← The Tamsen Show
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Today's podcast is sponsored by Midi Health.
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If you've ever walked out of a doctor's office feeling dismissed or brushed aside, you are not alone.
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Ready to feel your best and write your second act script? Visit joinmitty.com today to book your personalized insurance covered virtual visit. That's joinmitty.com MIDI the Care Women Deserve.
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Emoji Moment from Mark who writes I just want to thank you for making GLP1s affordable. What would have been over $1,000 a month is just 99 dol a month with Mochi. Money shouldn't be a barrier to healthy weight. Three months in and I have smaller jeans and a bigger wallet. You're the best. Thanks Mark. I'm Mayra Amit, founder of Mochi Health. To find your mochi moment, visit joinmochi.com.
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Mark is a Mochi member compensated for his story what are the most common symptoms of perimenopause? Women should be looking for hot flashes.
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And night sweats, weight gain and redistribution Anxiety, depression and panic attacks Sleep disturbances fatigue. Gosh, sexual dysfunction Gastrointestinal problems Bloating Digestion issues Brain fog Migraines dizziness Memory problems Joint pain Muscle aches Osteoporosis Heart palpitation Urinary dysfunction Allergies Body odor changes this is perimenopause. We're not even through the transition yet.
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I hate to break it to you, but if you think you're too young to be thinking about perimenopause, you're wrong.
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It is completely reasonable for someone in their late 30s, certainly early 40s, almost statistically impossible by their late 40s that something in their body is changing because of this hormonal chaos.
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Most women have no idea what perimenopause is, let alone what to do about it. That's why I'm doing this two part series with Dr. Mary Claire Haver, one of the leading menopause experts. She's a board certified obgyn, the author of the New Menopause and the upcoming book the New Perimenopause and someone I trust deeply. You might recognize her from my documentary the M Factor and today she's on the Tamsen show to break it all down.
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Boom. Almost all of the systemic inflammatory markers rise, insulin resistance increases. We start driving fat to the intra abdominal cavity with not a single change in diet and exercise.
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This is the education I wish I had and it's everything you deserve to know well before you're in it. Dr. Mary Claire, it's good to see you. Same we have been through a lot of menopause, right?
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Yep.
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Through the years.
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My very first stage appearance, you interviewed me, and that was the longest 40 minutes. I was so nervous. Ever since then, every time I get on stage, you're there, and it's been the best.
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Thank you. I remember that. I remember so well. We were like, back and forth on texts. We hadn't met. We're just two Texas girls that decided we're going to talk about menopause a bit. Well, it's good to see you. It really is same. I'm so happy for everything you've done, everything that you share, what you do every day to help millions of women around the world. I am excited about this conversation because I think this is kind of this next tier as we look to the next generation and say, like, what do they need to make sure they don't go through what we went through?
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Right, Exactly.
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So let's talk about perimenopause and dive into that, because that is a focus I know that you have had forever. First, talk a little bit about your background, though, and how you got here.
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I'm a traditionally trained md. I went to medical school in Louisiana for. For four years and then matched at my top program, which was University of Texas in Galveston, and did OB gyn. Absolutely had some of the greatest four years of my life, Made some of my very best friends, learned a tremendous amount of information, went out into private practice for three years after that, decided to go back into academics. I kind of missed that rigorous academic life, being around professors and studies and students. So I went back on as faculty and was really thought I would just do that for the rest of my career and retire my 70s and, you know, go on with my life. But the big turning point for me was my own menopause, where I realized there was a gap in my knowledge and in the cme, you know, the continuing medical education. Like, we really weren't focusing on health after reproduction ends. Outside of needing a hysterectomy or some kind of emergent issue. It didn't feel like anyone in medicine really had our backs at this age to help shepherd us into our best health for the last 30 years of our lives.
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What was your menopause experience? Because I know that, you know, all of ours is a little bit different. All of it comes at a different time. But you had so much knowledge, and then you realized you didn't. I didn't in that one area.
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So I had been on birth control pills for most of my reproductive life outside of having children to treat a condition called polycystic ovarian syndrome. And I'd done really well with them. It's not the right answer for everyone. And in my late 40s, my second oldest brother was ill with HIV and hepatitis. I'd made a decision about that time. Let me get off the pill and kind of see where I'm at. Am I menopausal? Am I getting close? You know, do I really need to be taking this at this time? And right as I got off, I went home to take care of my brother for his end of life and lost him after about two weeks and, you know, went through this incredible sadness and grieving and, you know, probably some depression and was really attributing these symptoms I was having to grief, and certainly it was playing a part of it. But then once I felt the grief bubble kind of starting to rise, I realized I'm still not sleeping. I'm having all this joint pain. I've gained all this weight, and my. What is going on with my stomach? Like, oh, God, this was happening to all my patients. I was really struggling with mental health. And it really took me as a clinician, stepping back from my own experience to say, wait a minute, when was my last period? Now, I had never had regular periods, so it took me about six months to realize that I was menopausal, and I was the expert, and I didn't even recognize it in myself.
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I think as shocking as that is probably to you, to even process that that happened gives a lot of other women a lot of relief knowing that it's not just them. And if somebody with an expertise like you have in all the years of training might not know, it makes total sense that a lot of us. So let's talk about that, because that's when you were menopausal.
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So you were.
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You went. Right. You were in menopause. You didn't even realize it. But there is this whole time leading up that all these were happening to you, all those symptoms you're describing, and that is per menopause, before menopause. So can you define what perimenopause is and why it really matters?
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So in order to define it, I think we need to define, you know, go back to the basics of what is menopause? Why do we have menopause? So menopause is medically, we define it as one year with after the final menstrual period. So you've gone one year without a natural period. Now you are menopausal for the rest of your Life. Okay, so medically, menopause is one day. Now we have a transition period to get to that called perimenopause. But what does that mean? So if we think back to ovulation from an endocrinological standpoint, the big difference between males and females is that males are able to generate their sex hormones, their genetic material, you know, through the sperm from puberty until death. Now, it gets harder as they get older, but they're still able to do it. Females are born with our entire, what we call germ cell supply, all of our eggs, and they last us from birth until we run out in menopause. And there's only a few species in the world that actually experience menopause where they run out of the ability to ovulate. And mammals, and us, some killer whales, I think, one species of giraffe. You know, it's really.
