Transcription
In 2023, 85% of women are complaining of menopausal symptoms, while only 10.5% are receiving treatment or therapy. I mean, it would be as if your testicles shriveled up and died at 51—that's the equivalent.
Let's get started. Dr. Mary CLA Haver, renowned menopause expert with more than 2 million followers, is helping countless women through their menopause experiences. Menopause is inevitable; suffering is not. But a woman is more likely to be prescribed an anti-depressant for her menopause than hormone therapy. Women by the thousands are like, "Oh my God, I had no idea." That's when I realized no one's talking about this.
So here's their laundry list of symptoms. We've categorized about 70, including brain fog, changes in sexual function, and weight gain. But here's the scary thing: studies have shown either a new onset or worsening of depression, anxiety, bipolar disorder, and ADHD. The risk for cardiovascular disease and diabetes increases, along with recurrent urinary tract infections, which is a major cause of death for women. They're suffering in silence, and I was one of those women.
I want to see my grandkids one day. I want to watch these women I've raised grow up and be the women they're meant to be. That choice might get taken away from me if I'm not careful. But there are lots of things we can do. For example, we see a dramatic loss of muscle mass, so focus on strength training. This will determine your longevity as you age—strength over skinny.
What about your diet? I developed a program for my patients, and it's not rocket science. Whether you're a man or a woman, menopause is going to affect you because it affects 50% of our society. There are 1.2 billion women being affected by menopause right now. Whether you're a man or a woman, most of us don't have the answers. How do we help? How do we talk about it? What is it? How does it affect the human body?
If you're in a relationship with a woman in perimenopause, which can start at 30, or a woman currently going through menopause in her 40s, 50s, or 60s, what should you do to support her? What can she do to support herself? The subject of menopause has exploded in public conversation, thankfully, but there are still so many unanswered questions.
That's why today I invited one of the leading voices on menopause globally onto my show. Even as a man who won't go through menopause myself, but has a partner and a mom who certainly will, there's something everyone can learn from this. I implore all men who maybe clicked on this episode or were sent this link to listen. Please just listen because you can learn something too.
For everybody new to this channel, can you do me a favor? If you like what we do here, you like the guests we have on, and you like the show that we bring to you, can you hit the Subscribe button? It is the single thing and the only thing I'll ever ask you. I would love you to join us on this journey, and if you do, I will repay you, and that is a promise. Do we have a deal?
Thank you, Dr. Mary CLA Haver. Why do you do what you do?
You know, I started out in medicine the way most people do. I wanted to help people. In our training in school, we get to have a little taste of all the different specialties. My very last rotation in my third year was OBGYN, and I really liked surgery. I really liked some of the surgical subspecialties, so I thought that would be my path. But then when I delivered my first baby and all that rush of emotion and dopamine and how beautiful that whole process was, I knew that was going to be my calling.
So I did the traditional four-year residency, loved it, and really did well. I went into private practice. After about three years of doing the private practice route, I realized I missed being in academics. I wanted that ability to do research, be around students, and teach as well as take care of patients. So I went back on as faculty, and everything was going great. I was very successful. I was doing paps, delivering babies, and providing birth control—everything the traditional OBGYN does.
Then I was aging as my patients were aging too. When I got to my 40s, I realized there was a big gap in my education and knowledge around menopause. So I started researching. Most of my patients were coming in, and the pain point was weight gain. They were like, "I'm not doing anything different. I'm working out. I haven't changed my diet." That little voice in my head was like, "Work out more."
We tend to move less. I was just going with the script that had been handed to me for years—that calories in, calories out is the only way. In medicine in the U.S., we have very little background in nutrition. We learn nothing in medical school and very little in residency about what nutrition actually is and how it can affect our bodies.
So I started struggling with my own menopause. My patients were all struggling, and I decided to go back to school to learn more about nutrition because I felt there was a big piece missing here. This weight gain was mostly centered around the midsection. I was learning about visceral fat and subcutaneous fat, the differences, and what's going on with our muscle mass. I realized there's a much bigger picture here than just calories in, calories out.
I enrolled at Tulane University in their culinary medicine program, and my mind was blown by how much I didn't know about nutrition, inflammation, and aging, and how it all affects us. But where was this menopause piece? So I took everything I learned and developed a little program for my patients, which became the Galveston diet. It was just a passion project for me.
Then I started talking about it on social media and realized that as my social media presence grew and the conversation got bigger, there were so many women suffering. Probably the majority of women in menopause were suffering not just from weight gain but from musculoskeletal issues, mental health issues, brain fog, skin changes, hair changes, and nail changes.
I just kept doing deeper dives and realized no one's talking about this. No one's talking about the multi-organ system failure that a lot of women are going through, and they're suffering in silence. Physicians aren't helping; we're not trained.
It's really my kids who encouraged me. I have two daughters—one's 23 and in medical school right now, and she's actually here with us. The other is 20. They were like, "Mom, you've got the social media presence; you really need to use it for good." That's where that conversation exploded for me on social media, and I realized by reading the comments what was really happening in the menopause world and how we need to bring it to the forefront.
For people that don't understand menopause, they might think it's a small issue affecting a small group of people. But how many women are affected currently by perimenopause, menopause, and postmenopause?
