← unPAUSED with Dr. Mary Claire Haver
unPAUSED with Dr. Mary Claire Haver
Menopause Masterclass: My Menopause Toolkit – HRT and more
01:04:44
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- [00:02]
Dr. Mary Claire Haver
One of the questions I get more than almost anything else is what hormones do you actually take? What is your menopause routine? What supplements are you on? And I get it when you're drowning in conflicting information. When one doctor says hormones are dangerous and another says they're essential, when the supplement aisle has 400 options and none of them come with context, you want to know what someone who actually understands the science does for herself. So today I'm going to walk you through everything. My hormone therapy regimen, why I choose each formulation, what it does, what the FDA approved alternatives are, and if my specific choice is not right for you, then I'm going to cover every supplement
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I take and why.
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Specifically, for my body and my risk profile. I'm going to talk about oral minoxidil for hair because that question comes up constantly and I want to give you real information. Before I start, I want to be clear about something.
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This is my routine.
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It is based on my symptoms, my lab work, my risk factors, my family history and my goals. It is not a prescription. What is right for me may not be right for you. The point of sharing this is not so that you can copy it. The point is to show you what a thoughtful, individualized, evidence based menopause plan
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looks like so you can have a
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better conversation with your own clinician about building yours. I also want to say this. I am a board certified OB gyn. I am a certified menopause practitioner and I still work with my own clinician on my protocol. No one should be managing their hormones alone, including me. So please hear this as education and transparency, not as medical advice for your specific situation. Let's start with hormones. I'm Dr. Mary Claire Haver, a board certified obstetrician and gynecologist and certified menopause practitioner. I am also an adjunct professor of obstetrician at the University of Texas Medical Branch. Welcome to Unpaused, the podcast where we
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cut through the silence and talk about
- [02:20]
what it really takes for women to thrive in the second half of life. The views and opinions expressed on Unpause are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis or treatment. I've really been loving the idea of throwing on a cute casual outfit and then pairing it with just the right piece of jewelry to pull it all together. It's funny how that one small detail can completely change the whole vibe of what you're wearing. It makes you feel more put together and a little more confident, even on the simplest days. That's the beauty of Jenny Bird. Everything is designed to mix and match. You don't have to overthink it or plan it out. Just grab a piece or a few and you're instantly elevated. Stack a couple of necklaces, wear a pair of bold earrings, or add some beautiful bangles and it always works. And the best part is how effortless it feels. The pieces are lightweight and easy to wear all day long, whether you're running errands, going out to dinner, or just getting ready at home. It's that perfect balance of simple and statement, which honestly makes getting dressed so much more fun and a lot less stressful. They also make the perfect gift. Whether it's a birthday or an anniversary, you really can't go wrong with jewelry, especially when it's Jenny Bird. Get a free gift with your first Jenny Bird order when you shop@jenny ginny-bird.com this podcast is sponsored by MIDI Health, the first virtual clinic created for women by women for the treatment of menopause. Don't let anyone tell you menopause is something you have to suffer through alone. Midi can help. Visit joinmitty.com to learn more.
- [04:21]
Google Health Sponsor
This episode is brought to you by Google Health. Stop chasing someone else's definition of health. What matters is what's healthy for you. Google Health offers a new kind of coach built with gemiini for effortless tracking, sleep insights and holistic coaching tailored to you. Visit googlestore.com to learn more and start a new relationship with your health. Requires Google Account, Google Health app Internet and Google Health Premium subscription Features subject to change availability and results vary. Not intended for medical purposes. Works independently of Gemini Apps. Check responses for accuracy.
- [04:53]
Dr. Mary Claire Haver
So this is embarrassing. This. This is how I replace my hormones right here. 7ways7 it does seem excessive, but it is. It is excessive when it is worth it. These are all of the hormones that I put in or on my body to support what I'm doing or to replace the ones that have gone missing. So we're going to start with Systemic Estrogen, Part 1. So I'm going to move some of these guys out of the way. So systemic estrogen therapy. When we think systemic, we're not doing local or topical. We are actually trying to get into your bloodstream and treat your brain, your bones, your heart, your endothelium, your muscles. Almost every cell of the body has some kind of estrogen receptor and this is how we're going to replace it. So I am a fully menopausal woman. I've been fully menopausal for probably close to 10 years now. So my ovaries have lost all of their eggs and the ability to produce any natural estradiol. My main source to replace my estrogen is systemic estradiol in the form of a patch. So when we talk about estrogen systemically replacement in general, I like to lump it into two categories. We have oral and non oral. And in oral that means pill. Okay. And we have a few pill options. And in non oral, we actually have a multitude of options of ways we can get it through your skin, through your mucosa, even through the vagina that will be a high enough level to go systemically. I have chosen for me and actually most of my patients choose this option as well, the generic estradiol patch. Now, caveat. There's a shortage of patches in the United States right now, and we have an entire blog on our website@thepauselife.com explaining to you creative ways to get your estrogen either through a patch or another form. We're going to go through the other forms today. I chose the patch for specific reasons. One, I like a continuous dose. I like a continuous steady state approach. When you put the patch on, your body is getting a continuous supply of estradiol. A transdermal approach does bypass the liver. So for those of you with a history of any clotting disorders or have had a blood clot, you are going to want a transdermal option to decrease your risk of forming blood clots. The good news is, is that transdermal does not increase your blood clotting risk. Oral might, but it's still very, very slight. But if you had a history of your high risk, you're going to want to avoid the oral formulations. When you do a patch, you are not getting peaks and trots. So some of the transdermal options, you have creams, you have gels, you have sprays, those are applied once a day. So you're getting a peak and a trough. I like to have that continuous dose, really for my brain health. I feel like my brain fog. Having a steady state of estrogen is a lot better. Multiple large studies, including the ESTER trial and the KEEPS trial, showed that transdermal estradiol, again, does not carry the same venous thromboembolism or blood clotting risk that the oral formulations do. Now, remember, most of those studies were actually done with oral birth control pills. Oral birth control pills have ethanol, estradiol which binds to the receptor 300 times the affinity of regular estradiol. It's really sticky. It doesn't like to come off. So when we look at the data around blood clotting, it is much higher for birth control pills, but they tend to apply that data for menopause hormone therapy. There is a slight increase risk with oral formulations in the menopause hormone therapy dose of plain estradiol, but it is very, very, very minor. So I don't want anyone afraid. This is much less expensive than this. So if you did not have insurance. Now, once you have insurance, I have no idea what your insurance company is going to charge you with co pays and deductibles and all the things. But if you had to pay cash out of pocket and you were willing to go find a coupon and hustle, this oral estradiol, like for example, through the Mark Cuban pharmacy, would probably be about five to seven dollars a month for a month's supply. This transdermal patch is somewhere in the neighborhood of 25 to $35 a patch. This particular patch you apply twice a week. So for me, I put mine on Tuesdays and Fridays. So I picked Tuesday because in my neighborhood in Galveston, Texas, that is the day the trash can comes. And when I pull out of my driveway and I see the trash cans lined up down the street, I know it's patch day. It's just some way for me to remember. And then Friday, because