[Mary Claire Haver, M.D] (0:00 - 0:09)
We define perimenopause as a zone of chaos. What used to look like this beautiful EKG, now is like I took spaghetti and threw it at the wall.

[Angela Foster] (0:09 - 0:17)
Your brain doesn't know what's happening, the brain hates the chaos. The symptoms that you're describing, I'm not sleeping as well, I've got brain fog, I have anxiety, I don't feel like me anymore.

[Mary Claire Haver, M.D] (0:18 - 0:44)
Usually the first signs of perimenopause are night cycle disruption, periods becoming erratic or last. It is mental health changes, both anxiety and or depression. It is sleep disruption and brain fog.

These are women who had their shit handled. They were running businesses, running mom groups, running after school activities, running their kids around and all of a sudden they're like, I cannot do this anymore. Occasionally in the chaos, you'll hit your normal levels, right?

And that's when you're like, what was all that about?

[Angela Foster] (0:44 - 4:11)
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Dr. Mary Claire Haver, you are a board certified OBGYN, Menopause Society certified practitioner, multiple times bestselling author, about to be again, right? New York Times bestselling author of The New Menopause, now have a brand new book coming out, The New Perimenopause. You have millions of followers because I think you just make this information so accessible.

So first of all, thank you for coming and spending time with us today. Thanks for having me. I'm going to dive in with a question that has come from my community in multiple formats.

And I think it is just so prevalent and what women are really feeling. And the question is this, why is everyday different? Do hormones shift that much?

One day I feel normal and the next day I feel awful. What is going on?

[Mary Claire Haver, M.D] (4:11 - 8:28)
We define perimenopause as a zone of chaos. So once we go through puberty as women or as adolescents, we don't have steady state hormones other than testosterone. Our oestrogen and our progesterone produced in the ovary and our stimulating hormones, the LH and FSH produced in the brain come down in waves.

And they're usually in a healthy person, very predictable where on day 12, your oestrogen will be this on day 16, your progesterone will be that. And what happens is you get an almost EKG like ebb and flow of hormones month after month after month. That's very, very predictable.

And most women, their brains, their bodies respond really well to this. So it's not steady state. There are some fluctuations, but they're very, you know, they're very reliable, very predictable.

Now we do have a few women who will have a lot of sensitivity to the drop in progesterone in the luteal phase and have premenstrual dysphoric disorder. After pregnancy, many, many women struggle with mental health due to the oestrogen decline. So, you know, if you think about it that way, and then when we get to perimenopause, which we call the zone of chaos, what happens is the best way I can explain it.

So bear with me. Females are born with their entire egg supply. Okay.

I didn't realise that. Like that wasn't like it was taught, but it wasn't like emphasised the like endocrinologic significance of that. And menopause represents the end of your egg supply.

Okay. The cells around the egg, which we call follicular cells and in humans, they're granulose and the gluten cells, those cells are where the hormones are actually produced. So in order to get this egg to ovulate each month, we have this stimulation coming from the brain saying we need oestrogen.

We want our oestrogen back. It starts pumping fluid around, you know, into around the eggs until one of them gets so big, it forms a system, pops and the egg comes out. Okay.

Meanwhile, the cells around those eggs are producing the sex hormones in this very regular basis. And then after ovulation, the progesterone is produced. So perimenopause begins when we reach a critical egg threshold level.

And it's different for every person. As far as when that happens to you, we can slow it down a bit. We think with good nutrition, anti-inflammatory foods, regular exercise, low stress, we can speed it up by smoking, trauma, inflammation, surgery.

I mean, there's lots of things that can speed it up. So now you've reached your critical egg threshold level. The signals come from the brain like normal.

Okay. But the eggs can't respond. There's not enough eggs to get that usual feedback of the hormone levels going back up to the brain.

So the brain's like, whoa, where's the oestrogen? And the rest of the brain's like, I sent the message. Like, you know, we sent the signals down and the brain says send more.

So now we get much higher levels of FSH and the pulsatility of LH starts becoming erratic. And FSH starts climbing, climbing, climbing in order to force the remaining eggs for one of them to ovulate. So then we'll get an ovulation that might be delayed.

