Build Strength, Live Longer: The Menopause Longevity Blueprint with Dr. Vonda Wright

I contend that although we certainly undergo some life-stage changes, what we call normal aging is actually normal aging for stressed out, under-nourished people who are not intentionally building muscle, not attending to their hormonal health, and not prioritizing mobility. Aging to frailty only seems normal because modern life has made it so and threatens to rob us of our vitality. It's why most of us spend a quarter of our lives deteriorating from chronic diseases that encompass what we now understand as sedentary death syndrome. The views and opinions expressed on UnPause are those of the talent and the guests alone, and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. I'm not going to be a part of this podcast. Both my grandmother and my mother had osteoporosis and fractures, so I always assumed it was inevitable for me too. A new menopause hormone therapy would give me an edge, but I honestly thought weak bones and multiple fractures as I aged would just be my destiny. I see older women every day who were clearly becoming frail, bent over, moving stiffly, faces showing pain with every step. Recently, on a flight, I noticed an elderly woman traveling with her family. She was very weak and had trouble balancing and had to be guided just to walk, and it was clear she was living with dementia. I could even see through her pants that she was wearing a diaper. Her family tended to her with such love and care, and I thought, my God, she's so loved and so well cared for, thank goodness. But I couldn't help wondering what the last 10 years of her life had looked like. Was this long, difficult end of life slog inevitable? Is this what we're all destined for? Or can we change the way we think about aging, frailty and independence? The first time I heard our guest, Dr. Vanda Wright speak, was at a menopause conference. I had never heard anyone talk specifically about aging for women. She told stories of women coming into the ER with a hip fracture, who also had heart trouble or incontinence, and they would look at her and say, I wasn't always like this. Hearing her speak stopped me on my tracks. She wasn't calm or detached about the way women age. She was furious. Furious that so many women are funneled down a path towards frailty, osteoporosis and muscle loss, when so much of it is preventable. Up until that moment, I had only heard osteoporosis and sarcopenia discussed as inevitabilities, something you diagnose, accept and manage with treatment. Almost never as something you could actually prevent. Dr. Wright shattered that narrative for me. She said, no, this doesn't have to happen. Here are the steps. She showed me that osteoporosis is largely preventable, that frailty doesn't have to define the latter decades of a woman's life. And hearing her say that completely changed the way I think, the way I practice medicine, and the way I counsel both my patients and my followers. I call this stretch of life the minospan, and we need to talk about it openly, urgently and with solutions. Because aging looks very different for women than it does for men. And if we understand the difference, we can change the trajectory. I'm Dr. Mary Claire Haver, a board-certified obstetrician and gynecologist and certified menopause practitioner, and also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to Unpaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life. Joining me today is Dr. Vonda Wright, a double board-certified orthopedic surgeon, internationally recognized researcher and sports physician with more than two decades of experience dedicated to high performance orthopedics, aging, and women's health. She is the author of best-selling guides like Younger in Eight Weeks, Fitness After 40, and her latest New York Times bestseller, Unbreakable, a women's guide to aging with power. Millions of women experience debilitating fractures every year from osteoporosis, and yet it's still framed as inevitable aging rather than a preventable, diagnosable condition. One out of two women will suffer an osteoporotic fracture after the age of 50 versus 20% of men. Most women have no idea that they can lose up to 20% of their bone mass in the first five years after menopause, and as bone mass decreases, fracture risk increases. As I told you, Dr. Wright's mission is to educate women and help them navigate midlife with clarity. That begins with seeing menopause not only as the moment when your period stops, it's the life stage many of us will enter for the next 45 years, and one we can meet with strength and resilience. Why did you leave nursing? Why orthopedic surgery? I know orthopedic surgery of all the things. I was fortunate to progress really rapidly in nursing. Smart kids in my generation were directed only a few pathways. There weren't that many. There was like, you should be a doctor, teacher, nurse, and I come from a really small town in Kansas. So of course I said, okay, I'll be a doctor even though nobody in my family was a doctor. And my parents were the first in their family to go to college. I get to college where I made it through freshman year, organic chemistry then comes in front of me, and on the second organic chemistry test I failed it, and I'd never failed anything in my entire life. And so I didn't know what to do with that. The end of the story is by the end of the year I had a B, but by then I had decided that I couldn't be a doctor. And no one told me that that was just bad thinking, right? So right after college I have a degree in biology. There was such a shortage of nurses that in three years I got another bachelor's degree and a master's degree in cancer nursing and started working on a cancer floor at 23 years old. But because I had the capacity to learn really quickly, I progressed really quickly in that job and I was promoted. Suddenly I was 27 thinking, I think I've learned what I'm going to learn from this career. So do I do a PhD? Do I go into the business of nursing? Or do I finally go into medicine? And I decided in the end that I need to take care of people and I need to do research and being a doctor allows me to do both. It had been 11 years since I took organic and all those things because I hadn't taken my MCAT. So I went back and I took all those things and went to medical school only for some reason to decide to do a surgical residency which dumped me out of my training at almost 40. So how old were you when you started medical school? 28. So there's not a lot of female orthopedic surgeons. I knew two, I think, on through all my training and they were bad asses. Why on earth, Vonda, would you pick something there? You're automatically an outsider. I mean, I knew that there weren't many women but I didn't realize it could be a problem and I'm going to tell you for sure. It never became a problem until I was in attending. Only when I was attending did I feel the difference in opportunity, the difference in acceptance of my work, the difference in salary. In my residency, I think we were well supported. This was an anomaly and amazing but out of 46 residents, there were eight women which is unheard of. I never knew in residency it was going to be a problem and plus I was a nurse and I was a cancer nurse and I wasn't about to be pushed around. But not until I got to my attending shift did I see the differences that still exist today even though when I trained there were 3% women and now there are 6% or 7% women. We're not at critical mass. Let's pivot a little bit. I want to hear about your own experience at midlife. You've talked about this before. So you're getting tossed out of your training, residency and newly minted at around 40. What was that like for you? What to be that old Mary Twill? You know, 40! Being in the best shape you've ever been. I was. 40 was amazing. I lived in New York, 38, 39. I moved back to Pittsburgh where I took a faculty job at 40. But you live in New York and you walk everywhere and you have access to amazing food and I started racing in the park and training for triathlon and I was single at that time so I could work out twice a day if I wanted. So I entered my attending shift at 40 in the best shape of my life as I describe it. I decided to have a baby so I had a child when my dear friends the Obies call us geriatric. But I exit that. And what I've become aware of Mary Claire is that, okay, baby at 40, I breastfed to almost 42. I think I went right into perimenopause because the chaos of pregnancy, then the resumption of your estrogen, weirdo. It goes back to work. I can't imagine what your cortisol levels were doing. I was in the hospital for six weeks and I was the head doctor for the University of Pittsburgh football team. So I was leaving my newborn to go take care of 150 football players, which is my job. But the cortisol crazy, right? So I don't, I think I went right from one hormonal stage to the other, but I didn't know it. I had no idea what was happening. You're going to laugh at this. I've said this out loud sometimes. I wasn't sleeping at a new baby, but different kind of not sleeping hot flashes. I lost my nouns and I thought that I was getting dementia. So I'd start looking it up online. I started having heart palpitations. I call my friend, the cardiologist to do a stress test and then I couldn't get out of bed, right? Triathlete training person couldn't get out of bed because of the musculoskeletal syndrome of menopause. But here's