The Perimenopause Masterclass: Anxiety, Brain Fog, Broken Sleep, Weight Gain & GLP-1s

Parimenopause is not early menopause. It is its own distinct biological phase and deserves its own episode. Parimenopause is about a seven to ten year transition before periods stop. This is not a general 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 don't feel like myself anymore, long before anyone says the word menopause. Parimenopause 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. If you've thought, why didn't anyone warn me? This episode is for you. 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. I'm 44 and my periods are all over the place. My doctor says I'm too young for menopause. What is actually happening to my body? I would guess that it is actually peri-menopause and since the theme of today's masterclass is peri-menopause, let's start with some basic definitions so we're all on the same page. Peri-menopause is more than just the waiting room for your menopause. It is its own distinct hormonal and biological transitory state. If you think of back when you were pre-menopausal, pre-menopausal, menopause had not entered the chat. You're steadily losing your egg count supply and we can talk about that in a minute. But you are still ovulating on a fairly regular basis. Now, for those of you who don't ovulate regularly or you're on suppression for birth control pills or whatever, you have to take this as a caveat or those with PCOS may not ovulate regularly. But for the 80% of you that do, when our estrogen supply drops after ovulation, the brain says, hey, where's this estrogen I've been looking for? And it starts sending signals out in the form of something called LH and FSH from the pituitary gland that then go and bind to the cells around our individual eggs. And that starts producing estradiol again. And the whole process repeats itself over and over again month after month after month until we hit peri-menopause. The length of peri-menopause can be seven to 10 years. So your brain realizes the egg supply count is getting low. That is peri-menopause. The first symptoms people typically have, they feel like something's not right. It's usually mental health changes looking like increasing anxiety or depression or new onset anxiety and depression with no real precipitating factors. Or I just don't feel like myself. I absolutely just don't feel like myself or brain fog. So peri-menopause begins in the brain and then the rest of the organ system start waking up and realizing that that steady and kind of ebb and flow that was very predictable supply of estrogen and progesterone is not going as planned. So we can have joint pain. We can see asthma changes. We see lots of skin changes. We see muscular changes. And one of the first things that my patients mentioned to me is that they see body composition changes. Suddenly having increasing amounts of fat deposits around their abdomen that they never really experienced before. Also with the aging process, we're losing muscle at a higher rate than we ever have in our lives before. So what I was under the assumption was in peri-menopause, they would just be this steady state decline. I really didn't understand what was really happening. It was never taught to me. What's actually going on is because the brain is searching, searching, searching for estrogen, it starts producing more and more and more stimulating hormones in the form of LH and FSH at much higher levels than you ever saw post-purity. And that is just pummeling the ovary, causing it to hyper-stimulate in some cases. So we're seeing estradiol levels sometimes in peri-menopause at very erratic levels, sometimes as high as 3 and 400. So those of you who have gotten a diagnosis of estrogen dominance, remember a one-time blood draw is not really helpful in peri-menopause. A one-time urine test, a one-time saliva test is only giving you the tiniest snapshot in years and years and years of what actually looks like hormonal chaos. And this chaos can last as it peters out as the ovary supply of eggs just keeps declining over time until we reach no more eggs that are producing any more hormones, and that is full menopause. So that transitions. So you at 44 who asked the question, you're not feeling right, your cycles aren't really that irregular yet. All of this is happening in the brain before your periods even become irregular. By the time your cycles start changing, you are usually at the end of your peri-menopause in those last few years before the natural final menstrual period. So peri-menopause, extremely chaotic, lasts seven to ten years, culminates with the end of ovarian production of estrogen and progesterone and most of the testosterone that's produced there. And it is a full body effect. It's not just hot flashes. It's not just cycle irregularity. We have brain symptoms. We have bone symptoms. We have muscle symptoms. We have gastrointestinal symptoms. There is not an organ system in peri-menopause that is not affected by this change. Why has medicine missed this for so long? And why are we only talking about this now? Because we didn't have a fucking voice. We didn't have a seat at the table. We were treated as small men. And it wasn't, it's not working for us as we age. Okay, I say this with full conviction. I say this with a wonderful OB-GYN residency and training and full support of the American College of OB-GYN. We are really good at obstetrics. I learned a ton about that. We're good at screening for breast cancer. We're good at screening for cervical cancer. We're great at that stuff. But where we see the biggest opportunity for you, who's listening right now, is in this last 30 to 40 years of your life. And to quote Lisa Mosconi, we are owed centuries of research. We must stop treating women as small men. We must. In order for us to stay healthy. There is a reason we have different health outcomes. Why we have four times the amount of autoimmune disease. Why we live 20% of our lives according to the McKinsey Institute in poorer health in our age match male counterparts. Okay, yes, we live about five to six years longer than men, but those years are not great years. And I don't have a single patient who says to me, I want to live as long as possible. And I don't really care if I'm healthy or not. And so if I can enjoy those years or remember those years, I don't have a patient yet who says, look, if I if I have dementia, that's great. Who cares, you know, I don't care. All of them. No one wants to be a burden on their family. They want to be benefactors to the people that they brought into this world. And a lot of them are doing the work taking care of their own parents and saying, hey, I'm going to jump in and I'm going to help and I'm going to do what needs to be done. But I don't want to do this to my children. And that's what we're trying to build here is a runway to help you do that as much as possible. So how did we get here? So medicine has a male default in research and clinical guidelines were all designed around male bodies. Okay, we have a long way to go to include females and studies to