And then sometimes we'll have a loop ovulation where we have a second ovulation back to back. So we can, in some cycles, end up getting much higher oestrogen levels than we've ever had outside of pregnancy. So what used to look like this beautiful EKG now is like I took spaghetti and threw it at the wall.

And it is a very chaotic thing. So the brain was used to this ebb and flow. Maybe you had a couple of bad days in your luteal phase, but nothing you couldn't manage.

And now your brain doesn't know what's happening. The brain hates the chaos. So usually the first signs of perimenopause are not cycle disruption.

Periods becoming erratic are last. It is mental health changes, both anxiety and or depression. It is sleep disruption.

Okay. You used to be a good sleeper and now you can't fall asleep or you're waking up in the middle of the night, sometimes both. And brain fog.

That, you know, where and how we process glucose starts changing when the oestrogen levels change. So in our auditory, in our processing centre that consolidates memory, we see it in the frontal lobe, also in the amygdala. That is where our emotions kind of process in the brain.

It's really fascinating when you look at the actual science.

[Angela Foster] (8:29 - 8:59)
It's really interesting. So what you're saying, and this, interestingly, this dovetails because we've surveyed thousands of women and when they've completed the quiz, what comes up so often is exactly the symptoms that you're describing. I'm not sleeping as well.

I've got brain fog. I have anxiety. I don't feel like me.

I don't feel like myself. Yeah. Yeah, exactly.

But then ask them, how do you feel? Do you feel in sync with your cycles? Yes, I do.

And it's obviously because what you're talking about here is the earlier stages. And so it's kind of coming over from a much more mental health perspective.

[Mary Claire Haver, M.D] (8:59 - 9:06)
I mean, it's the brain fighting to make the ovulations happen. And so that's causing chaos in the brain first.

[Angela Foster] (9:06 - 9:10)
And so that's why women can wake up one day and they feel good. And then the next day.

[Mary Claire Haver, M.D] (9:11 - 10:18)
Yeah. I mean, occasionally in the chaos, you'll hit your normal levels, right? And that's when you're like, well, what was all that about?

I feel fine. I don't know what. And then two, three, four weeks later, you're not managing the life you built.

These are not women by and large who are having new onset of any external dramatic factors in their lives they're trying to deal with. They built this life. They were rolling with the punches.

They had good days and bad days, but they hadn't managed. And then now they've lost their resilience to the normal day-to-day stresses. Now our stresses can be high at this time, right?

We've got ageing parents. A lot of us are raising teenagers, young kids, you know, job, all the things, body changes. And so, you know, that is a thing.

But I mean, my patients were my friends. You know, these are women who had their shit handled. Like they were running businesses, you know, running mom groups, running school, afterschool activities, running their kids around.

And all of a sudden they're like, I cannot do this anymore. Like I am not able to function in the life that I on purpose built for myself. And that's what I'm talking about.

[Angela Foster] (10:19 - 11:00)
Yeah, for sure. And I think the thing is, it's very difficult, isn't it? As you say, to distinguish between how much of this is hormones and how much of it is life.

Because I was having this conversation with one of my lawyer friends recently. I used to be a lawyer. And, you know, in our twenties, we didn't even think about resilience.

What was that? You don't even know the word until you actually need more resilience. But she was saying, you know, before in my twenties, I was in meetings.

Now I lead meetings, right? I didn't have kids. Now I'm kind of like leading a family.

So in so many areas, as you say, like ageing parents, you're being called to a higher standard at the exact same time that you don't have this hormone resilience. So what is the answer when we look at these very early symptoms? How can we bring our brains back online and feel like ourselves again?

[Mary Claire Haver, M.D] (11:01 - 12:03)
Sure. So, you know, it's a toolkit. I wish I could wave a magic wand and one thing would make everything better.

But we have to literally triple down on all of the lifestyle issues. Are you protecting your peace? Are you getting therapy if you need it?

Are you maintaining those important friendships and emotional connections in your life? Are you really eating an anti-inflammatory diet? Are you eating on the go?

