unPAUSED with Dr. Mary Claire Haver - Menopause Masterclass: My Menopause Toolkit – HRT and more

Episode Date: June 16, 2026

In this solo episode of unPAUSED, Dr. Mary Claire Haver answers one of the most asked questions she receives: what hormones do you actually take, and why? Rather than a general overview of menopause hormone therapy, this is a fully transparent, clinically grounded walk through her personal protocol, including every formulation she uses, why she chose it, and what the FDA-approved alternatives are for women whose needs or circumstances differ. Dr. Haver opens with systemic estrogen, explaining why she uses a transdermal patch as her primary delivery method, why she added a small dose of oral estradiol for bone protection after finding her serum levels were not reaching the threshold needed to preserve bone density, and why she believes routine estradiol level testing should become standard of care even though current guidelines do not yet reflect the latest absorption data. She walks through the key FDA-approved transdermal and oral estrogen options, including patches, gels, sprays, and oral formulations, covering the differences in delivery, cost, clotting risk, and SHBG implications. For full show notes, please click here. To learn more about listener data and our privacy practices visit: https://www.audacyinc.com/privacy-policy Learn more about your ad choices. Visit https://podcastchoices.com/adchoices

One of the questions I get more than almost anything else is, what hormones do you actually take? What is your menopause routine? What supplements are you on? And I get it. When you're drowning and conflicting information, when one doctor says hormones are dangerous and another says they're essential, when the supplement aisle has 400 options and none of them come with context. you want to know what someone who actually understands the science does for herself. So today, I'm going to walk you through everything. My hormone therapy regimen. Why I choose each formulation, what it does, what the FDA-approved alternatives are, and if my specific choice is not right for you. Then I'm going to cover every supplement I take and why,

specifically for my body and my risk profile. I'm going to talk about oral moments. an oxydil for hair because that question comes up constantly and I want to give you real information. Before I start, I want to be clear about something. This is my routine. It is based on my symptoms, my lab work, my risk factors, my family history, and my goals. It is not a prescription. What is right for me may not be right for you. The point of sharing this is not so that you can copy it. The point is to show you what a thoughtful, individualized, evidence-based menopause plan looks like so you can have a better conversation with your own clinician about building yours.

I also want to say this. I am a board certified OBGYN. I am a certified menopause practitioner, and I still work with my own clinician on my protocol. No one should be managing their hormones alone, including me. So please hear this as education and transparency, not as medical advice for your specific situation. Let's start with hormones. I'm Dr. Mary Claire Haver, a board certified obstetrician and gynecologist and certified menopause practitioner. I am also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to Unpaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life. The views and opinions expressed on unpaused are those of the talent and guests

alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. I've really been loving the idea of throwing on a cute casual outfit and then pairing it with just the right piece of jewelry to pull it all together. It's funny how that one small detail can completely change the whole vibe of what you're wearing. It makes you feel more put together and a little more confident, even on the simplest days. That's the beauty of Jenny Bird. Everything is designed to mix and match. You don't have to overthink it or plan it out. Just grab a piece or a few and you're instantly elevated.

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excessive, but it is, it is excessive when it is worth it. These are all of the hormones that I put in or on my body to support what I'm doing or to replace the ones that have gone missing. So we're going to start with systemic estrogen. I'm going to move some of these guys out of the way. So systemic estrogen therapy, when we think systemic, we're not doing local or topical, we are actually trying to get into your bloodstream and treat your brain, your bunch, your heart, your endothelium, your muscles, almost every cell of the body has some kind of estrogen receptor, and this is how we're going to replace it.

So I am a fully menopausal woman. I've been fully menopausal for probably close to 10 years now. So my ovaries have lost all of their eggs and the ability to produce any natural estradiol. My main source to replace my estrogen is systemic estradiol in the form of a patch. So when we talk about estrogen systemically replacement in general, I like to lump it into two categories. We have oral and non-oral. And in oral, that means pill. Okay, and we have a few pill options.

And in non-oral, we actually have a multitude of options of ways. we can get it through your skin, through your macosa, even through the vagina that will be a high enough level to go systemically. I have chosen for me, and actually most of my patients choose this option as well, the generic estradiol patch. Now caveat, there's a shortage of patches in the United States right now. And we have an entire blog on our website at thepawslife.com explaining to you creative ways to get your estrogen either through a patch or another form. We're going to go through the other forms today. I chose the patch for specific reasons. One, I like a continuous steady state approach. When you put the patch on, your body is getting a continuous supply

of estradiol. A transdermal approach does bypass the liver. So for those of you with a history of any clotting disorders or have had a blood clot, you are going to want a transdermal option to decrease your risk of forming blood clots. The good news is that transdermal does not not at least your blood clotting risk, oral might, but it's still very, very slight. But if you had a history of your high risk, you're going to want to avoid the oral formulations. When you do a patch, you are not getting peaks and troughs.

So some of the transdermal options, you have creams, you have gels, you have sprays. Those are applied once a day. So you're getting a peak and a trough. I like to have that continuous dose really for my brain health. I feel like for my brain fog, having a steady state of estrogen is a lot better. Multiple large studies, including the ester trial and the Keeps trial, showed that transdermal estrogen, again, does not carry the same venous thrombo embolism or blood clotting risk that the oral formulations do. Now, remember, most of those studies were actually done with oral birth control

pills. Oral birth control pills have ethanol estradiol, which binds to the receptor 300 times the affinity of regular estradiol. It's really sticky. It doesn't like to come off. So when we look at the data around blood clotting, it is much higher for birth control pills, but they tend to apply that data for menopause hormone therapy. There is a slight increased risk with oral formulations in the menopause hormone therapy dose of plain estradiol, that it is very, very, very minor. So I don't want anyone afraid. This is much less expensive than this.

