Menopause Masterclass: HRT Safety, Patch Absorption, Progesterone Intolerance, and Bone Density

I'm Dr. Mary Claire Haver, a board-certified obstetrician and gynecologist and certified menopause practitioner. I'm 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. The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis or treatment. If your skin or your nervous system feels a little overwhelmed lately, this may be your sign to simplify. Primarily pure blue tansy products are designed to calm stressed skin using real, biocompatible ingredients that work with your body, not against it. 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Hi, I'm Dr. Mary Claire Haver and welcome to our second Ask Me Anything episode. I love, love, love, love doing these because you guys have so many great questions and it makes me realize where the knowledge gaps are and where we need to fill them. So I've got the questions here on my phone and we're just going to jump right in. Dr. Haver, are you a real doctor? Great question. You should always question the credentials of people claiming to be medical professionals. So all of this is verifiable online and through our website, but I am an MD. I went to Louisiana State University Medical Center for my medical doctorate and then did my residency at the University of Texas Medical Branch and I graduated from all of that in 2002 and I am licensed to practice medicine. So we have to pass a national examination and then be licensed in the states where we practice. So I have licensed to practice in Texas where I live and in also in Colorado where I have a condominium so that when I'm there in the summers I can do telemedicine if needed. Can I stay on hormone replacement therapy, menopause hormone therapy if I have high risk of breast cancer, ALH fibroid or a history of polyps. These are really, really good questions. So a history of breast cancer or high risk may not mean that you've had breast cancer, but simply having a family history of breast cancer does not at all disqualify you from receiving hormone therapy. As a matter of fact, in the Women's Health Initiative, we found that women who were on estrogen, the estrogen only arm had a 30% relative risk decrease of developing breast cancer after taking that form of hormone therapy. So please don't feel like because you have a family history of any type that you may be disqualified. Now, if you are a pre-vibrant and have some very strong genetic component and it has been advised for you to have organs removed like your ovaries in order to decrease your risk of developing cancer, that is a much more nuanced conversation. For those of you who are genetic carriers of high risk, you really need to talk to, and especially if you're young and they're talking about removing your ability to produce estrogen before the natural age of menopause, these are very clear conversations and very nuanced that you need to have with your clinician. But the answer is not, not, not automatically no. Now there are anatomic things that could be going on in the body such as endometriosis, such as adenomyosis, such as polyps or even fibroids that again, nuance is required. It is not an automatic no for a patient with endometriosis, regardless of how you've been treated. So say you've had extrovertive surgery, meaning you've had hysterectomy and, you know, everything they could see removed. There is a chance if you were given estrogen only that you may have recurrence of your endometriosis, we're learning more about this now. However, these patients respond very well to make sure even after hysterectomy, you want to couple those patients with a progestogen to counteract the potential activity of estrogen on those endometriosis implants. Again, you need a specialist who knows what they're doing. This is not a cookie cutter, one size all. Information polyps, you just need to have them removed. Just a history of polyps does not at all decrease your ability to enjoy the benefits of hormone therapy. Does it mean you're going to get polyps again? Maybe. Even if you didn't take hormone therapy, you could develop polyps again. So it just requires close watching and treating the polyps appropriately if they do come back. Okay. Next question. When is hormone replacement therapy contraindicated? Good question. And what are safe alternatives? Okay. Let me be clear. There is no alternative to hormone replacement therapy. Let me be very clear. There is no alternative to estrogen progesterone and testosterone. What we have are things to treat other symptoms, but the only thing that replaces the loss of your ability to produce these hormones is giving you back the hormones. Okay. Now, what are the contraindications? You are patients who absolutely should not take estrogen or could not entertain the thought of hormone replacement therapy. Number one, if you have a tumor that is dangerous, that is currently being fed by such hormones. So for example, if you have endometrial cancer, if you have active ovarian cancer, if you have active breast cancer, this is not the time to start hormone therapy. If you are pregnant, this is not the time to start hormone therapy. If you have undiagnosed vaginal bleeding, meaning you're having something abnormal for you, post-menopausal bleeding, meaning you've gone a year without a period and now you're bleeding, that is an automatic referral to gynecology for evaluation. Don't start hormone therapy until that's evaluated. It doesn't mean you can't ever have it, but we need to figure out why you are bleeding. So anything that's unusual about your bleeding should be evaluated to make sure there's not an endometrial cancer, a tumor or something we need to treat before we start hormone therapy. In very rare cases of severe liver disease, I'm not talking about mild fatty liver with mildly elevated liver function tests. I'm talking severe liver disease that needs to be evaluated. We have to monitor your use of hormone therapy very, very closely because that is where estrogen is metabolizing. Because you can't metabolize it very well, have a buildup and get really high estrogen levels. It's not a never, it's not a no, but it does take someone who knows what they are doing and how to treat this. Also, if you have a very recent blood clot, if you're currently being treated for a history of blood clots pulmonary embolus, you don't want to be on any form of oral estrogen. Oral estrogen hits the liver first and increases our clotting factors. If you're high risk for developing blood clots, you want to avoid all oral, oral, oral, only oral forms of estrogen. But guess what? We have other forms of estrogen that will not increase your clotting risk, such as trans dermal, such as the gels, the creams and especially vaginal cream. Remember, vaginal estrogen is locally acting. It does not get systemically absorbed. It only acts in the vagina, treating those immediate tissues right there. There's not enough that gets absorbed into the bloodstream that can put you in any kind of a danger with increasing your clotting risk. So if you've been told you can't have hormone therapy because you have a history of migraines, because you have a history of blood clots, because you have a history of MTAs, your FAR, any other chromophilia, high risk clotting condition, does not mean at all that you cannot have HRT. This means you have to be careful about the delivery system that is chosen for you. How long is it safe or beneficial to stay on hormones after 60? Okay. There's