unPAUSED with Dr. Mary Claire Haver - Dr. Mary Claire Haver on Menopause: Recorded Live from LA with Dr. Rena Malik

Episode Date: August 25, 2026

This episode of unPAUSED was recorded live at the Wiltern Theater in Los Angeles in front of an audience gathered to talk about perimenopause, menopause, hormones, sex, brain health, and bone health. Dr. Mary Claire Haver is joined on stage by Dr. Rena Malik, a board certified urologist, pelvic medicine specialist, and sexual health expert, for a wide ranging conversation about what is actually happening in women's bodies during the menopause transition, and what every woman navigating midlife health should know.The conversation moves through the zone of chaos that is perimenopause, the hormonal unpredictability behind mood changes, sleep disruption, brain fog, and rising inflammation. Dr. Haver traces how estrogen loss drives increases in cholesterol, insulin resistance, and cardiovascular risk, and explains why the fastest rate of bone loss happens in perimenopause, two years before a woman's final period, making a bone density baseline in your forties, not your sixties, the smarter move against osteoporosis later in life.Guest links:The ‘Pause LifeDr. Mary Claire Haver (Instagram)Dr. Mary Claire Haver (Facebook)Dr. Mary Claire Haver (YouTube)Dr. Mary Claire Haver (Substack)unPAUSED (Apple Podcasts)Books“The New Perimenopause,” by Dr. Mary Claire Haver“The New Menopause"⁠ by Dr. Mary Claire Haver“Estrogen Matters: Why Taking Hormones in Menopause Can Improve Women's Well-Being and Lengthen Their Lives -- Without Raising the Risk of Breast Cancer,” by Dr. Avrum Bluming

Today's episode is a little different. This conversation was originally recorded live at the Wiltern Theater in Los Angeles, in front of an audience of women who came ready to talk about perimenopause, menopause, hormones, sex, brain health, bone health, and all the things we still don't talk about nearly enough. I was joined on stage by my friend, Dr. Raina Malick, a board-certified urologists, pelvic medicine specialist, and sexual health expert, who has become one of the most trusted voices in this space. Raina and I had a wide-ranging conversation about what is actually happening to women's bodies during the menopause transition, and why so many of us, including physicians, were never really taught to understand it. We went deep into the zone of

chaos that is perimenopause. The changes in mood, sleep, cognition, metabolism, and inflammation. What women should know about hormone therapy and the legacy of the women's health initiative and why protecting your bones needs to start much earlier than most of us realize. We also talk candidly about sex, pain, desire, vaginal estrogen, testosterone, and how to advocate for yourself when your symptoms are dismissed or you're told everything is normal. And because we had a theater full of women, we got to hear from them. too. We answered audience questions about everything from hot flashes and libido to GLP1s, heart palpitations, and how to separate good menopause information from whatever somebody is

trying to sell you on social media. But the message I hope you take away from this conversation is one that we ended with that night. Perimenopause is inevitable. Suffering is not. We have tools, we have information, we have a community, and the more openly we talk about this, and the more openly we talk about this, the better it gets for every woman coming behind us. I'm Dr. Mary Claire Haver, a board-certified obstetrician and gynaecologist and certified menopause practitioner and adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to Unpaused, where we cut through the silence and talk about what it really takes for women to thrive in the second half of life. Our schedules are packed. Our brains are carrying a mental load. And the last thing we need is more

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Hey everybody. I was excited. I'm Dr. Rina Malick. I'm truly honored to host today, Dr. Mary Claire Haver. She is a dear friend of mine. And as you all know, she has done more for advancing women's health and midlife and anyone I know. So let's give it up for the most amazing human, wonderful person, girls' girl's girl, Dr. Mary Claire Haver. All right.

So as you guys all know, the new perimenopause is a New York Times bestseller. So let's start off. What inspired you to write the new perimenopause? Why was this the right time? Because when you look at the happiness curve for women, it's a U-Shapes. and the Nader is at 47 years old. That is your most unhappy. The most likely time for, and trigger warning,

for a woman to commit suicide is between the ages of 45 and 55. You know, when we look at women leaving their jobs, and when you look at the peak career level for women, it's at 47. And I'm like, can we connect the dots here, hormonally and see what's going on.

I was also bombarded on social media, thank you guys, with women who had read menopause and said, hey, I'm not quite there yet. What about me? I learned more about rare infectious diseases in medical school than I did about menopause. Me too.

You know, I know more about scurvy than perimenopause. We never said the word perimenopause. in medical school. And in my residency, I knew how to pronounce it, and that it was just a transition into menopause, but we had no perimenopause clinics. There's never been a single long-term study in the treatment of perimenopause. And women are suffering. They're getting blindsided. And I thought, I'm going to do the best I can with the data we have and put something together so that women don't suffer unnecessarily. And you have tools to help manage this.

Yeah. And the reality is there's not a lot of it. lot of data. There's very few studies on perimenopause. So if I look at, so let's kind of look at women's health overall. And if we look at the NIH budget in 2023, now things are changing rapidly, so I'm going to go back to some older data. The majority of that funding went to pregnancy, important stuff, happy to have it, right? And to breast and ovarian cancer. Almost nothing for menopause, which affects 51% of the population. Almost nothing for anemeterosis, almost nothing for fibroids, almost nothing for PCOS, okay? But if I go right now to PubMed today and I type in the word, PubMed is where we go look up medical research articles, you know, the really high quality stuff.

And I type in the word pregnancy, we get 1.2 million articles so important. I am a great obstetrician, right? I know so much about pregnancy, getting people pregnant, keeping them pregnant, making them unpregant when they need to be in postpartum care. If I type in the word menopause, we have 104,000 articles. So it's like 12 to 1 pregnancy versus menopause. But if I type in the word perimenopause, it's 7,000. So more women will have perimenopause than have a baby. Some women don't have children, right, than are ever going to be pregnant.

So when you think about what that funding, what those numbers represent, that's brain power, that's institutional drive, that is NIH funding, that is private funding. It's just not been prioritized in women's health. And thank God you wrote this book because it needs to be. So let's start with how do you define perimenopause? So perimenopause, you know, medically is defined. It's a very simple definition as the transition to full menopause. from normal menstrual cycles, but it represents, you know, so much more than that.

I was under the assumption that perimenopause, the ovaries just kind of gently declined until they petered out, and then you didn't have a period anymore, and then you were old. So, you know, and all of my 30, when I was 30, going through my residency. And what we know now is it is this biologically very complex transition. that is marked by this massive chaos of hormonal change. And it lasts seven to ten years for most of us, you know. It's such a long time to be going through symptoms that are life-changing. Yeah.

That are life-changing. So why is there so much misunderstanding about, like, even you, who's an OB-GYN, thought that your ovaries just slowly decline? Why is it so misunderstood? do it. So when I went back and looked at people who've tried to define, you know, there was a group that got together, and they've done it twice, and it was called the straw staging, and they looked at the menopause transition and what would look like hormonally, but they only looked at menstrual dysfunction, you know, when your cycles become disrupted, and hot flashes. No one was kind

of connecting the mental health, the brain fog, the sleep disruption, the, you know, from the brain down, like the cascade of symptoms throughout the body, it really wasn't focused on. And when you simply define the menopause transition as the presence or opposite of a hot flash in a period, I mean, the picture looks very, very different than what is actually happening to a woman. Yeah. So what should women be on the lookout for when they may be entering perimenopause? Okay. So menopause really starts in the brain. And the ovaries, are just two really innocent bystanders, you know, sitting here in our pelvis, waiting to be told what to do, okay?