So if you did not have insurance, now once you have insurance, I have no idea what your insurance company is going to charge you with copays and deductibles and all the things. But if you had to pay cash out of pocket and you were willing to go. find a coupon and hustle. This oral estradiol, like, for example, through the Mark Cuban pharmacy, would probably be about $5 to $7 a month for a month's supply. This transdormal patch is somewhere in the neighborhood of $25 to $35 a patch. This particular patch, you apply twice a week. So for me, I put mine on Tuesdays and Fridays. So I picked Tuesday because in my neighborhood in Galveston, Texas, that is the day the trash man comes. And when I pull out of my

my driveway and I see the trash scans lined up down the street, I know it's patch day. It's just some way for me to remember. And then Friday, because it's three days later and it's before the weekend. So that system has worked really well for me. And I encourage patients to pick something on their calendar that's going to work for them. I also take a very small amount of oral estrogen, and I'll tell you why. This is a bone protection story. And I have a huge substack about this exact reason. So remember, hormone therapy was developed to stop a hot flash. The end point of does this medication work or not, and all the studies were, did her hot flashes go away? Well, it turns out that enough to stop a hot flash, enough to bind to that thermoregulatory center in the brain to stabilize that area to stop the hot flashes may not be enough for bone arc cardiovascular protection.

We need to get our estradiol up. So we know that there's a threshold for getting your ester's level up. to the point where you stop losing bone. And then there's an even higher level where you can actually begin to grow bone again. So remember, lots of things cause us to lose bone. It's not just whether or not you're metapausal. I'm talking specifically about the bone loss surrounding estrogen loss.

It seems like we max out. There's no reason to go above 70 in pica grams per decilator, the way that we measure in the United States. And so in our clinic, we look at symptoms, a lot of people do not absorb the transdermal patch well. So I was on the patch completely controlled, very happy with my patch, sleeping well, no hot flashes. But then I was reading the data that came out of Louise News News Newsome's clinic and papers that were published looking at absorption rates. And they were measuring serum estradiol levels and finding very big discrepancies amongst women

on how much they were absorbing from different level patches. So I am on the highest dose of there's no more than this. And I measured my levels twice. And they did not. approach bone protection. So my symptoms were controlled. My bones were probably needing more for maximum protection. So I said, okay, I can either add another patch to this, which would be fine, but it gets a little sticky with insurance companies because mine are covered. Or I can add a really low dose of oral estradial at night. Another key point about oral estradial. Because it does go into the liver first, we see improvements in cholesterol. more than with the patch.

My cholesterol went up shockingly in menopause like many of years did. With diet and exercise and lifestyle interventions, I was able to get it down a bit, but it was not normal. Adding the patch brought it down a little bit more, still not normal. Adding in the touch of oral estradiol, which I happen to take at night because I'm taking some other stuff at night too,

and it's just easy for me to remember, did get my cholesterol back in the normal range. And so for my systemic protection, I don't recommend this to everyone, I am taking two forms of systemic estrogen. I still like the patch to give me that continuous dose for my brain fog, but I'm adding in this little extra estrogen to get my levels up for my phones. And as a bonus, it helped my cholesterol come down. So, yes, in our clinics, we are measuring serum estradial levels, especially for people on transdermal because humans have varying absorption. rates. And we can't predict who's going to be a good absorber, a super absorber, or a poor absorber. So at about month three, we are recommending a high sensitivity serum estradial level for all of our

patients so that we can see what their levels are, especially if they have a history of osteopenia, osteoporosis, or family history. This is one of their treatment goals. We want to make sure they're getting absorbed enough. And then we can talk about changing the formulation, changing the dose, et cetera. So I want you to sit with us for a second. guidelines currently do not recommend routine testing of estrogenial levels. We were not recommending routine estrogen levels until the new data came from out from the UK saying that about 20% of patients were going to be poor absorbers of the transdermal options. That got us motivated to check. I think we are a decade away from the guidelines being changed. But I want to give you the

latest evidence. Here's the takeaway. Symptom control and disease protection. may have different thresholds in your body. The more we learn about what these levels mean in certain women, the more information we can have so that you can have an individualized, personalized plan just for you. So there are, and you'll see me glit down to look at my note, several FDA-approved transdermal estradial options that I don't have here. So I want to tell you about them. We have other patches. I pick generic because of cost. But there is Vival. Dot, Plamera, Minneville, Dottie, Estradot, and then also other brands of generic estradiol patches. These come in varying doses, typically ranging from 0.025 milligrams to this one, 0.1 milligram per day.

So we have five options. Another reason why I like to start with patches, because we have so many different levels we can start out. Some are actually changed weekly. Some can be changed twice weekly. And your clinician will start a dose appropriate for your symptoms and then adjust to see how you respond. Basically in our clinic, we adjust the dose to make sure her symptoms are controlled. Then at month three, we check levels to see how she's absorbing, to give you an idea. There is also the estrogen gel and the divvy gel. They are FDA approved. You apply them to the skin once a day.

Estrogel, it was studied from the wrists to the shoulder, so this whole way. And divigel comes in single dose packets applied to a small area of thigh. And of course, we have the spray. There is eivomis, which is FDA-approved estrogen-spray that is applied to the forearm. It comes with a little cup over the spray, so it's all contained in a little central area. I have tried it in the past, and it's going to be one to three sprays depending on the dose. All of the ones I've just discussed are bio-identical with 17 beta estradiol. All of them bypassed first liberal metabolism. The choice between page gel and spray is often about lifestyle, skin sensitivity, and personal preference. One of the problems with a certain percentage of the population with the patch is there

are people who will be sensitive to the adhesive in the patch. It's not really the medication, but it is the stickiness of the patch, usually causing some type of a mild, allergic-type reaction. If it is mild, some of our patients have tried to take Flonase or one of the generic steroids nasal sprays, apply it to the skin and let it dry naturally, and then put the patch on top of that and that does for a lot of patients seem to make them tolerate the patch a lot better. The other options of the gels and sprays, there is not a generic option, so cost can be an issue here. So oral estrogen options, this is plain generic estradiol. Perman is still available and out there. There is no generic for primland. For peremorin, it is proprietary. So again,