Are you prioritising your nutrition? Are you exercising on a regular basis? Are you prioritising your sleep?

And also in our clinic, we will do a lot of blood work to rule out other things that look a lot like perimenopause, like autoimmune disease, hypothyroidism, low iron stores is a ferritin level. What's her magnesium? How much vitamin D is she getting?

Like we are looking at all the pieces of the puzzle, right? And then helping her build a runway to help her get through this. For a lot of patients, we'll do a trial in perimenopause of hormone therapy, you know, and see what gets better.

And so for so many patients, it is a very important part of their toolkit in order for them to just maintain their homeostasis.

[Angela Foster] (12:04 - 12:10)
And how does a woman listening to this know when she might start to think about menopause hormone therapy? She knows.

[Mary Claire Haver, M.D] (12:10 - 12:45)
I don't have a single patient who's not intelligent enough to know something's not right. And I'm willing, you know, they're coming in saying, let's try it. Let me, let me have a chance.

I'm like, let's get some blood work, make sure your thyroid's functioning, you know, all the other things. And then let's go for three months. It's, it's so safe, right?

And see how you feel. It might not work for you, but it may be amazing. So let's give it a try.

And it's, you know, on the, on the menu is, you know, oestrogen plus or minus a progestogen. And then of course, possibly testosterone, depending on her symptoms.

[Angela Foster] (12:46 - 12:53)
So when you're looking at hormone therapy, what's the best place to start? Do you start with some women with progesterone only? It really depends on their symptoms.

[Mary Claire Haver, M.D] (12:53 - 13:33)
So if they're early in the, in the process, you know, we've done all the blood work and everything looks okay. And her main symptom is sleep disruption. We might start with progesterone first.

If it's mental health, we need to put in oestrogen. We need to stabilise that chaos, you know, and so it just really, it's a really nuanced decision on where to start, how to start. Now, if you start someone on oestrogen and they have a uterus without a progestin containing IUD in it, we need to add something to protect the lining of the uterus.

And for most women, that's going to be progesterone, but quite often women have had hysterectomies or have an IUD and I'm adding in progesterone for the sleep benefit.

[Angela Foster] (13:34 - 13:44)
It's interesting what you say there around oestrogen and the mental health benefits, because I think so many women struggle with that. And often they'll get met with an antidepressant prescription from their doctor.

[Mary Claire Haver, M.D] (13:44 - 14:09)
So if you look at the data that actually came out of Australia in 2023, they did a deep dive and looked at and started doing transdermal estradiol, so patches to treat women with mental health. So new mental health changes or were previously well-controlled on their meds. And they found that starting them on hormone therapy had better outcomes than starting them on SSRIs.

[Angela Foster] (14:10 - 14:13)
Interesting. And do you ever see a benefit for both?

[Mary Claire Haver, M.D] (14:13 - 14:29)
Yeah, sure. So if someone is better, but not 100%, we will go ahead and add an SSRI. And if they're well-controlled on their SSRI, we will keep them on it and then add oestrogen to it if they were previously well-controlled.

[Angela Foster] (14:29 - 14:53)
Okay, got you. And what about testosterone? I know I take a female testosterone out of Australia.

It comes from a testosterone cream that made a big difference to me in terms of, I know my doctor, she said to me, when you try this, you know that feeling when you're like, I really don't feel like unloading the dishwasher. It just feels like too big a hassle. All of a sudden, those things are going to feel easy.

And I think I can definitely say testosterone has made a difference.

[Mary Claire Haver, M.D] (14:53 - 16:40)
Yeah, the best data in testosterone that we have is for the treatment of hypoactive sexual desire disorder. So adding in testosterone for those patients can be really, really wonderful. And so when my patients are coming in complaining of desire issues and someone who doesn't have pain, when we look at female sexual function, there's usually five buckets that they may fall into.

So a pain disorder, an arousal disorder, a desire disorder, a relationship disorder, and testosterone does not help a relationship. And so once we kind of rule out those things, and then I'm like, okay, we'll give testosterone a try. And if it doesn't work in three months, it's not going to help them.