Right now, about a third of the female population of the world is in perimenopause, full menopause, or postmenopause. You do not get to opt out; all of us go through it. Because we have such individual expressions of how it affects our bodies, what we know now is that there are estrogen receptors in every organ system of our body. When those levels start declining, we see a very wide variety of symptoms.
It used to just be thought that it was a few hot flashes and some night sweats. Maybe your sleep's disrupted, your genital urinary system is going to take a hit, and your bones are going to get weaker. But what we know now is how much it's affecting our mental health, our capabilities, our skin, our bones, our kidneys.
You know, vertigo, frozen shoulder—anytime I post about those on social media, the internet explodes. Women by the thousands are like, "Oh my God, I had no idea." The validation piece is so huge for them because they've been dismissed for so long and told it's all in their head.
If we think about the transition from perimenopause to postmenopause, what is that sort of typical—and I know that's a tricky word to use—but what is the average age range? And what is the more possible age range?
In the U.S. and in most of Europe, the average age of menopause, which means one year after your last menstrual period, is 51. Perimenopause, which is when your body recognizes there's some declining estrogen levels and you're beginning to be symptomatic, can start 7 to 10 years before that.
Normal menopause is still 45 to 55. If you do the math and back that up 7 to 10 years, it is completely reasonable for a 35-year-old woman to begin to experience some of the symptoms of perimenopause.
So let's start with what it is. I would love you to explain this to me like I'm a 10-year-old, okay? Because I'm sure there are a lot of people, both men and women, that aren't clear.
So we're going to talk about gonads, right? What's gonads? Gonads are where our reproductive cells are produced. In men, it's the testes, where they're making their genetic material to produce sperm. In females, it's the ovaries.
The big difference between male and female is that males make their genetic material fresh constantly, from puberty until they die, unless they have some medical issue. Females, on the other hand, have our eggs develop while we're in utero. When our mothers are five months pregnant with us, we have our maximum eggs that we're ever going to have, and those are meant to last us until we go through menopause.
They lay dormant until we go through puberty, and then they wake up again, and we start ovulating. We have this monthly, cyclical hormone rise and fall with our cycles. Each month, we have a period, we get pregnant, we don't get pregnant, and the whole process starts over again.
Because we're born with that egg supply, over time, we're decreasing the amount and quality of those eggs. When a woman hits the age of 30, she is down to about 10% of the egg supply that she had at birth. When she's 40, it's down to about 3%.
It gets harder and harder for that ebb and flow of the natural hormones to do its job, and we start seeing fluctuations in periods and organ systems that are beginning to notice the lack of estrogen. Estrogen is a really powerful anti-inflammatory hormone in most of our body systems.
The musculoskeletal syndrome of menopause is really starting to be talked about quite a bit now. We're looking at things like frozen shoulder, generalized aches and pains, and most physicians aren't aware of this. Most know about hot flashes, night sweats, and sleep disruption.
But now that we're really opening the conversation as to how many organ systems are affected, we are seeing people coming out of the woodwork just so happy to know that they're not crazy and they're being validated.
What happens at these sort of three stages?
So we have the perimenopausal stage, which is when estrogen levels start to drop. We start seeing disruptions in the cycle. Instead of that nice monthly estrogen surge with ovulation, we start elongating the cycles, or they even get closer together. I call it the zone of chaos.
What used to be a very reproducible, dependable system starts failing. Some women will have irregular periods, meaning they're spacing out or skipping periods. Others will have really heavy periods—hemorrhagic, almost.
The way the body reacts to this is very individualized from patient to patient. Doctors love something that follows a checklist, right? We have all these complicated things we have to learn, and we have these checklists. But menopause is like pinning the tail on a moving donkey.
In perimenopause, it's very chaotic. Estrogen surges, then it goes away for a while. A woman in perimenopause can feel completely fine for a few months, then everything goes haywire, then she's fine again.
Not only is her estrogen declining, but her testosterone is declining as well. We're seeing loss of muscle mass, changes in sexual function, and decreased strength. There are some really good studies showing how testosterone also affects our mental health and cognition.
Why does this happen from an evolutionary perspective?
Anthropologists have looked at this heavily. There are only a couple of species in the world that go through menopause. Humans are one. There are a couple of species of whales, and I think they've now discovered one of the giraffe species can do it.
But by and large, most mammals will die while they're still ovulating. They're not going to go through menopause. There's something called the grandmother hypothesis, where there was an evolutionary advantage for women to survive if they stopped the ability to have children at some point.
You have to temper this with the fact that humans have prolonged their lifespan and health span because of modern medicine. So probably when we evolved, we weren't living this long. A woman my age was pretty rare—I'm 55.
It's hard to say. I think we have outlived how we were genetically built, and we're living longer and being forced to deal with the consequences of that.
So then the next stage is menopause.
Menopause itself is really just one day in your life. It's when you can throw the hammer down and say, "I'm never going to ovulate again. I'm done." If a woman is over the age of 45 and she hasn't had a period for a year, that's the definition.
Now it gets confusing because what if she's had a hysterectomy or doesn't bleed because of surgery or an IUD or something? Well, then we can't use her periods to help judge, and that's where we start doing blood work to see where she is in her menopause journey.