cost can be an option. In oral micronized estradial, it's always bioidentical if it just sets estrogenial on it and it typically comes in 0.5, 1, or 2 milligram tablets. I want to talk about something special and we use it a fair amount in our clinic and it is called duavi or duave. This is a combination of conjugated estrogens plus basidoxetine, which is a selective estrogen receptor modulator. So serms are things like tamoxifen, which is similar to basidoxifine in a lot of ways. So this particular combination, basidoxifine selectively binds blocks and downgrades estrogen receptors only in the breast and in the uterine cavity, in the endometrial cavity. So for patients who are having intractable bleeding on their hormone therapy or who are high risk

for breast cancer, it's being studied right now in stage zero breast cancer patients. So DCIS patients, there's a really fantastic study going on with this medication. This can be great for people with progesterone intolerance, this can be great because it does not contain progesterone. It contains a serum that will protect the lining of the uterus. I'm a big fan of this medication. I can't wait until it's generic so that it can be a lot more affordable for our patients. It can be a couple hundred dollars a month, which is, you know, for a lot of patients, that's off

the table. The tradeoffs with oral estrogen, again, it does go through. deliver, which means a very slight increase in clotting risk. It also does increase our SHBG, which is steroid hormone binding globulin. When your SHBG goes up, it binds all of the sex hormones and renders them enacted. So for patients who have issues with libido, testosterone, even in the general urinary syndrome of menopause, we do have testosterone or antigen receptors in our vulva. Oral estrogen can make that worse because the activity of testosterone, it's not able to do its job. So we have to keep that in mind.

And some people recommend checking SHBG levels. Certainly if you're having intractable libido issues and testosterone doesn't seem to be helping or intractable geno-urinary syndrome or topical testosterone doesn't seem to be helping. And SHVG might be something you'd want to ask your doctor for to see if it's elevated. And then you guys can discuss how to bring that down. This podcast is sponsored by Middy 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 normal. 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 midI.com.

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oral micronized progesterone. You can hear it. I'm shaking it on audio. I love this stuff. If I didn't have a uterus, I would still take it. It is mandatory to have something to protect. the lining of the uterus if you're taking estrogen. If you don't have a uterus, then it is optional. A lot of doctors don't understand this. We all know you don't give unopposed estrogen, unopposed meaning not with a progestin or something to protect the lining of the uterus. But if you had a hysterectomy or you have a marina IUD, the thing about progesterone is that it converts down to alopregnolone and the metabolic process. And alopregnolone alone loves across the blood-brain barrier, and it binds to the gap of receptor and causes a lot of calm

and sedation. And it is absolutely wonderful for sleep. One of the first symptoms in perimenopause is sleep disruption. And for those patients who are still having normal regular cycles, or maybe having some PMS or PMDD, in that second half of their cycle and are having sleep disruption, starting on progesterone can be really helpful. So the progesterone is dosed in 100 milligram tablets. So say you're on an estrogen patch. If you're on a 0.025 or a 0.05, 100 milligrams of progesterone should be

enough to protect the lining of the uterus. Once you go above the 0.05 patch, you're going to need 200 milligrams. I take this at night. We recommend taking it at night again because of the sedative effect. I don't miss it. I mean, I do not miss my dose. I might not put in my retainer.

I might forget to brush my hair, but I am almost never going to forget my progesterone. I don't depend on it so much to help me have that good, calm sleep. And, you know, I wear a sleep tracker. Don't recommend it if you're super anal like I am. But difference in my sleep, sleep quality, it's made night and day for me, and I just, just love it. Now, caveat, of course, everything is nuanced. About 10% of you will not tolerate this. Your body, you're going to have a paradoxical response to progesterone. Now, that might change if it's mixed with estradiol. So here's some

tricks, you can take these tablets and put them in the vagina and we'll miss the oral effect, we'll miss that bypass effect. So if you're having issues, putting this vaginally, these will melt and you will get absorbed right into protect the lining of the uterus. Some doctors do that. We have things like, again, do a V, like just skipping progester and on together. We have the combi patch, which is a combination of norethendrone, which is a synthetic progestin. I don't want to, you know, bad mouth progestin's too much. But I was always, on CompiPatch for the first three years of my menopause, and it worked pretty well. And then I saw the data around oral micronized progesterone being better for sleep, and I was struggling with

sleep. So I decided to switch. But I have nothing bad to say about Combi Patch, other than it's not generic. And it can be pricey. So we have options. Remember to ask about nuance and options when you go to talk to your clinician about what is available to you. So FDA approved progesterone and progestogen options. Again, Prometrium, which is oral micronized progesterone available in 100 to 200 milligram capsules. You can take them continuously every night. You can cycle them for two weeks or 10 days out of the month. That, again, is a personal preference.

In our clinics, we don't cycle a lot of patients. They tend to really, really love their progesterone and they want to take it every day. And there's nothing wrong with doing that. Note, it is peanut oil-based. So if you have a peanut allergy, this is not for you. You can have it compounded. in a, you know, sesame oil or non-penut oil formulation if you need. Okay, let's talk about byjuva.

Byjuva is a combination capsule of estradiol, so it's bioidentical plus progesterum. So it is basically these two put together in one pill and they have a baby. It's not generic. And so it's way more expensive than just getting the two generic options and taking two pills, whether than doing the byjuba, but it is available and your doctor might recommend it to you. It is FDA approved. And if you can't remember to take two pills at night, it is something you can consider. And then we have a ton of synthetic progestins.

Medroxy progesterone acetate. That is proverent. That was actually studied in the Women's Health Initiative. And norethendrone acetate are two FDA-approved synthetic progestins that are not bioidentical. They do protect the uterine lining absolutely, but they don't produce the aloprachnatea. So they have a different side effect profile. And one thing to remember is that norethendron does break down to ethanol estradiol. So people on norethendron will might notice by itself having lower hot flashes because they're getting that conversion to an estrogen component.

Many clinicians, most of us in the menopausee, do prefer oral micronized progesterone as our go-to because we're mimicking what the ovary actually did. And then, of course, for protection of the lining of the uterus, and I actually love this impairing menopause. for so many patients, a hormonal IUD. The lever-negestrel-containing IUD, liver-negesteral is the progestin that is in the IUD, embedded in the IUD, provides local progestigen to the uterus and is increasingly used off-label.