the wackiest thing and just shows that I got no education on this in medical school. I was an athlete my whole life and had a lot of amenorrhea. I was just that kind of athlete and low body fat for months. And I'm like, yes, because then you don't have to mess with it. Little did I know that was damaging my bones. I didn't know. You were robbing your body of estrogen. Yes. So I get to perimenopause and I start having heavy raging periods. And do you know what I said to myself? Mary Claire said, oh my God, I'm finally a woman. Because all the other girls had me. I never had real periods. Isn't that ironic? But then when I entered this place where I describe it as feeling like I was going to die out of control, like I've never not been in control. I'm a surgeon, right? Is my job to be in control. But my old body was revolting against me out of control. It makes me sad. I'm about crying. I figured it out. I did a deep dive. I became an expert in what I could. I read the books, right? I was not going to leave a stone unturned. But it makes me upset about all the women I meet right now who still don't know what perimenopause is. Yeah. I mean, I had all the resources in the world and I still didn't know. Same. I was the expert. That's right. You're an OB-GYN-A program director. I was the expert. I could not diagnose myself. I gaslit myself for six months and I was actually fully menopausal by that point. But I'd never had regular periods and I was blaming stress and my brother's death and all the things. And after like month six, I was like, oh my God, I might be a menopause. I know. Like, and I felt like a chapter of my life was ending. Why did you write Unbreakable? It's interesting. Unbreakable is actually how I treat women. This is not theoretical. It's not something that I had to make up to write a book. It's actually my approach to women. And so I felt like I was seeing enough women. I had a system that I was using and the need was so great, Mary and Claire. I mean, not everybody is going to read the papers we published in academic journals. My group published this paper on the Musculoskeletal Syndrome of Menopause and in Climacteric. So I'd like to raise my hand and say that was God's gift to papers, but it wasn't. It was a good paper. That tells me the need was so great that women are dying out there and need information, right? It's the same response, you know, that you get from the new menopause, right? Women are dying. They need information. And that made me think, okay, Mary Claire's written the seminal book on menopause. A lot of our friends have written great books on menopause. And I'm going to write the book that tells them now what? Now what? What do you do next? And so that's what Unbreakable is, but it's more than just physical resilience. But when we close the back cover of the book, I'm hoping that women close the cover on hopelessness and emerge with this great hope that their future can be unbreakable if they step in front of it. There's a couple of paragraphs early on that really strike me as probably two of the most important paragraphs in this book. And I would like you to read them for me. I don't think I can do them justice. Oh, you're so sweet. I'm hard to believe. Okay. I contend that although we certainly undergo some life stage changes that we call what we call normal aging is actually normal aging for stressed out undernourished people who are not intentionally building muscle, not attending to their hormonal health, and not prioritizing mobility. Aging to frailty only seems normal because modern life has made it so and threatens to rob us of our vitality. It's why most of us spend a quarter of our lives deteriorating from chronic diseases that encompass what we now understand as sedentary death syndrome. Let's dig in. The bone I had at 30 is not the bone I have at 57. No, it is not. In fact, that was two and a half bones ago. So explain that to me. Talk to me about how bone is made, how it turns over. Like what is the process of our bones? If we think of bones at all, the only time I contend that people think of bones is when Aunt Mary breaks one. Or mama. Or mama. But the reality is bones are not just a structural eye beam that our muscle is attached to. It is a structural eye beam. And thank God because if muscle weren't attached to it, muscle would just be a heaping pile of metabolic tissue steaming. It wouldn't have the form and function. We would not locomote. The bone, my friend, is the incubator of all of our baby blood cells. We make all of our immune system in our pelvis and long bones. In the bone marrow. It is the storehouse for all of the minerals that our body needs to function from our brain to our muscles. So structure. It is storehouse. It is incubator. It is endocrine organ secreting hormones that move to almost every other body part and do things like help you build a better brain. Walk me through a little bit of that. You've always said that bones are a master communicator. Yeah. So for our listeners, what does that mean? Yeah. So they make bones make hormones? They do. They make many kinds. I love to talk about two in particular, one called osteocalcin and one called LCN2. Osteocalcin is secreted by the bone. It can cross the blood-brain barrier and stimulate your brain to produce its own growth hormone called brain-derived neurotrophic factor, which helps you build a better brain. Your bones do that, right? It goes to your pancreas. The pancreas is responsible for secreting the hormone insulin, which helps us with our blood sugar and without the function of the pancreas. And so bone sends osteocalcin to the pancreas. It sends it to the muscle to help with glucose metabolism. If you're a man, it sends it to your testicles to help you make testosterone. And we think bones are just structural. They are talking all the time. Bones also secrete this other hormone called LCN2, which is directly influencing the feeling of satiety or feeling full after a meal. Whoa. I know. Exactly. And I had that same reaction that when I first read about it, like, what? But it makes so much sense. If our bones are the storehouses of minerals, if they're involved in glucose metabolism, why wouldn't bones also be interested in influencing when we're full? The system just works together. So when I say bones are the master communicators, they're talking all the time to every other tissue. It's just that we don't know how to listen to them. We're not good bone listeners. When you ask me the question of the bones you had at 30 or not the same bones you have today, that is because not only are they master communicators, but they're constantly renewing. The way bone is made, which is important in menopause, is there's a cell type called an osteoclast, which digs bone out. I think of it as Pac-Man. That's right. Maybe that's why I do this with my hand when I talk about it. It creates an acidic environment, so all the minerals and vitamins are removed from bones, so your body can use them. Well, your body's not going to leave itself full of holes. Coming up behind it is the osteoblast, which fills these little holes when we have enough estrogen is a balance. Because our bones are constantly remodeling. That's the key word. Every 10 years, we essentially have a new set of bones. But the problem happens when for some reason we are not balanced and we're breaking down more bone than we are building. And that happens in menopause? It happens. One of the reasons it happens is in menopause. One of the main reasons is because estrogen is a critical controller of the osteoclast. So this Pac-Man is partially controlled by estrogen. So without that, we're eating more bone than we're laying down. You can lay down. Yes. And this is peak bone mass. What does that mean? So peak bone mass is the bone mineral density. It's a measure of how much mineralization is in the bone. We reach the peak. We say 30, but it probably happens between 17 and about 25. And so I get a lot of young women. Their peak bone mass is osteopenic. Wow. Because I test almost everybody that comes into me. And if I catch it in their 20s, then we do a big job of trying to get you to a better peak bone mass. But that being said, I catch a lot of young women in their early 30s, definitely in their early 40s, who don't have amazing bone mineral density. So you're starting this decline from a lower starting point. We want to start this decline from as high as we can, because we are going to decline due to natural aging and then this catastrophic loss of estrogen. Let's talk about muscles and tendons for a little bit. Here's the thing. Muscle, tendon, ligament, bone, fat, annulus, the discs in our spine, they all come from the same kind of stem cell. They're all cousins. They all speak the same hormonal language. So they're all interacting. They're all talking together all the time. So that's why we can build better bone through the action of muscle. Yeah. That musculoskeletal unit always works together. Exactly. So strong muscles usually mean stronger bones. Better bones. Okay. So we talked about peak bone density. What is low bone density? Yeah. So the most common way to measure bone mineralization, bone density, is through this test called a DEXA scan. It uses X-ray to tell us about how much bone we have. So the top of the bell curve, the zero point, the average is the bone density of a healthy 30-year-old woman. When you get your DEXA scan, any positive number is fantastic. That means you have bone density