In the US, we have two FDA approved products for the treatment of desire. But you guys, you know, Australia, New Zealand now, and I think the UK is working on it, have approved products through the government for the treatment. The US does not.

So we either compound it or we borrow the men's version and microdose it here in the US. Now, as far as like emotional, we don't have enough data for me to say to a patient, this is going to help your depression, this is going to help your anxiety, this is going to help your sleep, but our patients are saying it does. So I always give that caveat, you know, I don't have enough data to clearly say there's a great study that looked, I think we're asking the wrong questions in these studies, by the way.

But anecdotally, and like all of us across the menopause who use testosterone are seeing the same thing in our patients of them saying that they're seeing benefits outside of just desire. And desire is a mood, right? Desire is in the brain.

Testosterone receptors are all over the brain, it just makes sense if we get you back to your levels that you had in your 20s and 30s, you might see some benefit.

[Angela Foster] (16:41 - 16:47)
And when you look at libido, and women, you know, reducing, is it the testosterone that's that's causing that?

[Mary Claire Haver, M.D] (16:47 - 17:23)
It's complicated. So like I said, you know, libido is in the brain. So in we call in medicine, we say desire, libido is a term by Freud, and I think he's a quack.

And so I try to not use that word. And so, but it's the desire. And it's like, did you ever have good desire, right?

It's not going to give you desire, if you were never desirous at 30. It really works best for desire in a patient who used to have great desire, who used to look forward to intimacy, who enjoyed it, you know, was spontaneous. And so for those patients, we see the greatest benefit.

[Angela Foster] (17:24 - 17:30)
Okay. And what about when you're talking about oestrogen? What about localised like oestrogen creams and things like that?

Yeah.

[Mary Claire Haver, M.D] (17:30 - 18:42)
So when we have patients with, you know, every woman is going to vagina is going to change after menopause, and you're through the menopause transition, and even postpartum, right, we use vaginal oestrogen in any low estrogenic state. So while you're nursing after having a baby, if you're suppressed, even on birth control, you will see changes in the vulva architecture, thickness, the ability to make mucus, the ability to fight off infection. So vaginal oestrogen should be over the counter.

I think it is in the UK. And it's so important to keep the health of the genital area healthy. So recurrent UTIs, number one treatment for prophylaxis should be vaginal oestrogen in a patient.

And so if they're having pain, and it's from general urinary syndrome of menopause, not all genital pain is that, right? We have vulvar disorders, and you know, those types of things have to be figured out. Before a menopausal patient, most of us are going to have significant changes to, you know, over time to our vulva.

And in our clinic, we try to get ahead of it and do prophylactic vaginal oestrogen for all of our patients, so that she never has to suffer. So this is in addition to taking... Yeah.

So quite often, our patients are on both systemic and low.

[Angela Foster] (18:42 - 18:46)
Okay. Interesting. And can systemic ever be enough?

[Mary Claire Haver, M.D] (18:46 - 19:32)
For a few patients, but not many. I mean, I have to say, eventually, most patients of mine will need an additional topical therapy. It's like hard to get enough.

You know, remember, when we're giving you menopause hormone therapy, we are microdosing what your ovaries used to make. We are not giving you physiologic doses that you had at 25, not even close. So to think that this microdose that was designed to stop a hot flash, okay, that's the whole reason why menopause hormone therapy was developed.

Not for mood, not for skin, not for your bones. You know, the bone finding was just anecdotal when they were treating women's hot flashes. And so when that is a microdose, it is not physiologic to a 30-year-old.

And so that tends to not be enough to penetrate to get through into the general urinary system. So we treat locally.

[Angela Foster] (19:33 - 19:40)
So this is interesting because still I hear a lot of doctors, right, going with the lowest dose. Is that good practise?

[Mary Claire Haver, M.D] (19:41 - 19:52)
That has been struck from the record. So if, you know, that's old thinking. So if any doctor is still saying that lowest dose for the shortest time possible, they have not kept up with the latest guidelines.

[Angela Foster] (19:53 - 19:53)
Okay.

[Mary Claire Haver, M.D] (19:53 - 19:55)
So you wouldn't start at the lowest dose?

[Angela Foster] (19:55 - 19:57)
No. Necessarily?

[Mary Claire Haver, M.D] (19:57 - 20:30)
No, not necessarily. I mean, sometimes, you know, it's a nuanced decision based on age, stage, risk factors, et cetera. But for a young, healthy patient, I am not starting at the lowest dose.

Well, in perimenopause, often we are if she's still cycling. And so we're just trying to give her enough to stabilise those dips and to calm the brain down, to have enough in the background so the brain's not like, you know. And so for that, for those patients who are younger, we will often start with the lowest dose, but not a postmenopausal, young postmenopausal patient.

Again, nuanced. This is years of treating patients.

[Angela Foster] (20:30 - 20:42)
Yeah, it's very nuanced, very individualised is what I'm hearing from you and everything that you do with all the blood work and everything. But a question that comes up commonly is, how long can you stay on it? Can you stay on it for the rest of your life?

[Mary Claire Haver, M.D] (20:43 - 21:50)
As long as for you, the benefits outweigh the risks and you want to do it. So that could be forever. Like I'm 57, I'll be 58 in a few months.

I don't see a scenario outside of developing a tumour that was being fed by the, you know, and that may happen. I'm not causing it to happen. But you know, if that happens to me, then, and you know, medical guidance suggests coming off of the hormones through my treatment would be optional.

I would do it. But until then, it's always protecting my bones. It's keeping my hot flashes away.

It is, I have, look, I am living my best life. Okay. Like you, every, you should want to be me.

I am like happier. I have better sex. I have better relationships.

I have better boundaries. I say no all the time. I am like living the life of my dreams.

I wake up and I cannot believe this is my house. This is my life. I live in this, this is my bed.

Look at this view, you know, and I live on the water on a little Island in South Texas. And just, I wake up with gratitude every day. And why would I mess that up?

Why would I change anything?

[Angela Foster] (21:51 - 22:07)
When would you say that you started to feel like that? Because what I'm hearing from you is when you're prescribing hormones, right? This is a lower dose.

And so the woman's hormone, until she reaches menopause, they're still going up and down, right? You've just raised the floor. So she doesn't go so low that she's too symptomatic, but she's still going to get oestrogen dominance.

[Mary Claire Haver, M.D] (22:08 - 22:40)
So yeah, menopause hormone therapy doesn't suppress ovulation, right? That's what you have to understand. It's not a high enough dose.

When we suppress ovulation, we are giving you mega doses of ethanol estradiol in the birth control pills or, or mega doses of progestins to bind so tightly to the hypothalamus pituitary to prohibit the like production of LH and FSH, which cause ovulation. Menopause hormone therapy doesn't do that. You're still cycling in the background.

We're just taking some of the chaos out of it to give you back some resilience.

[Angela Foster] (22:40 - 22:47)
So when would you say, just to give some hope, when does a woman start to feel as good as you're feeling now?

[Mary Claire Haver, M.D] (22:47 - 24:05)
Is that after the menopausal transition? I was on Mr. Toad's wild ride in perimenopause. I was not a menopause specialist.

I didn't understand. I just thought I was crazy. I was yelling at my kids all the time.

You know, I was on birth control, you know, for way too long for me. And, you know, I didn't understand what was happening. And so now that I see my patients in perimenopause, they just are just happy to get their lives back just to feel like, okay, I've got this.

For me, it's really been, I went through a lot in my late perimenopause. I lost my brother, two brothers and my dad. Okay.

So I had two brothers with one with cancer, one with hepatitis and HIV, and my dad had age related, you know, stuff. And they died within like four years of each other. And my dad and the second brother died nine months apart and it was COVID.

So that was a lot. And I was transitioning out of a job and, you know, just into a new position and, you know, a lot was going on. So I feel like once I decided to live the life I wanted to live and stop asking for permission from boss, you know, I build a clinic that I believed in and it was successful and, and just started being my true authentic self.

That was probably 53, 54, like four years ago.

[Angela Foster] (24:06 - 24:26)
I hear so many women in their, in their sort of early to mid fifties say to me, it just feels so good, like coming out the other side of it. Very consistent with what you're saying. What about birth control?