Then postmenopause is the rest of your life. The hot flashes might go away, night sweats might go away, and brain fog might get better. But pretty much everything else is going to continue to progress in a very linear fashion until you die without estrogen replacement, to put it lightly.
You seem somewhat dissatisfied with the current set of answers that the medical field, but just society at large, are offering for women in the perimenopausal and postmenopausal phase of their life.
I've sat here with a lot of women who are experiencing menopause at one stage or the other, and they also seem to be at a loss for answers. I was sat here two days ago with a very successful woman who has all the resources in the world. She basically said, and this is someone that has all the answers—people come to her because she has the answers—and the one thing she doesn't seem to have answers on, in her own words, in her life at the moment, is menopause.
She's rummaging around the internet, Googling things, finding contradictory information. When you sat down, you had that same energy. You feel like women have been, dare I say, let down by a system.
I think the medical system is letting them down. I think society is letting them down. Our value and our worth in medicine— you know, I came through this wonderful training program. I'm very proud of what I learned. I'm very proud of the care that I gave.
Except I was a horrible menopause provider for probably 15 years. I knew what I knew, I relied on my training, and I didn't look outside of the traditional confines of training. This is such a systemic problem.
I'm going to tell you a story, and this is true, and it's embarrassing, but I think it needs to be said because I think it really highlights how women are treated in medicine.
When I was in training, we had these upper-level residents. We have a hierarchy where you have different years of training. I was in my early years, maybe my first year, and we had these clinics that we would run to take care of patients.
In gynecology, everything gets lumped together—pediatrics, menopause. We had no specific menopause clinic. I maybe got six hours of lecture in a four-year curriculum.
So we had these women coming in in midlife, and they had multiple complaints. They didn't feel good, they weren't sleeping, they were gaining some weight. Just this laundry list of things that were a little on the vague side.
My upper levels would say, "Oh gosh, good luck with that. You've got a WW on your hands." That was code. We never wrote that in the chart. This was not taught to me by faculty; this was just kind of handed down in the lore of training.
A WW was a "whiny woman," and that was code. Now I know that she was perimenopausal, suffering from her list of symptoms, which we've now categorized about 70. They were frustrated because they didn't think they could help her.
Now remember the Women's Health Initiative, which was a study that was supposed to do a lot of good for women. It was originally designed and was stopped in 2002. That was the end of my training program—2002.
I come from one of the last groups of physicians in the U.S. that were ever trained in hormone replacement therapy, and then the rug was pulled out from under us. There were mistakes, misinformation in the reporting, and misinterpretation of the results.
All of that has been walked back and relooked at. We know that for the vast majority of women, hormone replacement therapy is safe and effective and can give a woman her life back if she chooses to take it.
But that option has been taken off the table for the vast majority of women. Recently, I just saw the numbers: 85% of women will come in complaining of what we know now. This was in 2023. The FDA looked at the numbers: 85% of women are complaining of menopausal symptoms, and only 10.5% are receiving treatment or therapy.
Is there something in you that feels somewhat, even though you're a doctor, let down by the medical system or skeptical about the medical system for personal reasons?
Yeah, I'm one of those women. I thought I'd be one of those girls who would just breeze through menopause because I was thin. I thought thin meant healthy. That mentality was alive and well when I trained and through most of my practice.
I came through a very fat-phobic training. Medicine as a whole is very biased against people's weight. Now that I've done a deep dive into nutrition and menopause, and really sat there and listened to patients, I realized that women who were gaining weight with menopause had done nothing different.
They're still exercising, they're eating the same. The only thing that's changed for them is their hormones, and they're being categorically dismissed at multiple doctor's visits. Or worse, here's their laundry list of symptoms. The root cause is menopause, but it's not recognized.
One medication could have taken care of everything, but they're going to seven, eight, nine different specialists on seven, eight, nine different medications to handle each symptom, whereas all they needed was just to get her hormones back, and she would feel amazing and be able to age the way she should.
When we talk about the potential health implications of women going through menopause, it's not just "WW," right? It's much more. That's how she feels, though, and that's how she's categorized probably by people around her.
But there are real health consequences and life-altering health consequences—lifespan-reducing health consequences. Yes, what are those?
We know that a woman's risk for cardiovascular disease increases. Her risk of diabetes increases. Her insulin resistance starts going haywire immediately. Your listeners and your viewers will be shocked to hear how many of their cholesterol levels shot up in their 30s and 40s with no changes in diet and exercise.
We see cholesterol levels changing, skin, hair, teeth—the dental changes, the inner ear changes, the vertigo is incredible. Frozen shoulder is legion.
What is frozen shoulder?
Frozen shoulder is an adhesive capsulitis of the shoulder joint, and it is very common in menopause. Estrogen has this amazing anti-inflammatory effect, especially in our bones, joints, and muscles. Frozen shoulder is super common, and it takes about two years of therapy to get it to break up.
The capsule that is right over the bone, where the muscles attach, becomes encapsulated and adhered and stuck. You have to get in there and break it up and do lots of training. A woman wouldn't be able to reach behind her back to do her bra. That's one of the things.
Or you go to take a picture with your girlfriends, and you can't lift your arm above your head. That's one of the studies that I present a lot of the stuff I do on social media. I like to have data, and I'll get 10,000 comments on, "Oh my God, that happened to me."