It's available for contraception for inundi for women on estrogen therapy. So if I have a perimenopausal patient, like so many of you who have outrageous periods, like heavy, heavy menstrual bleeding, cycles that are disrupting your life, becoming anemic, putting an IUD in that uterus with that progestogen there and the lining will actually thin the lining and for many patients within a couple of months get their bleeding under control. As a bonus, it provides contraception. So when we're in perimenopause and we're talking about therapeutic options, the conversation starts with do you need contraception?

I don't say do you need it. I say, what are you using for contraception? The pullout method is not it. I have too many perimenopausal babies that I've delivered from the pullout method. 100% would not recommend, please, please, please do something that contains contraception. When we start a patient on menopause hormone therapy, that is some combination of these three, right? This does not not suppress ovulation. Okay? This is not for contraception. You can get pregnant on menopause hormone therapy.

It gets less likely with age. But this is not suppressing your ovulation. So don't think of this. Oh, I'm fine. I can't get pregnant because I'm on hormones. These are not nearly high enough to consistently suppress ovulation. So if I have a patient doesn't want an IED who's having heavy periods or needs contraception and is having perimenopausal symptoms, we sometimes talk about using oral hormonal contraception

for these patients because I can get her symptoms under control most of them. I can provide her with reliable contraception and get her heavy bleeding under control all with one therapeutic option. So there are certain perimenopausal patients who our clinics have on birth control pills or oral contraception. There are others who are on menopausal hormone therapy.

We have so many nuances, so many options for all of you. What everybody wants to know about, testosterone. This is mine. This is what we prescribe to patients. This is AndroGel. So it is the men's version. Remember, we do not have an FDA-approved option in the United States for women. So we have to get creative. We have to get tricky. We have to do things off-label. So you can compound testosterone in some way to get it in your body, in a cream and a gel and a pellet, perhaps.

You can borrow the men's version, which is FDA-approved for men's. We're going to use it off-label for women. And we use the 10th of the dose. Okay, so we start our patients in general on about 5 milligram of the testosterone per day. What does that look like? So men use one to four pumps of this a day. One pump is 20 milligrams. So we need a fourth of a pump, which is basically a pea-sized amount. And I have not put it on today.

So those of you on video, I can show you what that looks like. So it is literally, I just do a quarter pump, a pea-sized amount like this. I put it on the inside of my wrist because I don't have hair follicles here. And then I just rub my two wrists and early forearms together until it evaporates. And that's how I apply my testosterone every day. It is once a day.

So I get a little bit of my pica trough throughout the day. Okay, it's dry, and I'm done. You should know a baseline testosterone level before you start this. And about three months after you start, if you're not having side effects, you should have another level drawn. We have lots of great data that shows that testosterone does help about 50% of women

with hypoactive sexual desire disorder. What is that? So you would call that in the lay population low libido. Basically, it is where you have low desire, where you love your partner. You used to want to do it. It was something you look forward to. It was fun. You enjoyed it.

But now you don't. and then you miss it. So we do need to normalize the conversation around what if you just don't want to ever do it again and you don't care. That's fine. That's fine. That's not who testosterone is for. It is not to suddenly create something that you never have before you don't want to get.

So it is a very specific set of patients. But again, I've talked about this on the podcast. I started it off-label because I had read that women who have naturally the highest quartile of testosterone levels, remember we all have different testosterone levels. have better bone and muscle strength, less frailty, less sarcopenia. And I was like, huh, what if I use this in physiologic ranges for a female? And then kept my workouts going, maybe this would help me hang on in my muscle, maybe builds a little more, a little faster. So I started it for that. But I have to say, I did not qualify for HSDD, but I have noticed an uptick

in the desire area, and I like it. And I think I would miss it if we took for testosterone away. So that is my end of one, full disclosure. I did notice some improvements in my energy, I think, and we check levels. Side effects of excess testosterone and women are acne. Hair growth in places you don't want it and losing hair in places you do want it, usually in the temporal area. If it's really high, we can see things like clitoral megali, which is not reversible. We can see voice changes, which are not reversible. Dosing matters, monitoring matters, and this is not something to DIY at all. So again, can you access it? So there's male-approved gels that are off-label, androgel, T-Stem, and there's something called Vogelexo. I haven't used

that one, but our clinic has used and drel gel and T-stem. For the T-stem, you want to get the tubes and not the packets. The packets, once you open them, the alcohol will start to evaporate and you basically have to use it all that one time. You can't, like, hold it and save it for later, and those packets are doses for men. So you want to make sure you get the tubes so that you can use multiple doses in the tubes. This costs me about $55 with a coupon and lasts about six months. So very, very, very affordable. Those of you who are paying hundreds of dollars every quarter for your pellets, I want you to ask your clinician, is there another way? You don't have to spend that much money to get excellent, excellent. FDA approved, monitored, great testosterone.

I have compounded testosterone cream in the past. We didn't have a good supply. prior for the androgel, we worked that out. So we were compounding with the local pharmacy for our patients. It works pretty well. It's typically at 0.5 to a 2% concentration that allows for more precise female dosing. And the downside is that those products aren't traditionally FDA regulated. So the quality really depends on the pharmacy. You can't expect to have the same quality coming out of each individual pharmacy because they don't have the same oversight. Subcutaneous pellets are very popular. I know, and many of you listening or watch, or using the pellets and might be happy with them. Some clinicians do use these. I just,

I'm very cautious about pellets because once they're in, you can't undo them. And there's one particular company that never made a female pellet. They just take the male pellets at lower doses, and they put them in the women. And the women are walking into my clinic with levels in the hundreds, which are far, far, far above a physiologic reins. Now we're talking about performance enhancement. Now we're not talking about replacing a female physiologic dose. And if You're into performance enhancement. That's up to you, but you need to be honest about why you're doing this. That is not what we do in our clinics here.