it's three days later and it's before the weekend. So that system has worked really well for me. And I encourage patients to pick something on their calendar that's going to work for them. I also take a very small amount of oral estrogen. And I'll tell you why this is a bone protection story. And I have a huge substack about this exact reason. So remember, hormone therapy was developed to stop a hot flash. The end point of does this medication work or not? And all the studies were, did her hot flashes go away? Well, it turns out that enough to stop a hot flash, enough to bind to that thermoregulatory or in the brain to stabilize that area to stop the hot flashes may not be enough for bone or cardiovascular protection. We need to get our estradiol up so we know that there's a threshold for getting your estrogen level up to the point where you stop losing bone. And then there's an even higher level where you can actually begin to grow bone again. So remember, lots of things cause us to lose bone. It's not just whether or not you're menopausal. I'm talking specifically about the bone loss, surrounding estrogen loss. It seems like we max out. There's no reason to go above 70 in picograms per deciliter the way that we measure in the United States. And so in our clinic, we look at symptoms. A lot of people do not absorb the transdermal patch well. So I was on the patch, completely controlled, very happy with my patch, sleeping well, no hot flashes. But then I was reading the data that came out of Louise Nuisance Clinic and papers that were published in looking at absorption rates, and they were measuring serum estradiol levels and finding very big discrepancies amongst women on how much they were absorbing from different level patches. So I am on the highest dose patch. There's no more than this. And I measured my levels twice and they did not approach bone protection. So my symptoms were controlled. My bones were probably needing more for maximum protection. So I said, okay, I can either add another patch to this, which would be fine, but it gets a little sticky with insurance companies because mine are covered, or I can add a really low dose of oral estradiol at night. Another key point about oral estradiol, because it does go into the liver first we see improvements in cholesterol more than with the patch. My cholesterol went up shockingly in menopause, like many of yours did with diet and exercise and lifestyle interventions. I was able to get it down a bit, but it was not normal. Adding the patch brought it down a little bit more, still not normal. Adding in the touch of oral estradiol, which I happen to take at night because I'm taking some other stuff at night too, and it's just easy for me to remember, did get my cholesterol back in the normal range. And so for my systemic protection, I don't recommend this to everyone. I am taking two forms of systemic estrogen. I still like the patch to give me that continuous dose for my brain fog. But I'm adding in this little extra estrogen to get my levels up for my phones. And as a bonus, it helped my cholesterol come down. So, yes, in our clinics we are measuring serum estradiol levels, especially for people on transdermal, because humans have varying absorption rates and we can't predict who's going to be a good absorber, a super absorber or a poor absorber. So at about month three, we are recommending a high sensitivity serum estradiol level for all of our patients so that we can see what their levels are, especially if they have a history of osteopenia, osteoporosis, or, you know, family history or this is one of their treatment goals. We want to make sure they're getting absorbed enough and then we can talk about changing the formulation, changing the dose, et cetera. So I want you to sit with us for a second. The guidelines currently do not recommend routine testing of estradiol levels. We were not recommending routine estradiol levels until the new data came from out from the UK saying that about 20% of patients were going to be poor absorbers of the transdermal options. That got us motivated to check. I think we are a decade away from the guidelines being changed, but I want to give you the latest evidence. Here's the takeaway. Symptom control and disease protection may have different thresholds in your body. The more we learn about what these levels mean in certain women, the more information we can have so that you can have an individualized, personalized plan just for you. So there are, and you'll see me glance down to look at my notes, several FDA approved transdermal estradiol options that I don't have here. So I want to tell you about them. We have other patches. I picked generic because of cost, but there is Vivel Dot, Chlomira, Minivel, Dottie, Estradot, and then also other brands of generic estradiol patches. These come in varying doses, typically ranging from 0.025 milligrams to this one, 0.1 milligram per day. So we have five options. Another reason why I like to start with patches, because we have so many different levels, we can start out. Some are actually changed weekly, some can be changed twice weekly. And your clinician will start at a dose appropriate for your symptoms and then adjust to see how you respond. Basically, in our clinic, we adjust the dose to make sure her symptoms are controlled. Then at month three, we check levels to see how she's absorbing. To give you an idea, there is also the Estrogel and the Divi Gel. They are FDA approved. You apply them to the skin once a day. Estrogel, it was studied from the wrist to the shoulder. So this whole way. And Diva Gel comes in single dose packets applied to a small, small area of thigh. And of course we have the spray. There is Eva mist, which is FDA approved estradiol spray that is applied to the forearm. It comes with a little cup over the spray. So it's all contained in a little central area. I have tried it in the Past and it's going to be one to three sprays depending on the dose. All of the ones I've just discussed are bioidentical with 17 beta estradiol. All of them bypass burst, liberal metabolism. The choice between patch, gel and spray is often about lifestyle, skin sensitivity and personal preference. One of the problems with a certain percentage of the population with the patch is there are people who will be sensitive to the adhesive in the patch. It's not really the medication, but it is the stickiness of the patch usually causing some type of a mild allergic type reaction. If it is mild. Some of our patients have tried to take flonase or one of the generic steroids, nasal sprays, apply it to the skin and let it dry naturally and then put the patch on top of that. And that does, for a lot of patients, seem to make them tolerate the patch a lot better. The other options of the gels and sprays, there is not a generic option. So cost can be an issue here. So oral estrogen options, this is plain generic estradiol. Premarin is stuck, still available and out there. There is no generic for premolin for Premarin, it is proprietary. So again, cost can be an option. In oral micronized estradiol, it's always bioidentical if it just says estradiol on it. And it typically comes in 0.51 or 2 milligram tablets. I want to talk about something special and we use it a fair amount in our clinic and it is called duavy or duave. This is a combination of conjugated estrogens plus vasodoxyphine, which is a selective estrogen receptor modulator. So SERMs are things like tamoxifen, which is similar to vasodoxifene in a lot of ways. So this particular combination, vasodoxifene selectively binds, blocks and downgrades estrogen receptors only in the breast and in the uterine cavity, in the endometrial cavity. So for patients who are having intractable bleeding on their hormone therapy or who are high risk for breast cancer, it's being studied right now in stage zero breast cancer patients. So DCIS patients, there's a really fantastic study going on with this medication. This can be great for people with progesterone intolerance. This can be great because it does not contain progesterone. It contains a serum that will protect the lining of the uterus. I'm a big fan of this medication. I can't wait until it's generic. So that it can be a lot more affordable for our patients. It can be a couple hundred dollars a month, which is, you know, for a lot of patients, that's off the table. The trade offs with oral estrogen. Again, it does go through the liver, which means a very slight increase in clotting risk. It also does increase our shbg, which is steroid hormone binding globulin. When your SHBG goes up, it binds all of the sex hormones and renders them inactive. So for patients who have issues with libido, testosterone, even in the general urinary syndrome, menopause, we do have testosterone or androgen receptors in our vulva. Oral estrogen can make that worse because the activity of testosterone, it's not able to do its job. So we have to keep that in mind. And some people recommend checking SHBG levels. Certainly if you're having intractable libido issues and testosterone doesn't seem to be helping. Or intractable genital urinary syndrome, where topical testosterone doesn't seem to be helping. And SHVG might be something you'd want to ask your doctor for to see if it's elevated. And then you guys can discuss how to bring that down.
