Mind Pump: Raw Fitness Truth - 2582: The Strange Signs & Symptoms of Perimenopause With Dr. Mary Claire Haver

Episode Date: April 24, 2025

Strange Signs & Symptoms of Perimenopause with Mary Claire Haver What got her into what she does now? (1:30) The dogma surrounding women’s health. (8:05) What is menopause? Perimenopause? (14:56) The average age of menopause. (21:34) How much does birth control mask these symptoms? (22:27) Why she believes antidepressants are overused. (24:00) How much does genetics play a role in the symptoms that women experience versus the way they ate or dieted leading up to perimenopause? (25:31) The not-so-common early signs and symptoms of perimenopause. (27:17) What does hormone therapy look like? (29:29) Zone of chaos. (32:22) Non-hormonal interventions: Training & diet. (33:38) Supplementation and menopause. (40:00) Common mistakes women make when trying to self-medicate to help themselves. (41:28) How do women equip themselves to speak with their doctor. (43:53) Why HRT is optimal for most women. (45:19) The typical hormone therapy options for women. (46:04) Busting women’s fears surrounding HRT. (47:52) Anything exciting on the horizon in this space? (48:35) The standard HRT dose. (49:50) Can a woman who previously survived breast cancer do hormone therapy? (51:59) PCOS and perimenopause. (52:57) Let’s talk about your libido. (53:43) Related Links/Products Mentioned The New Menopause: Navigating Your Path Through Hormonal Change with Purpose, Power, and Facts Visit MASSZYMES by biOptimizers for an exclusive offer for Mind Pump listeners! **Promo code MINDPUMP10 at checkout** April Special: MAPS HIIT or Extreme Fitness Bundle 50% off! ** Code APRIL50 at checkout ** History of Women's Participation in Clinical Research “Not feeling like myself” in perimenopause — what does it mean? Observations from the Women Living Better survey Experiences of Mothers Who Are Child Sexual Abuse Survivors: A Qualitative Exploration The musculoskeletal syndrome of menopause - PubMed The Women's Health Initiative Hormone Therapy Trials Mind Pump #2567: Women Who Lift: Breaking Myths and Building Muscle Mind Pump #2530: Why All Women Should Take Creatine The Menopause Society | Homepage Mind Pump Podcast – YouTube Mind Pump Free Resources Featured Guest/People Mentioned Mary Claire Haver, MD (@drmaryclaire) Instagram Website-The Pause Life Abbie Smith-Ryan, PhD (@asmithryan) Instagram Dr. Stacy T. Sims (@drstacysims) Instagram  

If you want to pump your body and expand your mind, there's only one place to go. Mind pump with your hosts, Sal DeStefano, Adam Schaefer, and Justin Andrews. You just found the most downloaded fitness, health, and entertainment podcast. This is mind pump. Today's episode, we talk about perimenopause. Believe it or not, it starts a lot sooner than you think. In fact, we learned with today's guest Dr. Mary Claire Haver, she's an OBGYN, she's the author of the new menopause. This is a New York Times bestseller. You can also

find her by the way on Instagram at Dr. Mary Claire, that's D-R-Mary C-L-A-I-R-E. We learned from her that perimenic pause starts sooner than most women think and your hormone tests won't even show it. You'll just have weird symptoms like suddenly gaining body fat in your midsection. That's one of them but there's a lot of them. Today's episode was very illuminating. This episode is brought to you by one of our sponsors, Masszymes. These are digestive enzymes that break down the fats, proteins, and carbs to give you better recovery, better absorption, better digestion.

You can find them at bioptimizers.com forward slash mind pump. That's B-I optimizers.com forward slash mind pump. Use the code mind pump 10, get 10% off. We also have a sale this month. MAPS hit and the Extreme Fitness Bundle 50% off. You can find both of them at mapsfitnessproducts.com. Just use the code April 50 for the discount. All right, here comes the show.

Dr. Mary Claire, thanks for coming on the show. Thanks for having me. Yeah, you came heavily recommended by one of our friends. She said you did such a great job on her podcast. And so many people write in and say they just learned so much from you. So it's like we had to have you on our show. So thanks for coming on. Thanks. These are my favorites.

I like talking to the other sex, you know, you don't have your own personal story to kind of work into the conversation. So it's all about education. We could learn a lot for sure. So what, so what got you into what you do now, right? Because you have a huge following on social media and one of the main things you talk about, among other things,

because you talk a lot of things, but paramedicopause, metapause, what made you go in this direction? Yeah, no, good question. I came from a background of being a general OB-GYN physician, so I'm board certified in OB-GYN. I did this traditional four years of medical school, got my MD, then did my four year residency in obstetrics

and gynecology. And when I think back, you know, I was the expert in women's health, right? And I aced all my exams and did well on my board. So, you know, I felt like I've got this, you know, I'm ready to go out in the world and take care of patients. And I just remember my first several years of practice having women and menopause come in and really just feeling like I was a deer caught in the headlights. Outside of pregnancy, the number one thing they were complaining of was weight gain and then libido issues, neither of which I'd really been taught on how menopause works into those problems and what we can really do about it. So that's all fine and good.

And I was giving the same advice, work out more, eat less. That was working for me at 30. And then I went through my own menopause and really had a rough time, really rough time and really got hit. I really felt like a ton of bricks. I didn't feel like myself. I was also grieving the loss of a brother at the same time. So I was like, okay, I'm just depressed from that. But muscle pain, joint pain, my back was always hurting. I wasn't sleeping

well. I was gaining weight in weird places. I'd always kind of had thin privilege. And suddenly I was kind of lumpy and gaining weight in my midsection mostly, which had never happened to me before. And I was really reluctant to consider hormone therapy. I did have the classic hot flashes and they were waking me up at night and I thought I cannot live like this. So I was trying meditation. I was trying journaling, which was all good for my mental health, but I still wasn't sleeping and nothing was helping the hot flashes. I tried different supplements. I was really scared of hormone therapy because of the Women's Health Initiative study and all the fallout from how the misrepresentation was, which we now know was, you know, the risks were overblown and the benefits

were totally not discussed. So I reluctantly decided to start hormone therapy and absolutely felt like I got my life back. Did my stress melt away? No. Did it go to the gym for me? No. Did it eat right for me? No.