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That's about it.
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Yeah, it's really rare. Perimenopause is when the signals that come from the brain that stimulate ovulation, which is what happens to a woman each month. So remember, we never have a steady state of hormones. As females, our sex hormones, we have an estrogen rise and fall in mid cycle and a little bit of a second bump towards the end, and then progesterone doesn't rise until after we ovulate and then goes back down to baseline. Testosterone fluctuates a tiny bit, but not nearly as much as what's coming directly from the ovaries. And those ovulations happen because these chemicals are coming from the brain, from the pituitary and hypothalamus that stimulate this. So in a healthy woman who has a regular cycle, so this is not a woman with pcos or an athlete who is suppressed because of her activity. You can very predictably say, on day 14, you're going to expect this. On day 21, she's going to do this. On day 28, her period's going to start, whatever that looks like for her. In perimenopause, the signals coming from the brain become resistant. The ovaries don't have enough eggs to listen to the signal. So the brain is like, where's my estrogen? Right. The ovaries don't act on their own unless they have a tumor. They are literally just following directions, and directions come from the brain. And so the brain is freaking out at this point. Where's my estrogen? I need estrogen. So it starts pounding the ovaries with higher and higher stimulatory hormones. That's FSH and LH in order to force those few eggs remaining, one of them to ovulate to get those hormone levels back up. So what happens in perimenopause instead of that very predictable ekg ebb and flow, rise and fall, we end someone taking spaghetti and throwing it against the wall and what we call the hormonal zone of chaos. So estrogen ovulations are delayed. We have much higher surges of estradiol than we ever did because the stimulating hormones are much higher. And then again, the progesterone never kind of gets to where it was. So we have long courses in perimenopause for most women of these unopposed estrogen cycles, or you know, what they call loop ovulations. So we'll see. If you did a one time blood test, you would say, oh, she's estrogen Dominan or she has high estrogen. This is normal, meaning common in perimenopause. It doesn't mean it doesn't cause her horrible distress, affect multiple organ systems, completely make her periods cattywampus. But it's just learning. And what, that's what I didn't learn in my training. I thought that the transition through perimenopause was this gentle, slow decline of estrogen and progesterone until she just stopped at the end. No, this system goes down fighting and these hormones go cattywampus, you know, rising, falling, dropping, dramatic, not showing up. Two months later, everything's fine. Then, whoa, you're, you know, having hemorrhagic periods, you're having horrible disrupted sleep, you're having mental health changes. And no one of us was taught to recognize this transition. All I learned about perimenopause was how to spell it. Oh, in residency, like we weren't allowed to even think about treating menopause, even if, you know. And that became taboo after the whi, until she was a year without a period. What do we do in the 7 to 10 year transition?
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And that's what we're all feeling today. That's what we all feel today. That's why there's that confusion. And it's funny, cause I think I get that question over and over is why don't we know anything about it? Why didn't our moms talk to us about it? I think we're just learning so much every single day right now, currently.
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I mean, it's so exciting to be a part of this movement right now. Because when we look at the NIH, right, or we go to PubMed which is PubMed, is where I go to look up medical articles. It is peer reviewed, the top articles, the, you know, the best information out there from worldwide. It's not just the research, it's research. Yeah. So if I type in the word pregnancy right now, today I will get about 1.2 million articles that mention the word pregnancy. Okay, Amazing, right? For those of us who had babies, this is so important. This represents billions of dollars of investment of brain power, of universities focusings for us to have these healthy pregnancies. Right?
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Somebody cares.
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Somebody cares. I type in the word menopause. And right now we are about at 98,000 articles.
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That is stunning.
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So less than 10 to 1.
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Stunning.
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So I'm like, okay, is my life after I was done having children less, like 90% less important than it was when I was able to bear children. And I'm not pointing a finger at one person or one clinician or at one university. This is a systemic problem. This is bikini medicine where a woman is a small man who happens to have breasts and a way to give him children. And this is a huge problem that we have. So now I'm gonna type in perimenopause.
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Does it show up?
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6,800. Oh my gosh, in 1980, I think. I don't wanna get the statistics wrong, but in the 80s is when the first articles popped up with even the word early 80s. In the 90s, medicine did not recognize there's a transition point until the 80s. And at that point there was only 35 articles. Like, it's really in the last five years that we're seeing, okay, this is a thing and this is something we need to study. We don't have a single large scale study on the treatment of perimenopause.
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And every woman, if they're lucky enough, will be there at some point.
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Yeah, 100% of us.
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I want to go back to the zone of chaos to make that clear because I think it's really important. That area is a time where we are. It lasts a long time. It could be four to 10 years.
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Four to seven to 10 years, where the body, you know, the hormonal signals it's taking from the brain to have these ovulations happen. We see an upregulation of the LH and fsh.
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So that means chaotic hormones, chaotic hormones.
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On the other end because estrogen can't respond because there's not enough eggs. So it's this battle, you know, each month or each cycle to get this ovulation happening.
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Like it used to like, it used to. So it's estrogen, it's progesterone, and it's testosterone.
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So testosterone's a little different. Testosterone's made in other tissues, so not just in the ovaries. We do get a fair amount produced in the ovaries, but we also have an adrenal pathway. So testosterone in a woman declines slowly over time, just like a man. And when a woman is 50, she can expect to have about half of the testosterone level she did at her peak, which is about at 25.
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Okay, all right.
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More of a natural steady state decline, less of the chaotic drama.
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So you wrote the new menopause incredible book. Now you're writing the new perimenopause, right Now. What's the reason for writing the new perimenopause?
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Because they asked me to. Because I had this whole generation of moms who read this and said, this is amazing, but I want to help my daughters, I want to help my nieces. I want the next generation to be prepared in a way. So can you back it up a little? Explain the zone of chaos. Explain. And like, let's get some anticipatory guidance in here for the next generation so they don't get hit like we did in the transition.
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Okay, so how young should women start thinking about perimenopause? What's too young? Is there a too young? What's a good age? Reasonable age.
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Talking statistics. Okay, the average age of menopause in the U.S. okay, so for the Caucasian female is roughly about the age of 51. So that's one year without a menstrual period. Okay. Transition being seven to 10 years. So now we have a normal curve. Right? Not every woman goes through at 51, thank God, because that's where we get all these numbers. So we have 46 to about 55 is considered normal under that 95th percentile curve. Okay, so 95% of women will go through the final transition between the ages of 46 and 55. Back that up 7 to 10 years. So it is completely reasonable for someone in their late 30s, certainly early 40s, almost statistically impossible by their late 40s that something in their body is changing because of this hormonal chaos.
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So you could be 38 and pretty much safely say even before your cycles become irregular. So that's the question, because I think that what happens is women say, I'm still getting my period. So how do I know whether or not I'm in perimenopause if I'm still getting my Period.
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There's the green scale, which was actually developed decades ago. Okay, the green scoring system. And it's. It was. I'd never heard of it until I was, like, doing research for the new book. So the green scoring system is. Are the symptoms that I'm having related to perimenopause? And it'll give you a statistical, you know, so you answer like 10, 15 questions. And it's things like dry skin, genital urinary changes, hair changes, mental health changes. All of those symptoms were recognized, but nobody talked about it. Like, I was reading this. Like, wait a minute. The Australasian Menopause Society was using it, you know, as a scoring system, but I'd never heard of it. Like, why is it. And they knew.
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Why haven't we heard about it?
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I can't point the finger at one thing. I think it's systematic dismissal of women. I think. And I talked about in the new menopause. I was brought up in the medical world with something that I had to really reflect on. And I still have to check myself for my own bias. That in medicine, when you can't figure it out and it's a female, it's most likely in her head. That women tend to somaticize psychological issues. So we were trained from an early. From very early in my training that women. It's not biology, it's psychology.
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Why? Why women in particular?
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I think because the system was built by men for men.
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Sure.
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And there's a lot about us that's very different, was never understood, recognized, looked at. So we must be a little bit crazy.
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Aren't you glad we all found each other, to confirm with each other that we're not and then to let the world know?
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I can't tell you how many meetings I sat in with tears in my eyes, listening to menopause researchers who had been doing this work for 20, 30 years, but no one heard them. And I thought, my gosh, God gave me a platform, you know, this voice that people like to listen to on social media. Like, I can break something down in 30 seconds and share it on social so fast, it'll make your head spin. But that has been my passion, is like, these people have been doing this work for a long time, you know, and we need to get this information because we are gaslighting and dismissing these women. And I was part of the problem. And I'm done. I'm done. I'm never gonna do that again. And the minute that I brought that message to social media, my world exploded.
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Yeah, of course. I've watched it, I've watched it.
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But you know, how many audiences did I sit in and like slap someone in the chest like, oh my God.
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Yeah, I know, I know. But you know what? Better late than never late. And two, now we have a way to move that information along that we didn't have 15 years ago or 10 years ago. So the world has changed and luckily we've got some of those platforms, good or bad.
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Social media has really allowed Democrat of a lot of information. It may be great information, it may not be great information completely. But I really think this menopause movement is because of social media.
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Go back to perimenopause. If there's no way really to test for perimenopause. Right. That we've said over and over again.
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And let me back that up.
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Yeah, I think that's the best.
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We don't have a one time blood, urine or saliva test. So save your money to your listeners.
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So anybody that's saying to you, come take this test, send it here, go.
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Pay $400 out of pocket.
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Forget that. Okay.
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Where in the zone of chaos are you checking? Okay, now you might have a couple of clues. When a patient comes to me and I'm not sure where she's at in the process, I do a lot of blood work because a lot of these symptoms can also be fibromyalgia, autoimmune disease, nutritional disorders, et cetera. So I'm doing blood work to rule out as much as I can or anything that's overlapping of other things that might be that. Right. And then it is a what we call a diagnosis of exclusion. You rule out everything else. And for a woman of a certain age with this set of symptoms, this is what it is. So we were talking in the car on the way over here about, you know, someone was selling a saliva test for cortisol. I'm like, I don't need a saliva test for cortisol to understand a woman's stress.
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Right, Right.
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I listen to her, I believe her.
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And not saying, it's all in her head.
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Right. Like, I don't need a cortisol level to understand that you're having significant amounts of stress. I just have to talk to her for five minutes. Done.
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You know, we've got a lot of voices out there, we've got platforms. We're talking about it more. Why aren't doctors bringing this up sooner still?
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They weren't trained. We're not. We're doing a disservice to women's health and the medical system, and I'll be very clear about this, and really stopping female specific medical treatment, education after reproduction. And so once she's done kind of bearing children outside of a diseased uterus or cancer, we are not doing a great job. And I've talked to multiple specialists. So, you know, our menopause, which, you know, we are, like, founding members, has multiple specialists, psychiatrists, endocrinologists, cancer specialists, et cetera. And we all sit around and talk about how when we look at data, they're not deaggregating female versus male. And one of the most stark examples of this is in cardiovascular disease. I upset a lot of cardiologists when I talk about this. But when you deaggregate, the data on statins explain that.
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Deaggregate.
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So when you look at a whole population, we're gonna take everybody in this room, and we're gonna check their cholesterol levels, and we're gonna put them on a certain medication and see what gets better and measure outcomes of do you have a heart attack or not?
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Right.
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Okay. So we take a big group, including men and women, and they all have high cholesterol. We're gonna put them on statins. Most of their. Almost all of their cholesterol levels will go down.
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Okay, okay.
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Yay. All right. We want lower cholesterol levels.
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Right? Right, right.