- [18:52]
This podcast is sponsored by MIDI Health. Have you noticed the conversation around menopause is suddenly every everywhere. It's trending on social media. Celebrities are opening up about their symptoms, and conversations that used to happen in whispers are finally out in the open. And honestly, it's about time. For decades, women were dismissed, ignored, or told their symptoms were just part of aging. And while I'm glad the conversation is happening, here's the truth. Menopause care isn't a trend. It's long overdue medical care that women have always deserved. If you've been listening to me, you know this isn't new territory for me. This is my life's work, helping women navigate perimenopause and menopause with real science. That's why I wanna tell you about MIDI Health. MIDI is a virtual menopause clinic staffed by clinicians who listen, who take your symptoms seriously, and never utter the words, it's all in your head. Like me, Mitti focuses on your health span, not just your lifespan. That means taking a comprehensive look at your metabolic health, bone density, cardiovascular risk, and cognitive function. Because all of it matters, MITI delivers the kind of proactive, evidence based care I've always believed women deserve. And the best part, women in all 50 states can access personalized care and it's almost always covered by insurance. So yes, I'm glad menopause is finally getting attention. But don't settle for noise. Get care from clinicians who are in this with you for the long haul. Book your virtual Visit today@joinmidi.com that's joinmidi.com
- [20:37]
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- [21:07]
Dr. Mary Claire Haver
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- [21:40]
Now let's talk about progesterone. Why do we need progesterone? Definitely if you have a uterus. Let me be clear. This is my progesterone. This is oral micronized progesterone. You can hear it. I'm shaking it on audio. I love this stuff. If I didn't have a uterus I would still take it. It is mandatory to have something to protect the lining of the uterus if you're taking estrogen. If you don't have a uterus, then it is optional. Okay, A lot of doctors don't understand this. We all know you don't give unopposed estrogen. Unopposed meaning not with a progestin or something to protect the lining of the uterus. But if you had had a hysterectomy or you have a rain iud. The thing about progesterone is that it converts down to allopregnolone and the metabolic process. And allopregnenolone loves to cross the blood brain barrier and it binds to the GABA receptor and causes a lot of calm and sedation. And it is absolutely wonderful for sleep. One of the first symptoms in perimenopause is sleep disruption. And for those patients who are still having normal regular cycles or maybe having some PMS or PMDD in that second half of their cycle and are having sleep disruption starting on on progesterone can be really helpful. So the progesterone is dosed in a hundred milligram tablets. So say you're on an estradiol patch. If you're on a 025 or a 05, a hundred milligrams of progesterone should be enough to protect the lining of the uterus. Once you go above the.05 patch, you're gonna need 200 milligrams. I take this at night, we recommend taking it at night again because of the sedative effect. I don't miss it. I mean I do not miss my dose. I might not put in my retainer, I might forget to brush my hair. But I am almost never gonna forget my progesterone. I depend on it so much to help me have that good calm sleep. And you know, I wear a sleep tracker and I don't recommend it if you're super anal like I am. But difference in my sweep sleep quality, it's made night and day for me and I just, just love it. Now, caveat, of course, everything is nuanced. About 10% of you will not tolerate this. Your body, you're going to have a paradoxical response to progesterone. Now that might change if it's, if it's mixed with estradiol. So here's some tricks. You can take these tablets and put them in the vagina and we'll miss the oral effect, we'll miss that bypass if you effect. So if, if you're having issues trans putting this vaginally, these will melt and you will get absorbed right into protect the lining of the uterus. Some doctors do that. We have things like again duvvy, like just skipping progesterone altogether. We have the combi patch, which is a combination of nor thendrone, which is a synthetic progestin. I don't want to, you know, bad mouth progestins too much. But I was on combi patch for the first three years of my menopause and it, it worked pretty well. And then I saw the data around oral micronized progesterone being better for sleep and I was struggling with sleep, so I decided to switch. But I have nothing bad to say about combi patch other than it's not generic and it can be pricey. So we have options. Remember to ask about nuance and options when you go to talk to your clinician about what is available to you. So FDA approved progesterone and progestogen options again, prometrium, which is oral micronized Progesterone available in 100 to 200 milligram capsules. You can take them continuously every night. You can cycle them for two weeks or 10 days out of the month. That again is a personal preference. In our clinics we don't cycle a lot of patients. They tend to really, really love their progesterone and they want to take it every day. And there's nothing wrong with doing that. Note it is peanut oil based. So if you have a peanut allergy, this is not for you. You can have it compounded in a, you know, sesame oil or non peanut oil formulation if you need. Okay, let's talk about baby is a combination capsule of estradiol. So it's bioidentical plus progesterone. So it is basically these two put together in one pill and they have a baby. It's not generic and so it's way more expensive than just getting the two generic options and taking two pills rather than doing the Bijuva. But it is available and your doctor might recommend it to you. It is FDA approved. And if you can't remember to take two pills at night, it is something you can consider. And then we have a ton of synthetic progestins, medroxyprogesterone acetate, I.e. provera, that was actually studied in the Women's Health Initiative. And norohendrone acetate are two FDA approved synthetic progestins that are not bioidentical. They do protect the uterine lining. Absolutely. But they don't produce the allopregnitolone. So they have a different side effect profile. And one thing to remember is that norethindrone does break down to ethinyl estradiol. So so people on North End Drone will might notice by itself having lower hot flashes because they're getting that conversion to an estrogen component. Many clinicians, most of us