We're here for menopause care. We're here for HSDD and to just give our patients their best life. If your clinician is curious and unfamiliar with it, isish, which is the International Society for the Study of Women's Sexual Wellness, health and wellness, has an awesome website, and they have so many resources to help clinicians learn how to properly prescribe, how to test and how to dose testosterone for their patients.

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L-A-N-G-E-H-A-I-R dot com and use the code unpaused for 20% off at checkout. Now we're going to talk. We're going to skip to vaginal and vulver health. So let me move these over here. Topical vaginal estradial. So this is plain generic vaginal estradial. This two probably should cost you no more than $15. You may have to hustle and go find a coupon or go through Mark Cuban or Walmart or whatever, but this is cheap. You should not be paying anything more than about $15 for your two. So I really want to talk about this section because of GSM.

We've had some incredible updated guidelines in the last year that have been adopted from every major organization that has anything to do with the female pelvis. GSM affects, severe GSM, severe affects up to 84% of postmenopausal women and is still remains right now the most under-treated, under-diagnosed, under-discussed consequence of estrogen loss. 100% of us will see changes in our genital urinary system after menopause if we're not treated.

And in my clinic, we have very aggressive conversations about using this prophylactically so that you never develop GSM, Why? Because this little tube will save lives. We can decrease 50% of urinary tract infections and postmenopausal women by using this prophylactically. And when we do that, we will cut down on 50% of Eurosepsis and death from Eurosepsis. So untreated GSM does kill women at very, very high levels, especially women in nursing homes, especially women with limited movement who don't have great hygiene because, you know, of arthritis or bed bound or just chronic incontinence, so many

women are suffering needlessly and not having access to this very simple treatment and tool of vaginal estrogen. Now, I choose the vaginal estrogen cream because of cost. It is messy. It's not for everyone. We have many options and we'll go through them. But, you know, keeping it in the $15 range makes it accessible to so many more women. Other things that happen in the general urinary system, The tissues become thinner, drier, less elastic, more fragile, more prone to irritation, tearing and infection. Your pH changes, the microbiome shifts, and the urinary symptoms develop. This is not cosmetic.

This is tissue health, and it really, really, really deserves treatment. So vaginal estrogen cream. So we have the non-generic form is called estrays. There's also still perimen cream available. Premarin cream is great. There's just no generic, and it tends to be one of the most expensive options. We typically use this twice a way. week. It comes with an applicator. I just tell my patients, put it from midnuckle here to the tip of your

finger and get up in there and rotorotor it about halfway up into the vagina. Then you take a little bit more and you're going to put it on the clitoris and go down both sides of the labia menorah. That's going to hit all of the hotspots that you need. There are vaginal tablets available. Vagifem and YuvaFem are 10 micrograms. They come with a small applicator. Now, these creams are alcohol-based. They can cause irritation. You might have a reaction to them. So the pills can be really, really helpful. It's just the applicator is like this little pencil and you have to put the tape of arthritis or you don't see very well. It can be harder. You can like try to put this tiny little pill on the tip of your finger and like wiggle it up into the vagina. You know, so there's pros and cons to all the things.

There is a vaginal insert. So imvexie is a suppository that is much easy. You know, it's a much easier to insert. It's nice and smooth and it's easy to push into the vagina. It comes in four and 10 microgram dosages and you don't need an applicator for the four microgram dose. However, there's no generic for Invexie. And again, cost can be an issue. My favorite way to replace estrogen down there is with the vaginal ring. Again, super sad. We do not have a generic, but God, it lasts for three months. You throw it up in the vagina. It finds a little home up there. It really does not bother you. It's like a tampon in place correctly. You don't feel it. And it is just constantly giving you that continuous supply of estrogen in the vagina for three months. And you don't

have to worry about it. You just set an alarm on your phone to go take out the old ring and put in the new one. You can leave it in for intercourse. I tell my patients to leave it in. See if you notices. You know, might be kind of fun. I don't know. But all of these options have been studied and they all help. So I do want to talk about DHEA. So DHA, we have an FDA approved option for the vagina called brasterone, which is a fancy name for DHA. So DHA also can be used for the vestibule. So for those of you who are having pain around the opening, pain around the vaginal opening, that is not responding. When you apply DHA there, and I have, this is an over-the-counter version that I also use. DHA will, in the cells, convert to estradiol and testosterone,

both. There are antigen receptors in the vestibule in the vulva. And so you're getting both estrogen and testosterone. So the prasterone is the suppositories, that is DHA, that you put in the vagina, they melt, they work up there, but then the medication kind of drubs out and you get it. You know, it makes its way to the vulva and to the vestibule around the opening. And so patients love it. It's very, very safe. Again, no generic, very expensive. This is a lower dose DHA for my friend Kelly Casperson for the vulva. I really like the texture of it. And I just like having that little bit of extra protection. And it also has vitamin D.

So it's a very nice oil-based lubricant and moisturizer, and I'm a huge fan of it. So I don't use prosterone because I have this. And my vaginal estrogen of which I use as well. Lots of questions. I know you guys are asking, what is this last guy? This is topical estrogen for my face.

So you actually can take this vaginal estrogen cream and put it on your face. Okay? it's recommended to do a pea-sized amount and you put it, especially on your eyes where the tissues is really thin and then you rub it and you put your moisturizer on top. The problem with this is, again, alcohol-based creams can be drying for the skin and not for everyone. So I have chosen to do this cream that has estriol, which is a cousin of estradiol, and it's a 0.3%. It has been studied showing efficacy and safety. You do not have systemic absorption. The nice thing about

topical. Anyone can use it. Anyone can use vaginal. Anyone can use it on the skin. And this I apply every morning. And it is in a seven alcohol base. It's in a moisturizing base. So it's basically taking the estrogen throughout throughout and a moisturizer. And it's just easier for me to apply. My skin doesn't get in dry. I can just put makeup on it from wearing makeup that day. It's not a big deal. So these are all of the seven ways. It's not something I recommend to every patient. This is purely cosmetic. It can be pricey. depending on where you get it from. And so, but I just wanted to throw it out there.

