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Perimenopause Solutions: Dr. Mary Claire Haver on Hormones, Sleep, and Mental Health
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- [00:00]
Tamsen Fadal
Today's podcast is sponsored by Midi Health. If you've ever felt ignored or dismissed when it comes to your health and midlife, trust me, you're not alone. Too many of us have been told just to live with it. Midi Health is changing that with personalized insurance covered care from expert clinicians. 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.
- [00:30]
Dr. Mary Claire Haver
This episode is brought to you by Progressive Insurance. Do you ever think about switching insurance companies to see if you could save some cash? Progressive makes it easy to see if.
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Tamsen Fadal
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Dr. Mary Claire Haver
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- [00:49]
Tamsen Fadal
Potential savings will vary.
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Dr. Mary Claire Haver
Not available in all states for a.
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Tamsen Fadal
Woman Perimenopause what is the right time to be thinking about all of this?
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Dr. Mary Claire Haver
Immediately?
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Tamsen Fadal
Let's explore. Explain what vaginal estrogen is and why it's so important.
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Dr. Mary Claire Haver
The number one treatment for a woman for recurrent UTIs is vaginal estrogen, not recurrent antibiotics.
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Tamsen Fadal
She's back. Dr. Mary Claire Haber returns to the Tamsen show that they are on birth control. How do you know when it's okay to switch over to hormone therapy?
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Dr. Mary Claire Haver
Those same clinicians who will put any and everyone on birth control pills will absolutely refuse to put someone on menopause hormone therapy. I'm like, you understand it is a microdose compared to the birth control pill.
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Tamsen Fadal
Every question you've ever had about perimenopause answered by a leading menopause specialist. What should she go into her doctor and say or ask for to be put in the right path immediately?
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Dr. Mary Claire Haver
I would get a bone density.
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Tamsen Fadal
Can we talk about the role that sleep plays in all this? Because it's really tough during this time.
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Dr. Mary Claire Haver
Cognitive behavioral therapy for insomnia is really, really helpful for a lot of my patients.
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Tamsen Fadal
Belly fat is very frustrating. Can we talk about some of the changes we should be looking at?
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Dr. Mary Claire Haver
So you're getting enough micronutrients in your diet to support good health? And, and that is the thing we really should be focusing on as soon as possible.
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Tamsen Fadal
Give me your top three changes to start protecting your bones.
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Dr. Mary Claire Haver
Lift weights, lift weights, jump training, low libido.
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Tamsen Fadal
It catches a lot of women off guard. Is there anything we can do to get that back?
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Dr. Mary Claire Haver
We have two classes of medications that are actually really, really helpful.
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Tamsen Fadal
Is it in my head that I'm not able to tolerate alcohol anymore or is that what's really happening right now?
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Dr. Mary Claire Haver
Let me clear.
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Tamsen Fadal
Perimenopause doesn't come with a rule book. Just a whole lot of questions and confusion. Why am I not sleeping? Why don't I feel like myself? And what can I actually do to feel better? In this episode, we are getting into the solutions. Leading menopause expert Dr. Mary Claire Haver is back to break down what actually helps hormone therapy, non hormonal options, diet, exercise, and the lifestyle shifts that really make a difference. If you're in perimenopause or headed into it, this episode has everything you need to know to take back control of your health, your body and your life. Let's get into it. Dr. Marie Claire, thank you for staying. Thank you for this next part because we have a lot to get through, so we're just gonna dive right in. So we talked about perimenopause before. We understand, you know what? It is the zone of chaos. For women who are not in perimenopause yet, what should they be doing right now to prepare?
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Dr. Mary Claire Haver
I would really focus on educating your about the process so you aren't blindsided when this inevitable change happens to you. Also, I would be focusing on lifestyle, like setting yourself up for success, to have the strongest, best, healthiest body to help you kind of weather these changes.
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Tamsen Fadal
I always look at things and I'm like, what is the most important thing? And I feel like everything is important all at the same time. For me, I feel like it goes back to sleep and kind of having that base of sleep. So then you can just even remember what you need to do to take care of yourself. Can we talk about the role that sleep plays in all this? Because it's really tough during this time.
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Dr. Mary Claire Haver
So we have different levels of sleep disruption associated with perimenopause and menopause. And so when we look specifically at the hormones, when we lose estrogen, a lot of women have disrupted sleep from the hot flashes. The hot flashes, night sweats, or palpitations, which is a vasomotor symptom, will actually wake them up. And so if we can get that under control, stop the palpitations, stop the hot flashes, usually with hormone therapy, they will have much better sleep without the disruptions. There's a whole subset of women who, even on hormone therapy without a single hot flash are now struggling with middle of the night awakenings or struggling with going to sleep or both. And even with perfect hormone therapy, we still have to guard our sleep with our lives in perimenopause. So we're Seeing a much lower tolerance to. To alcohol than we ever had before.
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Tamsen Fadal
I was thinking, is it in my head that I'm not able to tolerate alcohol anymore, or is that what's really happening right now?
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Dr. Mary Claire Haver
Well, we're seeing more studies come out on it, and it was usually everything I read about sleep in menopause. You know, they never talked about perimenopause, but in menopause, it was hot flashes waking her up from sleep. We stopped the hot flashes. She'll sleep. My patients aren't sleeping. And when I talk to Andrea Matsumura, who's our. You know, she's a sleep medicine specialist just focusing on menopausal women now, she says, you know, hot flashes are definitely a part of it, and you want those to go away. But just like creatine, our melatonin stores are not what they used to be. The way the neurotransmitters are functioning is. There is an aging process here outside of menopause, but especially in women, the burdens we take on in our lives. So cognitive behavioral therapy is really helpful once we get the hot flashes stopped. Cbti Cognitive behavioral therapy for insomnia is really, really helpful for a lot of my pat in helping with the middle of the night awakenings, being able to calm themselves back to sleep and not allowing that hamster wheel, what we call to take off, and especially at the beginning of the night when they're struggling to turn off the hamster wheel to fall asleep. Progesterone is really helpful for those patients as well, even if they've had a hysterectomy and don't technically need it for endometrial protection. What we know is progesterone affects GABA in our brain. It converts to allopregnenolone, and then that binds to GABA in our brain, which helps relax things and calm us down and gives us better sleep.