in the menopause do prefer oral micronized progesterone as our go to because we're mimicking what the ovary actually did. And then of course for protection of the lining of the uterus. And I actually love this in perimenopause for so many patient a hormonal iud, the levonorgestrel containing iud. Levonorgestrel is the progestin that is in the IUD embedded in the iud, provides local progestogen to the uterus and is increasingly used off label. It's available for contraception, for endometrial protection for women on estrogen therapy. So if I have a Perimenopausal patient, like so many of you who have outrageous periods, like heavy, heavy menstrual bleeding cycles that are disrupting your life, becoming anemic, putting an IUD in that uterus with that progestogen there and the lining will actually thin the lining. And for many patients within a couple of months get their bleeding under control. As a bonus, it provides contraception. So when we're in perimenopause and we're talking about therapeutic options, the conversation starts with, do you need contraception? I, I don't say do you need it? I say, what are you using for contraception? The pull out method is not it. I have too many perimenopausal babies that I've delivered from the pullout method a hundred percent would not recommend. Please, please, please do something that contains contraception. When we start a patient on menopause hormone therapy, that is some combination of these three, right? This does not not suppress ovulation, okay? This is not for contraception. You can get pregnant on menopause hormone therapy. It gets less likely with age. But this is not suppressing your ovulation. So don't think of this, oh, I'm fine. I can't get pregnant because I'm on hormones. These are not nearly high enough to consistently suppress ovulation. So if I have a patient doesn't want an IUD who's having heavy periods or needs contraception and is having perimenopausal symptoms, we sometimes talk about using oral hormonal contraception for these patients because I can get her symptoms under control. Most of them I can provide her with reliable contraception and get her heavy bleeding under control, all with one therapeutic option. So there are certain perimenopausal patients who our clinics have on birth control pills or oral contraception. There are others who are on menopause hormone therapy. We have some. So many nuances, so many options for all of you. What everybody wants to know about testosterone, this is mine. This is what we prescribe to patients. This is Androgel. So it is the men's version. Remember, we do not have an FDA approved option in the United States for women. So we have to get creative. We have to get tricky. We have to do things off label so you can compound testosterone in some way to get it in your body in a cream and a gel in a pellet. Perhaps you can borrow the men's version, which is FDA approved for men's. We're going to use it off label for women and we use A tenth of the dose. Okay, so we start our patients in general on about 5 milligrams of the testosterone per day. What does that look like? So, so men use one to four pumps of this a day. One pump is 20 milligrams. So we need a fourth of a pump, which is basically a pea sized amount. And I have not put it on today. So those of you on video, I can show you what that looks like. So it is literally I just do a quarter pump, a pea sized amount like this. I put it on the inside of my wrist, cause I don't have hair follicles here. And then I just rub my two wrists and early forearms together until it evaporates. And that's how I apply my testosterone every day. It is once a day. So I get a little bit of a pica trough throughout the day. Okay, it's dry and I'm done. You should know a baseline testosterone level before you start this and about three months after you start, if you're not having side effects, you should have another level drawn. We have lots of great data that shows that testosterone does help about 50% of women with hypoactive sexual desire disorder. What is that? So you would call that in the lay population, low libido. Basically it is where you have low desire, where you love your partner. You used to want to do it, it was something you look forward to, it was fun, you enjoyed it, but now you don't and then you miss it. So we do need to normalize the conversation around what if you just don't want to ever do it again and you don't care? That's fine, that's fine. That's not who testosterone is for. It is not to suddenly create something that you never had before you don't want to get. So it is a very specific set of patients. But again, I've talked about this on the podcast. I started it off label because I had read that women who have naturally the highest quartile of testosterone levels, remember we all have different testosterone levels, have better bone and muscle strength, less frailty, less sarcopenia. And I was like, huh, what if I use this and physiologic ranges for a FEMA email? And then kept my workouts going, maybe this would help me hang onto my muscle, maybe build a little more, a little faster. So I started it for that. But I, I have to say I did not qualify for hsdd. But I have noticed an uptick in the desire area and I like it and I think I would miss it. If we took the testosterone away. So that is my n of one full disclosure. I did notice some improvements in my energy, I think. And we check levels. Side effects of excess testosterone in women are acne, hair growth in places you don't want it, and losing hair in places you do want it. Usually in the temporal area if it's really high. We can see things like clitoromegaly, which is not reversible. We can see voice changes, which are not reversible. Dosing matters, monitoring matters. And this is not something to DIY at all. So again, can you access it? So there's male approved gels that are off label Androgel T stem and there's something called Vulgalexo. I haven't used that one. But our clinic has used Androgel and T stem. For the T stem, you want to get the tubes and not the packets. The packets. Once you open them, the alcohol will start to evaporate and you basically have to use it all that one time. You can't like hold it and save it for later. And those packets are dosed for men. So you want to make sure you get the tube so that you can use multiple doses in the tubes. This cost me about $55 with a coupon and lasts about six months. So very, very, very affordable. Those of you who are paying hundreds of dollars every, every quarter for your pellets, I want you to ask your clinician, is there another way you don't have to spend that much money to get excellent, excellent FDA approved, monitored, great testosterone.
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You.