a different conversation between, do I start hormone therapy after 60 or do I continue hormone therapy I'm happy with after 60? So let's talk about the second one first. Let's back it up. So if you are enjoying hormone therapy and you don't have a contraindication, you haven't developed a contraindication and you are happy with your treatment, you feel better, your bone density is kicking, you're getting up and living your best life, you feel amazing on it, you're not having hot flashes or any symptoms, your bones, your joints, everything's great, your mental health, guess what? There is no age at which you must stop. There is a window of opportunity for cardiovascular disease prevention. This was very clear in the Women's Health Initiative data and had a woman start hormone therapy before she develops heart disease. So probably within the first 10 years of her menopause or before the age of 60, she will likely have cardiovascular benefit which will slow menopause's effects on our cardiovascular risk such as insulin resistance, blood pressure and atherosclerotic plaque production and cholesterol levels. After the age of 60 or after some time once those processes have developed and are starting to make changes in your vasculature, estrogen is likely not going to be helpful for prevention and some small studies suggest it might be harmful once those diseases set in. Okay, now there's debate over that. I tell patients is after 60 they've never been on hormones, right, or more than 10 years since their menopause. You've likely missed the biggest window of cardiovascular opportunity but it's always going to protect your vagina. It's always going to protect your bones as long as you take it. There are benefits to you. It's always going to stop hot flashes if you give the right dose for most patients. So it doesn't mean no, it doesn't mean you must stop. It just means it's not going to be probably helpful to your heart especially if you have already started to develop cardiovascular disease risk factors. But there is no age at which you must uniformly stop. Let me say this clearly. Hormone therapy is not for the vast vast vast majority of patients dangerous and for most of us the vast majority of us the benefits will outweigh the risks. How do I know if my estrogen, progesterone, and testosterone doses are right? This is where it's so fun to be a gynecologist because watching academicians lose their minds over this question is hysterical to me. Everyone agrees we need to know what your baseline testosterone is. Everyone agrees we need to monitor your testosterone therapy to make sure that you are not super therapeutic. Where the controversy is is here. Your hormone therapy was developed for no other reason than to stop a hot flash. That's it. So the therapeutic end point was resolution of her or diminishing her vasomotor symptoms or hot flashes for night sweats. And now what we know is probably palpitations as well. That's it. You stop her hot flashes. She is therapeutic. No need to measure. It's not helpful. However, what about her bones? We have very clear data showing at what level estrogen, blood levels of estradiol are going to be stopped. Okay, there's two things to remember. We have accelerated bone loss starting in perimenopause, not menopause, perimenopause. The fastest rate of bone loss is in peri. And then it stabilizes but still declining in postmenopause. So we have levels of estradiol which will stop the decline, stop the loss. We have higher serum levels which will actually grow bone, grow bone. And that seems to be around 60 in the way we measure here in the U.S. and the ultra sensitive estradiol levels. You want to be around 60. Over 80 is not going to be more bone beneficial. More is not more but you need to hit about 60 to have the maximum bone benefit. So when my patients come to me and say, hey, I'm here to protect my bones. My mother had osteoporosis. I have osteoporosis. Blah, blah, blah, blah, blah. We go through the full toolkit for osteoporosis prevention and protection which also includes, if you know me, movement, resistance training, eating adequate protein, making sure you're getting enough calcium in your diet, making sure you have enough vitamin D, making sure that we give you tools to stop smoking if that, you know, making sure you're sleeping. All of these things are synergistic together to help grow and save your bones. But we have levels where we know your estradiol level should be in order to maximize the benefit to your bone. For those reasons, I am checking serum estradiol levels. Also remember this, all absorption is not the same. So here's the kicker. Absorption is different depending on formulation. What, Dr. Haver, not ever, you slap an estradiol patch on 10 different women and they're going to absorb differently? Yes. Okay. Amazing work done by Sarah Glenn and Louise Newsom with the Newsom Clinics in the UK looked at standardized estradiol, transdermal dosing, and measured serum estradiol levels. And it was all over the map. About 20% of women were what they called poor absorbers. We're not reaching physiologic doses with the highest dose of transdermal. So because of that research, when our patients are started on transdermal, usually patches what we use and why do we use a patch? Because it's cheap. In the United States, I know I have listeners all over the world. In the United States, it is absolutely insane what we do to women with our crazy insurance system and how we fund medical healthcare in this country. Generic patches tend to be of the most affordable, transdermal ways to get estrogen through your into your body in a transdermal fashion. The cheapest way to get estradiol is with the plain estradiol pill. And let me tell you, that prescription is $2 to $5 a month for plain old oral estradiol. But when we move up to the patch, if you can find them in the US right now, because there's a shortage because guess what? Everyone's talking about hormone therapy and going to their doctor and wanting to have a nuanced conversation and they're getting their prescriptions, which we are struggling to fill because of supply and demand. So my land, sandos, whoever's out there makes more fucking patches so we can get these on our women and have them get healthier and happier and get their lives back. So 20% of you are going to have a potential for having not great absorption. I read that. My hot flashes were controlled, absolutely controlled. On the highest dose patch out of curiosity, I checked my own serum estradiol level. It was 37. I checked it again two months later to be sure it was 39. I was not getting adequate estradiol to have maximum bone benefit. I am very, very motivated to not develop osteoporotic fractures as I age. Why? Because my grandmother had them and my mother had them. My mother has instaste dementia. She's horribly frail and she has horrific osteoporosis. I'm not interested in that being my future and I just refuse to accept that. So what am I doing to avoid that at all costs? Number one, I'm staying on hormone therapy and I checked my levels to make sure that I was getting the maximum bone benefit. Number two, I am serious about heavy lifting. I'm serious about heavy lifting too. I'm a thin person. That did not give me a lot of muscle. This, if you on video, this bicep is manufactured. I was not born with this. This was not a gift from God. This is me working out. This is me lifting weights because I don't care what I look like. I mean, I'm a little