, something different are all in her head, but hot flashes you can zoom in on. Before we get into some of the nuances of hormone replacement therapy, I want to talk about the topic of supplementation. And supplementation can be one of those things that can help people bridge the gap, and you're very clear on your end, that it's on top of all these incredible lifestyle recommendations, nutrition, movement, stress modulation and recovery, emphasis on recovery, and sleep is a big part of that as well too. So you have to have those basics that are there, community, if we want to add

that in as well, community and love. So what do people need to know about supplements, especially for those that are in menopause or on their way to menopause in that perimenopause period? So to date, there is no magical cure for menopause. No supplement is going to increase. your estrogen levels. That's, and if anyone's making that claim, that's a red flag. Okay. However, you can support your body through this change with the loss of estrogen. And people who have healthier diets, healthy, you know, healthy lifestyle tend to have less classic symptoms of menopause. And one of the things, so when I talk about supplementation, I'm like, what are menopausal women most likely deficient in? Let's start there. And so they're most likely going to be deficient

in fiber. So I have them track their fiber intake and if they're consistently falling short and they cannot hit it with food through, you know, they're allergic or whatever reason, then we talk about supplement. I really, really push for them to get to 25 on their own and then go ahead and supplement that last 10 to 8 grams with a fiber supplement. Number two is 85% of my patients are deficient in vitamin D and that's pretty consistent. We have a huge vitamin D not just low. I mean deficiency in the U.S. I try to get my patients above 60. Their blood levels consistently above 60. And so most people are going to need a supplement to do that.

Why is that? Because we're protecting our skin rightly so, again, from the sun, from skin damage and skin cancer. And our gut microbiome is changing. It's getting harder and harder to absorb. And most people in the U.S. are not eating vitamin D rich foods. And so, and they're not readily available. You'd have to eat a ton of salmon, a ton of fatty fish, you know, and that is just not something that's on the palate. of most Americans.

So, you know, certainly if you can get those vitamin D levels up naturally, yeah, you. But that's great, but most people can't. So that's one of the big things. I have a few supplements that I recommend for my patients. With that vitamin D, I'm adding K for increased bioavailability. I also throw some of my omega-3 plus D in there, I mean, omega-3, for the anti-inflammatory benefits. So, you know, in my nutrition training courses, you know, my professor was always like,

just try to get something rich in vitamin D in your diet every day. So just try to get something rich in omega-3 in your diet every day. You know, that's your push. So I talk to my patients about that. Now, there are, like, I really like turmeric. So, you know, not used in a lot of in the U.S. for cooking. It's popular in other cultures. It's a really powerful antioxidant, anti-inflammatory, you know, food product.

And so I often recommend, especially if they can't take estrogen, we may want to consider because it's been shown to help someone with hot flashes. It's been shown to decrease visceral fat because of the anti-inflammatory component to it. That's fantastic. I've also heard you talk about the importance of magnesium. Do you want to touch on that for a minute? Yeah. So MAG is one of the minerals that, you know, when we get a blood level, there's fat-soluble vitamins, K-A-D, and E. And those, when we get a blood level, we know that's kind of representing a level they've had over time because it's stored in fat. The others are water soluble. You pee them out every day. So it's possible to have a high mag one day, a low mag the next day, and just a one-time mag level

is rarely diagnostic of a chronic mac deficiency. So I have my patients again, track what they're eating. How much mag are you hitting every day? Remember, FDA, that's to keep you out of deficiency. We're going to try, I try to push my patients to get higher than that. Mad is also medicinal. So meaning at higher doses, it can do things besides replace what's missing. So higher levels of mag can help with calmness, can help with, you know, SSRI resistant depression. People magtherinate, they do really well with that. When people are struggling with sleep, I'm often recommending a magnesium supplement

for that. Fantastic. You know, I want to come back to one more thing that we talked about at the beginning of the podcast. You know, I've heard you share, and you shared earlier, I believe. you said, you know, it's not all calories and you're also not arguing that calories don't matter, right? Is that a fair statement to say that if I understand kind of a view? Of course. Law thermodynamics. I mean, yeah. Yeah, law thermodynamics. Do you, from your