separate men and women in studies and look at the outcomes differently. That's one of the things that I learned about some of the data and in some of the meds to lower cholesterol. They didn't de aggregate the male versus female data. Women have cardiovascular disease differently than men. Men tend to have their heart attacks, their clogged vessels way high up, you know, in the very larger arteries as they exit the go right into the heart muscle. They have these bigger blockages higher up. Women tend to have more diffuse microvascular disease. It's going to present differently. It's going to respond differently to the standard medications that were really tested in mostly men. So we have a male bias. Metabolic research rarely includes menopause. You know why it's hard. Even in the animals, we don't have a perimenopause model in rats, which is kind of the standard thing we test in, right? If they want to use a menopause model, they take out the ovaries. There's no transition. So we don't know how these medications are going to affect if when we're looking at preclinical data, preclinical meaning animal studies. When we say that, that's what we mean. We have a very long way to go. Doctors are taught to focus. I was taught. I was taught to focus on hot flashes on vasomotor symptoms, not the cardiometabolic red flags. We have to educate all of our clinicians. Every single clinician who touches a female should have mandatory training in the hormonal transitions that every single woman will go through. And they're not getting that right now. We have to mandate this. Women are prescribed antidepressants instead of being evaluated for hormone changes. Women are being prescribed statins instead of being evaluated for hormone changes. Women are being prescribed sedatives for sleeping pills instead of being evaluated for hormone changes. This has got to stop. This has got to be mandatory part of how we treat women as we go through this transition in perimenopause and then on into postmenopause. How does this bias cost us lives? The number one killer women in this country is not breast cancer. It's heart disease. And most of it is preventable. And even the calculators, the cardiovascular risk calculators, don't take into account menopause in the right way. They consider you being on HRT a risk of cardiovascular disease when that has never been proven true in a younger patient who was given menopause hormone therapy close to her menopause. We have so much work to do and how we diagnose, how we evaluate, how we treat. I had Dr. Andrea Matsumura on sleep medicine specialist, the screening tool for sleep apnea. For women, they don't get a point. If you're female, you don't get a point. We have sleep apnea. And so we are missing these diseases that have only really been evaluated in men with many of our screening tools. So if you're not taught to see something in school, in our training, we have a lot to learn and so much of what we do is great. You don't look for it. So if these screening tools are not really evaluating a woman and taking into account the hormone changes that are wreaking havoc throughout her body, we are going to miss ways that we could help women. And when you don't look for it, women are going to suffer. Okay, so what can we do about it? I'll have to refer to my notes because I get really impassioned here. We have to empower through evidence. We need to fund the studies. And the way we fund studies in this country are through two main ways, okay, or three, the National Institutes of Health, and we are undergoing a massive transition in how we fund studies looking at that institution. Yes, we needed changes made. Did we have to blow up the whole system? I think not. That would be my personal opinion. I think we have a long way to go. But the NIH, let me be clear, was massively underfunding women's health. They were not doing a great job in women's health. Okay, of the $43 billion budget, about 10% was going to women's health and most of that was going to pregnancy and breast cancer and some ovarian cancer. Those are the three main buckets. How else do we fund? Big pharma. It's how things work in this country. The pharmaceutical companies want to get paid for the drugs that they make. This is supply and demand, okay? They are putting up money to fund the studies so that they can sell their drugs to make money. This is how it works, okay? Estrogen is free. Basically, an oral estradiol is $2. No one's making money by selling oral estradiol. You need a designer estrogen. You need a designer progestin. That is where that money from Big Pharma is going into, is in these designer drugs, which I'm happy to have the research. But they're really esoteric and really, really not needed by the majority of patients. They can do plain estradiol and plain progesterone, which are so inexpensive that no one is going to make money. So there's no pharma money not really coming from that level. Third is private entities. And we are seeing women who are coming into a lot of money starting to fund these studies. So when we look at the Melinda Gates Foundation, I have to give her props. She is donating money to study women's health in a way that's never been done before, okay? So anyone listening out there who is a philanthropist and you want to go look for the studies being done in women, usually by women, for women, there are out there. There are so many great ways. Rachel Rubin's running several studies, you know, different universities are running studies. Stanford's got a great menopause program. A lot of the bigger universities are really opening up the floodgates for menopause research in really clinically significant ways. And those kind of things need to be funded. And that funding is available for women only because this is the diseases they affect. You might listen to this and think, oh my God, this is going to be horrible. I don't want to go through very menopause. It's a window of opportunity. It is a time of reckoning. It is a time for you to take stock of who you are, what's important to you, what your health risks are, what your family history is, and start doubling down on how you are going to live the next 30 to 40 years of your life. It's a wake-up call. But let me tell you, I am a 57-year-old woman the day we're recording this. I don't know when this is coming out. But I am as healthy as I've ever been. I may be healthier. I am living my best life. I am helping more women than I have ever helped in my life. I am changing lives as a fully menopausal woman. I have a toolkit that is probably excessive because I have exercise stuff in my toolkit. I have lots of nutritional helpers in my toolkit. I have stress reduction. I got therapy for the first time in the last couple of years. I'm doing the work. I'm working on my relationships. I'm working to make sure I am setting up a system that is going to support me for the next 30 years. This is a wonderful time of my life. And it should be, you should feel the same. And in perimenopause, it's time to take stock. It's time to see what do I need to do so that I am going to be okay. Not to put