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I have compounded testosterone cream in the past. We didn't have a good supplier for the Androgel. We, we worked that out. So we were compounding with the local pharmacy for our patients. It works pretty well. It's typically at 0.5 to a 2% concentration. That allows for more precise female dosing. And the downside is that those products aren't traditionally FDA regulated. So the quality really depends on the pharmacy. You can't expect to have the same quality coming out of each individual pharmacy because they don't have the same oversight. Subcutaneous pellets are very popular. I know. And many of you listening or watching are using the pellets and might be happy with them. Some clinicians do use these. I just, I'm very cautious about pellets because once they're in, you can't undo them. And there's one particular company that never made a female pellet. They just take the male pellets at lower doses and they put them in the women. And the women are walking into my clinic with levels in the hundreds which are far, far, far above a physiologic range. Now we're talking about performance enhancement. Now we're not talking about replacing a female physiologic dose. And if you're into, you know, performance enhancement, that's up to you. But you need to be honest about why you're doing this. That is not what we do in our clinics here. We're here for menopause care, we're here for HSDD and to just give our patients their best life. If your clinician is is curious and unfamiliar with it, ishwish, which is the International Society for the Study of Women's Sexual Wellness, Health and Wellness, has an awesome website and they have so many resources to help clinicians learn how to properly prescribe, how to test and how to dose testosterone for their patients.
- [35:12]
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- [39:48]
Now we're going to talk. We're going to skip to Vaginal and Vulvar Health, so let me move these over Here. Topical vaginal estradiol. So this is plain generic vaginal estradiol. This tube probably should cost you no more than $15. Okay? You may have to hustle and go find a coupon or go through Mark Cuban or Walmart or whatever, but this is cheap. You should not be paying anything more than about $15 for your tube. So I really want to talk about this section. Because of gsm, we've had some incredible updated guidelines in the last year that have been adopted from every major organization that has anything to do with the female pelvis. GSM effects severe. GSM severe affects up to 84% of postmenopausal women and is still remains right now the most under treated, under diagnosed, under discussed consequence of estrogen loss. A hundred percent of us will see changes in our genital urinary system after menopause if we're not treated. And in my clinic we have very aggressive conversations about using this prophylactically so that you never develop gsm. Why? Because this little tube will save lives. We can decrease 50% of urinary tract infections in postmenopausal women by using this prophylactically. And when we do that, we will cut down on 50% of euro sepsis and death from neurosepsis. So untreated GSM does kill women at very, very high levels, especially women in nursing homes, especially women with limited movement who don't have great hygiene because you know of arthritis or bed bound or just chronic incontinence. So many women are suffering needlessly and not having access to this very simple treatment and tool of vaginal estrogen. Now I choose the vaginal estrogen cream because of cost. It is messy. It's not for everyone. You have many options and we'll go through them. But you know, keeping it in the 15 range makes it accessible to so many more women. Other things that happen in the genre system, the tissues become thinner, drier, less elastic, more fragile, more prone to irritation, tearing and infection. Your ph changes, the microbiome shifts and the urinary symptoms develop. This is not cosmetic. This is tissue health and it really, really, really deserves treatment. So vaginal estrogen cream. So we have the non generic form is called Estrase. There's also still Premarin cream available. Premarin cream is great, there's just no generic and it tends to be one of the most expensive options. We typically use this twice a week. It comes with an applicator. I just tell my patients, put it from mid knuckle here to the tip of your finger and get up in there and Roto Rooter it about halfway up into the vagina. Then you take a little bit more and you're going to put it on the clitoris and go down both sides of the labia minora. That's going to hit all of the hotspots that you need. There are vaginal tablets available. Vagifem and uva femme are 10 micrograms there. They come with a small applicator. Now these creams are alcohol based. They can cause irritation. You might have a reaction to them. So the pills can be really, really helpful. It's just the applicator is like this little pencil and you have to put the tape of arthritis or you don't see very well. It can be harder. You can like try to put this tiny little pill on the tip of your finger and like wiggle it up into the vagina, you know. So there's pros and cons to all the things. There is a vaginal insert. So in Vexi is a suppository that is much easier to insert. It's nice and smooth and it's easy to push into the vagina. It comes in 4 and 10 microgram dosages and you don't need an applicator for the 4 microgram dose. However, there's no generic for Invexi and again, cost can be an issue. My favorite way to replace estrogen down there is with the vaginal ring. Again, super sad, we do not have a generic. But God, it lasts for three months. You throw it up in the vagina, it finds a little home up there. It really does not bother you. It's like a tampon, and placed correctly, you don't feel it. And it is just constantly giving you that continuous supply of estrogen in the vagina for three months and you don't have to worry about it. You just set an alarm on your phone to go take out the old ring and put in the new one. You can leave it in for intercourse. I tell my patients to leave it in, see if he notices, you know, might be kind of fun, I don't know. But all of these options have been studied and they all help. So I do want to talk about dhea. So dhea, we have an FDA approved option for the vagina called Prosterone, which is fancy name for dhea. So DHEA also can be used for the vestibule. So, so for those of you who are having pain around the opening, pain around the vaginal opening that is not responding when you apply DHEA there. And I have, this is an over the counter version that I also use. DHEA will in the cells convert to estradiol and testosterone both. There are androgen receptors in the vestibule in the vulva and so you're getting both estrogen and testosterone. So the prosterone is the suppositories that is DHEA that you put in the vagina. They melt, they work up there, but then the medication of drips out and you get it, you know, it makes its way to the vulva and to the vestibule around the opening. And so patients love it. It's very, very safe. Again, no generic, very expensive. This is a lower dose DHEA from my friend Kelly Casperson for the vulva. I really like the texture of it and I just like having that little bit of extra protection. And it also has vitamin D. So it's a very nice oil based lubricant and moisturizer and I'm a huge fan of it. So I don't use prosterone because I have this and my vaginal estrogen of which I use as well. Lots of questions I know you guys are asking, what is this last guy? This is topical estrogen for my face. So you actually can take this vaginal estrogen cream and put it on your face. Okay. It's recommended to do a pea sized amount and you put it especially on your eyes where the tissues is really thin and then you rub it in. You put your moisturizer on top of. The problem with this is again, alcohol based creams can be drying for the skin and not for everyone. So I have chosen to do this cream that has estriol, which is a cousin of estradiol and it's a 0.3%. It has been studied showing efficacy and safety. You do not have systemic absorption. The nice thing about topical, anyone can use it, anyone can use vaginal, anyone can use it on the skin. And this I apply every morning and it is in a, instead of an alcohol base, it's in a moisturizing base. So it's basically taking the estradiol throat and moisturizer and it's just easier for me to apply. My skin doesn't get dry. I could just put makeup on. If I'm wearing makeup that day, it's not a big deal. So these are all of the seven ways. It's not something I recommend to every patient. This is purely cosmetic. It can be pricey depending on where you get it from. And so but I just wanted to throw it out There. So these are the seven ways that I replace my