Dr. Mary Claire Haver: How to Navigate Menopause & Perimenopause for Maximum Health & Vitality

00:00:00.000 | - Welcome to the Huberman Lab Podcast,

00:00:02.240 | where we discuss science

00:00:03.720 | and science-based tools for everyday life.

00:00:05.920 | I'm Andrew Huberman,

00:00:10.160 | and I'm a professor of neurobiology and ophthalmology

00:00:13.320 | at Stanford School of Medicine.

00:00:15.240 | My guest today is Dr. Mary-Claire Haver.

00:00:18.040 | Dr. Mary-Claire Haver is a board-certified OBGYN

00:00:21.680 | and an expert in perimenopause, menopause,

00:00:24.960 | and all aspects of female-specific health.

00:00:27.760 | During today's episode,

00:00:28.800 | Dr. Haver explains exactly what perimenopause

00:00:31.480 | and menopause represent

00:00:33.000 | in terms of their underlying psychology and biology,

00:00:36.400 | and the specific actions that all women can and should take

00:00:40.160 | in order to navigate these stages in optimal health.

00:00:43.040 | She also describes the things

00:00:44.360 | that all women should know and do

00:00:46.640 | long before perimenopause arrives

00:00:48.880 | in order to best navigate perimenopause and menopause

00:00:51.840 | once they arrive.

00:00:53.040 | We discuss specific nutritional practices,

00:00:55.720 | supplementation practices,

00:00:57.660 | as well as conversations that you should have

00:00:59.720 | with your mother and with your physician,

00:01:02.060 | in particular, your OBGYN,

00:01:04.360 | not just as perimenopause and menopause approach,

00:01:06.900 | but at every developmental stage.

00:01:08.960 | A fair amount of our discussion

00:01:10.200 | centers around hormone replacement therapy,

00:01:12.280 | not just for estrogen, but for testosterone in women as well,

00:01:15.840 | and the many misconceptions and controversies that exist

00:01:18.960 | around hormone replacement therapy for menopause.

00:01:21.880 | Dr. Haver explains how the specific timing

00:01:24.000 | in which hormone therapy is initiated

00:01:26.160 | plays a key role in whether or not the hormone therapy

00:01:28.840 | is beneficial for women or not.

00:01:31.200 | And of course, today's discussion gets into ways to offset

00:01:34.280 | some of the more common difficulties

00:01:35.780 | associated with menopause,

00:01:37.160 | including sleep issues, hot flashes, inflammation, and more.

00:01:41.240 | By the end of today's episode,

00:01:42.980 | you will have a clear picture from Dr. Marie-Claire Haver

00:01:46.040 | about what perimenopause and menopause actually represent,

00:01:49.360 | the best way to approach perimenopause and menopause,

00:01:52.720 | and the various considerations

00:01:54.580 | around hormone therapy and lifestyle choices

00:01:57.040 | that can allow any woman to approach the years

00:01:59.800 | of perimenopause and menopause and beyond

00:02:02.280 | with the utmost vitality and wellness.

00:02:04.800 | Before we begin, I'd like to emphasize that this podcast

00:02:07.680 | is separate from my teaching and research roles at Stanford.

00:02:10.320 | It is, however, part of my desire and effort

00:02:12.600 | to bring zero cost to consumer information about science

00:02:15.180 | and science-related tools to the general public.

00:02:17.920 | In keeping with that theme,

00:02:19.000 | I'd like to thank the sponsors of today's podcast.

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00:06:22.820 | And now for my discussion with Dr. Mary-Claire Haver.

00:06:25.940 | Dr. Mary-Claire Haver, welcome.

00:06:28.180 | - Thanks for having me.

00:06:29.860 | - Delighted to have you here

00:06:31.140 | and to learn about menopause

00:06:33.500 | and other aspects of women's health.

00:06:35.900 | There's a lot happening in this area right now,

00:06:39.300 | and you are at the center of what I understand

00:06:43.780 | is a new direction for the understanding

00:06:46.440 | and treatment of menopause.

00:06:47.560 | - That's what we hope.

00:06:48.400 | - And related themes like perimenopause.

00:06:51.140 | And the many important aspects of female health

00:06:54.200 | that stem from it,

00:06:55.040 | like cardiovascular disease, osteoporosis, and so on.

00:06:58.080 | So we will get into all of that today.

00:07:00.240 | But just to kick things off, how do we define menopause?

00:07:04.200 | - So the medical definition of menopause,

00:07:07.480 | which I have a huge problem with,

00:07:09.320 | is one year after the final menstrual period.

00:07:13.680 | And the reason why I have a problem with it

00:07:16.760 | is not everyone has a menstrual period.

00:07:18.820 | What if you've had a hysterectomy?

00:07:20.960 | What if you have an IUD?

00:07:22.420 | What if you've had an ablation

00:07:23.700 | or something that's suppressing your periods, PCOS?

00:07:26.740 | So for a lot of women and even clinicians,

00:07:30.300 | they are struggling to find that diagnosis

00:07:33.200 | because it doesn't fit everything.

00:07:34.820 | What it represents is something much bigger.

00:07:37.080 | Menopause is also one day of your life.

00:07:40.820 | It is that one day exactly one year after your last period.

00:07:44.180 | But it represents the end of your ovarian function.

00:07:47.180 | Some of us call it ovarian failure, ovarian senescence.

00:07:50.620 | But basically what separates males and females

00:07:54.040 | is many things separate us.

00:07:56.960 | But in my world, we are born with all of our eggs.

00:08:01.240 | We have one to two million at birth.

00:08:04.140 | By the time we're 30,

00:08:05.920 | most of us are down to about 10%, maybe 120,000.

00:08:10.260 | By the time we're 40, we're down to 3% of our egg supply.

00:08:14.020 | And the quality is declining as well.

00:08:16.300 | So menopause is when you have no more eggs left

00:08:20.820 | and therefore no more sex hormone

00:08:22.620 | or very little sex hormone production from the ovaries.

00:08:25.260 | So estradiol levels will decline

00:08:27.180 | less than 1% of your reproductive years.

00:08:29.900 | Your progesterone levels will decline as well.

00:08:32.020 | Testosterone declines for sure,

00:08:34.020 | but we have other ways to produce it.

00:08:35.820 | So it's somewhere 50% or less than your healthiest years.

00:08:39.920 | - So is it fair to say that we need a redefinition

00:08:43.100 | of what menopause is?

00:08:44.780 | - I think so.

00:08:45.740 | I think defining it as the presence or absence of a period

00:08:49.420 | is a mistake.

00:08:50.900 | - Is there any consensus about the quote unquote

00:08:53.900 | typical age of onset for menopause?

00:08:56.780 | And is it changing?

00:08:57.820 | You know, I hear a lot about how the onset of puberty

00:09:00.920 | is shifting earlier in females.

00:09:03.900 | And given that puberty, at least by some definitions,

00:09:07.620 | relates to the onset of menses,

00:09:09.520 | one could imagine that menopause

00:09:12.560 | would be shifting earlier as well.

00:09:14.720 | - So the things that determine when we have puberty or not

00:09:19.720 | are different than the things that determine

00:09:22.240 | when we run out of eggs.

00:09:24.060 | Right now in the US,

00:09:27.480 | it's the average age of that one year after your cycle.

00:09:30.500 | So menopause, that one day is about 51 to 52 years old.

00:09:35.040 | However, normal is still 45 to 55,

00:09:38.120 | and there's a big variation.

00:09:40.320 | You know, that curve's pretty wide.

00:09:42.080 | Perimenopause begins seven to 10 years

00:09:48.120 | before that last menstrual period.

00:09:50.220 | - Wow, okay.

00:09:51.060 | And I say wow, because it's the first time

00:09:53.560 | I've ever heard a specific number tacked to this word,

00:09:56.560 | perimenopause.

00:09:58.400 | Maybe we could talk a little bit about perimenopause,

00:10:00.700 | since it sounds like it represents a transition phase

00:10:05.700 | into official menopause.

00:10:09.380 | However, one chooses to define that.

00:10:11.780 | What are some of the,

00:10:13.540 | I don't know if I should call them symptoms,

00:10:15.260 | or I should just-

00:10:16.620 | - Well, let me walk you through the endocrinology,

00:10:19.220 | and then we can go through symptoms, so you understand.

00:10:21.780 | So in a normal, healthy menstrual cycle,

00:10:24.540 | before menopause ever becomes an issue,

00:10:27.380 | the female hormone cycle is a very EKG-like,

00:10:30.500 | reproducible, monthly rise and fall

00:10:33.100 | of estrogen, progesterone,

00:10:34.860 | and then the brain hormones, LHFSH, and then GnRH.

00:10:38.620 | So the way it works is our brain, in the hypothalamus,

00:10:43.380 | is sensing for, has a little sensor in the blood,

00:10:46.620 | looking for estradiol levels.

00:10:48.020 | And when they get low,

00:10:48.900 | it sends GnRH down to the pituitary, saying,

00:10:51.420 | "Hey, tell the ovaries to start trying to ovulate

00:10:54.780 | "so we can get more estrogen on board."

00:10:56.700 | The process of ovulation is what drives up

00:10:58.820 | our estrogen levels, okay?

00:11:00.820 | So, pituitary sends out the pulses of LH and FSH,

00:11:04.780 | which then lead to ovulation.

00:11:06.940 | When we reach, in perimenopause,

00:11:09.380 | the beginning of perimenopause,

00:11:10.380 | that critical level of egg supply,

00:11:12.500 | those signals don't work as well.

00:11:15.620 | We start becoming resistant

00:11:17.660 | to the LH and FSH pulsatal surges.

00:11:20.220 | So, the brain's like, "Hey, I told you

00:11:24.780 | "we need more estradiol."

00:11:26.180 | And the pituitary is like, "I sent the signal."

00:11:29.020 | And the brain's like, "Send more."

00:11:30.740 | So, we get much higher pulses of FSH.

00:11:33.860 | And then finally, the ovary kind of, ugh,

00:11:36.140 | is able to get that egg out, but sometimes it's delayed.

00:11:39.740 | So, we have the timing of that monthly predictable cycle

00:11:43.900 | goes awry.

00:11:44.780 | Sometimes the periods are closer together.

00:11:46.740 | Sometimes they're further apart.

00:11:48.740 | But also, the estrogen and progesterone levels

00:11:51.460 | start changing dramatically.

00:11:52.780 | We see much higher surges of estradiol

00:11:55.180 | than we ever had in our pre-productive years,

00:11:58.260 | and then much lower levels underneath.

00:12:00.860 | So, we end up with this very volatile curve

00:12:03.100 | and not predictable at all.

00:12:04.580 | We call it, in our world, the zone of chaos.

00:12:06.980 | So, it is literal hormonal chaos.

00:12:08.700 | What used to look like this, you know, every month,

00:12:10.820 | is now just insane and very, very, very unpredictable.

00:12:15.820 | That is why we don't have a good blood test

00:12:18.820 | in perimenopause to make the diagnosis.

00:12:21.700 | Those of us in the menopause use symptoms,

00:12:24.800 | usually, to make the diagnosis,

00:12:26.260 | and we rule out other conditions that might overlap.

00:12:29.080 | So, perimenopause, basically, critical threshold.

00:12:32.420 | It's a downward trend overall of estradiol,

00:12:35.180 | but it is a very chaotic race

00:12:37.780 | till you flatline and bottom out.

00:12:39.540 | - I see.

00:12:40.380 | So, for those listening, your description

00:12:42.980 | of the kind of the amplitude of the estrogen surge,

00:12:47.260 | it gets much greater in this perimenopause phase.

00:12:50.180 | You also mentioned that follicle-stimulating hormone,

00:12:52.140 | which comes from the pituitary,

00:12:53.780 | has to be, or somehow is up-regulated in this phase

00:12:57.420 | because, I don't know, is it that the receptors for FSH

00:13:00.220 | are somehow not responsive?

00:13:02.340 | At the level of the ovary,

00:13:03.700 | do we know what's happening to the ovary?

00:13:05.820 | Is it, obviously, the signal's getting there,

00:13:08.180 | it's not effective,

00:13:09.300 | so then the brain is kicking out more FSH.

00:13:11.980 | Is it that the ovary is somehow-

00:13:12.820 | - So, the egg quality is poor,

00:13:14.780 | and then around each germ cell is the thecaludian cells,

00:13:18.860 | which is actually where the estradiol,

00:13:20.460 | the whole pathway going from, you know,

00:13:22.300 | actually testosterone's converted to estradiol.

00:13:24.500 | So, that whole pathway, you know, it still will respond,

00:13:28.900 | but the cells are just old, you know,

00:13:31.220 | is the way that it's been explained to me,

00:13:32.700 | and from what I've read.

00:13:33.660 | I think we need a lot more research in this area

00:13:36.220 | because that is how we're going to help women,

00:13:38.820 | I think, longer term, is understanding that process better.

00:13:41.820 | But, you know, all I learned in school 25 years ago

00:13:45.060 | was it's the transition to menopause, the end.

00:13:48.620 | You know, the whole endocrinological process,

00:13:51.020 | I didn't learn until about two years ago.

00:13:52.940 | - And my guess is, just based on my understanding

00:13:55.300 | of the only recent trend toward emphasizing studies

00:14:00.100 | of both female and male, even just mice and mouse models,

00:14:03.380 | which is where generally this stuff originates,

00:14:05.660 | and then it shifts into humans

00:14:06.780 | once certain targets are identified.

00:14:08.980 | Only recently has the NIH insisted

00:14:11.500 | that there be female mice in the studies of mice.

00:14:16.500 | I mean, it's been a few years now,

00:14:18.340 | but that's a, you know,

00:14:19.180 | sex as a biological variable is actually a requirement

00:14:22.180 | in most grant applications,

00:14:24.620 | unless, of course, there's a specific reason

00:14:26.380 | to study only one or the other sex of mice.

00:14:29.580 | So you can imagine that the dearth of research in this area

00:14:33.660 | is due to a long desert of absence of studies

00:14:38.660 | into what is perimenopause.

00:14:41.820 | So for women who are in the age range of perimenopause

00:14:44.900 | or who are thinking about this,

00:14:46.960 | are there things that they can do

00:14:49.020 | in order to either upregulate the sensitivity of the ovary

00:14:52.500 | to FSH or to somehow prolong this period of perimenopause?

00:14:57.500 | And I should also say,

00:14:59.900 | what are some reasons why they would want to do that?

00:15:02.780 | You know, obviously this is part of the arc of maturation

00:15:07.780 | of the female reproductive axis,

00:15:09.800 | but of course that alone is not a reason to not try and,

00:15:13.380 | I guess we say, optimize it for one's wellbeing.

00:15:16.900 | - So we don't know.

00:15:18.180 | When you, the best way I can highlight why we don't know

00:15:21.660 | or where the dollars are going for research,

00:15:24.140 | you know, we go to PubMed and you type in the word pregnancy,

00:15:27.820 | 1.1 million articles come up.

00:15:29.740 | Type in the word menopause, it's down to 97,000.

00:15:32.820 | - Really?

00:15:33.660 | - You type in the word perimenopause,

00:15:35.260 | and I checked this like two weeks ago,

00:15:36.700 | and it was like 6,400 and something.

00:15:39.300 | - Wow. - Yeah.

00:15:40.620 | - That is surprising.

00:15:42.380 | Or maybe it shouldn't be surprising

00:15:43.820 | given what we were just talking about in terms of-

00:15:46.140 | - So as far as like why those cells are becoming resistant

00:15:50.340 | and what's happening at the level of the receptor,

00:15:52.540 | I think we need a lot more research in this area.

00:15:54.780 | I think it's starting to happen

00:15:56.460 | because women are realizing there's a demand now

00:15:59.180 | because the older you are when you go through menopause,

00:16:02.660 | the healthier you are for cardiometabolic disease.

00:16:06.300 | It's the loss of estrogen

00:16:07.740 | that accelerates our path to those diseases.

00:16:11.300 | - So are there clinical signs of perimenopause

00:16:15.140 | that either directly or indirectly relate

00:16:18.300 | to these bigger surges in FSH

00:16:21.140 | and these larger amplitude estrogen surges?

00:16:25.620 | - The two best documented and studied

00:16:27.740 | are mental health changes.

00:16:30.060 | The brain does not like the chaos of,

00:16:33.220 | and the neurotransmitters are very, very sensitive

00:16:35.660 | to estrogen and progesterone and even testosterone.

00:16:39.420 | And so we see aberrations in serotonin and norepinephrine

00:16:44.840 | and in dopamine as the levels start becoming chaotic.

00:16:48.180 | So we have at least a 40% increase

00:16:51.420 | of mental health disorders

00:16:53.260 | and SSRI use doubles across the menopause transition,

00:16:57.940 | across perimenopause.

00:16:59.660 | And now the data is showing that women

00:17:02.460 | who are given hormone therapy in their perimenopause

00:17:05.300 | have a lower incidence of new onset depression.

00:17:08.260 | And now the neuroscientists are saying,

00:17:10.300 | hey, for these women who are developing depression

00:17:13.300 | and perimenopause, giving them estrogen

00:17:16.620 | is better than an SSRI.

00:17:18.460 | They're gonna have a better outcome.

00:17:20.340 | - I think most people don't realize how rich the brain

00:17:24.580 | and rest of the nervous system are with hormone receptors,

00:17:28.540 | in particular, estrogen receptors,

00:17:31.380 | and as you mentioned, testosterone receptors as well,

00:17:34.400 | androgen receptors.

00:17:35.520 | And the often direct relationship between estrogen

00:17:40.260 | and the neuromodulators such as serotonin, dopamine,

00:17:43.660 | epinephrine, acetylcholamide.

00:17:44.980 | - GABA for progesterone.

00:17:47.820 | - Yeah, it's interesting during neural development,

00:17:50.180 | which is where I started off,

00:17:51.800 | which was a neural embryonic development.

00:17:55.180 | The hormones exert these widespread roles

00:17:58.660 | in defining even which neurons

00:18:01.140 | will express certain neurotransmitters.

00:18:02.820 | And then somehow the field of neuroscience

00:18:05.660 | is only recently gotten on board.

00:18:08.300 | The idea that this intimate relationship

00:18:11.100 | between hormones and neurotransmitters

00:18:12.980 | is something to consider

00:18:14.340 | in essentially every aspect of brain health.

00:18:18.060 | Not just cognition, but maintenance of neurons

00:18:20.460 | and offsetting neurodegeneration and so on.

00:18:23.380 | I mentioned that only so that people,

00:18:26.400 | I think, typically think of hormones as something,

00:18:29.620 | sure, there's a signal from the brain,

00:18:31.700 | but that hormones are mostly of the body,

00:18:33.920 | when in fact hormones play an absolutely crucial role

00:18:36.500 | within the brain.

00:18:38.140 | - So you mentioned that during perimenopause

00:18:40.940 | there are symptoms that are, I guess,

00:18:45.100 | are mainly reflected as shifts in mental health.

00:18:48.820 | So is this women suddenly feeling kind of less optimistic?

00:18:53.820 | Is it like, what's the sort of constellation

00:18:57.740 | of psychological shifts that can occur?

00:19:00.060 | - So we see increasing anxiety.

00:19:03.660 | We see definitely loss of executive functioning.

00:19:06.740 | So new onset of ADD-type symptoms.

00:19:10.620 | We see, of course, the cognitive,

00:19:13.740 | what we call brain fog in lay terminology,

00:19:15.940 | which is cognitive.

00:19:17.620 | So they lose their words.

00:19:19.240 | They're not able to do the calculations at work.

00:19:21.420 | Like their executive functioning ability in their jobs

00:19:24.660 | is huge, like one in five women will quit their jobs

00:19:27.220 | because of menopause symptoms.

00:19:29.000 | - That's an outrageous number.

00:19:32.420 | - Yeah, and the economic impact is huge.

00:19:34.540 | And so now companies are starting to get on board.

00:19:36.380 | And this is the time of our lives

00:19:37.580 | when the kids are grown for a lot of us,

00:19:39.940 | and we're ready to lean into our positions

00:19:42.340 | and really get into leadership.

00:19:43.380 | We have all this experience, and now we can't,

00:19:46.340 | and now all of a sudden these,

00:19:47.700 | and their confidence is just wrecked.

00:19:49.660 | And then the depression, and they're not sleeping,

00:19:52.500 | and it's this horrible feedback cycle that they end up in,

00:19:55.460 | that we end up in.

00:19:56.740 | - Yeah, I wasn't aware that one in five is striking.

00:19:59.980 | - That came out of the UK,

00:20:01.180 | but they're starting to crunch the numbers here in the US,

00:20:03.460 | and it's looking very similar.

00:20:05.260 | - I know we're going to get into actionable tools later

00:20:08.220 | as it relates to menopause,

00:20:09.260 | but as long as we're discussing this phase of perimenopause,

00:20:12.220 | what are some of the basic things

00:20:14.820 | that women could, A, pay attention to?

00:20:17.380 | We don't want to make people hypervigilant

00:20:18.940 | to the point of anxiety,

00:20:20.580 | but certainly given the frequency

00:20:23.580 | and given the implications,

00:20:25.000 | it's important for them to pay attention to this phase.

00:20:28.660 | And then some of the things that they can do to,

00:20:31.500 | either behaviorally or perhaps through other tools,

00:20:34.040 | offset some of these changes.

00:20:37.140 | - Dysfunctional uterine bleeding, which is abnormal periods.

00:20:40.700 | So, and again, nothing's off the table.

00:20:42.780 | It could be heavy periods, menorrhagia,

00:20:46.180 | too frequent, too few, skipping.

00:20:48.960 | It's really, really chaotic.

00:20:50.960 | But a lot of women are suffering horribly

00:20:54.260 | from really debilitating periods,

00:20:56.320 | either through the volume of blood loss,

00:20:58.180 | or they're having cramps,

00:21:00.340 | and really, and so 90% of us will have that as a symptom.

00:21:05.340 | Fatigue is a huge one.

00:21:10.180 | A lot of them, the symptoms are kind of vague,

00:21:13.080 | and can be attributed to a lot of other things.

00:21:15.640 | In our, in my, what we call the menopause chat group,

00:21:19.720 | we have a lot of theories about a lot of conditions

00:21:22.320 | like fibromyalgia and the irritable bladder syndromes,

00:21:26.500 | and that probably just perimenopause and menopause,

00:21:29.720 | and doctors didn't know how to make that diagnosis.

00:21:32.960 | And so, musculoskeletal system takes a huge hit

00:21:36.700 | through the transition.

00:21:37.540 | So all of a sudden, you have no injury,

00:21:39.520 | and you're having hip pain, joint pain, back pain,

00:21:41.600 | with, you go to the doctor and you get an X-ray,

00:21:43.920 | you do whatever, workup, and they can't find anything wrong.

00:21:46.760 | Palpitations are huge.

00:21:48.800 | It is a vasomotor symptom.

00:21:50.560 | So along with hot flashes, palpitations.

00:21:52.560 | So a woman will walk into the emergency rooms

00:21:55.120 | sweating profusely, horrible palpitations.

00:21:57.520 | She's anxiety, and they'll tell her

00:21:58.880 | she's having a panic attack.

00:22:00.440 | You know, they'll work her up, you know,

00:22:02.360 | everything's negative, and just say,

00:22:03.520 | well, it's a panic attack, go home.