vain, I get that. But I am so terrified to age like my poor mother. She didn't want this. She didn't want to live like this. She didn't want to have dementia and osteoporosis and be so frail and have to live in a memory care unit and not be able to transfer out of her bed anymore. She didn't want this. I don't want this for myself and I refuse for it to be the future for my daughters. So I have a 30 year runway before that would potentially happen for me. I have a chance to change history here for myself and teach my daughters how to do it. So heavy lifting, adequate protein. I have lots of vitamin D. I do supplement vitamin D. I check my vitamin D levels. About once a year to make sure that I am at a good level. I'm eating foods very rich in calcium to make and I monitor my calcium intake with my little app on my phone. I'm doing jump training as well. I'm doing box jumps to try to stimulate that bone unit and all of that is working together and my bone density is amazing. I have the bones of a 35 year old for a skinny, you know, Caucasian girl. And that is hard to do for someone who dieted her whole life to be thin. So I am working really hard to make sure that that doesn't happen. So progesterone level. So we don't measure routinely in our clinics and most of the menopausee we do not measure progesterone levels. Progesterone we use therapeutically mostly for sleep and for endometrial protection. So we know how much it takes to counteract the estrogen we're giving to protect the endometrium from endometrial cancer. However, we often go above those basic doses to get people the sleep that they need if needed. Testosterone levels we are always monitoring. So in our clinic, we get a baseline, then we start therapy, we check three months later and then I'll check probably every year to make sure that their absorption is good and they are not being super therapeutic and therefore at risk for the side effects that you can get from testosterone. 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And I love that because it means you're not choosing between quality and affordability anymore. You just get both. Refresh your everyday with luxury you'll actually use. Head to quints.com slash unpaused for free shipping on your order and 365 day returns, now available in Canada too. That's qince.com slash unpaused for free shipping and 365 day returns. Quints.com slash unpaused. Have you ever felt like you were living just a B or B plus life? It's so dangerous to live that more dangerous than a B minus or a C plus life because when you're living a B or B plus life you don't change it. You think it's good enough. Is it? I'm Susie Welch. I host a podcast called Becoming You. People think okay an A plus life is not available to me but there is a way. We are all in the process of becoming ourselves. Wherever you get your podcasts. Many of you know I've spent my career pushing for better medical standards for women. MidiHealth is on that same mission, delivering the kind of care women have always deserved. For too long women have been told to just deal with perimenopause and menopause symptoms. Your labs are normal. This is just a part of aging. Eat less, work out more. That approach failed us and it's exactly why both my work and Midi's exist. These life and menopause aren't the beginning of the end. They're a critical window of opportunity. But education is only half the battle. Women need access to clinicians who actually understand the science of female aging. That's the gap Midi was built to close. Midi is focused on health span, not just lifespan. That means looking at your metabolic health, bone density, cardiovascular risk and cognitive function. It's the kind of proactive evidence-based care I've always believed women deserve. And it's exactly what Midi delivers. And here's what matters most. Women in all 50 states can access this care, covered by insurance, with clinicians trained in the latest menopause and longevity science. Because your zip code should never determine your access to quality menopause care. Look your virtual visit today at joinmidi.com. That's joinmidi.com. Why are my blood levels low despite using patches, gels or pellets? High SHBG, poor absorption. Yep, you just answered your own question. So SHBG is steroid hormone binding globulin. It is a protein that is made in the liver. And those of you on oral estrogen, you're going to have a little bit higher levels of SHBG versus transdermal because of that first pass effect of the liver. SHBG binds our sex hormones, binds estrogen progesterone and testosterone. And when they're bound to that protein, they're not active. So you need the hormones that are floating free in the bloodstream that are going to be active in the tissues rather than bound. So if you can lower your SHBG, and we can do that in a number of ways, you will increase the activity of your hormone levels and because we're unbinding them from the protein. Let's see. Optimal hormone ranges for bone, brain, heart and symptom control. All we know is bone. That's all the only thing people have measured. This is what just pisses me off about how we don't study women. We know everything about testosterone and men and different organ systems and how it may be affected. But like simple things like how much estradiol in the serum, where did we see the best cardiovascular protection benefit? When you're only measuring the presence or absence of a hot flash as therapeutic endpoint, we're not going to know that data. So what studies would Mary Claire want done? I would want to see serum estradiol levels, starting people at baseline, checking with their estradiol level is starting them on therapy, then watching the markers of heart disease like their insulin resistance, like their blood pressure, like their triglyceride level. And looking at markers of getting cardiac cats. I mean, that's a better test for a woman for her risk of cardiovascular disease than the coronary calcium score. Calcium score tells you, yep, you have calcified atherosclerosis, but you can't see the soft plaques. And for women, it seems like for us, the way we have heart attacks, the way the heart disease progresses in us, that doing the cardiac cats to look for the soft plaques may be a better indicator. So we don't know. And those are the tests. I think those are the studies I would love to see done. Persistent symptoms despite HRT. Guess what? Y'all are going to aren't going to believe this comes out of my mouth. Not everything is menopause. Sometimes you have arthritis unrelated to menopause. Sometimes you will have other disease processes that have nothing to do with menopause. So if you start hormone therapy in the hopes your arthritis will get better or in the hopes your anxiety or insomnia or joint pain will get better. And it doesn't. We can do a couple of things. I am always, when my patients come into clinic, I am not so interested in what their actual hormone, other than testosterone. If I can't determine if she's fully menopausal or not yet, we'll check hormone levels, but they're not as important as me ruling out other stuff. Hypothyroidism. Looking for autoimmune thyroiditis. Looking at autoimmune disease markers. Looking at inflammation markers. Looking at key nutrition labs. We do all of this for our patients because so much of this is intertwined. A lot of the, you know, in the columns of hypothyroidism and menopause, so many of the symptoms check off the same. So I need to rule out these other conditions