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Tamsen Fadal
So what would be the. Your top tools for sleep, including supplements? Because I think that's important, and there's a lot. I know that you have. I know you are, but. But I do think that it's really important to have these conversations because there are some women that either choose not to do hormone therapy or cannot do hormone therapy.
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Dr. Mary Claire Haver
I respect that.
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Tamsen Fadal
If my mother were here today with the type of breast cancer she had and how aggressive it was, she might most likely wouldn't be a candidate. I don't know. Things are changing every single day, but most likely not. So I wouldn't want her to be told there's no solutions for you Right. So if we look at the tools that are there for sleeping, can we talk a little bit about some of those so we can expand those out.
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Dr. Mary Claire Haver
Magnesium can be really helpful. It seems to help with the duration, the quality. Now that women are wearing sleep rings from different companies. And I'm a, you know, full disclosure, I'm a scientific advisor for Aura, and we're doing a very deep dive into perimenopause and menopause and sleep. So super excited about that. When we look at, you know, progesterone is one option, but magnesium can be really helpful for a lot of patients. There's different forms of magnesium. Some are better for gastrointestinal issues, some cross the blood brain barrier. I really like an L theronate or a bisclycinate to help with sleep. L Theanine is a wonderful anti anxiety supplement that does not cause sedation. So you can take it in the middle of the day if you're struggling. And then the right amount of melatonin. It turns out that most patients are using now. Like when I've tried melatonin, I was probably taking 10 to 20 times the dose. I really should be.
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Tamsen Fadal
So what I was taking 10 milligrams, I think.
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Dr. Mary Claire Haver
What's the dose for women? 0.3 to 0.5 maybe. And so it took me working with a sleep medicine specialist to figure that out.
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Tamsen Fadal
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 gonna 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 next steps 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 expert. Let's talk about women that are struggling with anxiety and or depression. Are there tools that can help break that cycle?
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Dr. Mary Claire Haver
In perimenopause, the best tool is going to be what you know is the newest data coming out is not going right to an ssri and she may need that. But to really, if it's perimenopausal, starting with stabilizing her hormones. And in those studies, they used an estradiol patch. They really like it because the patch specifically gives you a steady state dose. Whereas when we ingest something orally, depending on the half life or how long it takes body to clear it, we tend to have a spike and then it drops off. And sometimes our brain doesn't like that. It likes uniformity and to know it's coming. So for the mental health challenges, it looks like something like the patch or ring or something that gives you a steady state dose is going to be better.
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Tamsen Fadal
If a woman is feeling really mentally burnt out, where does she start? Because, you know, we have, we want to give women all these solutions and it's really important, but it's also important to realize that it's hard if you're just feeling so overwhelmed. How much longer can that list be? So where do you start if you're just sort of feeling burnt?
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Dr. Mary Claire Haver
I want to be really clear about this because the most common time for a woman to commit suicide and those rates are climbing, is between the ages of 45 and 55. And what is happening to most women in that time span, you know, why is this the same? Why are we all connected there? Because it's perimenopause.
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Tamsen Fadal
Why haven't we ever put that together?
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Dr. Mary Claire Haver
Because it's all in our head. You know, we were just willing to accept that this is the most likely time for women to end her own life and that, you know, there is help. You are not alone. And it may take. I'm a huge fan of therapy, behavioral therapy, psychotherapy, whatever it takes. Because there are a lot of demons that drive us that have nothing to do with hormones, you know, trauma. All of that plays in, and all of these things get compounded in perimenopause.
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Tamsen Fadal
I know there's a lot to cover with that. I know that it's important to have all these different disciplines also being aware of it. Do you feel like the area of mental health is. Is understanding and seeing this and bec a bigger part of this conversation?
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Dr. Mary Claire Haver
I really hope so. I, at least in my children's generation, they're in their 20s, that it is just something that is so well understood. My daughter, my oldest daughter, like, got herself into therapy. I'm like, do you need therapy? She said, don't we all? And to help her work through some childhood stuff, things that she had gone through. And I didn't force her or push her and she did it on her own. And as you know, and it really was the. The impetus for me to get therapy to help me through my brother's death and, you know, coming to terms with my own perimenopause and the mental struggles that I was going through.
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Tamsen Fadal
So let's go and talk about nutrition and diet changes of what women in perimenopause should be focusing on now, because I do. I know that's a big part of the conversation. I know belly fat is very frustrating and difficult. Just in general and in terms of your health, can we talk about some of the changes we should be looking.
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Dr. Mary Claire Haver
At rather than changes like, are these the best habits for you? I think most women, you know, their intentions are good and they think they're eating healthy. And it took me going back to school to learn about nutrition, like, no one taught me in medical school, other than severe protein calorie malnutrition. Like, that's quashior core and scurvy and, you know, rickets, real, you know, severe. But, like, no one taught me what a good basic nutrition plan, how to eat to stay healthy. So I think a lot of women, especially our generations approached nutrition is whatever it takes to stay a certain size, therefore we are healthy. And whatever caloric restriction that took most people know not to eat too much junk food, but it wasn't like, well, how much protein do you need? Are you getting enough fruits and vegetables? Are you getting enough micronutrients in your diet to support good health? And that is the thing we really should be focusing on as soon as possible so that those habits will carry us through. So are you getting adequate protein to support your bones and muscles, not to stay a certain size? Bones and muscles weigh a lot. We want big, heavy ones, big, juicy ones.
