Data/transcripts/6P8hrzjnetU_20241225194336.txt

welcome to the huberman Lab podcast
where we discuss science and
science-based tools for everyday
[Music]
life I'm Andrew huberman and I'm a
professor of neurobiology and
Opthalmology at Stanford School of
Medicine my guest today is Dr Mary Clair
Haver Dr Mary Clair Haver is a
board-certified OBGYN and an expert in
perim menopause menopause and all
aspects of female specific health during
today's episode Dr Haver explains
exactly what per menopause and menopause
represent in terms of their underlying
psychology and biology and the specific
actions that all women can and should
take in order to navigate these stages
in Optimal Health she also describes the
things that all women should know and do
long before per menopause arrives in
order to best navigate perimenopause and
menopause once they arrive we discuss
specific nutritional practices
supplementation practices as well as
conversations that you should have with
your mother and with your physician in
particular your OBGYN not just as per
menopause and menopause approach but at
every developmental stage a fair amount
of our discussion centers around hormone
replacement therapy not just for
estrogen but for testosterone in women
as well and the many misconceptions and
controversies that exist around hormone
replacement therapy for menopause Dr
Haver explains how the specific timing
in which hormone therapy is initiated
plays a key role in whether or not the
hormone therapy is beneficial for women
or not and of course today's discussion
gets into ways to offset some of the
more common difficulties associated with
menopause including sleep issues hot
flashes inflammation and more by the end
of today's episode you will have a clear
picture from Dr Marie Clare Haver about
what per menopause and menopause
actually represent the best way to
approach perimenopause and menopause and
the various considerations around
hormone therapy and lifestyle choices
that can allow any woman to approach the
years of Perry menopause and menopause
and Beyond with the utmost vitality and
wellness before we begin I'd like to
emphasize that this podcast is separate
from my teaching and research roles at
Stanford it is however part of my desire
and effort to bring zero cost to
Consumer information about science and
science related tools to the general
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huberman and now for my discussion with
Dr maryclair Haver Dr maryclair Haver
welcome thanks for having me delighted
to have you here and to learn about
menopause and other aspects of women's
health there's a lot happening in this
area right now yeah and you are at the
center of what I understand is a new
direction for the understanding and
treatment of menopause that's what we
hope and related themes like per
menopause yeah and the many important
aspects of female Health that stem from
it like cardiovascular disease
osteoporosis right and so on so we will
get into all of that today
but just to kick things off how do we
Define menopause so the medical
definition of menopause which I have a
huge problem with is one year after the
final menstrual
period And the reason why I have a
problem with it is not everyone has a
menstrual period what if you've had a
hysterctomy what if you have an IUD what
if you've had an ablation or something
that's suppressing your periods PCOS so
for a lot of women and even clinicians
they are struggling to like find that
diagnosis because it doesn't fit
everything what it represents is
something much
bigger menopause is also one day of your
life it is that one day exactly one year
after your last period but it represents
the end of your ovarian function some of
us call it ovarian failure ovarian sence
but basically what separates males and
females
is many things separate us but in my
world um we are born with all of our
eggs we have 1 to two million at Birth
by the time we're 30 most of us are down
to about 10% maybe
120,000 by the time we're 40 we're down
to 3% of our egg supply and the quality
is declining as well so menopause is
when you have no more eggs left and
therefore no more sex hormone or very
little sex hormone production from the
ovaries so estradiol levels will decline
less than 1% of your reproductive years
your progesterone levels will decline as
well testosterone declines for sure but
we have other ways to produce it so it's
somewhere 50% or less than your
healthiest years so is it fair to say
that we need a redefinition of what
menopause is I think so I think defining
it as the presence or absence of a
period is a mistake is there any
consensus about the quote unquote
typical age of onset for men and paws
and is it changing you know I hear a lot
about how the onset set of puberty is
Shifting earlier in females and given
that puberty at least by some
definitions relates to the onset of
menes uh one could imagine that
menopause would be shifting earlier as
well so the things that determine when
we have puberty or not are different
than the things that determine when we
run out of eggs um right now in the US
it's the average age of that one year
after your cycle so menopause that one
day is about 51 to 52 years old however
normal is still 45 to 55 and there's a
big variation you know that curves
pretty wide
um Perry
menopause begins 7 to 10 years before
that last minstral period wow okay I say
wow because um it's the first time I've
ever heard a specific number tacked to
this word per menopause maybe we could
talk a little bit about per menopause
since it sounds like it represents a
transition phase into official menopause
right um however one chooses to Define
that what are some of the I don't know
if I should call them symptoms sure
where I should uh just well let me let
me do let me walk you through the
endocrinology and then we can go through
symptoms so you understand so in a
normal healthy menstrual cycle before
menopause ever becomes an issue the
female hormone cycle is a very EKG like
reproducible monthly rise and fall of
estrogen progesterone and then the brain
hormones LH FSH and then g& RH so the
way it works is our brain in the
hypothalamus um is sensing for has a
little sensor in the blood looking for
estradiol levels and when they get low
it sends G&R down to the pituitary
saying hey tell the ovaries to start
trying to ovulate so we can get more
estrogen on board the process of
ovulation is what drives up our estrogen
levels okay so pituitary sends out the
pulses of LH and FSH which then lead to
ovulation when we reach in perimenopause
the beginning of perimenopause that
critical level of egg
supply those signals don't work as well
we start becoming resistant to the LH
and FSH pulle surges
so the brains like hey I told you we
need more estradiol and the pituitary is
like I sent the signal and the brains
like send more so we get much higher
pulses of FSH and then finally the ovary
kind of is able to get that egg out but
sometimes it's delayed so we have the
timing of that monthly predictable cycle
goes arise sometimes the periods are
closer together sometimes they're
further apart but also the estrogen and
progesterone levels start changing
dramatically we see much higher surges
of estradiol than we ever had in our pre
productive years and then much lower
levels underneath so we end up with this
very volatile curve and not predictable
at all we call it in our world the zone
of chaos so it is literal hormonal chaos
what used to look like this you know
every month is
now just just insane and very very very
unpredictable that is why we don't have
a good blood test in per menopause to
make the diagnosis those of us in the
mense use symptoms usually to make the
diagnosis and we rule out other
conditions that might overlap so per
menopause basically critical threshold
it's a downward Trend overall of
estradiol but is a very chaotic you know
race till you Flatline and bottom out I
see so for those listening um your
description of the um kind of the
amplitude of the estrogen surge it gets
much greater in this per menopause phase
you also mentioned that follicle
stimulating hormone which comes from the
pituitary has to be or somehow is
upregulated in this phase because I
don't know is it that the recept for FSH
are somehow not responsive at the level
of the ovary do we know what's happening
to the ovary is it obviously the signals
getting there it's not effective so then
the brain is kicking out more FSH is it
that the quality is poor and then around
each germ cell is the tholian cells
which is actually where the estradi the
whole pathway going from you know
actually testosterone's converted to
estrad so that whole pathway you know it
still will respond but the cells are
just old you know is the way that it's
been explained to me and from what I've
read I think we need a lot more research
in this area because that is how we're
going to help women I think longer term
is understanding that process better but
you know all I learned in school 25
years ago was it's the transition to
menopause the end you know the whole
endocrinological process I didn't learn
till about two years ago and my guess is
just based on my understanding of the
only recent Trend
toward emphasizing studies of both
female and male even just mice in mouse
models which is where generally this
stuff originates and then it shifts into
humans once certain targets are
identified um only recently has the NIH
insisted that there be uh female uh mice
in the studies of mice I mean it's it's
been a few years now but that's a you
know sex as a biological variable is is
actually a requirement in most Grant
applications unless of course there's a
specific reason to study only one or the
other um sex of mice so you can imagine
that um the dir of research in this area
is due to a a long um desert of um
absence of studies into what is per
menopause right so for women who are in
the age range of per menopause or who
are thinking about this are there things
that they can do in order to either
upregulate the sensitivity of the ovary
to FSH or to somehow prolong this period
of per menopause um and I should also
say what are some reasons why they would
want to do that um you know obviously
this is part of the um of the Arc of
maturation of the female reproductive
axis but of course that alone is not a
reason to not try and um I guess we say
optimize it for one's well-being so we
don't know when you the best way I can
highlight why we don't know or or where
the dollars are going for research you
know we go to PubMed and you type in the
word pregnancy 1.1 million articles come
up type in the word menopause it's down
to
97,000 really you type in the word per
menopause and I checked this like 2
weeks ago and it was like 6,400 and
something wow yeah that is surprising so
or maybe it shouldn't be surprising
given what we were just talking about in
terms of so as far as like why those
cells are becoming resistant and what's
happening at the level of the receptor I
think we need a lot more research in
this area I think it's starting to
happen because women are realizing
there's a demand now because the older
you are when you go through menopause
the healthier you are for cardi
metabolic disease it's the loss of
estrogen that accelerates our path to
those
diseases so are there clinical signs of
perimenopause that either directly or
indirectly relate to these bigger surges
in FSH and these larger amplitude um
estrogen uh surges the the two best
documented and studied are mental health
changes
um the brain does not like the chaos of
and and the neurotransmitters are very
very sensitive to estrogen and
progesterone and even testosterone and
so we see aberration in serotonin and
orpine and and dopamine as the levels
start becoming chaotic so we have at
least a 40% increase of mental health
disorders in and SSRI use doubles across
the menopause transition across per
menopause
and now the data is showing that women
who are given hormone therapy in their
per menopause have a lower incidence of
neonet depression and now the
neuroscientists are saying hey for these
women who are developing depression in
per menopause giving them estrogen is
better than an SSRI they're going to
have a better outcome I think most
people don't realize how rich the brain
and rest of the nervous system are with
hormone receptors in particular I
estrogen receptors and as you mentioned
testosterone receptors as well Androgen
receptors um and the often direct
relationship between estrogen and the
neuromodulators such as serotonin
dopamine epinephrine aceto Gaba for for
um
progesterone yeah it's it's interesting
during neural development which is where
I started off which was um neural
embryonic development the hormones exert
you know these widespread roles in
defining even which neurons will Express
certain neurotransmitters and then
somehow the field of Neuroscience is
only recently gotten on board the idea
that um this intimate relationship
between hormones and neurotransmitters
is something to consider in essentially
every aspect of of brain health right
not just cognition but maintenance of
neurons and um offsetting neurod
degeneration and so on um I mentioned
that only um so that people I think
typically think of hormones as something
sure there's a signal from the brain and
but that hormones are mostly of the body
when in fact hormones play an absolutely
crucial role within the brain yeah so
you mentioned that during per menopause
there there are symptoms that are I
guess it's are mainly reflected as
shifts in mental health so is this women
suddenly feeling um kind of um less uh
optimistic is it like what what's the
sort of um constellation of of of
psychological shifts that can occur so
we
see uh increasing anxiety we see
definitely loss of executive functioning
so new onset of add type symptoms um we
see of course the cognitive you know
what we call brain fog and and lay
terminology which is cognitive you know
so they lose their words they're not
able to do the calculations at work like
their executive functioning ability in
their jobs is huge like one in five
women will quit their jobs because of
menopause symptoms
um that's that's an outrageous number
yeah and the the economic impact is huge
and so now companies are starting to get
on board and this is a Time Of Our Lives
when the kids are grown for a lot of us
you know and we're trying we're ready to
lean into our positions and really get
into leadership we have all this
experience and now we can't REM you know
and now all of a sudden these and their
confidence is just wrecked so and then
the depression and they're not sleeping
and like it's this horrible feedback
cycle that they end up in that we end up
in yeah I wasn't aware that one in five
is is striking that came out of the UK
but they're starting to like crunch the
numbers here in the US and it's looking
very similar I know we're going to get
into actionable tools later as it
relates to menopause but as long as
we're discussing this phase of per
menopause uh what are some of the basic
things sure that women could a pay
attention to we don't want to make
people hypervigilant to the point of
anxiety but but um certainly given the
frequency and given the
implications um it's important for them
to pay attention to this phase and then
some of the things that they can do to
you know either behaviorally or perhaps
through other tools offset um some of
these changes uh dysfunctional uterine
bleeding um which is abnormal periods so
and again nothing's off the table it
could be heavy periods menaga too
frequent too few skipping it's really
really chaotic and but a lot of women
are suffering horribly from really
debilitating periods either through the
volume of blood loss or they're having
you know cramps and you know really and
so 90% of us will have that as a symptom
um fatigue is a huge one a lot of them
the symptoms are kind of vague you know
and can be attributed to a lot of other
things in our in my what we call the
menopausia chat group you know we have a
lot of theories about a lot of
conditions like
fibromyalgia and the irritable bladder
syndromes and that probably just per
menopausa menopause and doctors didn't
know how to put you know make that
diagnosis and so you know muscular