more than a healthy 30-year-old. But at minus one, we start calling that bone osteopenic, which means it's getting weak. If we continue to lose bone and our T-scores declines to minus 2.5, which is two and a half standard deviations below average. So that's osteoporosis. One in about two women will get osteoporosis about 40 to 50%. And if you do, you have a 50% chance of fracturing. So it makes your fracture risk much, much higher. And you wouldn't even care about that until you fracture. And then it's all anybody in your family can think about. Definitely all you're thinking about. When do you order a DEXA? Or when do you order a DEXA on everybody? I think just like we get our mammograms at 40, I think we should have our screening test by 40. Should have a baseline. Let's just figure it out, whether it's REMS, whether it's DEXA, just find one. In fact, we should probably do it at 35 when we have a little bit of estrogen still circulating. Just see what your baseline is. And if you're already low, then you really got to get after it because you're still probably producing some estrogen. Walk us through bone loss over time. Like, what is the process? What does bone do, right? So we're building peak bone density. If we're building peak dumps, bone density to 30. And then we stabilize for a while. Okay. And then just like men, we start to lose bone density at about 1% per year in a slow study decline. And men just continue like that. Men get osteoporosis, 2 million men in this country have osteoporosis. But they had this slow study decline. Nobody notices. For women in perimenopause, when estrogen walks out the door, as I like to say, and never looks back that girlfriend of ours, we start to rapidly lose bone density between 2 and 3% a year, such that in the five to seven years surrounding the end of perimenopause to menopause, we can lose 15 to 20% of our bone density. And most of us never know it. Have no idea. No idea. It's a shock when people, even women who are doing all the right things, will lose bone density because of the loss of estrogen. So that's what happens. So men and women do not age the same when it comes to bones. Now, what role we talked about estrogen does the other two hormones involved, coming from the ovaries, progesterone and testosterone, have any play in this? Yeah. Testosterone has a bigger role than progesterone. I mean, and the reality is these things need to be worked out. We don't know all the answers like how does progesterone affect it? How can we use the supplemental progesterone that some of us take at night? But because not enough research has been done, we know testosterone plays a big role in bone density in both men and women. But not as big as estrogen does. Estrogen does. What is sarcopenia? Yeah. So sarcopenia translated means a low muscle, a sarcomen muscle, pinae less, like osteopenia, sarcopenia. But it is not just about your total pounds of muscle. It is a functional definition. You want to be 45% muscle or more, actually. But it's functional, meaning can you sit to stand? How fast can you walk? Because the concept of sarcopenia has to do with function. Do we have enough muscle mass to function? Do we have enough strength in the muscle we have to get up off the floor or to walk fast enough to be safe? It's not running, but it's not the slow crawl we see some people do as they age. What is frozen shoulder? One of the most audible musculoskeletal symptoms of menopause has to do with our shoulders and it's not because suddenly your shoulder is bad for you. Estrogen walks away, we become highly inflamed everywhere. The shoulder is very susceptible. So the shoulder on the inside, you see it on the outside with skin and then muscle and then inside of that there's this layer called the capsule. The capsule will become so inflamed that overnight you wake up and your shoulder is killing you. And you didn't bump into the door, nothing happened. You're like, I don't know what happened. So like most women, you try to wait it out. You're like, I got this, I've suffered a little. And so women come to me in a relatively short amount of time and their arms will no longer move. They're excruciating and they can't get their arm up and they certainly can't hook their bra. I shared one of your videos on frozen shoulder years ago now and it was absolutely viral. The comments in the thousands and thousands of women. Oh my God, no one's ever said this. I've had this and one of the hallmarks I see is that women struggle to put their, you know, we always love to take our group photos. Oh right. Oh, can't put their arms around each other. They can't put their arms around. How would you know maybe if you had frozen shoulder? Like if someone is like sitting at home listening to this. Yeah. Are you in your perimenopausal years? Did your shoulder start hurting out of nowhere? Like you didn't hit it. No obvious injury. There was no obvious injury. Can you suddenly not reach behind your back or reach out to the side? Those are the two motions that go first and suddenly you can't put your bra on it from the back. You got to scoot it around in the front. Those are clues. This also happens in people with uncontrolled diabetes. So if you don't have diabetes, like where is this coming from? Here's the thing though. The medical term is called adhesive capsulitis. We orthopods have known about this for centuries. In fact, it's sometimes described in the conclusions of papers tends to happen in middle aged women with nobody then taking the next step to say, well, why? Why? What's a common. So bless their hearts. I have to say about my orthopedic peers whom I love. I do. But most of them, 94% of them were born without the benefit of ovaries. So they're never going to know what they don't experience. True. All they know is that women show up in midlife. Their shoulders don't work. And then it's going to take two years to defrost. Oh my gosh. Oh my gosh. Perimenopause is not early menopause. It is its own distinct biological phase. And it has been largely ignored. My new book, the new perimenopause is about the seven to 10 years before your period stop. A transition that is anything but gentle. Hormones fluctuate wildly. And for many women, this is when the anxiety, brain fog, sleep disruption, weight changes, mood shifts, joint pain, and that unsettling feeling of I don't feel like myself anymore begin long before anyone says the word menopause. Perimenopause often starts quietly. It shows up in the brain first, then the body, then everywhere else. And too often, women are told nothing is wrong. I wrote the new perimenopause because you deserve answers before things spiral. You deserve care before burnout. And you deserve a clear roadmap for a transition that medicine has ignored for far too long. The new perimenopause is now available for pre-order everywhere books are sold. Learn more and pre-order your copy at thepawslife.com. So you wrote a paper that changed my life called the The Musculoskeletal Syndrome of Menopause. And I was so excited for this because I, as you probably in medical school, got one hour of menopause. Oh, I don't even remember. Maybe. And then in my OBGYN residency, which was four years of 100 plus hour weeks, I had six scheduled lectures on menopause six hours in four years. And I was taught hot flashes, vasomotor symptoms. I was taught some vaginal dryness, atrophy. I was taught the bones would begin to deteriorate and sucks to be a woman for that. And there's not much we can do about it, you know, until she's diagnosed with osteoporosis, then we give her all these meds. I was never taught estrogen's effects, the loss of estrogen's effects on the musculoskeletal systems. For our listeners, walk us through what the musculoskeletal syndrome of menopause is. The musculoskeletal syndrome of menopause, which affects about 70 to 80% of all women. So think of all the women with hot flashes, equal numbers have one of these, right? Every musculoskeletal tissue, muscle, tendon, ligament, bone, cartilage, which is the smoother the nice lining of the end of the knee. Fat is a musculoskeletal tissue. We have stem cells. The disc center back, all of those, which our cousins have estrogen, alpha and beta receptors on them. So I always hold up my hand like a little basket because estrogen fits in there and then all the good things happen. Lack of estrogen in these tissues manifest as total body pain. It's called arthralgia. I think we throw every woman under the bus and call her fibromyalgia. When actually it's untreated arthralgia of the musculoskeletal syndrome of menopause. So total body pain. I had this. I'm an athlete. It was disabling. I mean, not so much that I couldn't work, but I had trouble getting out of bed. Number one, frozen shoulder, both due to inflammation. We have tendonitis. How about tennis elbow, golfers elbow, Achilles tendon, patellar tendon, all your tendons hurt for no reason. On the bottom of your foot it hurts. Your plantar fascia hurts. Women have a rapid increase of arthritis, which is loss of cartilage after 50. Before 50, men have more arthritis. After 50, women rapidly develop arthritis. I see this all the time in my clinic. It's because, again, estrogen, alpha and beta receptors are critical for maintaining cartilage. The cartilage is a matrix and without it, it just crumbles and we wear down our cartilage, which is irreplaceable. We get one set for a lifetime. All of these things happen for the same reason estrogen decline. You often