hormones. So, but we do have non hormonal, FDA approved alternatives, but we really have to take it symptom by symptom. But I did want to cover some of the big ones of these so that those of you who do have contraindications to certain hormones know what your options are. And then after this, we're going to get to supplements. So we have vioza or a felinex. So the lineage is a very new medication. It just came out in the last year or two. These are medications that bind to the thermoregulatory centers in the brain. It's just the Neurokinin 3 receptor, which is in our thermoregulatory center. It binds and stabilizes it. So hot flashes in most patients will improve. It specifically is targeting the mechanism where the hot flashes happen. And so without having to, you know, have estrogen in any other part of your body, if you or have been advised that that is not in your best interest. So it's great for hot flashes. So if you're an active breast cancer patient who's been told you're not a candidate for estrogen, these medications can be really helpful. A new one has come on the market from Bayer. I cannot remember the name of it of the day, but there's, there's competitors coming out. These are new. We're probably five to six years away from any generics being available. So again, cost can be a huge issue here. The only SSRI is paroxetine. That's the generic name or Brizdel that has been FDA approved specifically for hot flashes. It's a lower dose version of paroxetine. At 7.5 milligrams, it can reduce hot flash frequency by 50 to 65% in some women. And it's not a hormone. So if you're on tamoxifen, however, and you're having hot flashes because you're on tamoxifen, paroxetine is contraindicated because it does inhibit the enzyme. Very long name enzyme that converts tamoxifen to its active metabolite. That's a really critical drug interaction. So I'm happy to say that the tamoxifen patients can actually take the neurokinin receptor antagonist and can have benefit. But to be honest, hormone therapy is the gold standard. And forever people were defining menopause treatment as the reduction of hot flashes, nothing else. They weren't talking about your brain fog, your emotional status, your bones, your inflammation levels, your insulin levels. I mean all of that is affected. And estrogen is the best therapy to stabilize all of these inflection points in our chronic disease process. But if for whatever reason that is taken off the table for you, or if you just choose not to do it, there are options, but we have to take it symptom by symptoms. This is my supplement. God, it seems like a lot. It is a lot. I understand that. But I'm going to walk through every supplement I take, why I take it, and what it does for me specifically. But I want to repeat, this is based on me. This is my labs, my goals, my risk factors. Supplements should never be a guessing game. And supplements will never replace good nutrition. Most of your nutrition should come from food, whole foods, anti inflammatory foods, grains, nuts, seeds, legumes, lean proteins. I can't stress this enough. You cannot take a bucket of supplements and expect to have a miracle happen if you are not backing that up with good, high quality nutrition. Okay, so let's talk about this guy. This is a combination because I'm lazy. So, full disclosure, first of all, I own a supplement company called the Pause Nutrition. The Pause Life. And I started talking about menopause under in the frame of nutrition, in the frame of the Galveston diet, in the frame of trying to answer the question of body composition changes and why women were gaining weight. So we came up with a whole nutrition plan that was very successful. We had coaching groups to coach people through all the exercise recommendations and nutrition recommendations, and we were making supplement recommendations. Women tend to not be able to absorb enough vitamin D to stay healthy. Women tend to not be able to get enough fiber in their diet. So I was constantly recommending supplements. All right, I'd have patients come in with buckets and bags of supplements and I'd be like, what do you take this for? She's like, I don't know. They handed this to me and I couldn't tell who manufactured it if there were third party tests. Like, it's really, really hard out there because of lack of some of the regulations around it. And I thought, can I do this better? I think I can. And I really thought it for a long time because a lot of people don't feel like physicians should sell supplements. It's a bit of a red flag. And I felt a little bit of that myself. But here I was recommending, here are patients in trying to self diagnose, self treat, and coming in with buckets and bags of things that made very little sense. And I thought, okay, I can create something that is high quality. And third Party tested and put my name on it. I'm going to do it. And so we did. There are lots of good supplement companies out there. There are lots of supplement companies that are sus as hell. Okay, so you want to look for things that have studies, you want to look for things that are third party tested for purity and so to make sure they're not contaminated and to make sure that actually what they say is in it, is in it. Super proud that we were able to meet those goals and have really good high quality supplements on things that were actually studied in women in menopause and not 25 year old male athletes. So Omega 3, vitamin D and vitamin K combination. I like to combine things because I'm lazy and it's easy, easy, easy to combine omega 3 and vitamin D. Like they, they're like peanut butter and jelly as far as like they, they sit well together, they don't contaminate each other, there's no reaction. And vitamin K we threw in there for increased absorption. So one caveat, if you're on Coumadin, you should not be taking this cuz it has vitamin K. All right? So if you're on a blood thinner, talk to your doctor before starting any supplement. This has 4000 international units of vitamin D. It has 1.2, so about 1200 milligrams of EPA and another 800 milligrams of DHA. So, so those are the omega 3 fatty acids. These are critical when we check vitamin D levels in our clinic. And when you look across the spectrum in the U.S. most women, the majority well over 50% in our clinic, it's about 80% of menopausal women have low vitamin D levels. So there is deficiency levels which is below 30 ish in women and then there is optimal which is somewhere around 60 to 100 where you're not deficient, but you're, you're really optimal firing on all cylinders with nice high vitamin D levels. And you can take up to 4,000 units of vitamin D a day without needing to be monitored. Okay, now prescription strength vitamin d is about 50,000 IUs a week. Okay, so we're giving you 4,000 IUs a day with this. I love this. I love it for heart health, I love it for inflammation. And vitamin D is a hormone and it is critical in dozens and dozens of enzymatic processes in our body. Low vitamin D levels are rampant and they are linked to weight gain, diabetes, dementia, low sleep, cardiovascular disease, all the things. So if you learn nothing else from this talk today is go get Your vitamin D level checked, know where you are. So when my patients come in who are deficient, we're putting them on the prescription strength first. Okay. We want to give them a loading dose. We're giving them that prescription of that 5,000 50,000 IUs a week for about a month. And while on the other days they're not taking that, we're supplementing with this. And then we check their level at three months to see how they are maintaining. And then once a year, they seem to be maintaining at their annual visit. Love this stuff so much. Okay. So I take this every day. So this is our minnow multi. It's not really a multivitamin. I wanted to make a multi use, a multi layered product because there's so many good studies that looking at women in menopause and coenzyme Q10 and heart health, there is wonderful data on genocide, which is a phytoestrogen, which is a powerful anti inflammatory component. It's been studied in bone health, in women, in heart health, and in inflammation. And then we know that most of our patients are struggling to get these B vitamins. We see it in when we look at homocysteine levels. So we're checking homocysteine levels in patients and we're seeing a tremendous amount of a very high percentage of women who are struggling with high levels of homocysteine. And it's usually because they're not able to utilize their B12 or folate. And so this has very strong special B vitamins that are actually methylated for easier use within the body for these patients. And it seems to be working really well. So you've got your thiamine, riboflavin, niacin, B6, folate, B12, biotin, and then we have the genistin and then the coenzyme Q10 together. And it's just one pill a day.