So these are the seven ways that I replace my hormones. So, but we do have non-hormonal FDA-approved alternatives, but we really have to take it symptom by symptom. But I did want to cover some of the big ones of these so that those of you who do have contraindications to certain hormones know what your options are. And then after this, we're going to get to supplements. So we have VOSA, or a festival,

So, Fezoliniate. So Fezaliniate is a very new medication. It just came out in the last year or two. These are medications that bind to the thermoregulatory centers in the brain. It's just the Neurokynin-3 receptor, which is in our derma-dermoregulatory center. It binds and stabilizes it so hot flashes in most patients will improve. It specifically is targeting the mechanism where the hot flashes happen. And so without having to, you know, have estrogen in any other part of your if you have been advised that that is not in your best interest. So it's great for hot flashes. So if you're an active breast cancer patient who's been told you're not a candidate for estrogen, these medications can be really helpful.

And new one has come on the market from Bayer. I cannot remember the name of it of the day, but there's competitors coming out. These are new. We're probably five to six years away from any generics being available. So again, cost can be a huge issue here. The only SSRI is paroxetine. That's the generic name or Brisdale. that has been FDA approved specifically for hot flashes.

It's a lower-dose version of peroxatine at 7.5 milligrams. It can reduce hot flash frequency by 50 to 65% in some women, and it's not a hormone. So if you're on tamoxifen, however, and you're having hot flashes because you're on tamoxifen, peroxatine is contraindicated because it does inhibit the enzyme, very long name, enzyme that converts to moxif into its active metabolite. That's a really critical drug interaction. So I'm happy to say that the Tamoxifen patients can actually take the neurokina receptor antagonist and can have benefit. But to be honest, hormone therapy is the gold standard.

And forever, people were defining menopause treatment as the reduction of hot washes, nothing else. They weren't talking about your brain fog, your emotional status, your bones, your inflammation levels, your insulin levels. I mean, all of that is affected. And estrogen is the best therapy to stabilize all. of these inflection points in our chronic disease process. But if for whatever reason that is taken off the table for you or if you just choose not to do it, there are options, but we have to take it symptom by symptom. This is like supplement for the team. God, it seems like a lot. It is a lot. I understand that. But I'm going to walk through every supplement I take, why I take it and what

it does for me specifically. But I want to repeat, this is based on me. This is my labs, my goals, my risk factors, supplements should never be a guessing game and supplements will never replace good nutrition. Most of your nutrition should come from food, whole foods, anti-inflammatory foods, grains, nuts, seeds, legumes, lean proteins. I can't stress this enough. You cannot take a bucket of supplements and expect to have a miracle happen if you are not backing that out with good, high-quality nutrition. Okay, so let's start about this guy. This is a combination because I'm lazy. So full disclosure, first of all, I own a supplement company called the Paws Nutrition, the Paws Life.

And I started talking about menopause under in the frame of nutrition, in the frame of the Galveston diet, in the frame of trying to answer the question of body composition changes and why women were gaining weight. So we came up with a whole nutrition plan that was very successful. We had coaching groups to coach people through all the exercise recommendations. and nutrition recommendations. And we were making supplement recommendations. Women tend to not be able to absorb enough vitamin D to stay healthy.

Women tend to not be able to get enough fiber in their diet. So I was constantly recommending supplements. All right, have patients come in with buckets and bags of supplements. And I'd be like, what do you take this for? She's like, I don't know. They hated this to me. And I couldn't tell who manufactured it. If there were third party tested, like it's really, really hard out there because of lack of some of the regulations.

around it. And I thought, can I do this better? I think I can't. And I really thought it for a long time because a lot of people don't feel like physicians should sell supplements. It's a bit of a red flag and I felt a little bit about myself. But here I was recommending, here are patients in, trying to self-diagnose, self-treat, and coming in with buckets and bags of things that made very little sense. And I thought, okay, I can create something that is high quality and third-party tested and put my name on it, I'm going to do it. And so we did. There are lots of good supplement companies out there. There are lots of supplement companies that are suss as hell. Okay, so you want to look for things that have studies. You want to look for things that are third party tested for purity.

And so to make sure they're not contaminated and to make sure that actually what they say is in it is in it. Super proud that we were able to meet those goals and have really good, high-quality supplements on things that were actually studied in women in menopause and not 25-year-old male athlete. So, omega-3, vitamin D and vitamin K combination. I like to combine things because I'm lazy. And it's easy, easy, easy to combine omega-3 and vitamin D. Like they're like peanut butter and jelly as far as like they sit well together. They don't contaminate each other. There's no reaction. And vitamin K we threw in there for increased absorption. So one caveat, if you're on kuminant, you should not be taking this because it has vitamin K.

All right. So if you're on a blood dinner, it's on to your doctor before starting any supplement. This has 4,000 international units of vitamin D. It has 1.2, so about 1,200 milligrams of EPA and another 800 milligrams of DHA. So those are the omega-3 fatty acids. These are critical.

When we check vitamin D levels in our clinic and when you look across the spectrum in the U.S., most women, the majority, well over 50%. In our clinic, it's about 80% of it. menopausal women have low vitamin D levels. So there is deficiency levels, which is below 30-ish in women. And then there is optimal, which is somewhere around 60 to 100, where you're not deficient, but you're really optimal firing on all cylinders with nice high vitamin D levels. You can take up to 4,000 units of vitamin D a day without needing to be monitored. Okay. Now, prescription strength vitamin D

is about 50,000 I use a week. Okay, so we're giving you 4,000. I use a day with this. I love this. I love it for heart health. I love it for inflammation. And vitamin D is a hormone and it is critical in dozens and dozens of enzymatic processes in our body. Low vitamin D levels are rampant and they are linked to weight gain, diabetes, dementia, low sleep, cardiovascular disease, all the things. So if you learn nothing else from this talk today's, go get your vitamin D level checked. Know where you are. So when my patients come in who were deficient, we're putting them on the prescription strength first. Okay, we want to give them a loading dose.

We're giving them that prescription of that $5,000, $50,000 IUs a week for about a month. And while on the other days they're not taking that, we're supplementing with this. And then we checked our level at three months to see how they are maintaining. And then once a year, they seem to be maintaining at their annual visit. Love this stuff so much. Okay, so I take this every day. So this is our MinoMulti. Is that really a multivitamin?

I wanted to make a multi-use and multi-layered product because there's so many good studies that looking at women in menopause and co-inzyme Q10 and heart health. There is wonderful data on genocin, which is a phytoestrogen, which is a powerful anti-inflammatory component. It's been studied in bone health and women, in heart health, and in inflammation.

And then we know that most of our patients are struggling to get these B vitamins. We see it. And when we look at homoicine, So we're checking homocysteine levels in patients and we're seeing a tremendous amount of very high percentage of women who are struggling with high levels of homocysteine. And it's usually because they're not able to utilize their B12 or folate. And so this has very special B vitamins that are actually methylated for easier use within the body to these patients and it seems to be working really well. So you've got your thiamen riboflavin niacin B6, folate, B12, biotin.

and then we have the genocin, and then the co-enzyme Q10 together. And it's just one pill a day. Welcome back to another midi pause. I'm Dr. Mary Claire Haver, host of Unpaused. For years, I believe the gaps in women's health care came from individual failings, a distracted clinician, a rushed appointment, a misread symptom, a misdiagnosis. But the longer I practiced, the clearer it became. This is not about one clinician or one hospital.

This is about a system built on the male body as the standard and the female body as the outlier. Here we are in 26, with women across the country demanding more coverage, more information, more data, and the system is starting to respond. Women's health has been historically overlooked, underfunded, and frankly, misunderstood. From delayed diagnoses to limited access to care, the gaps are real, and they have real consequences. We've made progress, but there's still a long way to go. So how do we each play a role in creating change?

This is where platforms like Midi Health come in. Midi focuses on providing personalized, expert care for women navigating midlife health, especially menopause, an area that has been overlooked for far too long. They connect women with clinicians who specialize in these concerns, offering virtual care that is accessible, evidence-based, and grounded in real patient experiences. This includes everything from reproductive care to preventative screenings to mental health support. These are not luxuries. They are essential. When access is limited, it disproportionately affects women in underserved communities, which makes advocacy even more important.

Stay informed. Have conversations. Support organizations and platforms like Middy that are actively working to close those gaps. Vote with women's health in mind. And in your own life, create spaces where women feel heard and supported, whether it's at work, at home, or in your community. Change does not happen overnight, but it does happen when people decide it matters enough to speak up. There's nothing more important than understanding the options available to you in managing the symptoms you're experiencing. And if you want a little extra support, you can check out my menopause empowerment guide in the show notes for additional information and resources. I hope that this information helps you feel more confident and more empowered because you are your best advocate for the health care you need and deserve to achieve your best health. go to join midi.com, join midi.com, and connect with one of their clinicians today.

If you follow me, you know, I make a shake almost every day, or I'll make it and make it last two days. I had one this morning. And so in my shake, I call it the menopause shake, but really anybody can take it. My kids make it. It's a way for me to start hitting my nutritional goals early in the morning. So I break my fast with it. I take it down to the gym and I sip at it. for three to four hours until it's done. Or if I make a halfway mark, depending on if we have lunch plan. So in it is Greek yogurt,

Plank Greek yogurt, why for probiotics and for protein? Okay. And then we have, I put our collagen, so our skin and bone collagen right here, we're going to put two scoops in here. It has two separate collagen products.

One is called varosol, which was studied in skin for wrinkles and solulite appearance. So it's a vanity product. And it was, also in it is something called Forta Bone. I got super excited about Forta Bone when the studies were studied in menopausal women with osteoporosis and mastopinia and they saw benefit to their bones and they weren't on any other intervention. They followed them for five years, taking this every day. And so I was like, I want this. I want to combine these two collagens together and call it skin and bone.

And so here's the product. It's two scoops. I just throw this in the shake the unflavored version as well. This is new-ish for us. This is our wave protein products. So it's protein and we threw some creatine in there. It's brand new. I put a scoop of this in it. I like chocolate. We do have vanilla as well. And then when I make my water for the gym, actually back here, I didn't bring any with me, but I like electrolytes. Not because I think that they're a miracle or doing much for me. I like salt. And I'll put my salty electrolytes in here with a couple of scoops of creatulites. So studies on women are looking extremely good. If you look at Abby Smith-Ryne coming out of North Carolina, her research, looking at women and strength training and creatine, we can't make as much as we age. It's one of those things. And so it's so important for muscle recovery. Also, it seems to have a lot of good use for brain thong and sleep.

And so I put my creatine and my electrolytes and then I stay hydrated throughout the day with this guy. our creatine comes in a two-month supply and this beautiful guy right here. So do you need all of this? Probably not. But this is just what I take, what I do and why. I also, in that little shake, throw in a little extra fiber. So one scoop here has eight grams of fiber. This is flavorless. You can throw it in your coffee. You can throw it in water. You can throw it in whatever you want. But I'm able to get pretty consistently 25 to 30-ish grams of fiber in my diet. it just from food, mostly from avocados, seeds, not legumes, which are beans, but just gives me that little edge to take it over the top because for cardiovascular protection, for gut health,

25 seems to be pretty good, but for cardiovascular protection, women want to get 35 to 38 grams. So this just gets me over the top. Days I don't have yogurt, okay, for my probiotics. I will take a probiotic as well. There's decent studies done in menopausal women showing in better body composition, showing better gut health, et cetera. So I do do that. And I took this for a long time.