The ovaries don't, unless there's a tumor situation going on, don't really function on their own. They need the signals coming from the brain to ovulate each month. So let's go to premenopause. Before menopause enters the chat. So human females are born with their entire egg supply. And your maximum egg count is when you're five months in utero. like the egg that made you was in your grandmother inside of your mom while she was a fetus inside of your mother. If you think about how magical that is, right? So we go through process

called atresia. We don't really understand, shocker, how that works very well. You know, men, she's a urologist, so she understands both sets of gonads. I only got to learn about one. So when men make their stuff fresh, yay, it's this magical factory, and they're just cranking out new DNA. We're stuck with what we're born with. So by the time we're 30, females are down to about 10% of the original egg supply. And by the time we're 40, it's 3%. Full menopause represents the end of your egg supply. So I like to talk about the zone of chaos in the book.

it's on the cover if you guys haven't read it. So here's what happens in premenopause. The brain, in a normal menstrual cycle, have you guys have seen it from biology class. You get this EKG kind of rise and fall of hormones. We don't have steady state hormones in our reproductive years. Estrogen peaks at ovulation, drops off, then we have a little bit of a hump of a secondary peak,

and then it flattens out again until the signals come from the brain to say, let's ovulate again. Okay? Gesteroom comes in the second half of the cycle after ovulation, then goes away. So the brain, there's a gland in our brain called the hypothalamus, and it is looking for estrogen. It's like, where is it, where is it, where is it? Our levels are good. Our levels are good. And when the levels drop off in a normal cycle, it's like, huh, we're getting low. We want the estrogen back. So it sends a stimulating signal to another part of the brain called the pituitary gland,

which then sends out something called LH and FSA. I'm simplifying something very complicated. And those are the two hormones that go and bind to the cells around the eggs that make the hormones and then make the ovulation. And you get this beautiful EKG-like pattern, month after month, until you hit perimenopause. Perimenopause is a critical egg threshold level where the signals coming from the brain, the ovaries become resistant because there's not enough eggs to respond in the same way. So the brain, the brain goes a little crazy. You know, the brain glitch The brain is like, where's the estrogen? And the rest of the brain is like, I sent those signals.

And the ovary's like, I can't, I'm trying. There's just not enough X-lap. And so the brain's like, where is my estrogen? So in compensation, the brain starts making higher and higher and higher levels of those stimulating hormones to make the ovary push that egg out. Okay. So ovulations become delayed to get that to happen. progesterone can never quite keep up like it used to.

So it used to monthly look like this beautiful EKG predictable. You know on day 14, day 21, day 28, she's going to be doing the same thing every month. Now I take spaghetti and we have the zone of chaos. LHFSA, estrogen and progesterone become very, very unpredictable. We do these crazy things called loop ovulations where we'll double ovulate without a progesterone surge in some cycles. And so we end up with way higher estrogen levels than we have ever had outside of pregnancy. You know, that will happen every now and then. And God bless the researcher who collected urine samples on these women in 1996. You know, she did premenopausal, perimenopausal,

postmenopausal for six months and compared their estrogen metabolites, progesterone metabolites, and was astounded. Okay, that was in 1996. I didn't even hear about this until 2021. Yeah. That's wild. You know, buried in. academic journals. This work has been done, but it wasn't prioritized, it wasn't shared, it wasn't made common knowledge in my field. Yeah, that's, I mean, it's a shame, right? 1997. Yeah. And we're talking about it now in 2020. Yes. So symptom-wise, what are people going to experience if it starts in the brain, what are they going to see? So chaos is going. So it turns out our neurotransmitters, things like dopamine.

serotonin, neuropinephrine. Those are the chemical signals that go between the neurons and our brain. They are directly affected by the levels of our steroid hormones,

of our estrogen, our progesterine, and testosterone as well. And so when the estrogen starts glitching, dopamine takes a huge hit. Okay? So that's where we start seeing mental health changes,

rage, anxiety, depression. When we just look at the data and we de-aggregate the data for age and we look at menopausal stage, how close or far is she from her last semester period, we double the rate of mental health disorders across the menopause transition. The rate of SSRI prescription doubles in this age group. So brain fog, cognitive disorders. Hard to quantify. The original testing for cognition was does she have Alzheimer's or not? Does she have dementia or not? Not was she a high functioning soccer mom who was juggling 90,000 things and getting the kids to school and now she can't fucking, you know, remember to do anything. And so, or she was a lawyer or nurse or doctor or teacher

and she had this busy, beautiful, complicated life and she could roll with the punches and she had it managed. And now she's lost her resilience. I can't tell you time after time after time. patients would come to me and complain, I don't feel like myself. Yeah. I don't understand what's happening. Like, I have no new stressors. No one died. I haven't lost my job.

My husband loves me. Like, there's no external thing going on. I'm not well. And there was a paper last year that came out and presented at the menopause society called I don't feel like myself. And now it's a medical diagnosis. And it's all to do with perimenopause. Sleep disruption.

progesterone helps with sleep. And it goes away. Estradial helps with sleep. And we get these crazy erratic patterns. So, you know, it's this quadrangle, usually in the brain of women coming in, and you just can't figure out what's wrong, but you're not functioning the way you used to. Yeah. And I think patients feel like they're going crazy.

Yeah. They literally think that something is wrong. So I went to the bitches be a little crazy school of medicine. We were taught. that women tend to somatize psychological disorders. And that men didn't do that in general. That if you can't figure it out, she's probably just a little crazy.

Yeah. Are we all collectively going crazy between the ages of 35 and 45? Yes, everyone's depression, like going 31 times higher than it did the entire, their entire life? rest of their life. Yeah.

Or your well-managed depression, that you had your meds on board, everything was fine, and all of a sudden you're breaking through. As someone who takes care of men, men also sematicize their mental health issues. It is not. So let's talk about, you know, as we're talking about this, a lot of women are told, this is just stress, this is just aging, your kids are getting older, your parents are getting older, just deal with it, right? How can women push back and advocate for themselves?

So all of those things are usually happening at the same time. You know, we're in this sandwich generation watching our parents' age, trying to help them manage that journey, kids at different ages, job stress, you know, all the things going on. But here's what my patients tell me. I built this life on purpose. I had systems in place to help me manage this life, and I'm not managing.

and I can't help me figure out what's going on. So new systems have to be in place, right? Hormone therapy can go a long way, and it can be miraculous, but new system, you know, that's a tool in the toolkit. The other tools are stress management, putting up boundaries, saying no, telling your husband to stop chewing. Misophonia is real. No, I've had meals next to this sweet man for 33 years.

And in the last five, I cannot tolerate gustatory noise at all coming from him. It's not fair to him. I mean, poor guy, he's just having a sandwich. And I'm like, yeah, I had to invest in your plugs. But yeah, systems are so important. And I think we need to give ourselves grace, right? Like we are going through this zone of chaos. Our bodies are biologically changing.

And so it's okay if we need a little more help. Yes. I mean, giving ourselves grace, right? Understanding this isn't your problem. It's why I wrote the book. It's a validation tool. Every single woman in this room, if we're lucky to live long enough, is going to go through perimenopause and then menopause.