skeletal system takes a huge hit through
the transition so all of a sudden you
have no injury and you're having hip
pain joint pain back pain with you know
you go to the doctor and you get an
x-ray you do whatever work up and they
can't find anything wrong palpitations
are huge it is a vasomotor symptom so
along with hot flashes palpitation so a
woman will walk into the emergency room
sweating profusely horrible palpitation
she's anxiety and they'll tell her she's
having a panic attack you know um
they'll work her up you know
everything's negative and just say well
it's panic attack go home and no one
knew to connect the dots and figure out
that this woman was in her menopause
transition and this is how her body was
expressing it it's complicated because
we have sex hormone receptors as you do
in every organ system of our body and
when these levels start going chaotic it
can present in so many different ways
and so when the patients come to me I'm
doing blood work not a lot of hormone
levels because they're not super helpful
but I am doing thyroid workups and
autoimmune workups and looking for
nutritional deficiencies and anemia and
different things because I don't want to
miss those things and just pen
everything on per
menopause are there lifestyle factors
that can offset some of this it's not a
perfect correlation but the healthier
you are so anti-inflammatory diet you
know Mediterranean s galison dietes you
know nutrition pattern um regular
exercise good sleep habits you know all
the pillars of Health the healthier you
are when you hit per menopause the
better the course is going to be for you
they're looking at extending the life of
the ovary with pharmacology we know what
can shut it down faster so we have kind
of a genetic predetermined age of when
you're going to lose all your eggs but
we can speed that up so if you smoke
you're going to go through menopause
sooner than your twin would have if she
didn't smoke okay if you don't have
children and you ovulate regularly then
the more you OV the faster you run
through your egg supply okay interesting
I I wasn't aware of those data that's I
I don't know that most people are aware
of those if you have a hysterctomy and
you leave your ovaries behind I didn't
know I didn't never counsel my patients
about this you lose four years off the
life of your ovaries if you have a tubal
liation you use lose a year and a half
huge genetic disparities so
African-Americans tend to go through a
year and a half sooner and then there's
caucasians in the middle and then Asian
family tend to go through later and
they're not sure why you know a year or
two years years so there are if you have
chemotherapy if you have surgery if you
have any inflammatory process in the
abdomen irritable bowel or
endometriosis you're going to lose some
of the life of the ovary you mentioned
smoking are there any data on vaping not
yet I haven't seen any there might be
out there I just haven't seen it yet no
I'm I'm guessing uh if they're out there
they're not um prominent or you would
have seen them I'm curious about vaping
because a lot of people are vaping
instead of smoking and hopefully people
are neither vaping nor smoking because
it seems that we had an expert on vaping
on the podcast recently from Stanford
and it seems that um there's nothing
great about it right and there may be
some things really bad about it but was
just curious given that a number of
young women and men for that matter are
vaping nowadays who smoking rates have
gone way way down another 10 years
before we'd be able to you know see when
those women are going through menopause
you know because vaping I think of
vaping as younger the younger generation
um like my kids they're they people in
their 20s and 30s 10 V so we're you know
we're 20 years out from seeing how it's
going to affect them is there any
evidence that alcohol can impact
menopause I haven't seen any but I can't
imagine that you know heavy use of
alcohol would prolong the life of the
ovary in any way right so um and we know
that any use of alcohol has some
potential role in disrupting sleep and
presumably like everything else uh if
you disrupt sleep you disrupt things for
the for the worse and got it so you
mentioned um rough ages for onset of uh
menopause um 51 but anywhere from 45 to
55 and the per menopause uh is defined
as a period about seven years prior to
that 7 to 10 okay um what's the earliest
you've ever had a patient come in who
entered menopause what's the latest you
personal patient 27 and she came in just
a couple months ago so she had a special
condition we call premature ovarian
failure and she had found me on social
media and wanted to come just to make
sure she was doing everything right and
so early menopause is defined as between
the ages of 40 and 45 and then premature
menopause or pre premature ovarian
insufficiency it's not a complete
failure for most women but it is very
very low is any time before the age of
40 so this patient kind of got kicked
around for 2 years went to her doctor no
periods horrible hot flashes again she
was 25 and it was not on his radar and
he never tested her for menopause and it
took her you know 18 months to get the
diagnosis and so the longer your body is
away from estrogen the higher the risk
factor and it's been all over the news
this week where we know that untreated
premature ovarian insufficiency has a
earlier death so they have higher
cardiovascular disease diabetes stroke
all because estrogen is so protective
and they have to go so long without it
we can back negate most of those risks
by giving her aggressive hormone therapy
early so she came in to make sure she
was on the right dose because in
premature ovarian failure we don't want
to give them menopause hormone therapy
doses they're too low we want to get her
more like she would have which is three
to four times the amount of estrogen as
a reproductive aged woman and so and she
wanted to have a period so she would
seem like her friends you know it was an
emotional thing for her which I totally
respect and so um so we were doing
cyclical progesterone for her so that
she would have a withdrawal bleed and
feel like she was normal basic question
but I I'm curious all I'll ask um given
that levels of estrogen change so much
naturally during the course of the um
ovulation cycle menstrual cycle um with
estrogen therapy is it a constant dose
or it's modulated by week to week day to
day question so there are some formulas
so and when we look at hormonal
contraception so the the biggest
difference
between contraceptive Doses and
menopause hormone therapy doses they're
both based in estrogen and progesterone
mostly okay
the hormone therapy was developed to
stop a hot flash for decades menopause
was defined by the presence or absence
of you know severe menopause was defined
by hot flashes or not they didn't didn't
nothing else and so they developed the
formulations with enough estrogen to
stop hot flashes birth control was
developed to stop ovulation you don't
ovulate you don't get pregnant and it's
but the difference between lowd dose
birth control pill and higher dose
menopause hormone therapy is not that
far away and
so um that a lot of people don't
understand now the types of estrogen we
use in birth control are a little bit
different most birth control is ethanol
estradiol which is one of the synthetics
we have literally millions and millions
of women's year data on it we know it's
safety profile I think we're not
counseling patients adequately about
birth control as far as what it does to
their testosterone and what it can do to
you know oh it's fine it's safe I took
it for years but I think we need to do a
better job as a specialty on counseling
women but I do think it's a good
medication and then on menopause hormone
therapy you know it's much lower dose it
does not suppress ovulation so in per
menopause it's a little bit of the Wild
West which one we're going to use how
high do we want to go do we need to
suppress her ovulation because she's got
acne or horrible periods or cramps or
something where I want to suppress that
ovulation to help her
or can I give her menopause hormone
therapy doses which in effect think of
the hypothalamus I'm giving her just
enough estrogen to calm the brain down
and tell them everything's okay we're
not going to get those big Peaks and
drops and if she still ovulates that's
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huberman as long as we're on the topic
of birth control earlier you mentioned
that the IUD and presumably this is some
form of the IUD not necessarily copper
IUD can um disrupt or stop a period a
period um maybe we could talk a little
bit about the different forms of birth
control um IUD um as the pill quote
unquote um old term but um uh I think
most people know what we're referring to
when we say that the ring um and and on
and on um what is your stance on on
these different forms of birth control
as it relates to their safety um you
know a guess about a year and a half ago
I hosted a um a female physician guest
on on this podcast and both sides of the
uh birth control issue were touched on
one the relationship to um potential um
inhibition of certain forms of cancers
but then also the potential for certain
side effects maybe even Cancers and so
it you know it seems like it can play
out both ways and this is a very heated
topic yeah um in fact so much so that I
learned that if one is going to post a
clip of any of this on social media it
almost makes sense to have them in the
same post because we actually did both
of them we we we did a post where it was
more about the the pros of birth control
and then the cons of birth control as as
stated through um the words of this very
same clinician um so we will be sure to
so for anyone listening would you ever
answer comes first stay tuned for the
next answer because um my understanding
is that it's not a black and white issue
I think the best form of birth control
is a vasectomy and so much of
contraception is dumped in a female's
lap you know in a committed relationship
and I can't tell you the comments I've
heard when a patient comes to me and she
wants to get X Y and Z simply for
contraception she's absolutely perfectly
healthy there's nothing wrong with her
she just doesn't want to be pregnant and
I'm like okay you're done how you know
she's completed her family she's out you
know and I'm like tell your partner to
get a vecto oh he won't do that you know
so now all of the risk and the onus goes
on her and so we we go through the
options of surgical like you know tub
legation um which is basically blocking
the tube so when I you know talk to my
teenagers I'm like here's how you not
get pregnant a you don't have sex well
if that's not an option then we have to
either block the sperm stop the egg from
coming out or stop the place where they
communicate which is the fallopian tube
and so when we look at the different
forms of hormonal contraception which
are meant to stop ovulation suppress
ovulation because they're telling the
brain we have enough estrogen and
progesterone on board quiet down so it
doesn't send those signals to the ovary
right and so that can come in a pill
form a patch form a ring form and they
each have their own Pros cons risk
benefits you know transdermal has less
risk of blood clots versus oral has a
higher risk of blood clot in any form of
estrogen so so we talk about that we
look at their family history or if they
have MTHFR any of the clotting genes you
know then we Council directly versus the
IUD the iuds create an an inflammatory
environment in the uterus that blocks
and it creates a plug in the servic so
that the sperm can't get
through and then if any do get through
it's a toxic environment in the uterine
cavity for the sperm so that's really
how the those iuds work some iuds are
coated with progesterone progestin not
progesterone progestogen and those end
up decidualizing the endometrium so
thinning that lining from that constant
progesterone to the point where you stop
bleeding so a lot of my patients really
loved that option of being aaric no
periods just for the convenience of it
but they were still ovulating in the
background so we're not suppressing
their natural cycles just their periods
I see and is there any evidence that the
use of any form of birth control can
disrupt the um timing or the uh
availability of I realize availability
of eggs is a very um clinically naive
biologically naive statement but
basically what I'm saying can it can any
of them accelerate the onset of per
menopause can they delay the onset of
onset a little bit you know it's it's
maybe a year if you use it for a long
time from what the data shows so women
who suppress ovulation we lose about
11,000 eggs each month with the
ovulation process to get one out 11,000
race to the Finish Line and only one
makes it but we lose about 11,000 in the
process so women who are constantly you
know for a long time suppressing
ovulation will have um a slightly older
age of menopause had they not done that
when you say slightly older what's the
longest extension of of the best I could
see in the data was maybe nine months
okay from nine months use ofth control
so so maybe like 5 to 10 year use I have
to look at the data again to be you know
I'd have to look that one up but it was
years got it um to to gain an extra
maybe N9 months maybe a year of ovarian
life I see and um nowadays uh at least
if people have the means there's some um
Trend if you will toward um freezing
one's eggs um this might be a good
opportunity to just State something that
came up before when we had Dr Natalie
Crawford on the podcast to talk about
female fertility um I think surprising
to many people
was her statement that not because it's
controversial but because we just don't
hear this often enough that harvesting
eggs for freezing or for IVF does not
diminish the pool of eggs that one would
have meaning you're losing them each
month right anyway yeah and so they're
only pulling out I don't know 10 12
maybe in a cycle and when you're losing
11,000 with an ovulation so it really
isn't going to to effect when you go
through menopause such a crucial thing
for people to hear um I think uh there
were a number of comments when we posted
that clip on social media of people uh
women saying wow I didn't realize that
harvesting eggs would not um somehow uh
shift the onset of menopause earlier and
so for the record we are not saying that
we're saying that um it does not and um
and very interesting that the use of of
birth control but I'm guessing only
forms of birth control that suppress
ovulation can delay the onset of per
menopause menopause by about 9 months
maximum maximum um so things like the
copper IUD that right which um prevent
pregnancy by creating a unfavorable
environment for the sperm rather than
disrupting ovulation in any way will not
presumably extend par menopause
menopause okay just want to make sure
we're crystal clear for people you're
being very clear but I I want to make
sure that I'm clear on it and then
reiterate because this can be um uh kind
of tricky territory I think there are a
lot of assumptions about this stuff and
there's a lot of lore out there what why
do you think that is is that because of
the lack of solid research and
communication in this area I think so or
or is it something else you know I I I
think these are um tricky topics for for
uh discussion often because we hear all
this stuff like birth control pills
disrupt one's ability to get pregnant
when they come off or where it we just
learn that it can delay the onset of per
menopause which by extension means
there's a greater window for pregnancy
if one
um thinks about it that way but uh why
do you think it's it's so um such a
tangled discussion out there I think
just the way that Society views
pregnancy and female health and you know
at least you know I live on the internet
now you know this new life has brought
me life on the internet and this what
the algorithms are showing me yeah it's
a very friendly everyone is super
everyone loves you it's a listen it's
what you're doing um is so important and
uh I understand the the statement behind
that statement I I think um but it's so
important because it people are getting
the opportunity to learn about really