everyone's else's oxygen mask on first, but to put yours on first. And intervene early, test early, act early, make these changes as soon as possible so that it's not as difficult and you can be in my shoes. You should be able to be in my shoes. This isn't about how I look or, you know, I like to wear pretty clothes and do my hair for these podcasts. But this is about, can I take care of myself? Am I going to be independent in my last 10 years? And these were gifts my mother and my maternal grandmother were not given. They did everything they were told by the system in place. And both of them have ended up with long-term dementia, loss of independence and frailty to the point my mother is almost completely bedbound now. She hasn't walked other than to transfer to her wheelchair. My mother has not walked with a walker in almost a year. So I don't want that to be my future. And in order to make sure that doesn't happen to me, I need to do things very differently than she did. And she was on hormone therapy for a long time. So this has nothing to do with hormone therapy. This was everything to do with her dieting, destroying her bone and muscle strength so she could be a size six or four, whatever the number was at the time. Way too much alcohol use. She pretty much fell into alcoholism once she lost my three brothers and my dad. And I can't blame her for that. She didn't believe in therapy. It's more than just taking the scoop of fiber every day. It's more than getting access to hormone therapy if you need it. It is really trying to build a system that is going to support you for the next 30 years. Perimenopause isn't just about your period's ending. This isn't just aging. This is hormone loss. Hormone fluctuation, hormone loss. I really, I wrote the new menopause because I really feel that every woman deserves to know as much as they can about this life stage. And the old narrative that just doesn't serve us anymore. Perimenopause, we can move beyond these outdated definitions of the straw staging, of fluctuating periods and, you know, slowly declining and a few hot flashes. No, no. It starts with, I don't feel like myself, anxiety, depression and brain fog and sleep disruption. It starts in the brain. Okay, those are your wake up calls. That's how you know. When you go to your doctor, hopefully they're going to rule out other things that can cause similar symptoms. You need to have your vitamin D level checked. You should have your ferritin level checked. We have our lab resource guide. Again, another free resource available on our website. You want to know what labs we run in Mary Claire's clinic? I got them for you. Okay. You can print them out why we run them, which tests we would run with which symptoms and take that to your clinician or some of you may say, hey, I'll just go through a question, order them on my own. You can do that as well or a quest or lab core or whoever. So like, but we want you to be as prepared as possible and have all these free resources and guides so that you can set yourself up for success. Dear Dr. Haverb, everyone talks about menopause like it can happen overnight, but I've been feeling off for years. Anxiety, terrible sleep, weight gain, I can't explain brain fog, joint pain. Is this all related or am I just falling apart? It can be all related. If you were feeling absolutely fine. If your anxiety, if your weight gain, if your sleep disruption, if all of this is new to you and your son, and you're somewhere after the age of 35, it is worth going to talk to a doctor who is educated in this. It could this constellation of symptoms be related to my perimenopause? Now, there is a validated scoring system available to see if your constellation of symptoms might be related to menopause and we have it available on our website. We call it the menopause quiz and you go, you answer about 20 questions and you grade your symptom severity and it will tell you what the chances are that your constellation of symptoms is related to menopause. At the end of it, when you get your results and it's totally free, it will give you a resource guide that you can take to your doctor and resources and how to find a clinician who can have a legitimate conversation with you about what your options are at that point. So yes, your mental health changes. Yes, your weight changes. Yes, your joint pain. Yes, absolutely your sleep disruption. Often one of the first things to go because progesterone is great for sleep, is amazing for sleep. And when that progesterone starts drifting away in perimenopause, one of the things that we see and almost up to 50% of patients is severe sleep disruption, not just occasional insomnia. We're talking a definite pattern where you are not getting the quality sleep that you deserve. Next question. My doctor tested my hormones and said that they are normal, but I feel anything but normal. How is that possible? Again, in that zone of chaos, a one-time blood test, even saliva or urine test is a simple snapshot of what is happening in one moment in time and is not representative of what is actually going on in your body. So it is very, very likely that you will have some blood drawn and, hey, it looks normal, whatever that means to that doctor. In premenopause, before menopause enters the chat, we don't have steady state hormones other than maybe testosterone. Our estrogen ebbs and flows normally in the menstrual cycle as does our progesterone. So it really depends if you're having regular cycles, what cycle day you're having the blood drawn. If you're not having regular cycles, it's really nonspecific and not all that helpful to make that final determination of perimenopause. So how do we do it? You're going to be shocked here. We're going to talk to you. We're going to write down your symptoms. We're going to believe that these are actually happening. We're going to do blood work probably to rule out things that look a lot like perimenopause like inflammatory disorders, like autoimmune disease, like hypothyroidism. We do about 70 labs on our patients when they come in. One, I'm checking metabolic markers, insulin resistance, et cetera. And surprise, guess what goes up 20% across the menopause transition during perimenopause? Your LDL, your low density lipoprotein. I can remember being blindsided by my own blood work. Okay, here I am living my best life, working out, eating what I think is healthy and then naturally then and low and behold, my cholesterol starts ticking up. My total cholesterol and my LDL, my HDL stayed stable, started going up no matter what I did. I just remember being absolutely flabbergasted. When I opened the menopause clinic and all I did was take care of women in perimenopause and postmenopause. I remember like every morning opening up to review labs and saying, everyone has high cholesterol. Like 85%. I was shocked when I didn't see high cholesterol. And then I start digging and realizing, my gosh, you can expect your LDL to go up 20% across the menopause transition. And I'm not talking about patients who have a familial hypercholesterolemia, have been dealing with cholesterol. Most