talk about meeting women for the first time in the emergency room when they're shattered, broken, fractured as a orthopedic surgeon. Where should they have met you first? The youngest big fracture, life-changing fracture, not an ankle, not a wrist. The woman was 57. I write about her in my book and I met her in the emergency room. I had probably met her in the gym. We went to the same gym because she was doing everything she thought she could possibly do. She was looking at why her motivation was she was not going to age like her mother, who was frail and overweight. She was doing everything she thought Dr. Google would want her to do. She was lifting, but she was starving because she still believed that she could only be this big. If we're going to work that hard, we need to feed ourselves that hard. What you're referring to is when I meet women in the emergency room or on the floor because she has a hip fracture, it's the first time she's ever thought about her bones and she's forced to because fractures are excruciating. Finally, these bones that you think are silent are screaming so painful that you know in hospitals how the beds are kind of slick. People slide down to the end of the bed and they need to be pulled up in bed, but they won't let you touch them because it's too painful. There's so much pain. There's so much pain, but here's the reality and I've gotten not afraid to say these things out loud. You know that when I go to the bedside, she has been incontinent and she's usually laying there not because of bad nursing care, but because she's a constant incontinence because she's just lost her bladder control and we've done nothing about her pelvic floor or her prolapse bladder. Often when I'm trying to clear her for surgery, which we go through a certain procedure, do lab tests, she has a UTI. In fact, maybe she got dizzy and fell down because of her chronic UTIs, which we know is a thing. Then what happens now in the hospital is the medical doctor will come and clear her heart for surgery. It takes about 45 minutes to fix a hip, but the heart has to be healthy enough. But many women have not been treated with estrogen, only four or five percent, right? So they have microvascular heart disease that they may not even know about and it's difficult to clear their hearts. And then finally- Meaning clear their hearts for surgeries. Surgery to prime their hearts for surgery. They're not, they're going to survive the surgery. They're going to survive anesthesia. Thank you for clarifying that because it's a stress to undergo surgery and anesthesia. It's like running a race. You don't want somebody have a heart attack on the table. But the other thing, Mary Claire, is that either the stress of the incident or they've already got early Alzheimer's. They're not cogent. Their brains are not functioning the way they would want them to. So we've got all these things that frankly, my friend, we could have prevented had we gotten a hold of women when they were 35. So mama is 88. Yes. And she has never had a bone density scan in her life. And no one ever, ever, ever, ever talked to her about her bones. Her mother laid in a bed in continent with severe dementia and had broken, not a hip, but broke ribs, broke shoulder arm, you know, multiple falls. And spent probably the last good three to five years in a bed hallucinating in continent yelling out, you know, Not how she wanted to be. And my mother, no one ever talked to her about what mama could do to prevent that. Not even me. Now I tried to help her with vaginal estrogen. My mother's had struggles with incontinence since I was a child. And that is now has Alzheimer's is in a facilitated living facility. And on New Year's night, yes, fell looking for my father who passed away six years ago, hallucinated, thought she heard his voice fell shattered her hip. Got taken to the ER, passed clearance for heart, survived the surgery. Yes. It is eight months post-op and she is just now walking with a walker. She's been rolling around in a wheelchair, scooting herself around since that. And we finally got the right physical therapist in to really get her up and get her motivated. And no one is talking to these women, nobody about prevention, about this doesn't have to happen. She's exactly walking the path my grandmother did. And I am refusing, I know, for this, I'm changing the legacy for my daughters. Yes, you are. There is no way you'll let that happen. So, yeah, we're going to talk about how we're going to how, how, you know, what we can do about that. What part does inflammation play in all this? I'm so glad you asked that. Because it's not just one thing. It's not just menopause. It's not just calcium intake. The second chapter of the whole book is all about the science behind aging. Because I just don't want people to walk away thinking, just get on another exercise program or another diet that is so not what you and I are talking about. One of the things we talk about is this concept of inflamaging. It is chronic inflammatory processes in your body that never stop. Now, let's clarify. Inflammation is a normal bodily process when you twist your ankle and it gets hot and red and it swells up protective. Because your body is rushing to the scene. It is dumping growth factor. It is creating inflammatory cytokines to heal and to clean up the mess so that you can return to life. When we do not turn off our inflammatory processes, either because we're chronically stressed, which increases our cortisol levels, and increases all these inflammatory cytokines that we just normally produce, they never get taken care of, we enter a state of inflamaging, which is one of the motivators for all of our chronic disease. Whether it's your heart disease, whether it's your diabetes, whether it's your sarcopenia and your bone density. Because both bone and muscle are critically sensitive to inflammatory cytokines. When they are present all the time, they can increase loss of bone because they give osteoclasts, the bone eating cells, the advantage. So high inflammation, more loss of bone. The same for muscle mass. High levels of these inflammatory cytokines make us weaker, make us recover from muscle injury slower. Such that there are lots of studies that go way deep into the mechanisms of this. But we know that in some studies in women that when they measure these levels in the blood, they can correlate it to significant decreases in muscle mass and recovery. So this is not just theoretical. We know this happens. And so why do we become so inflamed? Because estrogen is a potent anti-inflammatory. I remember reading the data on blood inflammatory markers and some researchers, thank God, who were tracking them across the lifespan, specifically in women and seeing this dramatic uptick somewhere around 45 on average. And some other researchers said, hmm, I wonder if this is menopause. And they started looking at animal studies and then human studies and just how menopause itself, just from the loss of estrogen, changes in progesterone, becomes a pro-inflammatory state. I was floored by that. Exactly right. When women say, oh, I didn't have menopause. I didn't have night sweats, brain fog. I didn't feel bad. Or you know what, I just had it a little. Or I'm done with all that. Oh, I'm done. Well, okay. That just comes from the fact that we need to educate women continually to say that you may not feel it, but it's happening. It's happening. It is happening. Yeah, that loss of estrogen will follow you in every system for the rest of your life. That's right. Okay, talk to me about vitamin D and calcium. We hear a lot about that on social media and this one of the things that was taught in residency. So, you know, we talk a lot about those things in terms of building bone density, but we forget that vitamin D is critical for brain health and immune function and gut absorption. Calcium supplements, correct me if I'm wrong, have never been shown to decrease the risk of osteoporotic fracture. We need it from our food. It's not hard to accumulate 1800 milligrams, definitely not hard for 1200. Because a cup of yogurt has about 300 milligrams of calcium, salmon with bones in it, sardines, but, you know, who wants to eat those? But prunes and bok choy, there's just so many choices that I'd rather people try to get it from their food. The way I counsel my patients is these foods that are rich in calcium are also rich in so many other things that are wonderful for you. Great health. So, it's always better from food. So, earlier we talked about that one in two women after the age of 50 can expect to have an osteoporotic fracture. And, you know, that's our reality. However, in my clinic, I am recommending dexascan. So, let's go get your bone density checked. Often insurance won't pay for it until the age of 65 or if she has some severe risk factor. But even in that setting, I feel like that is too late. When my patients are diagnosed with low bone density, they are devastated. They cannot believe it. How do you counsel those patients in your clinic? They feel disappointed, ashamed, frightened. And then we don't just leave the conversation there. I think a dexascan number alone is useless unless you give a patient or a woman a plan. And so, we go through all the things we know that will help build better bone. And we know that we can stabilize or build better bone. What are those things? Every woman is a sentient being and gets to make her hormone decision. But I insist that she