00:22:04.680 | And no one knew to connect the dots

00:22:07.280 | and figure out that this woman

00:22:08.440 | was in her menopause transition,

00:22:09.800 | and this is how her body was expressing it.

00:22:11.880 | It's complicated because we have sex hormone receptors,

00:22:14.640 | as you do, in every organ system of our body,

00:22:16.920 | and when these levels start going chaotic,

00:22:20.000 | it can present in so many different ways.

00:22:22.160 | And so, when the patients come to me,

00:22:24.000 | I'm doing blood work, not a lot of hormone levels,

00:22:26.560 | 'cause they're not super helpful,

00:22:28.120 | but I am doing thyroid workups, and autoimmune workups,

00:22:31.800 | and looking for nutritional deficiencies,

00:22:34.480 | and anemia, and different things,

00:22:36.360 | because I don't wanna miss those things

00:22:38.560 | and just pin everything on perimenopause.

00:22:40.960 | - Are there lifestyle factors that can offset some of this?

00:22:45.760 | - It's not a perfect correlation,

00:22:47.320 | but the healthier you are,

00:22:48.960 | so anti-inflammatory diet, you know,

00:22:51.240 | Mediterranean-esque, Galveston diet-esque,

00:22:53.120 | you know, nutrition pattern, regular exercise,

00:22:56.880 | good sleep habits, you know, all the pillars of health,

00:22:59.800 | the healthier you are when you hit perimenopause,

00:23:02.000 | the better the course is going to be for you.

00:23:04.920 | They're looking at extending the life of the ovary

00:23:08.040 | with pharmacology.

00:23:09.760 | We know what can shut it down faster.

00:23:12.400 | So, we have kind of a genetic predetermined age

00:23:14.800 | of when you're gonna lose all your eggs,

00:23:16.840 | but we can speed that up.

00:23:17.960 | So, if you smoke, you're gonna go through menopause sooner

00:23:20.280 | than your twin would have if she didn't smoke, okay?

00:23:23.040 | If you don't have children and you ovulate regularly,

00:23:27.360 | then the more you ovulate,

00:23:28.840 | the faster you run through your egg supply, okay?

00:23:31.440 | - Interesting, I wasn't aware of those data.

00:23:33.600 | I don't know that most people are aware of those data.

00:23:36.240 | - No, if you have a hysterectomy

00:23:37.600 | and you leave your ovaries behind,

00:23:39.560 | I didn't ever counsel my patients about this.

00:23:41.640 | You lose four years off the life of your ovaries.

00:23:44.500 | If you have a tubal ligation,

00:23:45.840 | you usually lose a year and a half.

00:23:47.320 | Huge genetic disparities.

00:23:48.720 | So, African-Americans tend to go through

00:23:50.680 | a year and a half sooner,

00:23:52.400 | and then there's Caucasians in the middle,

00:23:53.880 | and then Asian family tend to go through later,

00:23:56.360 | and they're not sure why, a year, two years.

00:23:59.200 | So, if you have chemotherapy, if you have surgery,

00:24:02.080 | if you have any inflammatory process in the abdomen,

00:24:04.680 | irritable bowel, or endometriosis,

00:24:07.540 | you are going to lose some of the life of the ovary.

00:24:10.180 | - You mentioned smoking.

00:24:11.020 | Are there any data on vaping?

00:24:13.240 | - Not yet, I haven't seen any.

00:24:14.880 | There might be out there, I just haven't seen it yet.

00:24:16.480 | - No, I'm guessing if they're out there,

00:24:18.840 | they're not prominent or you would have seen them.

00:24:20.880 | I'm curious about vaping,

00:24:22.160 | because a lot of people are vaping instead of smoking,

00:24:24.880 | and hopefully people are neither vaping nor smoking,

00:24:27.920 | because it seems that, we had an expert on vaping

00:24:30.320 | on the podcast recently from Stanford,

00:24:31.880 | and it seems that there's nothing great about it.

00:24:35.720 | And there may be some things really bad about it.

00:24:37.520 | But I was just curious, given that a number of young women,

00:24:41.080 | and men, for that matter, are vaping nowadays,

00:24:44.080 | and whereas smoking rates have gone way, way down.

00:24:46.760 | - Another 10 years before we'd be able to see

00:24:51.760 | when those women are going through menopause,

00:24:53.840 | 'cause vaping, I think vaping is younger,

00:24:55.880 | the younger generation, like my kids.

00:24:58.780 | They're friends--

00:24:59.620 | - People in their 20s and 30s.

00:25:00.460 | - Tend to vape, so we're 20 years out

00:25:02.360 | from seeing how it's gonna affect them.

00:25:04.680 | - Is there any evidence that alcohol

00:25:06.720 | can impact perimenopause? - I haven't seen any,

00:25:08.840 | but I can't imagine that heavy use of alcohol

00:25:12.000 | would prolong the life of the ovary in any way, so.

00:25:15.360 | - And we know that any use of alcohol

00:25:17.480 | has some potential role in disrupting sleep.

00:25:19.880 | - Oh, 100%. - Presumably,

00:25:21.000 | like everything else, if you disrupt sleep,

00:25:23.000 | you disrupt things-- - Everything.

00:25:24.520 | - For the worse in that, got it.

00:25:26.680 | So you mentioned rough ages for onset of menopause, 51,

00:25:31.680 | but anywhere from 45 to 55,

00:25:35.680 | and the perimenopause is defined as a period

00:25:39.040 | about seven years prior to that?

00:25:40.600 | - Seven to 10, yeah. - Okay.

00:25:42.600 | What's the earliest you've ever had a patient come in

00:25:45.540 | who entered menopause?

00:25:46.960 | What's the latest you've ever seen?

00:25:47.800 | - My personal patient, 27,

00:25:50.760 | she came in just a couple months ago.

00:25:52.400 | So she had a special condition

00:25:54.480 | we call premature ovarian failure,

00:25:57.280 | and she had found me on social media

00:25:59.520 | and wanted to come just to make sure

00:26:02.080 | she was doing everything right.

00:26:03.800 | And so early menopause is defined

00:26:07.120 | as between the ages of 40 and 45,

00:26:09.880 | and then premature menopause

00:26:11.800 | or premature ovarian insufficiency,

00:26:14.360 | it's not a complete failure for most women,

00:26:16.000 | but it is very, very low,

00:26:17.800 | is anytime before the age of 40.

00:26:20.040 | So this patient kind of got kicked around for two years,

00:26:24.000 | went to her doctor, no periods, horrible hot flashes.

00:26:27.240 | Again, she was 25 and it was not on his radar,

00:26:30.320 | and he never tested her for menopause,

00:26:34.540 | and it took her 18 months to get the diagnosis.

00:26:37.840 | And so the longer your body is away from estrogen,

00:26:41.400 | the higher the risk factor.

00:26:42.760 | And it's been all over the news this week

00:26:45.080 | where we know that untreated premature ovarian insufficiency

00:26:48.800 | has an earlier death.

00:26:50.660 | So they have higher cardiovascular disease, diabetes, stroke,

00:26:53.520 | all because estrogen is so protective

00:26:55.440 | and they have to go so long without it.

00:26:57.140 | We can negate most of those risks

00:27:00.440 | by giving her aggressive hormone therapy early.

00:27:03.280 | So she came in to make sure she was on the right dose

00:27:07.160 | because in premature ovarian failure,

00:27:09.360 | we don't wanna give them menopause hormone therapy doses.

00:27:11.560 | They're too low.

00:27:12.400 | We wanna get her more like she would have,

00:27:14.560 | which is three to four times the amount of estrogen

00:27:17.440 | as a reproductive aged woman.

00:27:19.600 | And so, and she wanted to have a period

00:27:22.440 | so she would seem like her friends.

00:27:24.580 | You know, it was an emotional thing for her,

00:27:26.280 | which I totally respect.

00:27:27.880 | And so we were doing cyclical progesterone for her

00:27:31.520 | so that she would have a withdrawal bleed

00:27:32.960 | and feel like she was normal.

00:27:35.280 | - Basic question, but I'm curious, so I'll ask,

00:27:38.320 | given that levels of estrogen change so much naturally

00:27:42.680 | during the course of the ovulation cycle, menstrual cycle,

00:27:47.680 | with estrogen therapy, is it a constant dose

00:27:50.220 | or it's modulated by week to week?

00:27:52.720 | - Good question.

00:27:53.720 | So there are some formulas.

00:27:55.680 | So, and when we look at hormonal contraception,

00:27:57.840 | so the biggest difference between contraceptive doses

00:28:02.020 | and menopause hormone therapy doses,

00:28:03.840 | they're both based in estrogen and progesterone mostly, okay?

00:28:08.840 | The hormone therapy was developed to stop a hot flash

00:28:14.120 | for decades.

00:28:17.000 | Menopause was defined by the presence or absence of,

00:28:18.960 | you know, severe menopause

00:28:19.800 | was defined by hot flashes or not.

00:28:21.680 | They didn't, nothing else.

00:28:23.500 | And so they developed the formulations

00:28:25.640 | with enough estrogen to stop hot flashes.

00:28:28.280 | Birth control was developed to stop ovulation.

00:28:30.520 | You don't ovulate, you don't get pregnant.

00:28:32.060 | And it's, but the difference between low dose

00:28:35.720 | birth control pill and higher dose menopause hormone therapy

00:28:38.440 | is not that far away.

00:28:40.440 | And so that a lot of people don't understand.

00:28:44.360 | Now, the types of estrogen we use in birth control

00:28:46.920 | are a little bit different.

00:28:48.040 | Most birth control is ethanol estradiol,

00:28:50.120 | which is one of the synthetics.

00:28:51.320 | We have literally millions and millions

00:28:53.520 | of women's year data on it.

00:28:55.480 | We know it's safety profile.

00:28:56.840 | I think we're not counseling patients adequately

00:28:58.760 | about birth control as far as what it does to their

00:29:00.640 | testosterone and what it can do to, you know,

00:29:02.880 | oh, it's fine, it's safe.

00:29:03.720 | I took it for years, but I think we need to do a better job

00:29:06.200 | as a specialty on counseling women.

00:29:08.120 | But I do think it's a good medication.

00:29:09.960 | And then on menopause hormone therapy, you know,

00:29:12.680 | it's much lower dose.

00:29:14.040 | It does not suppress ovulation.

00:29:15.920 | So in perimenopause, it's a little bit of the wild west,

00:29:18.960 | which one we're gonna use.

00:29:20.440 | How high do we wanna go?

00:29:21.460 | Do we need to suppress our ovulation

00:29:22.920 | because she's got acne or horrible periods or cramps

00:29:25.160 | or something where I wanna suppress

00:29:27.040 | that ovulation to help her?

00:29:28.600 | Or can I give her menopause hormone therapy doses,

00:29:31.480 | which in effect, think of the hypothalamus.

00:29:33.280 | I'm giving her just enough estrogen to calm the brain down

00:29:36.080 | and tell them everything's okay.

00:29:37.800 | We're not gonna get those big peaks and drops.

00:29:40.080 | And if she still ovulates, that's okay too.

00:29:42.720 | - As many of you know,

00:29:43.560 | I've been taking AG1 for more than 10 years now.

00:29:46.440 | So I'm delighted that they're sponsoring this podcast.

00:29:48.920 | To be clear, I don't take AG1 because they're a sponsor.

00:29:51.680 | Rather, they are a sponsor because I take AG1.

00:29:54.800 | In fact, I take AG1 once and often twice every single day.

00:29:58.200 | And I've done that since starting way back in 2012.

00:30:01.920 | There is so much conflicting information out there nowadays

00:30:04.500 | about what proper nutrition is.

00:30:06.680 | But here's what there seems to be a general consensus on.

00:30:09.640 | Whether you're an omnivore, a carnivore,

00:30:12.000 | a vegetarian or a vegan,

00:30:13.680 | I think it's generally agreed

00:30:14.880 | that you should get most of your food

00:30:16.400 | from unprocessed or minimally processed sources,

00:30:19.420 | which allows you to eat enough, but not overeat,

00:30:21.920 | get plenty of vitamins and minerals,

00:30:23.520 | probiotics and micronutrients

00:30:25.520 | that we all need for physical and mental health.

00:30:27.960 | Now, I personally am an omnivore

00:30:29.720 | and I strive to get most of my food

00:30:31.280 | from unprocessed or minimally processed sources.

00:30:34.080 | But the reason I still take AG1 once

00:30:36.060 | and often twice every day is that it ensures

00:30:38.680 | I get all of those vitamins, minerals, probiotics, et cetera,

00:30:42.400 | but it also has adaptogens to help me cope with stress.

00:30:45.240 | It's basically a nutritional insurance policy

00:30:47.520 | meant to augment, not replace quality food.

00:30:50.200 | So by drinking a serving of AG1 in the morning

00:30:52.440 | and again in the afternoon or evening,

00:30:54.480 | I cover all of my foundational nutritional needs.

00:30:57.120 | And I, like so many other people that take AG1,

00:30:59.760 | report feeling much better in a number of important ways,

00:31:02.800 | such as energy levels, digestion, sleep, and more.

00:31:05.960 | So while many supplements out there are really directed

00:31:08.160 | towards obtaining one specific outcome,

00:31:10.520 | AG1 is foundational nutrition

00:31:12.280 | designed to support all aspects of wellbeing

00:31:14.460 | related to mental health and physical health.

00:31:16.960 | If you'd like to try AG1,

00:31:18.360 | you can go to drinkag1.com/huberman

00:31:21.800 | to claim a special offer.

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00:31:25.360 | plus a year supply of vitamin D3K2.

00:31:27.980 | Again, that's drinkag1.com/huberman.

00:31:32.320 | - As long as we're on the topic of birth control,

00:31:34.680 | earlier you mentioned that the IUD,

00:31:37.120 | and presumably this is some form of the IUD,

00:31:39.480 | not necessarily copper IUD,

00:31:41.040 | can disrupt or stop-

00:31:44.360 | - A period. - A period.

00:31:45.900 | Maybe we could talk a little bit

00:31:48.140 | about the different forms of birth control.

00:31:50.520 | IUD, the pill, quote unquote, old term,

00:31:55.360 | but I think most people know what we're referring to

00:31:58.840 | when we say that, the ring, and on and on.

00:32:03.280 | What is your stance on these different forms

00:32:05.240 | of birth control as it relates to their safety?

00:32:07.580 | I guess about a year and a half ago,

00:32:10.480 | I hosted a female physician guest on this podcast,

00:32:15.040 | and both sides of the birth control issue

00:32:18.400 | were touched on it.

00:32:19.240 | One, the relationship to potential inhibition

00:32:23.360 | of certain forms of cancers,

00:32:24.880 | but then also the potential for certain side effects,

00:32:27.400 | maybe even cancers.

00:32:28.440 | And so it seems like it can play out both ways,

00:32:31.040 | and this is a very heated topic.

00:32:33.240 | In fact, so much so that I learned

00:32:35.360 | that if one is going to post a clip of any of this

00:32:38.320 | on social media,

00:32:39.680 | it almost makes sense to have them in the same post,

00:32:41.960 | because we actually did both of them.

00:32:43.240 | We did a post where it was more about

00:32:45.400 | the pros of birth control

00:32:46.760 | and then the cons of birth control.

00:32:48.640 | As stated through the words of this very same clinician.

00:32:53.640 | So we will be sure to,

00:32:55.800 | so for anyone listening,

00:32:56.640 | whichever answer comes first,

00:32:59.440 | stay tuned for the next answer,

00:33:01.280 | because my understanding is that

00:33:03.880 | it's not a black and white issue.

00:33:05.560 | - I think the best form of birth control is a vasectomy.

00:33:08.680 | And so much of contraception is dumped in a female's lap,

00:33:12.760 | you know, in a committed relationship.

00:33:14.720 | And I can't tell you the comments I've heard

00:33:16.520 | when a patient comes to me

00:33:18.080 | and she wants to get X, Y, and Z

00:33:19.760 | simply for contraception.

00:33:20.680 | She's absolutely perfectly healthy.

00:33:22.240 | There's nothing wrong with her.

00:33:23.280 | She just doesn't want to be pregnant.

00:33:25.120 | And I'm like, okay, you're done.

00:33:27.000 | You know, she's completed her family.

00:33:29.040 | She's out, you know?

00:33:30.560 | And I'm like, tell your partner to get a vasectomy

00:33:34.160 | or he won't do that.

00:33:35.360 | You know?

00:33:36.200 | So now all of the risk and the onus goes on her.

00:33:39.960 | And so we go through the options of surgical,

00:33:42.920 | like, you know, tubal ligation,

00:33:44.800 | which is basically blocking the tube.

00:33:47.840 | So when I, you know, talk to my teenagers,

00:33:49.560 | I'm like, here's how you not get pregnant.

00:33:51.000 | A, you don't have sex.

00:33:51.960 | Well, if that's not an option,

00:33:52.960 | then we have to either block the sperm,

00:33:55.560 | stop the egg from coming out

00:33:56.880 | or stop the place where they communicate,

00:33:58.560 | which is the fallopian tube.

00:33:59.640 | And so when we look at the different forms

00:34:02.160 | of hormonal contraception,

00:34:03.440 | which are meant to stop ovulation, suppress ovulation,

00:34:06.440 | because they're telling the brain,

00:34:08.440 | we have enough estrogen and progesterone on board,

00:34:11.400 | quiet down so it doesn't send those signals to the ovary.

00:34:13.880 | Right?

00:34:14.720 | And so that can come in a pill form, a patch form,

00:34:17.720 | a ring form,

00:34:18.560 | and they each have their own pros, cons, risks, benefits.

00:34:21.240 | You know, transdermal has less risk of blood clots

00:34:23.840 | versus oral has a higher risk of blood clot

00:34:26.200 | in any form of estrogen.

00:34:27.640 | So we talk about that.

00:34:28.560 | We look at their family history,

00:34:29.680 | or if they have MTHFR or any of the clotting genes,

00:34:32.280 | you know, then we counsel directly versus the IUD.

00:34:36.400 | The IUDs create an inflammatory environment in the uterus

00:34:40.960 | that blocks and it creates a plug in the cervix

00:34:44.080 | so that the sperm can't get through.

00:34:46.600 | And then if any do get through,

00:34:48.480 | it's a toxic environment in the uterine cavity for the sperm.

00:34:53.160 | So that's really how those IUDs work.

00:34:55.640 | Some IUDs are coated with progesterone or progestin,

00:34:58.440 | not progesterone, progestogen,

00:35:00.040 | and those end up decidualizing the endometrium,

00:35:03.240 | so thinning that lining from that constant progesterone

00:35:06.440 | to the point where you stop bleeding.

00:35:07.880 | So a lot of my patients really loved that option

00:35:10.520 | of being amenorrheic, no periods,

00:35:12.680 | just for the convenience of it,

00:35:14.040 | but they were still ovulating in the background.

00:35:15.720 | So we're not suppressing their natural cycles,

00:35:17.800 | just their periods.

00:35:19.200 | - I see.

00:35:20.040 | And is there any evidence

00:35:21.240 | that the use of any form of birth control

00:35:23.520 | can disrupt the timing or the availability of,

00:35:28.520 | I realize availability of eggs is a very clinically naive,

00:35:33.600 | biologically naive statement,

00:35:34.760 | but basically what I'm saying,

00:35:36.080 | can any of them accelerate the onset of perimenopause?

00:35:39.960 | Can they delay the onset of perimenopause?

00:35:40.800 | - They will delay the onset a little bit.

00:35:42.960 | You know, it's maybe a year.

00:35:45.680 | If you use it for a long time from what the data shows.

00:35:48.520 | So women who suppress ovulation,

00:35:50.640 | we lose about 11,000 eggs each month

00:35:53.440 | with the ovulation process to get one out.

00:35:55.960 | 11,000 race to the finish line and only one makes it,

00:35:59.320 | but we lose about 11,000 in the process.

00:36:01.440 | So women who are constantly, you know,

00:36:03.400 | for a long time suppressing ovulation

00:36:05.680 | will have a slightly older age of menopause

00:36:09.840 | had they not done that.

00:36:11.440 | - When you say slightly older,

00:36:12.440 | what's the longest extension of sort of-

00:36:15.040 | - The best I could see in the data was maybe nine months.

00:36:18.680 | - Okay, from nine months use of birth control?

00:36:21.320 | - No, no, no, so maybe like five to 10 year use.

00:36:23.960 | I have to look at the data again to be, you know,

00:36:26.280 | I'd have to look that one up, but it was several years.

00:36:28.860 | - Got it.

00:36:29.700 | - To gain an extra maybe nine months,

00:36:32.600 | maybe a year of ovarian life.

00:36:35.560 | - I see.

00:36:36.400 | And nowadays, at least if people have the means,

00:36:40.280 | there's some trend, if you will,

00:36:44.040 | toward freezing one's eggs.

00:36:47.040 | This might be a good opportunity to just state

00:36:48.800 | something that came up before

00:36:50.000 | when we had Dr. Natalie Crawford on the podcast

00:36:52.640 | to talk about female fertility.

00:36:54.300 | I think surprising to many people was her statement that,

00:37:00.400 | not because it's controversial,

00:37:02.440 | but because we just don't hear this often enough,

00:37:05.280 | that harvesting eggs for freezing or for IVF

00:37:09.760 | does not diminish the pool of eggs

00:37:13.120 | that one would have,

00:37:14.720 | meaning you're losing them each month anyway.

00:37:18.640 | - Yeah, and so they're only pulling out 10, 12 maybe

00:37:22.000 | in a cycle, and when you're losing 11,000 with an ovulation,

00:37:26.240 | so it really isn't going to affect

00:37:29.080 | when you go through menopause.

00:37:30.840 | - Such a crucial thing for people to hear.

00:37:33.440 | I think there were a number of comments

00:37:35.120 | when we posted that clip on social media,

00:37:37.280 | and people, women saying, wow, I didn't realize

00:37:40.960 | that harvesting eggs would not somehow

00:37:45.960 | shift the onset of menopause earlier.

00:37:48.600 | And so for the record, we are not saying that.

00:37:50.600 | We're saying that it does not.

00:37:52.400 | And very interesting that the use of birth control,

00:37:56.200 | but I'm guessing only forms of birth control

00:37:58.320 | that suppress ovulation can delay the onset

00:38:01.720 | of perimenopause menopause by about nine months maximum.

00:38:05.520 | So things like the copper IUD.

00:38:07.320 | - That won't affect it.

00:38:08.160 | - Right, which prevent pregnancy

00:38:10.280 | by creating a unfavorable environment for the sperm

00:38:12.900 | rather than disrupting ovulation in any way,

00:38:15.080 | will not presumably extend perimenopause menopause.

00:38:18.100 | Okay, just wanna make sure we're crystal clear for people.

00:38:20.540 | You're being very clear, but I wanna make sure

00:38:22.340 | that I'm clear on it and then reiterate

00:38:23.680 | because this can be kind of tricky territory.

00:38:27.800 | I think there are a lot of assumptions about this stuff,

00:38:29.920 | and there's a lot of lore out there.

00:38:31.640 | Why do you think that is?

00:38:32.480 | Is that because of the lack of solid research

00:38:34.400 | and communication in this area?

00:38:35.840 | - I think so.

00:38:36.880 | - Or is it something else?

00:38:37.880 | You know, I think that these are tricky topics

00:38:41.920 | for discussion often because we hear all this stuff

00:38:46.400 | like birth control pills disrupt one's ability

00:38:48.920 | to get pregnant when they come off,

00:38:49.960 | or we just learned that it can delay

00:38:52.820 | the onset of perimenopause,

00:38:54.000 | which by extension means there's a greater window

00:38:56.440 | for pregnancy if one thinks about it that way.

00:38:59.400 | But why do you think it's such a tangled discussion

00:39:04.400 | out there?

00:39:05.960 | - I think just the way that society views pregnancy

00:39:10.960 | and female health and, you know,

00:39:15.460 | at least, you know, I live on the internet now.

00:39:17.660 | You know, this new life has brought me life on the internet

00:39:20.600 | and that's what the algorithms are showing me.

00:39:22.940 | Yeah.

00:39:23.780 | - It's a very friendly, everyone's written on it.

00:39:25.600 | - Everyone loves you.

00:39:26.920 | - It's a great, listen, it's what you're doing

00:39:29.240 | is so important.

00:39:31.760 | And I understand the statement behind that statement.

00:39:35.180 | I think, but it's so important

00:39:38.360 | because people are getting the opportunity to learn

00:39:40.920 | about really critical public health

00:39:42.880 | and female health issues in a way

00:39:45.500 | that just was inaccessible before.

00:39:47.320 | - Yeah, it is.

00:39:48.520 | And it's good and bad.

00:39:50.800 | You know, there's a lot of lore and misinformation

00:39:53.600 | that's getting propagated.

00:39:54.740 | And I feel like as a specialty,

00:39:56.440 | you know, as a women's health specialist,

00:39:57.680 | we did this to ourselves.

00:39:59.080 | You know, we have not properly educated ourselves.

00:40:03.640 | We have not spent the money, the research,

00:40:05.820 | really, you know, championed women after reproduction.

00:40:08.620 | When you look at the dollars and the research

00:40:11.760 | and where it goes in women's health,

00:40:13.360 | I mean, women's health just gets a little sliver

00:40:15.120 | of all the NIH funding.

00:40:16.760 | When you look at all NIH funding and what goes to menopause,

00:40:19.320 | it's 0.03%, less than half a percent.

00:40:22.920 | This is one third of a woman's life.

00:40:25.640 | And when you look at, God, McKinsey and company

00:40:28.360 | just published a report where they pulled 680 women

00:40:33.360 | and 80 studies on like chronic diseases,

00:40:35.280 | diabetes, hypertension, cardiovascular disease.

00:40:37.600 | And they looked at how they had,

00:40:40.000 | they were women included in the studies,

00:40:41.560 | but how many presented the data for the different sexes.

00:40:45.280 | Like what happened to men versus what happened to women?

00:40:47.120 | It was only 50% of the articles

00:40:49.760 | actually did sex-specific differences

00:40:51.760 | and how this medication affected this process or whatever.

00:40:54.520 | And then of the ones that did,

00:40:55.960 | 30% were women had poorer outcomes.

00:40:58.760 | And on the flip side, 10% of men had poorer outcomes.

00:41:02.400 | And these things aren't just being brought to light.

00:41:04.600 | So the lack of recognition of sex-specific differences

00:41:09.320 | in chronic disease and how menopause

00:41:10.960 | kind of plays into all that,

00:41:13.120 | I think is where the future needs to go.

00:41:15.200 | So we deserve as much good health as everyone else.

00:41:18.700 | 'Cause yes, we're living longer than men,

00:41:20.840 | but 20 to 25% of that life is in poorer health.

00:41:23.600 | - Wow, that's a really significant statement.

00:41:26.960 | I mean, I think that the National Institutes of Health

00:41:29.480 | has been terrific in establishing new institutes within it.

00:41:34.200 | They even have a complementary health institute now.

00:41:37.000 | There's the National Eye Institute.

00:41:39.200 | There's Cancer here.

00:41:41.020 | Is there a plan or one would hope

00:41:45.440 | for a dedicated institute for women's health?

00:41:48.200 | - Push.

00:41:49.400 | So there was one piece of legislation

00:41:52.040 | that got pushed through, the Biden signed it,

00:41:54.320 | and it was $100 million for women's health.

00:41:57.120 | And that got chopped up very quickly.

00:41:59.000 | Menopause did get a little piece of it

00:42:00.640 | because we're also really struggling with endometriosis

00:42:04.000 | and a lot of the female-specific uterine diseases

00:42:07.360 | and PCOS and things.

00:42:09.080 | And so we need more funding there as well.

00:42:11.420 | And then there's another bill that just got,

00:42:14.920 | that's the one Halle Berry was on TV talking about,

00:42:18.640 | another bill for $250 million.

00:42:20.560 | That bill includes language for education of providers.

00:42:24.900 | So we have a whole generation of providers.

00:42:28.080 | Like I graduated my residency training

00:42:31.040 | the year the WHI came out.

00:42:33.000 | So all, we had very little

00:42:35.320 | like real clinically significant menopause education.

00:42:38.520 | And then we knew about HRT and we were giving it in clinic

00:42:42.200 | if she was coming in with severe hot flashes.

00:42:44.540 | But that got taken off the table after the WHI.

00:42:47.560 | And then we have a whole generation,

00:42:48.640 | like all menopause education basically stopped after that.

00:42:51.400 | - So WHI, Women's Health Initiative, HRT.

00:42:54.120 | No, that's okay, just so that people are on board.

00:42:56.440 | Hormone Replacement Therapy.

00:42:58.040 | Yeah, it's a, well, we can encourage the expansion

00:43:04.840 | of research in these areas and with this discussion.

00:43:09.060 | And certainly I was on NIH panels for years

00:43:13.380 | as a regular member in the Eye Institute.

00:43:15.360 | And what I've noticed with NIH

00:43:18.080 | is that they are very responsive to the public call

00:43:22.200 | for growth of research in particular areas.

00:43:25.080 | You know, it can take time, it's government after all,

00:43:27.740 | and they need funding.

00:43:28.580 | There's a finite amount of funding,

00:43:29.720 | but I think that rarely do I ever get

00:43:32.880 | into legislature-based things.

00:43:34.500 | But if you are somebody who cares about more funding

00:43:37.340 | in a given area of research,

00:43:38.480 | it's actually very straightforward what to do.

00:43:40.440 | You call your congressman or senator and you tell them,

00:43:44.560 | literally you leave a message.

00:43:45.780 | I find this kind of interesting.

00:43:46.880 | And so it's kind of like what we learned in social studies

00:43:50.080 | and in elementary school.

00:43:53.240 | But you call your senator or your governor

00:43:57.380 | and you leave a message and you say,

00:43:58.880 | "Hey, you know, there's this issue

00:44:00.960 | "that impacts a ton of people and it's really important.

00:44:03.420 | "And the next time it comes up

00:44:06.200 | "when budgeting comes up in Washington,

00:44:10.060 | "it's really important.

00:44:11.120 | "And if you hear about a bill,

00:44:12.200 | "you can call and support a bill."

00:44:13.720 | And believe it or not,

00:44:14.560 | some of that stuff actually translates

00:44:16.720 | to more funding in a given area.

00:44:18.080 | In fact, the BRAIN Initiative,

00:44:19.920 | which unfortunately had its budget

00:44:21.840 | cut significantly recently,

00:44:24.080 | maybe put that funding back,

00:44:26.200 | but arose from the,

00:44:28.800 | I believe it was the child of two neuroscience professors

00:44:32.480 | up at University of Wisconsin.

00:44:33.960 | I'm probably gonna get some details wrong,

00:44:35.320 | but so the Khalil's are the professors, as I recall.

00:44:39.240 | And their son overheard all of these conversations

00:44:41.560 | growing up about the importance of brain science.

00:44:43.140 | And then eventually pushed through government channels

00:44:46.500 | for more money for brain research.

00:44:48.160 | And then we had a long phase of pretty,

00:44:51.120 | pretty substantial research and then it was cut.

00:44:52.720 | So these things, but it persists.

00:44:54.640 | And so these things really matter.

00:44:56.160 | - They do. - Like you can impact it.

00:44:57.080 | So, and maybe we should send them a clip

00:44:58.800 | of your statements on this podcast.

00:45:01.060 | Getting back to kind of things that people can control.

00:45:05.160 | So for people who are heading into perimenopause

00:45:07.520 | or who are in the perimenopause phase,

00:45:10.560 | aside from the typical things that we hear about,

00:45:13.480 | fortunately a lot these days,

00:45:14.600 | like getting adequate sleep, getting exercise, nutrition.

00:45:19.120 | Maybe we could touch a little bit on nutrition in a moment.

00:45:21.440 | You mentioned Mediterranean diet, Galveston diet,

00:45:24.320 | things that are going to promote overall health.

00:45:27.520 | Are there any things that people can do,

00:45:30.740 | maybe even take that would improve

00:45:33.840 | their outcomes in this phase?

00:45:35.120 | Like I've heard of people and I have no bias here

00:45:37.520 | or even knowledge of the research on this.

00:45:39.040 | If there is any people taking, for instance,

00:45:40.800 | grapeseed extract or people trying to do a number of things

00:45:44.360 | to reduce inflammation,

00:45:45.560 | kind of general themes around self-care

00:45:48.520 | and wellness these days.

00:45:49.760 | But what are sort of the five or six that come to mind,

00:45:53.160 | perhaps as like the things that can move the levers

00:45:55.800 | in the right direction?

00:45:56.680 | - What I would tell my 35 year old self,

00:45:59.480 | who just kind of went into this obliviously.

00:46:01.800 | And what I know now is your diet

00:46:06.640 | is probably one of the most important things

00:46:08.340 | that determines your level of inflammation.

00:46:10.600 | And then estrogen is a really powerful

00:46:12.720 | anti-inflammatory hormone.

00:46:14.080 | And we lose that protection when we go through,

00:46:16.360 | we start losing it through the transition.

00:46:18.200 | So whatever you can do in the other areas,

00:46:20.560 | especially with nutrition, sleep, stress reduction,

00:46:23.660 | we need to do it.

00:46:24.500 | So fiber, we are not getting enough fiber in our diet.

00:46:27.640 | In the Western diet, I think it's most women

00:46:29.400 | are getting 10 to 12 grams per day.

00:46:31.040 | And we need at least 25 and the health benefits

00:46:33.360 | tend to max out around 30, 32 grams per day.

00:46:36.740 | So focusing on foods that are rich in fiber.

00:46:39.080 | Fibers feed in the gut microbiome,

00:46:40.600 | slowing down glucose absorption,

00:46:42.440 | glucose levels, sugar absorption into the bloodstream.

00:46:45.540 | It is slowing down the rate of certain parts of transit

00:46:49.240 | and pulling more water into the gut.

00:46:50.920 | There's nothing bad about it, right?

00:46:53.560 | The foods that are rich in fiber

00:46:55.000 | have a lot of other stuff that's good for you too.

00:46:57.040 | Cofactors, vitamins, minerals, nutrients,

00:46:59.520 | they're just so helpful.

00:47:00.860 | And then anthocyanins, just find things that crunch

00:47:05.040 | and get as many colors as you can.

00:47:06.960 | Green, red, purple, yellow,

00:47:08.160 | every color represents a phytochemical

00:47:10.560 | that is going to be good for you

00:47:11.880 | in different areas of your body

00:47:13.360 | and try to keep it as varied as possible.

00:47:15.480 | We're not getting enough protein.

00:47:17.680 | And I have to thank Dr. Gabrielle Lyon,

00:47:19.840 | really helping me focus in on that.

00:47:22.600 | When I first wrote Galveston Diet,

00:47:24.560 | to be honest and transparent, it was for weight loss.

00:47:27.120 | And I was frustrated with my weight gain

00:47:29.960 | and that was the pain point my patients had

00:47:32.040 | and that was my pain point,

00:47:33.240 | but I didn't realize it represented something

00:47:34.920 | much more sinister than just the way it looked,

00:47:38.040 | the visceral fat gain.

00:47:39.560 | And so learning about visceral fat

00:47:41.760 | and what it really means.

00:47:42.840 | And that is, for your listeners,

00:47:44.060 | the fat that wraps around our internal organs.

00:47:46.240 | It's a very different fat than the subcutaneous fat.

00:47:48.920 | And a pre-menopausal woman, so we age matched

00:47:51.920 | and looked at visceral fat levels,

00:47:53.320 | measuring it with the DEXA scanners,

00:47:57.860 | you have about 8% of your fat is visceral

00:48:00.680 | as a pre-menopausal person.

00:48:02.020 | And then when you go through the transition, it's 23%.

00:48:05.320 | With no changes in diet and exercise.

00:48:07.680 | - The visceral fat is not something

00:48:09.280 | that gets enough attention.

00:48:10.520 | I think everyone thinks about subcutaneous fat

00:48:12.400 | because of its relationship to aesthetics.

00:48:13.240 | - It's cosmetically distressing, but really, yeah.

00:48:15.700 | - And one doesn't want too much of it

00:48:18.440 | for health reasons either,

00:48:19.800 | but it's the intravisceral fat that,

00:48:23.120 | at least by my understanding,

00:48:24.160 | is really the most problematic for our health.

00:48:27.760 | - It's a harbinger of chronic disease, so.

00:48:31.120 | - I read that weight gain is one of the primary symptoms

00:48:36.020 | of menopause itself.

00:48:37.360 | - Yeah, so you have to be careful how you think about that.

00:48:40.240 | When we plot weight gain versus age,

00:48:43.240 | it's a very straightforward linear curve,

00:48:45.520 | and menopause does not seem to affect that.

00:48:47.600 | What is happening is a body composition change.

00:48:50.560 | We are losing muscle and we are gaining visceral fat.

00:48:55.560 | And you might be gaining some subcutaneous fat,

00:48:58.220 | but those are kind of the key things that are happening.

00:49:01.380 | And so that's really, when I'm counseling patients,

00:49:04.120 | what I'm focusing on.

00:49:05.020 | 'Cause I have a body scanner in my office

00:49:06.740 | where I can tell them what their level of visceral fat

00:49:08.480 | is in their muscle mass.

00:49:09.360 | And so we, bone and muscle,

00:49:11.840 | that musculoskeletal unit works together.

00:49:14.540 | And so we see this acceleration of muscle loss,

00:49:17.400 | which controls our basal metabolic rate,

00:49:19.340 | which determines our resistance to insulin, which, you know.

00:49:22.140 | So it's just, that's the organ of longevity.

00:49:26.200 | That's what I've learned from Dr. Lyon, you know.

00:49:28.600 | And everything we can do to hang on to it

00:49:31.240 | and build is so important.

00:49:33.300 | So protein, going back to the original point,

00:49:35.640 | protein intake is key.

00:49:37.440 | And women, by and large,

00:49:38.880 | are getting 50 to 60 grams of protein per day.

00:49:42.040 | And we really probably need 80, 100, 120,

00:49:44.860 | depending on our body composition.

00:49:46.760 | - Yeah, thanks for mentioning Dr. Gabrielle Lyon.

00:49:48.700 | She's doing what I view as just-

00:49:50.520 | - Beautiful work in the world.

00:49:51.480 | - Yeah, terrific work, really promoting women's health

00:49:53.960 | and health generally.

00:49:55.920 | I know she's now, I believe it's exploring

00:49:58.960 | advanced training in urology for males as well.

00:50:03.240 | And so, you know, it's only fair to credit her

00:50:08.240 | with really expanding into these different areas,

00:50:11.100 | but especially this idea that we need,

00:50:15.900 | and women perhaps in particular,

00:50:17.960 | from what I understand, she'll be on the podcast soon,

00:50:20.480 | so we'll get more of an understanding,

00:50:22.960 | at least one gram of quality protein per pound

00:50:25.920 | of lean body mass, maybe even per pound of body weight

00:50:28.600 | per day in order to optimize their health.

00:50:30.960 | - Yeah, she's definitely on the higher end.

00:50:33.800 | You know, the WHO, the Women's Health Initiative,

00:50:36.080 | some of my favorite data, you know, it's not all bad,

00:50:38.600 | it's data, and was looking at frailty scores

00:50:42.360 | and protein intake in women.

00:50:44.040 | And what they found was women who were having 1.5 to 1.7.

00:50:48.640 | So basically, it was the higher their protein intake,

00:50:51.200 | the less likely they were to be frail, the end.

00:50:54.920 | And it was, you know, they were reaching,

00:50:56.800 | it was kind of peaking out somewhere around 1.5 to 1.7

00:51:00.080 | grams for kilogram of lean body mass.

00:51:03.480 | And most women are getting around,

00:51:04.720 | you know, the FDA recommends 0.8.

00:51:06.520 | - Wow, and source of protein also important, high quality.

00:51:11.040 | - Right, right, you need all the amino acids, yeah.

00:51:13.320 | - Very interesting.

00:51:14.940 | Now that's in menopause, but presumably also-

00:51:19.480 | - So starting those habits in peri,

00:51:22.000 | just getting that laid down and getting those habits

00:51:24.580 | laid down are gonna set you up for a much better

00:51:27.040 | post-menopause, a much healthier post-menopause.

00:51:29.720 | And we have to stop defining menopause

00:51:32.120 | by your hot flashes, you know.

00:51:33.960 | It may or may not make your hot flashes better.

00:51:35.800 | And we have great medications for that if it's disruptive.

00:51:38.820 | But I'm talking about your cardiometabolic disease risk.

00:51:42.320 | - I meant to ask this earlier.

00:51:44.360 | So forgive me for leaping back briefly,

00:51:46.780 | but is there any value in knowing the age at which

00:51:49.920 | your mother went into menopause as a metric

00:51:53.800 | or a sensor rather, or as a window into whether or not

00:51:58.680 | you will go into menopause at more or less the same age?

00:52:01.600 | - Yes, there is a, of course, it's not one-to-one.

00:52:04.560 | We get half of our DNA from our fathers.

00:52:06.520 | So, but I always ask, and there is a, you know,

00:52:10.880 | the latest data that looked at it,

00:52:12.520 | genetics is the biggest factor that determines

00:52:15.400 | when you're gonna go through menopause.

00:52:17.600 | So knowing when your mothers, your aunts, you know,

00:52:20.020 | went through and if there were any medical conditions

00:52:22.440 | associated with that is huge.

00:52:25.440 | - Okay, so now we're talking not so much

00:52:27.480 | about perimenopause, but also menopause itself.

00:52:30.960 | What is the typical constellation of symptoms

00:52:33.800 | as one enters menopause, like right at the beginning,

00:52:37.800 | and then does that constellation of symptoms change

00:52:40.440 | as one is, you know, a year, two years,

00:52:42.440 | three years into menopause?

00:52:43.280 | - So it's almost a hundred percent

00:52:44.800 | with body composition changes, like very, very close.

00:52:47.560 | You know, that visceral fat is tough to beat.

00:52:50.920 | It's beatable, but it takes a lot of work, you know.

00:52:53.560 | - Do people know if they have visceral fat?

00:52:55.280 | I mean, there's their scanning approaches to look at it.

00:52:57.960 | - You know, of course the gold standard is a DEXA

00:53:00.520 | or even an MRI, but no one can afford that.

00:53:02.840 | So we have, like what I have in my office

00:53:06.280 | is the in-body scanner.

00:53:07.280 | So it's electrical impedance scanner, and it's pretty good.

00:53:09.840 | - So you stand on the scale, hold the handles.

00:53:11.720 | - I have the medical, I have the highest grade one

00:53:13.520 | for my patients.

00:53:14.360 | And most people doing what I do, you know,

00:53:17.020 | utilizing a body scanner, use that one.

00:53:19.760 | But you can use the waist-tip ratio.

00:53:22.520 | And so the waist-tip ratio is a better measure

00:53:25.280 | of your risk of metabolic health

00:53:27.440 | than your weight or your BMI.

00:53:29.400 | So it's so simple.

00:53:30.480 | You take a tape measure and a calculator,

00:53:32.120 | you can do it in your head,

00:53:32.960 | but you measure the smallest part of your waist.

00:53:35.200 | And if you don't have a small waist, if it goes out,

00:53:37.160 | then just use your belly button.

00:53:38.120 | Just use something you can measure again.

00:53:40.200 | - Are people sucking in or are they relaxed?

00:53:41.840 | - You should be relaxed.

00:53:42.840 | And I tell my patients, you know,

00:53:44.560 | do it first thing in the morning when your bladder's empty

00:53:46.320 | and you're not bloated and, you know,

00:53:48.480 | and then the widest part of your hips.

00:53:50.120 | It's not perfect,

00:53:51.360 | but it's better than your weight or your BMI.

00:53:53.800 | - So widest part of the hips with people,

00:53:55.440 | feet parallel, standing up straight.

00:53:58.840 | 'Cause people are gonna go try this, right?

00:54:00.320 | - And so I only know the data for women, so forgive me,

00:54:03.380 | but for a female, if it's less than 0.7,

00:54:08.380 | then your chance of having clinically significant

00:54:12.520 | aberrations in visceral fat are low.

00:54:14.800 | And then if it's greater than one,

00:54:17.400 | you likely have higher levels of visceral fat.

00:54:20.760 | And so in clinic or when I was coaching online

00:54:24.280 | for Galveston Diet, we were using the waist-up ratio

00:54:27.160 | as one of the, you know, measures for their success.

00:54:30.360 | - When measuring the waist, which point along the waist?

00:54:33.840 | Is it right at the navel?

00:54:35.020 | Is it-

00:54:35.860 | - It's just wherever you're smallest.

00:54:37.360 | So that's kind of different for different women.

00:54:39.500 | So I would just say, look in the mirror,

00:54:41.060 | wherever your hourglass goes in

00:54:42.560 | is where you wanna kind of stick to.

00:54:44.520 | But if you don't have that kind of a waist

00:54:46.440 | and you have a wider waist, just pick the belly button

00:54:48.600 | 'cause you always know you can go back to that level.

00:54:50.760 | You know, that's 'cause we're tracking them over time.

00:54:54.280 | - Great, those are very useful recommendations.

00:54:58.480 | And how often should people do that?

00:55:00.720 | - You know, you should never weigh yourself every day.

00:55:02.680 | You shouldn't do this every day.

00:55:03.520 | We were having patients do it or, you know,

00:55:05.120 | our followers do it once a month.

00:55:06.920 | - So changes in body composition as measured by DEXA

00:55:11.280 | or impedance, or if you don't have access to that,

00:55:14.200 | waist to hip ratio,

00:55:15.600 | what are some of the other symptoms of menopause?

00:55:18.120 | - Fatigue, fatigue, multiple causes for the fatigue.

00:55:20.520 | A lot of sleep disruption.

00:55:22.280 | Sleep disruption is another huge thing.

00:55:24.280 | So all of a sudden you're struggling to go to sleep

00:55:27.640 | or you're having middle of the night awakens

00:55:29.560 | and not able to go back to bed.

00:55:31.080 | - That are new and different from previous-

00:55:33.400 | - New and different than before, right.

00:55:35.160 | - I see.

00:55:36.000 | - There was a recent study that came out

00:55:38.640 | and most of my patients in hindsight say,

00:55:40.960 | I knew something wasn't right

00:55:43.080 | or something was different, something had changed,

00:55:45.040 | but I couldn't put my finger on it.

00:55:46.480 | And they're just had a study come out saying something's,

00:55:50.040 | when they looked at what that means,

00:55:51.440 | what does I'm not feeling like myself mean?

00:55:54.240 | And it was psychological changes.

00:55:56.200 | So you lose resilience.

00:55:57.760 | You're suddenly more irritable.

00:55:58.920 | You're suddenly not able to like go with the punches

00:56:01.120 | or do, you know, you're not adjusting as well to change

00:56:05.120 | that you used to.

00:56:05.960 | You're snapping at your kids more, your partner,

00:56:08.160 | or you're, you know, you're getting frustrated at work.

00:56:11.240 | You know, it's just very kind of subtle

00:56:13.760 | and it takes going through it and then looking back to say,

00:56:16.440 | yeah, I really say maybe about 47

00:56:18.480 | that something was changing

00:56:20.360 | and I just thought I was just stressed out or whatever.

00:56:22.480 | And then now I can see

00:56:23.400 | that was the beginning of the pattern.

00:56:25.200 | So menstrual changes, as we talked about,

00:56:28.560 | you know, the big highlights, vertigo,

00:56:31.640 | tinnitus ringing in the ears,

00:56:34.800 | skin changes.

00:56:36.960 | So dry skin, itchy skin,

00:56:38.440 | feeling like you're having crawling under the skin,

00:56:41.080 | big gut changes.

00:56:42.160 | So new onset bloating,

00:56:43.440 | you're kind of eating all the same things

00:56:44.800 | and your gut's just not handling things like it used to.

00:56:47.440 | So the Zoe nutrition study took 1100 women

00:56:50.800 | and did stool samples through menopause,

00:56:53.160 | through the perimenopause-menopause transition

00:56:55.480 | and saw the changes in the gut microbiome

00:56:58.160 | from the loss of the sex hormones.

00:57:00.040 | And basically we went from what a typical female microbiome

00:57:03.880 | to that of a male through the transition.

00:57:07.880 | - Is there any direct evidence

00:57:10.160 | that supplementing the gut microbiome,

00:57:13.440 | and here I don't necessarily mean pills and powders.

00:57:15.800 | I mean, my understanding is that getting enough fiber

00:57:19.200 | and low sugar fermented foods

00:57:22.000 | can also support the gut microbiome.

00:57:23.800 | Things like sauerkraut, kimchi, kefir, miso.

00:57:28.800 | - Plain yogurt, just straight up, nothing added.

00:57:31.600 | - Yeah, so is there evidence

00:57:32.880 | that supporting the gut microbiome

00:57:34.320 | can make this stage of menopause more,

00:57:38.720 | I guess, reduce some of the symptoms of menopause?

00:57:41.400 | - So the best I could find was,

00:57:44.360 | most of them are done with supplements

00:57:46.000 | 'cause those are easier to measure

00:57:47.120 | than handing someone a cup of yogurt.

00:57:48.560 | - Right, and you know which bacteria you're providing.

00:57:50.680 | - So they did lactobacillus

00:57:53.760 | and looked and bifidobacterium, I think,

00:57:56.360 | and saw that women who were obese

00:57:58.360 | and hypertensive and menopausal,

00:58:00.240 | and they had visceral fat decrease

00:58:02.400 | and blood pressure improvements versus placebo.

00:58:05.560 | Also, it's hard to do placebo studies with food.

00:58:08.320 | - Right.

00:58:09.300 | - But they do, and then in the retrospective studies,

00:58:11.560 | they can look at dietary patterns.

00:58:12.840 | And women who ate rich foods fermented

00:58:16.380 | and lots of yogurt, Mediterranean-type diets,

00:58:20.080 | have better symptoms overall.

00:58:22.480 | - What's the difference between the Mediterranean diet

00:58:24.760 | and the Galveston diet?

00:58:25.920 | - So when I, so I got my culinary medicine certification.

00:58:31.120 | I was frustrated-- - Culinary medicine.

00:58:33.000 | - Yeah, so I was frustrated when I was working

00:58:36.840 | because I didn't know anything about nutrition,

00:58:38.640 | and suddenly everything I was trying to tell my patients

00:58:41.440 | was based on the one lecture I got in medical school.

00:58:43.880 | And good nutrition was like porn.

00:58:46.480 | You know it when you see it,

00:58:47.680 | the Supreme Court definition of pornography.

00:58:49.280 | And so the best I'd ever gotten

00:58:52.000 | was the gestational diabetic diet,

00:58:53.920 | and it was this Xerox things with,

00:58:56.080 | I was in the deep, I was in Texas,

00:58:57.440 | so it had tortillas and stuff on it,

00:58:59.200 | and it had been copied so many times

00:59:01.320 | you could barely read it anymore,

00:59:02.600 | and that was the diet.

00:59:03.600 | That was the only nutrition I'd ever hand it to a patient.

00:59:06.780 | And so I'm like, "Eat healthy."

00:59:08.480 | And so I'm like, "I gotta do better than this.

00:59:09.820 | "I don't know enough."

00:59:10.960 | And so we had a guest speaker for Alpha Omega Alpha,

00:59:13.960 | which is the Honor Society for medical school,

00:59:15.520 | and I was one of the advisors.

00:59:17.080 | And it was this guy, Tim Harlan,

00:59:18.780 | who had started this culinary medicine movement,

00:59:22.800 | and it was basically nutrition for doctors.

00:59:25.080 | And he developed this online program,

00:59:27.640 | and I had to go to New Orleans for a lab

00:59:29.240 | and San Antonio for a lab

00:59:30.360 | and work in kitchens where you were learning

00:59:32.080 | how to counsel patients, how to cook,

00:59:33.600 | and also basically getting a little minor in nutrition.

00:59:37.360 | So it was the best thing I've ever done.

00:59:40.680 | - Yeah, I was gonna say, very cool.

00:59:41.520 | - I mean, I learned about allergies and all this stuff,

00:59:44.000 | food allergies and things that I just didn't know,

00:59:45.600 | and just basic nutritional principles,

00:59:47.360 | like what it takes to build a healthy body,

00:59:49.240 | and I knew about kwashiorkor and severe deficiencies,

00:59:52.400 | but not good basic nutrition.

00:59:54.760 | And so they talked heavily about Mediterranean.

00:59:57.380 | They talked a lot about the fad diets and stuff,

00:59:59.720 | but the principles of the Mediterranean.

01:00:01.440 | I was like, I wanna teach this to my patients,

01:00:03.720 | but they're not gonna eat a lot of Greek yogurt,

01:00:07.320 | or they're probably not gonna eat a lot of feta.

01:00:09.620 | How can I kind of take these blocks

01:00:11.320 | and make it more Americanized?

01:00:12.640 | So that was kind of like the brainchild for me

01:00:14.320 | around Galveston Diet was, let me create something.

01:00:17.480 | And I really was into fasting at the time too.

01:00:19.480 | So I was like, let me put this fasting thing together

01:00:21.920 | with good nutritional anti-inflammatory principles

01:00:25.320 | and talk about the things we know

01:00:26.360 | or probably you should not have in a whole lot

01:00:28.880 | of processed foods and high sugars and stuff,

01:00:31.200 | and explain it in a way

01:00:32.560 | and how it's affecting their menopause

01:00:33.880 | and how can she approach her nutrition?

01:00:35.480 | And that's how Galveston Diet was born.

01:00:36.960 | It was for my patients,

01:00:38.000 | and then I gave it to my girlfriends,

01:00:39.880 | and then they started sharing it,

01:00:41.520 | and I talked about it one day on Facebook,

01:00:42.840 | and the world exploded.

01:00:44.120 | - In the best way.

01:00:44.960 | - In the best way, yeah.

01:00:46.200 | It led me here.

01:00:47.040 | - Right, right, and we all benefit.

01:00:49.800 | What is the evidence that fasting can be beneficial

01:00:54.320 | or detrimental to perimenopause and menopause?

01:00:57.760 | - So the jury's kind of still out on that one.

01:01:00.440 | I really liked the data that, I think it was Mark Mattson

01:01:05.440 | had done on neurodegenerative disease

01:01:07.760 | and using fasting as a tool there

01:01:10.240 | and lowering inflammation levels.

01:01:11.520 | So I was like, this is amazing, this is great,

01:01:13.120 | because so much about menopause is pro-inflammatory.

01:01:17.480 | - Is this intermittent fasting, so time-restricted feeding?

01:01:19.680 | - Intermittent fasting, yeah.

01:01:20.500 | So he was basically doing 16/8,

01:01:22.480 | and very scheduled intermittent fasting.

01:01:25.360 | And so that was something I was coaching my followers about,

01:01:29.080 | consider this, try this,

01:01:30.400 | this might be something to help lower inflammation.

01:01:32.960 | I pulled back on that,

01:01:34.240 | because it's really hard to get enough protein in

01:01:36.920 | for a lot of women, especially if they came in at 60,

01:01:40.280 | and now I'm telling them to double their protein,

01:01:42.840 | and then giving them an eight-hour window to do it.

01:01:44.600 | They're like, I'm walking around

01:01:45.520 | gnawing on a chicken breast all day.

01:01:47.640 | This is hard.

01:01:48.480 | - Right, and metabolizing protein is its own work.

01:01:51.240 | - Right, and so you have to spread it out

01:01:53.240 | throughout the day.

01:01:54.480 | And a lot of that work was done at UTMB,

01:01:56.840 | where I did my residency, and where I taught for years.

01:02:00.120 | And so I was friendly with the nutrition department there.

01:02:02.280 | I was getting all excited about everything.

01:02:04.120 | And they were like, I went to several of their conferences,

01:02:07.080 | and talking about breaking up protein intake

01:02:09.720 | into nuggets throughout the day,

01:02:11.440 | 'cause most women have very little protein with breakfast,

01:02:13.920 | maybe wheat gluten in their toast,

01:02:16.400 | and then have a little bit at lunch,

01:02:18.400 | and then stack their protein at night,

01:02:19.880 | and they're still not getting enough,

01:02:21.280 | but they're overdoing it in their evening meal,

01:02:23.280 | that's their big protein meal.

01:02:24.680 | And so, like teaching them to kind of,

01:02:27.320 | you know, what I was teaching in Galveston Diet

01:02:28.880 | was you need to have a healthy fat,

01:02:30.880 | a good healthy carb, and a protein

01:02:33.160 | with every meal and snack that you eat, you know?

01:02:35.400 | - Why do you think that protein

01:02:37.560 | has not been emphasized enough until recently?

01:02:42.440 | - I think because we didn't understand it.

01:02:45.640 | You know, we didn't understand how important muscle was,

01:02:47.920 | and I mean, we knew that protein intake

01:02:50.600 | was important for muscle,

01:02:51.640 | but muscle was for bodybuilders and not for women.

01:02:54.400 | I lived my whole life up until about five years ago,

01:02:58.440 | eating to be thin and moving to be thin.

01:03:01.280 | That thin was the only measurement of health

01:03:03.080 | that I needed to worry about.

01:03:04.440 | And what I did was chip away at my bone and muscle strength,

01:03:06.880 | and thank God I don't have osteopenia yet.

01:03:09.320 | You know, I've hopefully have reversed

01:03:11.160 | whatever trend I was on, and I'm naturally low muscle,

01:03:14.260 | so now it's just a battle to try to hang on

01:03:17.160 | to what little I have and build some.

01:03:19.440 | - And you resistance train.

01:03:21.200 | - Yeah, yeah, yeah, yeah.

01:03:22.600 | Now, now. - Three days a week.

01:03:23.800 | Three days a week. - Three to four days a week,

01:03:25.320 | yeah, I'm resistance training.

01:03:26.600 | Much less cardio.

01:03:27.520 | I was running marathons,

01:03:28.960 | and it was a great social thing with my girlfriends,

01:03:30.840 | but you know, everything I did was cardio.

01:03:33.680 | I taught step aerobics.

01:03:35.080 | You know, the only weights I did were maybe in Zumba,

01:03:37.180 | maybe one or two pounds, you know?

01:03:39.000 | So, and that was better than being on the couch.

01:03:41.360 | I mean, I loved the community and doing that,

01:03:43.920 | but you know, for me to like stay out of the nursing home,

01:03:46.840 | which was my ultimate goal for as long as possible,

01:03:49.400 | I need to pick up some weights and heavy weights,

01:03:51.200 | and so that's where my focus has changed.

01:03:53.360 | - Isn't it interesting that it wasn't until recently

01:03:56.160 | that it was only bodybuilders and football players

01:03:59.880 | and people preparing for military

01:04:01.200 | or a specific sport would resistance train,

01:04:03.920 | and now we are told that everybody,

01:04:06.400 | male, female, young, old, should resistance train.

01:04:10.600 | - Absolutely. - Probably three times a week.

01:04:12.480 | - Yeah, and my generation is struggling

01:04:14.860 | because we don't know how to do it,

01:04:16.620 | and so I'm, you know, and I'm not a personal trainer.

01:04:19.740 | I don't pretend, you know,

01:04:20.780 | I hire one to help me develop a program

01:04:23.000 | so that I don't hurt myself,

01:04:24.560 | and then I can get stronger, you know, progressive loads.

01:04:27.280 | So, you know, and again, Dr. Lyon,

01:04:29.400 | such a huge proponent of that,

01:04:31.200 | and so what I try to do publicly is show my workouts

01:04:34.360 | so that people, I normalize it and people see me doing it

01:04:37.400 | and they're like, well, she can do it, then I can do it.

01:04:39.320 | - That's great, super inspiring,

01:04:40.600 | and it really helps cross that threshold where people,

01:04:44.120 | as you said, they don't know how, it's scary.

01:04:46.240 | - Right.

01:04:47.080 | - For people who've resistance trained for a long time,

01:04:48.500 | they go into a gym, they know how all that stuff works,

01:04:50.520 | but for those that don't, it's-

01:04:52.140 | - You're wandering around, like, what does this one do?

01:04:54.020 | - Yeah, it's intimidating for a whole bunch of reasons.

01:04:56.140 | Well, thank you for putting that content out,

01:04:58.680 | both the prescription, if you will,

01:05:01.300 | but also the example that one can go about it.

01:05:03.900 | So I'm guessing if you could go back 20 years,

01:05:06.460 | you would have started resistance training earlier

01:05:08.180 | and eating more high-quality foods.

01:05:09.020 | - Yeah, stronger for skin and nutrition over calories

01:05:11.140 | and stop looking, trying to look a certain way.

01:05:14.380 | You know, you're undermining your future health

01:05:17.640 | by doing that.

01:05:19.080 | - I'd like to take a quick break

01:05:20.280 | and acknowledge our sponsor, InsideTracker.

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01:05:44.900 | is that you get information back about metabolic factors

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01:06:29.980 | - So what are some other symptoms of menopause?

01:06:33.380 | You mentioned body composition changes.

01:06:36.100 | The one that we hear about the most for some reason,

01:06:39.500 | I don't know, is hot flashes.

01:06:40.820 | - Yeah, so I think hot flashes,

01:06:43.260 | so in medicine, we call it a vasomotor symptom.

01:06:46.240 | So we have a dysregulation of the thermoregulatory center

01:06:50.620 | in the hypothalamus,

01:06:51.900 | and the thermostat gets reset, basically.

01:06:55.980 | And so what happens is we have this vasodilation of,

01:06:59.300 | it starts in the core, typically, for most women,

01:07:01.380 | somewhere in the chest, neck area,

01:07:03.460 | and you feel this heat.

01:07:04.840 | I can probably trigger one just by talking about it.

01:07:08.860 | And it goes up into the neck,

01:07:10.780 | and out into the extremities,

01:07:11.980 | and then you just start profusely sweating

01:07:13.900 | from all the blood vessels dilating.

01:07:15.700 | And then it can last minutes to a second,

01:07:17.780 | but for some women, it's preceded by sometimes palpitations,

01:07:22.140 | sometimes by this intense feeling of dysphoria,

01:07:26.540 | this intense sadness feeling,

01:07:28.180 | and then it just kind of passes.

01:07:30.220 | But say you're, wherever you are in your life,

01:07:32.820 | whatever you're doing, all of a sudden,

01:07:34.040 | you're just sweating profusely

01:07:35.860 | in the middle of some important area of your life,

01:07:37.940 | work, whatever your jobs are in your life,

01:07:40.540 | and it's disruptive.

01:07:42.260 | If it happens at night, you don't sleep.

01:07:44.460 | And for some women, it's severe,

01:07:46.300 | where they're having multiple ones a day.

01:07:48.820 | - And when, anytime you disrupt sleep,

01:07:50.460 | then daytime is far worse.

01:07:51.980 | - Yeah.

01:07:52.820 | - Regulation of everything. - You eat differently.

01:07:54.260 | Yeah, you stress differently, you know, everything changes.

01:07:57.180 | And so when my patients come in,

01:07:59.100 | the first questions we ask are sleep.

01:08:01.740 | And that's the first thing we work on is, you know,

01:08:04.660 | what can we do to get your sleep better?

01:08:06.900 | - What can be done for hot flashes,

01:08:08.420 | aside from the things that you've already described

01:08:10.500 | to offset menopause and brain menopause itself.

01:08:12.060 | - So the absolute gold standard is hormone therapy.

01:08:14.580 | It's like giving your body back the estrogen,

01:08:16.700 | which will get your serotonin levels back

01:08:19.340 | to where they were,

01:08:20.460 | and leave that thermoregulatory center alone,

01:08:22.700 | so it's back to where it used to be.

01:08:24.860 | - Let's talk about hormone therapy.

01:08:26.140 | - Sure.

01:08:26.980 | - It's a bit of a controversial topic.

01:08:28.260 | - For no reason.

01:08:29.100 | - Yeah, I was going to say, I don't know why.

01:08:31.100 | - Yeah, it's demonized, it got such a bad rap,

01:08:33.900 | and we need to, it's just some of the,

01:08:37.180 | what was the worst misinformation campaign

01:08:39.220 | in the history of medicine?

01:08:40.460 | - Wow, that's a bold statement, but I believe you.

01:08:42.900 | The way I understand it is that there was this

01:08:47.940 | large-scale hormone therapy trial,

01:08:49.900 | and the interpretation of that trial

01:08:53.460 | was something different than we now believe.

01:08:57.460 | - Right.

01:08:58.300 | - As a medical community.

01:08:59.140 | - The initial, so it was really groundbreaking at the time.

01:09:03.100 | Aging women were finally being studied.

01:09:04.700 | We knew from observational data

01:09:06.860 | that women on hormone therapy,

01:09:08.380 | probably 40% of the population of females eligible

01:09:11.100 | were on HRT, okay, so very large amount.

01:09:13.980 | So the women who were given hormone therapy

01:09:16.700 | had lower incidence of cardiovascular disease,

01:09:19.260 | older ages of cardiovascular disease,

01:09:21.020 | lower death from cardiovascular disease.

01:09:23.460 | Some people argued that that was an artifact

01:09:25.500 | of healthier, wealthier women get HRT,

01:09:28.300 | 'cause they go to the doctor, okay?

01:09:30.060 | So this is just because they're healthier,

01:09:31.500 | that they have less cardiovascular disease.

01:09:33.500 | So let's prove it.

01:09:34.980 | What do you do that with?

01:09:35.860 | A randomized control trial.

01:09:37.500 | So flaws in the study.

01:09:39.060 | So they take, I think there were 11,000-ish women

01:09:42.300 | in the estrogen-only arm 'cause they'd had hysterectomy.

01:09:45.300 | So for your listeners, if you have a uterus

01:09:48.020 | and you're getting estrogen,

01:09:49.180 | you must have a progestogen with it

01:09:51.780 | to protect the lining of the uterus from endometrial cancer.

01:09:54.020 | As long as you give an adequate progestin, you're fine, okay?

01:09:57.900 | But if you don't have a uterus,

01:09:59.340 | progesterone is not mandatory.

01:10:01.700 | So the women who had had hysterectomy

01:10:02.980 | got estrogen-only or placebo,

01:10:05.580 | and the estrogen at the time was Primarin,

01:10:08.020 | which was the number one prescription for HRT at the time.

01:10:10.460 | So nothing weird about that.

01:10:12.140 | - So it's just synthetic estradiol?

01:10:14.380 | - Actually, no.

01:10:15.380 | Primarin stands for pregnant mare urine.

01:10:18.700 | It is actually very natural.

01:10:20.940 | They take pregnant horses

01:10:22.540 | and extract the estrogens from their urine.

01:10:25.140 | Because they're pregnant and they were screeding a lot of it.

01:10:27.060 | And it was cheap and easy,

01:10:28.140 | and I have a lot of ethical issues about how they do that,

01:10:30.680 | but, and I don't prescribe it,

01:10:32.140 | but that's what was done at the time.

01:10:34.140 | So. - I've seen horses urinate,

01:10:36.860 | they urinate a lot.

01:10:37.820 | - There are dozens, like race horse, right?

01:10:40.300 | There's dozens of estrogens in that comp,

01:10:43.380 | but the main one is estradiol.

01:10:44.780 | So then there, the other group who had uteruses

01:10:49.220 | were given PrimPro, which is Primarin plus Provera,

01:10:52.980 | and, or placebo.

01:10:54.480 | So off we go.

01:10:55.420 | They recruit 11,000,

01:10:57.260 | and then I think 15,000 in the other arm.

01:10:59.380 | Huge study, it was like a billion dollar study.

01:11:01.260 | Like, we're so excited this is happening.

01:11:02.980 | And this started when I was in med school.

01:11:04.660 | And then they start recruiting patients,

01:11:07.300 | and then, you know, everyone's taking their meds.

01:11:10.180 | They excluded women with hot flashes.

01:11:12.940 | - What?

01:11:13.900 | - Because if your pot flashes go away,

01:11:16.940 | you know that you didn't get the placebo.

01:11:19.180 | So they excluded women with hot flashes,

01:11:21.980 | problem number one.

01:11:22.980 | - Yeah, that's a big problem.

01:11:24.060 | - Now, the end outcome,

01:11:26.140 | what they were trying to measure was cardiovascular disease.

01:11:28.300 | So they started with an older population.

01:11:30.180 | The average age was 63.

01:11:33.100 | - Whereas the typical onset of menopause is?

01:11:35.340 | - 51.

01:11:36.540 | - Wow.

01:11:37.380 | - So these women had been menopausal, you know,

01:11:39.420 | on average for 10, 12, 13 years.

01:11:42.320 | So time away from estrogen

01:11:44.540 | is when disease starts, accelerates, right?

01:11:47.460 | Okay, so put them on their meds, start measuring.

01:11:50.620 | In the estrogen plus progestin arm,

01:11:54.580 | they saw a non-statistically significant

01:11:58.700 | increased risk of breast cancer.

01:12:00.020 | And it was this, the relative risk, relative,

01:12:02.700 | now you know what this is,

01:12:03.660 | but your money or your listeners may not,

01:12:05.700 | was 25%, and I hope I get the numbers right.

01:12:08.940 | It was four out of 1,000 women per year

01:12:11.700 | to five out of 1,000 women per year.

01:12:13.720 | Okay, so placebo arm was four.

01:12:17.020 | So we have breasts, we are females, we get breast cancer.

01:12:19.820 | About four out of 1,000 women per year.

01:12:22.100 | And that increased to five.

01:12:24.020 | In the estrogen only arm,

01:12:25.900 | there was a 30% decreased risk of breast cancer.

01:12:28.860 | - Regardless of the average age.

01:12:31.700 | - And they kept that arm going.

01:12:33.020 | - Right, 'cause it's randomized.

01:12:34.140 | So presumably the average age

01:12:35.820 | for the other group is roughly 61 as well.

01:12:37.980 | - Yeah, they were matched, so in their 60s as well.

01:12:40.060 | So they call a press conference at the Watergate Hotel.

01:12:44.440 | - The Watergate Hotel of all places.

01:12:45.280 | - To announce the findings.

01:12:48.820 | They hadn't even published the data yet.

01:12:50.820 | No one had had a chance to read it.

01:12:53.160 | And the head researchers call this press conference

01:12:56.020 | and say estrogen causes breast cancer.

01:12:59.060 | - Exogenous estrogen from these.

01:13:00.940 | - Yes, yes.

01:13:02.060 | And they said it's a 25% increased risk.

01:13:04.580 | But the absolute risk was like 0.8% per year.

01:13:07.500 | But that didn't get, that's not a headline thing.

01:13:10.740 | So on every, like ABC, NBC, CBS,

01:13:12.900 | all the morning shows, nightly news, every major magazine,

01:13:16.900 | it was the number one medical news story of 2002.

01:13:19.300 | That estrogen was bad and it caused cancer and da-da-da.

01:13:22.900 | The estrogen only arm kept going.

01:13:26.340 | And they found after a couple more years,

01:13:28.460 | a slightly increased risk of stroke.

01:13:30.020 | So they stopped the study.

01:13:31.500 | The effects on cardiovascular disease were neutral,

01:13:34.580 | but there was lower colon cancer in both groups.

01:13:37.840 | But no one talked about that.

01:13:39.660 | So the American Heart Association in 2020

01:13:43.260 | went and looked at, they looked at ages.

01:13:46.500 | So there were younger women who were given HRT.

01:13:48.480 | And what they found was if you started hormone therapy

01:13:50.780 | between the ages of 50 to 59,

01:13:54.060 | you had a 50% decreased risk of cardiovascular disease

01:13:56.960 | and death from cardiovascular disease

01:13:58.300 | and all-cause mortality.

01:13:59.700 | - Wow, so age at which you start matters.

01:14:02.900 | - Estrogen, so that's where,

01:14:04.460 | there's something called the healthy cell hypothesis.

01:14:07.420 | And so basically estrogen is better at prevention than cure.

01:14:10.420 | And it's very protective,

01:14:12.420 | especially in the intima of the coronary arteries.

01:14:15.640 | So taking that estrogen away, we lose that protection.

01:14:19.000 | Once the disease builds up,

01:14:21.400 | there's some worry that adding estrogen,

01:14:23.580 | once you've developed atherosclerosis or a plaque,

01:14:26.660 | might loosen the plaque, especially in that first year.

01:14:29.820 | So which led for some people maybe

01:14:31.820 | to have a slightly increased risk of stroke.

01:14:33.620 | So when my patients come in,

01:14:35.040 | we are talking about these differences.

01:14:38.460 | It doesn't mean that after 60,

01:14:39.820 | you might not have cardiovascular benefit.

01:14:41.680 | We start losing the benefit.

01:14:43.680 | So it's the timing hypothesis is key.

01:14:45.820 | And it's the years away from estrogen that's the problem.

01:14:49.900 | There's a great study in the British Medical Journal.

01:14:51.980 | They looked at years of reproductive life plus HRT

01:14:56.980 | and looked at cognition scores

01:15:01.260 | and saw that the longer your body's exposed to estrogen

01:15:04.220 | in any form, like whether natural cycles

01:15:07.860 | or exogenous estrogen of any form,

01:15:09.980 | and it was estradiol in that study actually,

01:15:12.140 | then you had higher cognition scores, healthier brains.

01:15:17.140 | - Which had a just very, you know,

01:15:19.860 | top contour level makes total sense

01:15:21.520 | given that estrogen is neuroprotective.

01:15:23.780 | I realized it might not be neuroprotective

01:15:25.840 | in every instance and every neuron in the brain,

01:15:27.620 | but it's generally neuroprotective.

01:15:28.940 | - Generally neuroprotective, yeah.

01:15:30.140 | - And decline in estrogen is correlated

01:15:32.580 | with neurodegeneration, which does not mean it's causal.

01:15:36.220 | I have to ask, when they announced this study

01:15:38.680 | at the Watergate Hotel of all places,

01:15:40.740 | and the conclusion that they put forth

01:15:44.140 | was that estrogen therapies can increase rates of cancer.

01:15:50.460 | I have to wonder if that had something to do with,

01:15:54.560 | what I understand is a sort of party line

01:15:56.880 | around cancers and breast cancers in particular,

01:15:59.240 | which is that you wanna quote unquote

01:16:00.480 | block the estrogen receptor.

01:16:01.960 | You wanna get in there and give tamoxifen,

01:16:04.240 | or nowadays I'm sure there are other drugs

01:16:05.920 | that are more effective to block the estrogen receptor.

01:16:08.400 | It all seems to pile up on the side of a story

01:16:11.640 | that says, you know, estrogen and estrogen binding

01:16:14.080 | to the estrogen receptor is pro-cancerous,

01:16:16.600 | which obviously I think you're telling us

01:16:19.400 | in a indirect and direct way now,

01:16:21.800 | and we'll go further into, is simply not the case.

01:16:24.400 | - If you take a healthy breast cell

01:16:25.720 | and dump it at a Petri dish,

01:16:26.920 | and then marinate it with some estrogen,

01:16:29.080 | it's not carcinogenic.

01:16:31.480 | Estrogen is not carcinogenic.

01:16:32.960 | We live with it our whole lives.

01:16:34.020 | If it was in pregnancy, for those of us

01:16:36.740 | who are ever pregnant, when our estrogen levels skyrocket,

01:16:39.480 | we would see this into uptick in breast cancer,

01:16:42.840 | and we don't.

01:16:43.680 | - In fact, I think there's some evidence for the opposite,

01:16:46.440 | that getting pregnant prior to age 40,

01:16:49.680 | is it true that that's protective against certain forms

01:16:52.280 | of breast cancer? - That seems to be

01:16:53.100 | somewhat protective for certain forms of breast cancer,

01:16:54.560 | yeah.

01:16:55.400 | So we have this whole generation of physicians

01:16:57.800 | who really weren't taught much about menopause,

01:16:59.480 | don't understand the protective benefits of estrogen

01:17:02.120 | and menopause's effect on metabolic disease,

01:17:06.060 | and they have this mentality of estrogen is bad,

01:17:10.200 | and so a woman walks into her,

01:17:12.120 | today, 2023, they looked at the data.

01:17:14.080 | She goes into her doctor complaining of menopausal symptoms,

01:17:16.680 | which right now are still only recognized

01:17:18.480 | as general urinary syndrome menopause,

01:17:20.440 | hot flashes, night sweats, you know,

01:17:22.200 | the very cliche symptoms.

01:17:24.080 | Documents in the chart she's having, whatever,

01:17:27.480 | only 10% are offered any therapy,

01:17:31.160 | and they're most likely four to one

01:17:33.040 | to be offered an antidepressant.

01:17:35.640 | That is where it stands today.

01:17:36.880 | That is what we are fighting against,

01:17:39.140 | is not every woman will choose HRT,

01:17:42.440 | but every woman deserves an informed conversation about it,

01:17:45.320 | and let her make her choice.

01:17:47.480 | You know, if you believe the WHI data,

01:17:49.400 | which there are some problems there,

01:17:51.040 | the risk is small, okay?

01:17:53.520 | But did you talk to her about cardiovascular disease

01:17:56.600 | and diabetes and insulin resistance and her cholesterol?

01:17:59.760 | Because those things go up through the menopause transition

01:18:02.440 | with no changes in diet and exercise,

01:18:04.640 | and those are all, you know,

01:18:05.680 | you're more, even with the diagnosis of breast cancer,

01:18:07.880 | the most likely thing a woman is gonna die from

01:18:11.600 | is cardiovascular disease, a heart attack or a stroke.

01:18:15.160 | So framing it like that, I think, is where we need to head.

01:18:18.880 | And the other thing is, you know,

01:18:20.720 | I was a great OB-GYN in so many areas of what I did.

01:18:24.920 | Why should this all be dumped in the lap

01:18:26.920 | of the poor, busy OB-GYN who's running around the hospital,

01:18:29.380 | doing pap smears, trying to deliver babies,

01:18:31.000 | surgery, and all the things?

01:18:32.320 | Like, this should be required education

01:18:35.000 | for all, everyone in medical school.

01:18:36.760 | We are females, and we're not little men

01:18:38.680 | with breast and uteruses.

01:18:40.000 | We react differently to medications,

01:18:42.080 | disease, disease burden, you know,

01:18:43.960 | and that's not been studied adequately,

01:18:46.640 | and that's where the push needs to go.

01:18:49.120 | It's bigger than just hot flashes.

01:18:51.160 | - Do you think that one solution

01:18:53.200 | is to deepen the medical school curriculum?

01:18:57.700 | - Absolutely.

01:18:58.540 | And more, and I hate saying women's health,

01:19:01.880 | because everyone thinks breast and uterus, right,

01:19:04.000 | and reproduction.

01:19:05.160 | It's the health of women.

01:19:08.280 | And we're not addressing it differently

01:19:09.800 | than the health of a man.

01:19:11.400 | And we're different, you know,

01:19:13.080 | and so that, I think, is where we need to head.

01:19:16.080 | - Given that it's half of the population,

01:19:18.120 | one would imagine that the best thing to do

01:19:21.000 | is to make the core curriculum of medical students

01:19:24.240 | expand to include this, as opposed to making it a specialty.

01:19:27.800 | - I think so.

01:19:28.640 | - Does that mean a fifth year of medical school?

01:19:31.320 | I'm not kidding, I mean, I guess.

01:19:33.080 | - Maybe, I mean, people said,

01:19:34.000 | "Well, you'd have to extend the OB-GYN residency."

01:19:36.720 | I'm like, no, any specialist who touches a female

01:19:40.520 | should understand how that female,

01:19:43.200 | I mean, the starkest example is cardiovascular disease.

01:19:46.040 | How much longer we have to wait in the ED,

01:19:48.520 | how much more likely we are to die

01:19:50.440 | in the hospital setting from a heart attack,

01:19:52.080 | because we don't present the same symptoms as men do,

01:19:55.240 | and it's just, the default has always been

01:19:57.660 | how it happens to the basic, you know,

01:19:59.880 | really Caucasian male, and so, at least in the US.

01:20:02.700 | And so, because we respond differently,

01:20:05.020 | because we wait longer, because our symptoms

01:20:07.800 | are considered to be psychologically induced,

01:20:11.180 | less than biologically induced,

01:20:13.080 | and so, women are dying at higher rates.

01:20:16.960 | When you look at the data on statins,

01:20:18.860 | you get high cholesterol, so 80% of women

01:20:22.940 | will have abnormal cholesterol levels

01:20:24.960 | through the menopause transition,

01:20:25.920 | if they were normal before, okay?

01:20:27.440 | - So elevated LDL?

01:20:28.680 | - LDL and lowering HDL.

01:20:30.480 | So now they are at higher risk for cardiovascular disease.

01:20:33.360 | Automatically, a PCP will offer her a statin, okay?

01:20:36.260 | That is standard of care.

01:20:38.300 | Do you know that the American Heart Association

01:20:40.340 | published in 2020 that statins have never been shown

01:20:43.220 | to decrease their primary heart attack in a woman?

01:20:45.460 | Secondary, yes, but no primary prevention,

01:20:48.140 | and it does not decrease the risk of death

01:20:49.540 | from cardiovascular disease.

01:20:51.540 | - I did not know that.

01:20:52.380 | - Yeah.

01:20:53.220 | Yet, we're routine.

01:20:54.060 | You know what does?

01:20:55.380 | HRT, if given in the right window of opportunity.

01:21:00.220 | How is the HRT, in this case, estrogen HRT, given?

01:21:04.840 | Is it a patch?

01:21:05.680 | Is it injections?

01:21:06.720 | Is it a pill? - Yeah, great question.

01:21:07.640 | All the above.

01:21:08.480 | So we have, I like to break it down into oral

01:21:11.240 | and non-oral forms.

01:21:12.640 | So everything oral we ingest goes into the gut.

01:21:15.800 | The liver, the hepatic system will pick up the portal vein

01:21:19.000 | and take everything to the liver for processing.

01:21:21.760 | When that bump of estrogen hits the liver,

01:21:24.280 | we can see a slight increase

01:21:26.160 | in some of our clotting factors.

01:21:28.200 | So for that reason,

01:21:30.540 | I tend to go with the non-oral formulations

01:21:33.020 | to avoid that risk,

01:21:33.860 | especially if she has any family history of clotting

01:21:36.140 | or personal history of clotting.

01:21:37.660 | You know, we're going to go with a non-oral form.

01:21:39.660 | - So these are things like elevations and factor V Leiden.

01:21:42.660 | - MTHFR, if she's had a history of a blood clot,

01:21:45.020 | we are not going with an oral estrogen formulation.

01:21:47.460 | - And for people that haven't had a history of a blood clot,

01:21:50.020 | my understanding, which admittedly is very sparse,

01:21:53.900 | is that you can do a genetic test just by blood draw

01:21:56.780 | to see whether or not you have two normal copies

01:21:59.640 | of the gene for factor V Leiden.

01:22:02.400 | Some people are heterozygotes,

01:22:03.800 | so they're more at risk of presumably bleeding

01:22:06.880 | in that case, right?

01:22:08.920 | But in other words,

01:22:09.960 | can people go into this knowing whether or not

01:22:14.540 | they're more or less at risk

01:22:17.240 | from taking estrogen-

01:22:18.840 | - So I don't think that there's a high enough,

01:22:22.600 | for that reason,

01:22:23.640 | because we're not routinely screening for these things,

01:22:26.000 | unless they have a family history.

01:22:27.700 | I'm going with non-oral estrogen

01:22:29.460 | as a primary product for my patients,

01:22:32.020 | 'cause I can just skip that worry.

01:22:33.540 | - So a patch, typically.

01:22:34.660 | - So typically transdermal.

01:22:35.900 | So a patch, there's Evamist spray,

01:22:37.740 | there's FDA approved options of a patch,

01:22:39.540 | there's gels, there's a spray,

01:22:43.300 | and there is a vaginal ring, which I love, love, love,

01:22:47.100 | 'cause it's so, you put it in for three months,

01:22:49.020 | and it treats, you get a two for one,

01:22:51.480 | you get a local treatment in the vagina

01:22:53.100 | as well as a systemic treatment as well.

01:22:55.980 | It's just really expensive

01:22:57.020 | and typically not covered by insurance on the first tier,

01:22:58.980 | so very few of my patients can afford it.

01:23:01.020 | There are some injectables,

01:23:04.180 | which no one in the menopause uses.

01:23:07.140 | - The menopause.

01:23:08.260 | - Yeah.

01:23:09.100 | - What a great-

01:23:09.940 | - There are also-

01:23:10.760 | - You've mentioned the meniverse and the menopause.

01:23:12.740 | Are those terms that you coined?

01:23:13.780 | I love it.

01:23:14.820 | - I think I did, yeah.

01:23:15.980 | - Great, all right, you heard it here.

01:23:17.660 | - So the menopause is a group of healthcare professionals

01:23:21.260 | who are from multiple specialties.

01:23:23.980 | We have cardiologists, orthopedic surgeon,

01:23:26.240 | internal medicine, Dr. Lyon is a member,

01:23:30.340 | and we have a big group chat,

01:23:32.180 | and we all support each other.

01:23:33.620 | We support each other's books and research,

01:23:35.420 | and we send articles back and forth,

01:23:37.700 | and we support each other on social,

01:23:39.060 | but we also banded together to kind of negate

01:23:42.580 | one of the bigger publications on menopause

01:23:44.140 | that Wendell Lancet published.

01:23:45.620 | It's a whole 'nother discussion,

01:23:47.620 | but we are fighting for equity in menopause care

01:23:50.780 | in women's health.

01:23:52.500 | - Great, nothing succeeds like a group.

01:23:54.700 | - It's like the old menopause versus the new menopause.

01:23:56.940 | - I love it, love it.

01:23:58.400 | So hormone therapy to increase estrogen,

01:24:04.260 | how does it make women feel psychologically, physically?

01:24:08.640 | What are some of the positive changes that can occur,

01:24:10.460 | aside from just offsetting some of the negative?

01:24:12.820 | And I wanna make sure that I remember to ask,

01:24:15.700 | what if a woman has been in menopause for,

01:24:18.180 | has passed that point?

01:24:20.580 | 'Cause as you said, it's a day.

01:24:21.940 | So they passed that point a year earlier,

01:24:24.860 | two years earlier, three years earlier.

01:24:27.020 | Given the results of this first study,

01:24:29.260 | which as you explained, are problematic

01:24:32.500 | in their interpretation, the way it was interpreted,

01:24:35.220 | as opposed to--

01:24:36.060 | - Initially, yeah.

01:24:36.880 | - What's too long?

01:24:39.820 | Should women start estrogen therapy in their 40s,

01:24:44.820 | just to smooth the transition?

01:24:47.420 | - Maybe, we need more studies in this area.

01:24:49.300 | Like, should we just, the minute we figure out,

01:24:51.980 | like I would love, like I wear a glucose monitor,

01:24:55.420 | I have insulin resistance, so I--

01:24:57.620 | - For those listening, there's just,

01:24:58.620 | it looks like a little button sized sticker

01:25:00.980 | on the back of the arm.

01:25:01.820 | - I would love to develop one to track estrogen levels,

01:25:06.220 | starting your 30s, just see where you're at.

01:25:08.900 | Start seeing, are you having aberrations in your cycle?

01:25:11.860 | And we can start the perimenopause journey

01:25:13.620 | and talking about, should we begin supporting?

01:25:15.860 | I think there's a tremendous amount,

01:25:18.100 | opportunity for research in this area.

01:25:21.180 | But typically, we are not starting patients

01:25:23.700 | until they're very symptomatic of their perimenopausal

01:25:26.460 | or their postmenopausal, so in general.

01:25:30.260 | - So if a woman is in her, let's say late 30s,

01:25:34.580 | she is anticipating perimenopause,

01:25:39.900 | or maybe is in perimenopause,

01:25:41.860 | and wants to start low dose hormone replacement therapy,

01:25:46.860 | I think it's something worth mentioning that not all,

01:25:49.900 | presumably the dosages are tailored, and then blood.

01:25:52.360 | So a given dose is tried, blood is drawn,

01:25:54.900 | you measure estradiol.

01:25:55.740 | - So we're not, we don't have established levels

01:25:58.940 | of like therapeutic ranges of estradiol.

01:26:01.060 | What we found is that when we do that so far,

01:26:03.860 | I think we have some opportunity here.

01:26:06.100 | If my level's 50 and your level's 50,

01:26:08.220 | I could feel like I'm on top of the world,

01:26:09.380 | my symptoms are gone, you still need more.

01:26:11.660 | So we are titrating from symptoms.

01:26:14.340 | - I see. - Yeah.

01:26:15.380 | - Interesting, similar to what is done,

01:26:18.340 | similar-ish with testosterone replacement therapy,

01:26:21.380 | which these days, you know, I sort of half joke

01:26:24.620 | that you can change out the R in testosterone replacement,

01:26:29.300 | because a lot of people, a lot of men are taking testosterone

01:26:32.620 | not as a replacement, meaning their levels are not lower

01:26:34.940 | than 300 nanograms per deciliter,

01:26:36.740 | which is kind of lower range.

01:26:38.380 | They're sort of low, middle,

01:26:39.540 | and they're trying to get high, you know, higher range.

01:26:42.260 | But hormone replacement therapy, as I understand it,

01:26:45.500 | has never been strictly in men or women,

01:26:49.300 | strictly for people who are out of range,

01:26:51.860 | that in theory, it can be to optimize,

01:26:55.340 | reduce symptoms and to optimize well-being.

01:26:59.060 | And I don't know if the medical establishment

01:27:00.860 | wants it used that way,

01:27:02.340 | but certainly in the case of testosterone replacement therapy

01:27:05.140 | in men, it's being used that way quite often, in fact.

01:27:08.780 | So we don't have established therapeutic ranges

01:27:12.940 | for estradiol.

01:27:13.780 | If she's POI, premature ovarian insufficiency,

01:27:17.300 | we know we want to get her to 100 or around 100 or higher

01:27:20.780 | in picograms per deciliter.

01:27:22.620 | But in the menopausal patient, we're rarely checking levels,

01:27:28.220 | but I do think we have an opportunity to learn a lot more

01:27:30.860 | now that we're able to track,

01:27:32.140 | how is it affecting your cholesterol?

01:27:34.580 | We need to look at those numbers.

01:27:35.660 | Like, what's the optimal dose for cholesterol?

01:27:37.500 | What's the optimal dose for cardiovascular disease?

01:27:39.380 | All these studies have looked at was, was she on it or not?

01:27:43.380 | So that's where I think the opportunities can come.

01:27:46.580 | - So if a woman goes on hormone replacement therapy,

01:27:49.820 | how often is she coming in for blood draws

01:27:51.460 | or are you just, you know-

01:27:52.580 | - Well, it depends, like testosterone,

01:27:53.860 | we tend to check more often.

01:27:56.100 | We don't have an FDA approved option

01:27:57.620 | for women for testosterone.

01:27:59.340 | And so- - Really?

01:28:00.180 | - No.

01:28:01.220 | So we either try to get her T-stem

01:28:05.100 | or she's finding someone to insert a pellet or something.

01:28:08.620 | And there's other issues with that.

01:28:10.700 | What I do in Texas, it's really hard.

01:28:12.780 | The pharmacists do not like to do the T-stem for patients.

01:28:15.900 | And I've even been- - T-stem?

01:28:17.300 | - T-stem is the gel, you know.

01:28:19.020 | And I end up compounding it in a cream

01:28:23.260 | and do a transdermal cream for the patients,

01:28:24.900 | but there's such variable absorption.

01:28:26.580 | We do tend to check more levels of that

01:28:28.620 | just to try to get her therapeutic.

01:28:30.940 | So what for women at peak dose

01:28:35.060 | is somewhere in a healthy female, you know, 35 to 70.

01:28:39.420 | And so I had a woman coming in

01:28:41.140 | with signs of hyperandrogenism.

01:28:42.620 | You know, she's, you know, deep voice,

01:28:44.500 | hair growth, whatever, acne.

01:28:46.300 | And I'm gonna check a level.

01:28:47.140 | If it's above 90 for females, I need to look for a tumor.

01:28:51.060 | Like that's too high, okay?

01:28:52.500 | Or PCOS, it can get that high.

01:28:53.820 | Certainly above 200, that's outrageous.

01:28:56.300 | So I'm trying to get my patients, you know, 60, 50, 70,

01:29:00.860 | but if she's like 50 and she's got her libido back

01:29:04.020 | and she feels great and everything's wonderful,

01:29:06.220 | then I'm hold, you know, 'cause the higher we go,

01:29:09.460 | the more likely you are to have side effects.

01:29:11.500 | So you're losing hair, you know, temporal hair loss,

01:29:13.740 | voice deepening, acne, new chin hair, you know,

01:29:16.980 | losing hair where you want it,

01:29:17.940 | gaining hair where you don't want it

01:29:19.460 | is how I explain it to patients.

01:29:21.020 | - And so when you say 50,

01:29:22.540 | that's 50 nanograms per deciliter.

01:29:24.780 | I think many people, including myself,

01:29:27.060 | were surprised to learn

01:29:29.420 | that women actually have higher levels of testosterone

01:29:32.020 | than they do estrogen outside of-

01:29:34.500 | - In absolute ranges, yeah.

01:29:35.340 | - Right, in absolute ranges.

01:29:36.580 | - And I can tell you right now,

01:29:38.100 | your natural level of estradiol is higher than mine.

01:29:40.740 | Now I supplement, but you know,

01:29:43.140 | like when I go through menopause,

01:29:44.740 | your residual estradiol is now higher

01:29:46.660 | than a post-menopausal woman.

01:29:48.180 | - So this is the estradiol that I have

01:29:51.380 | because testosterone was aromatized into estrogen.

01:29:54.380 | - Yeah.

01:29:55.220 | - Interesting, interesting.

01:29:56.740 | - So much is breaking down around the old stereotypes.

01:30:00.660 | - Right, the man hormones and female hormones.

01:30:02.940 | Like testosterone is a human hormone.

01:30:04.340 | - Right.

01:30:05.180 | - Estrogen is a human hormone.

01:30:06.020 | - And they exist in both biological sexes.

01:30:08.740 | Yeah, it's sometimes unfortunate

01:30:12.460 | that compounds in the body get names like steroid hormones

01:30:15.940 | because then people hear steroids

01:30:17.260 | and then it has a gravitational pull

01:30:19.180 | toward anabolic steroid use.

01:30:22.620 | Or even the word fat.

01:30:25.500 | You know, it's like, you know,

01:30:26.860 | dietary fat versus subcutaneous fat versus-

01:30:30.140 | - Visceral fat.

01:30:30.980 | - Visceral fat.

01:30:31.820 | - You just have this negative connotation.

01:30:32.640 | - We need better nomenclature

01:30:33.700 | to avoid a lot of the confusion that exists out there.

01:30:36.500 | What are some of the other hormones that can be reduced

01:30:40.060 | and can possibly be replaced by hormone therapy?

01:30:42.820 | Like progestins, you know,

01:30:45.780 | is there a role for, you know,

01:30:48.220 | adjusting things like prolactin?

01:30:49.700 | Or is there a role for other hormones

01:30:52.540 | in what sure is to be a multifactorial thing?

01:30:57.100 | I mean, I think menopause is a process, not an event.

01:30:59.220 | - It's hypogonadism for females, right?

01:31:01.580 | And so we know that, you know,

01:31:05.020 | because the pituitary and hypothalamus are involved

01:31:07.640 | and that GNRH, you know, there's some cross reactivity.

01:31:10.460 | So for example, hypothyroidism.

01:31:12.280 | When I have a patient who's on her

01:31:13.900 | and doing well on hormone therapy for her thyroid,

01:31:16.620 | so she's on T3, T4, whatever she's on,

01:31:19.240 | I'm like, listen, you know,

01:31:21.680 | we need to recheck your thyroid levels in six weeks

01:31:25.020 | because giving you back estrogen

01:31:26.760 | is gonna mess with a little bit of that feedback cycle.

01:31:29.700 | So we need to make sure you're still therapeutic.

01:31:32.120 | So I think we've got more work to do

01:31:33.960 | with some of the other hormones.

01:31:36.040 | But when we talk about replacement and menopause,

01:31:38.760 | we are mostly looking at your estrogens,

01:31:41.120 | your androgens, and your progesterone.

01:31:44.120 | So the formulations can differ.

01:31:48.320 | But you know, there's a lot of misunderstanding

01:31:50.640 | around what is bioidentical versus synthetic.

01:31:52.880 | And I think a lot of cottage industries

01:31:54.640 | in this little bubble that we had for 23 years

01:31:57.160 | where doctors were afraid to prescribe hormone therapy

01:32:00.640 | and then women were desperate for care.

01:32:03.080 | We had some little cottage industries of people,

01:32:05.320 | I think were well-meaning and trying to help,

01:32:07.380 | but kind of developed terminology

01:32:10.120 | that really isn't medically specific,

01:32:11.920 | like estrogen dominance, you know, and what that really is.

01:32:14.760 | And so that is not a term that is in any medical journal.

01:32:17.520 | It's kind of something coined, I think,

01:32:19.040 | from a well-meaning provider trying to explain

01:32:21.480 | what's happening in perimenopause,

01:32:22.800 | that you're having more estrogen produced

01:32:24.560 | than progesterone than you used to have.

01:32:26.720 | So PCO patients do the same thing.

01:32:28.920 | You know, there's multiple reasons for that to happen.

01:32:32.280 | So when we talk about, you know, in the menoverse

01:32:35.460 | of what we're trying to replace,

01:32:37.520 | we all agree that we stick pretty much with estradiol,

01:32:41.240 | which is trying to give you back the water you were drinking.

01:32:43.320 | So I want to get as close to what your body used to make

01:32:45.680 | because that's what the receptor's like.

01:32:47.360 | I'm trying to give you progesterone, you know,

01:32:49.400 | rather than a synthetic.

01:32:50.540 | Not that they're all demonized.

01:32:51.840 | Progesterone doesn't work for everyone.

01:32:53.120 | I'm glad I have options.

01:32:54.660 | And then for your androgens,

01:32:56.400 | we pretty much just do testosterone

01:32:58.280 | and we do a transdermal again

01:33:00.000 | because the oral can be hepatotoxic

01:33:01.960 | unless it's undecanoate, which isn't available in the U.S.

01:33:04.960 | So, but there's no FDA-approved option for women,

01:33:08.500 | so it's not covered by insurance.

01:33:10.800 | We know it works for hypoactive sexual desire disorder,

01:33:13.800 | what your followers would call libido.

01:33:16.500 | We think, we know it helps. - Testosterone does.

01:33:18.200 | - Yeah, women at the highest quartile of testosterone

01:33:21.120 | have better bone density and stronger muscles.

01:33:23.220 | So I'm using it off-label for my patients who come in

01:33:25.620 | with osteoporosis, osteopenia, or sarcopenia.

01:33:28.240 | I'm using it off-label and telling them,

01:33:30.360 | this is probably a, it's not a Hail Mary.

01:33:32.500 | We think it works, but we don't have the, you know,

01:33:34.480 | it's not approved for that yet yet.

01:33:37.280 | We know it has receptors in the brain.

01:33:38.920 | My patients are saying that they're more clarity of thought.

01:33:41.680 | They're sleeping better.

01:33:42.520 | They really, really like the testosterone.

01:33:45.760 | So there's, you know, DHEA,

01:33:47.880 | there's a great vaginal preparation for DHEA

01:33:50.140 | called Intrarosa, and then the receptors there

01:33:52.620 | will start converting it into both testosterone

01:33:54.800 | and estradiol, you know, through the process.

01:33:57.040 | And so the sexual medicine docs really like Intrarosa,

01:34:01.160 | especially for breast cancer patients

01:34:02.580 | because they get that little boost

01:34:03.740 | of testosterone in the vulva.

01:34:05.460 | - Intrarosa?

01:34:06.440 | - Intrarosa's the brand name.

01:34:07.760 | I think it's Prasterone, Prasterone?

01:34:10.400 | - And this is a prescription drug?

01:34:11.640 | - Yeah, these are prescriptions.

01:34:12.560 | So Intrarosa's prescription DHEA, which sits for--

01:34:16.200 | - Specifically formulated for the vagina.

01:34:17.760 | - Got it, which sits further upstream

01:34:19.840 | to the production of testosterone and estrogen.

01:34:22.200 | - Right, and so fortunately, what's left in the vagina

01:34:25.760 | is able to, you know, plug that guy in

01:34:28.280 | and get it to produce both testosterone and estradiol,

01:34:31.320 | which testosterone is the immediate precursor.

01:34:33.360 | We have to aromatize it, right,

01:34:34.460 | to make estradiol in females as well.

01:34:36.540 | - These local effects on tissues are interesting.

01:34:42.080 | They make perfect sense if the highest concentration

01:34:44.140 | is at the site of release from the patch or the gel

01:34:47.080 | or the whatever, the, you said intravaginal.

01:34:51.220 | What is it?

01:34:52.060 | It's like a capsule?

01:34:53.040 | - I think the Prasterone is a insert,

01:34:56.200 | like a little gel-looking, not a gel,

01:34:58.100 | but I forget what the binding material is.

01:35:00.960 | But it's like a little insert you put in, and it melts.

01:35:02.720 | - Okay, so the local effects,

01:35:03.860 | because I guess, you know, it stands to reason

01:35:06.320 | that the highest concentrations can be at the site

01:35:08.600 | of the thing that's releasing the hormone,

01:35:10.320 | but then it also goes systemic

01:35:11.600 | by getting into the bloodstream.

01:35:12.520 | - Actually, so the local formulations,

01:35:15.720 | the Prasterone and the Enterosa,

01:35:19.120 | and as well as the estradiol formulated for the vagina,

01:35:22.480 | do not absorb systemically.

01:35:24.240 | They're so low dose.

01:35:25.440 | There's not been clinically significant tissue absorption.

01:35:28.440 | I have a formulation for my face as well.

01:35:30.400 | - So it's a cream?

01:35:31.280 | - A cream that I put on my face.

01:35:32.520 | It's Estriol, and so there's some decent studies

01:35:35.080 | with Estriol, but we lose 30% of our collagen.

01:35:37.840 | It's a very big pain point for women

01:35:39.400 | when they go through menopause,

01:35:40.400 | that we lose so much collagen so quickly

01:35:42.160 | in the first five years of menopause,

01:35:43.880 | and so we can slow that process down.

01:35:45.640 | We can't stop it completely.

01:35:46.960 | We can slow it down by using a topical estrogen,

01:35:49.300 | and the topical really seems to help

01:35:51.000 | with the elastin concentrations as well.

01:35:53.320 | - Interesting, so you will often prescribe

01:35:55.960 | a lot of local treatments for hormone.

01:35:57.280 | - Yes, and really, it's so safe.

01:35:59.440 | So we can take breast cancer off the table,

01:36:01.300 | all the discussion around blood clots and everything.

01:36:03.640 | Everyone can use vaginal estrogen, and they should,

01:36:06.600 | and I'll tell you why.

01:36:07.440 | - Starting at what age relative to menopause?

01:36:09.160 | - You know, the old menopause thoughts

01:36:11.280 | is do not give vaginal estrogen until she's symptomatic.

01:36:14.040 | Now, all of us will become symptomatic from GSM,

01:36:16.640 | so that's genital urinary syndrome of menopause,

01:36:18.760 | so from the pubic bone all the way to the sacrum,

01:36:21.080 | all of that tissue is heavily tied to estrogen testosterone,

01:36:26.080 | and when those levels decline,

01:36:27.560 | we see thinning of the tissue, loss of elasticity,

01:36:29.760 | loss of mucus production,

01:36:31.320 | as well as the health of the urethra,

01:36:33.560 | and so UTIs, like the best treatment for recurrent UTIs

01:36:36.760 | in a menopausal patient is vaginal estrogen.

01:36:38.880 | - Interesting. - Not recurrent antibiotics.

01:36:40.720 | - And what about- - So it's preventative.

01:36:43.280 | - Very interesting. - And we can probably

01:36:44.360 | keep 50% of women out of the ER and out of urosepsis

01:36:48.800 | if we gave them all prophylactic vaginal estrogen.

01:36:51.400 | All these little ladies in nursing homes

01:36:52.960 | should be on vaginal estrogen,

01:36:54.640 | so just to protect them from getting urosepsis.

01:36:58.960 | - Interesting, what about urinary incontinence

01:37:03.520 | and some of these other symptoms

01:37:04.840 | that are associated with more elasticity,

01:37:06.720 | presumably more elasticity of tissue in that region?

01:37:09.600 | - If you're early in a, so we have stress incontinence,

01:37:12.480 | and then we have overactive bladder urge incontinence,

01:37:15.680 | and so it definitely helps with urge incontinence.

01:37:18.440 | It helps to relax and decrease the inflammation

01:37:20.840 | in the wall of the bladder, so thumbs up there.

01:37:23.880 | So people are getting up at night

01:37:25.080 | and having that urge to go,

01:37:26.920 | but stress incontinence is an anatomical problem.

01:37:29.280 | We've lost the sling that holds up the urethra,

01:37:32.320 | and the female fails, right,

01:37:34.000 | from herniation and poor tissue health.

01:37:36.440 | We can build up that health,

01:37:38.040 | and there's physical therapy, there's lots of options,

01:37:41.320 | and no urogynecologist wants to take a woman to the OR

01:37:45.280 | to do a lift if she's not estrogenized.

01:37:49.240 | They're all gonna get vaginal estrogen,

01:37:51.280 | pre, through healing, and then forever

01:37:54.400 | to keep the tissue healthy.

01:37:55.760 | - Everything that we've been talking about

01:37:58.640 | for about the last 15 or 20 minutes

01:38:00.560 | seems to go directly opposite this large-scale study

01:38:05.240 | that was discussed at the Watergate Hotel.

01:38:07.760 | Is your read that the medical establishment,

01:38:11.800 | in particular the OBGYNs in the US and in other countries,

01:38:15.920 | understand now that that study was flawed

01:38:20.920 | to some extent in its design,

01:38:23.300 | or is what we're talking about here really cutting edge?

01:38:26.320 | I mean, if we were to gather a roomful of 1,000 OBGYNs

01:38:29.280 | trained in various decades and put them in there-

01:38:30.800 | - Maybe 10% would have any idea, but here's why,

01:38:33.660 | and I'm gonna call out the American Board of OBGYN

01:38:35.600 | directly on this.

01:38:36.960 | We take our board certification exams every year

01:38:39.060 | in our specialty, as every specialty does,

01:38:40.760 | and they give us a set of articles

01:38:42.440 | of the cutting-edge, newest research,

01:38:44.800 | and it's divided into categories.

01:38:46.480 | Obstetrics, office practice, gynecology,

01:38:48.680 | GYN surgery, pediatrics, oncology, you know.

01:38:51.960 | There is no menopause category.

01:38:56.680 | Nothing.

01:38:58.160 | So I went back over like 10 years of all my green journals

01:39:02.200 | and looked at how many articles

01:39:04.600 | were anything to do with menopause,

01:39:06.280 | and it was less than 1%.

01:39:08.480 | So they were not systematically trying to put

01:39:13.480 | the latest menopause information in front of us.

01:39:15.760 | They don't even recognize the Menopause Society

01:39:18.200 | as a entity.

01:39:21.240 | - Well, now they have to contend with the menopause-y.

01:39:23.440 | - They do.

01:39:24.280 | - And because-

01:39:25.120 | - You might see me banned from the A-Box,

01:39:27.600 | but you know what?

01:39:28.440 | - No, no, no, but-

01:39:29.260 | - I'm so proud of what I learned.

01:39:30.760 | I learned amazing things.

01:39:31.920 | I am a boss at delivering a baby,

01:39:34.280 | at taking care of a pregnant patient.

01:39:35.560 | I am great at pediatric gynecology.

01:39:37.200 | I was so good with adolescents.

01:39:39.120 | Where I failed, and where I let the system let me fail,

01:39:43.400 | was in the care of a woman after reproduction,

01:39:45.620 | outside of surgery, outside of her surgical needs.

01:39:48.520 | - Well, I have to imagine that given the medical profession

01:39:51.160 | is interested in the well-being of people

01:39:53.500 | and in, for sake of the discussion today, women,

01:39:56.780 | that they will be grateful that now you have a microphone.

01:40:02.080 | Many microphones in various contexts.

01:40:04.360 | So that is surprising to me, however.

01:40:07.400 | I would think that given the exciting findings

01:40:11.640 | around hormone replacement therapy,

01:40:13.560 | and the kind of obvious,

01:40:16.040 | at least when you described them to me,

01:40:17.840 | obvious flaws in these earlier studies

01:40:20.040 | of starting hormone replacement therapy

01:40:22.360 | when women are already 61,

01:40:24.560 | when they've already accumulated, in many cases,

01:40:28.320 | some health issues, that it would be kind of obvious.

01:40:31.400 | - You miss the ability to measure the protective benefits.

01:40:35.400 | But fortunately, we've got great studies

01:40:38.800 | coming out of the Danish data, the Scandinavian data,

01:40:41.920 | that are really looking at this again,

01:40:44.960 | and showing the protective benefits.

01:40:47.640 | - Is it generally the case that the studies out of Europe

01:40:51.640 | and Scandinavia are more forward-thinking?

01:40:53.880 | - It depends.

01:40:55.120 | Some of the most forward-thinking, shockingly,

01:40:57.640 | is come out of Asia, a lot out of China.

01:41:01.200 | And I asked my husband, he's worked there before,

01:41:03.040 | and he said, "There's as many researchers in China

01:41:06.480 | "that are female as male.

01:41:07.680 | "It's not like they have a big stay-at-home culture.

01:41:10.640 | "Women are expected to work, and they're getting PhDs,

01:41:15.060 | "and they're doing the research."

01:41:16.660 | And he thinks, in of one, his humble opinion,

01:41:20.440 | and he's an engineer, that's why.

01:41:22.560 | I was like, "Why do you think you've worked over there?"

01:41:24.200 | He goes, "I think because there's just as many women

01:41:26.660 | "who are writing the papers as men."

01:41:28.640 | - Interesting take.

01:41:29.720 | I like it.

01:41:30.560 | It makes good sense.

01:41:32.680 | What are the various things that people can do

01:41:36.600 | in terms of non-hormone replacement therapies

01:41:40.000 | that can support them through,

01:41:42.480 | really into and through perimenopause and menopause?

01:41:45.900 | We talked about nutrition earlier.

01:41:47.400 | Maybe we could touch on that a little bit more.

01:41:49.080 | We talked about behaviors, resistance training,

01:41:51.000 | maintaining, maybe even increasing muscle mass.

01:41:54.680 | There's no pressure to include them,

01:41:57.180 | but what about the various supplements that we hear about

01:41:59.820 | that can touch on, or we are told,

01:42:01.900 | can touch on these hormone pathways?

01:42:03.260 | Things like DIM, things like grapeseed extract,

01:42:06.300 | things like evening primrose.

01:42:09.900 | - I don't think they're harmful,

01:42:11.340 | but there's just not robust data to really support.

01:42:14.300 | So menopause society went and looked at all of them,

01:42:17.140 | even soy and everything,

01:42:18.460 | and they just, outside of cognitive behavioral therapy,

01:42:21.100 | which can be helpful, but it's not a menopause cure,

01:42:24.300 | they didn't find much in the supplement world

01:42:28.580 | that would stop.

01:42:30.940 | Remember, we're defining menopause as hot flashes

01:42:32.860 | and general urinary syndrome of menopause.

01:42:34.860 | So when I'm recommending supplements to patients,

01:42:38.500 | I do think there's some okay data on turmeric

01:42:40.860 | for maybe hot flashes,

01:42:42.140 | but I'm not saying to take that

01:42:43.700 | instead of replacing the estrogen

01:42:45.260 | your body is missing greatly.

01:42:48.020 | I like the anti-inflammatory benefits of that supplement.

01:42:52.360 | I'm recommending fiber.

01:42:54.040 | 80% of my patients are deficient in vitamin D

01:42:56.280 | and struggling to get it absorbed.

01:42:58.040 | I'm recommending creatine for muscle.

01:43:03.240 | I'm recommending, there's a specific bioactive collagen

01:43:06.720 | that was studied in menopausal women with osteoporosis

01:43:09.040 | where they saw improvement in bone density.

01:43:11.240 | So I'm recommending a weighted vest.

01:43:13.540 | Great studies, elderly women,

01:43:15.520 | but saw improvements in bone density.

01:43:17.160 | And I'm like, why do we wait until we're osteoporotic

01:43:19.560 | to make the diagnosis?

01:43:20.600 | - Yeah, this is interesting.

01:43:21.440 | So they looked at a weighted vest.

01:43:22.520 | - A weighted vest.

01:43:23.360 | They looked at creatine, weighted vest,

01:43:24.720 | vibratory training in nursing home dwellings.

01:43:27.680 | So they were kind of a population

01:43:29.160 | where they couldn't go anywhere.

01:43:30.120 | - Vibratory training is the shake plate.

01:43:31.840 | - The shake plate.

01:43:32.680 | And so, anything that stimulates

01:43:34.880 | that musculoskeletal unit will send the signal

01:43:37.740 | to get stronger.

01:43:39.360 | What most women don't realize,

01:43:40.840 | I mean, they know about osteoporosis, right?

01:43:42.760 | And they don't wanna have it,

01:43:44.000 | but they don't understand that like your habits

01:43:46.240 | in your 30s and 40s are gonna put you on that path.

01:43:49.580 | And that your body's gonna fight to lose muscle and bone

01:43:52.580 | naturally through the aging process

01:43:54.160 | and accelerated with menopause.

01:43:56.060 | It doesn't have to be that way,

01:43:57.320 | but you have to do the work, you know?

01:43:59.100 | And there's some hacks.

01:44:00.480 | And so I love the weighted vest for a hack.

01:44:02.020 | I'm like, do the dishes with it on, go walk the dog.

01:44:04.860 | You know, like--

01:44:05.700 | - How heavy?

01:44:06.540 | - So you want, in the nursing home,

01:44:07.900 | they started at 10% of their body weight.

01:44:10.020 | So I'm like, 10 pounds, 12 pounds, start with that.

01:44:12.180 | So now my husband's obsessed and we have six of them

01:44:14.820 | and they go from eight to 35 pounds, you know?

01:44:17.620 | So I have different weights that I wear.

01:44:19.100 | Like if I'm doing leg day, I'll put the heavier one on

01:44:21.340 | so I don't have to hold as heavy.

01:44:23.060 | - So you'll use a weight vest when you're doing leg day.

01:44:26.340 | Wow.

01:44:27.180 | - So I can't, 'cause I don't have great grip strength

01:44:28.900 | and you know, and so it'll help me

01:44:30.820 | be able to squat heavier, you know?

01:44:32.780 | But now I'm getting better.

01:44:33.660 | I've got the bar going, so I'm getting there.

01:44:35.980 | - I'm gonna tell my sister and my mom this.

01:44:37.660 | - Yeah, and you know--

01:44:38.500 | - I've got my sister, yeah, doing some resistance training.

01:44:41.860 | It's been--

01:44:42.680 | - And it's just a cheat.

01:44:43.520 | I'm so, it's so cute on social 'cause they'll post

01:44:45.400 | and tag me and they're walking their dog

01:44:47.060 | or they're doing whatever with their weighted vest on.

01:44:49.380 | And now in Galveston where I live,

01:44:51.080 | you can't go, you see it all over the sea

01:44:52.500 | while everyone's walking with their weighted vests on.

01:44:55.340 | - I love it.