or rule them in. All of this can be happening at the same time. So if you are on hormone therapy and certain parts of your presentation are not getting better, I check a level. What is your estradiol level doing? You know, if you're having persistent inflammation, I'm checking inflammation markers. I'm looking at your thyroid labs again. Like did we miss something? So then we can go up on the dose and see how you do, or we can start looking for other ways to treat those symptoms and conditions. Is this the best it will get or do I need dose forming timing changes, including testosterone? I want everyone to be living their best life. And I really think you can. I really think the last quarter of your life, the last third of your life, should be the best in your life. You have the most wisdom. You should be surrounded by the most love. You should be the most confident that you've ever, ever, ever been. You know, hormone therapy can go a long way to help restore balance when you've lost it, but it's not a miracle. You have to prioritize yourself. No one is coming to save you. You have to start putting yourself, your health, your life, your sanity first. Putting up boundaries, letting your grown ass children take care of themselves, letting your partners in life or whoever do their share of the domestic labor. Like this is the time for you to focus on you. So we are checking on our patients and she comes in and she's like, I am living my best life. I feel absolutely amazing. I have zero complaints today. Thank you for giving me my resilience back, you know, with whatever concoction we gave her. I'm not changing her dose based on some random ass lab marker. We're going to get her bum density. We're going to look for certain things. But like if she comes in saying she's doing amazing and all of her screening tests look good, we're keeping her on that dose. So it doesn't, you know, necessarily require adjustments at that point. Oh, this one's so good. Okay. Bleeding and uterine safety is the next caveat. Is spotted normal when starting or changing estrogen doses? Yes. Okay. Everybody gather around. 50% of you will have unscheduled vaginal bleeding when you start hormone therapy. 50% more with transdermal than with oral. Let me be clear. 50% of you will have unscheduled vaginal bleeding. It is normal. It is expected and it is not pathologic. Your uterus is getting used to having hormones thrown at it again, and it tends to bleed. Now, good news. It usually goes away on its own with no treatment. You do not need a biopsy or a workup. And if any clinicians are listening, do not put these women through biopsies and hysteroscobies and DNCs until it's been six months and the bleeding has not resolved. You can go lower on the estrogen, go higher on the progestogen to get the bleeding. As long as you've determined you've done an exam and the bleeding is not coming from the vagina, it's coming from the endometrium, you can monitor her for a few months, change the doses around. See, now, if the bleeding is persistent and you've done a workup and everything's normal, we have options. There is something called Duovir duave. I don't even know how to pronounce it correctly. DUAVE. It is a combination of permarin plus basodoxaphen. Basodoxaphen is a serum similar to tamoxaphen. Okay, tamoxaphen. But it binds, blocks and down regulates the estrogen receptors only in the breast tissue and the uterus. So for my patients, our patients who are having persistent bleeding or very high risk for breast cancer, we are usually going with Duovir for those patients to bind, block and down regulate the estrogen receptors in the breast and then they don't bleed. They just don't bleed. It's a wonderful side effect of that particular formulation. The problem is there's no generic. It's one standard dose. It doesn't work for everyone, but I just want everyone to know that there is an option. Our vaginal or alternative progesterone routes better for endometrial protection. We don't really know if they're better for endometrial protection. When our patients are having progesterone intolerance, meaning they're having side effects, they feel dizzy. I had a chronic bronchial cronone for fertility and I had horrible dizziness in the operating room. I was a resident doing all these fertility treatments and I used a certain progesterone and it made me loopy. So I get it. Some people have about, we think 10 to 15% will have an adverse reaction to progesterone. So you can go vaginal progesterone and kind of skip that first pass effect in the liver and get absorbed straight into the bloodstream. You just take the regular oral estradiol pill that has a gel cap and you can put it in the vagina like when you go to bed and it will dissolve overnight. You'll be able to absorb your progesterone that way. Some patients do really, really well with that. So that is an option, but no one has measured like oral versus vaginal approach for endometrial protection. Common sense will tell you it's getting right to the uterus immediately. So none of us hesitate to use it and worry about endometrial protection. I've never had a patient who did it that way who had any endometrial hyperplasia. What do I do if progesterone causes reflex, mood changes or poor tolerance? You don't tolerate progesterone. Look for alternatives. Duovie is an option switching to a progesterone, something like Combi patch. I was on Combi patch for a couple of years. It's not a bad medication. Using one of the progesterone alternatives may be an option for you or doing a merena IUD or a lulletta. One of the progesting containing IUDs could be a great option for you. Are creams, pestries or other delivery methods effective and safe? Listen, I think what you're really asking are compounded options as safe as FDA approved option because we have creams, we have the rings or pestries all available in FDA approved options. Those have been tested and I can tell you with confidence that they ran those through clinical trials and we know the safety efficacy of those types. But if you're getting them from a compounder, now I use compounding. I think it's a great option to have for a lot of things. But my go to for HRT is the FDA approved options that you would pick up at CVS. When should testosterone be added? Good question. Okay, definitely if you have hypoactive sexual desire disorder, I'm going to have a conversation with you about testosterone. What is that? HSDD is just the easier way to say that big long thing, hypoactive low activity of your sexual desire that causes distress. You need to norm, we, me, we all need to normalize when women don't ever want to have sex again. That's okay. That is totally up to you. HSDD is when it causes you distress. You had it, you miss it. If you don't ever care if you have sex again, that's okay. That is totally okay. That is not what I'm talking about here. We are not trying to magically induce a libido in you. Okay? You don't owe sex to anybody. No one ever died because they didn't have sex or didn't have an orgasm. Truth. And I direct quote from Rachel Rubin, you should go watch that podcast that I did with her because she's fantastic and she's the best. But she says clearly, no one ever died because they didn't have an orgasm or they didn't have sex. If you don't die and if you don't want to want, that is okay. However, if you want to want, you miss it, you miss the intimacy, you miss whatever, you miss just all the things. We have options for you. We have testosterone, which works pretty well in most patients. Is very well tolerated and doesn't require super physiologic doses like turning you into male, giving you male doses to work. There is anecdotal evidence. We have lots of evidence that suggests probably going to help you if you're working out, going to help you maintain your bone and muscle strength. There are testosterone receptors in our brain. We know, like all the studies that were done in men, that mental health and testosterone are related. That overall general health, well-being, quality of life and testosterone are related. We have more testosterone naturally in our bodies than we do estrogen. Be clear, ladies. We don't have as much as men. We have about a tenth of what men have, but it is still in our healthy years, not postmenopausal, more than the estradiol we have. It makes sense that most of my patients want to go ahead and give testosterone a try. To be clear, there are two FDA-approved medications for libido. One is Addi and the other is Vylesi. Addi is a pill you take every day. It works to stimulate dopamine production. Dopamine makes us happy, makes us want to do things that make us happy. For some patients, it works very, very well. It also makes you a little bit sleepy. It's great for sleep and you want to take it before you go to bed. Vylesi is an injection that you have this massive release of melanocortin, which stimulates dopamine. You want to do that injection, I think it's 45 minutes before the onset of activity. That's popular with my patients, mostly because there seems to be a praying mantis situation on the other side of that injection waiting for it to kick in. Like is it working? Is it working? Is it working? But again, intimacy is intimacy. Whatever works for you, I'm so glad that we have options for our patients. That is when we discuss testosterone with our patients. Can testosterone be used alone, especially in women with breast cancer or on terms? Yeah, 100%. Absolutely. What benefits and risks are supported by evidence? Definitely in a menopausal patient, the evidence is absolutely clear. The biggest risks seem to be hair growth where you don't want it and hair loss where you do want it here in the temple areas, like male pattern baldness. When really high doses, you can have things like clitoral megalae and a large clitoris or deepening of the voice that is non-reversible. Those of you who rely on your voice, if you're a voice actor, if you are a singer, if you sing in choir, menopause already changes the vocal cords. If you end up running high on your testosterone level, you could have some hypertrophy in the area and change your voice into something that you may not like. It is not considered to be reversible. This episode of Unpaused is brought to you by Alloy Health. We talk a lot about hormones affecting mood and energy, but they also play a major role in your skin. Collagen, hydration, elasticity. And in midlife, when hormone levels start to shift, your skin changes too. I first heard about Alloy through a close friend who is a dermatologist. 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For a limited time, our listeners are getting a free gift on their first purchase when they use the code Unpaused at checkout. Just head to jonesroadbeauty.com and use the code Unpaused at checkout. After you purchase, they will ask you where you heard about them. Please support our show and tell them our show sent you. Instagram teen accounts with automatic protections on who can contact teenagers and the content they can see. Instagram teen accounts have contact limits on by default, so teenagers get messages from people they know, not strangers. And default content settings. Plus teenagers under 16 can't change these default settings without parental approval. So parents can help teenagers connect safely. Learn more at instagram.com slash teen accounts. How can I protect bone if I can't lift or if I'm early post-historectomy? So I interviewed Dr. Jocelyn Whitstein here on the podcast. She's a North Phoenix surgeon and she basically is the first clinician that we know of that made the connection and wrote the papers between frozen shoulder and menopause and frozen shoulder and breast cancer treatment. She is my hero. She does a ton of education on her page about osteoporosis prevention, including for those of you who can't do heavy lifting, who can't jump. She has lots and lots of alternatives. And she wrote the, and we'll put it in the show notes, the total body bone and joint plan and they have recipes, exercises, pictures of her doing all these different exercises. So I would invest in her following her on Instagram. She is also a real doctor, board certified. She has like three or four certifications and God. Board certified orthopedic surgeon and sports medicine and fellowships. And I mean, she's like one of the most highly regarded clinicians on the planet when it comes to women's health, sports medicine, orthopedic injuries, et cetera, and frozen shoulder and how to keep your bones strong. Why do some women develop high blood pressure, bloating or weight gain on HRT? Great question. So hypertension is usually more related to oral estradiol than transdermal. So if you're on oral and you've developed high blood pressure, you would want to ask to be switched to a non oral form to see if your hypertension resolves. Your gut microbiome changes when you go through menopause. Okay. Your inflammation levels increase when you go through menopause. Fortunately, the weight gain on HRT, take testosterone, testosterone is an anabolic steroid. So anything anabolic can make you gain weight. So is your, are your bones growing? Are your muscles growing? That's weight gain. That's weight gain. Are you bloated because you have tons of gas, air, liquid? I mean, in your, in your gut, that could make you look distended and very, very unhappy. When you're first starting on hormone therapy, your gut, especially if you're doing oral, your gut is going to have to adjust. And that may cause some bloating, some discomfort, but it's usually self limited and goes away over time. Does sleep apnea, insulin resistance or inflammation play a role in menopause? Abs, fucking literally. Yes. Women see a dramatic increase in sleep apnea. And I had the incredible Dr. Andrea Matsumura on the podcast, who is a sleep medicine specialist. And she goes into detail about all of this. It is so worth your listen, because here's what I learned. Sleep apnea is massively underdiagnosed in women. We don't snore as much as men, so it's not recognized, but women are hypoxic. And they're, you know, one of the ways we are picking it up is that so many of us are wearing trackers of different types that are tracking our oxygen saturation. So if you're getting a pattern of low oxygen levels while you sleep, and if you're waking up from sleep, you know, in the middle of the night and your blood sugar is fine, you're not having a hot flash, this is consistent, you deserve to be evaluated for sleep apnea because it is so common in women and we are missing it and they are suffering long term because of it. Why do urgency and leaks persist despite vaginal estrogen? Great question. So why do we leak? Why do we leak urine? There's a great question. So I used to, I explained to patients that there's anatomic reasons, meaning the anatomy. So we have our bladder. So if you're watching me on video, I'm trying to, my, my hand out here is a bladder and then we have urethra with a little