makes it based on facts, not fear. And so, every day I recommend, well, I recommend your book. So, I say if you want all the world's data on the safety of your hormones, you're going to read estrogen matters. If you want to know what's about to happen to you, you read the new menopause. If you know how good sex can be at this age, you read you are not broken. And then, of course, I recommend it. Now, here's your plan, unbreakable. But as I explain to them, I say you must make your hormone decision because, and then I explain the role of estrogen on bone. It's going to be harder to get in front of this if we don't. But if you don't want to, well, what else are we going to do? We are going to learn to lift heavy weights. We are going to put down the Mambi Pambi five-pound weights that we lift 30 times to failure. And we are going to take the six or nine months to work up to lifting the hex bar that you lift when you deadlift, right? To lift heavy because it is that which is going to exert the most pulling force against your bone. We are going to jump around like a crazy person. I want people to jump 20 jumps a day, not just straight up and down, not landing lightly. I want you to thud on the floor because we need to generate four times body weight. You can do that. Walking generates about 1.2 times body weight, running two to three times. But we want a thud on the floor and that takes jumping from a height of about eight inches. If you cannot do that because your knees hurt too much, well, NASA uses rebounders or little trampolines. We can't use it as an excuse. We just have to do the best we can because lifting, jumping, plus or minus estrogen, plus nutrition, high in protein can help you stabilize and rebuild bone. And so of those things, the best data is from estrogen and lifting. Women always ask me, especially online, but either I'm afraid or I have osteoporosis. I can't lift. I see a lot. Anytime I post about lifting exercises, the comments are always full with, but what if, but what if I have osteoporosis already? Am I going to fracture? I have a herniated disc. I have arthritis. A lot of women are already dealing with conditions that are going to make these things harder. But you know the irony is. So, so Dr. Beck, who's from New Zealand, I believe, did a big study called the lift more and under supervision. We must be taught to lift heavy. We don't want to get hurt in her protocol. You're lifting the failure in five reps times five sets. That is heavy and nobody broke and everybody billed. No injuries. No injuries. And so yes, it can be done. And they all had osteoporosis. That's entry to the study was osteoporosis. What the irony about what you just said is people think that they can't lift because they have arthritis or they can't jump because they have arthritis. When I get someone coming to me for arthritis, I don't start with the medical interventions. I start with we're going to make you strong as a bull because your butt, core and hip strength will act as shock absorbers against the impact of your weight on your knees because regular activity is seven to nine times body weight on your joints. So if we don't want them to pound together, we have to build better muscle, right? People are so shocked when I say that we're going to make you strong first before we start doing all the medical stuff. But that's an approach that maybe they haven't heard at their standard doctors because you're right. We silo things, but the reality is if we want to treat the whole person, that person needs to be strong. Can you talk about some of the pharmaceuticals that have been developed to treat osteoporosis and when would you begin those? So there's several categories. The most common one that people are familiar with are the bisphosphonates, FOSMA max. And then now there's a new category of monoclonal antibodies that work on there's a receptor on the osteoclasts that it blocks. Those medications are offered to women when they have the diagnosis of osteoporosis, which is a T score of minus 2.5. But do you know nearly to a woman that I see, they've all said to me, I have osteoporosis. My doctor wanted to put me on a bisphosphonate to rescue my bones and I don't want it because of the side effects. Well, that's understandable because some of them are very terrifying sounding. But here's the reality, Mary Claire. We were talking about the women I treat and your own mama. If you get a hip fracture, 70% of all hip fractures are in women, 30% of the time you die in the first year. From that moment. Even after surgery. Even after surgery. From the complications, whether it's a UTI, sedentary living, bed sores, dementia, not being mobile, you lose 9% of your muscle mass laying in bed for a week or more. These things add up in already frail people, right? 30% you hit the floor. Those people who survive, 50% will never get to go back home because they can't get around, right? To live independently, you must be able to get up and down from a chair and do ADLs. This is why we care about fracture. Absolutely. No one would care unless the devastating outcomes of it. So what most women don't realize is most women are not offered any screening for osteoporosis currently. Currently. They just kind of get skipped and most people are diagnosed with their osteoporosis at the time of fracture. You can buy a DEXA scan without a prescription. You can Google DEXA scan near me. If you don't want a DEXA scan, there's a new technology using ultrasound called a REM scanner, right? It's not as common in the United States as it is in the UK or Australia, but it's coming. And it uses ultrasound, not even X-rays, to tell you bone quality. Because whether or not you fracture has more to do with the quality of your bone than how much mineral you have in it. Because what people don't know about bones either is that every time you take a step, if this is your femur, your leg bone, your thigh bone, it bends a little. It bends a little. And your body knowing that, perceiving that will build the strongest bone where you have the most bending. So the ultrasound type predictor will tell you the quality of your bone. But either one of these things, listen, can be purchased. So if you've got a clinician who just won't do it, then you can buy it yourself by saving up your Starbucks money. So do it just because we both told you to do it. But if that's not enough for you, think about these things. Is your mother shrinking? My mother has shrunk so much. She used to be my height. And now she's about down here, right? I can look over her head. Why are they shrinking? Because the vertebral bodies in our spine, our spinal cord is surrounded by an armor of bone. And they are like blocks, literally blocks. They sit one on top of each other. And as we lose bone, they collapse and shrink. So we lose height. So is your mother shrinking? Are you shrinking? Did you smoke when you were young because it was so cool? Smoking in nicotine is bone poison. Or did you have an illness when you were little like asthma, where you had to take a lot of steroids chronically? Or do you have an autoimmune disease? All of these things, and many more, frankly, are risk factors for osteoporosis. Or how about this, Mary Claire? What if you're like me? You're a young athlete and you never had periods. Or maybe you had periods, but you were an athlete and never fed yourself. So all of these things could make you at risk for osteoporosis. And if you're identifying with any of these things, go get yourself a scan. So when should women begin to think about being proactive or just begin to be proactive about protecting their bones? How about during our fertility periods? I start talking about this, and I have to be very careful with where I phrase this, but to build a baby, you're going to use at least 500 milligrams of calcium from your bones every single day. So, I mean, we're building a baby from ourselves, right? So either we're eating enough or we're taking it from ourselves. So there is a real entity called osteoporosis of pregnancy. Now, here's the good news. Our bodies are built to renew that. But only if you eat post pregnancy, many women are so focused on getting back in their genes that they don't eat. Or I may have used my breastfeeding period of life to get back to my original weight because I'm thinking, oh, I'm going to lose weight by doing this. Yeah, 500 calories a day out the breast. Yes, that was such bad thinking. Yeah. I didn't know at that point. Let's say you're breastfeeding. That requires about 500 milligrams of calcium, which we're going to take from our bones. And you hear me, audience, when I say, it's not that I'm anti-breastfeeding. I breastfed for as long as my daughter would let me, right? Over a year. But unless you know that you're going to lose your bone, you can end up osteopenic or osteoporotic just from something so natural. So mothers and lactating mothers need to be really conscientious about getting enough of great nutrition to rebuild. Historically, women would have baby after baby after baby. And now what I see millennial women doing is because they're waiting a long time to have children. They're getting their babies done because before they become midlife, right? And then maybe you don't have enough time to rebuild. So it worries me that teenagers aren't building enough bone. It worries me that young mothers don't know that they need to rebuild their bones. And then if they're like me, they go straight from postpartum to