01:44:56.180 | And it's hot down there a lot of the year.

01:44:57.020 | - Yeah, it's warm, yeah.

01:44:57.840 | - So no excuses people outside of Texas

01:44:59.860 | or in Texas for that matter.

01:45:01.180 | But my experience is that people in Texas

01:45:02.680 | don't tend to make excuses.

01:45:04.500 | Anyway, that's said like a real Californian here.

01:45:07.920 | We were talking about this a little bit earlier

01:45:09.340 | and female specific weight vests.

01:45:13.020 | - I would love to develop one

01:45:14.060 | because the ones were made for men and they're okay.

01:45:16.780 | But if you have larger breasts,

01:45:18.460 | it's hard where the snaps are to get it on right.

01:45:21.040 | And I know there's a big trend with rucking,

01:45:23.460 | but that puts all the weight on your back.

01:45:25.440 | And I really like the weighted vest 'cause I feel,

01:45:27.780 | and this is my opinion really,

01:45:29.660 | but that the reason why it's helping

01:45:31.620 | with their bone density is it's putting the weight

01:45:33.740 | on the entire axial skeleton

01:45:35.180 | rather than just the muscles on your back.

01:45:37.700 | So we're putting the force more evenly supported.

01:45:40.740 | - Yeah.

01:45:41.660 | - And so, but some of my followers

01:45:44.340 | have written in and said they're struggling

01:45:45.700 | because they have larger breasts

01:45:46.860 | and how to get this around.

01:45:47.700 | I'm like, I got to make one that's going to accommodate,

01:45:50.500 | you know, have longer, you know,

01:45:52.260 | distract down here underneath the breast.

01:45:54.460 | - Yes, someone should develop that.

01:45:55.540 | You should develop that.

01:45:57.020 | Not that you don't already have enough

01:45:58.160 | on your plate already.

01:45:59.260 | Along the topic, I like rucking.

01:46:01.140 | It is sort of backloaded, you know, by definition.

01:46:04.180 | Some of the weight vests that are out there

01:46:07.020 | are evenly distributed in a way

01:46:08.540 | that makes them pretty comfortable.

01:46:09.740 | They're not all loaded up upfront

01:46:10.920 | like a special operator or something would wear.

01:46:13.900 | - So positive effects of the weight vest

01:46:17.180 | would be increased bone density.

01:46:19.760 | You're doing more work.

01:46:21.600 | - You are burning a little more calories, right?

01:46:23.020 | - You're doing more work.

01:46:23.860 | - You're getting stronger.

01:46:24.700 | But I coach to it, you know, with my followers

01:46:28.300 | for this is part of my osteoporosis prevention pack.

01:46:31.940 | - Love it.

01:46:32.780 | Are you willing to share a few other things

01:46:33.980 | that are in the prevention pack?

01:46:34.820 | - So, you know, eating adequate protein,

01:46:36.780 | doing resistance training,

01:46:37.940 | wearing your weighted vest, creatine,

01:46:39.780 | five grams a day where most of the studies were done

01:46:42.060 | in the women.

01:46:42.900 | - Creatine, monohydrate.

01:46:43.940 | - Monohydrate, yeah.

01:46:44.860 | And then that collagen, consider that collagen.

01:46:49.100 | Full disclosure, I do sell that one.

01:46:50.660 | But really good investment, I think.

01:46:53.860 | - Maybe we can talk about collagen for a moment.

01:46:56.260 | It's a complete protein?

01:46:59.500 | - No, no, it's missing one, I think one or two amino acids.

01:47:03.620 | So it's not a complete protein.

01:47:05.880 | It's better than none.

01:47:07.060 | So I do like include my collagen

01:47:09.700 | in my protein intake for the day

01:47:11.140 | 'cause I eat all animal-based protein, pretty much.

01:47:13.940 | So I figure I'm covered my bases to have 10% of it coming,

01:47:18.620 | which is missing two amino acids,

01:47:19.980 | or I think it's one valine.

01:47:21.540 | I have to look it up, so.

01:47:23.020 | - And what are the specific effects of a quality collagen?

01:47:25.940 | - So, you know, there's a lot of controversy there.

01:47:28.100 | I've seen the videos.

01:47:29.260 | It is broken down into its component amino acids

01:47:32.180 | through the digestion process.

01:47:34.420 | But the first ones I looked at were totally for vanity.

01:47:38.540 | I was changing bathing, I was trying on bathing suits

01:47:41.580 | with my daughter, who was a little girl at the time.

01:47:43.740 | And I was complaining about the appearance of my cellulite,

01:47:46.660 | even thin people have cellulite.

01:47:48.140 | And she's like, "Oh, mommy, it doesn't look that bad."

01:47:50.460 | And I, you know, scientist in me was like,

01:47:53.820 | goes on PubMed and starts looking up articles on cellulite

01:47:57.780 | and how to decrease the appearance of it.

01:47:59.800 | And so I found these articles on something called Verisol,

01:48:02.740 | and it was a collagen made in Germany.

01:48:04.520 | And they'd studied, actually done

01:48:05.740 | like really high quality studies,

01:48:07.180 | like laser measuring wrinkles and cellulite.

01:48:10.100 | - Germans are precise.

01:48:10.940 | - And they, and it looked, they had positive outcomes.

01:48:14.100 | I'm like, well, it won't hurt me.

01:48:15.100 | So I ordered some, I Googled,

01:48:16.300 | "Where do I find this Verisol collagen?"

01:48:17.740 | I find this company, I order it.

01:48:19.260 | And then one day I talked about it on the internet.

01:48:22.540 | And the company called me and said,

01:48:23.660 | "Would you please let us know when you do that?"

01:48:25.860 | 'Cause they sold out of their supply for like three months.

01:48:29.280 | So the same like manufacturer of that particular Verisol

01:48:34.820 | made this FortiBone, did the studies,

01:48:38.740 | five years doing bone density scans on these women.

01:48:41.820 | It was a small study, but they saw improvements.

01:48:44.060 | We know what happens to bone density if you do nothing.

01:48:46.460 | It goes down.

01:48:47.460 | These went up.

01:48:48.580 | And I thought, okay, I wanna do,

01:48:50.380 | and I wanna offer this to people.

01:48:51.620 | Like, if not them, me, this is a high quality product.

01:48:54.760 | I can, you know, and that's, so that's part of my,

01:48:57.260 | what I offer to people or what I recommend.

01:49:00.980 | You can get it anywhere.

01:49:01.900 | Other people sell it, not just me.

01:49:03.220 | - Great, so I'm perplexed.

01:49:07.540 | This isn't a challenge, but I'm perplexed.

01:49:09.460 | How would a protein that's not a complete protein

01:49:13.380 | be beneficial for a body organ like skin,

01:49:16.460 | whereas the complete proteins

01:49:17.700 | don't seem to do it on their own?

01:49:19.420 | Nobody knows, okay.

01:49:21.500 | - I don't know.

01:49:22.340 | - Interesting.

01:49:23.160 | - Are they not studying the right thing?

01:49:24.000 | Are they not really looking at it?

01:49:25.340 | So I don't know.

01:49:27.260 | - It's great when I hear, I don't know,

01:49:29.140 | and the scientist in me says great area for exploration.

01:49:32.780 | 'Cause we don't really believe, in fact,

01:49:35.580 | we don't believe that amino acids

01:49:40.580 | that are derived from- - Target tissue, right?

01:49:42.100 | - Are derived from a particular body part

01:49:43.840 | target that tissue.

01:49:44.720 | We've heard this argument before.

01:49:47.540 | Dr. Lane Norton and I have both gone on record publicly

01:49:50.460 | saying there is basically zero,

01:49:52.300 | not basically, delete the basically.

01:49:53.620 | There is zero evidence that when you ingest heart,

01:49:56.580 | let's say you like eating liver or heart or skeletal muscle,

01:50:00.300 | that somehow the amino acids are selectively trafficked

01:50:02.940 | to the organ of the heart or the liver

01:50:05.300 | or the skeletal muscle.

01:50:06.340 | There's no evidence of that whatsoever.

01:50:08.160 | Certainly not in humans.

01:50:09.380 | If there is evidence, I'm sure they'll let us know

01:50:11.320 | in the comment section on YouTube and let us know.

01:50:14.260 | But yeah, it's perplexing why collagen

01:50:17.580 | would have a selectively beneficial effect on skin.

01:50:20.740 | - They didn't study it versus a steak.

01:50:22.660 | You know, they just looked at bone density

01:50:25.760 | if they took this product every day for five years

01:50:28.020 | and what happened.

01:50:28.900 | And they weren't, you know,

01:50:30.640 | they weren't having tremendous cardiometabolic disease.

01:50:33.580 | They weren't on bone building medications.

01:50:35.440 | They weren't on HRT.

01:50:36.900 | So, you know, they did a pretty clean.

01:50:39.040 | So there's, you know, not a huge study,

01:50:40.620 | but it was interesting.

01:50:41.580 | And I thought, okay, you know, I don't want to break.

01:50:44.300 | 'Cause if I break my hip,

01:50:45.620 | well, 50% of women will have an osteoporotic fracture

01:50:48.960 | before they die.

01:50:50.020 | - 50%. - 50.

01:50:51.240 | - What about men do we know just by way of comparison?

01:50:53.500 | - I think it's 25.

01:50:54.820 | - Wow. - But don't quote me on that.

01:50:56.100 | I need to look that one up. - That's okay.

01:50:57.300 | - So it's about half, okay?

01:50:59.380 | And then hip fracture, if you break that hip,

01:51:02.360 | if over the age of 65,

01:51:05.480 | you have your one-year mortality

01:51:08.020 | with surgical repair is 30%.

01:51:10.500 | If you're not healthy enough to have the repair,

01:51:12.420 | you can't afford to have it, it's 79.

01:51:14.860 | - Goodness.

01:51:15.700 | - So that's what we're trying to avoid is that, you know.

01:51:20.700 | And the tremendous, if you've seen the women

01:51:24.320 | who have tremendous osteoporosis in their spine

01:51:27.140 | and just how their lives are so hard

01:51:31.500 | and how much pain they live in every single day.

01:51:33.420 | You know, a lot of this is avoidable with aggressive,

01:51:36.820 | you know, being aggressive and intentional about this.

01:51:39.980 | And HRT can be a huge part of that as well.

01:51:42.500 | - What I'm about to ask is a little bit outside the box,

01:51:44.660 | but I feel fair asking it given that, you know,

01:51:48.740 | I'm not a clinician, but I have some background

01:51:51.100 | and certainly understanding

01:51:52.300 | of neurodegenerative conditions of the eye and vision.

01:51:56.380 | Have you ever observed in your patients

01:51:58.660 | that when they get on hormone replacement therapy

01:52:00.900 | for menopause, that things that are typically associated

01:52:04.100 | with aging, like diminished visual function,

01:52:06.700 | hearing, you mentioned tinnitus, also called tinnitus,

01:52:10.260 | I understand, but tinnitus.

01:52:11.100 | - Right, I can't.

01:52:11.940 | - We'll do both.

01:52:12.780 | Tinnitus, tinnitus, tomato, tomato.

01:52:13.620 | - And E.T. corrected me and said tinnitus.

01:52:15.000 | And I was like, okay.

01:52:15.900 | - We'll do both.

01:52:17.460 | Here that they report seeing better, hearing better,

01:52:22.460 | and any kind of sensory improvement

01:52:24.500 | or offset of sensory loss.

01:52:25.900 | - So we know the data's clear on dry eye

01:52:29.380 | and how that can affect,

01:52:31.140 | but how it affects like the optic nerve, you know,

01:52:35.180 | we know that estrogen is anti-inflammatory.

01:52:37.300 | So any kind of like inflammatory condition

01:52:40.220 | in and around the eye does tend to get better,

01:52:43.180 | but we need, you know, probably more data in this area.

01:52:46.540 | For hearing, most of the research

01:52:48.900 | is around tinnitus and vertigo.

01:52:51.300 | So the rate of which the crystals break off in the ear

01:52:54.700 | accelerates in menopause and people on HRT

01:52:57.060 | have less vertigo, new vertigo,

01:52:59.140 | than they would have had before.

01:53:01.220 | And I forget what the pathophysiology,

01:53:03.340 | I wrote it in the book, but I can't think of it right now.

01:53:06.100 | What the physiology was behind

01:53:08.020 | why tinnitus increases in menopause,

01:53:11.700 | but it's due to the estrogen levels declining.

01:53:13.660 | - You mentioned dry eye.

01:53:14.940 | - Yeah.

01:53:15.780 | - A lot of people might hear dry eye

01:53:16.600 | and think, oh, no big deal,

01:53:17.440 | but actually dry eye is one of the most frustrating things

01:53:21.980 | to have, and it's a, I believe,

01:53:25.700 | a many billions of dollars a year industry

01:53:28.220 | to find treatments for dry eye.

01:53:30.540 | So does estrogen replacement therapy improve dry eye?

01:53:33.340 | - It does seem to.

01:53:34.180 | They have less incidents.

01:53:35.460 | Most of the studies are just retroactive

01:53:37.300 | and they're looking at the incidents of those things

01:53:39.140 | on women on HRT for other reasons or not.

01:53:41.940 | And they just see, especially like frozen shoulders,

01:53:43.980 | the best data there, I think.

01:53:45.620 | And what they see is a decreased risk of occurrence.

01:53:49.260 | And then if they do have it,

01:53:50.460 | they have a shorter duration and easier course,

01:53:52.740 | you know, easier to treat if they're on HRT.

01:53:55.900 | - Fantastic.

01:53:56.740 | So what are some of the cases

01:53:59.540 | where a woman can't or shouldn't do

01:54:03.860 | hormone replacement therapy?

01:54:05.100 | And here we're using hormone replacement therapy

01:54:07.060 | as kind of a proxy for estrogen therapy.

01:54:09.560 | - Yeah, so any hormone sensitive cancer,

01:54:12.580 | A, one of the things a lot of women don't understand,

01:54:14.660 | if you have dysfunctional uterine bleeding

01:54:16.680 | that has not been evaluated,

01:54:18.140 | you should not start hormone therapy

01:54:19.580 | 'cause we don't know if it's cancer.

01:54:21.540 | So if you're having really heavy,

01:54:23.340 | especially if they're heavy bleeding,

01:54:25.020 | clots out of nowhere, you know,

01:54:26.820 | something unusual about the volume

01:54:28.820 | or the frequency of your bleeding,

01:54:30.900 | you need to go see a gynecologist

01:54:32.300 | and get that evaluated before you start hormone therapy.

01:54:35.300 | Okay, it may not be anything cancerous or tumorous.

01:54:37.500 | It might just be the hormone changes,

01:54:39.160 | but that needs to be evaluated.

01:54:41.320 | If known breast cancer,

01:54:42.500 | no, if you're actively having a blood clot

01:54:44.500 | that you're being treated for,

01:54:46.540 | they're saying let's hold off until that therapy is over.

01:54:49.560 | Even if you've had a hormone sensitive cancer,

01:54:53.820 | including breast cancer, depending on the stage,

01:54:56.020 | the type, and it's a very nuanced conversation,

01:54:58.540 | does not mean that you were automatically disqualified

01:55:01.360 | for hormone therapy after your treatment.

01:55:04.020 | So that is one of the biggest misconceptions out there.

01:55:07.020 | If you have really severe liver disease,

01:55:08.960 | I'm not talking about mild fatty liver disease,

01:55:10.780 | lots of menopausal women have that.

01:55:12.820 | And it does tend to get better with HRT.

01:55:15.140 | If you have severe liver disease,

01:55:16.980 | that is where estrogen begins to be metabolized.

01:55:19.720 | And so you could have abnormal metabolism.

01:55:22.360 | You don't want that.

01:55:23.200 | So that's gonna keep you from being a candidate.

01:55:26.280 | - Why do you think we're seeing,

01:55:29.480 | or at least hearing about, in my case, PCOS,

01:55:33.340 | polycystic ovarian syndrome, so much more?

01:55:35.740 | Is it because people are aware?

01:55:37.360 | Is it because-

01:55:38.400 | - I think two reasons.

01:55:39.300 | One, the obesity epidemic had led to more PCOS.

01:55:42.560 | That is definitely a risk factor for, you know,

01:55:45.840 | insulin resistance is usually the main pathophysiologic cause

01:55:50.040 | behind PCOS.

01:55:51.600 | And I'm a PCOS, thin PCOS sufferer.

01:55:54.320 | So I had it my whole reproductive life.

01:55:57.940 | - But you're not obese at all.

01:55:59.360 | - No, no, they missed it forever.

01:56:01.400 | I was just stressed out medical student.

01:56:03.360 | - Which can potentially cause PCOS.

01:56:05.200 | - With acne.

01:56:06.040 | Yeah, I mean, you can have,

01:56:07.880 | PCOS is a symptom of something biologically aberrant.

01:56:12.040 | Turns out I'm insulin resistant,

01:56:13.680 | which is why I, you know, even though I'm thin.

01:56:15.720 | And so we've had higher, increasing levels of obesity,

01:56:19.320 | which is a risk factor for that.

01:56:20.760 | Also, people are talking about it

01:56:22.640 | and writing books about it.

01:56:23.740 | Karen Tang just published,

01:56:25.480 | it's not hysteria, wait, hysteria.

01:56:28.520 | It's not hysteria.

01:56:30.500 | And she's a gynecologic surgeon,

01:56:32.460 | does a lot of work around endometriosis.

01:56:34.120 | So she has like huge chapters on PCOS

01:56:36.440 | and how to advocate for yourself

01:56:38.120 | and, you know, all about the disease process

01:56:39.760 | so people understand.

01:56:41.520 | - Interesting, what are some of the primary treatments

01:56:43.600 | for PCOS?

01:56:44.440 | Is it gonna be blocking androgens?

01:56:45.920 | - So, yes.

01:56:47.320 | And so for me, you know, in all my training,

01:56:50.320 | it was always put them on birth control

01:56:52.160 | because it will suppress ovulation

01:56:56.220 | and suppress the overproduction of androgens

01:56:58.360 | in their system.

01:56:59.320 | So I was a very happy birth control patient

01:57:01.680 | 'cause I was thin.

01:57:02.920 | For the obese patients, if we can help them lose weight,

01:57:06.240 | it does tend to, they start ovulating again.

01:57:09.160 | And so now with the new GLP-1s,

01:57:12.960 | a lot of PCOS will probably resolve itself

01:57:17.560 | and they'll start ovulating again

01:57:18.800 | and go back to normal cycles.

01:57:20.200 | That's the pregnancies that are happening from GLP-1s.

01:57:23.040 | - I see, so GLP-1 associated pregnancy.

01:57:24.880 | - GLP-1 babies, yeah.

01:57:26.600 | We saw a surge of that when all the patients,

01:57:29.400 | the obese patients were getting the gastric bypasses,

01:57:31.480 | then they get pregnant.

01:57:32.760 | And so we were advising them to not be pregnant

01:57:36.320 | until their weight was stable for a year after surgery

01:57:38.760 | because of the medical implications

01:57:40.320 | of nutrition and pregnancy.

01:57:42.000 | But they were so excited and cute

01:57:45.160 | and now their libido's up and they're getting pregnant

01:57:49.240 | and never really needed contraception before

01:57:51.800 | and just assumed they'd still have trouble.

01:57:53.720 | And so now they're ovulating and getting pregnant

01:57:56.080 | and we're seeing the same thing with GLP-1.

01:57:57.520 | So anyone listening out there who's prescribing a GLP-1,

01:58:00.360 | please talk to your female patients about contraception

01:58:03.100 | if they don't wanna be pregnant.

01:58:04.680 | - Very interesting and admittedly unforeseen implications

01:58:09.360 | of GLP-1.

01:58:10.240 | As long as we're there, what are your thoughts

01:58:12.320 | on Zempik, Monjaro?

01:58:14.440 | - I think that they can be a really important tool

01:58:17.480 | for a lot of patients.

01:58:18.740 | I don't think they're for everyone.

01:58:20.160 | I don't think people are being counseled adequately,

01:58:22.640 | a lot of them.

01:58:23.460 | I mean, in my area outside of Galveston where I live,

01:58:26.800 | there are med spas giving out GLP-1s.

01:58:29.080 | And as far as I can tell, they're just giving them the meds

01:58:31.480 | and sending them out the door.

01:58:32.320 | I've had patients coming in on it

01:58:33.780 | who were never counseled about the potential

01:58:35.960 | for muscle loss.

01:58:36.800 | So when I look at a patient's health,

01:58:38.820 | I look at a 30-year plan, right?

01:58:40.920 | And so they come in with a lifelong history usually

01:58:44.680 | of having a weight problem and a fat problem

01:58:47.240 | and here's this medication

01:58:48.660 | that's gonna take the food noise away

01:58:49.960 | and help them focus on the habits

01:58:52.160 | that are gonna keep them healthy longer.

01:58:53.400 | So I do have patients that I've prescribed it to.

01:58:55.440 | We have a very long discussion

01:58:57.040 | about adequate protein intake, resistance training.

01:59:01.360 | I have a way to measure their muscle mass.

01:59:03.820 | We are tracking that every month for them,

01:59:05.920 | every month to six weeks while they're on the medication.

01:59:09.580 | So women who are on HRT with the GLP-1

01:59:12.660 | have a 30% increased weight loss.

01:59:14.740 | - Wow. - Yeah.

01:59:16.620 | - Yeah, I appreciate that you mentioned

01:59:18.420 | that the use of Ozempic Monjaro

01:59:22.180 | is not mutually exclusive with resistance training

01:59:24.980 | and improved nutrition.

01:59:25.820 | - No, I think it's-- - The way it shows up

01:59:26.980 | on social media, it's sort of like people assume,

01:59:28.620 | well, you know, you gotta take great care of yourself

01:59:31.060 | and exercise, well, great.

01:59:32.320 | But there are also a number of people

01:59:33.760 | that are carrying excess weight to the point

01:59:35.360 | where they are at risk of injury when they exercise.

01:59:39.680 | I mean, everyone's at risk of injury when they exercise.

01:59:41.840 | But what I'm hearing is that you basically take the view,

01:59:44.520 | whatever can get people in a kind of forward center of mass

01:59:47.800 | around management of blood insulin levels, et cetera,

01:59:50.160 | 'cause it wasn't that the original FDA approval was for--

01:59:52.360 | - Yeah, diabetes. - Type 2 diabetes.

01:59:54.360 | - Type 2 diabetes.

01:59:55.480 | - And there's also some data, as I recall,

01:59:57.840 | that Ozempic Monjaro can reduce alcohol cravings.

02:00:01.840 | - So yeah, the reward center in the brain are the noise.

02:00:05.400 | So they're looking now, I guess,

02:00:08.080 | my friends who are like obesity medicine specialists

02:00:10.280 | and are all like reading every study that comes out,

02:00:12.680 | any kind of impulsive behavior or reward-seeking behavior,

02:00:16.000 | gaming, gambling, alcohol, you know,

02:00:20.440 | people are tending to do less of those behaviors

02:00:23.120 | because whatever's being blocked in the brain,

02:00:26.400 | and you know more about this than I do,

02:00:28.000 | seems to help with that, those drives.

02:00:31.560 | - That's interesting that the hypothalamus

02:00:33.360 | is a chock-a-block full of neurons

02:00:35.480 | associated with all sorts of drives

02:00:36.680 | and temperature regulation.

02:00:37.720 | You mentioned earlier, you know,

02:00:38.880 | the preoptic area of the hypothalamus

02:00:41.500 | involved in temperature regulation.

02:00:42.760 | And we've always viewed those as somewhat separate,

02:00:46.120 | but they're actually quite interconnected.

02:00:48.840 | And so I'm not entirely surprised

02:00:51.360 | that a drug that would reduce cravings for food

02:00:54.200 | might also reduce cravings for other things.

02:00:55.920 | It's gonna be really interesting to see

02:00:58.280 | what the science and the animal models

02:00:59.720 | and humans shows us over time.

02:01:01.040 | - Over time, yeah. - It's definitely happening.

02:01:02.800 | I mean, this is, has it hit a trillion dollar industry yet?

02:01:05.600 | It's probably hundreds of billions of dollars.

02:01:06.440 | - I know that the majority of big research and funding

02:01:10.920 | is being funneled into this.

02:01:13.020 | Maybe not all for the right reasons,

02:01:15.960 | but the obesity medicine specialists

02:01:17.920 | who are kind of who I turn to for how do I do this?

02:01:21.000 | How do we do it right?

02:01:22.760 | How do I not hurt someone just to get them to lose weight?

02:01:25.080 | And are very excited because these new levels,

02:01:30.080 | they say it's like the iPhone 12, the iPhone 13,

02:01:32.880 | they're just gonna get better and better

02:01:34.080 | with lower side effects, better profiles as time goes on.

02:01:38.400 | That we're gonna look back at the Monjoro

02:01:40.320 | and these earlier meds and be like,

02:01:42.760 | "Oh my God, what were we doing?"

02:01:44.680 | Because of the side effects.

02:01:46.160 | - Well, if nothing else,

02:01:47.120 | they're very interesting to pay attention to

02:01:49.120 | because it's clearly in the cultural zeitgeist right now.

02:01:55.120 | So every once in a while when a guest

02:01:58.200 | for whom the topic is of immense interest

02:02:01.320 | coming on the podcast,

02:02:02.160 | I'll put out a call on social media for questions.

02:02:04.800 | And so if you're willing,

02:02:07.200 | I'd like to just ask you a few of the audience questions

02:02:10.960 | and we can treat these as rapid fire

02:02:14.000 | or as much depth as you like.

02:02:17.260 | First off that many of the questions

02:02:19.720 | you've already answered,

02:02:20.920 | things like what is the role

02:02:22.360 | for testosterone replacement therapy in women

02:02:24.840 | as opposed to just estrogen replacement therapy.

02:02:28.400 | But one of the more common questions in here

02:02:30.440 | that we've touched on,

02:02:32.020 | but I think could deserve a bit more attention is,

02:02:37.020 | if a woman is in her 60s

02:02:39.020 | and has already gone through menopause,

02:02:41.160 | is it appropriate for her to consider

02:02:42.800 | or at least just talk to her doctor

02:02:44.200 | about hormone replacement therapy

02:02:45.680 | or is she putting herself at risk?

02:02:47.400 | - There's definitely worth the conversation.

02:02:49.360 | So if I have a patient who comes in

02:02:51.520 | and she's more than 10 years past her menopause

02:02:54.400 | or over the age of 60 and has not been on HRT,

02:02:58.000 | then we start looking at risk factors

02:03:00.520 | for cardiovascular disease or stroke.

02:03:02.600 | And so we're looking at her blood pressure,

02:03:05.840 | her lipids, her cholesterol and triglycerides

02:03:09.680 | and looking for things

02:03:11.240 | that are gonna put her at higher risk.

02:03:13.600 | She's lost probably the maximum cardiovascular benefit,

02:03:17.980 | but we don't wanna put estrogen

02:03:19.280 | on top of severe atherosclerotic disease.

02:03:22.160 | So if she has abnormal cholesterol,

02:03:25.240 | I'm gonna send her for a calcium cardiac score.

02:03:27.760 | I wanna see if there's calcified plaques around her heart.

02:03:30.760 | I may even, if stroke is a risk,

02:03:32.920 | we may even send her for an ultrasound,

02:03:34.760 | looking at the intimal thickness of the carotid.

02:03:37.440 | So if those are normal or low risk,

02:03:41.360 | then we will talk about the benefits of,

02:03:44.760 | what would the benefits be for her after the age of 60?

02:03:47.400 | Well, we probably lost the best

02:03:49.080 | of the cardiovascular protection,

02:03:50.560 | but it will always protect her bones.

02:03:53.400 | It will always protect her genital urinary system.

02:03:55.740 | It will always protect her skin.

02:03:57.200 | I mean, there's things that estrogen will do for us forever.

02:04:00.480 | And so, and then let her make the decision,

02:04:02.480 | certainly if she's still symptomatic,

02:04:04.400 | meaning hot flashes or things we can easily identify

02:04:07.160 | that we know estrogen will help with.

02:04:09.200 | But that first 10-year window is kind of critical

02:04:12.200 | for the preventative benefits,

02:04:14.600 | but it doesn't mean she's not gonna benefit forever.

02:04:16.780 | Now, when do we stop?

02:04:18.560 | Used to be, doctors make up numbers,

02:04:20.720 | three, 10 years, whatever.

02:04:23.040 | If she's been on it since early in her menopause

02:04:26.160 | and has not developed any of these diseases,

02:04:28.720 | and she wants to keep going, we're gonna keep her on.

02:04:31.280 | I will probably die with my estradiol patch on

02:04:35.000 | if I don't develop a reason to take it off,

02:04:37.400 | 'cause I know it's protecting me in so many levels,

02:04:40.040 | and I wanna keep that going.

02:04:41.440 | - In so many ways, it sounds very similar

02:04:44.300 | to testosterone replacement therapy in men.

02:04:46.360 | The idea is that people get on it and don't--

02:04:47.760 | - Yeah, well, you stop at 70.

02:04:49.040 | Why would you do that, you know,

02:04:50.780 | if you didn't develop a contraindication to it?

02:04:53.600 | - Very clear and potentially very actionable answer.

02:04:57.480 | Thank you.

02:04:58.720 | A number of the questions related to

02:05:01.240 | the relationship between menopause, hormone therapy,

02:05:06.280 | and mental health, mental wellbeing.

02:05:08.560 | But let's just keep it simple for now and ask,

02:05:13.080 | what are the things that women can do

02:05:15.000 | in order to optimize their mental health

02:05:19.000 | in perimenopause and menopause,

02:05:21.120 | and that they can do to offset any mental health issues

02:05:25.300 | that might arise during perimenopause and menopause?

02:05:27.680 | And there's a reason why I asked

02:05:28.760 | about those two things separately.

02:05:29.880 | One is just to--

02:05:30.720 | - Peri's very different than menopause for mental health,

02:05:33.760 | so it's a great question.

02:05:35.640 | So I just went to a menoposium,

02:05:38.320 | menopause conference in Chicago,

02:05:40.440 | and there was a whole section on mental health,

02:05:44.680 | and it was neuroscientists, psychiatrists,

02:05:47.360 | and menopause specialists all up there

02:05:49.840 | discussing the latest data.

02:05:51.160 | It was so fascinating.

02:05:52.120 | And so there really is a big difference

02:05:54.280 | as far as mental health for what's happening

02:05:56.320 | in perimenopause and what's happening postmenopause.

02:05:58.800 | And as we talked about earlier,

02:06:00.240 | in perimenopause we have that hormonal zone of chaos,

02:06:03.880 | and we see this, you know, in the Australian data,

02:06:06.480 | it's a four times risk of mental health disorders,

02:06:08.960 | especially depression.

02:06:10.960 | And then in postmenopause,

02:06:14.360 | a lot of these things tend to stabilize or get better,

02:06:17.280 | probably 'cause just the estrogen is bottomed out

02:06:19.400 | and the brain is not having to deal with these fluctuations.

02:06:22.280 | So we think that the data is looking like

02:06:27.280 | the best treatment for the mental health issues

02:06:30.640 | in perimenopause is going to be estrogen for stabilization

02:06:35.640 | and not the traditional SSRIs, SNRIs,

02:06:39.360 | you know, the antidepressants and the anxiety meds.

02:06:42.480 | - Not incidentally, one of the more common questions was,

02:06:46.360 | in this case, very specifically worded,

02:06:48.480 | I've been on HRT for five years and I'm 61.

02:06:50.680 | I feel great, but how long is it "okay" to be on them?

02:06:53.640 | Seems like I hear conflicting opinions.

02:06:55.080 | Well, we just heard a very straightforward opinion.

02:06:57.160 | So thank you for that.

02:06:58.120 | - As long as you want to be, as long as you're still healthy.

02:07:01.760 | - How can I stop waking up in the middle of the night?

02:07:03.800 | This is a problem since entering menopause.

02:07:07.960 | So we see sleep disruptions definitely from,

02:07:12.800 | not only from the vasomotor symptoms,

02:07:15.140 | which will wake you up, okay?

02:07:17.300 | If we can get those under control, you know,

02:07:19.460 | your sleep function should not be affected by that.

02:07:22.440 | What we're seeing though, is people, even with HRT,

02:07:26.160 | even with estrogen are still having

02:07:27.780 | middle of the night awakenings or racing thoughts

02:07:30.000 | or having, they get up to pee or something

02:07:32.100 | in the middle of the night and they can't go back to bed,

02:07:33.680 | usually 'cause their brain is going on.

02:07:35.760 | What we found is that progestin,

02:07:37.560 | probably through the effects of GABA,

02:07:39.920 | is very effective at settling your brain down

02:07:44.000 | and allowing for sleep.

02:07:45.120 | So I'm having my patients take their progesterone

02:07:48.520 | orally at night before they go to bed.

02:07:50.800 | And we're seeing better sleep with that.

02:07:52.920 | And that was also something covered in detail.

02:07:55.280 | I was so excited by the neuroscientists

02:07:57.520 | as part of her area of research,

02:07:59.080 | that they are showing clearly,

02:08:00.320 | and she can point to the neuroreceptors

02:08:02.120 | of where that's happening.

02:08:03.520 | That progesterone seems to be

02:08:05.800 | really protective for our sleep.

02:08:06.960 | Now, take hormones off the table.

02:08:10.000 | Sleep hygiene is still hugely important.

02:08:12.400 | And I need to see the studies to prove it,

02:08:15.180 | but I'm telling you, we do not tolerate alcohol

02:08:17.680 | like we did pre-menopausal.

02:08:20.360 | Women are in at least 90%.

02:08:22.440 | Every time I post about it online,

02:08:23.880 | I see thousands of comments of,

02:08:25.840 | "I quit, I had to give it up, I cannot sleep."

02:08:28.140 | And even in my own life,

02:08:29.200 | if I choose socially to have more than a glass of wine,

02:08:32.080 | I am giving up sleep.

02:08:33.520 | Like, it is a choice.

02:08:34.600 | I'm choosing not to sleep that night.

02:08:36.020 | I will wake up 2.23, 3.35,

02:08:38.700 | whatever time in the morning, sweating,

02:08:40.360 | and I'm like, you know,

02:08:43.520 | too much champagne at New Year's or whatever.

02:08:45.320 | So, you know, that is a choice,

02:08:47.160 | and it's something I counsel my patients about.

02:08:48.680 | Like, you probably can't tolerate alcohol like you used to.

02:08:51.560 | Aging's a factor here, our body composition changes,

02:08:53.900 | and there's probably something hormonally that's going on

02:08:55.760 | we don't understand yet.

02:08:57.200 | But like, you choose this,

02:08:59.200 | you're gonna choose not to sleep, more than likely.

02:09:01.320 | - Interesting, I wonder whether or not

02:09:03.000 | estrogen modulates the alcohol dehydrogenase enzyme,

02:09:05.960 | but time will tell.

02:09:07.560 | - I haven't seen the data yet, but I'm sure it's coming.

02:09:09.720 | - Here's an interesting one.

02:09:11.320 | How can men help their female loved ones

02:09:13.840 | navigate these stages?

02:09:15.860 | You get that question a lot?

02:09:17.040 | - My, and it's great.

02:09:18.840 | And it always comes on the,

02:09:20.000 | when I'm being interviewed by a male.

02:09:21.560 | You know, when I'm interviewed by a female,

02:09:23.700 | they're wonderful, but they have their own experience,

02:09:26.320 | and they have to talk about it.

02:09:27.600 | And that's fine, that's my job, you know,

02:09:29.280 | is women have to unpack their menopause trauma

02:09:31.220 | to me, but the men are just so curious,

02:09:33.280 | and just have so many questions,

02:09:34.340 | and then how can I support a partner?

02:09:36.480 | And, or my mom, or whomever in my life,

02:09:38.480 | who's dealing with this.

02:09:39.840 | One is acknowledge that this is happening,

02:09:42.360 | and try to educate yourself.

02:09:43.840 | There's my book, other books,

02:09:45.160 | there's lots of information now on the internet

02:09:47.000 | about the subject, but she is going through a transition

02:09:50.480 | that is rocking her world, more than likely,

02:09:52.940 | and is affecting her brain, her bones,

02:09:54.800 | her heart, her kidneys, her skin,

02:09:56.600 | her ability to relate, her ability to tolerate,

02:09:58.920 | and it's probably gonna affect her relationship

02:10:00.460 | in some way.

02:10:01.300 | Go there with her, go to the appointments with her,

02:10:04.580 | be there to advocate for her, you know,

02:10:06.760 | be a partner through this with her,

02:10:08.440 | 'cause you will get her back,

02:10:10.000 | but it's gonna take, you know,

02:10:11.560 | changing the way that you address things.

02:10:13.920 | - A couple of questions about, quote,

02:10:15.800 | "How to rekindle libido."

02:10:17.920 | - Oh yeah, no, it's a great-- - This person in particular

02:10:19.600 | says, "It's packed its bags and moved out

02:10:22.320 | "since I started menopause."

02:10:23.660 | They're reporting their individual experience,

02:10:25.580 | but you touched on testosterone therapy earlier.

02:10:28.520 | Any woman in her menopause journey,

02:10:33.060 | at any time, there's a 50% sexual dysfunction rate,

02:10:36.840 | meaning she's not happy with whatever's going on.

02:10:40.180 | Now, when we look at the buckets

02:10:41.660 | where sexual function fall into,

02:10:42.980 | we have orgasmic disorder.

02:10:45.120 | Now, in menopause, when we lose blood flow to the area,

02:10:47.900 | people can have delayed orgasms,

02:10:49.900 | or less, the peak of the orgasm is lower,

02:10:54.020 | you know, less vibrant orgasms,

02:10:55.900 | for lack of a better word.

02:10:58.140 | They have decreased blood flow to the area,

02:11:00.380 | they lose elasticity, so pain is another bucket.

02:11:03.260 | You know, it hurts, the skin gets torn,

02:11:05.780 | it's very fragile, it's very friable,

02:11:07.840 | so vaginal estrogen therapy can help there.

02:11:10.660 | There is arousal disorders where you want to do it,

02:11:13.900 | but the blood's not getting where it needs to go,

02:11:15.860 | so you're not having all the arousal-type symptoms,

02:11:18.860 | so sometimes Viagra, Sildenafil,

02:11:21.300 | topical Sildenafil can be helpful there.

02:11:24.060 | But the most common thing that women have

02:11:25.900 | is HSD, or of course, relationship disorder.

02:11:28.940 | You don't love your partner, you don't feel supported,

02:11:30.840 | it's gonna be hard to, you know--

02:11:32.240 | - Relationship disorder. - Yeah, relationship disorder.

02:11:34.000 | - The official term, yeah.

02:11:35.200 | - But then HSDD is hypoactive sexual desire disorder.

02:11:37.980 | That's in the brain.

02:11:39.160 | And so first thing I ask is,

02:11:40.800 | did you used to have a good libido or a drive?

02:11:43.400 | Yes, you know, and you have a good relationship

02:11:45.600 | with your partner, it doesn't hurt,

02:11:46.840 | you don't have to rule out the other things.

02:11:49.120 | That's where testosterone comes into play.

02:11:51.100 | That is those patients it does tend to help.

02:11:53.460 | There are two FDA-approved medications for libido,

02:11:55.820 | one is Vilese, it's an injection you give yourself

02:11:58.600 | and actually works for men as well,

02:11:59.680 | about 30 minutes before.

02:12:01.200 | - It's in the alpha melanocytes stimulating hormone pathway.

02:12:02.840 | - Yeah, so melanocortin.

02:12:04.040 | And then there is Addy, A-D-D-Y-I,

02:12:07.520 | works at the level, I think of dopamine, in the brain.

02:12:10.140 | So it's more in the family of SSRIs that, you know,

02:12:13.640 | so it affects neurotransmitter.

02:12:15.020 | And so you take that every day.

02:12:16.960 | And it works, it was only studied in premenopausal women,

02:12:21.640 | but it does, you know, it's modest,

02:12:23.040 | but it does seem to have an effect.

02:12:25.360 | So, but most of my patients,

02:12:26.660 | because testosterone has so many other benefits,

02:12:30.700 | and then the cost, to get it compounded in Texas

02:12:33.760 | is maybe 30 bucks a month.

02:12:35.120 | So it's really reasonable.

02:12:36.640 | And the Vilese and the Addy can be very expensive

02:12:39.200 | and usually not covered by insurance.

02:12:40.600 | So because of cost and potential other effects,

02:12:43.680 | most of my patients choose testosterone if it's HSDD.

02:12:46.720 | - I see.

02:12:47.560 | This is a question about the side effects

02:12:50.520 | associated with estradiol hormone replacement therapy.

02:12:54.160 | In this particular instance, the person says,

02:12:57.800 | what are the best alternatives to estradiol?

02:13:00.560 | I've tried tiny amounts and the side effects,

02:13:02.640 | in this case, skin rashes and hives

02:13:04.840 | are what they are describing.

02:13:06.120 | - So I wonder if it's the patch.

02:13:07.720 | So there's a certain percentage of patients who,

02:13:10.320 | it's not the estradiol,

02:13:11.520 | it's actually the adhesive in the patch.

02:13:13.680 | They will have a reaction to it.

02:13:15.360 | So one is try an alternative form.

02:13:17.940 | Another thing that one of the members on my team

02:13:20.520 | saw in her chat group is they get the Flonase,

02:13:23.520 | the corticone nasal spray over the counter

02:13:25.680 | and they spray it on and let it dry.

02:13:27.400 | Then they put the patch on and it decreases the risk

02:13:29.800 | of the reaction to the glue.

02:13:32.160 | I don't know how, if that lasts forever,

02:13:33.880 | but I thought that was a cool thing to know about.

02:13:36.160 | And, but what I typically do for my patients

02:13:38.640 | is change them to an alternative form.

02:13:41.160 | - Interesting.

02:13:42.360 | Thank you for that.

02:13:43.200 | They went on to ask about trying a new supplement

02:13:47.020 | called Equel, E-Q-U-E-L-L-E.

02:13:49.600 | - I think I read about that one.

02:13:51.280 | Again, I don't know what's in Equel,

02:13:54.080 | but again, not really robust studies,

02:13:56.480 | but most of these things are not harmful,

02:13:58.420 | but you may just, it may be a little snake oil,

02:14:01.140 | you know, throw your money away.

02:14:02.760 | Really the thing that's gonna fix the problem

02:14:05.000 | for most women is restoring your estradiol.

02:14:07.880 | - Yeah, because there were other questions about,

02:14:09.560 | you know, wild yam and things more in the supplement space,

02:14:14.560 | as well as things like acupuncture and herbal medicine.

02:14:17.200 | - So acupuncture can really be helpful,

02:14:20.900 | but again, it's hard to access

02:14:24.280 | and can be expensive for a lot of patients

02:14:26.000 | and it's not treating the root cause,

02:14:27.440 | but it definitely can help you deal

02:14:28.880 | with some of the symptoms and make you more comfortable.

02:14:31.440 | - And then last question, how best to attack,

02:14:35.440 | and here I'm quoting,

02:14:36.280 | "Attack the fat distribution problem at this time."

02:14:38.760 | - Yeah, you need a multifactorial approach to visceral fat.

02:14:42.080 | So nutrition, exercise,

02:14:45.560 | women on HRT have less visceral fat, you know,

02:14:48.060 | those are kind of the key things.

02:14:50.600 | And the way you approach your nutrition with the exercise,

02:14:53.640 | with the stress reduction,

02:14:54.880 | getting those cortisol level down

02:14:56.040 | are gonna make you healthier in every other way as well.

02:14:58.920 | - Great, well, Dr. Mary Clare,

02:15:02.340 | thank you so much for giving us just a wealth of knowledge

02:15:07.760 | about perimenopause, menopause,

02:15:09.600 | really explaining what those are clearly

02:15:13.280 | for the first time on this podcast.

02:15:15.080 | And really illustrating the things that people can do

02:15:18.760 | to think about these stages of life

02:15:20.520 | and to, I don't know if I should say tackle,

02:15:23.080 | or to dance with the stage of life,

02:15:25.240 | whatever term one prefers,

02:15:27.880 | in order to offset the negative effects.

02:15:30.320 | And it sounds like, in fact, it's very clear

02:15:33.280 | based on what you've told us

02:15:34.120 | that there are real levers of control,

02:15:37.440 | including hormone replacement therapy,

02:15:38.920 | but other things as well, nutrition, exercise.

02:15:43.280 | Sounds like when we put all these together,

02:15:45.040 | there's almost like a mindset

02:15:46.280 | around perimenopause and menopause that you are promoting,

02:15:50.920 | which is one of real agency,

02:15:53.080 | that this is not something

02:15:54.200 | that is going to bury us mentally and physically,

02:15:57.720 | that's something that really can be worked with.

02:15:59.360 | And I just wanna say on behalf of myself,

02:16:01.360 | 'cause I've learned so much from you here

02:16:02.800 | and the listeners and viewers of the podcast,

02:16:06.160 | thank you for the information today.

02:16:08.840 | Thank you for your clinical work.

02:16:11.040 | Thank you for your ongoing research into this area,

02:16:13.040 | for attending these conferences

02:16:14.280 | and learning so much about it

02:16:15.320 | so you can bring us the latest.

02:16:17.400 | And thanks for your public education efforts

02:16:19.840 | because they are really making a tremendous difference.

02:16:22.640 | - Thank you.

02:16:24.120 | - Thank you for joining me for today's discussion

02:16:25.960 | with Dr. Mary Claire Haver.

02:16:27.720 | To learn more about her work,

02:16:29.000 | please see the link to her website in the show note caption,

02:16:31.880 | as well as the link to her terrific book,

02:16:33.800 | "The New Menopause,"

02:16:35.080 | navigating your path through hormonal change

02:16:37.160 | with purpose, power, and the facts.

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02:18:02.740 | Thank you once again for joining me

02:18:04.120 | for today's discussion about perimenopause and menopause

02:18:07.560 | with Dr. Mary Claire Haver.

02:18:09.380 | And last, but certainly not least,

02:18:11.560 | thank you for your interest in science.

02:18:13.520 | (upbeat music)

02:18:16.100 | (upbeat music)

Dr. Mary Claire Haver: How to Navigate Menopause & Perimenopause for Maximum Health & Vitality

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