Not that I can fix it, but at least they know this is something that it's not your fault. You didn't do anything; your estrogen levels dropped, which led to increasing inflammation in those joints.
Have they seen that there's a reduction in lifespan in women that go through menopause that aren't treated in a certain way?
We know that women on HRT have a lower all-cause mortality.
What's HRT?
Hormone replacement therapy or menopause hormone therapy. In the studies that have been done, the observational studies, and in the WHI, women who were on hormones—especially beginning early in their menopause—have a lower incidence of new-onset depression in their menopause.
Suicide rates have increased, especially in Caucasian women, not so much in women of color in the U.S. during the perimenopause and menopause timeframe.
What is inflammation?
Sure, so inflammation—there's chronic inflammation and acute inflammation. Acute inflammation is what we need to survive. It is the body's reaction to a foreign invader or to an injury or an illness.
So you twist your ankle, right? We injure that tissue, and these chemical messengers are spread from the injured tissue, which basically tells our immune system, "Send blood that way. Send the white cells and the red cells and all the cells that are going to fight and heal this."
You're going to swell, you're going to have pain—that's going to keep you off of that joint so that it can heal. Acute inflammation also happens when we get viruses and other illnesses.
Chronic inflammation is this low-grade, kind of under-the-radar inflammation that's happening in the background. Autoimmune disease is a lot of chronic inflammation, but we also see aging itself.
We can't change the fact that we're aging, but menopause dramatically increases the amount of chronic inflammation that a female will go through just based on the lack of estrogen and testosterone in her body.
I'm trying to figure out why the lack of estrogen and the dropping estrogen causes inflammation.
It turns out estrogen is a really powerful anti-inflammatory hormone. So we're just removing that protective blanket, and now you're aging faster because of it.
Okay, so we need to make sure that we reduce inflammation by any means necessary. That was one of the components of the Galveston diet—anti-inflammatory nutrition.
If I wanted to have a low-inflammation diet, you said there about sugar. Is there anything else that I've got to be aware of or avoid or choose in a supermarket?
Sure, so I try to teach the principles in the form of let's add things in rather than restrict because then we get into eating disorders.
So keeping tabs on your added sugars—keeping those less than 25 grams—but fiber. That's one thing most people are not paying attention to. How much fiber are you getting in your diet per day? Most women are getting about 12 grams per day, and the minimum we should be getting is 25.
Vitamin D is another huge one. About 85% of my patients and women in menopause are vitamin D deficient—not just low, but deficient. We are protecting our skin against sun damage, of course. We're staying indoors more; we're on our screens all the time.
But we're also seeing our guts changing and our ability to absorb vitamin D decreasing. So making sure that you are checking your vitamin D levels regularly and supplementing when you need to or eating foods rich in vitamin D is another one.
Does vitamin D reduce inflammation?
Yes. Vitamin D is a vitamin, but it's also a hormone, and it has multiple functions in the body. Vitamin D deficiencies are linked to lots of chronic diseases. You're more likely to have hypertension, diabetes, stroke—all of the top seven causes of death in women.
So keeping those low is also important for mental health. There are lots of vitamin D receptors in the brain. The first thing I do is check a vitamin D level on my patients when they come in.
So many of my nutrition-based or medical doctors that I've spoken to on this show have spoken about fiber, especially in the last six months. People historically speak a lot about protein and all these kinds of things, but for some reason, everyone seems to be talking about fiber all of a sudden.
Fiber does lots of things for us. It slows down the absorption of glucose into the bloodstream, which keeps our insulin levels lower over time. It feeds our gut microbiome.
There are two types of fiber: soluble and insoluble. Insoluble is what kind of precipitates down to the bottom when you mix up a fiber supplement. That's the insoluble fiber that pulls water into the gut and moves things quicker through the colon.
Soluble fiber dissolves in water. That's the cloudy part that is the food for our gut microbiome. You don't need a prebiotic if you're getting enough fiber in your diet per day.
Keeping that gut microbiome fed, healthy, and happy is going to do a multitude of things. That kind of data is exploding right now in the research world as to where the gut microbiome affects our health.
Our gut microbes make these things called oxybutyrate, which are then absorbed into the bloodstream. People who have high levels of oxybutyrate are actually healthier and have less coronary artery disease, less dementia—less everything.
So really, nutrition—when I talk about the menopause toolkit—hormone therapy is just one very small part of the puzzle. But nutrition should always be first. It doesn't matter how many hormones you take if you're not covering your nutritional bases the way you should.
What are some fiber-dense or fiber-rich foods that are in every supermarket?
Avocado, chia seeds, nuts, berries, your cruciferous vegetables—things that are crunchy. That's fiber; that's making the crunch. Apples, you know. There’s so much.
You don't find much fiber in lean meats or any animal products. So it's going to be your fruits, veggies, seeds, and nuts—like asparagus, tomato, spinach, celery.
Yes, asparagus, celery, and tomato. Just think of things that, you know, the crunch is usually from the fiber.
Okay, fasting.
I'm a fan. It's not for everyone. It's not a great way to lose weight; the data on weight loss is conflicting at best. You can eat a lot of things that will undo the goodness of fasting in your eating window if you're not careful.
There's good data, though, on neuroinflammation and fasting and on systemic inflammation and fasting. So I recommend fasting for the systemic inflammatory benefits.
We do see some really nice lowering of insulin levels overall from fasting. There are so many different types of fasting people talk about.
When I'm teaching fasting to my students or to my patients, I recommend the 16:8 method. That's where Mark Mattson's data comes in. That's 16 hours of fasting in a row, followed by about an 8-hour eating window.
For others, again, it's individualized. Some people do a 14-hour fast, a 15-hour fast. Sixteen is just something to shoot for. If someone's going to consider incorporating fasting into their life, give yourself about a six-week trial.
Don't just try to go 16 hours without food if you've never done it before. Your body will adapt. The advice I got and what I do and what I teach now is that I used to break my fast about 6:00 in the morning before I exercised.
So I pushed that window to 6:15 and did that for three or four days until it felt normal. I wasn't hungry, then I moved it to 6:30, and I just kept bumping that window out in 15-minute increments over weeks.
By week five, I remember sitting at my desk with my lunch ready to go. I was still at the hospital at the time, and I said, "Oh my God, I made it! It's noon, and I don't feel bad."
So I had just slowly let my body adapt and adjust, and I've been fasting since 2015, probably 2014. It's just a normal, natural part of my life. I don't even think about it anymore.
Have you noticed any effects from that?
You know, I do so many things, it's hard to tell. Initially, I do find when I'm fasting, the clarity of my thought is much better. I get much more work done. It's when I do my best research and my best communicating with my followers.
In the morning, you'll often see me on social media in my pajamas with a cup of coffee while I'm getting ready for work because I get so excited about something I learn and want to share it with everyone.
I do find that once I break my fast, the synapses tend to not work as quickly for me.
I was thinking about this too, like from an evolutionary lens. Why fasting makes sense and why this sort of narrative that we're meant to have breakfast, lunch, and dinner—maybe breakfast? I don't know. That's a social construct.
There's really not great science. Now, there are humans that will do better by eating more meals more frequently, and that's why I say fasting is not for everyone. Especially if it triggers an eating disorder or if you have diabetes or hypoglycemia, fasting may not be for you.
But most people can do it successfully, and I really encourage people to experiment with it and see how they do.
I always try to think through an evolutionary framework. I was thinking about how in our hunter-gatherer past, meals were not available 24/7. We would have needed a really focused brain to go out on the hunt.
This explains why when we're hungry, our brain's working better. It almost seems like there's more, I don't know, oxygen or nutrients in the brain. The brain tends to work better using ketones for fuel than glucose, though glucose is the preferred fuel in the body.
When they did studies—animal studies, so take this with a grain of salt—they did mazes, and the animals tended to get through the maze quicker and learn quicker when they were fasted rather than after they were fed.
They were a little lazier.
You can also use ketones as an energy source if you use the keto diet. But I think, you know, when Matson and those researchers were doing their work, their research in Alzheimer's and dementia, there was no keto diet.
They were just knowing that people were utilizing ketones for fuel, which is a normal, natural process. We sleep, and we burn through the glucose in our bloodstream, then we burn up what's in our liver in the glucogenesis, and then it switches to fat to burn for fuel.
Now, there are people who like to take exogenous ketones. I've never experimented with that. I don't have any literature on menopause to support that use.
The third component of the Galveston diet is this idea of fuel refocus. That's looking at food, the macro and micronutrients. I'm really going hard on fiber, vitamin D, and magnesium—things that we tend to, as a gender, be deficient in, especially with menopause.
I'm really trying to highlight those things to make sure instead of counting calories, let's see how much vitamin D you're getting every day. Let's see how much fiber you're getting every day.
Is there a certain ratio of foods that we should be having?
I originally developed the Galveston diet for weight loss. If I had to write it over again, I went really heavy on fats—healthy fats, lower on carbohydrates, and 20% protein.
But I think if I were doing it again, where I'm counseling my patients now is I'm going much higher on protein. What I've learned since that book was written is how important protein intake is to maintaining muscle mass.
I'm also talking a lot about creatine. There are some nice studies done in what we call the elderly—65-year-olds and above, which I'm nine years from that right now.
We're seeing bigger gains in muscle mass and strength with creatine supplementation combined with weightlifting in the menopausal and postmenopausal patient.
I was going to ask you about this whole muscle mass point. Why is muscle mass so pertinent to this conversation?
What we know in menopause is that aging combined with menopause leads to a dramatic loss of muscle mass. In the first 10 years of menopause, we could lose up to 10, sometimes 15% of our muscle mass.
That muscle mass is going to determine your resistance to sugars. Your insulin resistance is really tied to your muscle mass, your functionality, and your ability to recover from a fall.
The other thing is what most people don't understand: the musculoskeletal unit acts as one. When we have low muscle mass, you are dramatically increasing your risk of osteoporosis.
Right now, this might shock you, but 50% of females will have an osteoporotic fracture before they die, and this is almost completely preventable.
What is an osteoporotic fracture?
Osteoporosis is when we lose the density of our bones. Throughout our lives, we remodel our bones. We chew up bone and lay down new bone. We reach our maximum bone density as females at about age 35, and then it slowly starts to decline through the aging process.
When we get to menopause, we see a massive loss of bone density. This loss of bone makes the bone weaker and much more likely to fracture. If you fall and break your hip in menopause, 30% of women with surgery will die in the first year, and 70% will die without surgery.
That year is marked by horrific pain and not being able to move. It's really miserable. So much of this is preventable. Going on hormone therapy, getting adequate exercise, doing resistance training, eating protein, adding in creatine, and making sure you're getting enough vitamin D is going to be huge at protecting our population from this happening as we age.
We can prevent the majority of this.
I want to talk specifically about hormone replacement therapy. You mentioned there was a study previously that scared people—the Women's Health Initiative.
That study suggested there was an increase in breast cancer if someone did hormone replacement therapy. So let's break it down.
Originally, the study was designed to see if we knew from observational studies whether hormone replacement therapy was going to truly be protective for cardiovascular disease. That was the function of the study—in women who took it versus women who did not.
We knew from observational studies that yes, they had a much lower risk of death from cardiovascular disease and all-cause mortality, meaning death from many causes, as well as heart disease itself.
To prove these things, you need to do a randomized controlled study versus placebo. Finally, in 1998, women were getting money. There was a new female head of the National Institutes of Health, and they were funding this study.
This was so exciting; women were lining up in droves to sign up for it. But because the endgame was to prove whether or not it was protective for cardiovascular disease, the average age of the patient was 63 years old.
They recruited and developed two groups: women with uteruses and women without—women who had had hysterectomies or were born without uteruses. Each of them had a placebo arm and then a medication arm.
When you don't have a uterus, you don't absolutely have to have progesterone. When you have a uterus, it's required to give a woman progesterone or progestin to protect the lining of the uterus from the estrogen. Unopposed estrogen can cause endometrial cancer, but we can negate that by giving her progesterone.
So we have an estrogen-only arm and an estrogen and progesterone arm, and they each have a placebo. Off we go. Let's take our meds, let's take our placebo, and let's start measuring.
What they saw in the estrogen plus progesterone arm after two years was a very slight increase in the risk of breast cancer versus placebo.
Now you have to understand there's a difference between absolute risk and relative risk. The relative risk went from—so the absolute risk went from four out of a thousand women per year to five out of a thousand women per year.
So one out of a thousand women treated in the estrogen and progestin arm developed breast cancer over placebo. That is a 25% relative risk increase, and that is the statistic that set the world on fire.
The researchers held a huge press conference at the Watergate Hotel in D.C. Every major news outlet—this was before the internet—announced that estrogen causes breast cancer.
Now remember, these women were on estrogen plus progestin. The estrogen-only arm continued for a few more years because the women on estrogen only not only did they not see an increased risk of breast cancer, but they had a 20% decrease in the risk of breast cancer relative to placebo.
The relative mortality went down 40%. We think it's because estrogen feeds a breast cancer cell, but it doesn't cause breast cancer. Our highest levels of estrogen are in pregnancy, and it's so rare to ever be diagnosed with breast cancer.
A healthy breast cell has estrogen receptors, and all that estrogen receptor positive means is that that breast cancer cell went from healthy to cancer through a mutation but retained its estrogen receptors.
We can use those receptors against the cancer cell to treat the breast cancer. That study has been walked back. Multiple studies have been done, but the whole mindset has not changed.
Myself as an OBGYN was still taught the lowest dose for the shortest amount of time and only in women where absolutely nothing else is helping her hot flashes. Menopause was defined by the vasomotor symptoms—that's it.
You know, vaginal estrogen, which is just putting estrogen locally in the vagina, is one of the biggest things we see. A huge amount of patients—well over 50%—is something we call genital urinary syndrome of menopause.
The bladder, the vagina, and all of the tissue in between have a lot of estrogen receptors. When we take the estrogen away, that tissue becomes very thin. We lose elasticity, and we see recurrent urinary tract infections.
The most likely treatment to help a woman in menopause with recurrent urinary tract infections, which is a major cause of death for women, is vaginal estrogen. It's safe for everyone, even with breast cancer.
Even that option is taken off the table for so many women who are suffering needlessly with horrible painful intercourse, dryness, and recurrent UTIs. It's just such a simple thing to help a woman and fix, and they're not being offered that treatment.
Is vaginal estrogen the only form of administering estrogen?
No, so when we look at hormone replacement therapy, we have—think of it like steroids. Say you have a rash, and you go to your pharmacy and pick up a cortisone cream. That's local therapy.
Vaginal estrogen cream is local therapy. There are pills, different ways to put it in the vagina, but that's considered local therapy. It's not absorbed systemically; we're just treating it kind of at the moment.
Systemic therapy is when it's treating everything—our brains, our bones, our genital urinary system—from the inside out. You can ingest it; there are creams, patches, rings, and pellets that are now available.
There are multiple ways to get this medication into your body.
What's the most popular form of administering hormone replacement therapy?
It depends on the country. In the UK, it tends to be a gel or a cream, which is where most GPs, if you can get one that will follow the guidelines and prescribe it, I think it's the easiest pharmacologic option to get in the UK.
In the U.S., it tends to be the patch for the non-oral form. We also have pills available as well. There's a caveat with estrogen pills.
Whenever we ingest anything—food, medication—it goes into our stomach, into the intestines, and then it gets picked up by the portal hepatic circulation, the liver. The portal vein goes straight to the liver for processing.
When that bump of estrogen or testosterone typically hits the liver, we see some problems. For testosterone, it's liver toxicity, and for estrogen, we see bumps in our clotting factor.
You'll see a lot of women who are terrified of hormone therapy because of this potential risk of blood clots. They either have a genetic risk of blood clots or a gene, or they've had a clot in the past.
But if they avoid oral estrogen and go with a non-oral form like the patch or the ring or even a pellet, then we bypass the liver, and we don't have the increased risk of clotting.
Are there any other side effects?
In life, there's no such thing as a free lunch. So with estrogen, we have to look at each. When we look at hormone replacement therapy, we have our estrogens, our androgens, which would be testosterone, DHEA, and androstenedione, and then we have our progesterone, which is the bioidentical form.
There are synthetic progestins available, but I tend to just prescribe the progesterone. Each of them has issues that might happen.
With estrogen, you can see headaches. That's kind of a red flag for us. We worry you can see migraines getting worse. Some patients you have to be really careful with going low dose.
You can see unexplained bleeding. About 40% of patients on menopausal hormone therapy will have vaginal bleeding. It doesn't mean it's a period; we have not woken your ovaries up. They're gone.
We are just stimulating that tissue in the lining of the uterus, and it's bleeding a little bit. It's usually self-limited; it can go away on its own. If it persists past several months, we'll get ultrasounds to make sure we're not missing a polyp or something.
It's one of the things I warn my patients about. So things I worry about: headaches, some women depending on the formulation. For the patch, it has an adhesive to get it to stick to your skin, and probably 10% of women will have some kind of allergic reaction to the adhesive.
We have to look for alternative forms. Thankfully, there are multiple forms on the market, and for patients, we have to do some trial and error to find out not only which formulation is going to work best for her but also what dosing is going to work best for her.
If I were a menopausal woman and I came to you and said I need help, you must get thousands of messages like that—thousands of messages a week probably.
If I walked into your practice, where would you start with me?
I start by letting you tell your story. I tell my story, and it's a typical story that you hear, right?
What happens next?
Symptoms. I will get blood work sometimes to check hormones to see if I'm not clear where she is in her journey. I may get blood work to help me define if she's perimenopausal or postmenopausal, especially if she's had a hysterectomy.
I'll get a lot of blood work around checking her thyroid. A lot of things look like menopause, right? Fatigue and night sweats might be hypothyroidism, weight gain, hypothyroidism, autoimmune disease—all this rheumatoid arthritis.
I want to make sure I'm not missing something else that looks like perimenopause. I'm doing blood work around that, nutrition deficiencies, vitamin D, basic labs for her blood count and her electrolytes. I'm doing this full panel.
But then I'm beginning to treat immediately. We have a discussion around her sexual wellness. Is she struggling with desire? Then we'll have a discussion around testosterone.
So I'm struggling; my desire is gone. Okay, so it's very common. When we talk about female sexual function, there are kind of five buckets why a woman would be suffering or not happy.
One is a relationship disorder, and no amount of medication really helps with that. We want to make sure she's in a good place with her relationship, supportive partner, all that.
So we have a discussion about that. Then there's an arousal disorder, where that's what most men are treated for when they talk about libido issues. It's really nothing's wrong here; they're struggling to maintain an erection.
So we use Viagra and those types of medications for that. If a woman has an arousal disorder, vaginal Viagra can be helpful for that.
We talk about that. We talk about orgasmic disorders. Some women have never had an orgasm in their life. Imagine if that was 10% of men. I think it would be a national emergency.
I think we would divert military funding in the U.S. to get this fixed, and it's just something we don't talk about or offer much help.
Then that leaves desire. Most women who are in secure relationships love their partner but miss that part of the intimacy they used to have. That desire to initiate—that desire seems to go away with menopause a lot.
For those women, testosterone might be helpful, or there are a couple of FDA-approved medications as well—Addyi and Vyleesi. We have talks about costs and how to get it prescribed.
Testosterone has no FDA-approved option for women, so quite often I will have to compound that medication for them at a local compounding pharmacy versus going to a chain pharmacy to pick it up using their insurance.
I know that you're coming from the UK; our health systems are a little bit different. But because my reach is so large now, I try to include all the different health systems when I'm talking about your options.
Give me a case study of a patient that walked into your door.
Gosh, I had a patient who came in, and her name is Michael. She won't mind me saying it because we're really good friends. She came in, and it was a typical case—overweight, not sleeping, some brain fog issues, some joint aches and pains—all the things.
She was the sweetest woman, absolutely adored her husband, but was struggling with desire as well. So we started her on a nutrition plan. She hired a personal trainer, got serious about lifting, and started on hormone therapy.
She is my biggest cheerleader on social media. She's constantly sharing her story online so that other women can learn that they don't have to suffer as well.
She just can't believe the thing that makes her angry is that she didn't come sooner and that she suffered for so long without looking for help. She came from San Antonio, which is about a three-and-a-half-hour drive to come and see me.
Here's the scary thing for me, or it's honorable. I have a menopause clinic I started two years ago, and I have a waiting list that's longer than this wall. Women are flying in regularly to come and see me, which is such an honor, and I'm so grateful that they trust me.
But it's ridiculous that they can't find menopause care in their backyard. They have to get on a plane to come and see me because they cannot find care wherever they are.
I've started a list of providers on my website that my followers recommend—where they found good menopause care. They write a testimonial, and we just compile them. We look online to make sure it's a real doctor and they have a phone number that works.
The North American Menopause Society, now called the Menopause Society, has a list of certified providers on their website as well.
I got an email sent to me after listening to one of the episodes on this podcast from what appears to be a very helpless husband. It was a very long email, and they said that one of the conversations we had on this podcast about menopause at one point had really helped them.
But the key question that remained for that person was: when does a supporting partner know how and really at what point to help? Because no male partner wants to turn around to their wife and go, "I think you've got menopause," and start diagnosing them.
But they also don't want to just sit back and be quiet.
I think it usually begins with something you can't quite put your finger on. She's reacting differently; she's not as resilient as she used to be. She's not managing situations the same way.
I think once we start taking this shame and stigma out, suggesting that perhaps this is menopause will not cause her to fly off the handle.
Normalizing this conversation and removing the stigma might make everyone go, "Oh, I mean, I didn't realize it in myself. I thought it was grief-related."
I was like, "Wait, when was my last period? Oh, I think I'm in menopause." I gaslit myself, like, "No, no, no, you're not sleeping. You're waking up all night. You're upset. Your mental health and your brain fog are all because you're just grieving his death."
Then my next brother, Jude, was diagnosed with stage four esophageal cancer shortly after Bob died. He was diagnosed when Bob died and survived a few years. Bob died at 56, and Jude died at 57.
I'm 55, and I don't know. I know a lot of it was lifestyle, but I still have those genetics, and I'm about to survive three of my six brothers.
I know that.
These choices that I make with my nutrition, my exercise, my sleep, my stress reduction—what I call the menopause toolkit—and my choice for HRT are all important. I want to see my grandkids one day, if I'm lucky enough to have any. I want to watch these women I've raised grow up and be the women they're meant to be. That choice might get taken away from me if I'm not careful.
So, a lot of what I do and why I do it is because I have to; I may not get the choice. What an incredibly important mission you're on and what incredible work you're doing.
As we've talked about, there's been a group of people in society that have kind of been disillusioned, but they've also felt incredibly isolated in their experience. It seems that there's been a real shift in recent times towards the conversation around menopause. Hopefully, these conversations will dismantle the stigma, which is often the first thing that needs to fall for people to be able to take action and have those conversations.
Speaking from my own experience, I didn't really understand what any of this stuff meant until I started doing this podcast. I had the first couple of guests on, and then someone said the word menopause to me. We started having a conversation about it, and I thought, "Oh my gosh, maybe when I was in school, someone should have told me about this phase of life."
We talk about how to get a job, but it seems the education system stops caring once we've had kids. That's what we're experiencing here as well. It's really, really crazy, and the work you're doing is so unbelievably necessary.
What I love about the way you write and how you educate people is that it's so science-based but also so accessible at the same time. That's always been my superpower, I think. I realized that very quickly in my career: I had this knack of being able to take something really complicated and break it down into terms that people could understand—terms that most people would be able to grasp and walk away from.
You have nuance and empathy, which are the necessary ingredients when you're talking about subject matter like this, where everyone's symptoms are typically quite different from one another. They will have different circumstances. We talked about other conditions and contraindications that might complicate things, and you seem to have a really wonderful empathetic view on all of those things. You appreciate that everyone's circumstances are entirely different.
I'm excited, and I'm really looking forward to having more conversations like this and learning more. Although I am a 30-year-old man, I have a partner that I love, a mother that I love, and an older sister that I love. My sister is 36, and my mom is nearly 60 now.
I challenge you to have this conversation with her and ask her about her experience. I really applaud all the men that got this far in this conversation and chose to listen. They have an appreciation that the betterment of 50% of our population, who are going to go through something, is the betterment of all of us.
They also have a role they can play in being a support, encouraging, and having the conversations that will bring down the stigma and the suffering of what is currently about 1.2 billion people but will be 50% of people in our population.
I highly recommend everybody checks out both this book, which is the Galveston Diet, and also, can we pre-order the upcoming book now? Yes, it's available for pre-order wherever you buy books. It will be out in 2024, for sure—the latest being May.
That's called The New Menopause, so you can pre-order that now wherever you get your books. That's the culmination of many decades of very, very hard work, so I'm very excited to read through that myself. The Galveston Diet book is out now as well; it's been out for a little while.
We have a closing tradition on this podcast where the last guest leaves a question for the next guest, not knowing who they're leaving it for. The question here is: You get one last conversation with somebody you love—a child, maybe your husband, maybe someone else. What do you say to them in that conversation that maybe they haven't already had?
I love you. There's nothing more than love. I've had that conversation three times: with my dad, too. My Bob and Jude were five years apart, and my dad was shortly after Jude. Watching my parents bar three kids was a lot—just love.
Thank you.
You're welcome. Thank you so much.
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