But it just kind of pulled things back in alignment where I felt like I was in control of my life again. And the efforts I was doing to stay healthy were beginning to work again. So I started talking about my experience on social media. I had a small Facebook following, just kind of talking about gynecology. But as I would broach the subject of nutrition and menopause and weight gain and menopause, the world like stood up and paid attention, at least my world on Facebook. So Facebook started growing pretty quickly. And I had gotten a culinary medicine certification so I could learn more about nutrition because how much they teach me in medical school?

Zero. And I just felt like I wasn't able to help myself or my patients. So I went and got certified in nutrition, really learned a ton and put together a little program that I made for my patients and a few of my followers on social and my girlfriends in town. And called it the Galveston diet, just kind of a joke, because we live here on the island. I live on the island of Galveston outside of Houston. So it really was working well. Everybody loved it. I was talking about it on social media.

That was growing. So then I was starting these little Facebook groups and kind of guiding people through the process, which was anti-inflammatory nutrition. I was a huge fan of fasting back then, and I've kind of backed off from that a little bit because I need protein and it's hard to get it in eight hours. And it just, things were growing, but as I was talking about nutrition and menopause, weight gain and menopause, people were asking me more and more questions about just menopause. So I would research there, you know, when a thousand people ask you on social, is my frozen shoulder related to menopause? I stopped saying, I don't know, and I start digging, right? And I was finding all of these weird symptoms that I'd never been taught to attribute to menopause that were actually related. And

I started realizing, wait a minute, there's estrogen receptors throughout our body. This is not just hot flashes and night sweats and sleep disruption. You know, this is really a total body effect that women are going through. And the more I discuss those things, the bigger and bigger it grew. COVID hit and my kids were home who were teenagers in early college and they were like, Mom, you got to do this TikTok thing. And I said, No, no, no, that's for kids. And they started showing me other clinicians who were on TikTok educating. And so my very first TikToks were me dancing, kind of like swaying to music, pointing to different facts. Remember that trend.

And those really took off. So suddenly, like within a few months, I had several hundred thousand followers on TikTok. And of course, my dopamine is exploding. And this is amazing. And I'm making making more and more content around that. But like, I was literally learning alongside my followers. Like they'd ask, I'd research, I'd then I'd share and then another video would go viral. Because, you know, another million women would be like, Oh, my god, that happened to me, the itchy ears, the, um, 10, 10 tinnitus or the vertigo, um, the gastrointestinal palpitations, the GI changes, you know, of course, weight gain is always the center of every woman's, you know, but has that grew, you know, people

were like, I'm tired of chasing on social, write a book. And I wrote the new menopause, which ended up being a number one New York Times bestseller. And, you know, our growth on social has just continued to grow. We just hit, I think I have six million total across, you know, between Instagram and TikTok, we're a little over five million. And then we've got another million between Facebook and YouTube. Do you think that one of the reasons besides being a great communicator do you think one of the reasons why this really struck a nerve is that women have

been told I hear this all the time that they've been told it's all in your head whenever they come to the doctor with anything other than hot flashes like everybody's they'll hot flashes yeah you get that but then they, oh, because this is what I was taught as a trainer. I know fat loss, I know muscle building, I know correctional exercise. I was told that fat distribution doesn't change. You can't, it doesn't, no, people are coming. I store body fat in my belly now. I never used to.

I'm like, nah, that doesn't work that way. Body fat distribution doesn't change. Do you think that that's just a major experience of most women when they go to the doctor when they come to talk about these things? The major experience, and this is because of the systemic way that we approach menopause in medical training across the board,

and this is worldwide, nobody's doing it well, is that we have relegated menopause to a very small set of symptoms. And that dogma has not changed in 25 years. When you look at guidelines and updated guidelines, like from the American College of OB-GYN, they haven't updated menopause in over 10 years. And as this new data and information is coming out about, wait a minute, this distal fat is very different than subcutaneous fat. And it goes up from 8% total body fat in a premenopausal woman to 23% postmenopausal women.

What changes in diet and exercise, right? And so the old dogma was fat is fat, you know, calories in calories out. Calories are important. No one's negating that. But, you know, there is a pro-inflammatory drive of new fat to the intra-abdominal organs, which is in and itself pro-inflammatory. So it's a much more nuanced conversation around body fat distribution and visceral fat is dangerous, much more dangerous. Visceral fat is more tied to the risk of chronic disease, of diabetes, hypertension, stroke,

to the risk of chronic disease, of diabetes, hypertension, stroke, than a subcutaneous fat ever has been. That's why now when we define obesity, we're not using BMI or weight anymore. We're using abdominal circumference because that is a reasonable marker for the amount of visceral fat that they have. Why did we suck so bad at this?

Why was it so overlaid? No, it's a great question. I mean, it's serious. It's like every woman goes through it, so how could we miss so big on something so common? Yeah. So when we look historically, and anthropologists have looked at it, and what we realize is forever in science, women's health was considered to be... When I say women's health, what do you guys think about?

What's the first thing in your head? Yeah, reproductive. And having a baby. That's it. Absolutely. Pregnancy. I mean, the vast majority of my training, so obstetrics and gynecology, right? Obstetrics is everything to do with pregnancy and gynecology is the uterus, fallopian tubes, ovaries, right? But who's tending after the gender specific, so how women uniquely have heart attacks, how they uniquely have, So forever the science was on men, mostly guys that look like you, no problem with that, right? I mean, that's who was doing the studies, creating the studies

who the doctors were, who the researchers were. And they're like, we're just going to get guys that look like us. And we're just going to assume that these, this will hold forth for women, women were excluded because of worries. It was reasonable worries of birth defects. So women of reproductive age were excluded from studies until 1997. Oh, I didn't know that. Wow, 1997? That's huge.

There was a drug called luteinide, which was given to women for high premises, so for nausea, vomiting, and pregnancy. So they're not healthy. Which caused horrible birth defects, like limb, you know, like paddle limbs. Just be a little kind of flipper. Is that the one where they flip the molecule? They did a mirror image of the molecule

thinking, oh, this is a safe drug, when in reality it was like it's actually different? Is that what happened with it? I'm not sure how they developed it. I'm not sure about it. But, you know, they gave it, women took it, their nausea got better, and then their babies had terrible birth defects, right?