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However, when we deaggregate, meaning let's look at males versus females, and who actually doesn't have a heart attack anymore and who doesn't die from a heart attack. Men, by far, have better results than women. Women don't see a benefit for the prevention of a heart attack. Primary heart attack, secondary. Yes. Because we have heart attacks differently than men. So when we look at our cardiovascular disease, and really, there's some amazing cardiologists who have done this work. I'm just reading their research. Women tend to have diffuse microvascular disease in their coronary arteries. So the arteries actually pop out of the aorta, dive right into the heart muscle, and then spread out and feed the heart muscle tissue. Women's diseases typically start, not all women, lower and more diffuse in the heart muscle, where men tend to have those big lads. So the widowmakers immediate immediately. When they escape, they get the plaques. So that's why you can go and stent those and open them up and whatever. Much more difficult. So here's the woman coming in for her heart attack. She has atypical chest pain. We are 51% of the population. Why is my heart attack atypical? So we're training the ER docs, the cardiologists, the family medicine that, you know, everyone knows. Chest pain, shortness of breath, neck pain radiating down the left arm. That's not how a woman generally has a heart attack.
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You know, a very good friend of mine, she and I walked to Central park and she said, oh, my chest. Like, I think it's like, cough left over from COVID And I said, are you sure? I think you should probably go see a doctor. I'm okay. I'm just going to sleep it off today. The next day, she's on the phone with the doctor in the process of having a heart attack. And the doctor luckily realized, like, you need to get to an emergency room right now. This woman walked to park like a mile, you know, went home, slept how she stayed alive, you know, during that time. So it's stunning to see. And it all goes back to what we were talking about at the very beginning of, you know, what we have, not what the disservice that we have continued to do for women in so many areas. All right. We talked about why doctors don't bring this up a little bit sooner because they just aren't trained. But even just recently, I talked to somebody and she said to me, I went to the doctor and I said, hey, I think I'm having symptoms of perimenopause. I'm gaining weight. I'm not sleeping. I feel a lot of anxiety and social anxiety. I don't want to go out and do things anymore. And the doctor said, it's not about jumping on hormones to lose weight. It's about making the lifestyle changes first. When women hear something like that from their doctor. This Woman's in her mid-40s, by the way. Just preface that. What do you want women to do with a doctor like that, aside from giving them a full education?
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It's sad that when they did a survey just a couple of years ago looking at graduating residents. So these are the brightest, the best, you know, freshly minted new clinicians in family medicine, internal medicine, and OBGYN. And less than 8% felt competent to take care of menopause. This is not the doctor's fault. No, this is the training program's faults. You know, how we approach women's health. So one is, it's incredibly frustrating that this is probably an incredibly well trained in every other aspect, well meaning, really bright clinician who just hasn't had the time, the inclination, or the education to be able to help you in this situation. They don't know what they don't know.
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Do you have to fire your doctor? You have to go find another doctor.
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So you can go to menopause.org which is the website of the Menopause Society, and look for a certified clinician. Now, not everyone on the list is certified. Certified means they've taken the test and passed it. So they've. They've demonstrated a level of education above what they got in training. It's not perfect on our website.
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What the normal doctor might.
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It is definitely more because I've done it myself. We have a list of testimonials in the hundreds on our website. You know, hopefully there's someone you could match up with there. I really love a lot of the telemedicine options that have come out. You know, these are mostly female founded specifically built to take care of the menopausal women. Recognizing there's a gap here in our clinical care. Agree. One of the nicest things that I'm most excited about is the Menopause Society received an anonymous donation and I've heard 5 million, I've heard 10 million. But a lot of money.
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It's a lot of money.
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They want to train 25,000 clinicians.
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Now, clinicians could be anything. Obgyns, any discipline, any person who has.
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The ability to prescribe. And that could be a nurse practitioner, a pa, you know, anyone who. You really have to step outside of the box of your training to get this. We're not doing this in residency programs and I was a former director. I know what was on the curriculum and intensive menopause training and education and clinical. Clinical expertise was not part of the OBGYN curriculum.
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Pack.
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On social media. You've been very raw about the fact saying that you felt like a bad mom in perimenopause, irritable, short fuse, not yourself. It was really, really vulnerable. And I think a lot of women feel that way. What can you say to those women that are going through this right now and they see it in themselves and it's almost, it's impossible to stop.
- [28:45]
C
I think I see these women who come to my clinic and they are, by the time they get to me, they're at their wit's end, you know, because I don't accept insurance. So they are making a sacrifice to pay out of pocket to come and see me. But that's how, how bad it's gotten for them. And these are women who had managed their lives. They had built a family, built a career, built a life that they were sustaining. They rolled with the punches. They had good days and bad days, but they had it managed. And then all of a sudden they can't. Something happens, something changes, something inside of them. They didn't go through a death. It's not like anything in their environment changed, but their resilience is gone. And that's what was happening to me. You know, a lot of things were happening at work. Increasing administrative burden, you know, that I had never been used to before. Having to document and, you know, spending hours on charting, you know, having to take away from my face to face patient time. I was losing so much satisfaction at work. Not because of my staff or my patients were lovely, but just the hours. I was also getting older and OB is hard. And so the hours, the 3am calls to go deliver babies, which I love doing. And I joke if babies only came between 8 and 5 and they all were healthy, I would still be doing OB on the side, you know, perfect, a 9 to 5 baby, 9 to 5 baby, but that's not reality. So, you know, hours were getting tougher on me. I had teenagers and so my oldest, who's now in medical school was like, mom, it was really unfair for me to go be a teenager and you be going through Perimenopause. At the same time, I can remember just screaming at the girls, you know, where they. Typical teenage stuff. And I would just lose it, and it's not fair to them. I remember, like, slamming on the brakes in the car. And my daughter's here watching this us record. And she's probably rolling her eyes right now and, like, remember thinking to myself, I'm crazy. I'm being crazy. I just slammed on the brakes in the middle of the road with my car. Cause my daughter said snapped at me for something. And I'm like, that was dangerous. Your children are in the car. You know, if your husband had done this, you would have, like, you know, lit into him. And I'm like, I'm not okay. I am not okay. What is wrong with me? I would ask myself, what is wrong with me?
- [31:07]
A
Do you tell these women you're normal?
- [31:09]
C
Yeah. And normal. Remember?
- [31:11]
A
And then there's some solutions.
- [31:12]
C
The myth of normal. Normal in medicine means common.
- [31:17]
A
Okay?
- [31:18]
C
Not. Not pathologic.
- [31:20]
A
Okay. So you're. So it's understandable what you're going through. That's what you say to that.
- [31:24]
C
And it's not your fault. And let's get you some help, okay? I'm trying to be the doctor I needed.
- [31:30]
A
I think you're doing a damn good job.
- [31:31]
C
And we survived. My marriage survived. My kids have turned out okay. But it got a little sketchy. Well.
- [31:37]
A
And understandably. And you are not alone.
- [31:39]
C
Yeah.
- [31:40]
A
Brain fog. Word loss, forgetfulness, debilitating cognitive symptoms. Okay, why does this happen in perimenopause?
- [31:47]
C
When we look at neurotransmitters. So why does our brain work? Because we have a bunch of nerves that between each nerve are neurotransmitters. These little chemicals that send signals, electrical impulses back and forth, and they all communicate. And when our estradiol levels go cattywampus and then disappear when our progesterone disappears, things like gaba, serotonin, norepinephrine, all of the neurotransmitters, we see fluctuations in those levels, and we see shrinkage in the area of the brain where memory is stored. And so we see verbal. You know, specifically, when they looked at different cognitive testing, it's the verbal memory that dips in perimenopause with the hormonal chaos.
- [32:32]
A
And some examples of that are. Can't remember a name.
- [32:35]
C
I can't remember. Like, surgical instruments. Like the thing with the hole in it that has the. These are instruments I had used for 25 years not being able to find Your keys, getting in the car and not, you know, we all do it from time to time where you were wondering if you have dementia. Sure. It's so bad. Sure. So, yeah, Kai. And then, right, on the flip side of that, those same neurotransmitters are involved in our mental health. So new onset mental health disorders, mostly anxiety and depression. And then, you know what, we're looking at the ADHD part of it as well. Just that, you know, visual spatial abilities. Women who were well managed, well controlled, all of a sudden are not managed or they're having new diagnoses in perimenopause.
- [33:19]
A
That's what I was gonna ask. Is it ADHD or is it something that simulates it where it's so close so you don't.
- [33:24]
C
So the ADHD purists say it's not. Because this starts in childhood, it's a wiring problem. But the symptoms are very, very similar. So we're treating them. You know, we start with hormone therapy, but some of these patients will need some of the stimulants to get their levels controlled.
- [33:39]
A
So I was given ant antidepressants when I was in perimenopause. I'd gone through a divorce. I was having, like, work was very stressful at the time. I was being moved all over the place. I was early morning, I was late at night, I was working doubles. I was anxious. I would have these, like, really dark days that getting out of bed was impossible. I was given antidepressants, I was given Lexapro, but I was having all those other symptoms. I was having the periods that were erratic. I was having. I wasn't able to sleep. I. I felt the weight gain. I was definitely having the brain fog. Antidepressants, Is that a solution? Is that helpful or is that a band aid? Or would you recommend that possibly along.
- [34:19]
C
With hormone therapy specifically for perimenopause? Let's start there. In that chaos area, we see about a 40% increase in the mental health disorders, anxiety and or depression. Those patients actually, and this is great data coming in the last couple of years out of Australia, respond better to stabilizing their hormones, usually with a menopause hormone therapy estradiol patch. There's something that happens to the brain. So we are calming that hypothalamus down and telling it we're not seeing those lows because we've got a low dose of estrogen on board. Now, this is not contraception. This is not the pill.
- [34:53]
A
Right.
- [34:54]
C
Those patients do better with menopause hormone therapy and perimenopause than they do with increasing their SSRI if they were on one before and well controlled or a new start. So for you, perhaps at that time, but we didn't know. Right. The studies hadn't been done, and no one. People were struggling to recognize menopausal symptoms as anything more than a little vaginal dryness and a few hot flashes. And if you complained of more of that, you were just a complainer.
- [35:22]
A
It was in my head.
- [35:23]
C
Yeah.
- [35:24]
A
And I've just heard so many women over and over being prescribed the. The antidepressant and then, like, not even.
- [35:29]
C
Having some of the SSRI categories will actually dampen the hot flashes. So, you know, when we were terrified of hormone therapy, of giving a woman natural estrogen, why are we scared of our own hormones? I have no idea. No man is scared of testosterone. We see resolution, and we treat the multiple.
- [35:48]
A
Or, you know, we felt that was safer. It was just a safer option. All right, talk about not feeling like yourself, because I think that that's probably the overriding statement that we've heard over and over again. I just don't feel like myself anymore. I look like myself. There's a study that. That's actually called that. Is that right?
- [36:04]
C
Yeah.
- [36:05]
A
Tell me a little bit about that.
- [36:06]
C
Not feeling like myself. And for the rest of the paper, they call it NFL, whatever the letters are. But that article hit me like a lightning bolt, because that was the first time I saw data and science backing up what decades of my patients had told me. And there's nothing more nebulous to a clinician than a patient coming in and saying, I just don't feel like myself. And I'm like, where do I start from here? But that is actually the most common symptom.
- [36:34]
A
Is that where we start, though? If you're saying that to yourself, if there's a woman listening, says, like, I don't feel like myself, is that kind of where you start looking and saying, am I in my late 30s, early 40s? Am I not sleeping? Am I having irregular periods? Is that where the perimenopause conversation should be starting?
- [36:50]
C
That's where I would start it. Absolutely. Your environment hasn't changed. Right. But you've lost your resilience. You've lost your ability to interact with the world. You've. You know, something's not right. I mean, I have these patients coming in. Something's not right. I don't feel like myself. And at the time, I didn't know what to tell them. I just thought, oh, here she comes. That whiny woman again, not going to.
- [37:13]
A
Be able to solve it.
- [37:14]
C
Not going to be able to solve it for her. Pat her on the knee, take a vacation, get more sleep, lose weight, drink.
- [37:19]
A
Water, all the platitudes and come back and leave.
- [37:23]
C
And no one had taught me this probably is perimenopause.
- [37:30]
A
If you've ever caught yourself wondering, am I in perimenopause? What is going on? I've made something for you. It's my free guide called how to perimenopause. It's 18 pages. Inside, you're going to find insights from some of the top experts I've interviewed, the doctors, the specialists who are leading the conversation on women's health. Inside, you'll find the most common early symptoms to watch for. The exact test you should be asking your doctor about. Lifestyle shifts that actually make a difference from nutrition to movement to stress and clear neck so you don't get stuck or feel dismissed by your doctor. You can download this for free right now@tamsenfadell.com howtoperimenopause. It's also linked in the description because you don't have to figure this out alone. You deserve real answers backed by real expertise. What are the most common symptoms of perimenopause women should be looking for?
- [38:24]
C
Interesting you asked because I recently asked my followers to submit testimonials for the new book. And we went through a laundry list of symptoms with them. So I compiled everything. The five most common symptoms. Number one, hot flashes and night sweats. Everybody knows that. Number two, so that's 85.9%, 82.4% weight gain and redistribution. So new belly fat, 82.3% anxiety, depression and panic attacks, 81.7% sleep disturbances and then 80.6% fatigue. Gosh, now we're still in the 70s. Sexual dysfunction, gastrointestinal problems, bloating, digestion issues, brain fog, migraines, dizziness, memory problems, joint pain, muscle aches, osteoporosis, heart palpitations, irregular heartbeat. That was 51.8% for palpitations in our survey.
- [39:15]
A
And you had said 48 before. That's right on. That's right on target.
- [39:18]
C
Right?
- [39:19]
A
Wow.
- [39:20]
C
Skin, hair and nail changes, 46% dry or itchy eyes, 39% burning mouth sensation, taste changes, urinary dysfunction, allergies, body odor changes. This is perimenopause. We're not even through the transition yet. This is early.
- [39:35]
A
And that's four to seven to ten year transition. What is the cost of a woman being told to tough it out or.
- [39:42]
C
Symptoms being dismissed, suicide, osteoporosis, dementia. You know, when we look at the status quo, let's go with the old menopause where tough it out, you got this girl, it's just a couple of years. You can it or okay, it's severe. Fine, we'll give you a few hormones, but only for like a year or two. That starts a woman on a path of medical dismissal. And, you know, she's making 80% of the medical decisions for her family. Right? She's buying the prescriptions, making the doctor's appointments, doing all the things she has learned systemically to second line her own healthcare. She's also being taught to stay in a small body, be small and tiny, be thin, and you'll be healthy forever. And what ends up is she's got a 3 to 1 chance versus her husband of needing a nursing home admission, 3 to 1 of having or 2 to 1 of having dementia. And, you know, she's losing her independence, she's losing her ability to take care of herself. And she's, you know, requiring a lot of intervention from her family, from society, from the medical system to keep her alive when she's not really healthy. And that's what my patients want, is, you know, when all of that starts. We have this incredible window of vulnerability in perimenopause. It starts well before your period ends. The fastest rate of bone loss in osteoporosis begins in perimenopause. We're not checking you for bone loss until 20 years later.
- [41:11]
A
So when does that bone loss start in perimenopause?
- [41:14]
C
So in the last couple of years before the final menstrual period. So, like, you don't know what's going on. You have no. And the bones are quiet. They're not screaming at you and saying, I've just lost 20% of my bone density. And you're gonna have to, like, live on these stores for the rest of your life and pray to God you don't fracture.
- [41:30]
A
How important is it to teach women that in perimenopause? Because I feel like if I'm in perimenopause and I'm in my late 30s, because I don't know if I would have listened. I would. I would have been like, I don't.
- [41:40]
C
We've got.
- [41:41]
A
I've got my whole life left to live.
- [41:42]
C
We've got every single orthopedic surgeon who cares about women screaming it from the rooftops, who are breaking, fixing all these hips and like, why is this happening? I Mean, Vonda Wright, our friend, talks about going to the OR with these women, and their bones are like butter and they're also incontinent and they have dementia. And, you know, my own mother, 88 years old, fell on New Year's Day in her nurse in her memory care unit broke her hip, as expected for osteoporosis. And I was digging through her chart and looking through, and she'd never been screened for osteoporosis in her life. No one had ever, ever, ever talked to my mother about her bones, ever.
- [42:21]
A
Unbelievable. 80 years old.
- [42:22]
C
It was always be thin. My mother, I don't remember my mother. Not on a diet and not trying to make. Force herself into a smaller body. And all she did was cardio. My mom was a runner and stopped, you know, when incontinence got in the way. And that wasn't treated properly. And so she just stopped exercising at all because she'd pee on herself.
- [42:40]
A
All point, we're going to go back and start doing those bone density tests at an earlier age.
- [42:45]
C
I'm encouraging my patients. I'm like, if you're willing to invest, like, if insurance won't cover it, I'm like, we have to stop relying on insurance right now until we fix the insurance issue. But right now, if you are relying on insurance for your preventative care, that's probably a mistake. And if you're going to invest in anything, I'm like, go get a bone density scan at 50. At 45.
- [43:07]
A
Yeah. Not. Not. Wait till you're 60 years old.
- [43:09]
C
Wait till you're 65 when insurance is going to deem you well. And I don't know a single orthopedic surgeon who disagrees with me.
- [43:15]
A
No, I don't either. I. I completely agree with you. I'm shocked that we haven't had those kind of guidelines. We have the guidelines for mammograms. We have guidelines for.
- [43:22]
C
Yeah. The guidelines for most medical societies as far as osteoporosis prevention.
- [43:26]
A
Yeah.
- [43:26]
C
Is roll up the rugs, don't let her trip.
- [43:29]
A
Yep.
- [43:30]
C
And take some Tums.
- [43:31]
A
Yeah. And hope that we don't see years old. Take some Tums. Right. Okay. Can we list some of the big physical changes that you perimenopause years that women are struggling with, in particular in perimenopause.
- [43:42]
C
Definitely. You know, when we look at the uterus, you know, we have these chaotic hormone signals coming from the brain talking to the ovaries, which then talk to the uterus, and 90% of us will have dysfunctional uterine bleeding. So only 10% skate through with like no real changes in their periods and they just stop.
- [44:01]
A
90%.
- [44:02]
C
90% will have abnormal dysfunctional uterine bleeding. Now, to be clear, not all bleeding, abnormal bleeding is, is perimenopausal. Of course, it could be polyps, it could be fibroids. And that's one thing gynecologists are really good at. They can get in there, get the ultrasounds, do the biopsies, hopefully with pain control, and, you know, get you worked up appropriately. And then is it perimenopause? Now we're going to talk about how we're going to treat this for you.
- [44:25]
A
Okay?
- [44:26]
C
So that, that's one of the biggest things.
- [44:27]
A
So heavy periods, one of the big.
- [44:29]
C
Ones, musculoskeletal pain, it starts early. Joint pain, secondary one.
- [44:33]
A
Is there another big one that we see in perimenopause?
- [44:35]
C
It's like these skin changes. So dry skin, dry eyes, dry mouth, anything with a mucous membrane tends to, or oil production tends to kind of dry out towards the end of perimenopause.
- [44:45]
A
Heart palpitations, is that a perimenopause or a menopause?
- [44:48]
C
Perimenopause for sure. Again, chaos. So there's a node, the sinoatrial node on the heart that drives how your heart beats, you know, kind of gives it that baseline. And so when it gets sporadically fed in perimenopause, we see it go crazy. And so the palpitations that are hormonally related, which 43% of women will have significant palpitations in perimenopause. So here's this poor woman, 44 years old, rolling into the ER scared to death. She's not sleeping, she's gained some weight, she's having horrible palpitations. She gets a million dollar workup, goes home with a month long Holter monitor, all this stuff. And no one in her clinical care was ever taught to connect the dots that all of these things or perimenopause.
- [45:34]
A
The heart palpitations are so scary. I mean, you know, I've told the story a hundred times that I landed on the floor of the studio bathroom as a result of that. And I'll never forget, I was like, I'm gonna have a heart attack down here. I didn't know what was it is this. It is very, very scary. And I've heard one woman after another and then exactly what you're saying. Go to the er, go get workups, not know what's going on. Perimenopause Never a mention, never mentioned. Belly fat is another one of the big, big concerns.
- [46:00]
C
I mean, that's what brought me to the menopause table, was vanity, vanity, I.
- [46:05]
A
Mean, to the whole body. Change.
- [46:07]
C
I had thin privilege most of my life outside of pregnancy, and I got that weight off pretty fast. And then all of a sudden, like my patients, I'm sitting here walking around with the new belly that I'd never had before. And I really hadn't changed diet and exercise, but I'm in my brain saying, that's impossible.
- [46:24]
A
Why does that happen?
- [46:24]
C
So turns out estrogen is this miraculous hormone in our body and it controls inflammation. It's an anti inflammatory hormone. And when we take it away or make it go cattywampus, it's a downward decline, but it's a roller coaster. But as those levels decline and then go away, you lose that tampening down effect of the estrogen. So boom, almost all of the systemic inflammatory markers rise, insulin resistance increases. When all that happens, we start driving fat to the intra abdominal cavity with not a single change in diet and exercise.
- [47:02]
A
And it makes so many women so upset. And I get it, I completely get it. Because you feel like your body's just kind of betraying you, giving up on you, betraying you. All the tricks that worked before don't work anymore.
- [47:14]
C
They're struggling. They're really struggling. And I lived through it myself. And that, that took me down the rabbit hole of learning. No one ever taught me this. I thought estrogen was a hormone only involved in reproduction, only really affected our ovaries. I knew the bone density would decline, but I really felt like that was more of an aging thing and it was just inevitable, you know, and there was not much, you know, you waited till you got osteoporosis and then we treat with all these very expensive and difficult medications.
- [47:43]
A
There has been a link. There was an article that I read recently. There may be a link now between perimenopause and eating disorders. Does that surprise you? I don't, I don't.
- [47:53]
C
No, not at all. Having seen once your body stops responding to the system you built to maintain your weight, and our whole focus in our generation was that number on the scale. I think the younger, like my daughters, are less focused on that. They understand muscle and bone and everything, hopefully. And all of a sudden, like all the tricks and things that you did no longer work, it is incredibly frustrating. So in that article, in perimenopause they see more binge eating, and in post menopause we see more Restriction. So perimenopause. I think because of the mental health changes, we tend to, like, eat our feelings. Right, of course. And the food noise kicks up because all the things that you did to control your weight no longer work. So you are nonstop thinking about, where's my next meal? What am I gonna eat? How am I gonna cook? Are the kids gonna be able to eat what I like? I mean, I used to make a separate meal than my kids because you.
- [48:52]
A
Were trying to restrict or I would.
- [48:54]
C
Not eat the pasta. You know, a little bit of almond mom in there. They make fun of me for that. But, like, you know, that's not normal. No. You know, I just accepted it as my how I had to live in order to stay this weight.
- [49:11]
A
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- [51:40]
A
So for women with endometriosis, or PCOS, how does perimenopause show up differently?