tube that comes out, right? And then like that. And so when we're young and healthy, we have a sling that goes under the urethra, the tube that drinks the bladder is called the urethra. There's a sling there that when we cough and laugh and sneeze and jump, the sling holds that urethra in place. Okay. But after we have babies and we have obstetric injury and we get older, if you cough a lot, if you have poor collagen, if you're malnourished, if you're obese, use that sling goes out. Okay. You start losing that sling and then you start your ability to hold onto urine when you're, when you're stressed, when you're physically go through a stress in the pelvic floor, like jumping, laughing, coughing, sneezing. That sling fails and you leak. That is called stress incontinence. Now we have something called urgent incontinence is very different with the same outcome you leak. So it is an involuntary spasm of the bladder, meaning the bladder wall is full of muscle and it just starts spasming. Why does that happen? It can be because of inflammation. It could be because of aging. It could be because of signaling, bad signaling coming, you know, to the bladder itself from our nervous system. So urgent incontinence, sometimes there's a trigger and you can like put a key in the lock and it triggers your bladder to, um, to spasm. You, all of a sudden feel like you have to go and you start running to the bathroom and you leak usually on the way or you just can't make it. Now everybody does that from time to time, unfortunately, but for others, it's just a pattern. And so fortunately this is treated, this urgent incontinence is treated with medication. It's a parasympathetic action and it calms the bladder wall. Um, side effects of oxybutanin is usually one of the meds that we use or one of the long acting forms and it can cause dry mouth, dry eyes. So again, nuanced conversation with your doctor on how to treat that. So if it's just GSM, so general urinary syndrome, menopause, everything kind of acts better, acts more healthy in the presence of estrogen. So the first thing we usually do is give your general urinary system estrogen back and then see how the symptoms are. And if they persist, then we need further evaluation for stressing continents. How do we treat that generally surgical? Okay. Some surgical way to lift that sling back up. There's also pestries and some other things we can do, but if you're healthy and young and it can tolerate surgery, it's a very minimally invasive procedure to have that sling repaired. And most patients do really, really well with it. That's typically done by a Euro-gonecologist or a urologist with special training in female anatomy, but you should not be leaking. We should see no diapers for adults. We shouldn't. That makes me sad. Every time I see the diaper aisle, because I have to buy them for my mother. How do we let this happen? Why, why do we do this to women? You know, when you look at the percentage of women that end up being incontinent versus men, it's really sad. Men getting continents too. But, you know, when I see sex-based differences, it just makes me sad and wonder why, why are we allowing this to happen? What else can help beyond hormones? Pelvic floor physical therapy. Pelvic floor physical therapy can change your life. I think it should be mandatory for every single woman who has a baby. Think about the stress we're putting on our pelvic floor, carrying a giant watermelon around at the end of pregnancy and then pushing such watermelon out of our pelvic floor. We are ripping and herring and shredding things that don't necessarily bounce back. And everyone should be evaluated, I think, for pelvic floor PT as a normal routine part of any, any genital surgery, any, any hysterectomy, any time we're jacking with anything down there, especially after having a baby, even a C-section. You deserve to have your pelvic floor evaluated and managed so that you can live your best life. Which supplements? Here we go. Okay. Full disclosure, Dr. Haver. Has supplement company. So take everything I say with a grain of salt. Know that you do not have to buy it from me and that the advice I give you is generic. I'm not even going to tell you what supplements I sell. Okay. You have to go to the website and look it up. She lists Omega magnesium, collagen, CoQ, 10, NAD, et cetera. Okay. I wish that no one needed a supplement. I wish you could put me out of business by just eating whole world foods all the time. Unfortunately, most people, it's just the way we live. We have food deserts. It's not always available. It's hard to meet all of those nutritional checkboxes with your diet alone. And that's where supplements should come in. You should supplement, should supplement a healthy diet. Now that being said, what do we see in our clinics? We only take care of menopause patients. Most women, due to the aging process, due to different, the microbiome changing across menopause, due to the way we are protecting rightly so our skin against the sun so we don't get skin cancer. And if you don't believe sun causes skin cancer, you are listening to the wrong podcast you need to move on. We are deficient in vitamin D. 80% of my patients when we surveyed the labs are not just low deficient in vitamin D. A deficiency means that you are not getting enough vitamin D to reach the basic minimum processes. Okay. That's different than optimal. Optimal means you're getting enough for everything to be working at an optimal level. There's a big gap between I am horribly deficient and I am at an optimal level. So you should know what your vitamin D level is. In our clinic, we try to make sure that our patients are reaching a level of 60 to about 100. Okay. Deficiency starts at 30. Is that the cutoff for deficiency in our labs is 30. But that's not enough. We don't want you to just be barely over the line. We want you to be at an optimal level. So all of our patients, we are checking a vitamin D level. If it is low, sometimes we have to give them a prescription amount, which is 50,000 I use per day. We'll do that as a loading dose. And then we're recommending somewhere between two and 4000 international units per day. When you talk to Lisa Moscone, another fantastic podcast that we did and brain health. When you talk to Louise, Dr. Louise and Nicola, the two brain health specialists all have tremendous amount of things to say about Omega 3 fatty acids. Okay. If you can get them in your diet, great, hard to do, hard to do. So you may want to consider supplementing somewhere around 2000 milligrams of Omega 3 fatty acids, which includes DHA and EPA. Okay. If you are a vegan or vegetarian, that's going to be a little tougher to do. You're going to have to go higher on that level because you're going to have to get like an algae based Nordic natural. This makes it really nice one for a vegan or vegetarian form of that Omega 3 fatty acid. Fortunately, it's found in large amounts in fatty fish. So for our patients, we usually recommend a combo of vitamin D with Omega 3 fatty acids and throw in some vitamin K in there for increased absorption. And it's a real tidy way to kind of hit those nutrients at once. You should know beyond the shadow of a doubt how much fiber you are getting per day. And here's the truth. Most women are getting 10 to 12 milligrams of fiber in their diet per day. And you need minimum of 25. Optimal for heart health is 35 for women. So am I suggesting you triple your fiber intake in one day? Absolutely