Because you mentioned it, that was one of the questions from my community. Many women are actually on birth control. So then the question is.

Yeah.

[Mary Claire Haver, M.D] (24:27 - 25:38)
And I was too. And it was controlling other stuff that I had going on. Like I don't want to demonise birth control, but a lot of clinicians, that's all they know how to give premenopause.

And, you know, if a patient needs contraception, okay. If she's having heavy, heavy, heavy, irregular periods, birth control can do amazing things to help control that. If she's on birth control and perimenopause to control her symptoms, you know, so like sometimes in the placebo week, we might give her a little bit of oestrogen to kind of tide her over, not enough to suppress her periods or anything, but like, there's lots of ways that, you know, I will use birth control pills and perimenopause and patients do amazingly well, or if they're on them and happy and only really having symptoms in the placebo week, then there's stuff that we can do. You know, if their husband won't get a vasectomy or they haven't had sterilisation and they need contraception, they can get pregnant.

It's, it's harder, but it can happen and they don't want to be pregnant. This may be, you know, or their cycles are out of control, you know, and the Mirena IUD is not an option for them. Then, you know, I love having lots of tools in my toolkit here, but it's not my go-to.

[Angela Foster] (25:38 - 25:44)
It is not your go-to, but say a woman is on birth control. She feels very happy on it.

[Mary Claire Haver, M.D] (25:45 - 26:27)
Is there a reason? Okay, don't fix it. So I'm still doing all the labs.

I'm still like going through, if she's having, you know, she feels good, but she's having weight gain or like, she's having just a couple of symptoms. We'll do the full workup and then start like making a plan. You know, once you go through full menopause at that, you know, and to make that diagnosis, we're going to have to pull her off the birth control pills for a few weeks and then check her lab levels.

A lot of women like on their placebo week, we'll start having hot flashes. That's one clue. Or like if you start getting really symptomatic on your, in your placebo time, then that's a big clue.

And so sometimes like at the very end of the pill pack, like at the end of placebos, we can do some hormone blood work to make some guesses.

[Angela Foster] (26:28 - 26:32)
Okay. And what about belly fat? This is so super common.

[Mary Claire Haver, M.D] (26:32 - 27:26)
Oh yeah. So that's what brought me to, to my knees. I've had thin privilege most of my life and you know, all of a sudden this new body composition change.

So new accumulation of belly fat. I mean, this is a expected biological consequence of hormonal chaos. If you do nothing different, you will shift weight to your abdomen.

That's it. So there's very few women who can get through menopause without this happening. Now, is it inevitable?

No. Or is there stuff we can do? Absolutely.

You know, and it's more than cosmetic, right? No one wants a big tummy because the way we were socialised that we all should look like 14 year olds. But actually the intra-abdominal fat is metabolically dangerous.

And so in our clinic, we have a body composition scanner. So every single patient leaves my office knowing how much muscle mass she has, how much total body fat and how much visceral fat she has. We don't even talk about her weight.

We don't care what she weighs.

[Angela Foster] (27:26 - 27:30)
And what have you found are the best ways to shift the visceral fat?

[Mary Claire Haver, M.D] (27:30 - 28:18)
Yeah. So that's, that was the evolution of the Albertson diet. And so anti-inflammatory nutrition is huge.

So really, really focussing on whole grains, legumes, seeds, nuts, plants, you know, heavily plant-based as close to nature as we can get it. Avoiding processed foods, avoiding simple carbohydrates as much as possible, not counting fruits and vegetables. That's, that's God's fruit.

You know, that's God's sugar. And that's, that's usually fine. Cause it comes with vitamins, minerals, nutrients, fibre, right?

Very, very different than heavily processed foods where all the nutrients have been stripped away and they're chemicals and all these things that kind of disrupt the way we're really supposed to eat, making sure we're getting enough protein that, that really seems to turn the needle and healthy fats can be amazing for satiety and helping people stay full longer. What about bloating?

[Angela Foster] (28:18 - 28:20)
This is another abdominal symptom.

[Mary Claire Haver, M.D] (28:21 - 29:55)
So great, great question. So bloating is the presence of too much gas, liquid, or solid in the gut. That's all it is.

Okay. Too much air, too much water, too much solid. And that usually happens, you know, if you, nothing in your diet has changed, but you're all of a sudden having bloating, then your gut microbiome has changed.

And we know this like Zoe, the Zoe team out of the UK, like collected stool samples on a bajillion women all through the menopause transition. And they saw the body, the composition changes of the stool, like the decrease in the amount of healthy back to, you know, healthy gut bugs and decrease in the, the profile. So instead of having this like really robust profile with lots and lots of different healthy bugs, you get really tight.

And so are the gut microbiome approaches that of a man. So we have a very different gut microbiome premenopausal, and then we become more manlike. And so, you know, we're really starting to understand the function of the gut microbiome and the gut bugs that produce these chemical and neuromodulators that go back into the bloodstream and do all this positive stuff.

And so we see loss of that across the menopause transition, also in perimenopause, how we reprocess oestrogen. So the oestrogen metabolites will get excreted through the liver into the bile and then into the colon. And then the gut bugs will like reconstitute it back into estradiol and send it back up the pipe.

It's really, really fascinating. And so, you know, when I have a patient who comes in with bloating, the first thing we do is look at their diet.

[Angela Foster] (29:56 - 30:00)
And when you, do you think you can fix it with diet alone, or do you sometimes need to add things like probiotics?

[Mary Claire Haver, M.D] (30:00 - 30:26)
I try diet first and like loading up on fibre and multiple sources of fibre, loading up on antioxidants and, you know, all the things that keep, you know, both, both soluble and insoluble fibre, all the things that keep the gut microbiome happy and the water intake, sleep is important. Stress reduction, that's all important, like lowering those cortisol levels. And so, and then we'll add a probiotic if, if we feel like it might be helpful.

[Angela Foster] (30:26 - 30:36)
If it's needed. And what about when we're looking at stress resiliency, you mentioned that looking at women's HRV, do you see changes in things like their resting heart rate, their heart rate variability?

[Mary Claire Haver, M.D] (30:36 - 31:29)
It's funny, because I'm going to have Kristin Holmes, who's like, knows more about HRV than anybody in the country, in the world. And so we're going to be talking about this across, because they track, you know, and they have all the data across menopause. And my patients who wear the trackers, I don't, I took my ring off to do weights.

I just got out of the gym. And, and so I was like, ah, I left it downstairs. And so we do see changes.

Yes, we need more data to really kind of suss out what it is. You know, for me, the HRV alcohol kills it for me. Like if I drink within six hours of bedtime, my HRV tanks almost every time.

And that, that seems to me the most predictable thing. Now, if I have my tea and I do my red light therapy, and I do my sauna blanket, I don't have a sauna here, but you know, have a little blankie thing I can get under. It really makes a big difference for my HRV.

[Angela Foster] (31:29 - 31:47)
So a lot of this from what you're saying can be addressed naturally through changes in diet, through changes in movement, stress, resiliency, sleep. What about when we look at supplements, are there specific supplements that you find helpful with perimenopausal women? You know, in full disclosure, I sell supplements.

[Mary Claire Haver, M.D] (31:47 - 34:56)
So take this with a grain of salt. There are no supplements that cure menopause. Let me be clear.

Okay. I've seen all these advertisements. Get your sexy back, get your life back, all this stuff.

When I talk about supplements, supplements don't fix an unhealthy diet, right? You can't like eat a bunch of processed food, go through the drive-through, you know, get your Whataburger, which is my drug of choice here in Texas. And then take a handful of supplements and they're going to somehow negate each other.

That's not how it works. Supplements are meant to supplement a healthy diet. Okay.

So when I'm approaching supplements, it's usually from a nutritional standpoint with a patient. All right. How much fibre are you getting per day?

Is that a struggle for you? We might need to add a fibre supplement to get you over the hump. And probably the best data on supplements is on fibre.