perimenopause. Because they not get a chance because we build up 20% in perimenopause. So yeah, they never have that chance to rebuild. To get back. So conventional wisdom, conventional medical advice that my mother and likely my grandmother got was to always fight to be in a smaller body. What is this constant workout? Cardio, eat less, cardio, eat less. Because if you're this size, then you're healthy. How much of this epidemic, and I believe that we are living in an epidemic of frailty, sarcophenia and osteoporosis for our women in that last decade. How much of can we lay at the feet of we've been telling women the wrong thing? I think we need to redefine what healthy is. Because my mom knew. Little, little, skinny. To this day, with her dementia, I walk in the room and she comments on my size. Does she? You're looking nice and thin today, honey. Thanks, mom. Well, you know what? That is what she was taught. I cannot get my 86-year-old father to only compliment how I look. In fact, I got a little nasty with him. Bless his heart. It's just as I said, Daddy, I am smart. But that is the generation they grew up in. So here's what I see happening. Tell me if you think so. Our really elderly, your parent, your mother, my parents, and the baby boomers. I don't know if we'll ever get it through their head that it's okay to take up space. The X-er is like us. We were raised like that. I was raised like that. Where it's an aesthetic. I mean, you got to ask yourself, were we taught that really because skinny is healthy? Or were we taught that because in the world we were raised, there's an aesthetic of attractiveness that has to do with your size. But I am very hopeful that the millennials, or definitely the generation of my 17-year-old, or your daughter's older than my 17-year-old, will value their strength versus their thinness. So when I think about my exercise patterns throughout my life, when I was younger, my daughter's age, I moved my body to be thin. So I did it for aesthetics purely. And I thought that was healthy. And then when my 30s and 40s, I moved my body for performance. I got into racing, marathons, triathlons with my girlfriends. It really was a social thing to do. And we were healthy. And we look good. Now, this morning, I'm in the gym, and I am moving my body for longevity. What is your vision of that? What is moving your body for longevity mean? When I think of longevity, when we talk about women's longevity, all of us that are working together towards this are trying to reframe the narrative. For men, longevity, living longer is longevity and glorified in every press. Women win when we just talk about longevity. We win. We win. We've been living six years longer anyway. But we suffer longer because we've spent our life on anti-aging. The superficial, and it's not the inside out anti-aging. It's the superficial, do we look young enough? Are we little enough? Right? So we're reframing that to women living longer. Well, how do you want to live longer? I talk about in Unbreakable, what it means to me is I want to do what I want, when I want it, how I want it. I want to only ask for help if I want to ask for help, not because I can't help myself. So if you want to be independent, if you want to have the kind of relationships that fill your soul, and you're older, it takes daily work now on all the kinds of things. You went to the gym at five o'clock this morning. Nutrition is a huge part of your practice in your life, right? There's the daily investment of your help. That's the only way to get there. Because what happens if we just leave time to itself? Well, we don't answer the time bombs of aging. We don't build the kinds of shields that you're building from a lifestyle. And we're going to become frail. I don't want to burden my children. They will step up. I know my girls. If I need help, they're going to come in and do it, or find a really nice nursing home for me, if they can't take care of me. But God, I don't want to do that to them. You don't want to. I want to die like my grandfather. He drove a truck the day he died. Oh, my gosh. He drove a truck, went out about his business in his 90s. He probably should not have been driving, by the way. But he lived out in the country on a farm. They all do it. God Home had a massive heart attack and it was over. Me too. I want to die like Queen Elizabeth, who on Tuesday met the Prime Minister of Great Britain, and on Thursday just didn't wake up. That's what I mean if I get to choose. What about the difference between lifespan and health span? And I think, you know, all this talk about anti-aging longevity and all the wellness bros saying they want to live to 120. I do not want to live to 120. What if it means I'm not going to have my loved ones? You know, if they die before me, I am not interested in that. I don't have a single patient who tells me I want to live forever. They all say, well, fix my half-lashes, give me my life back. Okay, now then we sit down and say, let's talk about your mom. Let's talk about your grandmother, the women in your family, how they age, what are we looking at in the next 30 years? If you're lucky enough, if you run the cancer gauntlet, and you know, we're going to decrease that risk too with all of the exact same changes, you know. And they're like, I don't want to be a burden. Women say that to me in my office. And then I'm like, great, because here's the plan we're going to start. And we start building a blueprint together. And one of two things happens, either they are all for it and they're like, tell me how to do this. Set me up with a trainer. Like they are all action, or this is what happens. Okay, well, I can't give up my sugar. Okay, and so there becomes an excuse for everything. And to which I say two things. Number one, you can't out excuse me because I've been doing this 30 years. I've been an answer for every excuse. And they kind of chuckle when I say that. But number two, if you don't want to burden your children, then you better get active right now, because that's what's going to happen. Either they're going to have to make a hard financial decision about who's paying for the nursing home, which can cost $7,000, $15,000 a month. Yeah, and eat up your life savings, or you're going to move in with somebody like my parents do, which we made that choice, right? Right. So it's one of those two things. So either stop making excuses, take the action you need, or just know you're going to burden somebody. When do you order a dexa? Or when do you order a min? I order a dexa on everybody. Same. I think just like we get our mammograms at 40, I think we should have our screening test by 40. You should have a baseline. Let's just figure it out, whether it's REMS, whether it's dexa, just find one. In fact, we should probably do it at 35 when we have a little bit of estrogen still circulating. See what your baseline is. And if you're already low, then you really got to get after it, because you're still probably producing some estrogen. Do you have another way to measure body composition? Do you have one of the impedance scales in your office? Yeah, well, we have in-bodies in our facility. I like those. I mean, I think, do you know the date? I don't know how accurate they are. I mean, they're close enough. They're close enough. Because we're actually looking for trends. More than absolute numbers. So for our listeners, when we talk about body composition, we're talking about not just their bone density, like we would get on a dexa. But these scales in our office do not give us bone density. But what they do give us is they can tell us how much muscle, where the muscle is. So I can look at muscle mass, especially for my GLP-1 patients. I want to know their baseline and where we're heading throughout their treatment. It also tells us where the fat is, what type of fat. Is it visceral fat, which is around our organs, or is it subcutaneous fat, which actually is not that harmful. No. So, yeah. Curves are good. Curves are healthy. Curves in a premenopausal women, meaning subcutaneous fat out of her skin, especially in the hips and thighs, is actually protective for your bones and cardiovascular disease. Because you have to carry around a little bit heavier body than someone like me who wasn't blessed with wonderful curves. Yes. There's benefits of all body types. Why is insurance company, and I think it's gatekeeping a little bit, is the decision to not have bone density, and this is based on, you know, it's not an insurance company making an independent, it's not going to be a military firm, it's going to be a military firm, it's going to be a military firm, it's going to be military firm, it's going to be military firm, it's going to be military firm, it's going to be military firm, it's going to be military firm, Probably that's what the thinking was. We're gonna treat osteoporosis with drugs. And is their T score likely to be low enough? Well, it's actually bad thinking, 65, right? Or in Australia, 70, interestingly. Okay, if you're in a disease care model, okay, I can see why you did that. Although I know that 30 year olds are osteoporotic, 40 year olds. But if you're in a preventive care model, like we are for breast cancer, you're gonna do it much earlier because we know interventions, the longer you're preventing, the less likely, meaning the endocrine society data show that you need to be on estrogen optimization for 10 years to have the biggest effect on fracture risk. Not started at 65 