- [55:46]
Welcome back to another MIDI Pause. I'm Dr. Mary Claire Haverto, host of Unpaused. For years, I believed the gaps in women's health care came from individual failings. A distracted clinician, a rushed appointment, a misread symptom, a misdiagnosis. But the longer I practiced, the clearer it became. This is not about one clinician or one hospital. This is about a system built on the male body as the standard and the female body as the outlier. Here we are in 2026, with women across the country demanding more coverage, more information, more data, and the system is starting to respond. Women's health has been historically overlooked, underfunded, and frankly, misunderstood. From delayed diagnoses to limited access to care, the gaps are real and they have real consequences. We've made progress, but there's still a long way to go. So how do we each play a role in creating change? This is where platforms like MIDI Health come in. MITI focuses on providing personalized expert care for women navigating midlife health, especially menopause, an area that has been overlooked for far too long. They connect women with clinicians who specialize in these concerns, offering virtual care that is accessible, evidence based, and grounded in real patient experiences. This includes everything from reproductive care to preventative screenings to mental health support. These are not luxuries. They are essential. When access is limited, it disproportionately affects women in underserved communities, which makes advocacy even more important. Stay informed. Have conversations. Support organizations and platforms like MITI that are actively working to close those gaps. Vote with women's health in mind and in your own life. Create spaces where women feel heard and supported, whether it's at work, at home, or in your community. Change does not happen overnight, but it does happen when people decide it matters enough to speak up. There's nothing more important than understanding the options available to you in managing the symptoms you're experiencing. And if you want a little extra support, you can check out my menopause empowerment guide in the show Notes for additional information and resources. I hope that this information helps you feel more confident and more empowered because you are your best advocate for the healthcare you need and deserve to achieve your best health. Go to, join MIDI.com join MIDI and connect with one of their clinicians today,
- [58:36]
if you follow me. You know I make a shake almost every day. Or I'll make it. And we'll make it last two days. I had one this morning. And so in my shake, I call it the menopause shake. But really, anybody can take it. My kids make it. It's a way for me to start hitting my nutritional goals early in the morning. So I break my fast with it, I take it down to the gym, and I sip at it for three to four hours until it's done. Or. Or if I make the halfway mark, depending on if we have lunch plan. So in it is Greek yogurt. Plain Greek yogurt. Why? For probiotics and for protein. Okay. And then we have. I put our collagen. So our skin and bone collagen right here. We're gonna put two scoops in here. It has two separate collagen products. One is called Verisol. Which was studied in skin for wrinkles and cellulite. A appearance. So it's a vanity product. And it was also in. It is something called for. I got super excited about fortabone when the studies were studied in menopausal women with osteoporosis and osteopenia and they saw benefit to their bones and they weren't on any other intervention. They followed them for five years taking this every day. And so I was like, I want this. I want to combine these two collagens together and call it skin and bone. And so here's the product. It's two scoops. I just throw this in the shake, the unflavored version as well. This is new ish for us. This is our whey protein product. So it's protein and we threw some creatine in there. It's brand new. I put a scoop of this in it. I like chocolate. We do have vanilla as well. And then when I make my water for the gem actually back here, I didn't bring any with me. But I like electrolytes. Not because I think that they're a miracle or doing much for me. I like salt. And I'll put my salty electrolytes in here with a couple of scoops of creatine. So studies on women are looking extremely good. If you look at Abby Smith Ryan coming out of North Carolina, her research looking at women and strength training and creatine, we can't make as much as we age. It's one of those things. And so it's so important for muscle recovery. Also it seems to have a lot of good use for brain fog and sleep. And so I put my creatine and my electrolytes and then I stay hydrated throughout the day with this guy. Our creatine comes in a two month supply and this beautiful bag right here. So do you need all of this? Probably not. But this is just what I take, what I do and why I also in that little shake, throw in a little extra fiber. So one scoop here has 8 grams of fiber. This is flavorless. You can throw it in your coffee, you can throw it in water, you can throw it in whatever you want. But I'm able to get pretty consistently 25 to 30 ish grams of fiber in my diet just from food from mostly from avocados, seeds, nuts, legumes, which are beans. But just gives me that little edge to take it over the top. Because for cardiovascular protection, for gut health, 25 seems to be pretty good. But for cardiovascular protection, women want to get 35 to 38 grams. So this just gets me over the top days. I don't have yogurt. Okay. For my probiotics, I will take a probiotic as well. There's decent studies done in menopausal women showing in better body composition, showing better gut health, et cetera. So I do do that. And I took this for a long time. This is magnesium. L Threonate. This is a MAG that is very good at crossing the blood brain barrier. It was actually studied in SSRI resistant depression. And it really did seem to help those patients who were not doing well with severe depression on their antidepressant medication. And so it, it just has a really great way to cross the blood brain barrier. So I tend to take this in the day to get my MAG levels up and up to my brain sleep. So finally we have our pause sleep. So sleep disruption is one of the most debilitating symptoms of perimenopause and menopause. And it really compounds everything. Poor sleep worsens insulin resistance, it worsens body composition, increases inflammation and impairs your cognitive function. Like we have to prioritize sleep. And so many women are being medicated with sedatives to kind of force them to sleep, but they're not getting the good, high quality sleep. They're not getting the deep sleep when you're chronically on these medications. So I partnered with a sleep medicine specialist, Dr. Andrea Matsumura, to come up with a product that was evidence based that would help women, specifically their needs in the sleep phase. So if you're having hot flashes and that's waking up from sleep, we need to fix the hot flashes. And that is not what sleep is doing. This