not. Your gut will not be happy. You will be bloated and you'll hate me and you'll say mean things about me. Okay. This is something you need to slowly introduce over time. The more variety of sources of fiber that you get in your diet and that is things like nuts, seeds, legumes, vegetables, fruits, whole food. If you can get 35 grams a day from your food, avocado, I'm like an avocado a day ish girl. And that helps me get a ton of fiber in my diet. Amazing. Go for it. If you can't supplementing with fiber, it's basically harmless. It's not going to hurt you. It's usually pretty cheap. Using something with a base of psyllium husk, hopefully with some other nutrients added to it, would be a reasonable thing to do. And I supplement my own fiber. I use about an eight gram supplement on a daily basis. I think creatine is something we don't measure creatine levels in humans, but the data is very clear on the benefits to women, the benefits to women in menopause, even if you're not lifting weights. Definitely if you are lifting weights. You know, when we look at the studies done on creatine and strength training, it seems to be a synergistic thing with protein intake. So the studies for women were done showing benefits at three and benefits at five. And you know, now that when you look at Abby Smith-Ryan's work coming out of North Carolina, Dr. Smith-Ryan, she is doing a lot of work on women in perimenopause and menopause and seeing benefits outside of just muscle and bone. Seeing we're seeing mental health. We're seeing cognition. So you want to kind of ease into creatine, start with about three milligrams per day and then you, a gram, sorry, and then you can increase. I on a regular basis do five, but when I'm traveling or stress or didn't sleep well and certainly on like heavy, heavy lifting days, I doubled that up to 10 per day. Let's see what else they ask about. CoQ10, really great studies actually done on menopausal women looking at potential heart benefits of CoQ10. Something you should probably look into. I'm going to just stay out of the NAD conversation. Again, I think that's more with the wellness crowd. I haven't seen enough data done in menopausal women showing benefit for me to be excited about NAD or to recommend it in my clinic. Welcome back to another MIDI pause. I'm Dr. Mary Claire Haver, host of Unpaused. When it comes to health care, there's no one size fits all solution. When you face your symptoms with a tailored individual approach, you'll have a better chance of finding the solutions you need. MIDI health is modern, evidence-based care designed specifically for women in this stage of life. You get access to clinicians who understand what's happening in your body, along with personalized treatment plans. Menopause is so much more than just hot flashes. What we're continuing to understand through both research and lived experience is that these hormonal shifts can ripple through nearly every system in the body. And they don't always present in obvious ways. For many women, it's a collection of symptoms that can feel disconnected at first. Joint discomfort, heart palpitations, brain fog, skin changes, even tingling sensation or a rise in anxiety. What makes this especially complex is just how often these experiences are dismissed. So many women are told it's just stress. But when you begin to view these changes through the lens of menopause, it can bring a completely different level of clarity. There's validation and understanding what's actually happening and real empowerment and knowing there are effective ways to address it. Progress starts with a personal plan. Booking your first visit with MIDI health takes less than 10 minutes. It's important to talk with an expert who understands what you're experiencing. That's personalized care. MIDI health is setting a new standard for health care. As the nation's fastest growing women's telehealth company, MIDI provides accessible insurance-covered services. MIDI fills the critical health gaps women face in perimenopause and menopause. If you want a clinician in your corner who understands what your body and brain need right now, MIDI is there for you. Go to joinmidi.com, joinmidi.com and connect with one of their clinicians today. Can act, you puncture or diet, meaningly improve symptoms. Okay, so we have lots of lifestyle things that we know can improve your symptoms of menopause. You can improve your hot flashes, you can improve your joint pain, you can improve your weight gain, you can improve your insulin resistance, your gut health, all of the things. So when I talk about menopause care, I always do it in the framework in our clinics of a toolkit. Okay, this was the basis of my book, The New Menopause. It is the menopause toolkit. And it is looking at where do we, how can we optimize your nutrition? Where are the gaps? How much fiber are you getting? How much are you getting enough protein to maintain your bone and muscle mass? Or, you know, when we look at exercise, are you doing enough of the right kind of cardio to maintain your heart health? Are you doing, you know, enough lifting to keep your bones and muscles strong? What is that going to look like for you? We're looking at stress reduction. And I think it's important that I talk about this here now. I was doing a deep dive, you know, I think about a lot, a lot about longevity. And I don't want to get too political here. When we look at the longevity conversation and how it's being driven and given, you know, what's happened with the files that have been released recently and revelations about certain physicians, I think you have to be careful about worshiping at the altar of longevity. I think the conversation isn't relevant to women because I take care of women. I listen to women. I know what their needs and wants are. And I don't have very many, if any, a couple of people in social media have said, I want to lift 120. I can't think of a single one in our clinic who has walked in the door and said, I want to live as long as possible. I never want to die. I want dying to be optional. That does not come out of their mouths. Here's what they say to me. I want to be a benefactor and not a burden. I want to be with my loved ones for as long as possible. I want to enjoy those years. Because guess what? Women win the longevity race, doing nothing. Right now, we live six, six this year is longer than our male counterparts. Here's the problem. We are not as healthy. We are spending more of that life plagued with chronic conditions. We're twice as likely to require long-term nursing home admissions. We are twice as likely to lose our independence because we become so frail. We can't take care of ourselves or women are three times more likely to develop Alzheimer's and dementia than their male counterparts. These diseases happen to men. A woman can expect to have 50% of us will have an osteoporotic fracture before we die. 50%. Okay. The runway to decrease those risks starts as early as possible. How ever you are listening to me, it is never too late to change those statistics, but we have to work at it. When I look at the longevity literature and the books that have been written and all the bros talking online, here's one key thing they're not discussing. Trauma and sexual assault. When I looked at the data, a history of childhood sexual assault will decrease your longevity if untreated. And I don't want to not give hope here. It is as almost approaches smoking. Someone being assaulted as a