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Tamsen Fadal
What do we need to do for that? When it comes to protein, the FDA.
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Dr. Mary Claire Haver
Recommends for women 0.8 grams per kilogram of lean body mass. So divide by 2.2. So that's less than half a gram perish per pound. That is enough to keep you out of severe protein calorie malnutrition, okay? That is not enough to grow your muscles and therefore your bones. Not even close. So when we look at the Women's Health Initiative data, so it's just a data set that is, you know, interpretation was blown out of proportion. When we go back and look at the data on women who did not have frailty with age, they followed these women. They're still following them, okay? When they look at the women who had the lowest chance of Frailty or who had the lowest frailty indicators, meaning they could take care of themselves. They were climbing mountains, raising grandbabies, you know, doing all their stuff. In the 70s and 80s, okay, they had the highest levels of protein intake, and now we're talking 1.3 to 1.5, double what the FDA is recommending.
- [14:09]
Tamsen Fadal
Wow.
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Dr. Mary Claire Haver
Okay. For protein intake. So when I'm counseling patients, I have a body scanner. I'm looking at their muscle mass. I can tell them how much visceral fat they have. And I'm counseling for protein intake based on that, not the number on the scale.
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Tamsen Fadal
And the type of protein really does matter. I know you did a post recently talking about complete versus incomplete protein. Can you talk about the difference between those two things?
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Dr. Mary Claire Haver
So people understand, complete proteins mean they contain all the amino acids that we can't make ourselves. Okay, so glycine, leucine, valine. You know, there's certain amino acids we can generate, you know, without having to intake them, but we can't synthesize all of them. Okay, so complete protein means you have the complete nutritional. You know, all. It checks all the boxes. Incomplete proteins we can piecemeal, meaning beans and rice. You'll kind of hit all the boxes if you eat those together, right? If. If you go to vegan or vegetarian sources. So in general, the sources from animals, because you're eating the actual muscle contains all of the amino acids that we need to be complete versus when we use vegan, vegetarian sources, we have to kind of rob Peter to pay Paul and sometimes supplement to make sure that we are getting enough. So when look at women who do well, you can have about 36% of your protein being from, like collagen, which is not a complete protein. And then as long as you get the remaining 2/3 from something that's complete, you're going to be okay.
- [15:38]
Tamsen Fadal
AI.
- [15:41]
Dr. Mary Claire Haver
Had the time of my life.
- [15:45]
Tamsen Fadal
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- [16:09]
Dr. Mary Claire Haver
Emoji moment from Sadie who writes, I'm not crying. You're crying. This is what I said during my first appointment with my physician at Mochi, because I didn't have to convince him I needed a GLP one.
- [16:21]
Tamsen Fadal
He understood, and I felt supported, not judged.
- [16:24]
Dr. Mary Claire Haver
I came for the weight loss and stayed for the empathy. Thanks, Sadie. I'm Mayra Amit, founder of Mochi Health. To find your mochi moment, visit joinmochi.com.
- [16:35]
Tamsen Fadal
Sadie is a Mochi member, compensated for her story. Low libido. We talked about it in the prior episode. It catches a lot of women off guard. Yeah, I think it, it causes a lot of issues in relationships. Is there anything we can do to get that back?
- [16:53]
Dr. Mary Claire Haver
We have to look at it carefully. Like, why is this happening? Is this a relationship issue? Are you having pain? Are you having dryness? Are, you know, we have to fix those barriers. Okay, so now everything's. We've got your 25 year old vagina back. We've got, you know, everything's there. But then you, you love your. I can't tell you how many patients are like, I love this person. Like, I've always loved this person. We used to have an amazing sex life and now I could care less. And I miss it. They have to miss it. Yeah, that's the other thing.
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Tamsen Fadal
Okay, all right, that's important.
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Dr. Mary Claire Haver
We can normalize that. A woman has the right to say she never wants to have sex again, and that's her decision. But these are the patients who come in and they're like, I really miss this. I miss this intimacy and I want that back. And so we have two classes of medications that are actually really, really helpful. And so one is testosterone. So we have the androgens, which building those back up to remember, we lose. By the time we're 50, we're down to about 50% of our highest testosterone levels when we were younger. So we restore those levels. Now we don't have to overshoot. We can talk about pellets.
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Tamsen Fadal
Okay. Yes. I was just going to say we're.
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Dr. Mary Claire Haver
Going to talk about pellets so we can stay in female physiologic ranges. We don't have to transition a patient to male levels in order to get her libido back. And that was studied in physiologic ranges in fully menopausal women, and they did amazing. Now, as a bonus, though, we don't have FDA approved reasons for this. Women with higher natural testosterone levels have higher bone and muscle mass. You know, so my sarcopenic patients or patients with osteopenia who are lifting the weights and doing the things, adding that touch of testosterone may actually be helpful for them. And if they have low libido, we're going to use it for them anyway.
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Tamsen Fadal
Does it help with strength training? Does it help with building more muscle quicker?
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Dr. Mary Claire Haver
So we need more studies we definitely, if we, if we can believe the male data would work for women, yes, we can make that conclusion. But most of the studies done in the postmenopausal women were looking at naturally occurring testosterone levels, not in supplementing as far as like bone and muscle strength.
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Tamsen Fadal
So I want to do, I want to go solutions.
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Dr. Mary Claire Haver
So strength training, the second class of medication. So let's go back to libido. So we had the testosterone and now we're going to talk about. There's two that work in the brain, kind of in the mood area, because libido is a mood. It is, Right. Kelly Casperson, I stole that line from her. So when we use something like Addi or Vilisi, so say you want to go the non hormonal rate or testosterone didn't work for you. Addi and Vylice both work by releasing dopamine.
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Tamsen Fadal
And these are pills, they're prescription pills.
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Dr. Mary Claire Haver
So Addi is a pill that you take every day, kind of like building up your stores. Right. It causes dopamine to rise and dopamine makes us want to do things, makes us more receptive to good ideas. Whereas Vylisi actually causes a dump of melanocortin. So it's a very fast, I will say fast acting, but it's a shorter time period of action and you give it about 45 minutes before the onset of what would be maybe activity. And then the melanocortin rises the dopamine levels and they become more. Now when it works for a patient, from what I hear, it works really, really well.
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Tamsen Fadal
Let's talk about pellets, because you brought them up and I think it's really important. I was on the road and every stop somebody raised their hand and said, I'm on pellets. But, but, but I have a lot of questions. Why don't you talk about pellets? So can we explain? We're going to go into the pellet.
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Dr. Mary Claire Haver
I don't want to demonize a delivery system. A pellet is an implantable device that is packed with hormones that slowly releases, you know, the medication into your system.
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Tamsen Fadal
Estrogen, progesterone, testosterone.
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Dr. Mary Claire Haver
So typically progesterone is not put in the pellets. It doesn't absorb well through the skin. So they know better than to put a projection in that. So they put estrogen. So they'll do estradiol plus or minus an estriol and I've even seen estrone. So they'll do like three sometimes. And then there's always testosterone. I've never Seen a patient given just an estrogen pellet only to, you know, testosterone's the base and they might add estrogen to it. So it was given to men. Now these are compounded. So they're not going through the same level of rigorous testing. Yes, no testing at all, actually, from the fda. And we knew that testosterone in the medicinal form, meaning it's gone through all the testing, works for men. So they've compounded into this formulation. So what I understand from the lore of one particular company is they said, hey, let's try this in women. They are having issues with testosterone too, but they never made a women's pellet. They just put the low dose men pellet in women. So these women are coming in minimum 2 and 300 now, normal female physiologic ranges. At their peak, testosterone levels were probably no higher than 40 to 70. And these women like in there because I got the paperwork to see, like I pretended to sign up for the company because I wanted to see what these patients were being exposed to. They have no clinical testing. There's not a single decay curve that has ever been published. And these women are desperate. And here they are going to a clinician who offers them nothing else, makes them incredible promises and gives them low level male doses, sometimes very high. You know, so male doses, the lowest male normal level is in the high two hundreds.
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Tamsen Fadal
Okay.
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Dr. Mary Claire Haver
And it goes up to about a thousand.
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Tamsen Fadal
And so what are these women getting?
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Dr. Mary Claire Haver
I've seen like weeks after insertion, 3, 4, 500 level ranges of what they're running. So they're basically transitioning to male doses. So they're getting male levels. So with that comes acne and clitoromegaly and hair, you know, losing hair in the male pattern, baldness. And you are stuck with that. There's no way to get it out. You know, you could surgically go in and remove it, but you're basically stuck with this for months until it, until it wears off. And I just think we can do better. And what bothers me is these clinicians by and large are not offering any other form. They're not offering Androgel or T stem or any of the FDA approved options which we borrow from men or even a compounded cream.
- [22:46]
Tamsen Fadal
Well, so let's talk about the other options, because there are other options to get testosterone. And by the way, the pellets make you feel like you're up here and.
- [22:53]
Dr. Mary Claire Haver
You do massive dose. Yeah.
- [22:57]
Tamsen Fadal
And then it kind of trails off a little bit and then you need a it again. Right. And then that's that's, that's the cycle. That's the cycle. Okay, so let's talk about the other doses because you and I are very involved in, in testosterone and fda.
- [23:10]
Dr. Mary Claire Haver
I'm a fan.
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Tamsen Fadal
Unlabeling, but talk about testosterone, because there is not a female.
- [23:16]
Dr. Mary Claire Haver
Not just in the US we have them in other countries, you know, their version of the fda. Like government approved options for women that are available from their pharmacy. We don't have that in the U.S. fDA is never, you know, the systems that control the FDA. Up until now, no administration has done women's health well. So I don't want to throw anybody under the bus, but, you know, no one's bothered to get any form of testosterone approved for women for the treatment of high, despite multiple medical societies saying it's safe, it's effective, and we should have this in our toolbox to help women with desire issues. So a patient comes to me and she wants to give testosterone a try. So I can either compound it at the local pharmacy, I can try a pellet, which I won't do because I haven't found a safe way to give it to her, or I can borrow the men's version, which is usually in the form of Androgel or T stem.
- [24:07]
Tamsen Fadal
It's a little gel. And then you, you distribute. Just, you put a little bit on every day. Right. So my tube lasts daily dose for quite, quite a bit.
- [24:15]
Dr. Mary Claire Haver
Yeah. So I use the Androgel pump and that bottle cost me about $50 and it lasts me several months, five months.
- [24:21]
Tamsen Fadal
And then, you know how much is going on. You put it on every day.
- [24:24]
Dr. Mary Claire Haver
Okay. I check levels, you know, my patients, myself, to make sure, to make sure I'm absorbing well.
- [24:30]
Tamsen Fadal
And that is the one area where we should be testing, correct?
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Dr. Mary Claire Haver
Absolutely. If you are doing testosterone, you should get a baseline, you know, without medication level, know what your baseline testosterone is, and then monitor at least once or twice until you hit steady state. And know that, okay, I'm a good absorber. This is working for me, and I've consistently been able to maintain a healthy level.
- [24:54]
Tamsen Fadal
Okay, I have one small favor to ask you. If the Tamsen show has ever made you feel seen, stronger, more informed, whatever it is, I'd really love your help. We have just been nominated for a Signal Listeners Choice award in the self improvement and self help category. And your vote would mean everything. You can just scroll down to the episode description, tap the link and cast your vote. I promise it takes less than a minute and it really helps us keep amplifying the voices and the stories that matter. Thank you. Thank you. Thank you for being a part of this community. I'm so excited to keep doing this together. So for a woman in perimenopause, what is the right time to be thinking about all of this?
- [25:35]
Dr. Mary Claire Haver
Immediately.
- [25:37]
Tamsen Fadal
Okay. Whether it's testosterone, estrogen, progesterone, immediately, it's.
- [25:42]
Dr. Mary Claire Haver
Like pinning the tail on a moving donkey in perimenopause. And what works in one phase of your perimenopause may not work midway. You may have to change it when at all, you know, ends. And sometimes birth control pills might be an option for you if you need contraception. If you're having heavy, crazy, irregular periods and we're trying to manage them, I might lean towards the birth control pill option. But say you've, you know, you've got a Mirena iud, your husband had a vasectomy, or, you know, your partner's had a. You don't contraceptive not. Or you have a female partner, you know, that's not an issue for you, and your periods are not disrupting your life. We may lean harder into the menopause hormone therapy option, which a lot of clinicians don't understand, that we can start using the MHT doses in perimenopause.
- [26:25]
Tamsen Fadal
And that's really true. And that's the confusing part of it. And I think it confuses women too, because if they are on birth control to manage some symptoms, how do you know when it's okay to switch over to hormone control?
- [26:35]
Dr. Mary Claire Haver
That's a good question. There's some school of thought, people I respect, who really feel like, keep them on till 55. On birth control. On birth control, that's, you know, and that's their kind of clinical experience. Again, we don't have any large scale studies to like, say, what's the best treatment for perimenopause. I don't know if we'll ever have them. So we really have to lean into our clinical expertise for this. For a lot of my patients, that's kind of hitting a nail with a sledgehammer. And so because it's a much higher dose and they'll.
- [27:04]
Tamsen Fadal
Birth control is much higher.
- [27:05]
Dr. Mary Claire Haver
Yeah, much higher dose than menopause hormone therapy. It's also a different formulation. Riddle me this. Tamsin. In the United States, for birth control, we have 35, 40, 50 options. Right. And they're all synthetic. We don't have a birth control dose that contains high enough levels to suppress ovulation. For estradiol and progesterone. Together, they do in other countries, but not here. Why? That's an economic decision. It has nothing to do with science or medicine. That's purely the economics of big pharma. And I love pharmacology. Like, I'm very happy.
- [27:41]
Tamsen Fadal
I get it.
- [27:41]
Dr. Mary Claire Haver
But pharmacologic options. But it's like, why? Whereas in menopause hormone therapy, for $2, I can get the microdose that is estradiol, that is gonna stop her hot flashes and protect her bones comp. Compared to ethinyl. And there's a lot of talk around. Well, and estrogen receptors and estrogen receptors and these things. Not true. Let me clear the air. Ethanol estradiol, which is in most birth control pills, does not act exactly the same once it, you know, it binds to the same receptors. But you cannot expect it is a little more inflammatory than plain estradiol is.
- [28:17]
Tamsen Fadal
And we're so scared of it.
- [28:18]
Dr. Mary Claire Haver
300 times more potent than estradiol.
- [28:21]
Tamsen Fadal
I wish that everyone really understood that the difference between birth control and estradiol, because the fears of estrogen, progesterone, dating back to 2002, dating back to the Women's Health Initiative, and how same clinicians.
- [28:34]
Dr. Mary Claire Haver
Who will put any and everyone on birth control pills will absolutely refuse to put someone on menopause hormone therapy. I'm like, you understand, it is a microdose compared to.
- [28:44]
Tamsen Fadal
And that's where the education comes in, or the lack of education. Difference between bioidentical hormones and the kind that most doctors prescribe.
- [28:52]
Dr. Mary Claire Haver
Again, are we talking about birth control pills? Are we talking about menopause hormone therapy? So in menopause hormone therapy, most commercial available products are all bioidentical, meaning chemically identical to what our body's made, except for Premarin. Premarin is conjugated mare's urine. It comes from horse urine who are pregnant. And so they have really high levels of estrogen, as we all do as mammals. Right. So they were able to extract this. And it is actually composed of about 10 different estrogen products. Estradiol is one of them, but it has things like estrella. And so the studies on the heart, health, on taking HRT and early menopause, that was all done with Premarin. So I don't want to demonize Premarin. Ethically, it's not my favorite way. Why would I not use regular estradiol? Why would I not try to give the patient back exactly what her body made in the amounts that she made it? Roughly? And so, you know, so I choose not to use premarin. Also, the vaginal option for Premarin works great. It's $400. They don't make it generic. Why would I not use $10 vaginal estradiol for my patients?
- [29:59]
Tamsen Fadal
So a lot of women have been told that menopausal hormone therapy is dangerous or they're not candidates for it. So I want to just clear that up. Who is not a candidate for it? For the most part, when we talk about most women and why is it.
- [30:14]
Dr. Mary Claire Haver
It safe for most women, the benefits will far outweigh the risks. It's gonna protect her bones. It's probably, if you start early enough, gonna protect her endothelium and from cardiovascular disease. It will also probably protect her, especially if she's high risk for dementia, if started early with all the lifestyle things. Right. And so. But who can't take it? Okay. If you have a tumor that is threatening your life, that is actively being fed by these hormones, that is not for you.
- [30:39]
Tamsen Fadal
A cancerous tumor. Yeah. Okay.
- [30:41]
Dr. Mary Claire Haver
Okay. Or sometimes a benign one. You know, like, we need to get that taken care of. You know, if. And there's this one's a little controversial. If you have an, you know, recent blood clot and they're still kind of figuring out why that happened, and you're on a blood thinner, we probably need to hold off. Okay. You know, even though that's only really oral estrogen, transdermal estrogen does not increase our clotting factors. It never happens.
- [31:01]
Tamsen Fadal
Explain the difference between those two things.
- [31:02]
Dr. Mary Claire Haver
Yeah. So we have. When we talk about, you know, we have local therapy for hormone therapy. So that's like vaginal estrogen, topical estrogen for the face, et cetera.
- [31:09]
Tamsen Fadal
Okay.
- [31:10]
Dr. Mary Claire Haver
Then we have systemic estrogen. We're going into the blood stream, and we're going to treat your brains, your bones, every organ in your body.
- [31:16]
Tamsen Fadal
Okay? That's your patch. That's your patch, your pill, your gel.
- [31:19]
Dr. Mary Claire Haver
Your cream, your trochee, your. You know, we have multiple ways to get it through the skin, through the mucosa, or swallow it to get it into your body. When we swallow anything, it goes to the gut, the hepatic system. There's a special vein that draws everything into the liver for processing first. And when that bump of estrogen hits the liver, we have an upregulation in certain proteins, and some of those can lead to increased risk of clots.
- [31:46]
Tamsen Fadal
Got it.
- [31:47]
Dr. Mary Claire Haver
Okay. So for a woman at risk for blood clotting, just avoid oral estrogen if she needs a birth control pill. If we need a contraceptive option, we can give her the birth control patch, we can do the birth control ring. You know, we have options for all of this.
- [32:01]
Tamsen Fadal
And it's funny because I just had a friend of mine say, like, no, I'm at risk for blood clots. They said there's nothing I can do.
- [32:06]
Dr. Mary Claire Haver
That is not true. And that's, you know, thank you. There's a lot of things I think American College of Obgyn has to work on. They are very clear in their guidelines how safe non oral estrogen is compared to oral with the risk of clots.
- [32:19]
Tamsen Fadal
Is there a test that you have to do before you take hormone therapy?
- [32:24]
Dr. Mary Claire Haver
No, if we just believe women, symptoms.
- [32:29]
Tamsen Fadal
It'S diagnosed by symptoms. So if you go into your doctor.
- [32:31]
Dr. Mary Claire Haver
So she's over 45 and she hasn't had a period for a year. That is menopause.
- [32:36]
Tamsen Fadal
And if she is 45 but still having periods, she is perimenopause more than likely and she is a cannabis.
- [32:43]
Dr. Mary Claire Haver
Now I'll do blood work to rule out. I'll look at her symptom profile and usually she's got a list. Not because she's crazy, because she's a woman, likely in perimenopause, or she has hypothyroidism and, or she has a nutritional deficiency. You know, how much iron deficiency is common at this age because of these crazy periods. And the first thing that goes ferritin and that's, you know, we're not catching it early enough to intervene.
- [33:08]
Tamsen Fadal
What should a woman, if a woman's listening today and says, like, I don't know, I'm 43 and I've got a couple of these things, but I don't know how bad they really are. What should she go into her doctor and say or ask for to be put on the right path?
- [33:22]
Dr. Mary Claire Haver
First of all, she has to find a menopause educated provider. And like we talked about in the last session, those are hard to find. You know, you cannot just walk into any primary care doctor or OB GYN's office and, and expect them to have been able to keep up with all of the education on this. We, all of us who do this work well, had to step outside of our own training to be able to do this. But say she, you know, she's not super symptomatic, immediately I would get a bone density. What are your bones?
- [33:48]
Tamsen Fadal
Before anything else.
- [33:48]
Dr. Mary Claire Haver
Before anything else. That'd be the first test because the bones go out quietly and the earlier we catch it and intervene on bone loss. Why do we wait until we're Osteoporotic. Why would we not start intervening and doing the lifestyle changes and the exercise and nutrition and the protein and the creatine and all the things we know when you stack them together, are going to decrease your risk of an osteoporotic fracture at 80. So let's look at those bones now and see where you're at. Because we reach our maximum bone density typically in our late 20s to 30s, and aging starts chipping away at it, and then menopause really chips away at it. You know, we are on a race against time with our bones and our brains.
- [34:32]
Tamsen Fadal
If you're in perimenopause right now, or you know you are, you think you might be, this is the time to be focused on bones.
- [34:39]
Dr. Mary Claire Haver
It's a window of opportunity. I talk about it as a window of vulnerability, especially for bones and mental health. But, God, it's such a wonderful, you know, time for you to, like, make those changes, get these lifestyle things.
- [34:51]
Tamsen Fadal
So what do you do? Give me your top three changes to start protecting your bones.
- [34:54]
Dr. Mary Claire Haver
Lift weights. Lift weights. Jump training. So jump rope. Anything that stimulates the musculoskeletal unit will grow stronger bones. And we can grow bones at any age. This is not something at 30 that you can't do at 80. It gets harder as we get older, but you can definitely do it. So prioritizing not just cardio to be thin, but building big, juicy bones and muscles, and that's going to usually take consistent resistance training. And then for about, you know, if you follow Stacy Sims, who I love for her exercise physiology, you know, and Abby Smith Ryan, who's incredible with her work on creatine and women in menopause, you know, jump training, 10 minutes, three times a week, just sending that stimulatory process to the musculoskeletal unit balance so you don't fall. You don't fall. You tip. You tend to not break. So, you know, Vonda writes, you know, advice on standing on one foot while you're brushing your teeth.
- [35:49]
Tamsen Fadal
We all did it.
- [35:50]
Dr. Mary Claire Haver
You know, I'm a fan of the weighted vest, so I don't. I think you do a weighted vest in place of resistance training. But I advise my patients to wear a weighted vest while they're doing other daily activities. That's adding that extra level of balance of proprioception, because you have to work harder to stay afloat. When you've got ten to eight pounds on you, what's a good size?
- [36:11]
Tamsen Fadal
What's a good weight of vestibule?
- [36:13]
Dr. Mary Claire Haver
So studies when you looked. And again, these are studies done in living facilities, so typically in nursing homes. And look at the women in nursing homes. They're very frail, of course. So for those women, they saw improvement in their bone density, typically, and now they were doing resistance training as well and balance starting at about 10% of their body weight. Okay, so I'm advising patients, you may need to start at 5 because you're not conditioned yet. But make it always the plan that you're going to get up to that 10%, whatever that looks like for you.
- [36:44]
Tamsen Fadal
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- [39:26]
Dr. Mary Claire Haver
I mean I think you should get it at a vending machine.
- [39:28]
Tamsen Fadal
I think it should be an everyday bathroom. I do too. So let's explain what vaginal estrogen is and why it's so important because it's not even. I look at these as like today or tomorrow issues sometimes, you know and I, and I think that like osteoporosis is a today for tomorrow. So vaginal estrogen the same way in.
- [39:43]
Dr. Mary Claire Haver
Women'S health especially to do anything with menopause so men don't get gsm. General urinary syndrome of menopause because they don't go through it. Why do we wait till we break to fix something? Why, why are we waiting till our product? Why are we waiting until we're you know to do these interventions and then.
- [40:00]
Tamsen Fadal
We panic to try to do about it and it winds up being a pill and you know instead of being.
- [40:04]
Dr. Mary Claire Haver
Preventative 100% of women will have GSM.
- [40:07]
Tamsen Fadal
And what does she realize?
- [40:08]
Dr. Mary Claire Haver
That genital urinary syndrome of menopause to different degrees and that means your tissues that line your urethra, your, which is the tube that drains our bladder all around our bladder, our whole vagina, the whole perineum, the labia. There's. It's the big thing on TikTok is we labia tends to shrink as we go through menopause because we lose estrogen and testosterone. So if we treat with local estrogen therapy this is non systemic, it acts locally in the vagina so there's no systemic absorption. It's not helping your bones, it's not helping your brain. It's also not feeding a potential tumor that you might have.
- [40:45]
Tamsen Fadal
It's just for your vagina.
- [40:47]
Dr. Mary Claire Haver
Just for your vagina. We can cut rates of UTIs and therefore urosepsis by up to 50%. The number one treatment for a woman for recurrent UTIS is vaginal estrogen, not recurrent antibiotics. We're doing a huge disservice. Every time we take that round of antibiotics. We're disrupting our gut microbiome, we're disrupting other parts of our health. I mean, I love having antibiotics. It saves lives. But when they looked at the cancer data, zero increased risk of recurrence. These women with breast cancer who are on these, you know, for their treatment of their breast cancer, they're on tamoxifen, they're on their AIs, and their whole quality of life is being ignored by the medical system. They could all be on vaginal estrogen. It will 0 increase risk of recurrence in these patients, even during treatment. We can save their sex life, save their vagina, save their vaginal health, their urethral health, their bladder health. And people were just so terrified of estrogen for no reason. And when they look at those, women live longer. So the ones who were given vaginal estrogen have a higher survival.
- [41:58]
Tamsen Fadal
Why is everyone not started on vaginal estrogen then?
- [42:01]
Dr. Mary Claire Haver
Good question.
- [42:02]
Tamsen Fadal
We're talking about because we have to.
- [42:03]
Dr. Mary Claire Haver
Go in, we have to find the right provider who's going to believe our symptoms and not tell us just to use coconut oil and lube. And I love lubricants. Sure, I think everyone should be using a lubricant. But, like, that is not treating the root cause.
- [42:16]
Tamsen Fadal
And what will vaginal estrogen do for you? Because what happens when you push you back?
- [42:20]
Dr. Mary Claire Haver
I will grow back your vagina.
- [42:22]
Tamsen Fadal
What happens though?
- [42:24]
Dr. Mary Claire Haver
Like, explain that we lose estrogen. So what if under a microscope, when you biopsy a vagina and God forbid you have to have one of those, but if I took a premenopausal healthy woman with normal estrogen levels and biopsied her vagina, there would be multiple layers of tissue, beautiful, juicy, with these globules of mucus, you know, for lubrication. And it was just that when you look at it visually, it'll be pink and moist and, you know, lots of rigations. And like now we're going to go to post menopause and take estrogen away way it becomes very Thin. It looks like a desert under a microscope. There's no more mucus production. We lose the elastin, we lose the elasticity. Things shrink in the area. It becomes very, very painful. Very, very easy to injure with just intercourse. So a lubricant may help a little bit, but it's not treating the cause. If we just give her vaginal estrogen, it's a miracle. She will grow the tissue back to its premenopausal state.
- [43:20]
Tamsen Fadal
I do want to talk about advocacy though, research, talking to your doctor, because those are all really important things that we all have to do right now. The onus is on us to all do it. If your doctor doesn't acknowledge you're impairing menopause, how do you talk to them at that point?
- [43:37]
Dr. Mary Claire Haver
Hopefully they are willing to listen. Hopefully they have time. You can direct them to the Menopause Society. You can print out the Menopause Society guidelines, which don't actually cover perimenopause, but it's a start for them to at least get them curious. So I always advise these followers, not my own personal patients, to go in armed with. You're giving an opportunity that you may be able to educate your clinician and just handing them these society guidelines, especially the ones for gsm.
- [44:06]
Tamsen Fadal
And what are the guidelines?
- [44:07]
Dr. Mary Claire Haver
Your life might not be changed, but you could, through that clinician who might take those guidelines home and read them, change the future of those patients that.
- [44:16]
Tamsen Fadal
Follow you and those guidelines. Explain what it is, explain what the options are and maybe we'll make the doctor feel like, okay, let me just go and process that this and do a little bit of research and just feel better about it overall. Questions a woman should bring into her appointment. I know we say don't plan on doing this at the end of like your regular exam. Right.