- [51:45]
C
Endometriosis, you know, is an inflammatory condition where we have ectopic growth, meaning outside of its usual home. So the endometrium is the tissue that lines the inside of our uterus, and it creates our periods, also the place for a potential baby to grow each month. We tend to shed that each month with our periods, and we're still debating on why this happens. But in endometriosis, the tissue grows outside of the uterus. So it could be on the uterus, on the ovary, somewhere on the bowel, anywhere in the abdominal cavity, because remember that our abdomens are open, the whole system slides all over each other. So in perimenopause, with these massive fluctuations in hormones, that tissue is very sensitive to estrogen. So really we can see exacerbation of symptoms. Symptoms can get better. In some patients, anything is off the wall. And the treatment of perimenopause in patients with endometriosis and postmenopause is really nuanced. It's absolutely treatable, but because we have ectopic tissue, there's a few things we have to really discuss with the patient and have to get really aggressive with certain giving her progesterone, you know, if she hasn't had surgery. So in pcos, she's not ovulating regularly. And now we're going to add in hypothalamic dysfunction coming from the brain on top of a system that's already broken, you know, on top of her insulin resistance. We're going to make insulin resistance worse with perimenopause she's already insulin resistant, which caused her pcos. So really it's hard for these patients because they don't see it coming. So in pcos, they already are struggling sometimes with their thyroid, definitely struggling with their weight. Their cholesterol is going out of, you know, going out of whack earlier. So it's very, very similar when you look at, on a molecular basis with pcos. But a lot of patients don't recognize that their symptoms are worse because they're going through this change because they've already.
- [53:39]
A
Got a lot of those hallmark symptoms that we would be looking at for people.
- [53:42]
C
And they're like, oh, it's my pcos.
- [53:44]
A
So what do they do? They just have to work closely with.
- [53:46]
C
A doctor that really, really have to find a specialist who knows what they're doing.
- [53:50]
A
I think it can be difficult for women that are in their 30s and 40s when it comes to sex in particular, because I think that, that, you know, that is part of, part of our confidence, that is part of what we want. And a lot of times women in perimenopause start losing that desire, that libido that anything that, you know, that we wanted maybe in our 20s or early 30s. Can you talk a little bit to that? Because that's not an uncommon time to feel that. Correct. And then on top of it, your periods are going crazy.
- [54:16]
C
When we look at female sexual function for someone who was very happy with their sexual function, I'm not talking about people with lifetime issues, disorders, whatever, but everything was fine. And then it's not fine. Okay? It's complicated. I liken it to a men's libido or sex drive is more like the light switch just off. On. It's usually on, you know, which is probably a gross overgeneralization. Also an area of medicine I don't study, so I can, you know, be glib. But for a female, that light switch becomes the flight deck of a 747. And so we look at the buckets around her sexual function. We have pain. Does it hurt? 50% of us have pain with intimacy and don't talk about it. So we have to fix the pain. Otherwise the brain doesn't want to do something typically that hurts. Is it an orgasmic disorder? Has she ever had an orgasm? Did she used to have orgasms and now she can't? I mean, that sometimes is a nerve conduction, a blood flow issue. Those are fixable, right? Is it an arousal disorder? Like the brain is saying, yes, let's go, but there's Nothing happening. No blood flow to the area. Right. That responds typically well to vaginal Viagra for some patients. Or then is it a desire issue? And that's what most women have. Or they can have a mix of the buckets. So we screen for all of that. So in the desire issue, I'm like, okay, do you have a partner that you love and respect and that you used to have? Look forward to this. And this was a beautiful part of your life. Yes or no, right? No, I hate him. I'm like, okay, well that's. Yeah, that's different. That's different. We go through like, like really what's going on here? How much of this did I learn in my training? Zero. I did not learn one thing about female sexual function in my residency because.
- [56:04]
A
It was considered a luxury to even be. It's considered. It wasn't medical.
- [56:08]
C
It was medical, psychological. There was nothing biological about it. I go out into private practice and outside of pregnancy, the top two things people are like getting up the courage to talk to me about are their weight and their sex lives. And I have zero education and training on how to help them. I was literally a deer in the headlights.
- [56:28]
A
But there's so many different solutions. So many, so many different solutions.
- [56:31]
C
So many. So, you know, pain, orgasmic, whatever. So now we're left with desire. There are two FDA approved medicines now for the treatment of female sexual desire disorders. One is Vilisi and the other is Addi. Addi is a pill you take every day. Are good friend Cindy Eckert developed it. Incredible studies. Took her seven years to get it through the fda. For females, it took forever to get these just two baby drugs. We also have testosterone, which there's an international consensus on how well it works for women's libido. But the FDA still hasn't gotten around to approving a formulation for women.
- [57:07]
A
But we're going to talk more about it because I'm going to ask you if you will stay for a second, a part two.
- [57:13]
C
I would love to.
- [57:13]
A
You'll stay for a part two because we got to get to solutions. Okay. If you've been wondering what's happening to your body, why you can't sleep, why your mood has shifted, why things just suddenly feel harder, I hope this episode gave you a name for it, but knowing what's going on is just step one. Next we talk about what to do about it. In part two, Dr. Mary Claire Haver and I are breaking down the real solutions. Hormone therapy, new hormonal tools, nutrition, lifestyle and how to actually get the care that you need not just to survive this phase, but to come out stronger on the other side. If this episode helped you in any way, can you do me a quick favor? Take 30 seconds to subscribe, follow and leave a review. It really helps us bring you more powerful conversations and guests. And please keep in touch. Make sure you're following heamson show on social and if you have any questions or want to suggest an upcoming topic, email me@podcastamsenfadell.com thanks so much for being here. We could not do this without you.
- [58:11]
C
You.
- [58:11]
A
I'll see you next Wednesday. Today's podcast is sponsored by Midi Health. Too many women in midlife are dismissed when they bring real health concerns to their doctor. I've been there and I know how frustrating it feels to be told it's just aging. Midi Health is changing that, finally offering expert personalized insurance covered virtual care for women in midlife. Ready to feel your best and write your second act script? Visit joinmitty.comtamsen today to book your personalized insurance covered virtual visit. That's joinmitty.com Tam Midi the care women deserve.
- [58:50]
C
Your sausage McMuffin with egg didn't change your receipt did the sausage McMuffin with egg extra Value meal includes a hash brown and a small coffee for just $5 only at McDonald's for a limited time.
- [59:04]
B
Prices and participation may vary.