child, sexually, when we look at the data will decrease her longevity almost as much as smoking, as much as her being obese. Why? Cardiovascular disease, carrying that burden your whole life, living without amount of stress and cortisol. For unresolved trauma is that dangerous. If we're serious about longevity, we must stop childhood sexual assault. We must protect our children from this possibility and stop protecting the people who are perpetuating these crimes. If you really want to be serious about women living as long and as healthy forever. I've talked to a couple of psychiatrists and people who specialize in post-traumatic people with high ACE scores, adverse childhood events, ACE. And ACE scores, they go through a history and look at adverse childhood events, trauma, sexual abuse, physical abuse, mental abuse, etc. And you get a score. And those scores can play into how healthy you are as you age. You didn't cause this. You did nothing. However, there are resources we can bring your risk down if you get help, if you go through counseling. So in the show notes, we are going to have a list of resources for you, books, websites, and how to find therapists out there because you deserve it. But I think that when we have this conversation about longevity and we are leaving out the elephant in the room, we are doing a disservice to every human on this planet who's ever been abused, especially children. And we are adding another layer of protection for the perpetrators that get away with this. How do I have evidence-based conversations when doctors dismiss symptoms, won't adjust doses, or want to just push pellets? Okay, anytime you walk into a clinician's office and they are railroading you into one specific form of therapy, and at least in Texas, it's usually a pellet. Why? I don't want to demonize a pellet. A pellet is just a way to get medication in your body, and there have been FDA-approved pellets in the past. The pellet industry, as it has developed over the last decade or so, is operating under a loophole of compounding and being sold as some miracle cure. Okay, the only way to get testosterone in your body, not a fan, you deserve all of your options. Okay? You deserve to know about oral, you deserve to know about transdermal patches, pills, creams, gels, but if they're like, nope, we just do pellets here, run. You deserve better. You deserve better. Now, if you go through all of your options, and you and your clinician decide together, this is what I want to try. I want to try pellets. Okay. That's up to you. But you better damn be sure you are being monitored in physiologic ranges. Okay? And physiologic range of testosterone for a female should not go above much above 100. Not to say that there's a few patients who might do well at that dose, but that is not where you start. And you should never be above 200. Let me explain this in clear language. If you were not given exogenous testosterone, if you were not on any testosterone therapy and you came in complaining of hair loss or whatever, which would prompt me to check a testosterone level thinking you might have a tumor, that is a level above 90. If you come in with a spontaneous testosterone level above 90 to 100, I am obligated. It is malpractice if I don't investigate why you have that. Now, it might be PCOS, if it's above 200, and I don't draw, and I don't go look for a tumor, I could lose my license for malpractice. So why would I take that patient and run her over 200, you know, by or beware? How do you find, okay, so this is a great question, and we do have options. On our website at thepawslife.com, we have lists and lists and lists of testimonials given by you guys, people who took it in their hearts. I have a great doctor, I've had a wonderful experience. They go and they fill out a questionnaire from us. Where's the doctor address, and then they write their testimonial. We just organize them by state and city. So you can go to that list and see if there's some, and we just vet them that they're actually doctors and they see patients. Okay, we don't, I don't know these people. I don't know these doctors, but like, I was just trying to be helpful. Word of mouth is a great place to start, but it is unreasonable currently and probably for the next 20 years that you walk into your doctor's office and expect to have an educated conversation. They need extra training and they can get that training from Rachel Rubin, has an awesome course, Heather Hirsch has an amazing course, or be certified by the Menopause Society. Menopause.org has a list of certified providers on their website that you can find. Finally, there are some great telemedicine options out there. They are listed on our website. You can go and compare and check and see things like alloy health, MIDI health are great places to start. But again, do your research. MIDI does take insurance. Alloy does not, but the prices seem to be pretty reasonable. I've, I know acquaintances who've used both services and have been very, very happy with them. How is the new Perry menopause book different than the new menopause book? Great question. Perry menopause is not early menopause. It's its own distinct biological phase and it deserved its own book. The new menopause is about life after the ovaries stop producing hormones and teaches you how to protect your brain, your bones, your heart, your muscles and your metabolism in post menopause. The new Perry menopause is about the seven to 10 year transition before your period stop. This is not a gentle decline. Hormones fluctuate wildly. This is when many women first experience anxiety, brain fog, sleep disruption, weight changes, mood shifts, joint pain, loss of resilience and that unsettling feeling of, I just don't feel like myself anymore. Long before anyone ever says the word menopause. Perry menopause often starts quietly. It shows up in the brain first, then the body, then everywhere else. Most women are never taught to recognize it and are told nothing is wrong. I wrote the new Perry menopause because you deserve answers before things spiral. You deserve care before burnout and you deserve a roadmap for a transition medicine has ignored for far too long. If you thought, why didn't anyone warn me? This book is for you. That is all of the questions I have for today. Thank you so much for joining me today. I absolutely love to be of service to you. I love answering your questions. I love reading. I love researching. I love providing evidence. So if you would love for me to do another AMA with your questions, please in the comments after the episode today, drop your questions. We will monitor them and try to get them answered for you. You can find full episodes of Unpaused on YouTube at Dr. Mary Claire. 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 honest and accurate information on health, fitness and navigating midlife at thepauselife.com. My new book, The New Perry Menopause, is available everywhere you buy books. If you're loving this podcast, I have an important request. Please take a moment to follow Unpaused on your favorite podcast app. Following and listening is what pushes this information to more women who need it. So if this podcast has helped you feel seen, understood or supported, hit follow right now so you never miss an episode. Thank you for being here with me. Let's keep going. Unpaused. Unpaused is presented by Odyssey in conjunction with Pod People. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis or treatment.