of their lives. I'm talking about women who had stone cold, normal cholesterol levels who all of a sudden, with no changes in diet and exercise, nothing has happened except they've entered the menopause chat and their lipids are starting to change. Triglycerides go up, HDL can drop, not as much as LDL goes up, but all of these will make you more vulnerable to atherosclerotic disease. I told my doctor about my symptoms and she said, it's probably just stress or that's just part of getting older. Why does this keep happening to women? So what I think you're asking is, why is it that you go to a board certified family practitioner, internal medicine doctor, OBGYN, whoever your primary care doctor or clinician is, and you are presenting with this constellation of blood work, constellation of your symptoms and they aren't able to connect the dots. This is not the fault of an individual doctor. It would be way easier to dismiss this and to say they just don't care. They're just being a jerk, but this is actually a severe systemic problem. We have not prioritized women's health after reproduction ends. We are not teaching on a large scale basis all of these doctors who are charged with your healthcare, how menopause affects a woman. Maybe your OBGYN will understand what's going on with your cycle irregularity and hot flashes. Most docs will get that. A bunch of hot flashes, your cycle is becoming irregular. Most doctors will be able to say, okay, menopause. However, your cholesterol, your anxiety, your joint pain, your sleep disruption, your weight changes, your new belly fat, we're not teaching that by and large. Now we're working on it. We need a robust menopause curriculum, which is not available in most programs. So it is really sadly up to us to educate ourselves. Sometimes we'll know more than the doctor. And one thing we've tried to do at the pause life, if you go to our website and you look at the menopause empowerment guide, it's free. It's like 15 pages now. We keep dumping more stuff in it. It is a set of resources with tons of links available for you to educate yourself and resources for you to take into your clinician so that hopefully you can maybe educate them some and be able to get what you need. Also, we have resources on how to find doctors who are menopause certified. You can go to menopause.org for the menopause society and try to find a menopause educated clinician there as well. I thought perimenopause was just about periods and hot flashes. Why do I feel like my entire body is breaking down? That's a great question because we have estrogen receptors and those on video, we're going to fly in an image here. There's a great study. It was the first time I saw this. It absolutely just stopped me in my tracks. It was the location of the G coupled estrogen receptors throughout the human body. They're everywhere, guys. They're in the brain. They're in our skin. They are in our bones. They're in our gut. They're in our epithelium. They're in our vagina. They're in all of the tissues in our body. It just was so validating for me to see that scientifically. Then they listed all of the disease states, including things like fatty liver, including things I'd never thought about before and really what happened metabolically, how estrogen affects the liver and how you make cholesterol, how estrogen affects the liver, and how you make cholesterol. How estrogen is an anti-inflammatory hormone. So when it goes away, we lose some of the protection against inflammatory processes in our body. So please, nothing else. Go to our website at thepawslife.com. Look up the menopause empowerment guide. Download it for yourself so you have some resources for you. My cholesterol is suddenly high and my doctor is talking about heart disease risk. What does that have to do with perimenopause? So remember, estrogen affects the liver and affects how we make cholesterol. So it drives up our ApoB. It can actually drive up Lp little a. Men Lp little a appears to be more genetic, but we see an increase in Lp little a. These are specific, very small cholesterol particles that have a much higher association to the risk of atherosclerotic disease and cardiovascular disease than just your total cholesterol. So in our clinic, we are doing deeper dives into lipid panels on patients, not getting just the standard lipid panel. We're getting all these extra markers so we can counsel our patients appropriately. Also, there's something called vascular flexibility. So your blood vessels in the presence of estrogen are more flexible. They're more squishy. They're more able to handle the blood passing through. However, when estrogen levels decline, we lose that flexibility and the arteries actually become stiffer, which makes our blood pressure rise. So those of you, including myself, who have seen a rise in your blood pressure, you enjoyed this nice normal blood pressure most of your life. And then all of a sudden you're going through menopause and you see it rise. It's not because you did anything wrong. This is a predictable biological consequence of this fluctuation and decline of estrogen levels. And it is not fair to you that you did not know this and that this is blindsiding you at this time if you're seeing it happen. 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Plus, my doctor is worried about bone density. Is this connected to hormones? It absolutely can be. So there are estrogen receptors in our muscle and our bones and our tendons and our joints. Okay, we know that. There's also testosterone receptors and probably a few progesterone receptors in there. And what has been defined is something called the Musculoskeletal Syndrome of Menopause. We now think that a lot of fibromyalgia, which is a condition that occurs in mostly women between the ages of 35 to 60, what else is happening during that time? You have to start thinking. And so we think that a lot of women who are being diagnosed with fibromyalgia may actually just have the Musculoskeletal Syndrome of Menopause and are having increasing inflammation in their joints, bones and muscles. Osteoporosis is something different. Osteoporosis, so the rate at which we are chewing up bone and the rate at which we lay down bones. So up until we're not sure, age somewhere between 20 and 30, we are laying down more bone naturally than we chew up. Bone is always remodeling, right? You're always chewing some up and laying down new bone behind it like Pac-Man, right? Coming out with new bone. When we go through perimenopause, we see the greatest level of rate of bone loss, okay? Then we even postmenopausal women. So the biggest acceleration in your loss of bone actually starts happening in perimenopause. For that reason, my patients are very interested in having their bone density evaluated at the beginning of perimenopause. So we know what their baseline is. Sadly, insurance will not cover this unless you have kind of an extraordinary risk factors. So a lot of patients will have to fight to get that covered or they're choosing to pay out of pocket to get a baseline bone density scan so they can understand, you know, where do I need to focus here? What are my goals? Your goal is not to have a vertebral fracture and have horrible back pain like your mom did or have a hip fracture and end up with a horrible quality of life, you know, or have long bone fracture in the arm because you just kind of tripped and fell one day. If you want to limit those risks, you know, you need to know what your baseline bone density is because we can start making changes in perimenopause to support your bone and muscle strength so that you don't have as high a risk as you age. You can actually grow bone at any age, but it does take work and it takes understanding what your starting baseline is. So estrogen plays so many roles in the body, but I want to focus on kind of what I call my top five. And this is what I talked about a lot in the new perimenopause. We're going to talk about brain. We're going to talk about heart, muscle and bone, liver and our immune system. So in our brain, the sex hormones or the progesterone, estrogen and testosterone have direct effects on our neurotransmitters. How we produce things like dopamine and serotonin, these chemical messengers that hop from neuron to neuron in the brain and is it why we have memory, why we have mood, why we have anxiety is directly related to these chemical messengers. And when we lose estrogen and lose progesterone, we see changes that quite often will be severe mood changes. Anxiety and depression are the top two. We see changes in the processing speed in certain areas of our brain. The way we process glucose changes, amazing work done by Dr. Lisa Mosconi looking at energy metabolism in the brain across the menopause transition. And there are certain areas of the brain to do with memory and cognition that change dramatically across the menopause transition. Estrogen is involved in our strength, like we talked about in our bone and in energy use in both. And in our liver, in fat and glucose metabolism, and then our immune system, it's directly tied to inflammation control. These estrogen receptors, both alpha and beta receptors are everywhere. But really where we're seeing the metabolic consequences and where we're seeing the hardest hits for women in perimenopause are going to be in fat cells, in the brain, in the liver and in our muscle. So it's not just fertility that changes. It definitely changes, right? But it is so much more than that. It is your metabolism, is your energy stores, and it is your resilience. So another common question we get this seeing this question right here. I'm eating the same way as I always have, but I am suddenly gaining weight around my middle and my blood sugar is creeping up. I feel more inflamed than ever. What's happening? Another similar question. I've gained 15 pounds around my middle. Despite eating well and exercising, my doctor says I need to eat less and move more. But is something else going on? Yes, yes, yes, yes, yes, yes. Okay, let me break it down for you the best I can. So the best way to explain this is something I like to call, you know, we talked about earlier, the musculoskeletal syndrome of menopause. I wrote a paper with a couple of medical students and Dr. Rocio Salas-Wailin, where we coined the term the metabolic syndrome of menopause, specifically to look at a cluster of what's happening of increasing abdominal obesity or what you would call belly fat. Now this is the fat not under the skin. This is the fat that is inside of our abdomen that wraps around our internal organs. Also, it could be leading to high triglycerides, a lower HDL, that's the good cholesterol, and elevated fasting glucose and increasing insulin resistance. Those two go together and high blood pressure. This happens due to estrogen loss and not because you're letting yourself go. Okay. Specifically, when we talk about what's happening with the increasing intraabdominal fat, there's several kind of factors. There's a traffic circle, right? And there's several entries into the circle that's spinning into a woman getting more and more visceral fat or abdominal fat. One, your insulin resistance is getting worse. So your ability to take in a glucose load, so eat a sandwich, eat a salad, eat whatever that has glucose, eat a cookie, and how much insulin it takes to drive that blood glucose into the cells. So when you become more insulin resistant, it takes more and more insulin levels. Okay. Higher insulin levels are linked to more inflammation and more visceral fat. So the higher your insulin levels are, really after you eat. So when you don't see those insulin levels declining, you don't see blood sugar going back as quickly as it used to, back to a normal level after a glucose load. We are seeing increasing levels of inflammation and more and more fat being driven to the intraabdominal cavity. Once that fat gets to the intraabdominal cavity, it kind of acts on its own. Subcutaneous fat doesn't produce as many inflammatory cytokines. These are inflammatory chemical massagers that can go and inflame other parts of your body, your brain, your gut, your joints. But the intraabdominal fat does do that. And that is new for many women. So when we look at the data, they did scans looking at premenopausal women and then perimenopausal women and postmenopausal women. And they measured with either a dexa scan or an MRI how much visceral fat they had, how much intraabdominal fat. And you take age out of the equation because remember women go through menopause at different ages. So if you match them to their menopausal status and not their age, we see a pattern forming somewhere between menopause and menopause. Somewhere between 8 to 10% of a woman's total body fat is intraabdominal in a premenopausal woman. Okay? However, you take her through the menopause transition and that can increase 18. I've seen as high as 30%. So I like to like round it off at about somewhere in the 23, 24% range. So you can basically double to triple the amount of visceral fat that you have simply by going through menopause. No other reason. Okay? But there's several factors leading to that. Inflammation levels are getting higher. Insulin resistance is increasing. That makes your blood sugar level stay up higher longer, which also increases inflammation. And you're losing the protection of estrogen, which in itself is an anti-inflammatory hormone. And all of those things are driving more and more fat to the abdomen. Also, we're seeing sleep disruption. Women who don't sleep, who are having trouble falling asleep or staying asleep, who aren't getting the good quality sleep, have higher levels of visceral fat, which is leading to more inflammation, right? Which is leading to also changes in their diet. You crave more things that are unhealthy, like simple carbohydrates, when you don't sleep, right? You're tired, you're exhausted, you start reaching for comfort food, you start reaching for things. These are all psychological changes that happen throughout the menopause transition. Next question. What are the actual health risks if these metabolic changes go unaddressed? We see some pretty scary statistics. Cardiovascular risk doubles across the menopause transition. So premenopausal women enjoy a lower risk of cardiovascular disease than their male counterparts. And one of the key factors we think that is leading to being healthier in a premenopausal woman versus her male twin, right? Is that she has more estrogen on board, which is giving her that level of protection. It's lowering her inflammation levels. It's keeping her blood vessels more flexible, and it's decreasing the rate at which she can develop atherosclerosis. Once that estrogen protection goes away, we see her quickly meet the risk of amends by the time she's 60 and then surpass him. We see increasing rates of diabetes, which again is another risk factor for heart disease. We see insulin resistance really start increasing across the menopause transition. We've really treated menopause like a footnote instead of a pivot point for metabolic health. So a lot of you are asking, okay, well, do I just need to get on hormone therapy and that's going to fix everything? No, no, I wish I could tell you just take your HRT and everything's going to be fine for most of you. That is, it's going to be helpful, but it's not going to be everything. You are going to have to double down on your lifestyle in order to avoid some of these risks and stay as healthy as possible for as long as you possibly can. And fortunately, when we adopt a lot of these behaviors, it affects multiple disease risk states. So when we look at women who don't have heart disease and what their habits are, women who don't have dementia and what their habits are, women who don't have osteoporosis and what their habits are, many of those habits are the same. They eat adequate protein, they limit their processed foods, they exercise on a very regular basis to include strength training and some cardiovascular training. They are social, they stay connected to their communities, they have lower stress levels because they have friends. All of this is important. So I wish that I could just wave a magic wand and tell you, get on hormone therapy and it will solve all of your problems, but that is not what happens at all. It is unlikely that if you eat the standard Western diet and live a sedentary life and take hormone therapy, that it is going to dramatically improve your lifespan or your health span. It most likely will have minimal effect. It will definitely help your hot flashes and probably help you. It will help your bones as long as you take it. But without the package, the toolkit, right, of the lifestyle changes, of prioritizing yourself, of staying metabolically healthy, you are not going to be able to live your best life in that last decade. We're going to get into some nitty gritty stuff here. And I don't mean for this to sound political at all. It's not really political. It's like the powerful versus the powerless. That's how I like to think about it. So pick your side of politics, whatever that is. Everyone talks about cardio for weight loss, but all I talk about is weightlifting. Okay, your basal metabolic rate, right, your BMR, your base, how many calories you burn at rest? Okay, not moving. Is determined by how much muscle you have. So we have a body scanner in our clinic that measures muscle mass. It measures your body fat. It tells you if the fat is visceral or subcutaneous. It tells you how much body water you have if you're dehydrated or, you know, so that number on the scale is so much more than just how much fat you have, which is all women tend to think about, right? Your muscles weigh your bones way. You want heavy muscles and you want heavy bones. You want to gain weight. You want to gain weight in those areas. Okay. But everyone's fixated on fat. So calories are important. No one can deny that, right? You eat in a consistent caloric excess. You are probably going to store fat. That's just how biology works. However, how many calories you're burning at rest is determined by how much muscle you have. And your aging process and menopause is chipping away at that muscle strain. So you have to work to keep it. And if you didn't start out with much like me, naturally, you know, a thinner person with low muscle mass, I'm working really, really hard so that I can keep my basal metabolic rate high. Also, that muscle is a big juicy organ that soaks up glucose and lowers my risk of diabetes, lowers my insulin level. Okay. The most geroprotective organs that we have in our bodies, geroprotective, do you know what that word means? It means protecting you in the gerotinological ages, 65 plus. Are your ovaries which go away and your muscle mass? They seem to be the most protective, geroprotective. And so we have the opportunity to build muscle at any age. It takes work. I just saw a study that was done with 80 year olds taking them into the gym, putting them through resistance training protocols, and they improve their muscle strength and muscle mass. Okay. Making sure you're getting enough protein to provide enough substrate amino acids to build those muscles, to grow muscle. You must have the building blocks of protein, which are amino acids. So really rethinking this whole like, work out more, eat less, be thin, be thin, be thin is the only way to be healthy is not going to be your best bet. What tests should I be asking my doctor for? When should I start and should I wait until my symptoms are really bad? Okay. You should not wait until your symptoms are really bad. So here's the quick and dirty. Here's kind of five things I think you should know about yourself at any age, right? If you're premenopausal, perimenopausal, postmenopausal, these for women in midlife, these are five lab tests. I really, really think you should know. This is part of our lab checklist. That is free to download 100%. Go to the website at the pause life. You can find it. But if I was going to give you top five, so you guys get your pencils out, you can take notes. Number one would be you should know what your fasting insulin and fasting glucose are. Those are so important. Why? Because we have no diabetes, pre-diabetes, diabetes, right? It's a continuum of blood sugar. We all start out with how our body is, how much insulin is secreted in relation to a glucose load. So your fasting insulin and glucose level, you can run it through something called the HOMA, H-O-M-A-I-R insulin resistance calculator. They're free online. You put in those two numbers and it will tell you and you want it to be less than two, just FYI. You want that HOMA-I-R score to be less than two. Anything above two is insulin resistant. You may have totally normal blood sugars. This is a red flag early warning system, okay? A marker to tell you, hey, I need to work on this. I need to make some changes because I am insulin resistant. I'm not pre-diabetic yet, but over time I have much more likely to be. So that would be one thing to get an early warning system. So fasting insulin, fasting glucose. Number two, you need to know what your ferritin level is. Why? Ferritin is our iron storage hormone. It is the first thing to go when our iron levels are low. Your blood iron may look totally normal, but what is stored in the bone marrow is what's important. And they've changed it. It used to be 30 was the cutoff. In the last few years, they moved it up to 60 for a ferritin level. So it can pick up low iron stores way, way, way, way earlier before you ever become anemic. Again, it's an early warning system, right? And this is one of the things we see aging and menopause chip away at. Low ferritin levels are related to fatigue, hair loss, brain fog, anxiety, all things that happen in perimenopause, right? So it is one of the critical labs that we get to try to differentiate. Is this perimenopause or does she also have a low ferritin level that we can treat, right? By giving her iron either through an iron transfusion or oral iron supplementation, iron-rich foods. Number three, vitamin D. You need to know your vitamin D level. And remember, there is low, which is less than 30. There is optimal, which is 60 to 100. Okay? So you don't want to be low or deficient. You want to be optimal, which is in the way we measure in the U.S. 60 or above. Number four, you should know we're sure L-P-littleleus. Lipoprotein A can be genetically determined, but we do see an uptick in levels for, as you go through menopause. So if you have low levels, we have vitamin D, which is a lot of things that we can do to help you. Number four, you should know we're sure L-P-littleleus. Lipoprotein A can be genetically determined, but we do see an uptick in levels for, as you go through menopause. So if you had it done in your 30s and you've been told, oh, you don't need to check it again, it was normal. Not if you're one. You really should check it in postmenopause as well. So once you go through the menopause transition, we don't see it increase more in the data that I've seen, but it's not something it's a one and done. For men, it's a one and done. But for women, you should recheck it after menopause if you've had it checked before. Why? Because heart disease is the leading cause of death in women, and L-P-littlele is significantly associated with the risk of cardiovascular disease. And you can get in there and get early before you could pick that up before your total cholesterol increases and know what that is. Number five, and this one is controversial, but we do do it in our clinic, and I'll explain why. This is a high sensitivity C-reactive protein. I was always taught, don't measure something if you're not going to treat it, right? And so high sensitivity C-reactive protein is a general marker of inflammation. I can't tell you where the inflammation is coming from. Only that you have it with the CRP. We can have guesses as to where it comes, but it is associated with metabolic dysfunction, cognitive decline, and accelerated aging. So it often can tell us there's some inflammatory, and our clinic, we're like, something is causing you to have inflammation. We are going to start doing things we know that can lower inflammation. That's going to be exercise, stress reduction, monitoring your sleep, increasing your protein, increasing your fiber intake, increasing your fruit and vegetable intake. Like, we're going to hit it with all the things and monitor that and see what's going to help it come down. Remember that your symptoms are data. Brain fog is data. Chronic fatigue is data. Weight gain, especially in your midsection, is data. Poor sleep is data. These translate symptoms into physiology, and the blood work just kind of helps complete the picture. And so, again, our lab checklist has these and many, many more tons of resources available to you. If you go to pauselife.com and just go in the little search bar and type in checklist, and you can get it downloaded to your inbox for free. And then you can take that to your clinician or just get the labs ordered on your own. Dr. Haver, do you believe in GLP-1 therapy? Okay, it's not Santa Claus. It's not as if I believe in it or not. Asking for my opinion means we're going to leave science off the table, and I'm not willing to do that. We utilize GLP-1 therapy appropriately in our clinic for our patients, and I have literally seen it work miracles for our patients, especially those who have struggled with lifelong issues with weight or obesity or insulin resistance. We have two hours of podcast, two separate podcasts done with Rocio Salas-Wayland. If you want a deeper dive from an actual expert, she wrote the book, Waitless. I'm not going to lie, I was skeptical when they first came out. I did not know all of the research that had been done over the last 20 years. Remember, I didn't treat diabetes, and if I had gestational diabetics, we used insulin or something like Metformin to treat them in pregnancy. I did not manage this at all outside of a pregnancy. So when I started utilizing my menopause clinic, I just thought those medications were only indication was to treat diabetes, and I would send them back to their endocrinologist to have that done. But when the indications for obesity started surfacing, again, you have to imagine my background of me being a little bit skeptical, because I was seeing what everyone else was seeing was all of a sudden these dramatic and sometimes scary weight transformations on looking across social media of some of the people I followed to the point where I was guessing based on their physical appearance, and this is a little bit of judgment, that they were likely losing muscle mass along with fat loss. Now, I can't prove that, but just looking at their facial structure and how their bodies were, it looks really difficult that they would have been able to lose weight that quickly without suffering from muscle mass loss. And that's going off the data we had from gastric bypass patients and knowing what their muscle loss is with rapid weight loss after surgery. And here we are playing the long game with patients looking at muscle mass and bone strength. So I was really skeptical until I started following Dr. Genesewak and Dr. Rocío Salas-Wailin on social media and looking at the medical research journal articles, they were presenting and then pulling them myself and reading them myself and realizing, wait a minute, I am allowing my own bias to stand in the way of what is what could be potentially best for a patient, especially when when Dr. Rocío was really focusing and showing the body composition scans on her patients who were not losing any or significant muscle mass because of the way she was counseling them. And I was like, oh, so I got educated. And then we started on a very limited basis trying this medication on some of our patients who were struggling with obesity with the caveat that we were making sure that they knew how much protein that they would need and that they were committed to resistance training in order to, as they lost weight through this, how the mechanism of the medication worked. But they were getting adequate protein and adequate stimulation for the muscle and bones so that we would not put them in a position where they would have such significant muscle loss and bone loss where they would be at risk for for sarcopenia or frailty as they aged. Keeping that in context, we've done really well with this medication. A, we do body scan everyone. We know what their body composition is. We know how much muscle mass they have. And if they are losing muscle mass more than 10%, we are counseling them to come off the medications and adjust the dosing and really recommit to what the end goal is, is a healthier body, less visceral fat, less inflammation, and maintaining their bone and muscle strength. We're very aggressive at recommending getting a baseline bone density before starting a GLP one so that you know what your bone density is before we start and how we need to focus on that as well. It turns out pretty much the same thing that helps grow muscle grows bone. And so those two things can usually go together. But you know, we take an hour with our patients on a new patient visit and then if they decide that, you know, if we decide as a clinician, they're a good candidate, we bring them back for another hour to counsel them on the GLP one usage and how to do it in the safest way possible. Every medication comes with risks and benefits. Every medication will have pros and cons. These medications are not for everyone. You know, and so yes, we use them. Our patients are doing extremely well, but it is not here's your shots and go home and go be skinny. That is not the way we counsel our patients. We are very, very specific as to how we manage them, how we monitor them and how we help them stay healthy through the process. So to wrap up the GLP one conversation and people struggling with weight who've had a lifelong struggle or struggle in menopause and perimenopause. You are not broken. This body composition change you are experiencing is a remember this, say this over and over. This is a predictable biological consequence of my hormone change. This is a predictable biological consequence of my hormone change. So what that usually means for most of us is you cannot keep going with the same lifestyle that you had and enjoy the same health benefits. Things are going to have to change. The GLP one is simply a tool in the toolkit. There are multiple tools in the toolkit, adequate resistance training, adequate cardio, you know, exercising your body, lowering your stress, focusing on your sleep, doing all the things that are going to make a healthier body and help these medications help you. There are tools available. GLP one is just one of them. But the most important tool is information, education and a clinician who believes in you and just believes that menopause is part of this process. And you deserve that. Perimenopause can be hard, but it's also really full of possibility. It's okay for both things to be true at the same time. If you look at it as a window of opportunity, which is how I look at it with our patients, you can get ahead of so many things that can be affecting you long term. You can feel bad today, but still believe that tomorrow will be better. You can be struggling and still be very, very strong. You are not declining. You are transitioning and this transition is going to affect 100% of us who are lucky enough to live long enough to go through this process and where you end up really, really, really is up to you. I want you to know this. The tools exist. The knowledge exists and a community exists for you. What you need to thrive through this and then get you through the next 30 to 40 years is available. You just need to know where to look and what to ask for. And now you do. This is the beginning of a new chapter and it should be the best third of your life. That's how it is for me. And I really believe that the last third of your life should be the best third of your life. So what are my top takeaways? Find a menopause educated or menopause trained provider. We have a list of resources on our website. It is in the menopause empowerment guide. There are great online resources. Join a community online or in person. I welcome you to join our community at the pause life. We are in there answering questions, providing resources. But the best part really is the community and then sharing all of their stories, their resources, their struggles and just oftentimes the question is answered before. We can get to it by someone in the community who went through the same thing, found the resources and fixed the problem. If you are not starting resistance training, I want you to get curious about it. There are so many resources online. You don't have to just jump into a gym and spend lots of money. You can do very simple things at home, you know, with your own body weight that can be effective. I like to meet my patients where they are. So if you are sedentary, just start walking a one 30 minute walk after dinner every day can lower your risk of diabetes. I think by 50% and some patients. Okay. If you if you're sedentary, so don't feel like you have to suddenly train for a triathlon or a marathon. Just going for a walk every day can lower your stress, improve your sleep and decrease your risk of diabetes and insulin resistance. Track your protein intake for a few days. Download a free nutrition tracker. My favorite is chronometer. It's free. It was developed for nutrition scientists and it can just help you get an idea of how much fiber are you getting? How much vitamin D are you getting? How much magnesium are you getting from your food? If you purchase pre-order the new Perry menopause, this is pretty cool. We have a symptom tracker. So you get a whole guide. You get the whole first chapter to read for free. We'll just give you the PDF. And in the back of it is like a three page symptom tracker that you can actually take to your doctor and share with them to help you explain what your symptoms are. Decide on one intervention. Intervention. You're going to try and commit to it for three months. Is it going for that 30 minute walk a day? Is it upping your fiber intake by 10 grams a day? Is it monitoring your protein intake? Is it, you know, checking your vitamin D level and enjoying a vitamin D supplement? Just commit to one intervention. Do one small thing. Is it finding a menopause educated provider and making an appointment to discuss your symptoms and what hormone therapy could possibly do for you? Also, share this podcast. Share this information with a woman who needs it. That is how we grow. That is how we maintain. That is how more and more and more women, how we get to normalize this so that the demand increases and that our institutions, our teaching institutions, our training institutions will be forwarded. Our institutions will be forced to keep up with us and the demand that we are providing. And the most important thing is believe that better is possible because it is. Believe that you deserve this. Believe that this, your life after reproduction ends should be your time of wisdom, your time of thriving, and your time to have the best third of your life. 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 on Amazon and everywhere you buy your 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 Haber. 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.