when you have a bad dexa scan, but it's better if you start earlier to give your bones all that runway. So that's why I think is we're working in a disease care model. Let's got osteoporosis, well, we've got a drug for that. Let's give you the drug. We wouldn't give you the drug if you didn't have the diagnosis. So why check? And estrogen is FDA approved and most women don't know this. Most doctors don't know this. Or the prevention. Prevention of osteoporosis. That's right. Yes, it is. It's the only drug approved for the prevention of osteoporosis is. That's right. And the other reason I think women don't get them is it's not thought about in most medical circles, right? In OBGYN, it is in our guidelines to discuss osteoporosis and to recommend, like it was one of our little check boxes. So I can say in mine, but most women stop coming to me when they're done having babies. You know, when I was doing traditional general OBGYN gynepractice, they were like, I'm done having kids. I'm just gonna go to my internist or my family medicine doctor. And I think we as a medical specialty or you know, all of medicine is really dropping the ball, especially for prevention in women. Well, the whole medical system is a disease care model. There's never the whole person care. Let's pivot. I love that you're trained in orthopedic surgery because you were trained to treat both men and women. Yes, I do. I don't have that privilege. I still do. So I only, the only penis I saw were baby boys at birth and I did a few circumcisions and then gave up on that practice. And then my husband's is the only one I have to tend to now. When I talk to orthopedic surgeons, especially females, when I talk to our female urology friends, people who came up through the system and treat both genders, it's shocking to them when they get out into practice and they realize the bias against women that is built into the system. So in my education, we had a term called WWWWWW which was whining women or whining white women. And I talk about it in the book and I always give lectures on it. Basically a woman in her 40s would come in with multiple vague complaints and we couldn't figure out what it was. Turns out it was probably perimenopause, some multi-system effect that she was having that we couldn't figure out. And the urologists, our friends, Dr. Kasperson and Dr. Rubin would said, hey, wait a minute, these patients are coming in with the same complaints, sexual dysfunction, things hurt or aren't working down there. And the men, you just go all in, you rush in to fix the problem and you give them the medication. And the women were getting pats on the head and coconut oil and just said, you got this babe, do you see the same thing? Yes, because, and I may have historically been guilty of it, because when a man comes in in midlife, dragging around and multiple tendon issues, like everything hurts, multiple tendons or rupturing tendons, I test his testosterone and then I send him off to get some testosterone. Even because in men, the physiology is different, but obviously, I'm encouraging my millennial sons to get their testosterone checked in their youth, they're in their mid-30s, because that's how we know what to correct back to, because even if a guy in midlife, rupturing all his tendons feels terrible, moping around, moody as heck, has a testosterone that is between 250 and 1,000 something, which is normal. If he used to be 800 in his youth and he's now 300, that's a big delta, but we're sending that guy off to get some testosterone, because God forbid, we let anybody feel like that. But when women come in and have multiple things going on, they're accused, it's all in their head. They get a psychiatric referral. Or maybe they're labeled with fibromyalgia. And I don't believe that everybody I say that comes in and wears that diagnosis has something like that. I think it's untreated, perimenopause, that affects the musculoskeletal system. So now there is parody in my clinic, but when I have queried my Instagram following, what have orthopedic surgeons said to you? What have they said? And it is appalling. It is appalling the blaming, the dismissive, the you're just getting old, there's nothing wrong with you, it's in your head, if you talk to your whoever about it. The musculoskeletal system is at least eight to 10, depending how granular you wanna get, whole organ systems, muscle, tendon, ligament, how can we just ignore that, right? So I'm this much encouraged, this much. You can even see the space here, because I can't attract the attention of my own peers, to publish these things in our own literature, to do grand rounds at our departments, except I have to shout out Mount Sinai, which is led by a woman, we did this two years ago. The International Cartilage Research Society just called me to say, I think we're missing something. We need these researchers to learn about perimenopause. So we're sneaking in a talk to their whole assembly. It is a slow drip. That needs to be a roaring conversation. Right, you and I both, and I'm back on as adjunct faculty, come from this academic world, and it's really, that's where the magic happens. That's where the guidelines happen. The guidelines are what insurance decides what they will and won't pay for. That's who gets screened for certain things. And I just want all the listeners to understand, from new research to a guideline changing, on average right now is 17 years. Oh my God, that is a generation of people. 17 years, on average. Now that, one of the beautiful things about the internet, good and bad, is that now regular people, smart people, women who can make decisions for themselves actually have access to some of the medical journal articles, and they're coming in asking better questions. But we have this whole force of wonderful physicians who do care, who just weren't trained. Of course. And so where do you see, what is a stopgap for this gen, these Gen Xers are not taking it. They're not having it. My Gen X patients are like, absolutely not, I'm not gonna live like this, fix me. But I can't, you can't be the doctor for everyone, I can't be the doctor for everyone. Where can they go now? Where can someone find better help? Yes, so I require women to be responsible for themselves. So they must become educated. So that's why I recommend the Bevy of Books that I discussed with you. You must get the information for yourself. Number one, number two, you can go the regular path, you can go to your primary care of your OB and have this educated discussion. And if they're not caught up with you, if they blow you off, it is okay to keep them as your disease care person. But you must not stop there. So many women who write to me, they're like, my doctor said no, so I just stopped. That's not the answer, seek out somebody who knows. So where do you find that person? Well, you're right, I can only see so many patients, you can only, there are many telehealth companies now that are staffed by legitimate clinicians who can expand the database. But in order to get in front of this, it has to start being taught in medical schools. Now for a MIDI pause sponsored by MIDI Health. If you're in midlife and feeling bloated, sluggish, or frustrated that the same diet you've always followed suddenly isn't working, you're not imagining it. As estrogen levels drop, we lose some of estrogen's protective effect on metabolism, heart health, and gut function. This shift can mean slower digestion, rising cholesterol, more insulin resistance, and potentially more belly fat. This is where getting enough fiber becomes critical. I recommend women get 25 to 30 grams of fiber per day, and it doesn't have to be complicated. Simply add a tablespoon or two of chia, flax, or hemp to your meals. Include lentils, beans, berries, avocados, whole grains, and other fruits and vegetables into your daily menu. If you fall short, don't worry, supplement the gap with a high-quality fiber supplement. Remember, this isn't about dieting. It's about supporting your body's changing needs. Menopause is a biological transition, not a decline. When we understand how nutrition supports it, we can all thrive. So if you could design midlife care for women, what would that look like? Well, what it will look like is, from the minute you, either if you decide to have children, or the minute you are done having children, you would automatically go into a holistic program, a whole woman preventive care model that includes education, that includes annual labs, that includes exercise teaching. So I think the takeaway here is, we have to take our prevention into our own hands. We're responsible. Yeah. You can't count on the medical system. Nor should you. To be really an active partner in your prevention of disease. Right, prevention is on us. How much protein do you shoot for in a day? Me, I shoot for 130, because that's a good weight for me. I'm short, but I'm really muscle-y, so that's what I need to take in a day. And it's not got much volume of food when you consider that a cup of Greek yogurt is 25 to 30. Your morning shake has 55 grams of protein, for God's sake, right, and you drink it. You try to talk it out as much. You do. So people think you have to eat this tremendous volume of food. You don't actually to get in that much. And I find when you're focusing on protein, when you're eating that much, the other stuff tends to just fall to the side. I mean, I'm eating complex carbohydrates. I'm eating plenty of healthy fats. And