critical public health and female health
issues um in a way that just was
inaccessible before yeah it is and I I
it's good and bad you know there's a lot
of lore and misinformation that's
getting propagated and I feel like as a
specialty you know as a women's health
specialist we did this to ourselves you
know we have
not properly educated ourselves we have
not spent the money the research really
you know championed women after
reproduction when you look at the
dollars and and the research and where
it goes in women's health I mean Women's
Health just gets a little sliver of all
the NIH funding when you look at all NIH
funding and what goes to menopause it's
0.03% unb less than half a percent this
is onethird of a woman's life and when
you look at McKenzie and Company just
just published um a report where they
pulled 680 studies on like chronic
diseases diabetes hypertension
cardiovascular disease and they looked
at how they had they were women included
in the studies but how many presented
the data for the different Sexes like
what happened to men versus what
happened to women it was only 50% of the
Articles actually did Sex specific
differences and how this medication
affected this process or whatever and
then the ones that did 30% of women had
poorer outcomes and and the other and on
the flip side 10% of men had poorer
outcomes and these things aren't just
being brought to light so the the lack
of recognition of sex specific
differences in chronic disease and how
menopause kind of plays into all that I
think is where the future needs to go so
we deserve as much good health as
everyone else because yes we're living
longer than men but 20 to 25% of that
life is in poor
health wow that's a a really significant
statement I mean I think think that the
National Institutes of Health has been
terrific in establishing new institutes
within it um they even have a
complimentary Health Institute now
there's the the national eye institute
there's you know cancer here um is there
a plan or one would hope for a dedicated
Institute for Women's Health there push
um so there was one piece of legislation
that got pushed through the Biden signed
it and it was a $100 million for Women's
Health and that that got chopped up very
quickly and menopause did get a little
piece of it because we're also really
struggling with endometriosis and you
know a lot of the female specific
uterine diseases and and PCOS and things
and so we need more funding there as
well um and then there's another bill
that just got that's the one hi Berry
was like um on TV talking about another
bill for $250 million that bill includes
language for education of providers so
we have a whole generation of providers
ERS like I graduated my residency
training the year of the Whi came out so
all we had very little like real
clinically significant menopause
education and then we knew about HRT and
we were giving it in clinic um if she
was coming in with severe hot flashes
but that got taken off the table after
the Whi and then we have a whole gener
like all menopause education basically
stopped after so Whi Women's Health
Initiative HRT no that's that's okay
just so that people are on board hormone
replacement therapy
um yeah it's um it's a Well we can
encourage the uh expansion of of uh
research in these areas and with this
discussion and um certainly uh I was on
NH panels for years um as a regular
member in the I institute and what I've
noticed with um NIH is that they are
very responsive uh to the public call
for growth of research in particular
areas you know it can take time it's
government after all and they need
funding there's a finite amount of
funding but but I think that um R rarely
do I ever get into legislature based
things but if you are somebody who cares
about um more funding in a given area of
research it's actually very
straightforward what to do you call your
Congressman or Senator and you tell them
literally you leave a message I find
this kind of interesting it's so it's
kind of like what we learned in um
social studies and uh in elementary
school but you call your you call your
um Senator or your governor and you
leave a message and you say Hey you know
there's this issue that impacts a ton of
people and it's really important and um
the next time it comes up uh when
budgeting uh comes up in Washington it's
really important and if you hear about a
bill you can call and support a bill and
believe it or not some of that stuff
actually translates to more funding in a
given area in fact that the brain
initiative which unfortunately had its
budget cut significantly recently maybe
put that funding back um but you know
arose from the um I believe it was the
child of two Neuroscience professors up
at University of Wisconsin I'm probably
going to get some details wrong but um
so the khil are the are the professors
as I recall and their son over Hood all
these conversations growing up about the
importance of brain science and then
eventually pushed through government
channels for more money for brain
research and then we had a a long phase
of of um pretty pretty substantial
research and then it was cut so these
things um but it persists and so these
things really matter can impact so and
maybe we should send them a clip of of
your statements on this podcast getting
back to um kind of things that people
can control so for people who are
heading into per menopause or who are in
the perimenopause phase um aside from
the the typical things that we hear
about fortunately a lot these days like
getting adequate sleep um getting
exercise um nutrition maybe we could
touch a little bit on nutrition in a
moment you mentioned Mediterranean diet
Galviston diet um things that are going
to promote overall health right um are
there any things that people can do
maybe even take that would improve uh
their outcomes in this phase like I I've
heard of people and I have no bias here
or even knowledge of the research on
this if there is any of people taking
for instance grape seed extract or
people trying to do a number of things
to reduce inflammation kind of General
themes around um self-care and wellness
these days but what are sort of the five
or six that come to mind um perhaps as
like the things that can move the levers
in the right direction what would tell
my 35-year-old self you know who just
kind of went into this obliviously and
what I know now
is your diet is probably one of the most
important things that determines your
level of inflammation and then estrogen
is a really powerful anti-inflammatory
hormone and we lose that protection when
we go through we start losing it through
the transition so whatever you can do in
the other areas especially with
nutrition sleep stress reduction we need
to do it so fiber we are not getting
enough fiber in our diet in the western
diet I think it's most women are getting
10 to 12 grams per day and we need at
least 25 and the health benefits tend to
max out around 30 32 grams per day so
focusing on foods that are rich in fiber
Fiers is feeding the gut microbiome
slowing down glucose absorption you know
glucose levels of sugar absorption into
the bloodstream it is slowing down the
rate you know certain parts of Transit
and pulling more water into the gut like
there's nothing bad about it
right the foods that are rich in fiber
have a lot of other stuff that's good
for you too co-actors vitamins minerals
nutrient you know just they're just so
healthful um and then ansans you know
just find things that crunch that are
and get as many colors as you can you
know green red purple yellow every color
represents a phytochemical that is going
to be good for you in different areas of
your body and try to keep it as varied
as possible um we're not getting enough
protein and I have to thank Dr Gabrielle
lion you know really helping me focus
and on that you know when I first wrote
galison diet to be honest and
transparent it was for weight loss and
you know I was frustrated with my weight
gain and I that was the pain point my
patients had and that was my pain point
but I didn't realize it represented
something much more Sinister than than
just the way I looked you know the
visceral fat gain and so uh learning
about visceral fat and what it really
means and that is for your listeners the
fat that wraps around our internal
organs it's a very different fat than
the subcutaneous fat and you know a
premenopausal woman so we age matched
and looked at visceral fat levels
measuring it with the uh um dexus
scanner
you have about 8% of your fat as
visceral as a premenopausal person and
then when you go through the transition
it's 23% wow with no changes in diet and
exercise the visceral fat is not
something that gets enough attention I
think everyone thinks about subcutaneous
fat because it's relation cosmetically
distressing but really yeah um and one
doesn't want too much of it for health
reasons e either but the it's the um
intval fat that at least by my
understanding is is really uh the most
problematic for for for our health it's
a harbinger of of chronic disease so I
read that weight gain is one of the
primary symptoms of menopause itself
yeah so it's you have to be careful how
you think about that when we when we
plot weight gain versus age it's a very
straightforward linear curve and
menopause does not seem to affect that
what is happening is a body composition
change we are losing muscle and we are
gaining visceral fat and so and you
might be gaining some subcutaneous fat
but those are kind of the key things
that are happening and so that's really
when I'm counseling patients what I'm
focusing on because I have a body
scanner in my office where I can tell
them what their level of visceral fat is
in their muscle mass and so we bone and
muscle that muscular skeletal unit works
together and so we see this acceleration
of muscle loss which controls our basal
metabolic rate which determines our
resistance to insulin which you know so
it's just that's the the organ of
longevity that's what I I've learned
from Dr lion you know and everything we
can do to hang on to it and build is so
important so protein going back to the
original Point protein intake is key and
women by and large are getting 50 to 60
grams of protein per day and we really
probably need 80 100 120 depending on
our body composition yeah thanks for
mentioning Dr Gabrielle L she's doing
what I view world yeah terrific work
really promoting Women's Health and
health generally I know she's now I
believe is exploring um Advanced
Training in uh in urology for males as
well and um so you know it's um it's
it's only fair to to credit her with
with really expanding into these
different areas but especially this idea
that we need and women perhaps in
particular from what I understand um
she'll be on the podcast soon so we'll
get more of a of an understanding at
least one gram of quality protein per
pound of lean body mass maybe even per
pound of body weight per day in order to
optimize their their health yeah she's
she's definitely on the higher end you
know the Whi the Women's Health
Initiative some of the my favorite data
you know it's not all bad it's data and
was looking at Frailty scores and
protein intake in women and what they
found was women who were having 1.5 to
1.7 so basically it was the higher their
protein intake the less likely they were
to be frail the end and it was you know
they were reaching that was kind of
peeking out somewhere around 1.5 to 1.7
gram per kilogram of lean body mass and
most women are getting around you know
the FDA recommends
08 wow and source of protein also
important high quality right right you
need all the amino acids yeah very
interesting um now that's in menopause
but presumably also so starting those
habits in Perry just getting that laid
down and getting those habits laid down
are going to set you up for a much
better post-menopause a much healthier
postmenopause and we have to stop
defining menopause by your hot flashes
you know it may or may not make your hot
flashes better and we have great
medications for that if it's disruptive
but I'm talking about your your
cardiometabolic disease risk I meant to
ask this earlier so forgive me for for
leaping back briefly but is there any
value in knowing the age at which your
mother went into menopause as a metric
or a sensor rather uh for or a as a
window into whether or not you will go
into menopause at more or less the same
age yes there is a of course it's not
one to one we get half of our DNA from
our fathers so but I always ask and
there's a you know the latest data that
looked at it genetics is the biggest
factor that determines when you're going
to go through menopause so knowing when
your mothers your aunts you know went
through and if there were any medical
conditions associated with that is huge
okay so now we're talking not so much
about perimenopause but also menopause
itself what is the typical constellation
of symptoms as one enters menopause like
right at the beginning and then does
that constellation of symptoms change as
one is you know a year two years three
years into menopause so it's almost 100%
with body composition changes like very
very close you know that visceral fat is
tough to beat it's beatable but it takes
a lot of work you know do people know if
they have visceral fat I mean there's
their scanning approach
gold you know of course the gold
standard is a DEA or even an MRI but no
one can afford that so we have in like
what I have um in my office is the
inbody scanner so it's electrical
impedance scanner and it's it's pretty
good so you stand on the scale hold the
hand I have a medical I have the highest
grade one for my patients um and most
people doing what I do you know
utilizing a body scanner use that one um
but you can use the waist tip ratio and
so the waist tip ratio is a better
measure of your risk of metabolic Health
than your weight or your BMI so it's so
simple you take a tape measure and a
calculator you can do it in your head
but you measure the smallest part of
your waist and if you don't have a small
waist if it goes out then just use your
belly button just use something you can
measure again are people sucking in or
are they relaxed you should be relaxed
and I tell my patients you know do it
first thing in the morning when your
bladder's empty and you're not bloated
and you know um and then the widest part
of your hips it's not perfect but it's
better than your weight or your BMI so
widest part of the hips with people feet
feet
people are going this and so um I only
know the data for women so forgive me
but um for a female if it's less than
0.7 then your chance of having
clinically significant aberration in
visceral fat are low and then if it's
greater than one you likely have higher
levels of visceral fat and so in clinic
or when I was coaching online for
galison diet we were using the waste
ratio as one of the you know measures
for their success when measuring the
waist um which point along the waist is
it right at Naval is it it's just
wherever your smallest so that's kind of
different for different women so I would
just say look in the mirror wherever
your hourglass goes in is where you want
to kind of stick to but if you don't
have that kind of a waist and you have a
wider waist just pick the belly button
because you always know you can go back
to that level you know that's because
we're tracking them over time great
those are um very useful um
recommendations and how often should
people do that I you know you should
never weigh yourself every day you
shouldn't do this every day we were
having patients do it or you know our
followers do it once a month so changes
in body composition as measured by dexa
or impedance or you don't have access
that waste of hip ratio uh what are some
of the other symptoms of menopause
fatigue multiple causes for the fatigue
um a lot of sleep disruption um sleep
disruption is another huge thing so all
of a sudden you're struggling to go to
sleep or you're having middle of the
night Awakenings and not able to go back
to bed that are new and different from
prev new and different than before right
I see there was a recent study that came
out and most of my patients in hindsight
say I knew something wasn't right or
something was different something had
changed but I couldn't put my finger on
it and they just had a study come out
saying something's then when they looked
at what that means what does I'm not
feeling like myself mean and it was
psychological changes so you lose
resilience you're suddenly more
irritable you're suddenly not able to
like go with the punches or or do you
know you're you're not adjusting as well
to change that you used to you're
snapping at your kids more your partner
you're you know you're you're getting
frustrated at work you know it's just
very kind of subtle and it takes going
through it and then looking back to say
yeah I really say may maybe about 47
that something was changing and I just
thought I was just stressed out or
whatever and then now I can see that was
the beginning of the pattern so
menstrual changes as we talked about um
you know the big highlights
vertigo tenus ringing in the ears um
skin changes so dry skin itchy skin
feeling like you're having crawling
Under the Skin big gut changes so Nuance
set bloating you're kind of eating all
the same things and your guts just not
handling things like it used to so the
Zoe nutrition study took 1100 women and
and did stool samples through menopause
through the per menopause menopause
transition and saw the changes in the
gut microbiome from the loss of the sex
hormones and basically we went from what
a typical female microbiome to that of a
male through the
transition is there any direct evidence
that um supplementing the gut microbiome
and here I don't necessarily mean pills
and powders I mean um my understanding
is that getting enough fiber and low
sugar fermented foods can also support
the gut microbiome things like um
sauerkraut kimchi miso miso um plain
yogurt just straight up nothing added
yeah so is there evidence that
supporting the gut microbiome can um
make this uh stage of menopause more I
guess um reduce some of the symptoms of
of menopause so the best I could find
was most of them are are done with
supplements because those are easier to
measure than handing someone a cup of
yogurt right and you know which bacteria
you're provot so um they did
lactobacillus and looked and bifido
bacterium I think and saw that women who
were obese and hypertensive in
menopausal and they had visceral fat
decrease and blood pressure improvements
versus placebo um also it's hard to do
Placebo studies with food you know so
right um but they do and then in the
retrospective studies they can look at
dietary patterns and women who ate rich
foods fermented and lots of yogurt you
know Mediterranean type diets um have
better symptoms overall what's the
difference between the Mediterranean
diet and the Galviston diet so so um
when I so I got my culinary medicine
certification I was culinary medicine
yeah so I was frustrated in when I was
working because I didn't know anything
about nutrition and suddenly like
everything I was trying to tell my
patients was based on like the one
lecture I got in medical school and you
know good nutrition was like porn you
know it when you see it you know the
Supreme Court definition of pornography
and so you know the best I'd ever gotten
was the gational diabetic diet and it
was this Xerox things with you know was
in the Deep I was in Texas so it had
like tortillas and stuff on it and and
it had been copied so many times you
could barely read it anymore and that
was the diet we would that was the only
nutrition I'd ever like handed to a
patient and so I'm like eat healthy and
so I'm like I got to do better than this
I don't know enough and so we had a
guest speaker for a Alpha Omega Alpha
which is the Honor Society for medical
school and I was one of the advisers so
and it was this guy Tim Harland who had
started this culinary medicine movement
and it was basically nutrition for
doctors and he velop this like online
program and I had to go to New Orleans
for a lab and San Antonio for a lab and
work in kitchens where you were learning
how to counsel patients how to cook and
also basically like getting a little
minor in nutrition um so it was the best
thing I've ever done say very cool I
mean I learned about allergies and like
all this stuff you know food allergies
and things that I just didn't know and
just basic nutritional principles like
what it takes to build a healthy body
and and what you know I knew about
quashi oror and like severe deficiencies
but not good basic nutrition and so you
know they talked heavily about
Mediterranean they talked a lot about
The Fad diets and stuff but you know the
principles of the Mediterranean I was
like I want to teach this to my patients
but they're not going to eat a lot of um
Greek yogurt or they're probably not
going to eat a lot of feta you know like
how can I kind of take these blocks and
make it more Americanized that was kind
of like the brain child for me around
galison diet was let me like create
something and I really was into fasting
at the time too so I was like let me put
this fasting thing together with you
know good nutritional anti-inflammatory
principles and talk about the things we
know were probably you should you know
not having a whole lot of you know
processed foods and high sugars and
stuff and and explaining in a way and
how it's affecting their menopause and
like how can she approach her nutrition
and that's how Gallison diet was born it
was for my patients and then I gave it
to my girlfriends and then they started
sharing it and I talked about it one day
on Facebook and the world exploded in
the best way in the best way yeah it l
me here right so right um and we all
benefit what is the evidence that
fasting can be beneficial or detrimental
to um per menopause menopause so the
jury's kind of still out on that one I
was re really liked the data that you
know uh I think it was Mark Matson had
done on neurod degenerative disease and
and using fasting as a tool there and
lowering inflammation levels so I was
like this is amazing this is great
because so much about menopause is
pro-inflammatory you know is this
intermittent fasting so Tim restri he
was basically doing 168 you know and uh
you know very scheduled intermittent
fasting and so that was something I was
coaching my followers about you know
consider this try this this would might
be something to help lower inflammation
I pulled back on that because it's
really hard to get enough protein in for
a lot of of women especially if they
came in at 60 and now I'm telling them
to double their protein you know and
then giving them an eight hour window to
do it they're like I'm walking around n
on a chicken breast all day you know
this is hard right and metabolizing
protein is its own work right and so you
have to spread it out throughout the day
you know and a lot of that work was done
at UTMB where I did my underground I
mean my residency and where I taught for
years and so I was friendly with the
Nutrition department there I was getting
all excited about everything and they're
like you know I went to several of their
conferences and like talking about
breaking up protein intake into nuggets
throughout the day because most women
have very little protein with breakfast
maybe weak gluten in their toast and
then have a little bit at lunch and then
kind of Stack their protein at night and
they're still not getting enough but
they're overdoing it in their evening
meal that's their big protein meal and
so like teaching them to kind of you
know what I was teaching in galison diet
was you need to have a healthy fat a
good healthy carb and a protein with
every meal in snack that you eat you
know why do you think that protein has
not been
emphasized um enough until recently I
think because we didn't understand it
you know we didn't understand how
important muscle was and I mean we knew
that protein intake was important for
muscle but muscle was for bodybuilders
and not for women I lived my whole whole
life up until about 5 years ago eating
to be thin and moving to be thin that
thin was the only measurement of Health
that I needed to worry about and what I
did was chip away at my bone and muscle
strength and thank God I don't have
osteopenia yet you know i' I've
hopefully have reversed whatever Trend I
was on and I'm naturally low muscle so
now it's just a battle to try to hang on
to what little I have and build some
resistance train yeah yeah yeah yeah now
three days a three days a week three to
four days a week yeah resistance
training much less cardio I was running
marathons I and it was a great social
thing with my girlfriends but you know
everything I did was cardio I taught
step aerobics you know the only weights
I did were maybe in Zumba maybe one or
two pounds you know so and that was
better than being on the couch I mean I
loved the community and doing that but
you know for me to like stay out of the
nursing home which was my ultimate goal
for as long as possible I need to pick
up some weights and heavy weights so
that's where my focus has changed isn't
it interesting that it wasn't until Rec
Rec L that um it was only bodybuilders
and football players and people
preparing for military or specific sport
would resistance train and now we are
told that everybody male female young
old should resistance train absolutely
probably three times a week yeah and the
my generation is struggling because we
don't know how to do it and so I'm you
know and I'm not a personal trainer I
don't pretend you know I hire one to
help me develop a program so that I
don't hurt myself and then I can get
stronger you know Progressive loads so
you know and again Dr lion such a huge
proponent of that and so what I try to
do publicly is show my workouts so that
people I normalize it and people see me
doing it and they're like well she can
do it then I can do it it's great super
inspiring and it really helps uh cross
that threshold where people as you said
they don't know how it's scary right for
people who resistance trained for a long
time they go into a gym they they know
how all that stuff works but uh for
those that don't it's you're wandering
around like what does this one do you
know it's intimidating for a whole bunch
of reasons well thank you for putting
that content out um both the uh
prescription if you will but also the
example that that one can go about it so
I'm guessing if you could go back 20
years you would have started resistance
training earlier and eating more
stronger skinning nutrition over
calories and and stop looking trying to
look a certain way you know you're
you're undermining your future health by
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docomo to get 10% off so um what are
some other symptoms of menopause you you
mentioned body composition changes the
one that we hear about the most for some
reason I don't know is hot flashes yeah
so think hot flashes um so in medicine
we call it a Vaso motor symptom so we
have a a disregulation of the thermo
regulatory Center in the hypothalamus
and that that the the thermostat gets
reset basically and so what happens is
we have this vasal dilation of it starts
in the core typically for most women
somewhere in the chest neck area and you
feel this heat yeah I can probably
trigger one just by talking about it um
and it it goes up into the neck and out
into the extremities and then you just
start profusely sweating from all the
blood vessels dilating and then it can
last minutes to a second but for some
women it's preceded by sometimes
palpitation sometimes by this intense
feeling of of dis Foria you know this
intense sadness feeling and then it and
then it just kind of passes but you know
say you're you know wherever you are in
your life whatever you're doing all of a
sudden you're just like sweating
profusely in the middle of some
important area of your life work you
know whatever your jobs are in your life
and it's disruptive if it happens at
night you don't sleep and for some women
it's severe where they're having
multiple ones a day and when any time
you disrupt sleep Then daytime is far
worse regulation you yeah you stress
differently you you know everything
changes and so when my patients come in
the first questions we ask are sleep and
that's the first thing we work on is is
you know what can we do to get your
sleep better what can be done for hot
flashes aside from the things that
you've already described to offset
menopause absolute goal standard is
hormone therapy is like giving your body
back the estrogen which will readjust
get your serotonin levels back to where
they were and leave that thermal
regulatory Center alone so it's back to
where it used to be let's talk about hor
therapy it's a bit of a controversial
topic for no reason yeah I I was going
to say I don't know why yeah it's
demonized it it got such a bad rap and
we need to to it's just some of the was
the worst misinformation campaign in the
history of medicine well that's a bold
statement but I believe you the um the
way I understand it is that there was
this large scale hormone therapy trial
um and the interpretation of that
trial was something different than we
now believe um as a medical ini so it
was really groundbreaking at the time
aging women were finally being studied
we knew from observational data that
women on hormone therapy probably 40% of
the population of females eligible were
on HRT okay so very large amount so the
women who were given hormone therapy had
lower incidence of cardiovascular
disease older ages of cardiovascular
disease lower death from cardiovascular
disease some people argued that that was
an artifact of healthier wealthier women
get HRT because they go to the doctor
okay so this is just because they're
healthier that they have less
cardiovascular disease so let's prove it
what do you do that with a randomized
control trial so flaws in the study so
they take I think there were 11,000 is
women in the estrogen only arm because
they'd had hysterectomy so for your
listeners if you have a uterus and
you're getting estrogen you must have a
progestogen with it to protect the
lining of the uterus from minimal cancer
as long as you give an adequate proest
you're fine okay but if you don't have a
uterus progesterone is not mandatory so
the women who had had hysterectomy got
estrogen only or Placebo and the
estrogen at the time was primin which
was the number one prescription for HRT
at the time so nothing weird about that
so it's just um synthetic estrad
actually no uh primin is is primin
stands for pregnant mayor urine it is
actually very natural they take pregnant
horses and extract the estrogens from
their urine because they're pregnant and
they were screeing a lot of it and it
was cheap and easy and I have a lot of
ethical issues about how they do that
but and I don't prescribe it but that's
what was done at the time so I I've seen
horses urinate they urinate a
lot there's dozens of estrogens in that
comp but the main one is estrad so um
then there the other group who had
uteruses were given Prim Pro which is
primin plus
proa and or Placebo so off we go they
recruit 11,000 and then I think 15,000
in the other arm huge study it was like
a billion dollar study like we're so
excited this is happening this started
when I was in med school and then they
start recruiting patients and then um
you know everyone's taking their meds
they excluded women with hot
flashes what because if your hot flashes
go away you know that you didn't get the
placebo ah so they excluded one with hot
flashes problem number one yeah that's a
big problem this the end outcome the
what they were trying to measure was
cardiovascular disease so they started
with an older population the average age
was
63 whereas the typical onset of
menopause is 51 wow so these women had
been menopausal you know on average for
10 12 13 years so time away from
estrogen is when disease starts
accelerates right okay so put them on
their meds start measuring in the
estrogen plus progestin arm they saw
a non-statistically significant
increased risk of breast cancer and it
was this the relative risk relative now
you know what this is but your Mone your
listeners may not was 25% and and I hope
I get the numbers right it was four out
of a thousand women per year to five out
of a thousand women per
year okay so Placebo arm was four so we
have breasts we are females we get
breast cancer about four out of a th
women per year and that increased to
five and the estrogen only arm there was
a 30% decrease risk of of breast cancer
regardless of the of the average age M
and they kept that arm going right
because it's randomized so presumably
the average age for the other group is
roughly 61 as well they were match so in
their 60s as well so they call a press
conference at the Watergate Hotel the
Watergate Hotel announce the
findings they hadn't even published the
data yet no one had had a chance to read
it and these the head researchers called
this press conference and say estrogen
causes breast
cancer exogenous estrogen from these
yeah yes and they said it's a 25%
increased risk but the absolute risk was
like 8% per
year but that didn't get that that's not
a headline thing so on every like ABC
NBC CBS all the morning shows Nightly
News every major magazine it was the
number one medical news story of 2002
that that estrogen was bad and it caused
cancer and da d da the estrogen only arm
kept going
and they found after a couple more years
a slightly increased risk of stroke so
they stopped the study the effects on
cardiovascular disease were neutral but
there was lower um colon cancer in both
groups but no one talked about that so
the American Heart Association in 2020
went and looked at they looked at ages
so there were younger women who were
given HRT and what they found was if you
started hormone therapy between the ages
of 50 to
59 you had a 50% decreased risk of
cardiovascular disease and death from
cardiovascular disease and all cause
mortality wow so age at which you start
matters estrogen so that's where there's
something called the healthy cell
hypothesis or and so basically estrogen
is better at prevention than cure and
it's very protective especially in the
Tima of the coronary arteries so taking
that estrogen away we lose that
protection once the disease builds up
there's some worry that adding estrogen
once you've developed a sclerosis or a
plaque might loosen the plaque
especially in that first year so which
led for some people maybe to have a
slightly increased risk of stroke so
when my patients come in we are talking
about these differences it doesn't mean
that after 60 you might not have
cardiovascular benefit we start losing
the benefit so it's the timing
hypothesis is key and it's the years
away from estrogen that's the problem
there's a great study in the British
medical journal they looked
at years years of reproductive life plus
HRT and looked at cognition scores and
saw that the longer your body is exposed
to estrogen in any form like whether
natural cycles or exogenous estrogen of
any form and it was estradi in that
study actually then you
had higher cognition
scores healthier brains which had a just
very you know top Contour level makes
total sense given that estrogen is
neuroprotective I realize my not be
neuroprotective in every instance in
every neuron in the brain but it's
generally neur neur protective and
decline in estrogen is correlated with
neur degeneration which does not mean
it's causal I have to ask when they
announced this study at the Watergate
Hotel of all places um and the
conclusion that they put forth was that
estrogen therapies can um increase rates
of cancer
um I have to wonder if that had
something to do with what I understand
is a sort of party line around Cancers
and breast cancers in particular which
is that you want to quote unquote block
the estrogen receptor you want to get in
there and put give tamoxifen or nowadays
I'm sure there are other drugs that are
more effective to block the estrogen
receptor it all seems to um pile up on
the side of a story that says you know
estrogen and estrogen binding to the
estrogen receptor is proc cancerous
which obviously I think you're telling
us um in a in a indirect and direct way
now and we'll go further into is simply
not the case if you take a healthy
breast cell and dump it at a petri dish
and then marinate it with some estrogen
it's not teratogen I it's not
carcinogenic estrogen is not
carcinogenic we live with it our whole
lives if it was in pregnancy for those
of us who are ever pregnant when our
estrogen levels Skyrocket we would see
this into uptic in breast cancer and we
don't in fact I think there's some
evidence uh for the opposite that
getting pregnant prior to age 40 is is
it true that that's protective against C
be somewhat protect for certain forms of
breast cancer yeah so we have this whole
generation of Physicians who really
weren't taught much about menopause
don't understand the protective benefits
of estrogen and and and menopausa effect
on metabolic disease and they have this
me this mentality of estrogen is bad and
so a woman walks into her today 2023
they looked at the data she goes into
her doctor complaining of menopausal
symptoms which right now are still only
recognized as genit urinary syndrome
menopause hot flashes night sweats you
know the very cliche symptoms
documents in the chart she's having
whatever only 10% are offered any
therapy and they're most likely four to1
to be offered an
anti-depressant that is where it stands
today that is what we are fighting
against is not every woman will choose
HRT but every woman deserves an informed
conversation about it and let her make
her choice you know if you believe the
Whi data which there are some problems
there the risk is small okay but did you
talk to her about about cardiovascular
disease and diabetes and insulin
resistance and her cholesterol because
those things go up through the menopause
transition with no changes in diet and
exercise and those are all you know
you're more even with the diagnosis of
breast cancer the most likely thing a
woman is going to die
from is cardiovascular disease a heart
attack or a stroke so framing it like
that I think is where we need to head
and the other thing is you know I was a
great Oben in so many areas of what I
did why should this all be dumped in the
lap of the poor busy OB Jen who's
running around the hospital doing pops
smar trying to deliver babies surgery
and all the things like this should be
required education for all everyone in
medical school we are females and we're
not little men with breast and uteruses
we react differently to medications
disease disease burden you know and
that's not been studied adequately and
that's where the the push needs to go
it's bigger than just half flashes do
you think that one solution is to deepen
in the medical school curriculum
absolutely and more and and I hate
saying women's health because everyone
thinks breast and uterus right and
reproduction it's the health of
women and we're not addressing it
differently than the health of a man and
we're different we you know and so that
I think is where we need to head given
that it's half of the population yeah um
one would imagine that the best thing to
do is to make the Core Curriculum of
medical students expand to include this
as opposed to making it a specialty I
think so does that mean a fifth year of
medical school I'm not kidding I mean I
I guess maybe I mean people said well
you'd have to extend the the OBG in
residency I'm like no any any specialist
who touches a female should understand
how that female I mean the starkest
example is cardiovascular disease you
know how much longer we have to wait in
the Ed how much more likely we are to
die in the hospital setting from a heart
attack because we don't present the same
symptoms as men do and it's just the
default has always been how it happens
to the basic you know really Caucasian
male and so at least in the US and so
because we respond differently because
we wait longer because our symptoms are
considered to be psychologically induced
less than biologically induced and so
women are dying at higher rates when you
look at the data on
Statin you get high cholesterol so 80%
of women will have abnormal cholesterol
levels through the minum PO transition
if they were normal before okay so
elevated LDL LDL and lowering HDL so now
they are at higher risk for
cardiovascular disease automatically a
PCP will offer her a Statin okay that is
standard of care do you know that the
American Heart Association published in
2020 that statins have never been shown
to decrease their primary heart attack
in a woman secondary yes but no primary
prevention and it does not decrease risk
of death from cardiovascular disease
they're know that yeah yet we're routine
you know what does
HRT if given in the right window of
opportunity how is HRT um in this case
estrogen HRT given is it a patch is it
injections is it great question all the
above so we have I like to break it down
into oral and non-oral forms so
everything oral we ingest goes into the
gut the liver the hepatic system will
pick up the portal vein and take
everything to the liver for processing
when that bump of estrogen hits the
liver we can see a slight increase in
some of our clotting factors so for that
reason I tend to go with the non-oral
formulations to avoid that risk
especially if she has any family history
of clotting or personal history of
clotting you know we're going to go with
a non-oral form so these are things like
elevations in Factor 5 lighten MFR if
she's had a history of a blood clot we
are not going with an oral estrogen
formulation and for people that haven't
had a history of a blood clop my
understanding which admittedly is is
very um sparse is that you can do a
genetic test just by blood draw to see
whether or not you have U two normal
copies of the of the gene for Factor 5
lien um some people are heterozygotes so
they're more at risk of presumably
bleeding in that case right um but in
other
words can people go into this knowing
whether or not um they're more or less
at risk from taking estrogen so I don't
think that there's a high enough for
that reason because we're not routin L
screening for these things unless they
have a family history I'm going with
non-oral estrogen as a primary product
for my patients because I can just skip
that worry so a patch typically so
typically transdermal so a patch there's
even miss spray there's FDA approved
options of a patch there's gels there's
a ring there's a um spray and um there
is a vaginal ring which I love love love
because it's so you put it in for three
months and it treats you know you get a
two for one you get a local treatment in
the vagina as well as a systemic treat
treatment as well um it's just really
expensive and typically not covered by
insurance on the first tier so very few
of my patients can afford it um there
are um some injectables which no no one
in the menop posi uses um there the
menop yeah great there are also mention
the mene and the menop posi are those
terms that you coined I love it um I
think I did yeah great all right you
heard it here so the menasi is a a group
of healthcare professionals who are from
multiple Specialties we have card
ologist orthopedic surgeon um Internal
Medicine you Dr lion is a member and we
have a big group chat and we all support
each other we support each other's books
and research and and we send articles
back and forth and we support each other
on social but we also band it together
to kind of negate one of the bigger
Publications on menopause that when the
lanet published it's a whole another
discussion um but you know we are
fighting for equity in menopause care
and and Fe and Women's Health great
nothing succeeds like a group it's like
the old menopause versus the new
menopause I love it love it um so
hormone therapy to increase estrogen how
does it make women feel um
psychologically physically what are some
of the positive changes that can OCC
aside from just offsetting some of the
negative and I want to make sure that I
remember to ask what if a woman has been
in menopause for you know uh has passed
that point because as you said it's a
day so they passed that point um a year
earlier 2 years earlier 3 years earlier
um given the results of this first study
um which as you explained it are uh
problematic and their interpretation the
way it was interpreted as opposed to
initially yeah yeah um what's too long
should um women should wom starten
therapy in their 40s just in just to you
know smooth the transition maybe we need
more studies in this area like should we
just the minute we figure out like I
would love like I would glucose monitor
I have um insulin resistance so for
those listening there's just it looks
like a little button sized um sticker on
the back of the arm I would love to
develop one to track estrogen levels
starting your 30s just see where you're
at you know start seeing are you having
aberations in your cycle and we can
start the per menopause journey and
talking about should we begin supporting
I think there's a tremendous amount
opportunity for research in this area um
but typically we are not starting
patients until they're very symptomatic
if they're per menopausal or they're
postmenopausal so in general so if a
woman is um in her let's say late
30s um
she is anticipating perimenopause maybe
is in per menopause and wants to start
lowd dose um hormone replacement therapy
I think it's something um worth
mentioned that not all you know
presumably the dosages are tailored and
then blood so a given dose is tried
blood is drawn you measure estradi so
we're not um we don't have established
levels of like therapeutic ranges of
estradi what we found is that when we do
that so far I think we have some
opportunity here if my level's 50 and
your level's 50 I could feel like I'm on
top of the world my symptoms are gone
you still need more so we are titrating
from symptoms I see yeah interesting
that's similar to what is done
similarish with um testosterone
replacement therapy which these days um
you know I sort of have joke that the
you can uh change out the r in
testosterone replacement because a lot
of people are a lot of men are taking
testosterone not as a replacement
meaning their levels are not lower than
300 n per deciliter which is kind of
lower range um they're sort of low
middle and they're trying to get high
you know higher range but hormone
replacement therapy as I understand it
has never been um strictly in men or
women strictly for people who are out of
range that it in in theory it can be to
optimize reduce symptoms right and to
optimize well-being right um and I don't
know if the medical establishment wants
it used that way but certainly in the
case of testosterone replacement therapy
in men it's being used that way quite
often in fact
so the we don't have established
therapeutic ranges for estrad if she's
POI premature Varian insufficiency we
know we want to get her to 100 or around
100 or higher in picograms per deciliter
um and but in the menopausal patient
we're rarely checking levels but I do
think we have an opportunity to learn a
lot more now that we're able to track
how is it how does it affecting your
cholesterol we need to look at those
numbers like what's the optimal dose for
cholesterol what's the optimal dose for
cardiovascular disease all we all these
Studies have looked at was was she on it
or not so that's where I think the
opportunities can come so if a woman
goes on hormone replacement therapy how
often is she coming in for blood draws
or are you just you know well depend
testosterone we tend check more often
there's we don't have an FDA approved
option for women for testosterone and so
no so we either try to get her t- stem
mhm um or she's finding someone to
insert a pellet or something and there's
there's other issues with that um what I
do in Te Texas it's really hard the
pharmacists do not like to do the t-
stem for patients and I've even T t-
stem is the gel you know um and I end up
compounding it in a cream and do a
transdermal PR for the patients but
there's such variable absorption we do
tend to check more levels of that just
to may try to get her therapeutic so
what for women at Peak dose is somewhere
in a healthy female you know 35 to 70
and it's so so I had a woman coming in
with signs of hyperandrogenism you know
she's you know deep voice hair growth
whatever acne and I'm going to check a
level if it's above 90 for females I
need to look for a tumor like that's too
high okay or PCOS it can get that high
certainly 200 that's that's outrageous
so I'm trying to get my patients you
know 60 50 70 but if she's like 50 and
her she's got her libido back and she
feels great and everything's wonderful
then I'm hold you know because the
higher we go the more likely you are to
have side effects so you're losing hair
you know temporal hair loss voice
steepening acne new chin hair you know
losing hair where you want it gaining
here where you don't want it is how I
explain it to patients and so when you
say 50 that's 50 nanograms per de
I think um many people including myself
were surprised to learn um that women
actually have higher levels of
testosterone than they do estrogen um
outside absolute ranges right in
absolute ranges and I can tell you right
now your natural level of estradiol is
higher than mine now I'm I supplement
but you know like when I go through
menopause your residual estradi is now
higher than a postmenopause a woman so
this is the uh estrad that I have
because testosterone was aromatized into
into EST yeah interesting interesting uh
so much uh is breaking down around the
uh the old
stereotypes female hor like testosterone
is a human hormone right estrogen's a
human hormone and they exist in in both
U biological Sexes yeah it's um it it's
sometimes unfortunate that compounds in
the body get names like steroid hormones
because then people hear steroids and
then it has a gravitational pull toward
um anabolic steroid use um or uh even
the word fat you know it's like you know
dietary fat versus subcutaneous fat
versus fat we need better nomenclature
um to avoid a lot of the confusion that
exists out there what are some of the
other hormones that um can be reduced
and can possibly be replaced by hormone
therapy like progestins um you know are
there is there a role for um you know
adjusting things like prolactin or is
there a is there a role for other
hormones in that what sure is to be a
multifactorial thing I mean I think
menopause is a process not an event
hypogonadism for females right and so we
know that you know because the pituitary
and hypothalmus are involved and that
G&R you know there's some cross
reactivity so for example hypothyroidism
when I have a patient who's on her and
doing well on hormone therapy for her
thyroid so she's on T3 T4 whatever she's
on I'm like listen you know we need to
recheck your thyroid levels in six weeks
because giving you back estrogen is
going to mess with a little bit of that
feedback cycle so we need to make sure
you're still therapeutic so I think
we've got more work to do with some of
the other hormones um but when we talk
about replacement and menopause we are
mostly looking at your estrogens your
androgens and your progesterone so the
formulations can differ um when we you
know there's a lot of misunderstanding
around what is bioidentical versus
synthetic and I think a lot of cottage
Industries in this little bubble that we
had for 23 years where doctors were
afraid to prescribe hormone therapy and
then women were desperate for care we
had some little cottage industries of
people I think were well meaning and
trying to help but kind of developed
terminology that really isn't medically
specific like estrogen dominance you
know and what that really is and so that
is not a term that is in any medical
journal it's kind of something coined I
think from a well-meaning provider
trying to explain what's happening in
per menopause that you're having more
produced than progesterone than you used
to have so PCO patients do the same
thing you know there's multiple reasons
for that to happen um so when we talk
about you know in the miniverse of what
we're trying to replace we all agree
that we stick pretty much with estradiol
we're just trying to give you back the
water you were drinking so I want to be
get as close to what your body used to
make because that's what the receptor
like I'm trying to give you progesterone
you know rather than a synthetic not
that they're all demonized progesterone
doesn't work for everyone I'm glad I
have option
and then for your androgens we pretty
much just do testosterone and we do a
transdermal again because the oral can
be hepatotoxic unless it's uno8 which
isn't um available in the US so but in
there's no FDA approved option for women
so it's not covered by
insurance we know it works for
hypoactive sexual desire disorder what
your followers would would call libido
um we think we know testosterone women
at the highest quartile of testosterone
have better bone density and stronger
muscles so I'm using off label for my
patients who come in with osteoporosis
osteopenia or sarcopenia I'm using it
off label telling them this is a
probably a hel it's not a h Mar we think
it works but we don't have the you know
it's not approved for that yet yet um we
know it has receptors in the brain my
patients are saying that they're more
clarity of thought they're sleeping
better they really really like the
testosterone um so there's you know DHEA
there's a great vaginal preparation for
DHEA called inosa and then the receptors
there will start converting it into to
both testosterone and estradi you know
through the process and so um the sexual
medicine docs really like in Roa
especially for breast cancer patients
because they get that little boost of
testosterone in the vulva intr Roa intr
Roa is the brand name I think it's
prostone and this is a prescription drug
yeah these are prescriptions so intr
roa's prescription DHEA was specifically
formulated for the vagina got it which
sits further Upstream to the production
of testosterone and estrogen right and
so fortunately
the what's left in the vagina is able to
you know plug that guy in and get it to
produce both testosterone and estrad
which testosterone is the immediate
precursor we have to aromatize it right
to make estradi in females as well these
local effects on tissues um are
interesting um I they make perfect sense
if the highest concentration is at the
site of release from the from the patch
or the gel or the whatever the um the
the you said intravaginal what is it
it's like a capsule uh I think the
Prestone is a um insert like a little
gel looking not a gel but a um I forget
what The Binding material is but it's
like a little insert you put in okay so
the local effects because I guess you
know it stands to reason that the
highest concentrations can be at the
sight of the thing that's releasing the
hormone but then it also goes systemic
by getting into the blood actually so
the the local formulations e the
prostone and the um the inosa and as
well as the estradi formulated for the
vagina do not absorb Sy ically they're
so low dose there's not been clinically
significant tissue absorption I have a
formulation for my face as well so it's
a cream a cream that I put on my face
it's estriol and so there's some decent
studies with estriol but we lose 30% of
our collagen it's a very big pain Point
for women when they go through menopause
that we lose so much collagen so quickly
in the first five years of menopause and
so we can slow that process down we
can't stop it completely we can slow it
down by using a topical estrogen and the
topical really seems to help with the
elastin concentrations as well
interesting so you you will often
prescribe a lot of local treatments for
hormone it's so safe so we can take
breast cancer off the table all the
discussion around blood clots and
everything everyone can use vaginal
estrogen and they should and I'll tell
you why starting at what age relative
toop the old menopause thoughts is do
not give adinal estrogen until she's
symptomatic now all of us will become
symptomatic from GSM so that's genital
urinary syndrome of menopause so from
the pubic bone all the way to the sacrum
all of that tissue is heavily you know
tied to estrogen testosterone and when
those levels decline we see thinning of
the tissue loss of elasticity loss of mu
mucous production as well as the health
of the urethra and so UTI like the best
treatment for recurrent u in a
menopausal patient is vaginal estrogen
interesting not recurrent antibiotics
and what about um so it's preventative
we can probably keep 50% of women out of
the ER and out of urosepsis if we gave
them all prophylactic vaginal estrogen
all these ladies in nursing homes should
be on vaginal estrogen so just to
protect them from getting Euros sepsis
interesting what about um like urinary
incontinence and some of these other
symptoms that are associated with more
elasticity presumably more elasticity of
of tissue in that region if you're early
in a so we have stress incontinence and
then we have um overactive bladder urge
incontinence and so it definitely helps
with urgent condet it rela you know it
helps to relax and decrease the
inflammation in the wall of the bladder
so thumbs up there so people are getting
up at night and having that urge to go
um but stress incontinence is an
anatomical problem we've lost you know
the the sling that holds up the urethra
and the female fails right from
herniation and and poor tissue Health we
can build up that health and we you know
there's Physical Therapy there's lots of
options and you you know no Euro
gynecologist wants to take a woman to
the o to do a
lift if she's not estrogenized they're
all going to get vaginal estrogen pre
you know through healing and forever to
keep the tissue
healthy everything that we've been
talking about for about the last 15 or
20 minutes seems to go directly opposite
this large scale study that was
discussed at the Watergate Hotel um is
your read that the medical establishment
in particular the OBGYNs in the US and
in other countries understand now that
that study was um flawed to some extent
in its design no or
is what we're talking about here like
really cutting edge I mean if we were to
gather a room full of a thousand OBGYN
trained in various decades and put there
10% would have any idea here's why and
I'm going to call out the American Board
of Oben directly on this we take our
board certification exams every year in
our specialty as every specialty does
and they give us a set of Articles of
The Cutting Edge newest research and
it's divided into categories obstetrics
office practice Gynecology GYN surgery
Pediatrics onc you know there is no
menopause
category
nothing so I went back over like 10
years of all my green journals and
looked at how many articles were
anything to do with menopause and it was
less than 1% so they were not
systematically trying to put the latest
menopause information in front of us
they don't even recognize the menopause
society as a like entity well now they
have to contend with the menop posi they
do and because and they might you might
see me banned from the a but you know
what no no no but I'm so proud of what I
learned I learned amazing things I am a
boss at delivering a baby of taking care
of a pregnant patient I am great at
pediatric Gynecology I was so good with
adolescence where I failed and where
this I let the system let me fail was in
the care of a woman after reproduction
outside of surgery outside of her
surgical needs well I have to imagine
that given the medical profession is
interested in the well-being of people
and in uh for sake of the discussion
today women that um they will be
grateful that uh now you you have a
microphone um many microphones uh in
various contexts so uh that is
surprising to me however I would think
that given the exciting findings around
hormone replacement therapy and the I'm
kind of obvious at least when you
describe them to me obvious flaws in
these earlier studies of you know
starting hormone replacement therapy
when women are already 61 when they've
already accumulated um in many cases um
some health health issues that uh it
would be kind of you miss miss the
ability to to measure the protective
benefits so but fortunately we've got
great studies coming out of like the
Danish data the Scandinavian data that
are really looking at this again and
showing the protective benefits so is it
generally the case that the studies out
of Europe and Scandinavia are more
forward W thinking it depends you know
some of the most Forward Thinking
shockingly is um come out of Asia a lot
out of China and I asked my husband he's
worked there before and he said there's
as many researchers in China that are
female as male it's not like they have a
big stay-at-home culture you know
they're they're not um women are
expected to work and they're getting
phds and they're they're doing the
research and so and he thinks at Le in
his in of one you know his humble
opinion and he's an engineer you know
that that's I was like why do you think
you've worked over there he goes I think
because there's just as many women who
are writing the papers as men
interesting take I like it um it makes
good
sense what are the various things that
people can do in terms of a non hormone
replacement therapies that can support
them through really into and through
perimenopause and menopause we talked
about nutrition earlier maybe we could
touch on that a little bit more we
talked about behaviors resistance
training maintaining maybe even
increasing muscle mass um there's no
pressure to uh include them but what
about the very supplements that we hear
about that can touch on or we we are
told can touch on these hormone Pathways
things like dim things like grape seed
extracts things like um evening primrose
I I don't think they're harmful but
there's just not robust data to really
support so um menopause Society went and
looked at all of them even soy and
everything and they just outside of
cognitive behavioral therapy which can
be helpful but is not a menopause cure
um they didn't find much in the
supplement world that would stop
remember we're defining menopause as hot
flashes and general urinary syndrome of
menopause so you know when I'm
recommending supplements to patients I
do think there's some okay data on
turmeric for maybe hot flashes but I'm
not saying to take that instead of
replacing the estrogen your body is is
missing greatly um I like the
anti-inflammatory benefits of of you
know of that supplement I'm recommending
F 80% of my patients are deficient in
vitamin D and struggling to get it
absorbed you know um I'm recommending
creatine for muscle I'm recommending um
there's a specific bioactive collagen
that was studied in menopausa one with
osteoporosis where they saw Improvement
in bone density so I'm recommending a
weighted vest great studies elderly
women but saw improvements in bone
density and I'm like why do we wait
until we're osteoporotic to make the
diagnosis yeah this is interesting so
weighted vest a weighted vest they
looked at creatine weighted vest
vibratory training in nursing home
dwelling so they were kind of a
population where they couldn't go
anywhere vibratory training is the shake
plate uh the shake plate and so you know
anything that stimulates that muscular
skeletal unit will will send the signal
to get stronger you know what most women
don't realize I mean they know about
osteoporosis right and they don't want
to have it but they don't understand
that like your habits in your 30s and
40s are going to put you on that path
and that your body is going to fight to
lose muscle and bone naturally through
the aging process and accelerated with
menopause it doesn't have to be that way
but you have to do the work you know and
and there's some hacks and so I love the
way to vest for a hack I'm like do the
dishes with it on go walk the dog you
know like like how heavy so you want in
the nursing home they started at 10% of
their body weight so I'm like 10 lb 12
PBS start with that so now my husband's
obsessed and we have six of them and
they go from 8 to 35 lbs you know so I
have different weights that I wear like
if I'm doing leg day I'll put the
heavier one on so I don't have to hold
as heavy so you'll use a a weight vest
when you're doing leg day mhm wow so I
can't cuz I don't have great grip
strength and you know and so it'll help
me be able to squat heavier you know but
now I'm getting better I'm got the bar
going so I'm I'm getting there you know
I'm want to tell my sister and my mom
this yeah and you know I've got my
sister yeah doing some resistance
training it's been and it's just a cheat
I'm so it's so cute on social because
they'll post and tag me and they're
walking their dog and they're doing
whatever with their way to vest on and
now in galvaston where I live you can't
go you see it all over the sea wall
everyone's walking with their weighted
best on I love it and it's hot down
there a lot of the year so no excuses
people outside of Texas or in Texas for
that matter but my experience is that
people in Texas don't tend to make
excuses anyway that's said like a real
Californian here um we were talking
about this a little bit earlier in uh
female specific weight vests I would
love to develop one because the ones
were made for men and they're okay but
if you have larger breasts it's hard
where the Snaps are to get it on right
and I know there's a big Trend with
Wrecking
but that puts all the weight on your
back and I really like the weighted vest
because I feel and this is my opinion
really but that you know the reason why
it's helping with your bone density is
it's putting the weight on the entire
axial skeleton rather than just the
muscles on your back so we're putting
the force more evenly supported yeah um
and so but some of my uh followers have
written in and said they're struggling
because they have larger breasts and how
to get this around I'm like I got to
make one that's going to accommodate you
know have longer you know dist strap
down here underneath the breast so
that's yeah someone should develop that
you should develop that um not that you
don't already have enough on your plate
already uh along the top I like rucking
it is sort of backloaded you know by
definition um some of the weight vests
that are out there are little um are
evenly distributed in a way that makes
them pretty comfortable they're not all
loaded up up front like like a a special
operator or something would wear so I
positive effects of of the weight vest
would be increased bone density you
you're doing more burning a little more
calories
getting stronger but I'm I'm I coach to
it you know with my followers for this
is part of my osteoporosis prevention
pack love it are you willing to share a
few other things that are in the
prevention pack uh you know eating
adequate protein doing resistance
training wearing your weighted vest
creatine five grams a day where most of
the studies were done in in the women
creatine monohydrate monohydrate yeah
and then um the that cagen consider that
uh collagen full disclosure I do sell
that one but um really good investment I
think
maybe we could talk about collagen for a
moment um it it's a complete protein no
no no it's missing one I think one or
two amino acids so it's not a complete
protein um it's better than none so I do
like include my collagen in my protein
intake for the day because I eat all
animal-based protein pretty much um so I
figure I'm I'm covered my bases to have
you know 10% of it coming with just
missing two amino acids or I think it's
one valine I have to look it up so and
what are the specific effects of a
quality collagen so you know there's a
lot of controversy there I've seen the
videos it is broken down into its
component amino acids you know through
the digestion process but the first ones
I looked at were totally for vanity I
was changing bathing I was trying on
bathing suits with my daughter who was a
little girl at the time and I was
complaining about the appearance of my
cellulite even then people have
cellulite and oh mommy it doesn't look
that bad and I you know scientist in me
was like goes on PubMed and starts
looking up articles on on cellulite and
how to decrease the appearance of it and
so I found these articles on something
called verisol and it was a college in
made in Germany and they'd studied
actually done like really high quality
studies like laser measuring wrinkles
and cellular ger are precise and uh they
and it looked they had positive outcomes
I'm like well it won't hurt me so I
ordered some I Googled where do I find
this verisol collagen I find this
company I order it and then one day I
talked about it on the
internet and the company called me and
said would you please let us know when
you do that cuz they sold out of their
supply for like 3 months so the same
like manufacturer of that particular
verosol made this
forone did the studies five years doing
bone density scans on these women it was
a small study but they saw improvements
we know what happens to bone density if
you do nothing it goes down these went
up and I thought okay I want to do and I
want to offer this to people like if not
then me this is a high quality product I
can rep you know and that so that's part
of my um what I offer to people or what
I recommend you can get it anywhere
other people sell it not just me great
um
so I'm perplexed this isn't a challenge
but I'm perplexed how would a protein
that's not a complete protein um be
beneficial for a body organ like skin
whereas the complete proteins don't seem
to do it on their own nobody knows okay
I don't know interesting are they
studying the right thing or they're not
really looking at it so I don't know
there great when I hear I don't know the
know the scientist in me says great area
for for exploration because we don't
really believe in fact we don't believe
um that amino acids um that are derived
are derived from a particular body part
Target that tissue we've heard this
argument before um Dr Lane Norton and I
have both gone on record publicly saying
there is basically zero not basic delete
the basically there is zero evidence
that when you ingest heart uh let's say
you you like eating liver or heart or
skeletal muscle that somehow the amino
acids are selectively trafficed to the
organ uh of the heart or the liver or
the skeletal muscle there's no evidence
of that whatsoever certainly not in
humans if there is evidence um I'm sure
they'll let us know in the comment
section on YouTube and let let us know
but yeah it's it's it's perplexing why
collagen would have a selectively
beneficial effect on skin they didn't
study it versus a steak you know they
just they just looked at bone density if
they took this product every day for 5
years and what happened and they weren't
you know they weren't having tremendous
cardi metabolic disease they weren't on
bone building medications they weren't
on HRT so you know they they did a
pretty clean so there's you know not a
huge study but it was interesting and I
thought okay you know I don't want to
break because if I break my hip well 50%
of women will have an osteoporotic
fracture before they die 50% 5050 what
about men do we know just by way of
comparison I think it's 25 wow but don't
quote me on that I need to look that one
up so it's it's about half okay and then
hip fracture if you if you break that
hip if over the age of 65 you have a
your one-year mortality with surgical
repair is 30% if you if you're not
healthy enough to have the repair you
can't afford to have it it's 79 goodness
so that's what we're trying to avoid is
that you know and the tremendous if
you've seen the women who have
tremendous osteoporosis in their spine
and just how their lives are so hard and
how much pain they live in every single
day you know this a lot of this is
avoidable with aggressive you know being
aggressive and and intentional about
this and HRT can be a huge part of that
as well what I'm about to ask is a
little bit outside the box but I feel um
Fair asking given that um you know I'm
not a clinician but I have some
background and certainly understanding
of neurod degenerative uh conditions of
the eye and vision have you ever
observed in your patients that when they
get on hormone replacement therapy for
menopause that things that are typically
associated with aging like diminished
visual function um hearing you mentioned
tenus also called tentis I understand
but tenus I think we'll do both tenus
cored and said tenus we'll do both um
here that that they um they report
seeing better hearing better and any
kind of sensory Improvement or offset of
sensory loss so we know the data is
clear on dry eye and how that can affect
um but how it affects like the optic
nerve you know we know that estrogen is
anti-inflammatory so any kind of like
inflammatory condition in and around the
eye does tend to get better but we need
you know probably more data in this area
for hearing most of the research is
around tenus and vertigo so the the the
rate of which the crystals break off in
the ear accelerates in menopause and
people on HRT have less vertigo new
vertigo than they would have had before
and I forget what the pathophysiology I
wrote it in the book but I can't think
of it right now um what the physiology
was behind why tenus increases in um
menopause but it's due to the estrogen
levels declining you mentioned dry eye a
lot of people might hear dryeee and
think oh no big deal but actually dry
eye is one one of the most frustrating
things um to have and it's a uh I
believe a many billions of dollars of a
year industry to find treatments for for
dry eye um so does estrogen replacement
therapy improve dry eye it does seem to
they have less incidents most of the
studies are just retroactive and they're
looking at the incident of those things
on women HR on HRT for other reasons are
not and they just see especially like
frozen shoulders the best data there I
think and um what they see is a
decreased risk of occurrence and then if
they do have it they have a shorter
duration and easier cour you know easier
to treat if they're on HRT fantastic so
um what are some of the cases where uh a
woman can't or shouldn't do hormone
replacement therapy and here we're using
hormone replacement therapy is kind of a
proxy for for estrogen therapy yeah so
any hormone sensitive cancer a one of
the things a lot of women don't
understand if you have dysfunctional
uterine bleeding that has not been
evaluated you should not start hormone
therapy because we don't know if it's
cancer so if you're having really heav
especially if they're heavy bleeding
clots out of nowhere you know something
unusual about the volume or the the
frequency of your bleeding you need to
go see a gynecologist and get that
evaluated before you start hormone
therapy okay it may not be anything
cancerous or tumorous it might just be
the hormone changes but that needs to be
evaluated um if known breast cancer no
if you're actively having a blood clot
that you're being treated for they're
saying let's hold off until that therapy
is
over um even if you've had a hormone
sensitive cancer including breast cancer
depending on the stage the type and and
it's a very nuanced conversation does
not mean that you automatically
disqualified for hormone therapy after
your
treatment so that is one of the biggest
misconceptions out there if you have
really severe liver disease I'm not
talking about mild fatty liver disease
lots of menopausal women have that and
it does tend to get better with HRT if
you have severe liver disease that is
where estrogen begins to be metabolized
and so you could have abnormal
metabolism you don't want that so that
you're that's going to keep you from
being a
candidate why do you think we're seeing
or at least hearing about in my case uh
PCOS polycystic ovarian syndrome so much
more is it because people are aware is
it because I think two reasons one the
Obesity epidemic had led to more PCOS
that is definitely a risk factor for for
you know insulin resistance is usually
the the main pathophysiologic cause
behind PCOS and I a PCOS then PCOS
sufferer so I had it my whole
reproductive life um both but you're not
obese at all no no they missed it
forever I was just stressed out medical
student which can potentially cause PCOS
with acne yeah I mean you you can have
PCOS is a symptom of something
biologically a barent turns out I'm
insulin resistant which is why you know
even though I'm thin and so we've had
higher increasing levels of obesity
which is a risk factor for that also
people are talking about about it and
that writing books about it Karen Tang
just published um it's not Hyster wait
hysteria it's uh it's not hysteria and
she's a gynecologic surgeon does a lot
of work around enetri so she has like
huge chapters on PCOS and how to
advocate for yourself and you know all
about the disease process so people
understand interesting what what are
some of the primary treatments for PCOS
is it going to be blocking androgens so
yes and so for me you know in all my
training it was always put them on birth
control because it w it it will suppress
ovulation and suppress the over
production of androgens in their system
so I was a very happy birth control
patient because I was thin for the obese
patients if we can help them lose weight
it does tend to they start ovulating
again and so now with the new go 1s a
lot of PCOS will probably resolve itself
and they'll start ovulating again and go
back to normal Cycles that's the
pregnancies that are happening from G
ones I see so glp1 associated1 babies
yeah gp1 we saw a surge of that when all
the patients the obese patients were
getting the gastric bypasses then they
get pregnant and so we were advising
them to not be pregnant until their
weight was stable for a year after
surgery because of the medical
implications of nutrition and pregnancy
but they were going to you know they
were so excited and CED and now their
libido's up and and they're you know
getting pregnant and um never really
needed contraception before and just
assum they'd still have trouble and so
now they're ovulating and getting
pregnant and we're seeing the same thing
with gop1 so I'm anyone listening out
there who's prescribing a gop1 please
talk to your female patients about
contraception if they don't want to be
pregnant very interesting and um
admittedly uh unforeseen uh implications
of glp1 as long as we're there um what
are your thoughts onic monjaro um I
think that they can be a really
important tool for a lot of patients I
don't think they're for everyone I don't
think people are being counseled
adequately a lot of them I mean in my
area outside of galvaston where I live
there are Med Spas giving out GOP ons
and as far as I can tell they're just
giving them the meds and sending them
out the door I've had patients coming in
on it who were never counseled about the
potential for muscle loss so when I look
at a patient's health I look at a
30-year plan right and so they come in
with a lifelong history usually of of
having a weight problem and a fat
problem and and here's this medication
that's going to take the food noise away
and help them focus on the habits that
are going to keep them healthy longer so
I do have patients that I've prescribed
it to we have a very long discussion
about adequate protein intake resistance
training you know I have a a way to
measure their muscle mass we are
tracking that every month for them every
month to six weeks while they're you
know on the medication so women who are
on HRT with the glp1 have a 30%
increased weight
loss wow yeah yeah I appreciate that you
mentioned that the use of OIC monjaro is
not mutually exclusive with resistance
training and improved nutrition the way
it shows up on social media sort of like
people assume well you know you gotta
take great care of yourself and exercise
well great but there are also a number
of people that are carrying excess
weight to the point where um they are at
risk of injury when they exercise um I
mean everyone's at risk of injury when
they exercise but what I'm hearing is
that you basically take the view
whatever can get people in a kind of
forward Center of mass around management
of blood insulin levels Etc cuz wasn't
that the original FDA approval
diabetes diabetes um and there's also
some datas I recall that OIC monjaro can
reduce alcohol cravings that so yeah the
reward center in the brain are the the
noise so they're looking now I guess
that my friends who are like obesity
Medicine Specialists and are all like
reading every study that comes out any
kind of impulsive behavior or
reward-seeking behavior gaming gambling
alcohol you know people are tending to
do less of those behaviors because
whatever the whatever is being blocked
in the brain and you know more about
this than I do seems to help with that
those drives that's interesting that the
hypothalamus is uh choca block full of
neurons associated with all sorts of
drives and temperature regulation you
mentioned earlier you know the preoptic
area of the of the hypothalamus involved
in temperature regulation and we've
always viewed those as somewhat separate
but they're actually um quite
interconnected and and so I'm not
entirely surprised that uh a drug that
would reduce cravings for food might
also reduce cravings for other things
it's going to be really interesting to
see um what the science and the animal
models and human shows us over time it's
definitely happening I mean this is has
it hit a trillion dollar industry yet
it's probably hundreds of billions of
dollar know the majority of big F
research and funding is is being
funneled into this um maybe not all for
the right reasons but the the Obesity
Medicine Specialists who are kind of who
I turned to for how do how do I do this
how do I do it right
um how do I not hurt someone just to get
them to lose weight you know and are
very excited because these new levels
they say it's like the iPhone 12 the
iPhone 13 like they're just going to get
better and better with Lower Side
Effects better profiles you know as time
goes on that we're going to look back at
the Muro and these earlier meds and be
like oh my God what were we doing you
know because of the side effects well if
nothing else there very interesting to
pay attention to because it's uh clearly
uh in the cultural Zeitgeist right now
so every once in a while when a guest
for whom the topic is of immense
interest coming on the podcast I'll put
out a call on social media for questions
and so uh if you're willing I'd like to
just ask you a few of the audience
questions um and we can treat these as
rapid fire or um as much depth as you
like um first off that many of the
questions you've already answered things
like um what the role for testosterone
replacement therapy in women um as
opposed to just estrogen replacement
therapy but one of the more common
questions in here that uh We've touched
on but I think could um uh deserve a bit
more attention is you know if a woman is
in her 60s and has already gone through
menopause is it appropriate for her to
consider or at least just talk to her
doctor about hormone replacement therapy
or she putting herself at risk there's
definitely worth the conversation so if
I have a patient who comes in and she
she's she's more than 10 years P her
menopause or over the age of 60 and has
not been on
HRT then we start looking at risk
factors for cardiovascular disease or
stroke and so we're looking at her blood
pressure her lipids her you know
cholesterol and triglycerides and
looking for things that are going to put
her at higher risk she's lost probably
the maximum cardiovascular benefit but
we don't want to put estrogen on top of
severe atherosclerotic disease so if she
has abnormal cholesterol I'm going to
send her for a calcium cardiac score I
want to see if there's calcified plaques
around her heart I may even if if stroke
is a risk we may even Cent her for an
ultrasound you know looking at the
intimal thickness um of the kateed so if
those are normal or lowrisk then we will
talk about the benefits of what what
would the benefits be for her after the
age of 60 will we probably lost the best
of the cardiovascular protection but it
will always protect her bones it will
always protect her genital urinary
system it will always protect her skin I
mean there's things that estrogen will
do for us forever and so and then let
her make the decision certainly if she's
still symptomatic meaning hot flashes or
things we can easily identify that we
know estrogen will help with but you
know that first tenear window is kind of
critical for the preventative benefits
but it doesn't mean she's not going to
benefit forever now when do we stop used
to be doctors make up numbers three 10
years whatever if she's been on it since
early in her menopause and has not
developed any of these diseases and she
wants to keep going we're going to keep
her on I will probably die with my
estradiol patch on if I don't develop a
reason to take it off because I know
it's protecting me in so many levels and
I want to keep that
going in so many ways it sounds very
similar to testosterone replacement
therapy and Men the ideas that people go
on why you stop at 70 why would you do
that right you know if you didn't
develop a contraindication to it very
clear and um potentially very actionable
answer thank you um a number of the
questions related to um the relationship
between menopause hormone therapy and
mental health mental well-being um but
let's just keep it simple for now and
ask what are the things that women can
do in order to um optimize or their
mental health in per menopause and
menopause and that they can do to offset
any mental health issues that might
arise during per menopause and menopause
and there's a reason why I asked about
those two things separately one is just
to very different than menopause for
mental health so a great question so I
just went to a menop posium menopause
conference in
Chicago and uh there was a whole section
on mental health and it was uh
neuroscientist psychiatrists and and
menopause Specialists all up there
discussing the latest data it was so f
fascinating and so there really is a big
difference as far as mental health for
what's happening in per menopause and
what's happening postmenopause and as we
talked about earlier in per menopause we
have that hormonal zone of chaos and we
see this you know in the Australian data
it's a four times risk of mental health
disorders especially
depression and then in
postmenopause a lot of these things tend
to stabilize or get better probably
because just the estrogen is bottomed
out and the brain is not having to deal
with these fluctuations
so we think that the data is looking
like the best treatment for the mental
health issues in per menopause is going
to be
estrogen for stabilization and not the
traditional ssris snris you know the
anti-depressants and the anxiety meds
not incidentally uh one of the more
common questions was um in this case
very specifically worded I've been on
HRT for 5 years and I'm 61 I feel great
but how long as it quote unquote okay to
be on them seems like I hear conflicting
opinions well we just heard a very
straightforward opinion from you so
thank you for that as long as you want
to be as long as you're still
healthy how can I stop waking up in the
middle of the night this is a problem
since entering menopause MH so we see
sleep disruptions definitely from not
only from the vasomotor symptoms which
will wake you up okay if we can get
those under control you know your sleep
function should not be affected by that
what we're seeing though is people even
with HRT even with estrogen are still
having middle of the night Awakenings or
racing thoughts or having they get up to
pee or something in the middle of the
night and they can't go back to bed
usually because their brain is is going
on what we found is that progestin
probably through the effects of Gaba is
very effective at settling your brain
down and allowing for sleep so I'm
having my patients take their
progesterone Orly at night before they
go to bed and we're seeing better sleep
with that and that was also something
covered in detail I was so excited by
the neuroscientist that's part of her
area of research that they are showing
clearly and she can point to the neuro
receptors of where that's happening that
progesterone seems to be really
protective for our sleep now take
hormones off the table sleep hygiene is
still hugely important and I need to see
the studies to prove it but I'm telling
you we do not tolerate alcohol like we
did Prem menopausal women are in at
least 90% every time I post about it
online I see thousands of comments of I
quit I had to give it up I cannot sleep
and even in my own life if I choose
socially to have more than a glass of
wine I am giving up sleep like it is a
choice I'm choosing not to sleep that
night I will wake up 2:23 3:35 whatever
time in the morning sweating and I'm
like you know too much champagne at New
Year's or whatever so you know that is a
choice and it's something I councel my
patients about like you probably can't
tolerate alcohol like you used to aging
is a factor here our body composition
changes and there's probably something
hormonally that's going on we don't
understand yet but like you choose this
you're going to choose not to sleep more
than likely interesting I wonder whether
or not um estrogen modulates the alcohol
dehydrogenase enzyme but uh time hav't
seen the data yet but I'm sure it's
coming here's an interesting One how can
men help their female loved ones
navigate these stages yeah you get that
question a lot my and it's it's great
and it always comes on the when I'm
being interviewed by a male you know
when I'm interviewed by a female they're
wonderful but they they have their own
experience and they have to talk about
it and that's fine that's my job you
know is women have to unpack their
menopause trauma to me but the men are
just so curious and just have so many
questions and then how can I support a
partner and or my mom or whomever in my
life who's who's dealing with this one
is is acknowledge that this is happening
and and try to educate yourself there's
my book other books there's lots of
information now on the internet about
the subject but she is going through a
transition that is in her world more
than likely and is affecting her brain
her bones her heart her kidneys her skin
her ability to relate her ability to
tolerate it's probably going to affect
your relationship in some way go there
with her go to the appointments with her
be there to advocate for her you know be
a partner through this with her because
you will get her back but it's going to
take you know changing the way that you
address things a couple of questions
about quote how to rekindle libido oh
yeah this person in particular says it's
packed bags and moved out since I
started menopause they're reporting
their individual experience but um you
touched on testosterone therapy earlier
any woman
in her menopause Journey at any time
there's a 50% sexual dysfunction rate
meaning she's not happy with whatever is
going on now when we look at the buckets
where sexual function fall into we have
orgasmic disorder now in menopause when
we lose blood flow to the area people
can have delayed orgasms or less um the
peak of the orgasm is lower you know
less vibrant orgasms for lack of a
better word um they have decreased blood
flow to the area they lose elasticity so
pain is another bucket you know it hurts
the skin gets torn it's very fragile
it's very Frable so vaginal estrogen
therapy can help there there is arousal
disorders where you want to do it but
the blood's not getting where it needs
to go so you're not having all the
arousal type symptoms so sometimes
Viagra selenophile topical selenophile
can be helpful there there and but the
most common thing that women have is hsd
or of course relationship disorder you
don't love your partner you don't feel
supported it's going to be hard to you
know relationship disorder official the
official term so but then hsdd is
hypoactive sexual desire disorder that's
in the brain and so first thing I ask is
did you use to have a good libido or a
drive yes you know and you have a good
relationship with your partner it
doesn't hurt you we have to rule out the
other things that's where testosterone
comes into play that that is those
patients it does tend to help there are
two FDA approved medications for libido
one is VII it's an injection you give
yourself and actually works for men as
well about 30 minutes before it's in the
alpha melany stimulating hormone path
mordon and then there is um Addie addyi
works at the level I think of dopamine
in the brain so it's more in the family
of ssris that you know so it affects
neurotransmitter and so you take that
every day um and it works it was only
studied in premenopausal women but it
does you know it's modest but it does
seem to have an effect so but most of my
patients
because testosterone has so many other
benefits you and then the the cost the
to get it compounded in Texas is maybe
30 bucks a month so it's really
reasonable um and the V and the atti can
be very expensive and usually not
covered by insurance so because of cost
and and potential other effects most of
my patients choose testosterone if it's
hsdd I see this is a question about the
um side effects associated with estrad
hormone replacement therapy in this
particular instance um the person says
um what are the best alternatives to
estrad I've tried tiny amounts and the
side effects in this case um skin rashes
and hives are what they are describing
so I wonder if it's the patch so um
there's a certain percentage of patients
who it's not the estradiol it's actually
the adhesive in the patch they will have
a reaction to it so one is try an
alternative form another thing that one
of the members on my team saw in her her
chat group is they get the flon so
corticon nasal spray over the counter
and they spray it on and let it dry then
they put the patch on and it decreases
the risk of the reaction to the glue um
I don't know how if that lasts forever
but I thought that was a cool thing to
know about and um but what I typically
do for my patients is change them to an
alternative form interesting um thank
you for that they went on to ask about
um trying a new supplement called equil
EQ u e l e about that one again I don't
know what's an equil um but again not
really robust studies but most of these
things are not harmful but you may just
it may be a little snake oil you know
throwing your money away really the
thing that's going to fix the problem
for most women is restoring your estr
yeah because there were other questions
about you know wild yam and and things
more in the supplement um space um as
well as things like acupuncture and
herbal medicine so um acupuncture can
really be helpful
um but again it's it's hard to access
and can be expensive for a lot of
patients and it's not treating the root
CA but it definitely can help you deal
with some of the symptoms and make you
more comfortable and then um last
question um how best to attack and here
I'm quoting attack the fat distribution
problem at this time yeah uh you need a
multifactoral approach to visceral fat
so nutrition exercise women on HRT have
less visceral fat you know um those are
kind of the key things and and the way
you approach your nutrition with the
exercise with the stress reduction
getting those cortisol leveled down are
going to make you healthier in every
other way as well great well Dr Mary CLA
um thank you so much for giving us just
a wealth of knowledge about per
menopause menopause really explaining
what those are clearly um for the first
time on this podcast and really
illustrating the things that people can
do to think about these stages of life
and to to I don't know if I should say
tackle or to dance with the stage of
Life whatever um term one prefers in
order to offset the negative effects and
it sounds like in fact it's very clear
based on what you've told us that there
are real levers of control yeah
including hormone replacement therapy
but other things as well
nutrition exercise um sounds like when
we put all these together there's almost
like a mindset around per menopause and
menopause that you are um promoting um
which is one of of real agency that this
is not something that is um going to
bury us mentally and physically that's
something that really can be worked with
and I just want to say on behalf of
myself because I've learned so much from
you here and uh the listeners and and
viewers of the podcast thank you for the
information today thank you for your
clinical work um thank you for your
ongoing Research into this area for
attending these conferences and learning
so much about it so you can bring us the
latest and thanks for your public
education efforts because they are
really really making a tremendous
difference thank you thank you for
joining me for today's discussion with
Dr Mary CLA Haver to learn more about
her work please see the link to her
website in the show note caption as well
as the link to her terrific book the new
menopause navigating your path through
hormonal change with purpose power and
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