understanding, when a woman's body starts to notice and see this internal major drop in estrogen and the other fluctuations in hormones that are taking place, and they see this redistribution of let's say they start to see this gain and jump in visceral fat, which you talked about earlier. They also do see, again, there's a difference between visceral fat and subcutaneous fat. Women do see, in many instances, some buildup of subcutaneous fat in the body. They notice their clothes may be fitting a little bit differently. Do you think that the primary driver of that is inflammation? and or is there also that these hormonal changes are driving behavior changes that are increasing

the overall consumption of calories? So when the like PhDs have looked at this, leptin and ghrelin change dramatically. So these are the two hormones that control our hunger and our satiety. Two of the big ones that are affected with the GLP1 agonists, right? So they change in a negative way as in your, you feel. you're hungry or sooner and you're full less long, you know, when we lose estrogen. That's going to drive a behavioral change. Now, some people can override that and restrict their caloric intake.

But for most people, it's so subtle and it doesn't take that much of a change to increase your caloric intake. So, but again, this is part of a much bigger picture. And there's so many things that feed into a person's weight. The other thing that we've touched on that is so important is we lose muscle mass through the menopause transition, we peak out at about 30, and then without serious resistance training and protein intake, we are dramatically losing muscle mass through the metapause transition. It accelerates. And so muscle mass is what determines our basal metabolic rate, which determines how many calories

you can have a day without having, you know, without having fat deposited. So all of this is happening at once feeding into each other. Thank you for that breakdown. Thank you for that explanation. You can't talk about body composition shifts, loss of muscle mass, you know, satiety and all these things without me getting a chance to ask you about some of these GLP-1 antagonists that are out there, of course, Ozempic and other things. I see you as being somebody who has their foot in sort of both worlds, just helping, you want to help women. That's your goal, right? That's your goal. That's your mission. So I figured I'd get a very honest answer from you. What are your thoughts on things like

ozempic and these other similar weight loss drugs that are out there. I think they're just another tool in a toolkit. And like any medication, including hormone therapy, I'm having a very direct conversation with my patients about risks, benefits, goals, long-term side effects, you know. And so for some patients, this may be an important tool in their toolkit for their overall health. Do I think it's for everyone? No.

Do I think it's for cosmetic weight loss? No. I think that if a health care provider, and I think it's in the hands of the provider, unfortunately, it's in some hands they're just giving out the medication and not following the patient, not checking her muscle mass. So if I have a patient on a GLP1 agonist, we've had a very long conversation about goals, how are we going to manage this, prioritizing protein, making sure they're going to the gym, like starting those habits before we start the medication to make sure she can maintain them.

and then having her come back every six weeks to check her muscle mass. And that's critical. She understands before she leaves my office that the goal is not to get to a number on the scale. The goal is to maintain as much muscle mass as possible and a 10 to 15% loss, especially most of my obese patients have great muscle mass because they're carrying around a really heavy weighted blanket every day to live their life. And so that means they have extra muscle on board. And as they lose the fat, they will lose some.

of that muscle just because going to the bathroom is less stress, you know, is less work for the muscle. And we talk about weighted vests and ways they can make up for the fat loss to keep their muscle strong. So, you know, I'm a fan. I don't think it's for everyone. I think it's a very intense conversation. It's a very long commitment. And it may be something you have to be on for the rest of your life. Thank you for that. I appreciate the nuances that were covered on all that. So I said we were going to come back to the topic of hormone replacement therapy. Talk about that conversation. You know, as you mentioned, you said, it's going to be helping a lot more women out there than you previously were sort of led to believe earlier on in your practice and career as a physician. And yet still, you've talked about it may not be the right fit for everyone.

So what question should a patient be asking their doctor to navigate that aspect of, you know, hormone replacement therapy and whether or not it's a good fit for them? First of all, you have to find a doctor who's willing to have the conversation with you. And so that's the first barrier is find a doctor who's menopause educated. So one resource is go to the Menopause Society website, which is menopause.org, and look for a certified provider. Okay. Now, there are other providers out there who aren't certified who are fabulous, but how do you find them? So this is one way. You go to their website.

You look for the certified check. That means they took the test to become certified. Call ahead. Talk to the office. Say, listen, I'm coming in to discuss menopause. is this physician going to discuss hormone therapy with me? You know, there's no guarantees. We have resources on our website of my followers have turned in testimonials,

of wonderful clinicians who've helped them. So, you know, we have lots of ways. There's some really wonderful online menopause providers that are doing telemedicine, and that may be another option. But you cannot, sadly, right now, expect to walk into your fabulous OB-GYN's office who delivered your babies and did your surgery and, you know, took care of you to be menopause educated. worth having the conversation with them because a lot of them are realizing, whoa, like me,

I got to get up to speed on this. This is bigger than we thought. And I want to be helpful. Or they just don't have the time. I mean, you're so busy delivering babies and running back and forth to the OR that how it really takes to unpack someone's menopause trauma and get to the bottom ever of everything is becoming a luxury. Yeah.

So step one, finding the right physician. And it's okay to sort of prescreen. I always tell people, you know, it's not. create a pre-screen and have a early appointment with somebody with any kind of physician that you might be working with and see if there's a match, obviously, that's one component, but also does this person have a track record of helping people make the right decisions and choices that will ultimately end up leading for help? Okay, so now somebody has a doctor that's more open-minded, potentially certified in this approach on the menopause.org website. Let's start off with the obvious.

is there, you know, who are typically the archetypes of people and their health situations or unique life circumstances that hormone replacement therapy truly would not be a fit for them? If we're speaking in broad strokes, everybody knowing this isn't a medical appointment here, always talk with your own doctor, but what are the broad strokes for who it's not a fit for? So there are absolute contraindications to almost every medication. So for menopause hormone therapy, so specifically talking about estrogen plus or minus progesterone. We are anyone who has undiagnosed vaginal bleeding, meaning if you have postmenopausal bleeding and it's not been evaluated.

If you have dysfunctional uterine bleeding, like something is off with your periods, this could be malignancy or hyperplasia. We don't want to feed that with hormones. We need to go get that tested evaluated. Most likely it's not that. But so that needs to be evaluated before you start hormone therapy. So any abnormal bleeding, abnormal to you. The second is an active. hormone-sensitive cancer. So if you have active breast cancer, if you have active endometrial

cancer, if you're having active ovarian cancer, you are not a candidate for hormone replacement therapy at this point. Another is if you are in the middle of a blood clot, like if you have an active deep venous thrombosis, at least within, you know, and you're still being treated for those first six months, active DVTs or the first six months of a DVT, you are not going to be a good candidate. Now, after your treatment and everything's settled down, you might be a candidate for a transdermal option of estrogen because it doesn't increase your clotting factors like the oral forms would. If you have severe active liver disease, a lot of estrogen is metabolized in the liver, and if you can't metabolize it, that's a problem. So I'm not talking

about mild fatty liver disease and mild elevated liver functions. I'm talking serious liver disease. You're not going to be a great candidate either. And if you've had a stroke, especially a thrombotic stroke, you also may not be a candidate as well. Great. Fantastic. Thank you for that. The good news is that's not going to be the vast majority. That is still a population set.

That's not going to be the vast majority. Let's talk about the vast majority of people that are there. When individuals are now choosing, and let's say they've decided to go down this pathway, of course, you know, again, I'm starting at the basics here for a lot of people that don't know about these things. And also, too, the men, because every men that's here has a mom, has a woman in their life that they love. has sisters, has cousins, has friends. So the more educated we all are on this topic, the better off the entire world is. How is the doctor sort of determining what is the right makeup of what drugs you'd end up getting when it comes to hormone replacement therapy?

Sure. So we look at estrogens. We look at progestogens and we look at androgens when we're talking about replacing hormones. So the primary hormone and where most of the research is done and the safety profile is done on estrogen. So we'll start there. So estradial is the hormone that your ovaries used to make. So for most of us in my space, what I call the menopausee, we pretty much stick to forms of estradiol because it is most similar to what your, it is what your ovaries used to make, and I'm just trying to give you back the water you used to drink.

I don't really think of hormone therapy as medication as much as just allowing your body to continue some critical processes. you know, metabolic and indignant processes that kept you healthy. And so we have oral and non-oral forms. So they both work great as far as benefits, but oral does seem to carry a slightly increased risk of blood clots, maybe seven or eight out of 10,000 per women, but we can negate that increased risk with a non-oral formulation. So for most of my patients, I start with a transdermal option, usually a patch. I have several straits. They're FDA approved. They're generic They're very affordable, and people can use their insurance to get them.

Now, for progesterone, if you have a uterus, progesterone is mandatory. If you don't have a uterus or you have a marine IUD or a Skylar or a progestin-containing IUD, it's optional. And so we found that progesterone is actually really helpful for sleep, also helpful for nighttime erasing thoughts and anxiety and can be really calming. So for those patients, I'm often recommending oral micronized progesterone. You never want to do a transnormal progesterone. Again, we're going with the body identical type because it's a humongous molecule and it does

not absorb through the skin. So those of your listeners, if anybody's been prescribed progesterone cream, that is probably not your best option. If you're also on estrogen, I would call your provider immediately. You are not protected against endometrial cancer with that. Testosterone's a little different. We don't have an FDA. approved option for testosterone for women. There are men's, of course, available. So if you are in a

state where it's easier to get the T-STEM or the gel in the men's option and your insurance will cover it and the pharmacist will actually prescribe it for you, they don't know. In Texas, it's tough. Nobody likes to get involved in women's health care more than a Texas state legislator than a Texas state pharmacist. They like to put up a fuss for things. So To get around that, I, you know, because it's not made for women and they're very uncomfortable describing it, I will often do a compounding option of a cream, which absorbs very well through the skin and is very safe. Fantastic.

You know, last item that I want to, you know, touch back to on this topic of hormone replacement therapy is that really when you intervene and the age is a big part of this conversation that's here. Just retouch on that topic, you know, in the context of us talking about it as an intervention. So as far as long-term protective health benefits, we have to look at things a little differently instead of how old, how young. It's your time away from estrogen where the disease processes accelerate and start. We don't, the way I explain these patients, we don't want to put estrogen on top of cardiovascular disease, pre-existing cardiovascular disease. You don't want to

put estrogen on top of a stroke or a vascular issue in your head, you know, or dementia. You know, if you're already having plaques or vascular dementia, you don't want to give a patient. in estrogen for that. It's better at prevention than cure. And so the younger you start, the closer to your natural menopause or even in perimenopause, the better your outcomes are going to be for all of these disease states. And so when we reach maybe around 60 or 10 years from natural menopause, we start losing the cardiovascular benefit of protection. It doesn't mean it's not safe. It just means I can't tell a patient, I can decrease your risk of cardiovascular disease at this point. What I'm also doing is getting a full lipid profile with an APOB, with an LP little A,

maybe out ordering a calcium cardiac score so we can make sure that there's no calcifications in her carotid artery, you know, in her arteries around her heart, or to carotid so that, you know, that makes me feel better that we're not, you know, potentially increasing risk there. So. But so if a woman's been on. on hormone therapy and done well and has not developed any of these diseases, I will continue her hormone therapy as long as she wants. So I might die with an estrogen aisle patch on. I'll be lucky if I, you know, if I don't develop a contraindication, I have no intention of taking estrogen out of my life. I want to live in long, healthy life, and this is part of it.

In addition to some of the protective benefits, the improvement in sleep, are there any case studies of patients, stories of people that you've worked? work with where this before and after idea of what their life was like, of course, with all the foundational, you know, lifestyle things that we're talking about here, you know, you're not just throwing medication out of this situation. You're really restoring the body's natural access to the hormones that it previously had. Are there any stories that come to mind or examples that you might want to share with our audience? So yesterday I got a package at my office from a patient who came on the menopause cruise with us.

And she, and the package was for my staff, a little tiny sweet gifts. I mean, we don't expect that from our patients. But she wrote this letter that was incredible. And I get these types of letters all the time, every day of her quality of life, how she looked at herself, her body, her future has dramatically changed. It's not about a bikini. It's not about, you know, though that would be nice. This is about her functionality, how she processes relationships.

relationships, how she's functioning at work, you know, her level of stress is down because she's not worried about, you know, her cholesterol being so high anymore. Like, we are seeing improvements across the board. Patients are much healthier. And there is, and I'll tell you this, there is a big fight in the menopause world right now against old school menopause, like researchers and those of us on the front lines. And we are not standing. for it. They're just published in the Lancet, which is a big British medical journal that, you know, the headlines look great. The conversation around menopause has to change, and it was the most misogynistic, paternalistic thing I've ever seen. Basically, at the end of the day, only if she

has severe hot flashes should you give her estrogen. She just needs to suck it up and get over and get on with it and learn how to live without estrogen. And we are putting our foot down on the front line. We have over 300 signatures on this thing. We've written a rebuttal. And this is not what's happening in clinical practice. These women are thriving. They're getting their lives back. They are so happy. All aspects of their health are better. I'm not privy to seeing that fight firsthand, but thank you for telling us about it. And I think I would be, if I didn't ask this at least, you know, to touch on this, because this is where the conversation started. What is still driving that way of doing things? Is it ego? Is it...

These researchers were female. And I think they're just so entrenched and they're not seeing patients. You know, they're just... They're statisticians and, you know, and I think they're just entrenched in their mentality and their research and maybe they had easy menopausos and why are we making such a fuss about this, you know, internalized misogyny. I don't know. It's like those of us who are actually doing menopause care at all ages are like, this

is ridiculous. you're taking options away from women and they're going to be less healthy. Well, chances are, what is that Upton Sinclair quote? You know, you can't get a man to change his idea or a woman in this case. You can't get a man or a woman to change their idea on something if their job depends on them not changing it. And so chances are if you are a senior lead and your name is on this paper that's being published, your entire career has been built on a specific way at looking at things. And it's part of the story, but it's not the whole story because evidence-based medicine, as I've

understood from hanging out with incredible practitioners like yourself, one part of that is traditional clinical research. Another part of that is clinical experience. You're learning something by actually working with the patients, hearing the stories from the front line. And so you cannot look at any one aspect and just say, I see. It's like the old analogy of the blind individuals trying to describe what an elephant is and one's on the trunk and one's on the leg and ones on the tail and they're all describing different things. You are leading a movement of women and the men who love and support them, of course, to say that it does not have to be this way. There's a different way to exist and you're doing it through community and you're doing an incredible job.

One last item on that topic of community. You've shared how it's so important for women to understand that you don't have to suffer in silence. Like, go and start talking about this. Meet other women. Connect other women. Any lasting tips that you want to share on that topic of community and how it's so important, especially for this demographic in population, either in menopause, postmenopausal, or even in perimenopause? You know, so many of my patients now can't tell me.

what their mother's experiences were because they didn't talk about it. Or, you know, these are things we don't talk about in our culture and our family, you know. And their mothers couldn't even tell them when they went through menopause. It just was this fugue state. And that they realized that we have to change. It's time to tell our stories. This is an important part of our story. And if we don't educate the next generation, they're not going to be prepared.

And most of the regret I see in my patients now who are menopausal is that they weren't prepared. They had no idea all these things. They just thought it would be a few hot flashes and they'd missed their period and it would be over. And they had no idea that it could catastrophically affect so many aspects of their life. And that, you know, if they just would have known, they would have been prepared, like known the questions to ask, you know, had this army of information behind them so that they could go in and advocate for themselves. Incredible. Well, one of the ways to begin that process of community is you are bringing an incredible group and people together just through your own books, social media, online experience.

I'd love for you to share Dr. Mary Claire Haver. How can people keep in touch with you? But not only that, be a part of this community that you're building. So we have the poslife.com, which is our website. And we have a community link there where we're sharing stories. and information and tips and free resources there. You can follow me across all social media channels pretty much. I'm, except Twitter.

I'm on, I just never got to that one. But Instagram, Facebook, and TikTok and YouTube are my biggest ones, most active ones. We're just lots of information and videos, and you'll see comments and see other physicians. I'm trying to elevate because they're doing important work as well. Lisa Mosconi, absolutely, is one of them, Gabrielle Lyon. You know, there's so many of the miniverse and the menopausee that we're all fighting together to get to the same thing, which is to get women to their best health for the last third of their lives.

Well, you did it today on this podcast here, and you definitely have made the lives of our audience better. Thank you again for being on the podcast today. And a big shout out to my sister, who was really, your name had come across my desk a few times. I'd even seen one of your pieces of content, but I didn't really, you know, sometimes you don't get how good a TV show is until somebody says, hey, listen, I know you gave it a shot, but let me tell you why you really have to sit down and watch this. And that was my big sister, who I love and adore Herschel, who really, really presented your work in a way where I was like,

oh my gosh, this is like a whole movement. So thank you to my big sister for introducing me to your work at a level that just got me so excited. Well, thanks for having me. It was incredible to share the menopause message with your audience. Hopefully to learn something and be able to be better advocates for themselves. Hi, everyone, Drew here. Two quick things. Number one, thank you so much for listening to this podcast. If you haven't already, subscribe, just hit the subscribe button on your favorite podcast app. And by the way, if you love this episode, it would mean the world to me. And it's the number one thing that you can do to support this podcast is share with a friend, share with a friend who would benefit from listening.

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