This is inevitable. It is a normal meaning common biological transition, right? It doesn't have to be pathologized, but it doesn't mean it's not without big life changes and losing the ability to manage the life you built. Yeah. We spend a lot of time thinking about what we put in our bodies. We choose foods that nourish us. We talk about supplements.

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Bareminerals.com. This podcast is sponsored by Midi Health. Have you noticed the conversation around menopause is suddenly everywhere? It's trending on social media. Celebrities are opening up about their symptoms. And conversations that used to happen in whispers are finally out in the open. And honestly, it's about time. For decades, women were dismissed, ignored, or told their symptoms were just part of aging.

And while I'm glad the conversation is happening, here's the truth. Menopause care isn't a trend. It's long overdue medical care that women have always deserved. If you've been listening to me, you know this isn't new territory for me. This is my life's work. Helping women navigate perimenopause and menopause with real science. That's why I want to tell you about Midi health. Midi is a virtual menopause clinic staffed by clinicians who listen, who take your symptoms

seriously, and never utter the words, it's all in your head. Like me, Midi focuses on your health span, not just your lifespan. That means taking a comprehensive look at your metabolic health, bone density, cardiovascular risk, and cognitive function because all of it matters. METI delivers the kind of proactive evidence-based care I've always believed women deserve. And the best part, women in all 50 states can access personalized care, and it's almost always covered by insurance. So yes, I'm glad menopause is finally getting attention, but don't settle for noise. Get care from clinicians who are in this with you for the long haul.

Book your virtual visit today at join midi.com. That's join M-I-D-I-D-com. So let's talk a little bit about how perimenopause affects brain health, mood, and cognitive function. So from a brain perspective, when you talk to the brain scientists, you know, we talk to Lisa Mosconi and Luis Nicola, you know, these PhDs who study brain health and particularly Alzheimer's. In menopause, you know, so there's a difference between brain. brain fog and dementia. Okay?

And Lisa explains it the best. Brain fog is, I can't find my keys. Dementia is, I don't know what these keys are for. Big difference, right? Because the tests were developed to see if you had dementia, it's really hard to quantify brain fog, but you just ask a woman, she'll tell you. You know, you get in the car, you don't know where you're going,

you walk into a room, you can't remember why you got there. You can't remember the word of that thing that's on the table over there. I was in the OR asking for instruments. I was like, you know, the one with the square in right now, just pop it in my hand. You know, and that wasn't the hainy. You know, those were tools that I had used for 25 years, and I could not get the name to come up. Word salad, you know. That's brain fog.

Your brain is undergoing a tremendous transition. So not only are our neurotransmitters changing the levels at which they operate through the transition, we're rewiring the brain. And we actually come out the, other end that are problem solvers. It's not necessarily all negative, but the transition could be pretty harrowing. You know, women are leaving relationships, leaving jobs through this transition, when they just need support while the brain kind of rewires for the next 30 years. Another thing that happens is how we utilize glucose changes. We rely, it's harder for glucose

to get where it needs to get in the brain, especially in the amygdala that controls our emotions, our emotional response center, and in the frontal cortex where memories are stored, so you're more forgetful of things that used to just come so easy to you. Yeah, and so how can we support ourselves through that transition? So, you know, know that you're okay,

you're going to be fine. That's, you know, you're not crazy, and you're probably not developing Alzheimer's. So if it doesn't get better and the things we ask you to put in place, So there's nutritional things. Like when patients come to me, we're doing blood work. Usually in perimenopause, not so much hormones,

because the levels fluctuate so much. A one-time blood urine saliva tests for estrogen progesterone is usually not super diagnostic. So we actually have to listen to the patient and believe her. Yeah. Revolutionary, right? But I do do a lot of blood work, typically. I'm doing things like, you know, the basics. Like you would get at a woolwoman exam, a seat.

you know, CBC, sorry, basic blood count, looking for anemia. But we're going a lot deeper. So we're doing, not only your Olympic panel, we're doing an LP little A, which is now recommended by the American Heart Association, LP little A, these are really specific markers for cardiovascular disease and an ApoB. So you guys should be looking at having that done. We're doing a deeper dive. We're not looking just for anemia.

We're looking for iron stores, right? That's the first thing to go. So we're looking at ferritin levels. Is she low in iron? Is this something easy to fix? everyone should know your vitamin D level, everybody in here. So vitamin D is one of the most common deficiencies we see, so there's low, and then there's not optimal.

So the way we measure in the U.S., most labs typically a level of 30, below 30 would be considered deficient. That's a crisis, right? If you're below 30, vitamin D is hard to get enough in our diets, you know, and super easy to supplement. So vitamin D, we're checking inflammation markers. I mean, I just want to make sure I'm not missing anything because so many things can be true at the same time. Does she have an autoimmune disease?

Is it hypothyroidism? Like, I can't tell you how I've diagnosed lupus in my clinic. I've diagnosed so many things that women were kind of brushed themselves off, weren't, you know, didn't know how to advocate for themselves at the doctor's office. Oh, your labs are normal. They weren't looking deep enough, you know, for us to be able to intervene. Yeah. So then we fix the deficiencies and we talk about possible hormone therapy and how that might be. might be helpful for her. I think a lot of people are struggling with in that perimenopausal transition

talking about hormone therapy. How do they bring it up with their doctors? And do they get pushback? Oh, you're not in menopause yet. Yeah. So a lot of, you know, if you can find a clinician who's willing to talk to you about hormone therapy, a lot of them are nervous in perimenopause because, again, it's not their fault. It's lack of training, right? So if they haven't sought training outside of the traditional OBGYN, internal medicine, family medicine, It could be anybody, right? Then if they're not certified by menopause society, which isn't perfect, but it's a nice thing to have, you know, you really need a clinician who's informed.

So a lot of you will hear, you have to wait until you've gone to your formally menopausal, which is one year without a period. But actually, we know now that's not true. You know, when we look at the mental health data, women were treated with transdermal, usually estrogenal patch for mental, new onset mental health disorders, and they were responding better in perimenopause than with the traditional SSRIs. Things like, you know, Prozac and things.

You know, good drugs, but I think we're massively over-utilizing them rather than giving them some hormone support during this time. Yeah, absolutely. And so I think what you're getting at is get a second opinion if you feel like you're getting that pushback. Yeah. Because it is an appropriate discussion to have. And, you know, it's not your clinician's fault.

We're busy. You know, most clinicians, out there are having to, you know, forced to see patients in 10, 15-minute visits. Nobody wants to do that. That is being controlled by forces outside of them. And so another caveat is that this isn't your well-woman exam. Your well-woman exam is your screening for breast and cervical cancer, really. And so they might get some basic labs. But if you want to go in to talk about menopause or perimenopause, that should probably, if you're using insurance, that should be a problem visit. You know, schedule extra time. Let the staff know how to time why you're coming.

ask if they're comfortable talking about this, do they treat women in perimenopause? Yeah, before you hit the door. Save yourself some time in a copay. So you talked about inflammation. I want to read a passage from your book, page 253. It says, why inflammation increases in perimenopause? Estrogen is a powerful anti-inflammatory hormone. It downregulates the expression of pro-inflammatory cytokines like IL6 and TNF alpha and helps maintain gut. barrier integrity and vascular health. When estrogen begins, it's unpredictable decline in perimenopause.