- [44:33]
Dr. Mary Claire Haver
So this isn't a, well, this, you know, any kind of menopause care. Perimenopause care should not be considered to be part of the well woman exam. That is a very specific set of screening tests, right. That are covered, you know, under preventative care. So if you're going in specifically to discuss your perimenopause, make a problem, visit it. It's going to give you more time, you know, call ahead. Does this doctor consider themselves educated and, and you know, are they Menopause Society certified? Like, do your research before you go. Don't waste your time. You know, ask whoever's answering the phone, do they ever prescribe hormone therapy, you know, and if it's 100% of the time, that's a red flag, right? Right. If it's never, that's a red flag.
- [45:13]
Tamsen Fadal
You know, why is 100% of the time red flag?
- [45:16]
Dr. Mary Claire Haver
Because not everybody's a candidate state.
- [45:17]
Tamsen Fadal
Okay?
- [45:18]
Dr. Mary Claire Haver
So you'll see these hormone clinics pop up and every single patient going in there gets hormone therapy when, you know, they didn't get worked up. So.
- [45:25]
Tamsen Fadal
And then our pendulum swings and we have a bigger problem.
- [45:27]
Dr. Mary Claire Haver
So we have a bigger problem. Like if you have undiagnosed vaginal bleeding, you shouldn't start hormone therapy until that gets worked up. You know, if you have an allergy to one of the components, you know, the peanut oil, for example, in progesterone, you shouldn't take that form. There's other progestins we can give you or a Mirena IUD or something. Something.
- [45:43]
Tamsen Fadal
What do you want women to track before they come and see you for an appointment?
- [45:47]
Dr. Mary Claire Haver
You should track your cycle. Is it beginning? You know, by the time your cycle becomes disrupted, you are well into the process. So go in armed with that information to help your clinician along. What has your body composition been doing? So your waist hip ratio, what is your cholesterol doing? A beautiful study that came out of Asia looked at a very. The small, dense LDL particle, which most of us don't check for. And it is one of the earlier. It doesn't go up with aging. It only goes up with menopause in women. And so, you know, and in the perimenopause transition. So they are starting to use it in Asia as a way to, you know, help diagnose a woman in perimenopause.
- [46:24]
Tamsen Fadal
Cholesterol. We also see thyroid. Correct. What are some of the other things we see?
- [46:27]
Dr. Mary Claire Haver
Insulin resistance. So besides waiting till her A1C goes up, you know, you can do the HOMA insulin resistance score, which is a fasting. It's looking at a ratio of your fasting glucose to your fasting insulin level. And so asking for that specifically, you know, 80% of my patients, and this is more of an aging thing than menopause, are deficient in vitamin D. So I'm always checking that level as well.
- [46:50]
Tamsen Fadal
Everybody wants you as a doctor. I'm telling you what, what research is being done right now that you're feeling good about, excited about, and then where do we need to push harder? I know we, you know, there are. There are a group of us, it keeps getting bigger, which is super exciting. But there's a group of us that are really all trained trying to push for some of the same things, advocating in all different areas.
- [47:10]
Dr. Mary Claire Haver
Where do you think political climate is moving away from really depending on, like, the nih because that funding is drying up. So there's a lot of exciting things happening state to state. And, you know, happily for us women, it's all the states. It's not just the red states or the blue states. We're seeing legislature in my home state of Texas, which, you know, looking at providing menopause resources, like mandated and paid for by the government. They'll have a website that teaches about menopause. I mean, that's something, right? And so other states are mandating Louisiana that menopause care be covered by Medicaid and Medicare. And so that, you know, there in Medicare codes, there's not even a code for menopause.
- [47:50]
Tamsen Fadal
What is it?
- [47:51]
Dr. Mary Claire Haver
What's our code?
- [47:52]
Tamsen Fadal
I can't even imagine.
- [47:53]
Dr. Mary Claire Haver
So what's our code? You know, it's. It's zero. We have a very long way to go. We are seeing some exciting things on the research world. There's a couple of companies that are looking at extending the life of the ovary. So, like, how can we eke out hormones out of the ovary for longer without pregnancy? You know, most of us who, you know, don't want to be pregnant at 50 or 60, and so we are still aging humans, but, like, is there a way to, like, get our ovaries to squeak out the natural estrogen a little bit longer to help protect us?
- [48:23]
Tamsen Fadal
Is there anything you were excited about just watching this? And we've watched it happen and change over the past several years. I remember the first time I. I mean, we talked together on that stage, but even, I think before that, I interviewed you for the Galveston Night. We've seen a lot change.
- [48:37]
Dr. Mary Claire Haver
Seeing the conversation, getting the feedback from my followers. You know, we're in New York here filming, and I've been with my daughter and some friends walking around the streets of New York and just being stopped by strangers. Just that they're saying, thank you. Something I did said, or they read or heard me on a podcast or, you know, picked up the book has changed their lives, life. And that wasn't a conversation I was having five years ago.
- [49:00]
Tamsen Fadal
Mm. Mm. It's amazing. Dr. Mary Claire, thank you.
- [49:04]
Dr. Mary Claire Haver
Thank you.
- [49:05]
Tamsen Fadal
I could do ten episodes with you.
- [49:06]
Dr. Mary Claire Haver
We could keep it.
- [49:07]
Tamsen Fadal
Thank you for sticking around.
- [49:07]
Dr. Mary Claire Haver
Okay.
- [49:08]
Tamsen Fadal
What an incredible conversation. What you're going through is real. I hope you know that. And you shouldn't have to figure it out alone. Thank you to Dr. Mary Claire Haver for laying it all out for us. I do feel like we could have a part 3, 4 and 5. 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 just like this one. And please keep in touch. Make sure you're following the Tamsen show on social and if you have any questions or want to suggest an upcoming topic, I would love to hear from you. You can email me@podcastamsenfadell.com thank you so much for being here. We could not do this without you and I'll see you next Wednesday. Hey everybody, I want you to know today's episode was sponsored by Midi Health. If you're ready to feel your best and write that second act so script, visit join midi.com today to book your personalized insurance covered virtual Visit. That's join MIDI.com MIDI the care that Women deserve.