is for the woman whose vasomotor symptoms are controlled or she doesn't have them, who is struggling to go to sleep or struggling to stay asleep. So she and I decided to put three key elements in this product. So it is a combination of alpha wave L theanine. L theanine is a natural relaxant. It's a natural antianxiety medication. So we are relaxing the mind with this. It also has a magnesium product, this glycinate, that crosses the blood brain barrier. Well, that gets into the system and relaxes the body and muscles. And then finally it has a very, very small dose of a long acting melatonin. It only has 3 milligrams. I was overdosing melatonin. I never understood how to use it. And so what melatonin does is reset your circadian rhythm, circadian Rhythm is what controls when you go to bed, when you wake up, when the cortisol levels spike, it's so, so, so important. So relax your body, relax your mind, reset the circadian rhythm. You want to take this an hour or two before you go to bed so that it's all kicked in and kind of working. So around 7, 8 o', clock, I will take my two pills and I'll start reading and winding down for the night in my nighttime routine to go to bed. One last thing I want to talk about is another prescription that I take. I actually take it at night. On my bedside table, I have my sleep supplement, I have my progesterone, I have my oral estradiol and I have my minoxidil. So vanity products that I use to keep my hair on my head. And I started with topical minoxidil. I, you know, my perimenopause was fraught with hair loss. Like I, you know, I was born with a lot of hair. And so you know how you have your daily allotted hair loss in the shower? I was having like postpartum hair loss and it was very, very scary. So of course I called my dermatology friends and they're like, try this, try that. You know, we had blood work done, they looked for low iron and all the other things it could be. And then they're like, okay, we'll try topical minoxidil. And so it's basically generic Rogaine. And get the men's strength, the 5% extra strength. Don't worry about the women's, you don't need that. And that seemed to work really well. And I did it for a few years, but it just got messy. Right. I was using the alcohol base and it would make my hair kind of sticky. And now that I color my hair to color the grays, the whole like hair map of when to wash my hair. But I got to put the minoxidil in, but I can't have minoxidil in because the color won't stick. Just got to be a lot. And then my derm friends were like, well, just switch to oral. And I was like, oh, okay. So the oral doses, you only need about 2.5 milligrams and they make it in a five. So I just cut this in half and it is $5 for a nine month or three month supply. It's really, it's generic. It's so inexpensive. So in my nighttime, take all my meds routine, I'm just going to crack one of these in half. And then take all that before I go to bed. Oral minoxidil works by prolonging the growth phase of the hair cycle. So our hair has a growing phase, a falling out phase, and a resting phase. And it also helps to dilate the blood vessels that feed the hair follicle, to keep the follicle healthy. So this medication was developed to lower blood pressure, but the doses you take it for blood pressure control are 10 to 40 milligrams. For hair, you only need 2.5. So that's what I take. It seems to be working really well. I rarely miss it. If you're experiencing hair loss, minoxidil may not be for you. You need to have your vitamin D level checked. You need to have your ferritin level checked. You need to maybe see a dermatologist. But this is one of the things, and I've done all of that, that works really well for me and I'm happy to have my hair back. So that's my routine. You might think it's excessive. I like it. It works for me. So my transdermal estradiol patch, plus a little bit of oral estradiol at night for bone protection, my oral micronized progesterone at bedtime, my testosterone gel every day, my vaginal estrogen twice a week. So when I put my patch on, I use my vaginal estrogen as well. My daily topical estradiol, my DHEA for the vestibule, and then I have all my potions and powders that I put in shakes. I have my methylated bees, my CoQ10, my biotin with our minimal tea, and then my paws sleep with L theanine, magnesium and cystic stain release melatonin and then the oral minoxidil from my hair. So, yeah, it's a lot, but everything is there for a reason. I was losing my hair, I wasn't sleeping as well as I should be to protect my brain from dementia. And so to protect my stress levels, to protect my cortisol and my body composition. Everything I take is for a reason. I take fiber to lower my risk of diabetes, to lower my. To help keep my body composition in check, to lower my risk for heart disease. My recommendation is test. Check your levels of nutrients, check your intracellular magnesium, check your ferritin, get your vitamin D levels checked, know where you are, track what you eat. Are you getting enough protein? You may not need a protein supplement if you're able to get it all in. Not everybody has to take this. Most of us should be taking creatine we just can't make enough of it. If you're getting enough fiber in your diet, you don't need a fiber supplement. So know what you're eating, know what you're intaking, know what your blood levels are of important key levels and nutrients your and then supplement after that. You deserve individualized care built on your needs, your goals. Very, very, very personalized for you. If you want a lap panel recommendation that is going to inform you of most of these things, we have our free lap checklist@thepawslife.com, which you can download. We'll email you the PDF that shows all the labs that we recommend to our patients and why we recommend them. We also have scripts on how to talk to your doctor in that so remember, you're not broken, you're not crazy. You are in a biological transition for the rest of your life and it deserves a biological response. Menopause is inevitable, but suffering is not thanks for listening today.
- [69:08]
I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram Dr. Maryclair and get honest and accurate information on health, fitness and navigating midlife@thepauselife.com My new book, the New Perimenopause is available now everywhere and anywhere you buy books and through our website. If you're loving this podcast, be sure to click Follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review
- [69:38]
and be sure to share the show
- [69:40]
with the women you love. We would be so grateful. You can also find full video episodes on YouTube at Dr. Maryclaire Unpaused is presented by Odyssey in conjunction with Pod People. I'm your host, Dr. Mary Claire Haver. This episode was sponsored by MIDI Health, the first virtual clinic created for women by women for the treatment of menopause. Don't let anyone tell you menopause is something you have to suffer through alone. MIDI can help. Visit joinmidi.com to learn more.
- [70:15]
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