This regulatory function falters. This is really powerful. Explain this to people. What's happening? What does it mean when they're having this inflammation increase? So female bodies work better with estrogen on board. There's no denying that, right? And when that goes away, why?

estrogen serves multiple functions in the body, not just for reproduction, which is an important part, but it is a powerful anti-inflammatory hormone. And we remove that protection. We see inflammation increase. We see, you know, markers of inflammation in the blood go up with no changes in diet, no changes in exercise, no new chronic disease states. We see the rate of metabolic syndrome double across the menopause transition. That's increasing waist circumference, increasing blood pressure. So estrogen makes our blood vessels. It gives them more pliancy, more elasticity, and when we remove that, they become stiffer and blood pressure goes up. It's protective in the liver. So the way that we clear our LDL changes, and so LDL levels rise. I mean,

whose LDL rose? And you're like, wait a minute, I've done nothing different, right? So all of a sudden you have high cholesterol. So we see about a 20% increase in LDL across the menopause transition. And LP little A goes up a smidge as well. So we used to think LPA little A was just genetic, and you check it once, and you have it or you don't. But if you've had it in premenopause, you need to check it in postmenopause because it may creep up on you. So insulin resistance, that's another huge one. So we see, you know, we have diabetes, pre-diabetes, and then we have insulin resistance, and we can measure that with something called the Homa IR score.

It's a little algorithm we use where we look at a fasting insulin and fasting glucose level. and then we can plug those numbers basically. You can go online and get an app and plug those numbers in and it will tell you what is your HOMA-I-R score, H-O-M-A-I-R, if you want to look it up, and you can do it yourself. And so if it's less than two, you're good,

but if it's more than two, you are considered to be insulin-resistant, meaning your body is using more insulin than a healthier person with the same glucose load, you know, to get that glucose into the cell. And high insulin levels, high-glucose levels, cause inflammation on their own. So we just kind of end up in this like traffic circle where

everything's feeding towards inflammation. And that's going to disrupt your sleep and drive more fat to the abdomen and your sleep's disrupted because your hormones are going crazy. And it's 3 a.m. 317 and you're like, when I was in second grade, I took an apple from the teacher's desk and I really should have not done that. I need to, you know, confess. And yeah. Yeah. It's just too relatable. So, you know, I think there's so much confusion about hormone therapy, and a lot of that started with the women's health initiative. Yeah. And it really shaped, in a way, a whole generation of women. Can you walk us through what happened and how we ended up here? So Women's Health Initiative was, there was a female director for the National Institutive Health for the first time ever. And we had a ton of data on women and health and health. hormone therapy. So at the time of the women's health initiative, about 40% of menopausal

women were on some form of hormone therapy. And back then, the most common form was primarin or primpro, which is conjugated equine estrogens plus metroproxyprogesterone acetate. And no big deal, right? That's what people got. So they decided, and they knew that women who were on HRT tended to have less heart disease. Okay. Well, did they tend to have less heart disease? Because this is observational data. This is not a randomized controlled trial. Did they really have lower heart disease or it's just that these women were healthier, wealthier, had more access to health care, they tended to be Caucasian, you know, is this a real thing, a real finding? So we look at observational data to make these assumptions, and then we do randomized controlled trials to prove it. Okay,

so we were going to prove. So at the time, it was a billion-dollar study to study women's health. I mean, we were excited. I mean, I was like, yes, this is, you know, we know, we think estrogen's great, and women do so well on it. And, you know, it probably prevents heart disease, but we're going to get that proven. So they collect, God, I think over 30,000 women for the study. Because in what they were looking for was heart attacks, right, heart disease,

the average age of the study was 63 years old, really. You know, women have heart attacks in their 60, 70s, 80s. So they couldn't start at the average age of me. menopause because it would be so expensive to study the women for that long, right? So they started with a little bit older population. And then they also measured breast cancer and other things. You know, they had lots of men, but that wasn't the end point of the study. And Dr. Blooming's here somewhere, and he tells the story way better than me because he

was kind of there. But if you haven't read estrogen matters right now, download it. And this book is like magical, and it changed my life. And so basically, there was a signal, meaning. there were two arms. You got estrogen only if you'd had hysterectomy, or you got the combined if you still had a uterus, and they give everybody the meds, and off they go, and they start measuring. A couple of years in, there's a signal in the estrogen progestin group that it's not statistically significant, but it was a slightly increased risk of breast cancer. It was very, very small.

Like four out of, like, a thousand. I mean, it was so small. But a press conference gets called. A paper gets written without, you know, this was done at multiple centers, like over a dozen centers in the U.S. and just a couple of the researchers get together and they write a paper that says basically estrogen causes breast cancer

for lack of a better thing. And the estrogen-only arm, by the way, did not show an increased risk, actually showed a decreased risk, the women who were just doing the primaran by itself. And the women who were on the combined were diagnosed at a lower stage and had a better

survival rate than the women who were not on anything. So, you know, because we had a placebo arm, right? And then nobody knew who got what, okay? They excluded women with hot flashes. Why? Because they'd know if they were on the medication or not. What was hormone therapy developed for to stop a hot flash? So those women were out of the trial. Like there were so many little like, this makes no sense. But what happened was this thing went viral before there was viral. It was the number one medical news story of 2002. A genie got out of a bottle that took 23, 24, 25 years to get back in. So I was my chief year, the end of my chief year.

And I remember the whispers in Eminem, which is our morbidity and mortality conference. You know, we have once a week where we review cases and all the faculty. The faculty are all arguing in the back. And they, no one had, they couldn't, when they did the press announcement, no one had read the study. It wasn't even published yet. And so this was before the internet where I can go right now on PubMed and pull up whatever I want and read it. But like, you had to wait for the journal to be mailed and delivered to your house and then, you know, read it and then call your buddy and see what he thought.

Like, the Internet's changed a lot of that now. We're a lot faster to disseminate information. But like, just the verbiage around it and the way people felt about hormone therapy really, really, really. changed. I was scared. I was very hesitant to prescribe it. I was doing anything and everything to prescribe other things before I would give hormone therapy because I was under the impression. And I think that carried for a lot of clinicians for a long time. It wasn't until I was sitting at a menopause conference four years ago. My first one, I was invited to speak on a panel about nutrition and menopause. But I sat in that audience and I watched Dr. Blooming and Dr. Taveris

and Dr. Malone sit on that stage. and break down what happened with the WHOI. And I had tears in my eyes. How did I not know this? Why at this? I was a good girl. I did all my CMEs. I read all my articles.

I was a straight-A student. I blew the top off my boards, and no one had sat me down and prioritized menopause for me as an OBGYN. And I thought, what are we doing? Yeah. And it was that moment I decided to pivot. I'm like, nutrition is a huge part of what I preach,

but like I want to I need to talk about menopause. I need to talk about hormone therapy and I need to talk about brains and bones because all of the speakers at this conference were connecting the dots for me about the multi-organ system effects of menopause and how there's estrogen receptors everywhere. Yeah.

And how women are suffering really needlessly and we need to change the way we educate our clinicians. It's amazing how the media can pick something up and transform it to something it's not. and everyone believes it. Because very few people actually read the papers. Right. Very few people go and look at it.

Yeah. Until 2021, 2021. Yeah. And it's a real shame because a lot of women were told that they couldn't, we would be giving them cancer by giving them harm with therapy. So in 2022, the guidelines from the Menopause Society. So as an OBGYN board certified, I follow the American College of OBGYN. Okay, you have a similar board.