This is magnesium L 3 and 8. This is a mag that is very good at crossing the blood brain barrier. It was actually studied in SSRI resistant depression. And it really did seem to help those patients who were not doing well with severe depression on their anti-depression medication. And so it just has a really great way to cross the blood brain barrier. So I tend to take this in the day to get my maglop. levels up and up to my brain,

slash sleep. So finally, we have our pause sleep. So sleep disruption is one of the most debilitating symptoms of perimenopause and menopause, and it really compounds everything. For sleep worsens insulin resistance. It worsens body composition, increases inflammation, and impairs your cognitive function. Like, we have to prioritize sleep. And so many women are being medicated with sedatives to kind of force them to sleep,

but they're not getting the good high-quality sleep. They're not getting the deep sleep when you're chronically on these medications. So I partnered with a sleep medicine specialist, Dr. Andrea Matsumura, to come up with a product that was evidence-based that would help women specifically their needs in this sleep phase. So if you're having hot flashes,

and that's waking up from sleep, we need to fix the hot flashes, and that is not what sleep is doing. This is for the woman whose vasimotor symptoms are controlled or she doesn't have them who is struggling to go to sleep or struggling to stay asleep. So she and I decided to put three key elements in this product. So it is a combination of alpha wave L-thianine. Elthianine is a natural relaxing. It's a natural anti-anxiety medication.

So we are relaxing the mind with this. it also has a magnesium product, this glycinate that crosses the blood-brain barrier well, that gets into the system and relaxes the body and muscles. And then finally, it has a very, very small dose of a long-acting melatonin. It only has three milligrams. I was overdosing melatonin. I never understood how to use it. And so what melatonin does is reset your circadian rhythm.

Circadian rhythm is what controls when you go to bed. bed when you wake up, when the cortisol level spike. It's so, so, so important. So relax your body, relax your mind, reset the circadian rhythm. You want to take this an hour or two before you go to bed so that it's all kicked in and kind of working. So around 7, 8 o'clock, I will take my two pills and I'll start reading and winding down for the night in my nighttime routine to go to bed. One last thing I want to talk about is another prescription that I take. Actually take it at night. On my bedside table, I have my sleep supplement. I have my progesterone.

I have my oral estradi. And I have my monocidil. So vanity product that I use to keep my hair on my head. And I started with topical monocidil. You know, my perimenopause was fraught with hair loss. Like I was born with a lot of hair. And so you know how you have your daily, a lot of hair loss in the shower? I was having like postpartum hair loss.

And it was very, very scary. Of course, I call my dermatology friends and they're like, try those, try that. You know, we had blood work done. They looked for low iron and all the other things they could be. And they're like, okay, we'll try topical monocidil. And so it's basically generic rogain and get the men's strength, the 5% extra strain. Don't worry about the women. You don't need that.

And that seemed to work really well. And I did it for a few years, but it just got messy, right? I was using the alcohol base and it would make my hair kind of sticky. And now that I color my hair, I color the grays, the whole, like, hair map and when to wash my hair, but I got to put the monoxidil in, but I can't have monoxidolin because the color won't stick. Just got to be a lot. And then my Durham friends were like, well, just switch to oral. And I was like, oh, okay.

So the oral doses, you only need about 2.5 milligrams, and they make it in a five. So I just cut this in half. And it is $5 for a nine month, for a three month supply. It's generic. It's so inexpensive. So in my nighttime, take all my meds routine. I'm just going to crack one of these in half. And then take all that before I go to bed.

Oral monocidol works by prolonging the growth phase of the hair cycle. So our hair has a growing phase, a falling out phase, and a resting phase. And it also helps to dilate the blood vessels that feed the hair follicle to keep the follicle healthy. So this medication was developed to lower blood pressure. But the doses you take it for blood pressure control are 10 to 40 milligrams per hair. You only need 2.5. So that's what I take. It seems to be working really well.

I rarely miss it. If you're experiencing care loss, an oxidil may not be for you. You need to have your vitamin D level checked. You need to have your ferretin level checked. You need to maybe see a dermatologist. But this is one of the things, and I've done all of that, that works really well for me, and I'm happy to have my hair back. So that's my routine.

You might think it's excessive. I like it. It works for me. So my transdermal estradial patch plus a little bit of oral estradiol at night for bone protection, my oral micronized progesterone at bedtime, my testosterone gel every day, my vaginal estrogen twice a week. So when I put my patch on, I use my vaginal estrogen as well, my daily topical estradiol, my dhia for the vestibule. And then I have all my potions and powders that I put in shakes. I have my methylated bees, my co-cutin, my biotin

with our minimalty. And then my paw's sleep with altheon, magnesium, and sustain-release melatonin, and then the oral monoxide for my hair. So yeah, it's a lot. But everything is there for reason. I was losing my hair. I wasn't sleeping as well as I should be to protect my brain from dementia. And so to protect my stress levels, to protect my cortisol and my body composition, everything I take is for a reason. I take fiber to lower my risk of diabetes to help keep my body composition and check to lower my risk for heart disease. My recommendation is test, check your levels of nutrients, check your intracellular magnesium, check your ferretin, get your vitamin D levels, check, know where you are. Track what you eat. Are you getting enough protein? You may not need a

protein supplement if you're able to get it all in. Not everybody has to take this. Most of us should be taking creatine. We just can't make enough of it. If you're getting enough fiber in your diet, you don't need a fiber supplement. So know what you're eating, know what you're intaking, know what your blood levels are of important key levels in nutrients and then supplement after that. You deserve individualized care, built on your needs, your goals. Very, very, very personal. for you. If you want a lap panel recommendation that is going to inform you of most of these things, we have our free lap checklist at the pauselife.com, which you can download. We'll email you the PDF that shows all the labs that we recommend to our patients and why we recommend them. We also have

scripts on how to talk to your doctor in that. So remember, you're not broken. You're not crazy. You are in a biological transition for the rest of your life, and it deserves a biological response. Menopause is inevitable that suffering is not. Thanks for listening today. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at thepawslife.com. My new book, The New Peri Menopause, is available now everywhere and anywhere you buy books and through our website. If you're loving this podcast, be sure.

to click follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and be sure to share the show with the women you love. We would be so grateful. You can also find full video episodes on YouTube at Dr. Mary Claire. Unpaused is presented by Odyssey in conjunction with pod people. I'm your host, Dr. Mary Claire Haver.