And so because of that, they threw out the baby with the bath water. They said, okay, we're gonna exclude all women who might even, you know, women just aren't gonna be excluded because we can't risk this ever happening again. And so that kind of stuck for a couple of decades until now women are required to be in studies that we haven't even reached 50% yet. So when we

look at data on how statins work, right, most of that was done on men. And if you de-aggregate the data on statins and high cholesterol, women's high cholesterol will get better with a statin, no problem. But it won't decrease her risk of a heart attack. Why? Because we have heart attacks differently than guys. Explain. So most men will have a blockage in the very first part of the arteries that leave the aorta. So you guys would know it as a widow maker, right? So that's the interior descending artery of coronary artery. And so that very first part, and the most thickest, widest part

is where those clots tend to form in women, and men, excuse me, women have diffuse microvascular disease. Their disease tends to be down into where the arteries branch out deeper into the muscle. So therefore the way that they have a heart attack, the symptoms they present with rather are very different than a man. A man comes in, we all know it from watching all the medical shows, clutching his chest and radiating

to his neck down his left arm. Women come in with chronic fatigue, abdominal pain, shortness of breath, you know, it's not clear. And so a woman has a 50% higher chance of dying from a primary heart attack than a man. She's much less likely to be properly diagnosed in the ER and it takes a lot longer because we've used this typical model of a male without understanding that we're getting better, that women actually disease differently. We die differently than men. Wow. I think part of it too is a culture that tells women, you tough it out. it's just part of life. Here's the other thing, and this is embarrassing to admit,

and it took me a long time to really tease out my own bias and what I was taught. We were taught that women tend to somaticize ecological problems. We were never taught that about men. It's all in her head. There's no what's all in his head. So I still still still to this day, I have to when a woman comes in with complaints in her mid 40s, she's got her laundry list, I have to hold that back, right? That that training automatically leaps to the front. Well, she's probably a little

bit you know, women tend to be unhappy at this age. Women tend to, you know, but actually it's not true. These hormone changes are killing, are literally killing us. And doctors aren't trained to recognize them. Now, let's talk about paramenopause and menopause and when you tend to start seeing it happen and what are the early signs that maybe

aren't so common, right? Like let's start paramedic. Great question. Thank you for asking. This is my jam. Okay, so let's start with what is menopause. Turns out menopause is one day in a woman's life. One day, medically defined. It is one day after her, one year to the day after her final menstrual period. Okay. Well, there's a lot of problems with that. You know, what does she do in leap year? Do you have to wait 366 days? Is it, you know, such a random arbitrary, what if she sat a hysterectomy? What if she doesn't have regular periods? What if she has an IUD that's stopping her periods? You know, does she not get to be menopausal? So what's actually happening in menopause

is ovarian failure. So men, you guys have a set of testicles. We have the corresponding set of ovaries, right? Most adults understand that. And so you can make your genetic material fresh every day. Every day, the testes are still working, right? Creating, you know, little gametes that get brought out into the world or

not, I'm gonna let you guys figure that out. And then women, we go through puberty. And then we start we are born with all of our eggs, a set supply. So female is born with one to 2 million eggs. And that will last her until they run out. And menopause represents the end of the egg supply. So when we start ovulating, so by the time we're in puberty, when we start ovulating, we are down to three or 400,000 eggs. There's a process called atresia, which is a kind of a selection, you know, kind of a survival of the fittest, we get the healthiest eggs that actually get

to ovulate. A woman will only ovulate three to 400 times in her life. And so you got a one to two million egg supply and they're not all healthy. And then we're hopefully gonna get just the juiciest, most healthy eggs out at the end. So we're losing the unhealthier eggs through this process of atresia. We start ovulating each month,

we lose a thousand eggs to get one out. And so we keep just depleting, depleting, or depleting our egg supply. Perimenopause is when something kind of magical happens. Every month, we have a signal coming from the brain. The hypothalamus in our brain, you guys are scientists, know that hypothalamus creates hormones. Well, it's constantly sensing for estrogen in a woman's blood.

When the estrogen levels get low, it says, okay, ovaries, it's time. So it sends a signal to the pituitary, something called GnRH, and says, hey, tell the ovaries to wake up. It's time to get an egg out. We need some more estrogen. Okay. So in the process of ovulation is where we see the estrogen production rise in the female. So then the pituitary says, got it, boss, sends out LH and FSH, which bind to the cells around

the egg, the follicular and granulosa cells, I'm getting very technical. And those are the cells that produce the estrogen and the progesterone and sub testosterone. So that goes monthly in this beautiful EKG like ebb and flow pattern. If you've ever seen the female reproductive cycle, you'll see these kinds of curves where you peak estrogen in the middle and blah, blah, blah. And that for a healthy woman is a very repeatable normal cycle month after month after month. On day 10, you can predict what's going to happen day 16, unless she's pregnant or ill, okay, or has PCOS or some disease. Okay. When we hit to perimenopause, we are at a critical egg threshold level where the typical signals

coming from the brain Don't work the ovaries becoming resistant to those signals. So the hypothalamus is still looking for estradiol and it's not coming from the eggs Okay, so then it gets mad it starts saying hey, where is my estrogen? The pituitary says dude I sent the signal the pituitary and it's like send more So the pituitary starts pounding the ovary with higher and higher levels of FSH in order to force the ovulation. So what happens in peri, what used to look like that pretty EKG becomes a zone of chaos. In order to force the ovulations become delayed, which is why cycles become irregular, we get these much higher like bursts of estradiol than we've ever seen in our lives before outside of pregnancy. And then progesterone never kind of keeps up, you know, after ovulation. So what used to be beautiful and predictable and normal and the brain knows what's coming

now is just throw spaghetti out the wall and here we go. So over time, it's a decline in estradiol, but it is literally a roller coaster on the way down. And so perimenopause is a seven, you know, four, seven, 10, depending on who you read, year long stretch where symptoms begin. And so menstrual, we've always in medicine defined perimenopause, if you even thought about it,

by cycle irregularity, right? Well, guess what? The cow is out the barn by the time your cycles become irregular. Perimenopause begins in the brain. So when that hypothalamus is having to work double time and the pituitary is working triple time to get those hormones out to force the ovulation, we start seeing sleep disruption, mental health changes, and brain fog, cognitive

changes, usually in the verbal and learning sections of the brain. And those hit well before the cycle becomes disrupted. How long before? Does it feel like a slow gradual climb for the woman or is it like a ton of bricks hits her? Most it depends. Patients kind of approach, you know, differently. For some, it's there's a great paper that just came out in the last few months called Not Feeling Like Myself. I mean, how vague can you get? But literally they tied it to very menopause. Like she's like, look, I built this life that I was managing. I had my stresses down. I had it. I had it. I was in control. And suddenly I've lost my resilience. I can't put my finger on it. But something is wrong. It's usually

the mental health and cognition changes that are hitting her hard. Her periods aren't irregular. So no one's waving a flag externally saying, hey, something's going on with your hormones, but she knows something is up. So for some, it's like the rug got pulled out from under them, and others, they just feel like, ah, the last few months is just getting worse and worse. How long before does this happen in the brain

before you start to see, typically, the changes in the menstrual cycle? Yeah, so by the time their cycles become irregular, for most women, you are about two to three years out from full menopause. Wow, wow. Wow, and with- It's a long time to be going through this

without knowing for sure what's going on. Without knowing, right? And so I don't tell this to scare your listeners. I don't want them to be, I'm like, oh, all this crazy stuff's gonna happen. But imagine if you weren't gaslit. Imagine if you were like, oh, this might be my periodimenopause, I got this.

You know, that you could understand. I think just knowing and educating and understanding in what's happening to your body will alleviate so much of necessary suffering. Well, doctor, when does this, what age, what's the age range that this starts to happen, where the perimenopause starts? Great question.

All right, let's do the math. So the average age of menopause in the US for a white woman is 51. Now, genetic ethnically, it's all over the map. African Americans tend to go through about 18 months sooner. Asian women tend to go a little bit later. Southeast Asians, so like from the Indian continent, they go through average of 46. And there's a window of normal. So for, um, in the U S 46 to 55 for full menopause, right? Remember perimenopause,

back that up seven to 10 years. So what are you looking at? And it 30s, you know, so a good chunk to, you know, at least a third of a woman's life is spent with or over is not functioning the way that they were in peak fertility time. Now, how much, how much does birth control kind of mask some of those symptoms? That's a great question. So a lot, actually. So when we approach treatment of perimenopause or women are just utilizing birth control pills, you know, oral contraception, or the patch or the ring or, you know, they're basically suppressing the hypothalamus. So what you're doing when you when you're on the pill

or taking hormonal contraception, you're giving your body enough hormones to tell the hypothalamus, we're cool, shut down. You don't ovulate, you don't make a baby. Okay, turns out we use birth control that actually works for acne cramps, you know, we have a lot of medical indications that we use off label for hormonal contraception. So, you know, I was on continuous birth control pills because I have polycystic ovarian syndrome. So I kind of masked the whole thing. I was like, live my best life going through, you know, and then at 48, I got off the pill, my brother had died. And I was like, let me see where I'm at hormonally and figure out what's going on here. My husband's like, I'll get him assigned to me. And, and I was immediately menopausal. So I went through somewhere in

the background. Like, so for a lot of women who are on the pill, especially if they're doing continuous, then they may not notice a whole bunch, though it's happening in the background. So, on the pill who have mental health changes and weight gain and all the things, because you can't stop what's going on behind the scenes in the ovary.

Dr., so when you said mid-30s is kind of when it's starting to happen, I immediately thought about some stats that I'm familiar with, with women in particular and prescription antidepressants. Yeah. They spike. It's the saddest thing. Is that what you think's happening?

Because you see that. Exactly what's happening. So here's the data. In the perimenopause transition, so in that seven to 10-year period, because of the chaos, we have a 40% increased risk of mental health disorders, so usually depression and or anxiety. And the default is an antidepressant. I love having those medications available, but I think they're overused. Once you go through the menopause transition, the rate of SSRI use doubles, doubles. Okay. So we have one in, one out of 10

is on it pre menopausal and then one out of five, and then it goes to one out of four over the age Wow. So I'm really 25% of us are depressed, you know, from some, you know, from some chemical imbalance chemical imbalance been totally improving. So what we know now is that women in perimenopause, at least not post menopause, but a new onset of a mental health disorder in perimenopause is better off being treated by supporting or replacing her hormones than an SSRI. Wow. Yeah. How much does genetics play a role in the symptoms that women experience versus maybe the way they ate and dieted and exercised leading into... Sure. We need to do a lot of work in this area. We know that timing of menopause, there's a big genetic correlation. Now, a lot of things, what we don't know a lot about is what can extend

the shelf life of your ovary, right? We're born with a certain amount of eggs. How can you keep them health? Certainly anything that keeps you healthy will keep your eggs healthier longer. Right. We're all going to lose them. That that there's no way around that yet. Those there's some great studies happening there on

everything from transplanting healthy, you know, taking out a little bit of the ovary at 25 and putting it back in the 50 to different medications and compounds that could extend the life of the ovary. Usually in the fertility world, but it actually works to, you know, keep you out of menopause. But you know, if you smoke, but it actually works to keep you out of menopause. And so, but if you smoke, if you have abdominal surgery, if you have a hysterectomy, you'll lose average of four years off of the life of your ovary.

So, and I don't think a lot of patients understand that, hysterectomies are needed, but, and all the women who are having their ovaries removed for no other reason than, oh, we just don't want you to get cancer, that is a travesty. If you have any abdominal, like inflammatory disorder, the ovaries are just floating there

in the soup of the abdomen. And so we will see the shelf life of the ovary and then trauma. Great study done, sad study, looking at women who were sexually abused, whose kids were then sexually abused, they will lose nine years off of the life of the ovary. Symptoms tend to run in families,

so if your mom had hot flashes, there's a good chance that you had hot flashes, your mom had joint pain, but it's not one to one because you get half your genetics from your father. What are some of the other symptoms? You named a couple I wasn't even familiar with. Joint pain, itchy, itchy.

So we have this cliche, well-known, you know, well defined, so hot flashes or vasomotor symptoms. There's a thermoregulatory center again in the hypothalamus that becomes completely discombobulated when we go through the, when the estrogen levels begin to fluctuate and then, and then decline. And so that thermoregulatory center will just, all of a sudden, the vessels will dilate are usually centrally it'll start kind of in the chest and then expand up the neck and head and then out to the extremities where you'll have profuse sweating palpitations or a known symptom of a vasa motor symptom.

You'll have this incredible like crushing anxiety right before the hot flash. So but then that's the cliche sleep disruption. So if the hot flashes wake you up from sleep, that's one kind of sleep disruption. But these 2 a.m., 3 a.m. wakeups, we are struggling to maintain our blood sugars. Insulin resistance rises precipitously in the menopause transition with no changes in diet and exercise. Our insulin resistance goes up, visceral fat goes up, and our blood pressure goes up. Our LDL goes up. The APO-B goes up, visceral fat goes up, and our blood pressure goes up. Our LDL goes up, the APOB

goes up, the LDL, I mean, the HDL goes down. Starting in the brain, of course, brain fog and the mental health changes. We have receptors in our lungs, asthma tends to get worse or have nuance at asthma, all over our skin. So dry skin, dry eyes, dry mouth, anything in the mucosa can get drier. We have well documentation of the genital urinary system. So, you know, dryness in the intimate area, loss of mucus, loss of elasticity, that's easy to replace with local estrogen there.

Joint pain, the great paper that just came out called the Musculoskeletal Syndrome of Menopause, looking at the, they went, you know, did a deep dive frozen shoulder dramatically related to menopause. Women on HRT tend to have less incidence of frozen shoulders. So really there's the endothelial cells that line the arteries, not just the coronary arteries, but you lose elasticity, the vessels become stiffer, and you're much more likely to form plaques. Estrogen is very protective against plaque formation in the vessels. What does hormone replacement typically look like then?

Is it estrogen, progesterone, testosterone, like all three? Sure. So we kind of address each separately because they each have different jobs in the body. So we usually start with estradiol in my clinic. So the original estrogen preparations available for humans were, they hadn't figured out really how to make estradiol and big batches cheaper. So they were going and collecting horse urine and finding this like group of estrogens that were like 10 different estrogen compounds. There's estrone, estrillin, estrace, I'm sorry, estriol, estriol, estrone, estrodial. So, and then

they compounded it all into a pill and called it Premarin, pregnant Mary urine, Premarin, and gave that to people and it worked great. It binds the receptors, it, you know, so most of the data on the safety efficacy and including the WHI study, were done with this particular form of estrogen. Now, in modern prescribing practices, most of us in my world who are menopause educated don't use primorin. We use just plain estradiol. We're just trying to give her back exactly what her ovaries used to make.

Just like in men, you're just going to take testosterone. That might be undeconoid or whatever binder it has attached to it, but you're just trying to give your body back the testosterone that it made at higher levels for men so that you perform better. Progesterone is mandatory if you're giving a woman with a uterus estrogen to protect that lining of the uterus. You never want to give a woman with the active uterus estrogen alone. You can lead to hyperplasia or potentially malignancy. So you can negate that completely by giving her a progesterone with the estrogen. In my world, we give her progesterone. Again, exactly what the ovaries used to make. Turns out progesterone works beautifully in the brain,

upregulates GABA, which helps with sleep. So my patients with sleep disruptions, middle of the night awakenings, anxiety at night, restless legs, progesterone can be really wonderful for them. Testosterone, absolutely. I'm a huge fan. And, you know, female levels peak, just like men, we have a peak. You guys peak at about 19 to 20. We peak at about 30, 25 to 30 of age. And then there's a gentle decline our whole lives. It doesn't fall off a cliff like estrogen, progesterone, duv and menopause. But women who are suffering from hypoactive sexual desire disorder and have a healthy relationship and don't have pain and can orgasm and don't have any other aspects associated with sexual dysfunction, do really well with testosterone. There are two other FDA approved medications

that work in the brain to help with desire. And then we think testosterone, though we don't have great studies yet, but a lot of the observational evidence for women is showing same as men, mood, recovery, stamina, et cetera. My patients love it. So do you test someone's, so when someone comes in with symptoms of

perimenopause, do they then do a blood test first before you determine hormone therapy? Or is it based off symptoms or both? You want the next billion dollar company? Yeah. Find the test that's going to diagnose perimenopause because we don't have it. So it's all simple. Remember that zone of chaos I talked about, spaghetti? What level are you going to use? It's all over the map.

And so, you know, unless you're wearing a continuous hormone monitor, you know, and able to see all these crazy changes, it's really hard to diagnose with blood. So the way we diagnose, now post-menopause is easy, low estrogen, high FSH, done. Okay, straightforward. high FSH. Done. Okay. Straightforward. In Peri, I will send the FSH and estradiol and a testosterone level for all patients just to kind of, I don't want to miss anything, but usually we can make the diagnosis of perimenopause by guess what? Listening to the patient and believe her. So I do do a lot of blood work. I don't want to miss anything. So a lot of the symptoms of perimenopause look like lupus or hypothyroidism or nutritional deficiency or inflammatory disorder. So I'm often doing panels and panels of blood work to rule out those other conditions.

And then we treat what's left. Well, let's okay. Let's talk about non hormonal interventions. I noticed as a trainer, I mean I trained people for two decades, and a lot of my clients were middle-aged women. I'd say probably a majority, just because they tend to be the ones that hire trainers. And I noticed generally they responded far better, and this was for most people,

but they really did respond better to traditional strength training. Rest in between sets, get you strong, get you off the circuits, get you off the aerobics classes, high protein, I just think- That, 100%, that is one of the biggest changes I've made is that here's how I talk to my patients about it. We lose muscle with the aging process, both of us, males and females.

For females, it accelerates beginning and period menopause and that whole body composition change where the scale is going up, but muscle loss is really accelerating and then we're replacing it with visceral fat. And so they're just getting unhealthier and unhealthier and unhealthier and shortening their health span. And so when women come to my clinic and we talk about, okay, let's put out the fire of your menopause to your functional again. So that takes two or three months to get the right dose.

And you know, it's a lot of trial and error. So finally, she's like, I got this, I feel great. I'm happy. I got my hormones, you know, whatever. Then I'm like, let's talk about the diseases that are plaguing your elders. And in females, we're looking at sarcopenia, osteoporosis, and dementia. And what helps all three of those things? Weight training, resistance training, and building the muscle that your body is shedding. Okay. And that message is very clear to women at this age. They're looking at their moms. See, women are, you know, when we look at when I, you guys follow the wellness bros,

I'm sure. And they're, you know, I'm like, don't think about the sauna or the cold bath yet. We got to get your hormone straight. We got to get you in the gym. You know, like, those are the key things that are going to keep you healthier longer because women are living longer than men by like five years, probably because that estrogen that we had was higher and keeping us healthier for longer. But what's taking out our health span and not happening to guys as much is the sarcopenia and frailty and dementia. And so, and women are like, uh-uh, I don't want to live 10 years

in a nursing home. I don't want to be stuck in a bed with not able to, you know, losing my independence. And that is what really is motivating women to get to the gym. Not to get in a bikini, not to look a certain way. It is to stay out of a nursing home. My mantra is every day in the gym is one day less than a nursing home.

That's great. And I'm 90% doing resistance training. I do, I turn my treadmill into a walking desk. So I'm getting plenty of cardio. I always have, but yeah. That's great. No, that's what we notice. And now with diet, at least back when I was training, it might be changed quite a bit now, but when I was training clients, the message was always low fat, low fat, low fat. And knowing what I know about fat and even dietary cholesterol

and how it contributes to hormones and hormone health, they all did much better when I increased their protein and increased their fat intake. Those are the two things. So what are you seeing on your side with that? So women are, you know, I've kind of, when I wrote Galveston Diet, which was my first book, you know, it was all about weight loss, weight loss, weight loss, because that was what I was worried about, what everybody was worried about.

But in this journey, I've learned so much more. I don't talk about weight anymore. I talk about body composition and living longer and stronger and trying to be in a bigger body and not a tinier body. Right. And it just, I'm like, protein and plants, those are your priorities, right? Protein and plants and with a lot of protein comes fat. So our Greek yogurt, a lot of the protein sources have plenty of fat available.

We're doing avocado and olive oil and really healthy, rich sources of fat. We are really helping patients, especially those, because I have a body scanner. I have the medical grade in body scanner for my patients. And we are having really frank discussions and it's so like freeing for these patients to finally not look at calories or look at food as the enemy or how can I eat less? They're always now like, we need to eat more, especially on a GLP-1. So, you know, if they're coming in pre-diabetic and we get them started on a GLP-1, which is a huge amount of our patients in menopause, they are so excited because they are just focusing on how to fill that plate and how to eat as much as they can to stay healthy. It's such a better way to live.

Yeah. Are you seeing, do you think there are any changes? Because I see in the data, like, you know, where it shows that girls are starting puberty younger, probably tied to obesity. We're seeing lots of potential effects of things like xenoestrogens. Fertility seems to be getting worse or declining. Men, sperm counts in women, you're seeing this with fertility. Do you think that there's some environmental factors that may be that... There has to be.

There has to be. I mean, we need more research. I'm, you know, I think about all the crazy stuff I did, you know, had a hot water bottle from, you know, the, from the gas station drinking, you know, leaving in my car in Texas at a hundred degrees and drinking new water, plastic, and, you know, I just thought nothing of it at the time and how in our family

were really paying attention to what we're cooking and how we're storing food, where the food comes from. You know, I was the convenience queen and I just just want to die when I think about what I gave my kids when they were little because I was rushing from what you know, from the hospital to go pick them up in ballet and you know, and all the the way we built our lives around these convenience foods and what it's really done to our health long-term. And slowly I'm starting to see the changes. My kids who are 21 and 24 now are much more aware than I ever was at that age.

It's a miracle I'm alive, actually, if you were looking at 21 and crazy stuff I did. But my kids don't live like that. They're very conscientious, especially my oldest is in medical school. And she has a degree in nutrition as her undergrad. So she did nutrition science for her undergraduate degree. So she's really on top of it. It's really cute and fun for me to watch how different they approach their health than I did at that age. So I think there's. Yeah. What about supplements? There are supplements like Chastberry and evening primrose oil and that people will take for some of the.

So the menopause society took a hard look at, you know, a lot of the claims being made by some of the companies. And I don't think there's a great menopause cure out there. There's not a great supplement that is going to resuscitate the life of the ovary. When I say menopause cure, I mean like bring estrogen back into your body. We haven't found that yet. But we know that the human body like so I have a supplement company and we sell things like fiber and vitamin D and, and turmeric, turmeric, there's good

studies done on menopause and arthritis and inflammation and pain, you know. And so I looked at where the nutritional gaps were in most women in menopause, my patients weren't getting enough fiber really struggling there. I have about an 80% patient population deficient in vitamin D, not just low, I mean like in the twins. We have a huge amount of ferritin deficient, you know, patients who are coming in

with low iron stores, you know, and so when I'm talking about supplementation and menopause, I do the deep dive through nutrition. I don't, you know, certainly there's a couple of hot plots, you know, there's some phytoestrogens like soy, like black cohosh, evening primrose oils, and decent anti-inflammatory that can help with, you know, take the edge off some of the symptoms, but they're not fixing the root cause. You have to be careful when you talk about supplements for menopause. I talk about supplements in menopause. Most likely to be.

Oh, good point. Very, very good point. Are there common mistakes that women make trying to self-medicate to help themselves? Is that common? Alcohol. Alcohol. Yeah.

Talk about how bad that potentially is. It is so bad for you. I grew up in the era of, oh, there were little bit was healthy for you. That's not true. So, I grew up in the era of, you know, oh, it was there a little bit was healthy for you. That's not true. So there is, we need more studies, but from from the hundred thousand women I've talked to, okay, in my, in my practice, women are not tolerating alcohol the way they

used to. It is not happening. And so in my life, if I choose to drink, I am choosing not to sleep. I will wake up at three o'clock and I don't know if it's that's cortisol. My aura ring yells at me. And, you know, all the indicators are this is not good for me. This is not leading to my best life. Now, I have really restricted not restricted. Yeah, restricted compared to what I during COVID. Oh, my God. So now it's like when I'm out with my girlfriends, or I'm celebrating, I'm really conscientious about if I choose to drink and how much and, you know, just I know it's not good for my body is I'm not processing it the same, but I just see

so many women who are devastated by these changes, and feel like you know, alcohol is a very short term fix to kind of numb a few things, but the long-term consequences just don't seem to be worth it. Where women are seeing some relief is with THC. And so, just from anecdotal, no one's prescribing it for that. But just talking to patients, talking to women, especially in states where it's readily available, they are seeing better sleep, more relaxation, better mental health even, with some judicious use of THC for their menopause. I like what you said about supplements with menopause,

not for menopause. I read some really good data on creatine. Oh yeah, that's my favorite. Sorry, I left that one out. I'm a huge creatine fan. I just finished mine. God, Abby Smith Ryan is the best on this and Stacey Sims, you know, got really, really good data.

I mean, Abby does the research, but on women specifically and how, you know, brain seems to be recovering better. You know, our brains just take this hit when those hormones go crazy. And creatine, plus if you're doing the resistance training, creatine is more than additive. It seems to be synergistic. One of the challenges that, because people are listening and I know because I've talked to women like this, I'll send them an episode and they're like, that's great. But when I go to my doctor, how do they equip themselves? I wish I could tell every woman listening, you just walk into your OB-GYN and you hand

them this list of symptoms. We're not training our medical professionals. This wonderful OB-GYN who delivered your babies and has been your bestie and given you great care, 80% chance they've received zero training in menopause. This is a problem. Now we're fighting legislatively to, you know, force these changes. What do we do until then? Okay. If you go to my website, which is the PawsLife.com, we have a list of providers and it's basically crowdsourced. Wonderful people who've had a great experience with a menopause educated clinician have done little testimonials and we've organized them by country, city and state. Oh, that's awesome. That's great. All the people are fine. And no one pays to be on the list. It's totally free, right? If you go to the Menopause Society, which is menopause.org, they have a list of certified

providers of which I am one as well. Unfortunately, there's only about 3,000 of them for all the women in America. And so we have a long way to go. There's some great, really cost-effective telemedicine options that are out there. So on our, we have all of this listed on our website. We have blogs on how to find a provider who might know what they're talking about and be able to help you and take your insurance or are you willing to pay out of pocket, et cetera.

That's great. Now, I know the answer to this, but I would love to hear from you. What do you say to people that are like, well, it's a natural part of life. You go through menopause, your body's supposed to go through these changes, and we're forcing you now to. So is presbyopia, so is erectile dysfunction.

You can raw dog menopause, and you can be healthy. It's possible, you don't have to take HRT. But for most women, you are not gonna be optimal. And so it's gonna be harder, and there may be things you don't realize. The way you're sleeping, your cholesterol, your recurrent UTIs. When I tell you the women in the nursing homes

with bladder infections and all of this, could have just been cured with adrenal estrogen. What does it typically look like to do hormone therapy for women? Is it injections, creams, pills? It depends on the provider and what they're comfortable with. In our clinic, and most of them, we call them menopause, like my friends who all over the world,

most people are doing mostly transdermal estrogen, so a non-oral formulation. Anything we ingest orally, anything, food, medication, goes to the liver for processing first. And when that bump of estrogen hits the liver in an oral formulation, we do see a slight upregulation in our clotting factors. And so for women who are prone, that could increase your risk of a blood clot, and we don't want that to happen.

So because of that, most of us and some other, there's some inflammatory markers we get a little bit worried about. But overall, for most women, oral estrogen is safe. But if I had everything equal, I usually do transdermal. I usually do a patch because I have a steady state dose going to the patient at all times. And the patches are generic and they're really, really, really like 25 bucks for the month. So most, most patients can afford that if they don't have insurance for progesterone, we're doing oral.

Usually the progesterone molecule in its natural form is humongous and doesn't pass through the skin very well. So we get really nervous with these progesterone creams that they're really ineffective and not protecting the lining of the uterus and then for testosterone, it's kind of choose your own adventure because we don't have an FDA approved option for women. So I prescribe typically T-system or androgel, the men's formulations, and we just have to cut the dose a lot.

And that can get a little tricky with, you know, a pea sized amount. On something a man would do four pumps, we just need like a quarter pump, because women need 10 times less the dose of men. But that bottle for a woman, that, that antigen bottle will last, you know, is maybe $50 and will last her about six months. Wow. What do you, what are some of the biggest fears that the women have with that? You'll kill them. That'll give them cancer and all of that has been completely blown out of the

water and it's just proven, but we're struggling to get that message. I mean to this day, like I have a petition to the FDA right now and, um, it's looking good that we're going to get a meeting to have the black box morning removed from vaginal estrogen and from the estrogen products you opened it up. And it's like, you will die of stroke, heart attack. It's it, it freaks people out of course. Right.

And that can, you get your testosterone. It's like, you could have a heart attack or liver failure or they just, they just remove that the black box from testosterone. Yeah, there was a little bit of that. So we're fighting for that for women. It's looking good. So stay tuned. Hopefully I'll have good news soon. Anything else on the horizon that you see that you're excited about? Like, are we, are we progressing in this area? Are we getting better? What do you, Yes. A lot more clinicians are getting menopause certified. A lot are getting interested in the space. A lot are just realizing where the gaps are. Like my

daughter in med school, like it's a priority for them. Even the guys in her class are, it's kind of a new way, you know, it's new and it's fun, exciting. There's a lot of research opportunities. So the kids are going after it. So many menopause papers are coming out. So that's great. There's great research looking at it, like I said, extending the life of the ovary, different medications that might work for that. And just in overall, that women are at least Gen X and below are like, this, I'm not gonna live like this. I want better than my mother had, I want better than my grandmother had, you know, I don't want to have this frail loss of independence and being dependent on my family for 10 years

while I decline and eventually die. And so women are getting excited about this last third of their lives and all the opportunities available to them and knowing they have to change their habits and stick to them in order to live that way. But it's like, for the first time, I'm seeing this generation really rise up and really want to take control of this part of their lives.

And it's pretty exciting to be a part of it. That's great. Now when someone starts, let's say they start with you or somebody who knows what they're doing, and they do the testing to rule out any inflammatory issues or lupus or anything else, like, okay, we're going to start you on

this hormone replacement therapy. Does it start like at a standard dose for most women and then you kind of work around and say, okay. Yeah. So like in the patch, for example, for estradiol, we have five strains. And depending on her age, her level of symptomatology, so for an older patient who's not super symptomatic, I'm going lower dose, right? For a younger patient who's very symptomatic, I'm going a little bit higher dose. But I tell the patients, this is trial and error. There's about 20% of patients are poor absorbers through the skin. So there could be some back and forth trial and error. We may need to try a different formulation. So there's a

lot. I wish I could just get a blood level and say, oh, this is what you need and have some tests to know how well she's gonna absorb the medication but we don't have that yet. So just telling the patient to be patient and know that this will be a little bit of back and forth till we find out that the kind of program that's gonna work for her because we're working in general with three hormones at once right? Yeah. Yeah, you know the estrogen the progesterone and then the testosterone for most patients as well. And each one of those poses something different. So you know, my anxiety is still kind of about, oh, probably progesterone, or this feels a little bit,

so probably that, okay. And are you finding that it's kind of becoming, that there's like a general range that you're tending to find most women within, or is it all over the place? So we don't have standardized, like what is the therapeutic range for estradiol? Does not exist.

And so when we're checking levels, I'm just making sure they're absorbing or they're not super absorbers. But for example, if my level is 100, which is totally fine and your level is 100, if you're a woman, you may feel like shit and I feel amazing. And so we'd have to up yours and still stay in a safe range. So we don't really have that, you know, what's the level that we're good, like thyroid, right? Or to stop scrown in general. I mean, some guys may feel great

and be completely functional at 400 and other guys need to go up to 800, right? It's kind of, we have to listen to the patient and let her be the judge. All right, so controversial one, question now. A woman who has previously survived breast cancer, can she do hormone replacement therapy? Because I've heard people say that. She can do vaginal estrogen 100%. Okay.

100%. Okay. So that's a given for almost everyone. Systemic, maybe. It depends on her stage, her age, her desires, her risk factors. What's happening is the conversation is only going around risk and not benefit for these patients. And breast cancer survivors are being left in the dust. These women are, it's a travesty what's happening to them, especially the ones put into surgical or iatrogenic menopause from chemotherapy or surgery. That they're like, you're lucky to be alive,

go out into the world and now they have osteoporosis and heart disease and diabetes. Cause no one addressed the loss of estrogen in their body. Right. Their libido is in the tank. They are having horrible pain, you know, and, and they're like, okay, you're alive. Bye. What about people, you said PCOS, you said yourself, what about PCOS?

Like that, that, Yeah. So there's a couple of like nuances PCOS PCOS, it's harder to make the diagnosis of peri because they are so much the same, right? Cap chronic inovulations are both very similar, but kind of treated similarly. So you really need someone who knows what they're doing. And then endometriosis, right? You can't just willfully give someone estrogen after endometriosis. You must give them progesterone.

You must do it at much higher levels than you would on another patient because we don't want to reactivate an endometriosis implant that didn't get treated or which could lead to malignancy in the future. You need someone who knows what they're doing. Where else are we missing really big? I mean, you talked about SSRI what they're doing. Where else are we missing really big? I mean, you talked about SSRI stuff. You talked about breast cancer. Where else are we missing big?

Libido, if you guys want to talk about it. I think knowing that so many women who other previously felt like they had, they were happy with their sexual life. Right. And then all of a sudden they're not happy, right. Or their partner's not happy,. They just never want to do it again. They don't care. I mean, this is, you know, we feel like when I talk, you know, I have several patients who are divorce

attorneys, and they love to tell me all the things. And so they feel like menopause is is a factor. Now, for some women, menopause gives them this permission to circle the wagons take care of me, cut the crap in their life. And for them, the divorce was needed. They're finally able to leave a relationship that wasn't serving them. But you know, I have these women coming in who are like, I love this man. I love my partner. He you know, they're amazing. They they, you know, take care of me that all the things and I we used to have this great sex life and now I just

don't want to be touched. And these are the women who are just coming in devastated by this. And I mean, it just opens my heart to be able to help them, right? And give them back that part of their life that just no one would talk to them about. They were ashamed or embarrassed to go to their regular GYN who they were never taught to do anything and to know that we have medication available. This is real. It's not your fault and you can, you don't have to live like this if you don't want to. Is it, is it common to see both desire and orgasms change or is it normally? Yeah, so one of the things if you think about, you know, the physiology of an orgasm for females,

we have to get blood flow to the area for a long enough time. We need to have stimulation to that area. The nerve conduction has to be working well. So, like in diabetes, in hypertension, you know, we can have disease processes that will decrease that. When we lose estrogen to the area, delayed orgasms become a thing, which gets really frustrating. You have decreased blood flow, so you don't have as much mucus production. So, for those patients, sometimes vaginal testosterone

like the DHEA suppository, which is Intrabrosa, it converts to estrogen and testosterone. That could be miraculous for these patients because we do have testosterone receptors in the vulva and like around the entroitus. So again, you need someone who knows what they're doing. It's, you know, what you don't want to tell the patient is relax, have some wine, go on a vacation,

blah, blah, blah, blah, blah. That's malpractice. Well, this has been great. Our audience really loved this. I really appreciate you coming on the show. You had to do it again for sure. Yes, and I was not aware of some of those symptoms that you mentioned, so I think that's absolutely fascinating.

And I'm so glad you have a list of doctors, because one of the challenges we have sometimes, we'll have someone come on the show. It's hard to refer. And then they're like, where do I go? Like, where do I go with this? So I'm so glad that you at least have a list of 3,000 doctors that people might be able to point to.

Yeah. All right, well thank you so much for coming on the show. You're welcome. Thank you. Thank you so much. You're awesome. Thank you. Bye bye.

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