What is it? Urological association. Yeah. So the AUA, we're ACOG. Very complicated. And so ACOG guidelines for menopause hormone therapy have not changed since 2014. They still say the lowest dose

for the shortest amount of time and only in postmenopause. No mention of perimenopause. Menopause society was a rogue organization that formed from a bunch of docs. Wolf-Udian, if I say it right, formed it. And it was just like some concerned people

who wanted to learn more and talk about menopause, it's not recognized by ACOG. And their guidelines have not been picked up. So, like, if you're a board-certified OBGYN, and I'd never heard of the menopause society until I was at that first meeting. I didn't even know such a thing existed. Yeah.

And as a urologist, we learned nothing about menopause, but I was shocked when I first found out that OBGYNs weren't managing it, and they weren't taking care of it. And that's why I learned about menopause, because I was like, who was taking care of all the women? Right. Where are all the Viagra-laden penis is going? Exactly. Exactly.

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That's wherefigs.com code FigsRX. Yeah. So absolutely. Well, let's talk about sex. Okay. So perimenopause changes sex for women. It changes libido. It changes their vulvar architecture.

Let's talk about it. So when I have a patient who comes to me in clinic and says, Dr. Haver, they usually just call Mary Claire or whatever, I'm not happy with my sex life. This is not a band-aid, right? It's not a cookie cutter. We start diving in. There's kind of four to five areas, and they could overlap. But I'm like, how's your relationship?

Is this a relationship? disorder, right? Do you feel supported by your partner? Do you love your partner? And they're like, oh my God, I hate him. And I'm like, well, nothing in my toolkit is really going to help you, you know. So, okay, so we rule that out quickly. I have extensive, you know, questionnaires that patients come before they fill out before they come, and we do one for sexual health. And it's, are you having pain? So we have a pain disorder, right? And the majority of that pain, if it's new, is generally urinary syndrome of menopause, right? The thinning, the loss of elasticity, the dryness.

Okay, that's a blood flow problem. That is a skin architecture problem. There's also arousal disorders. So again, another blood flow problem. That is what men tend to have. That is erectile dysfunction. That's our equivalent. You can't get the blood flow going,

and that could be because of diabetes, you know, could be because of the arteries of narrowing from, you know, microscopic, arthroscopic, arthrosclerotic disease in that area. I mean, there's lots of ways. And then there's desire disorder as well. So desire is what happens in the brain. And that is like, this is a good idea. And desire is complicated for a lot of people. And so my question, you know, my questions to the patients are, did you ever have good desire? Did you ever want to do this on a regular basis? Did you look forward to it? Was it fun? You know, and now that's changed. And do you miss it? We have to

normalize that I've had patients tell me, I don't care if I never have desire again. And I'm like, okay. You know, you have to want it back. It has to be a problem, right? We don't want to pathologize what could be normal for some people. Asexuality is the thing. And so they're like, I miss it. I want it back. So pain we fix first. I don't start going into desire until we get normal anatomy back, right? Most humans don't want to do things that hurt that are supposed to be pleasurable. There's a few. That's okay.

Yeah, that's okay too. But so we treat vaginal estrogen, is it vulva dinia, you know, the pain is not always GSM, but for a menopausal woman who never had pain before, it usually is that. So we go right into treatment with some kind of. of local estrogen in the vagina. Typically because of cost and ease of use, we're doing the vaginal estrogen cream. So we get the pain fixed, and sometimes they come back and they're like, we're all good. It doesn't hurt anymore. My brain's like, yes, let's do this again. But sometimes they come back and they're like, still struggling. So then we start talking about, you know,

desire is a mood, right? And what do we know works for desire? Certainly if you are, if you surgical menopause or premature menopause, testosterone is your friend. We know we have great data. That's the best data for testosterone. The data is decent for menopausal women. Where we don't have data because no one cares about perimenopausal, isn't perimenopause, but I treat them anyway. So a trial of testosterone, or there are two FDA-approved medications. One does have an indication for perimenopause now. And one is called Adi, and the other is by leasy. So Adi is philbastirin. That one.

And so I like to say, Adi, it's easier. But it's a medication you take every day. It works by upregulating dopamine. Remember what's happening to dopamine in our brains? Dopamine is that hormone that's like, I want to have a good time. This is my reward, my fulfillment, my, you know. So Viglisi also increases dopamine, but it is an injection that we would give a patient 30 to 45 minutes before the onset of intercourse.

and it causes melanocortin to release, which then upregulates dopamine. And when it works, it works really well. And patients can like it. But a lot of my patients are hesitant to, like, do an injection with a potential praying manis on the other end going, is it working? Is it working? Is it working? Where the addie is just, you take it every day, and it's just kind of there in the background.

Yeah, I will say, I think from taking care of women with low desire, when you get your desire, when you get your desire back, you feel like yourself again. You really do. And it's okay. I think we need to normalize wanting desire. Like, it is okay to want that back. And it's important to talk to your doctors about it. So my testosterone story, and my husband is not here, but he's heard me tell it in public.

God bless him. I have low muscle mass. I've always been thin. It's something I've struggled with. And I'm just doubling down at the gym and working so hard to, like, get muscle so I don't die at 80. And I read, you know, studies that said women with naturally higher levels of testosterone have lower frailty scores, have better muscle mass. And I was like, you know, I'll try it. I'll, you know, I checked my levels. They were on the lower end for my age,

you know, nothing crazy, but I'm like, I'll do a trial of this. And I would not have qualified because we have a scoring system for HSDD, hypoactive sexual desire disorder. We did it when we did it was fine. You know, nobody was complaining. However, I go on this med to, for my muscle mass, and there's a little uptick in the area. Got better. So, and I would miss it if it was gone. And I didn't qualify to say this is a problem, but it just kind of like put a little pep in my step, and everybody's happier in my house. I mean, sex is great. Orgasms are great. Yeah, Our organisms are great. I want to talk about something that's really relevant right now.

The Black Box warning was removed. Yay. Yay! Woo! A lot of hard work from a lot of people to get that removed. Yeah. Really important. But there is a shortage of estrogen patches.

What can we do? Okay. There is a shortage of estrogen patches. There is also, I'm reading in some areas, and this is kind of how estrogen patches started, a shortage of vaginal estrogen, which scares me even more. because our elder generation really needs it.

So we have sprays, we have gels, we have other forms, we have oral, okay? Most people are great candidates for oral estrogen therapy. There's plenty of that. They're not going to run out of that, and it's $2. Generic, okay? So don't be afraid to switch a formulation, shop around, call ahead. I am with Express Scripts. So far, they still have my patches.

So you have to get a little creative about it. but we do have other options. There's plenty of estrogenial out there. And compounding, you know, this might be a good stop gap until we can get the supply back up. If anybody wants to open an estrogenial factory, I'm in. You've got your investors right here. Okay.

So we've talked about mood. We've talked about sex. But hormones also prevent osteoporosis. Yeah. What is the connection between estrogen and our bones? Okay. So our bones are constantly remodeling. like Pac-Man.

So you have Pac-Man. That's why anybody ever broke a bone? Most of us have broken something. And so that, you know, if it's a non-community fracture, meaning the bones are still lined up, they just stick a cast on it and they heal all by themselves. Why? Because we're constantly chewing up old bone

and pooping out. Le Peckman are chew and poop out bone. Okay, I'm very simplistic. Any orthopedic surgeons out there are dying. And so... No, they probably like it. Estrogen is very much in control of this. process in women. And what key factor to remember is that men have estrogen too. And when we go

through menopause, our estrogen levels drop lower than men's baseline. Okay? So people are like, well, men don't have this. I'm like, you never lose your estrogen, right? You just have a slow, steady state baseline. So when a woman loses all of her estrogen, the resorption rates increase. We can't, we're chewing up more bone than we can lay down behind it. And so, and we reach our peak bone density as women, somewhere in our 20s, you know, maybe early 30s. And that's kind of the bank of your bone that you build. So this is the lesson I'm trying to give my kids is like, jump, lift, don't just do poli, I love polities, you know, just keep those bones as healthy as you can because then the aging process and then menopause, you know, the fastest rate of bone loss is in peri menopause,

two years before your period stops. So, you know, I think waiting till 65 is a mistake. do not allow insurance to dictate your health care if you take nothing else from me today so i think it is a worthy investment it doesn't take much to get it covered by insurance at a younger age you need one risk factor okay if you smoke if you're low weight if your mother you know was shrinking if she has lost to your purse you know throw those risk factors and they're all in the book throw those risk factors out there and see if insurance will cover at a younger age i get them in perimenopause on my patients They want to know their baselines because the younger you are, the easier it is to grow more bone. You can grow bone at any age.

Let me be clear. The studies were done in women well into their 80s and 70s and 80s. And just from lifting, they grew bone. So it is reversible, but it gets harder as we age, right? And so gets your bone density. It's $99 in Houston if you want to pay out of pocket. I think that's a worthy investment in your health. Because why?

Why do we care? Because 50% of you right now, if things say, the way they are, are going to fracture before you die. And if you break your hip, 30% of us will die in that first year with surgery. If you're not healthy enough or you can't afford the surgery, 79% in that first year. And these are not good years.

I know it because my mother's living it. She fractured her hip over a year ago. She has not walked since. She fell out of the bed almost exactly a year later and fractured her pelvis in three places. And she has Alzheimer's. This was preventable. She got bad advice.

She did everything the doctor told her. She dieted. She tried to be thin. She drank too much. She didn't take, she didn't check her vitamin D, didn't know what her calcium intake was. She didn't do the things. She was told to be thin and you'll be fine.

And not take home on therapy because it would give her breast cancer. And now she's, you know, can't remember anything. She deserved better. She did. And you all deserve better. Yeah. We all deserve better. And yeah, you lose one to two percent, you lose one to two percent of your bone every year.

Yeah. Starting in perimenopause. Yeah. That's a lot. And it just chips away. Okay. So you've talked about what we can do, jumping, lifting. Yeah.

So I, with my patients who come in with low bone density, it's a multifactual approach, right? And not everybody with osteoporosis fractures, you know, don't fall. how do you not fall balance work on your balance balance balance on one foot you know brush your teeth standing on one foot like purposefully work on your balance you know yoga has a lot of great balance poses in there jumping lots of studies done on jumping all you need is eight inches jumping for like 10 minutes couple of times a week three times a week okay i would not go out rush out and buy a vibration plate i don't you know there's way better ways to improve your bone HRT will always protect your bones, always, no matter what age you are, okay? And it doesn't take much. Adequate vitamin D

intake, so low vitamin D levels are about 60% of you. If you're not supplementing with vitamin D, we'll have a low vitamin D level. Please get your level check, know where they're at. Such an easy thing to supplement. And adequate calcium intake. Calcium supplements don't prevent bone fractures, but diets rich in calcium do, there's a difference. So make sure you're getting your calcium from food. So we've talked about things that people can do. And lift heavy, lift heavy, yeah. Yes, lift.

Everyone should be lifting. So we've talked about what women can do, you know, to protect their mom. But what about women in their 20s and 30s? What should they be doing now to set themselves up to ease this transition and to be as healthy as possible? Vote. Besides that. Don't take your health for granted. I mean, I'm just trying to get my 22-year-old to wear sunscreen.

So she likes to tan. don't worry about being skinny. I know there's some young people out there. Your curves are genetic. Embrace that. Vesceral fat, the intra-abdominal fat that causes increased inflammation is very different than rocking some curves back here.

Okay? Bigger butts are more healthy. Okay? Embrace it. Don't try to diet your way to look a certain way or to look like a 14-year-old. We're learning who gave us that mentality, right,

from all what's happening in the world right now. So, you know, work to be stronger. Bones and muscles weigh a lot. Get a bigger body. Take up space. Use your voice. Yes. Yes.

You matter. All vaginas matter, but, you know, and all vaginas need estrogen. Yes. Yes, they do. Welcome back to another midi pause. I'm Dr. Mary Claire Haver, host of Unpaused. Let's talk about something so many women experienced during menopause,

but don't always connect to menopause, anxiety and depression. When people think about menopause, they usually think about hot flashes. But for a lot of women, the emotional and mental symptoms can be just as disruptive, sometimes even more. you might suddenly feel anxious for no obvious reason. You may wake up every night at 3 a.m. and not be able to fall back asleep. Or maybe you feel emotionally flat, overwhelmed, irritable, are just unlike yourself. And the important thing to know is this isn't all in your head. Hormonal shifts during menopause can directly impact mood, stress response, and sleep regulation. changes in estrogen and progesterone can affect neurotransmitters like serotonin and dopamine,

which play a huge role in emotional well-being and sleep quality. These symptoms are often the first signs of the hormonal shift known as perimenopause. But here's where so many women get frustrated. When they bring these symptoms up, they're either dismissed or immediately handed a quick fix without looking at the bigger picture. Managing your health at this stage of life can be complex, and every woman needs a menopause-trained clinician who's there to answer questions, discuss the risks and benefits of hormone therapy, and figure out the best way to help you thrive. That's why having access to specialized menopause care

matters so much and why Midi Health is such an important resource. Midi connects women with clinicians who actually understand the connection between menopause and mental health. Instead of treating symptoms in isolation, they take a more comprehensive approach, looking at hormones, lifestyle health factors, stress, sleep quality, and overall health together. And that personalized care can make a huge difference. For some women, that may mean hormone therapy. For others, it could mean sleep support, nutrition changes, stress management tools, or non-hormonal treatment options. The point is, there isn't a one-size-fits-all solution, and Mitty helps women figure out what works best for their body and their symptoms. And the convenience matters, too.

Being able to access expert care virtually from home makes these conversations so much more approachable, especially for women who may have spent years feeling unheard or brushed off. Because menopause doesn't just affect you physically. It can affect your emotional health, your relationships, your confidence, and your quality of life. So if your anxiety feels higher lately, if your sleep has suddenly changed, or if you just don't feel like yourself, don't ignore it. Ask questions, seek support, and know that better menopause care and better understanding does exist. Go to join midi.com. Join MIDI.com and connect with one of their clinicians today.

All right. We are going to move to the questions you guys asked with the QR code. So first question, postmenopausal for 10 years with no symptoms, based on HRT benefits, is a still recommended. So when we look at benefits of HRT, right, it's always going to be beneficial for hot flashes, no matter your age. And we used to think that there was a, you know, the prevailing wisdom, which was absolutely wrong, was that, you'll only have hot flashes for four years. Not true, okay? If you're a woman of color, you're going to have hot flashes, I don't know, 28 years, who even knows? So it will always benefit you to decrease hot flashes. Hot flashes are a red flag for risk of cardiovascular disease are very sleep disruptive. Like sleep is great. Sleep is

gold. Sleep is everything. And so if your hot flashes are waking you up, it's always going to be helpful for that. There is a window of opportunity for cardiovascular disease. Okay? Estrogen becomes a very preventative thing, but not so much curative. So women with estrogen on board have a delayed accumulation of plaques, delayed accumulation of atherosclerosis. So, but once those disease process start, estrogen doesn't really help to reverse, as far as we understand, doesn't really help to reverse that. So the further you are away from your menopause, you're losing the cardiovascular benefit. That's where the 60-year-old 10-year thing came from. It doesn't mean you can't have it. You may have lost the majority of your cardiovascular benefit, but it's always going to help your bones forever.

So if you start, and you can enjoy cardiovascular preventative protection for years and years and years, if you started early enough. But it doesn't mean you're not a candidate at a certain age. I mean the 2022 guidelines, it doesn't say stop at 60 or stop at 65 or stop at a random age. If you're on it and you're happy and you're healthy and it's your bones are kicking and your brain is swimming and you're having lots of sex, stay on it. It's fine. Absolutely. And the bone thing is so critical. It is FDA approved for the prevention. Nothing is FDA approved for the prevention of osteoporosis except hormone therapy. And if your clinician isn't is like, oh, you don't have hot flashes. you don't need this, you deserve that conversation.

Protect your bones. Next question. Parimenopause and menopause information is a hot topic at the moment. How do we vet the information and avoid being taken advantage of being sold things that are not useful or could be harmful? So, I mean, most of this is like swirling around social media, right? So if you're not on social media, you're probably fine. But look at credentials, you know, who's... giving you this information, what are they, who are they? If they say doctor in the title,

but they don't fully qualify their, you know, if they're a DO, if they're an MD, if they're a chiropractor, if they're whatever. I mean, it doesn't matter. Like, where's this information coming from? What studies are they quoting? If it seems too good to be true, it probably is. And let me be clear, no supplement, and this is a doctor who sell supplements, is going to resuscitate the health of your ovaries. It doesn't happen. So if, and it's not going to bring back your sex life and it's not going to grow bone, you know. So you, buyer beware. If it seems too good to be true, it probably is. Look at the credentials of who this is. If they're leading you down a rabbit hole of, you know, click here and go over here and da-da-da-da-da. Just be careful. There are people

who see this movement and are trying to capitalize on it not in a good way. Follow estrogen matters right now. Get out your phones. One of the best resources. Doctor, if your breast cancers survivor, pre-viver, Dr. Karenman, you know, Dr. Sharon Malone, Dr. Rachel Rubin, Dr. Kelly Casperson, Dr. Suzanne Gilbert, who's here. There are so many, you know, Dr. Malik, there are so many great providers out there doing incredible medical education and medical communication. So just follow them. Yeah. And I list them all in the book. If you look in the acknowledgments in the back, those are the people you want to follow. Yes, yes. And look, She sells supplements, but you'll never see her talking about them on her platform.

It is all education. And that's where you know. Her goal here is a talk about education. People who are trying to educate you without trying to lead you down some marketing rabbit hole. Like, that's a good sign. Yeah. We sell like vitamin D and fiber. So, yeah.

They're great. Not menopause cures. Believe me, I would sell it if we could figure out one. Yeah. And if someone tells you, oh, I got the secret and no one's telling you, trust me. If there was something we could do to make your... life better? We would do it.

Yeah. We would do it. Peptides don't cure menopause either. Sorry. Yeah. All right. What is up with these night sweats and how do we abate them? Okay.

So night sweats. We lose control over our thermoregulatory center in our brain, specifically in the hypothalamus. There's a neurokinin receptor that goes catty-fricking wampus when it loses estrogen. And it just starts firing at random times, usually at the most inconvenient times of your life, and that happens to about 85% of us, right? So restoring estrogen back into your body at microdosis compared to what you made as a premenopausal woman helps most women get rid of the hot flashes. And if you don't have hot flashes, you sleep better, your bones are better, less things get

better, right? Now, if you're not a candidate for estrogen or you're not interested, there are new neurokinin receptor antagonists that have come out that basically just bind to that receptor and kind of stabilize it. They work pretty well. Before those were invented, those just came out in the last couple of years. We were using, there's an SSRI that we use, there's a blood pressure medication. There's a few things that kind of stabilize it fairly well, but the gold standard is hormone replacement therapy. Yeah. And some of those other medications have lots of side effects, like the bladder medication. Yeah. Yeah. Okay. What is highly recommended for libido? We talked about this a little bit.

Yeah. But I'll later you to me. So testosterone, usually, I usually lay out the menu to my patients. And they almost always pick testosterone to try first, probably because their friends are on it or they were curious about it. They read something about it. But it also has potentially some other benefits in the brain. You know, we need more research on that.

I'm not going to say, oh, it's going to improve your mood clearly or it's going to do all these other things. But, you know, a lot of my patients are coming back and saying that they're having benefits. outside of their desire. And so we just have an honest conversation about that. And if it doesn't help you in three months, then it's probably not going to help your desire, and we start looking at other options.

And I would just add, like, you need to cultivate an environment of desire, and I think that we don't talk about that enough. But, like, how are you supposed to go from working all day, taking care of your kids, to now wanting to have sex? Like, you need to put some work into cultivating a space where sex is fun, and you're looking forward

to it. It's exciting. And so I think, you know, you have to put some work in that with you and your partner and figuring out time and things that you can do that can be really fun. All right. What do we do if we're already on birth control, like an IUD or the pill? How do we determine if we have perimenopause, symptoms or something else? So if you have an IUD, the progesterone and it, the progestin, it, the progestin, acts locally, right? So for most women with that particular IUD, their periods will, go away, right? It thins the lining of the uterus, and we use it to treat heavy bleeding, off-label, and lots of other things, and so it's great for contraception. But my patients are coming in and saying, I'm not sleeping. I'm having hot flashes. I'm having, you know, all the brain symptoms

first. And so, you know, again, no great blood test for any of this. Their cholesterol is creeping up. They're having all the signs and symptoms. So we'll just launch right into a treatment discussion at that point. And if they've had a hysterectomy, again, they're not going to have a period. You know, the blood test will clearly tell us if she's post-menopausal, right? Because the estrogen flat lines and the FSAH stays elevated forever, right, unless you treat her. And so that's an easy diagnosis after hysterectomy, so I will check hormones in those patients, just to see did we miss full menopause, somehow she got through Perry without any symptoms. But if her levels aren't clear that she's post-menopausal, I'm going to assume she's Perry if she's that age and she has this constellation

of symptoms and all her other labs look okay. Yeah, and then for people who are already on oral contraceptives. So it will mask a lot of the symptoms. If you start noticing in your placebo week, especially if you're on a seven-day placebo, if you're starting to be symptomatic, especially with mental health or sleep disruption that week, that's it. I mean, I'm like, you're there. Yeah. But speaking of hormone levels, how do you know what your own optimal hormone levels are other than being in the normal range and feeling okay? Good. So because our hormone levels fluctuate month to month and a normal healthy woman at a cycle, you know, we don't have like a baseline like your thyroid, right? To know at 23, my

T-SH was blah and or my T-4 was whatever. We don't have that, right? So we know that everything for symptomatic treatment for menopause was titrated to the presence or absence of a hot flash. But there is some decent data looking at when women were growing bone, like when they stopped their bone loss by looking at bone density scans. And so, we have some numbers around that. And there's a brand new study that came out, well, now a couple of years, looking at a lot of women are doing transdermal therapy. And so we all absorb differently.

And assuming, you know, that, and we found out that it takes less for most women to stop a hot flash than it does to fully protect our bones. So in our clinic, for the transdermal patients, you know, especially if she's not, you know, we're worried 20% of you are not going to be great absorption. turns out I was one of them, so I'm a little sensitive here. And we are checking post-treatment levels to see what her absorption rates of. And if bone density is important to her and she already has low bone density, we may up her dose based on that number and not the presence or absence of a hot flash

so we can get her better bone protection. It's amazing to me that it took OBGYN so long to figure that out, because we know for men they don't absorb testosterone and transdermally 20%. It's amazing. It's amazing. What is the known impact of H.R.T on GLP1 users? Can they coexist? Okay, there's one study that looked at women who were on GLP ones or on GEOP1 and they were

postmenopausal or or on GLP 1 plus HRT. And the women who were, had the combination and they only looked at their weight, so I don't love looking at weight for things. I like looking at body composition, right? But, you know, it's America, and they only care about the scale. So they had 30% more weight loss when they were on combined, H.R.T. and GOPP1. So there's a synergism there, and it surprises none of us who do menopausal medicine, right? Because their inflammation is lower.

Their gut microbiome is healthier. You know, so many things are better when you're on H.R.T. versus off. So it doesn't surprise me at all that women had a better, you know, weight loss outcome. than when the combine was together. Yeah. I think the important thing for people on GLP-1s is to make sure that they are getting nutrition and weightlifting. Yeah, so our patients, we have an hour counseling session

before they started GLP-1. And we measure their body composition every two to three months while they're in the weight loss phase of it to make sure we're not losing muscle at a critical level. Yeah, absolutely. Next question is how to stop heart palpitations. So it turns out 45% of women in menopause and perimenopause will have heart palpitations. It's a lot.

Yeah. It is a common, common, common symptom of menopause. Again, there are estrogen receptors on the sinoatrial node that controls our heart rate. And when you take the estrogen away, it stops not working right. And you have palpitations. And so AHA has not, the cardiologists have not said, let's give everybody a trial of hormone therapy and see if their palpitations get better. But on our end of the world, they are.

And so you still deserve a workup. Not all palpitations are due to menopause, but a whole lot are, 43%. And so, you know, for us, I think cardiology is making leaps and bounds right now, recognizing menopause. They've just added menopause as a risk factor for cardiovascular disease. that's huge. Like the scoring systems never, you know, the cardiovascular scoring systems until this year never considered menopause

as a risk factor, and we know it is. And so, you know, we're getting there, I think. So, you know, one of the, so beta blockers are typically what women get for, you know, persistent palpitations that are life disruptive. But I think, you know, in our clinic, if they're not responding right away to HRT, we're making sure they're getting into cardiology.

Yeah. Absolutely. Absolutely. How can we prevent crepey skin? Does HRT help? So newsflash, you're going to lose 30% of your collagen in the first five years of menopause. So it's not just cosmetics. That's skin health, how you heal, wound, you know, when our skin breaks, you know, and yes, my neck. I know. I feel you girls. So topical estrogen can slow that down. You know, we are aging. This is, you know, we need to normalize aging skin.

But it does go very, very quickly across the menopause transition. So we can slow it down a bit with some topical estrogen. It's not FDA-approved for that. You have to use it off-label. So you can take your vaginal estrogen. I wouldn't do that now because we really need it for vaginas and we're running out. So, you know, vanity aside, they're comfortable. that can compound estriol, which is a weaker form of, you know, of an estrogen that does work.

It's been studied and it works for skin. But, yeah, you'll lose 30% of your college and typically untreated in the first five years of menopause. The sad realities of aging. What, if someone's on a vaginal estrogen and still having issues, and I think we should do- You see a gynaecologist right away. Like, not all issues are GSM. We have multiple other vulvar disorders that it could be. And so, you know, don't just assume if you're a doctor, you know, some of you may go and see someone

who's not a trained gynecologist. And so I think it's a reasonable first try to give you vaginal estrogen. But if you're not responding quickly, like within six weeks, it's time to get in to see someone who knows how to look at the vulva and make the right diagnosis and you might even need a biopsy. Yeah, and I would tell a lot of women, because I see a lot of women for this, recurrent urinary tract infections are often due to lack of estrogen in the vulva and in the vagina. So please, if you are suffering with recurrent UTIs, talk to your doctor about vaginal estrogen

because it will prevent and it will cure you. When should women start preparing for menopause? And is there anything teenage girls, teenage girls should start paying attention to early on? So, I mean, my children are living proof. You can survive your mother constantly talking about menopause and get into your 20s. I think normalizing the conversation. This is a normal part of life. We're all going to go through it.

We don't want to hide it. We don't want to minimize it. We don't want to pathologize it. You know, just this should be a normal conversation and they should be something that they expect. I mean, I'm on the other end of perimenopause. I mean, I'm 57. I'll be 58 in a couple months.

I am literally living my best life. Like, and it should not, like, your period should never stop your life, right? You shouldn't have to not go to an activity. The pain shouldn't be so bad that you can't participate in something or you're planning around your site. Menopause should be the same way, right? And that we just, this is so manageable.

This is so doable. This is, you know, a change in our health trajectory, but it doesn't have to be so bad. And you shouldn't quit your job, end your marriage, unless you really need to get out of that marriage. Or quit that job. But, you know, like, you, can be this incredibly, like, I am in my wisdom.

This is the best time of my life. My children, thank God, are healthy and thriving. You know, I've been with the same partner for 33 years, and God bless him for putting up with me. And, you know, but like, like, I am so looking forward to my next 30 years. And I am refusing what happened to my mother and my grandmother to be the future for my children. Yeah.

I'm not going to allow it. And don't live in fear. I think a lot of this social media noise makes people really scared about what's to come. The good news is you can get through this, you will get through this, and you have wonderful support like the new perimenopause and so much education out there that you didn't have access to. Yeah, no. Yeah. All right, I want to end with, if you could leave every woman in this room with one empowering message about perimenopause, what would it be? I mean, it's inevitable, but suffering is not, right? We have tools to help you. There's lots of things

out there. There's a community out there. And talk about it. Don't hide it. Let's normalize it. Let's just make it a part of a normal everyday conversation. Absolutely. Will y'all take a picture with us? Yes. Okay. Let's get the music going. All right. I want to get a picture with everybody in the audience. Come on, Juan. All right. We're putting the lights up. Smile pretty. Thank you. Thanks everybody. You can find full episodes of Unpaused on YouTube at Dr. Mary Claire. Also, you can find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at theposedlife.com.

Unpaused is presented by Odyssey in conjunction with good roommate media and longwave digital. This episode was sponsored by Middy Health, the first virtual clinic created for women, by women, for the treatment of menopause. Don't let anyone tell you menopause is something you have to suffer through alone. Midi can help. Visit join midi.com to learn more.