I'm really focusing on protein and fiber are my top two goals. And I hear, my daughter loves to make TikToks about meals she makes. And she's like, here's my high protein, high fiber. I'm like, poor baby. I love that you did the right thing. You did the right thing. But, and I know you focus on fiber, and I love to help people understand that I am not anti-carb. I am anti-simple carbon sugar, because fiber often comes as carbs. Is carbs, right? Things rich in fiber are carbs. Rich in fiber are carbs. Complex carbohydrates. Yes, that's right. So I'm not anti-carb. It's not a war against carbs. It's just who you let in. And it has to be high fiber. Have to be picky. What does a adequate workout program look like? How many days in the gym? How long should you be in the gym? So it's not about time. It's about time under tension, which means how many reps you're doing and how many sets you're doing. So no matter what kind of lifting you're doing, you need to lift a failure, meaning by the end of the set, you can't lift it anymore. So if you wanna lift for endurance, you're gonna lift a little tiny weight 30 times. That does not interest me in old age. If you wanna build big muscles like bodybuilders, then you're gonna lift medium reps for women. That's like 10 to 15 for four sets or so. And that's what's gonna stimulate enough damage that you're gonna build muscle. But in midlife and beyond, I teach people to lift for strength and power. Strength so that we can do what we wanna do when we wanna do it. And power, meaning lifting over time so that we don't fall down, that we can move quick enough to not have a fatal fall. So strength and power take a different kind of lifting. Lifting for strength is lower reps, higher weights. I've been treating people for 30 years. I know people want very specific instructions. So my last lifting program, which is the one I published was four reps, four sets. And that's all in the book. It's all in there. So what that means is when I'm doing a bench press, I can do four reps. I may be able to squeeze out five, but I'm not doing six without the bar coming down because I'm lifting to failure. And then I'm gonna recover for two or three minutes before my next set. But this type of lifting will build our strength. And then once we're really good at it, and it might take us six months, nine months a year, then we can add speed, meaning it'll take us three seconds to go down in a squat, and then we spring up in one second. That speed work helps us build the power we need to age without falling down. And so it sounds complex. It's not really once you learn, this is a great time to hire a trainer for a short period of time. Don't get another purse, get a trainer. So I say in the holidays, but to get great benefit, you can do it as little as twice a week. I'd rather you do it four times a week, and it doesn't take that long. You can pound out a complex set in about a half an hour. I've seen you talk about certain tests, certain milestones that women should meet. And the Jim Bros love to talk about this. I posted a video of myself doing pushups. You sure did. When you talked about a woman should be able to do 11 pushups. And I got, it went viral, not because I was doing 11 pushups because every personal trainer in America jumped in about my form, which needed some work. But okay, so we've got the 11 pushup test. Don't worry about it. Yes. What else is there? I wanna clarify why we even do things like that. Because the response I got, whether it was the pushups challenge, or the sit to stand tat challenge, meaning can you get up and down off the ground without using your hands, your knees, or there's a pistol squad, anything, anything. The point is not, or I'll say it another way, 90 more than 90% of the time, women responded like you do, they're like, can I do this? I'm gonna try to do this. I'm gonna get better at this. Let's challenge ourselves. Let's be positive about the future. There were a small percentage of women and Jim Brose who came on and said things like, why are you shaming women? Why are you isolating and excluding people? To which I say, why do you expect so little from women? Why do you think that we can't do hard things? Because we birthed the babies in this world, right? We do hard things already. We figure it out. So when I do those kinds of challenges, it's aspirational because there is a line called the frailty line where your VO2 max, your fitness is so low, you can't get up from a chair by yourself. That is the day you have to be moved into assisted living, whether it's with your kid or in a home, because you can't get up from a chair yourself. Nobody wants to pass that line. And we can build that. So that's the purpose of all these tests, whether it's push-ups, which tells you what your upper body strength is, what your core is, whether it's grip strength, it's testing your grip strength online, which we have all done, is not about how strong your hand is in squeezing a tennis ball. It is a measure of your total body strength, such that if you have a decrease in five kilograms of grip strength, it infers an increase in all-cause mortality of 16%. It's big. It's not about squeezing a tennis ball. It's about your total body strength. That's what those are for. Well, I've loved having you on today. Thank you so much. I have a few questions I kind of ask everyone. What is the best part of this stage of your life right now? I may have come to this late in my life, but this is the most authentic I've ever been. People are surprised when they meet me. They're like, oh, you're just the same as you are online. I'm like, there's only one me. The most authentic, the most confident, because I think that we learn from the memory of our successes, and I have figured out a lot of stuff in my life, and I know I can figure anything out. I've said this to you before, because I am in a male field, I have more professional support now, and I don't even know the right word to say, camaraderie, collegiate, whatever. Then I have ever had, and from that, I mean, it's you, it's the extended group of people that we've done to. It's the menopause. It's the five of us that talk every day. That enables me to go further, faster, harder, and I've never had that before. Wonderful. What are your non-negotiables? Like, how do you take care of you? What does Vonda do? We have a thing in the menopause, is what would Vonda do? Oh my gosh, you got it. Because she's our touchstone. The lifestyle person. None of us want to end up in a nursing home, so you are my nursing home prevention program. Oh my gosh. Well, if that's the truth, then you're going to be in bed at the same time every night, and you're going to get up at the same time every day when you can, because you are not going to compromise on your sleep, which is completely restorative, and that includes anything that might muck it up. Alcohol. Alcohol. Drown hat. Being too late, stress at night. I am not compromising on that. Number one. Number two, at this point, eating the way I eat is just the way I eat. It's not a burden, it's not a diet, it's a lifestyle. With the protein, with the fiber, with the knowing what I'm eating, it doesn't mean that I don't occasionally have sugar, but it's not how I used to live, which was always having sugar, right? Non-negotiable. And then it's lifting weights, whether, you know, when I'm traveling, it's very hard, so sometimes it's just push-ups in the hotel room or anything I can sit in. You know what I like people to remember as we've just laid out a bunch of things to do, right? Do this, do that, and it can be overwhelming, but we have to return to what do we value, and why do we even want to do this? But the number one reason has to be because you believe that you are worth it. You believe that you are worth the daily investment of your health, not because your children need you, not because something else you, as a person, have value and worth, and you are worth the work. What I'm finding in menopause, and with my patients, with myself, with my girlfriends, is that they are, something about menopause kind of crystallizes that acknowledgement, that if I don't do this, no one's coming to save me. There's no hero. You have to be the hero of your own story. You have to be the CEO of your own healthcare. Thank you so much for joining me. I've told you this before, but you've changed my life. You've changed my patients' lives. You've changed the way I practice medicine, and I could not be more grateful for you joining us today on Unpaused, and for your support through all of this. It's my privilege. As a reminder to our audience, her book Unbreakable is available now, and listeners can also check out her podcast, Hot for Your Health, wherever they get their podcast, and follow her on Instagram, at Dr. Vanda Wright. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire, and get the honest, accurate information on health, fitness, and navigating midlife at thepauselife.com. If you're loving this podcast, be sure to click follow on your favorite podcast app, so you never miss an episode. Unpaused is presented by Odyssey in collaboration with Pod People. I'm your host, Dr. Mary Claire Haver, and be sure to share the show with the women you love. We would be so grateful. You can also find full episodes on YouTube at Dr. Mary Claire. The views and opinions expressed on Unpaused are those of the talent and the guests alone, and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment.