ZOE Science & Nutrition - Your new menopause toolkit with Dr. Mary Claire Haver & Dr. Sarah Berry

Episode Date: May 9, 2024

The menopause transition can bring unexpected challenges — the effects can significantly impact daily life and long-term health. Dr. Mary Claire Haver is a board-certified gynaecologist and a menopause specialist. She's helped thousands of women in perimenopause and menopause to realise their health goals. In today’s episode, she joins Jonathan and ZOE's Chief Scientist Dr. Sarah Berry to shed light on what to expect during these life stages. Sarah and Mary Claire describe practical strategies for managing symptoms, critical conversations to have with healthcare providers, and how to advocate for yourself effectively in medical settings. 🌱 Try our new plant based wholefood supplement - Daily 30 *Naturally high in copper which contributes to normal energy yielding metabolism and the normal function of the immune system Learn how your body responds to food 👉 zoe.com/podcast for 10% off Follow ZOE on Instagram.  Timecodes: 00:00 Introduction 01:33 Quickfire questions 05:53 There is a lack of menopause training in medical school 07:02 Most women are going into menopause blind 07:43 Why menopause symptoms vary 09:30 The hormonal ‘zone of chaos’ 11:45 ZOE PREDICT data on menopause symptoms 13:36 How long do perimenopause symptoms last? 17:52 Perimenopause at age 35? 18:34 Why hormone tests are worthless 20:53 The risk of chronic disease after menopause 24:53 Why does menopause increase hunger? 28:39 Why medicine and research is male-dominated 32:34 How to talk to your doctor about menopaue 34:12 Pregnancy research - 10x more extensive than menopause research! 35:14 Mary Claire’s toolkit of strategies for menopause 36:34 What are the long-term health benefits of hormone replacement therapy? 38:36 Is HRT safe for most women? 42:47 Brand new ZOE study results: diet and menopause 49:16 Top 3 tips to help with symptoms 54:34 What is ‘frozen shoulder’ and how can you treat it? 📚 Mary Claire's book The New Menopause 📚 Books from our ZOE Scientists Every Body Should Know This by Dr Federica Amati Food For Life by Prof. Tim Spector Mentioned in today's episode Menopause transition and cardiovascular disease risk: Implications for timing of early prevention: A scientific statement from the American Heart Association in Circulation The controversial history of hormone replacement therapy in Medicina Dr. Vonda Wright’s website Have feedback or a topic you'd like us to cover? Let us know here Episode transcripts are available here.

Welcome to ZOE Science and Nutrition, where world-leading scientists explain how their research can improve your health. Today, we discuss a condition that half the population face, but only a fraction get adequate support for. We're talking menopause. Your doctor may not know how to identify your symptoms. You may even have thought these are simply symptoms of aging. Well, we're joined by a menopause doctor to demystify this life stage. She'll clear up questions about hot flashes and bust myths on heart health. Dr. Mary Clare is a board-certified gynecologist, menopause specialist, and best-selling author. Dr. Sarah Berry also joins us with some exciting new discoveries

from Zoe's health study about nutrition during menopause. Sarah is an associate professor in nutrition at King's College London, who led the Zoe Predict study on over 1,000 people, which uncovers the way women respond to food during menopause. So whether you're approaching this stage of life, already in it, or want to support the women in your life, this episode is an eye-opening journey into understanding and thriving through menopause. Mary-Claire, thank you so much for joining me today.

Thanks for having me. And thank you also, Sarah. Great to be back, Jonathan. So Mary-Claire, we have a tradition here at Zoe, which we haven't told you about before. So we always start with a quick fire round of questions. Okay. And they come from our listeners, and we have some very strict rules. You can say yes or no, or if you absolutely have to, a one-sentence answer.

Okay. Are you willing to give it a go? Let's do it. All right. Do you think that most women know what to expect from menopause? No. You got there before I even answered the question. That's good.

Do most women have symptoms? Yes. Do most women know that they have started to go through menopause? No. Can most women expect their doctor to be supportive? No. Is it possible to prevent bone loss and osteoporosis after menopause? Absolutely.

Sarah, can you improve your menopause symptoms with diet? Partially. Does your metabolism change during menopause? Absolutely. And then finally, Mary-Claire, and you have a whole sentence, what's the biggest misconception about menopause? That it's just hot flashes. We've talked about menopause on a number of episodes,

and I believe we're going to continue to talk about it. And we're definitely seeing more about it in the media, although I know that is different from country to country, but definitely seen that growth everywhere. But every time I have this conversation and Mary Claire and Sarah and I were talking before the show, I'm always amazed by how little it has been studied. So like how little science understanding there is and also how taboo the subject was when I was growing up and how even now I don't feel like those sort of taboos are being completely smashed. And I often talk to Mary Claire about the fact that my mother went through this and I had absolutely no idea. I didn't say a single word. I only found out anything about it when I discussed it with her a couple of years ago,

when I first sort of started to understand what a big deal it was, because this was sort of invisible to me. And it's not just because you're male. It was the same for me growing up that I remember occasionally my mum saying, oh, I'm feeling a bit hot and bothered. But yeah, you didn't talk about it. And I have no idea what my mum's symptoms were, what age she went through the menopause. And even now, I'm at that perimenopausal age I'm 47 lots of my friends are going through the menopause but lots of my friends still talk about it kind of in hushed tones so even though we are talking about it more it's still a bit something to be you know not you know not to shout from the rooftops about. Well my own mother it was this dark room she'd go into. I just remember my father would say, leave her alone, it's menopause.

It was this really scary thought process. And I learned so little about it in medical school and even in my traditional OBGYN training. Can you just define what OBGYN means for listeners outside of the U.S.? Sure. It's someone who has specific training. And in the United States, it's four years of training in obstetrics and gynecology, otherwise known as women's health. When I graduated and started practicing medicine, I hated menopause. Like, hate's a strong word. I just, you know, there's nothing we can really do for these women. It's just, you know, this terrible time in their

lives, et cetera. And it's really a disservice to half of the population that we are not talking about this and learning as much as we can about it. And I think what really shocked me is something you said earlier when we were chatting before the podcast, that you had only one or two hours training in your whole medical career on menopause. And this is something that I find also as a nutritional scientist shocking because medical students also only get one or two hours training on nutrition. And the fact that menopause and nutrition in total, they're getting about two to three hours training to a five, six, seven year medical degree. That's just really not on. It is immensely surprising to me. And how does that tie into this

thing that you've talked about a lot publicly about us not talking enough about menopause? I think, you know, when we look at how society views the aging woman, how society views menopause, if you go on AI right now and ask them to create a menopausal woman, it's going to be a very gray haired, frail, very, very elderly-appearing woman who does not appear to be in good health. And is that an accurate representation? Absolutely not. You know, I am a 55-year-old fully menopausal woman,

and I am probably as healthy as I've ever been in my life. Which is a really positive story and definitely something I want to pick up on because I think, you know, there is a lot of negativity. Now, you also just said right in those quickfire questions that sort of most women are going into menopause blind. Exactly. You know, what do you mean by that? So because we're not talking about it, we're not sharing the cross-generational stories of how the menopause affected, you know, your mother, your aunts, the women in your life, because there's a big genetic component

in how your body's going to express the estrogen withdrawal symptoms. People are blindsided, if I would have known, if I would have known. So there are very cliche symptoms of menopause that you can't really blame on anything else. And the classic is the hot flash. So for years, all of the science centered around vasomotor symptoms or hot flashes. If you just talk for a minute, make sure everybody understands what you're talking about. So some countries call it hot flashes. In the U.S., we call it hot flashes. Basically, this eruption of heat that starts in our core and tends to go up into our chest and head and neck and then out into the extremities. It's very disrupting. Quite often, it's preceded by a panic attack. In some patients, you get this level of anxiety.

Then you get really hot, then you start sweating. This could be in the middle of a boardroom presentation, in the middle of teaching children. At any point of your life, these hot flashes, flushes, can cause significant sleep disruption. We know that when you go through the menopause transition, the loss of estrogen accelerates our bone loss. So osteoporosis starts, osteopenia and osteoporosis start to begin to manifest. And then there's genital urinary symptoms, which we have lots of estrogen receptors in our vagina and our bladder. And when we lose estrogen in those areas, we start having dryness, loss of lubrication, and recurrent urinary tract infections. So those are kind of the ones we know. But modern science is teaching us that we have estrogen receptors,

estrogen-sensitive tissues all over our body. So another woman's menopause may skip over all of those traditional symptoms, easy to, oh, that clearly must be menopause. And of course, her cycles, right? Cycle disruption, and then they stop, period, stop. But there's neurological symptoms, cognitive disorders, mental health changes, gastrointestinal changes, as you guys know, musculoskeletal issues that pop up. So a lot of women don't realize that their menopause may be manifested by a frozen shoulder or tinnitus or vertigo that, you know, came out of nowhere suddenly in this time period clumped around her last menstrual period.

As Zoe's chief scientist, I wanted to talk about something that's not talked about, menopause symptoms. Over half of people on the planet experience perimenopause and menopause, yet symptoms are often misunderstood or dismissed. Zoe's new Menoscale calculator lets you score your menopause symptoms. Your Menoscale score may help you make sense of what you're experiencing. Personally, as a woman experiencing perimenopause, it's a key talking point with my friends. And now we have a score that we can share with each other. To me, this calculator is a game changer. At Zoe, we're moving menopause research forward. We recently conducted the largest research analysis of menopause and

nutrition in the world. In our research, participants reported an overwhelming number of symptoms. 66% of perimenopausal women reported experiencing over 12 symptoms like weight gain, memory problems and fatigue. The good news is our research shows that changing our food habits may reduce the chance of having a particular menopause symptom by up to 37% for some women. The Menoscale calculator puts our science in your hands. Go to zoe.com forward slash Menoscale to get your score. The calculator is free and only takes a couple of minutes. As we scientists say, if you can't measure it, you can't change it. All right, back to the show. But what happens is, is you don't suddenly go to bed one night, a premenopausal woman, and wake up the next day, a postmenopausal woman.

There's a period of transition, which is called the perimenopausal phase. And during that perimenopausal phase is when the burdensomes, I think, can be particularly challenging for women. And this is because you're having a decline in oestrogen, but not in a nice steady way where, you know, it's slowly declining and your body's adjusting each day to this tiny little decline. It's this state of hormonal chaos. You're having these like, it's like a roller coaster. That's exactly how I explain it to patients, the zone of chaos. You know, you've got other hormonal changes happening in the background, but the most disruptive is these, this kind of roller coaster of estrogen. And it's like oscillating. So it's going up and down and up and down.

You know, some days it might be down all day. Some days it might fluctuate throughout the day. And so as well as each woman's symptom being different, day to day, what you experience is quite different, I think, as well. Which must be very confusing to not have a sort of solid... You have no idea that this is coming. You just think your periods will stop one day and you might have a few hot flashes. You think you have dementia. You think you're on the path to Alzheimer's, especially if you have a family history. And here you are suddenly forgetful,

suddenly struggling for words, suddenly having anxiety, suddenly having increasing depression. And no one let you know that this might happen and to be aware so that you weren't so scared and terrified when these symptoms started happening to you. And I think because there was this misconception, which you said right at the beginning was one of the biggest misconceptions that menopause is hot flushes. So many women don't have hot flushes, but have these other symptoms. I'm one of those. I've never had a hot flush. I have terrible brain fog, as Jonathan knows quite often. I also get the palpitations, particularly in the morning. And it's really scary when you first get them. And even though I've researched in menopause, it took me, you know, really kind of blindsided me when I started

getting them in the morning. And I was scared, what's going on? And that's for someone that's educated in this. Waking up with those kind of really scary palpitations or the brain fog you know it's i think a frightening time if you don't know exactly what is a normal symptom or a symptom that you might get and going back to the point i made earlier that everyone's symptoms are variable this is another challenge i think because you know when you're in that perimenopausal transition you do talk to all your friends about it because if you're having symptoms it's so all-consuming because you feel out of control from so many things you felt in control of before but because your friend's symptoms will differ to your symptoms it then is an added area of concern it's like oh well is this

normal because you're having this but I'm not I'm having this and actually from our own ZOE predict data where we've looked at the prevalence of symptoms, we actually see hot flushes ranks about five, I think, in terms of the prevalence. And yet we're always talking about it as being the main symptom. So there's a couple of large databases in the US that have been created by the new menopause telemedicine companies. So they do, you know, collect data on their patients or people who are interested in becoming a patient. And they said the number one thing is, you know, sleep disruption, anxiety, weight gain, hot flushes are coming in at about fifth. Yeah, that's interesting. So we see that over 80% of people report disturbed sleep as their main symptom. We have about nearly

80% anxiety, which is the next one, and then brain fog, and then the weight gain, and then, like you say, the hot flushes is a bit further down. We have about 80% with musculoskeletal issues, and for 20% of them, it's their worst symptom, their most life-disreporting one. And when you say musculoskeletal symptoms? Usually joint pain or adhesive capsulitis, which is frozen shoulder, like the generic name is it.

So you get the lack of movement. It's really painful. You can't put your hand behind your back, which is frozen shoulder, like the generic name is it. So you get the lack of movement. It's really painful. You can't put your hand behind your back, put on your bra, and it requires probably usually about a year of therapy, physiotherapy. And there are definitely things we know now that you can probably do to prevent that occurrence happening. I want to know what that is, but maybe we'll come on to that later. So I think we've talked quite a lot about the symptoms as you're going into perimenopause. And Sarah, you mentioned something about actually potentially the symptoms could actually be worse in perimenopause than after menopause. What does that look like and what happens then after time after menopause?

Great question. So we have the best data on hot flushes, on vasomotor symptoms is the medical term, because that's pretty much all that was studied in menopause for 40 years. And we know that the duration of hot flushes begins in perimenopause. The worst of the symptoms is clustered around the last menstrual period in that year. But on average, they last about seven years. In women of color, at least in African-American women, that can go up to 10 years of symptomatology. But the majority of women will eventually, you know, the thermoregulatory center will adjust after several years to the lack of estrogen and stop firing. So that is where the hot flushes and the hypothalamus are

and what controls our body temperature. It gets disrupted, and those will go away. So that's where kind of this thought process around, well, menopause is temporary. If you just chin up and hang in there, these hot flushes will be gone. And just focusing on that one cliche symptom, I think, is really a problem in the

way a lot of studies are done. Your genital urinary system is always on the decline. Your cognition will likely return, but it'll never be what it was before. You'll likely get most of it back. How long, on average, would a woman expect to have symptoms during this perimenopause period? Just to sort of look at that. Great question. Because you've sort of got the second half, it sounds like, with previously very little focus on the first half. So let's go way back to embryology, because I think for your listeners, if they really understand what the menopause is, that they'll get a clearer grasp. So big differences between male and female. Females are born with all of their egg supply that has to last them till they're menopausal.

Males have the opportunity to make their germ cells, you know, our little cells that create people eventually, you know, every day. So they're constantly, a little factory is creating new ones. We're born with all of them. They start deteriorating for even in the utero. So at five months gestation, you have your max amount of eggs. You're born with about one to two million on average. So then you start ovulating. We lose about 11,000 a month through the ovulation process. And by the time you're 30, the average woman is down to 10% of her egg supply that she had at birth. And by the time she's 40, she's down to 3%. Menopause represents no more eggs. You're done. You have exhausted that supply, and there will be no more estradiol produced in any clinically significant form from the ovaries.

And estradiol, you just mentioned. It's the main hormone, the main estrogen hormone that is produced by the ovaries, and it's the most biologically active estrogen hormone in our bodies. So it is the one really responsible for keeping our inflammation levels down, supporting our reproductive function, et cetera. In perimenopause, we start to see these very dramatic ups and downs rather than this nice EKG because our levels of egg supply are dropping so low. Rather than like a nice smooth up and down curve over like roughly four weeks or whatever it is, suddenly you're saying it's sort of jumping all over the place? So our brain produces like hormones.

The brain is constantly checking for estrogen in the blood supply. There's like a little monitor in there. And when estrogen levels get low, the brain says, hey, pituitary, let's create more stimulating hormone so that we can get an egg out this month. And that process goes really well until perimenopause. And then the egg quality and the number gets so low, the brain has to really push and push and push to get those hormone levels up.

And it gets harder and harder each month, which is where the chaos comes from. The symptomatic expression of that usually begins seven to 10 years before the final menstrual period. Which is a really long time, isn't it? Because I might have thought listening to that, that you're like talking about the last 12 months or something, but like seven to 10 years, it's a long time. So, and if you think of average menopause in most countries is around 50, 51, maybe 52, in India, it's 46, significantly less. But still, the normal curve, 95% of women will have their menopause, at least in the U.S., with the average of 51 between 45 and 55.

That's still considered to be normal. Back that up 7 to 10 years. It is completely reasonable for a 35-year-old woman to begin, her body is showing her something's not right. Things are changing. And that could be joint pain, brain fog, weight gain. One of the biggest symptoms is she's tired all the time. And then if they do bring it up with their healthcare provider who's not trained to be able to diagnose perimenopause or recognize this as a potential constellation of symptoms

that might be related to hormone changes, well, just get on with it. You're okay. Maybe some tests are run. Everything looks normal. And another problem is a one-time blood test or urine or saliva is not clinically diagnostic for perimenopause because of the chaos that's going on. Yeah, they've estimated that there's billions of pounds that are spent unnecessarily, total waste of money on doing hormone tests where perimenopausal women are saying,

well, I want my hormones tested. And so these are being done unnecessarily because it's fluctuating so much. Unless we can be continually sensing, you know, over a couple of weeks, waste of time generally. So the point might be that you get a test, it says that your estrogen is fine, but if you tested it like eight hours later, it might have been really low. And so just like one test is no good. And so you don't use that in your practice. No, to diagnose perimenopause, I never do a one-time blood test. It is a diagnosis of exclusion.

And I will listen to her symptoms. There's a green score, a very validated scoring system done in perimenopause. And they don't even use the menstrual period. They use about nine or 11 symptoms and her severity. And it's everything from mental health, general urinary symptoms, et cetera. And I use that score to be able to tell her, okay, most likely it's this, but because you've gained some weight, let's check your thyroid. I'll do lots of blood work, actually, to rule out other conditions that might look like some of the symptoms of perimenopause. I don't want to miss an autoimmune disease or a nutritional deficiency. And so that's where the focus of when I, in my patients, where I do the blood work, but rarely on hormone testing.

So I just want to be clear, just because I think a lot of listeners will be really surprised. There is no sort of one-time perimenopause test, whether it's a blood test or a scan or anything that just gives the answer. So you need to work with your doctor to understand this. It's like excluding a lot of other things is what gets you to the point that you're saying, yes, I feel quite confident about this diagnosis. Exactly. And I think Marie-Claire made a really important point there that for the women that are coming to her, she will make sure actually these symptoms aren't an indicator of something

more sinister. And so something I think we need to be mindful of is, given that we are thankfully now talking about menopause and talking about symptoms a lot more, and certainly in the UK, it's all over social media. We do also need to highlight that not all of these symptoms will be necessarily menopausal. And so it is worth also speaking to your healthcare provider just to check that there isn't something else underlying. We've talked a lot about sort of the symptoms you're experiencing through perimenopause and after menopause. I'd love to talk a little bit about what this means for sort of long-term changes to health and Sarah I know this is something that's like really important in your research but I know that it isn't just about the symptoms that you're going through in this period.

It's also about sort of changes in general to your health risk. Could you talk a little bit about that? Yeah, and this is something we looked at in our ZOE predict studies. So in our study with 1,100 individuals, we looked at people who were pre-peri or post-menopausal, and we looked at lots of different things. But one thing that we really focused on was their disease risk. So we looked at lots of different things. But one thing that we really focused on was their disease risk. So we looked at what we call intermediary risk measures. We

want to look at what are the risk measures that put you at higher risk of the heart attacks, the stroke, et cetera. You know, high blood pressure, high cholesterol, worse insulin sensitivity, high levels of inflammation, visceral adiposity, which is the fat around your tummy. And we looked at this in our PREDICT cohort. And what we found was that PERI and postmenopausal women had significantly worse intermediary risk factors. They had higher blood pressure. They had worse insulin sensitivity. They had higher cholesterol. They had higher inflammation. They had higher visceral adiposity. Which is the weight shifting around your stomach. From subcutaneous to intra-abdominal. Which is like from a healthy place around your hips all the way over to this

unhealthy place around the rock. The place where I saw all my fat as people have, as I've discovered in previous shows. Oh Jonathan, you don't have any fat there. But yeah, it's shifting it from the pear, so around your hips. And oestrogen actually directs the fat, funnily enough, to your hips. You lose oestrogen and then it goes in a more male-like configuration, which is that apple around your tummy. But lots of people say, like Marie Claire said, well, hold on, that just happens when you age. And so what we looked at as well is we looked at males as they age in these risk factors, the blood pressure, the cholesterol, et cetera. And what you see is as you age each year, they go up a little bit.

It's a longitudinal. Yeah. And you get this kind of nice straight, pretty straight line or as straight as you can get in human biology and science. When we looked at our females, we found all of the females for most of these risk factors are sitting nice and low. So we're doing a lot better than our male counterparts, hit the menopause or perimenopause. And suddenly,

well, that line goes off the charts and often in most of these risk factors even goes above. And we've got in our paper that we published on this some really lovely figures actually from our own real data showing that, which is really interesting. You know, it's not scientific, but when I posted about how shocked I was in my patient population looking at cholesterol levels, and 80% of my patients have hypercholesterolemia in their menopause journey, meaning elevated levels of bad cholesterol. Their HDL drops and the low density go up in a negative health fashion. I think it had millions of views, comments of, no one told me, you know, they just said I needed to change my diet. Well, I haven't changed, and with no changes in diet and exercise, none. That menopausal status, estrogen deprivation, or the loss of our estrogen, the senescence of our ovaries, is a direct risk factor into these more likely to be associated with cardiac disease.

And Sarah, can you explain for a minute, because I know this is, you know, your big area of expertise, what's going on in the way that these women are responding to food? Because that's really changing, isn't it? And that's what's sort of explaining why these cholesterol levels are going higher and you know their responses to the blood sugar is is changing and i think you've could you just explain that yeah i mean there's loads of changes going on um everywhere from like our hunger receptors in our brain and again this is something that i think you know surprises everyone they're like i'm eating exactly the same food but i feel so hungry all the time. Oestrogen even impacts the hunger receptors.

It impacts the release of fullness hormones. It impacts how we metabolize. So it's completely transforming the way that you engage with food and how you feel. Yeah. So first it's impacting, yeah, people are hungrier because it's mucking up your hunger and your fullness signals, the release of those hormones. When you're eating those foods, it's also changing how you're processing those foods. And this was some really interesting findings from the

ZopaDict research and quite novel findings. And what we did is we looked at how people were processing the fat that they were eating from the meal and how they were processing the carbohydrates that they were eating. And we can measure this by measuring in the blood circulating blood glucose, or we also call blood sugar levels, which typically after a meal would rise, reaching a peak about 15 minutes, return to baseline about two hours. We can also measure how we respond and metabolize the fat in the meal by measuring something called triglycerides in the blood. And that's a slower, you know, reaches a peak about four hours, returns to baseline around eight hours. And what we found is when we gave our 1,100 participants standardized meals that contained exactly the same amount of fat, exactly the same amount of carbohydrate, the peri- and post-menopausal

women had what we would call unfavorable post-meal responses in this circulating fat, in this circulating blood sugar. So what was happening was, is that the post and perimenopausal women had significantly higher increase in circulating blood sugar, which we know if it's excessive repeated over long periods of time, increases our risk of chronic diseases, type 2 diabetes, cardiovascular disease, obesity and so forth. So that means basically you could be eating exactly the same food as you were eating five years before and your body was just fine with it. And now suddenly, like every time you're doing this each day, it's just this little bit of damage day after day after day. So it's like, it really is true. You are doing the same thing as

before and now you sort of can't cope with it in the way that you could before. The conventional thinking around this is that the patient is not being truthful. That's impossible. Like when you don't take into consideration the gut microbiome, you know, metabolism changes associated with the menopause transition. I've seen it in the literature when I was researching for the new menopause. This kind of, you know, paternalistic, well, women do tend to somaticize their symptoms. Women do tend to, you know to stop moving quite as much. And there may be some truth to that.

And they are hungrier. We know that. But just believe the patient. She's telling you, I have not changed my diet and exercise. And all of these cardiometabolic risk factors have worsened for me. What's going on? You said, and again, coming back to these quickfire questions, you shouldn't necessarily expect your doctor to be supportive, which is like, it's quite a strong thing to say.

I mean, could you maybe start with that? Why is that? And then love to talk through. So how could you help a listener to be able to talk well to their doctor to get the right focus and treatment? It's really, you know, of course, for some people, it's a personality thing. They just have a checklist, and if you don't fit the checklist, you know, but if you're not trained and educated as to this basic biologic process, you don't know how to associate it with what's going on. So I think we have a huge problem across the world in how we train and educate our healthcare providers in as far as the far-reaching aspects of the menopause and the menopause transition. And so I think that's the first problem.

So I arm my patients with lots of tools. I arm my followers with lots of tools to try to advocate for themselves. I'm like, there's no guarantee, but I give them research studies to print out. And these are big meta-analyses. These are big, big things, not little, small. And so that they can, the American Heart Association wrote a beautiful study on the menopause transition and the risk of cardiovascular disease. I hand them that. I give them things from the Menopause transition and the risk of cardiovascular disease. I hand them that. You know, I give them things from the Menopause Society in the U.S. or the British Menopause Society in the U.K., you know, with tools to advocate for themselves because often they are educating their providers. I teach them the words to say to go in and ask for certain treatment options that might be available to them that the physician may not have realized could help them. I think the next generation of doctors, I hope, are going to be more aware.

And I think, like my daughters in medical school, I think her generation forward were great. But it's going to be our generation to kind of retire the ones who are out, who aren't learning, don't have the time or inclination or care really to pick up this new information. The menopause, the societies are not on board yet with menopause. So it really has to come from above. I mean, there's, we just have so much, this is a big shift to course correct. And I do find it a bit surprising because one of the striking thing is how many doctors are women today, right? So that's definitely a shift from, you know, when I was a small child. You know, we were trained in male medicine, male-centered medicine, that any female experience,

whatever it was, was abnormal and, you know, different than the standard. The male patient was standard. And we have so much work to do around that as well. It's the same in research. You know, most scientific nutrition, biological research is undertaken on males, because males are easier to study. You don't have to think of their menstrual cycle. You don't have to think of whether they're pre, peri or post. And I know I've often told you this, Jonathan, but Marie-Claire, before I started working with Zoe, I had conducted about 30 randomized control trials looking at the impact of diet on cardiometabolic disease. I had never recruited

females into my trials because it meant it would triple the cost of running the study because I'd have to recruit more individuals to take into account all of the factors that I just said. And you can't get that funding. And so unfortunately, you know, as a female only, you know, up until five, six years ago, I was only including males in my studies. Fortunately, at ZOE, you know, we're really kind of pioneers in terms of, you know, we're over-indexing on females in our research, which is fabulous, which is why we can produce all of these great, great findings. Hi, I have a small favor to ask. We want this podcast to reach as many people as possible as we continue our mission to improve the health of millions. And watching this show grow is what motivates the whole team at Zoe to keep up the really hard work of creating new episodes each week.

So right now, if you could share a link to the show with one friend who would benefit from today's information, it would mean a great deal to me. Thank you. So coming back to this woman who's going in to see her doctor, so hopefully she sees a doctor who is completely informed, and that's great. But let's say they're worried that maybe their doctor isn't going to be completely up to date. What can they walk into that doctor's office with, or how can they approach this to try and make sure that they do get the best outcome for them? I'd say for her to educate herself as much as possible, because at this point, she knows her body better than anyone. To be very clear, write down her symptoms,

make sure she has her family history ready. In the US, we have something called the Well Woman Exam. That is not the time to talk about menopause symptoms. You have a 10-minute visit. Half of that's in startups, getting your breast cancer screening and your cervical cancer screening. Schedule a special visit, a problem visit, just to discuss the menopause. Call ahead and see if they are willing to discuss this. Do they feel comfortable?

Would they have an open conversation with you? Because a lot of physicians, rightly so, know that they have a lack of education. They're very, very busy discussing this, you know, doing surgery and delivering babies. I mean, and it's really sad in the U.S. that this all gets dumped in the lap of the poor, busy OBGYN. And this really should be internal medicine and family medicine or GPs. And so taking the time, do your homework, go in prepared with questions, go in prepared with your history, go in with all your previous blood work and lab tests that you've had done so that you can create a clear picture for your physician to be able to help you. One of the starkest examples of where the focus and priority in women's health, there's two. If you go into PubMed, which is Google for doctors,

Google for medical scientists, and you type in the word pregnancy, 1.1 million articles come up. Then if you just type in the word menopause, we have 94,000 articles. And when you think of the money, the brainpower, the lab space, is the last third of our lives not worth us? Once our reproduction ends, are we no longer only worth 10% of the research funding and dollars? So you're basically saying there's 10 times as many medical trials and studies and papers on pregnancy than on menopause. Yes. Well, in that PubMed search, if you then put nutrition and menopause, you get in the hundreds. And yet if you were to put nutrition...

Quite a lot of those are yours. If you were to put, you know, nutrition and, I don't know, cholesterol, you'd get in the hundreds of thousands. And so it's crazy. That is crazy. Well, I think that's really fantastic advice. I'd love now to talk about, well, what's the advice that you can give today to our listeners, whether it's for themselves or for loved ones. And I know in your book, Mary Claire,

you talk about sort of a toolkit of strategies. It's not like just one answer. We should probably start with medicine and talk about hormone replacement therapy, but I definitely want to make sure that we have time to talk about a lot of the other things because of course that's a conversation with your doctor. And then I think for many of these other things are things that you can implement at home. So hormone replacement therapy is something I discuss with all of my patients. We talk about the risks and the benefits.

We direct those risks as to what may apply to her. And we talk about the benefits for everyone. We talk about the cardiovascular benefits, the neuroprotective benefits, the osteoporosis prevention benefits, the general urinary preservation benefits. We talk about, yes, it will help your hot flashes. It will probably help with your brain fog. Could you talk for a minute just about those benefits around long-term health? Because again, I think it's often being presented as something that's very much around symptoms, but it's interesting that all those things you just started with were about sort of the long-term risks that Sarah was talking about earlier. So one of the meta-analysis that stopped me in my tracks and really changed my practice of

medicine was in 2020 when the American Heart Association published a treatise on the menopause transition and cardiovascular risk changes. And they really were very, very clear that a woman's cholesterol dramatically moves towards an unfavorable profile through the menopause transition very, very quickly. Usually it's a slow process over time, like Sarah talked about, and then all of a sudden it just, boom, accelerates beginning in perimenopause. And they talked about looking back at the Women's Health Initiative study. If you started hormone therapy very early in your transition state, within the first 10 years or before the age of 60, there is a cardiovascular benefit to being on hormone therapy. So you're less likely to have a heart attack or a stroke. You're less likely to have

a heart attack, not a stroke, less likely to have death from a heart attack, and less all-cause mortality. Which is just death. Death from anything. 50% reduction of cardiovascular disease. And we see in our own data from our zoopedic studies some suggestions of why this is. And so when we looked at individuals who were taking HRT versus those not taking HRT, we found that those individuals taking HRT had significantly lower blood pressure. They had significantly lower cholesterol, particularly the bad cholesterol. They had significantly better insulin sensitivity, significantly lower visceral, so the tummy fat, and significantly

lower inflammation. And it's this inflammation that's actually, I think, really interesting as well post-menopausally that we know chronic inflammation underpins many long, you know, chronic diseases like your type 2 diabetes, cardiovascular disease, etc., even some cancers. And the fact that HRT was reducing the increase that you see post-menopausally in inflammation was interesting. But I think the problem with HRT, there's been so much confusion. And you mentioned about the Women's Health Initiative. And this is a landmark study that came out in the early 2000s, 2002, that had this big headline saying... They called a press conference to stop the study and share

this incredible finding that not only was estrogen not cardioprotective, it was increasing your risk of breast cancer. And this is before they had actually completed all of the statistical analysis. I mean, you know, Jonathan, having just gone through the process of the papers we've done, and we've just finished a Marie Claire and a randomized control trial, that everyone's blinded who's doing the analysis to actually the analysis that we're doing, that we wouldn't even consider talking about it until, you know, it's undergone lots of review processes. So no, the whole way that these results were presented was not appropriate. Plus, the type of HRT that was given to these individuals was oral HRT. So

that was in the form of, you know, a tablet. Premarin and Prempro. In the UK, I know it's a little bit different in the US, but in the UK, we only prescribe transdermal HRT. So these are the patches or the gel. How you process the oral, the tablets, versus the transdermal HRT is different. Very different.

But also the evidence, and you know, you mentioned this, didn't you, that the timing of taking it versus the risk is really important. And so in the Women's Health Initiative, women were being prescribed it later in their 60s. Yeah, so they were in their 50s to 79 was the catch ages. And so the average age was 62, much older than the traditional patient would have been started on hormone therapy. But their outcome that they were measuring was cardiovascular disease. So I get that they wanted an older population because it takes a while to develop, to get your outcome. And the longer you run a study, as you know, the more expensive it is. So it turns out that estrogen is better at prevention than cure.

And when you put estrogen on top of disease, sometimes it can make it worse. Whether it's oral or transdermal, estrogen can make platelets stickier. And if you have issues in your cerebral blood vessels, you have an increased risk of clot. No increased risk in the first seven years of therapy in the WHI, 50% reduction of cardiovascular disease. And we see in our own data from our zoopedic studies, some suggestions of why this is. And so when we looked at individuals who were taking HRT versus those not taking HRT, we found that those individuals taking HRT had significantly lower blood pressure. They had significantly lower cholesterol, particularly the bad cholesterol. They had significantly better insulin sensitivity,

significantly lower visceral, so the tummy fat, and significantly lower inflammation. And it's this inflammation that's actually, I think, really interesting as well post-menopausally that we know chronic inflammation underpins many long, you know, chronic diseases like your type 2 diabetes, cardiovascular disease, etc., even some cancers. And the fact that HRT was reducing the increase that you see postmenopausally in inflammation was interesting. But I think the problem with HRT, there's been so much confusion.

And you mentioned about the Women's Health Initiative. And this is a landmark study that came out in the early 2000s, 2002, that had this big headline saying... They called a press conference to stop the study and share this incredible finding that not only was estrogen not cardioprotective, it was increasing your risk of breast cancer. And this is before they had actually completed all of the statistical analysis. I mean, you know, Jonathan, having just gone through the process of the papers we've done, and we've just finished a Marie Claire and a randomized control trial, that everyone's blinded who's doing the analysis to actually the analysis that we're doing, that we wouldn't even consider talking about it until, you know, it's undergone lots of review processes so no the whole way

that these results were presented was not appropriate plus the the type of HRT that was given to these individuals is was oral HRT so that was in the form of you know in the UK I know it's a little bit different in the US but in the UK we only prescribe transdermal HRT. So these are the patches or the gel. How you process the oral, the tablets versus the transdermal HRT is different. Very different. But also the evidence, and you mentioned this, didn't you, that the timing of taking it versus the risk is really important. And so in the Women's Health Initiative, women were being prescribed it later in their 60s.

Yeah, so they were in their 50s to 79 was the catch ages. And so the average age was 62, much older than the traditional patient would have been started on hormone therapy. But their outcome that they were measuring was cardiovascular disease. So I get that they started, you know, they wanted an older population because it takes a while to develop, you know, to get your outcome. And the longer you run a study, as you know, the more expensive it is. So it turns out that estrogen is better at prevention than cure. And when you put estrogen on top of disease, sometimes it can make it worse. Whether it's oral or transdermal, estrogen can make platelets stickier. And if you have issues in your cerebral blood vessels, you have an increased risk of clot. No increased risk in the first seven years of therapy in the WHI, but they did see a very slight increased risk.

And what the data scientists think is that was probably they had preexisting disease and then you added estrogen on top of it for the older patients. But clearly, the data is clear. When you start estrogen or you continue someone's estrogen, you know, who has no clots, no plaques in her arteries, she's going to be fine. And so that means, I guess if I understand that right, it's not for everybody. But Mary Claire, it sounds like if someone is coming into your clinic, quite a lot of those women end up taking hormone replacement. Is that? Yes.

After we discuss, you know, the risks and benefits for her, most of them will decide to, yeah. Because there are some cases where there is increased risk, and it's important we mention that. Of course. Yeah, there are contraindications. If you've had breast cancer, et cetera. So there will be some people that it isn't appropriate for. Exactly. Yeah. So this is an individual people that it isn't appropriate for. Exactly. Yeah.

This is an individualized conversation with your doctor, but that's a big shift, isn't it? A big shift. Almost no one should take it to actually you're saying probably the majority of women who end up coming to see you at this point in their lives much earlier are. You know, clearly we know that when we lose our estrogen, we're less healthy on multiple ways to measure human health. And it's now looking very clear that the longer your body is exposed to estrogen, that was published in the BMJ, the British Medical Journal, looking at cognition. They looked at risk of dementia and how long, instead of saying, was she on HRT or not on HRT or is she menopausal and what stage is she in? They simply looked at lifetime exposure to estrogen in any form, whether it was from the time you stop your periods, from the time you start, however many years that was, plus hormone therapy in the form of estrogen. And the more years you had estrogen on board, the lower your risk of cognitive deficits.

Amazing. I would love to switch to some of the other things that people can actually do for themselves. There'll be a lot of listeners who'd like me to be honest, sort of five years ago thought, well, can really nutrition have any impact on like this sort of catalog of really serious symptoms? You know, what does the data say, Sarah? So the data shows that nutrition can have an impact on symptoms. And what we certainly know is that it can have a huge impact on all the kind of disease risk factors that Marie-Claire and I've been talking about. So nutrition can help with the

two problems of menopause, one the symptoms, but one the increased disease risk. Now, it might work better for some people than other people. And it's really important that we say that. What we found in our data is that when we look at people's overall diet quality, those people that have a higher overall diet quality have a significant reduction in symptom prevalence. So they have lower levels of sleep disturbances. They have lower levels of hot flushes, lower levels of anxiety, palpitations, et cetera. And for some of these, this is like 30, 40, 50% lower depending on the symptoms. And is this one of these nutrition studies on 20 people, Sarah? Of course not, Jonathan. It's our ZOE studies. So this data actually comes from the ZOE health studies

research platform. So this was actually in hundreds of thousands of individuals, which is fantastic, because that gives us the power to delve even deeper, which we haven't done yet. So we need to do another podcast in about a year when we're next in New York with you to divulge these kind of details. But what we've started by looking at was just overall diet quality. What we're going to be doing next is looking at individual components of diet and looking, you know, how does it differ depending on clusters of symptoms or depending on, you know, other characteristics such as, you know, the age at which you might have started that kind of perimenopause transition.

And, you know, a lot of women will say, okay, at least on my social media following, you know, I'm choosing not to take it or I have an absolute contraindication. What can I do? And then I say we have to double down on all the other aspects of the toolkit, especially nutrition. And Mary Claire, if you are taking hormones, does that mean you can just forget about all the rest of this? Absolutely not. If you don't maximize your nutrition, hormone therapy is really only going to help your heart flashes. Yeah, nothing offsets a bad diet, Jonathan. And this is where the whole kind of,

the supplements, all of these other kind of silver bullets that people take, nothing offsets a bad diet. We need to make sure we are having that healthy balanced diet. And I think for me, the icing on the cake in terms of the evidence for symptoms and diet is from some what we call longitudinal analysis and science so this is brand new and it's not yet been peer-reviewed right last week so it's even quite new for you so we followed people who were on the ZOE program. So this is where we're encouraging people to have the healthiest diet possible for them. And we took baseline measures prior to them starting the ZOE program where we looked at menopause symptoms and we looked at their diet.

And then after 18 weeks, we collected added information about their menopause symptoms. Had they changed? What symptoms did they they changed? What symptoms did they now have? Severity, et cetera. And I must say, I was really surprised by this. We found a huge reduction in the prevalence. So how many symptoms people were having and how many people had each symptom. So we were having up to about 70% reduction in some of the symptoms. And this was after about four months, you're saying? This is after about four months. Pretty fast. Yes. And we checked, had you started HRT in this time? So we adjusted

according to that as well. Are there lots of studies showing a particular diet intervention and its impact on menopause? There are some studies out there. So there are some cross-sectional studies. So the studies where at one point of time, look at what's your diet and what's your symptom prevalence. Those studies show that generally, if you're following a Mediterranean style diet, which is a very kind of healthy, plant-rich diet, that you have less symptoms than those not following that kind of diet. Those following a Western style, as we call it in nutrition research diet with heavily processed foods, have more symptoms. There's a couple of randomized controlled trials, but not many looking at whole dietary patterns.

So these are trials where they'll randomly allocate one group of people to follow a Mediterranean style diet and another group of people to follow like the typical US or UK diet. They also see improvements and symptoms if you're following that Mediterranean diet. Then there's hundreds of studies on individual supplements, on individual foods, on individual nutrients. And I think this is where we need to be a little bit careful that there's a lot of inconsistencies. Now that's partly because there haven't been enough good studies on each individual nutrient, et cetera. But I think that this idea that you can have a silver bullet where you just take, I mean, I can't remember.

A probiotic or turmeric. Yeah. Where it's like a single component. And you see some of the claims are made. I don't know if you have this term here. We call it menowashing. It's getting here. So you stick menow in front of it. You double or charge up to 10 times because you put menopause in front of it. And hey, you know, you're like rubbing your hands together and off on your yacht in the Mediterranean having retiring early. But there isn't enough evidence yet for that. There's some interesting evidence coming out around soy isoflavones isoflavones are a particular chemical

that mimics estrogen and there's some really interesting interaction with the microbiome related to this and that's a fascinating area and i really think like watch this space on that where there is i think you know enough evidence to say may for many people supplementing with isoflavones may have an impact all of these studies even these hundreds of like individual like food item studies their outcome is hot flushes it's the easiest thing to measure so basically your study is pretty much the first one ever to actually look at this full set of symptoms yeah and i've never thought about that until i mean i've always been looking literally thinking well what about this and this symptom but because of

that misconception anything to do with menopause if it's not measuring a hot flash, it doesn't exist. I'd love to talk about other actionable advice, Mary Claire. So we talked about the hormones and the diet. If you were going to say to somebody here, here are like the three other things that you could really do that could make a difference, potentially on top of those others, what would they be? So again, you have to let go of the notion that menopause is hot flushes, right? So if I, like my big three are usually make sure you're getting a minimum of 25 grams of fiber in your diet per day. Most women on the Western diet are getting 12, and that's going to hit so many points in

what you're dealing with. It's going to help with cholesterol. It's going to help with your blood glucose. It's going to help with your insulin levels. It's going to help with your gut motility. It's going to help with your microbiome. And that should come from food. This is not your source of fiber. This is a little helper. You need to get this from food because those foods are also packed with micronutrients, minerals, vitamins, healthy fats, other things that will keep you healthy as part of a profile. Nutrition is a profile. It's not one thing. So one is fiber. The other is watching the amount of added sugars that you have. So not fruits and vegetables or

dairy, but sugars added in cooking and processing and in alcohol. You need to limit those to less than 25 grams per day. Women who do that consistently have less visceral fat, less hot flashes. We have pretty decent data to show that you're healthier when you do that. And the keto movement really, so many of my patients who've done keto for years are really anxious when they see sugar levels. And I try to talk to them about the difference between an added sugar and a sugar that's naturally found because a sugar molecule is a sugar molecule, of course. But those naturally occurring sugars are wrapped in a package, usually with fiber and vitamins and minerals and nutrients, and have a very different impact on your health than a simple sugar that's through processing. And then to add in consistent resistance training, muscle training.

Most women are doing cardio, and they didn't want to gain weight. They didn't want to gain weight. They didn't want to be bulky. And they didn't understand the impact of weight training and keeping strong muscles and bones. When I talked to my patients, when I talked to my followers, I did this questionnaire and said, what scares you the most about getting older? It shocked me because for me, it's cancer. I've lost two brothers to cancer, multiple aunts and uncles. It's just my genetics. And it's okay. But you kind of come from your place of what you know and it was overwhelmingly to not be able to think

and to not be able to move. Basically, not be able to care for myself and be a burden on my family as I age. They want to limit that time as much as possible. And so what causes people to go into a long-term care facility or not be able to care for themselves is loss of being able to walk, move, break a hip, you know, whatever, or dementia, you know, whichever form of dementia. So like, if we just look at frailty, what can we do to decrease that risk and muscle mass and bone strength? And that begins now in our 30s, 40s, 50s, you know. And they're not the same thing, are they? Like the bone strength and the muscle mass? The musculoskeletal unit works as a unit.

So stronger muscles mean stronger bones. You're sending that signal that's going to slow down the rate of bone resorption that we see accelerate when we have our estrogen loss. And so, you know, that remodeling process slows down so that we can hang on to strong bones. And so what are you advising your patients to do? At least two days a week of resistance training with probably weights. I tell them there's, you know, YouTube videos now, there's lots of free resources, start investing. And my favorite, like, hack is get a weighted vest. There's some beautiful studies, small, but they're there,

done on women in their 70s and 80s wearing weighted vests. They were in long-term care facilities and looking at their improvements in their bone density and muscle strength. Now, this was combined, some with creatine, some with—they're all doing muscle training. But just wearing that weighted vest and also the vibration, the vibratory, which not everyone has access to. But wearing a weighted vest to like clean the house or walk on the treadmill. And when you walk your dog, adding in that little bit of extra stress will send that chemical signal, you know, to the bones and muscles to be more resilient and to be stronger. So literally wear the weighted vest while either just walking around

the house or something like that. And that's going to sort of do all this extra pounding on your bones and sort of muscle work that will make a difference. Right. And just start at 10% of your body weight. That's a very safe place to start. So we often talk about exercise snacking because I think if people haven't been used to either doing weights or any exercise, it's really daunting to suddenly do that 30 times a day. Right. Go into a gym. And so something we really advocate is do an exercise snack. And by this, it could mean do 10 squats, do a wall push-up.

You know, you can do this when you're on the move. You use your own body weight as your weight. You only need 30 seconds. It can actually build up to doing quite a lot over the day if you're snacking on exercise in that way. And I think that's a really great way to start. I did want to pick up on one thing that you'd mentioned earlier. You talked about a frozen shoulder being quite common. And I at least hadn't heard about this before.

I hadn't either. I'm imagining now that there'll be a set of listeners who are suddenly going to be thinking, well, I've got that. I suspect some of them will not have associated this with menopause and may just be basically grinning and bearing this. Is there anything you can do if this is something that you're living with? So what it is, is adhesive capsulitis. The capsule around the shoulder joint becomes adhesed and freezes. And so you start losing, the beginning stages, you have pain and loss of movement. You can't put your hand over your head. You can't put your bra on.

You know, you can't reach behind your back. And it's very, very, very painful. And in the advanced stages, it could take a year or more of physiotherapy to get in that physical therapy to break down and regain your movement. And quite often, they'll have it on one side and they'll go to the other. So when I talked about it, so many people asked me on social media about frozen shoulder. Instead of saying, no, I've never heard of it, I'm curious. So I start digging in the literature.

I find a study, recent study coming out of Duke University where the head of the orthopedic surgery department, who was a woman, and the head of OB-GYN, who was a woman, got together and said, there's too many patients who are having this. And they're all menopausal. Is there a connection?

And what they found in reviewing the literature is that we know the age at which you get, and it's definitely perimenopause and menopause, early menopause. And if you're on hormone therapy, the risk is significantly less that you will develop frozen shoulder. But say it's too late, you're not on hormone therapy, you know, so it's preventative. What can you do? Know early this might happen to you. When you start noticing, I can't quite reach, this is hurting, or just feel stuck, immediately go to orthopedic surgery. Go get a referral for physical therapy. Go online and look at the exercises that you can do. Dr. Vonda Wright is an orthopedic surgeon and she does a lot of menopause care. She talks about this extensively. You know,

things that you can do in the early stages to prevent having this severe adhesive capsulitis and then ending up needing surgery. I'd literally never heard of it. And I imagine there will be some people listening to this who are suddenly going to go out and speak to a doctor who didn't otherwise thank you. I would love to try and summarize what we've covered. We've covered a lot of things, and I know the two of you will correct me where I've got this wrong. So we actually started by talking about the fact that the symptoms of menopause are actually quite different from the way that many people understand them, including women going through it, including doctors and scientists, that are amazing. These hot flashes or hot flushes are only the fifth most common symptom, even though they're like the only one that people have historically used

to decide whether or not someone's going through menopause. I think you said, for example, both bad sleep and anxiety, sort of 80% of women are having it. And then there was this very long list of other symptoms you can have, both things like bone loss at a long term, joint pain, this frozen shoulder I've never heard of, forgetfulness, anxiety. It's an amazing and very complex catalog of things. And this is part of the reason why often it's been hard to diagnose.

You explained a bit about what's going on and the fact that we've historically thought about menopause as very much like it's at the point when you stop having eggs, but that actually we now understand that there's this long period, sort of seven to 10 years, I think you were saying before the point of your last egg, where there are suddenly not that many eggs left. And so instead of having this sort of constant amount of estradiol, did I get that right? Which is this form of estrogen being produced. We have this hormonal chaos, I think you said Sarah. So it's all over the place. And so actually sometimes the symptoms could be worse because it's not like it's just stopped. It's sort of up one day and down the other. But that also means the total period that you're experiencing this is a lot longer than people have previously

said, because you might have seven to 10 years before menopause, you know, maybe seven years afterwards, you said maybe 10 years if you're African American. So like this really long period that could even start when you're 35 and might go on until you're 60. So this is a very, you know, big period of a woman's life. And it's made harder still because there is no test. Mary Claire, I cannot just go into your clinic and get like a single test that tells me you have perimenopause. We're great at postmenopause. Postmenopause is, I understand, quite straightforward. But for perimenopause, you don't know what's going on. And therefore, we said like the first thing actually is just if you understand what's going on and that you may be going through perimenopause,

that already might help with your stress reduction because suddenly at least you understand what's going on in this area. I think you shared some great examples where even when you're as educated about this as you are through your work, as an individual experiencing it, it can still be a shock because it's not so obvious to just this one symptom. You then went and said, not only are there all these symptoms, but actually it really is having a big impact on your long-term health and that this is something that has not been well understood, but that suddenly a woman's risks of many long-term diseases, and we talked a lot about sort of cardiovascular, sort of heart-related diseases,

but they're just in general, the risks to your bones, all these sorts of things start to shoot up. And I think explain that this is because there are these little receptors for this estrogen, like everywhere in your body. And so sort of every part of your body is changing. And I actually have for the first time that we now know you get hungrier, for example, but that also the way you process the food that you were always eating no longer works the same way. So suddenly you're eating the same food that you were eating five years ago before you were fine with it. And now actually it's starting to cause you this harm. And so you're seeing the raised cholesterol and all these other things, more inflammation, weight moving towards your stomach, which is more

dangerous. So suddenly you need to change things around your diet as well as everything else that before you're okay with. And then we talked about, okay, so what can you do about it? We talked about hormone replacement and that there's really been a big shift in understanding the benefits and the risks that the way that you get this been a big shift in understanding the benefits and the risks that the way that you get this now is different from in the past. So that's a conversation with your doctor, but that in general, you are now prescribing this to a lot of the patients who are coming to you versus a situation where it might've been viewed as like, you know, for 5%. Right. I think in the past we were overemphasizing the risks unnecessarily,

and we were dramatically under emphasizing the benefits. And we're really understanding the benefits a lot more now. So I think that's really interesting. Then we talked about nutrition, Sarah, you said some sort of amazing new data, some of which has not even yet been released. And that's very hard, by the way. So I'm quite pleased that Sarah must be very convinced about it. We wanted to share it before it's peer reviewed, that not only do you see that diet is correlated with big differences in symptoms, and I know that's already been published, but also this new data about members of Zoe who are following their individual guidance, getting this retest, and actually seeing amazing results.

I think you said 70% of people saw their symptoms decrease in just um four months so in a very short period of time and across this whole cluster of symptoms which i know sarah is very excited about and there will be sure we'll be talking a lot more about that soon mary clay you gave some great really practical tips about um what you could do so first was like fiber within food double it so this is like all those healthy plants that support you in many ways and you see that as really important. Watching the amount of added sugar you have. So not worrying about the fruit, but worrying about, you know, all the things that are in there.

Drinks and the cakes and all of these sorts of things. And then you talked about how important consistent resistance training. So which you were saying you're trying to advise your patients at least two days a week to be working with weights. And that might well not be what they've been thinking about before, but now because of all these risks to do with bone loss, but also the strength that's going to allow you to continue to stay in your home, that's really important to ensure they can do what they almost all want to do, right? Which is to stay at home for as long as possible,

not break a hip, but also not get dementia. And you have this brilliant tip that I hadn't heard before. Get a weighted vest. You can start at just 10% of your body weight. You could just wear that while you're doing some activities around the house. And that alone could really make a difference, which I love because I think we have a lot of listeners talk to us about the idea of going to the gym is really scary. And so I think we often talk about like, what are ways to sort of start to make those changes? And finally, I mustn't forget this frozen shoulder thing. So there will be a bunch of people listening to this, either listening to themselves

or thinking about their wife who's been sort of complaining about this for some time, but doesn't want to make a fuss, is really busy. And so if you have got sort of part of this frozen shoulder, you should go and get that checked out because that is now sort of being identified as a real menopause symptom. And it sounds like it gets very serious if you aren't taking it seriously. So it's something you should go and have checked out. Absolutely. We need to add that to our list of symptoms that we ask in the Zobby app. I feel like we'll be coming back next year and there'll be even more

symptoms on this. I've got, I think, 70 listed in the new book. app. I feel like we'll be coming back next year and there'll be even more symptoms on this. I've got, I think, 70 listed in the new book. That's amazing. Mary Claire, thank you so much for coming and joining us today. Thanks for having me. I thought that was fantastic. I hope you learned something today

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