You know, as far as women in the U.S. and I'm assuming it's the same, get about eight to 10 grammes of fibre per day. But for maximum gut health, we're looking at 25 for women and for cardiovascular health is actually 32 to 35. So my goal is 35 grammes a day.

And so I do a little bit of a fibre supplement in my shake, which I, this is my ritual. To help me get over the hump, right? Is she getting enough vitamin D?

About 80% of my patients are deficient in vitamin D. That's something we can measure and very easily. And it's just hard to absorb.

It's harder as we get older. We're staying out of the sun to protect our skin, you know, and it depends on where you live, if you're not in an area with a lot of sunlight. And so, and vitamin D is critical to multiple body functions.

And so that's quite often something we'll recommend. Our vitamin D supplement also has vitamin K to increase absorption and omega-3 fatty acids, which, you know, we don't have a deficiency, but it just really, really is a powerful antioxidant and anti-inflammatory. Then we look at things like creatine.

Okay. Creatine. I mean, if you eat 12 chicken breasts today, you can get creatine.

We just don't store it as well as we get older. It's an age-related decline in our I am constantly in the gym trying to stay strong so that I avoid the nursing home that my mother and grandmother needed, you know, because of their frailty with age, like for years. Right.

And so creatine is helping me with muscle recovery. And, you know, there is some data to suggest it's great for brain health. I also have, you know, I recommend quite often a protein supplement if women are struggling to get enough protein in their diet.

We, turmeric for patients who are struggling with inflammation and menopausal women has shown to be helpful. We looked at some studies that were done on a certain type of collagen for bone health and skin health. And so that's another thing you might consider.

So it's not like I'm like rolling out a bucket, you know, or a wheelbarrow full of supplements and saying, here you go. It's like, what are your goals? What are we missing?

If she's getting enough fibre in her diet from food, we're good. You don't need this extra stuff, you know? And so I do like the studies on coenzyme Q10 for heart health for women specifically.

But, you know, if she's sedentary and smokes, coQ10 is not going to do anything. And so, you know, you really have to like, this goes on top of the healthy lifestyle as like a sprinkle.

[Angela Foster] (34:56 - 35:05)
Which is why they're supplemental. Yeah, absolutely. What made you write the new perimenopause after writing new menopause?

Patients ask me to, you know, they're like, what about us?

[Mary Claire Haver, M.D] (35:05 - 35:34)
And so now the postmenopausal patients are like, Hey, I'm like, let me birth this baby before I get pregnant with the next one. And so the new perimenopause is not the waiting room for menopause. It is its own completely distinct biological transition.

It's very, very different because of the brain symptoms that are happening that really calm down in postmenopausal, you know, in the menopause. And so it deserved its own book. And I don't want any woman to walk into this blindsided.

[Angela Foster] (35:35 - 35:53)
Well, I think you're sharing so much valuable information to help women. It's just fantastic. When you get to menopause, which is obviously one year after your last period, how quickly do things then stabilise for women in terms of the brain and everything?

So hormonally, everything flatlines.

[Mary Claire Haver, M.D] (35:53 - 36:53)
So treatment becomes actually easier for us, you know, because we're not fighting against waves in the background. Okay. Brain health does tend to stabilise quite a bit within the first couple of years of postmenopause.

So mental health gets better. And then the brain fog does tend to get better. So those are the key things.

The musculoskeletal stuff does not get better, you know, unless you give oestrogen, the, you know, skin changes do not get better. So, you know, the brain does tend to, you know, we call it the neuroscientists call it like a recalibration, a remodelling of the brain. And so during the remodelling process, like any remodelling process, it's hell.

But then when it's done, you're like, this looks so great. And so we were designed to remodel our brains through the menopause transition. We function more efficiently postmenopausal with, you know, so it's really interesting.

You can count on the brain symptoms getting better. Sleep is another, sleep is, that is something we still struggle with postmenopausal.

[Angela Foster] (36:54 - 37:20)
Unique you on. Yeah. I mean, reassuring on the brain ones, right?

Because I think so many women are struggling and just the up and down this of it all despite menopause hormone therapy and all the other good things. Thank you so much. This has been so amazing.

The new pair of menopause is coming out. There it is. Amazing, amazing, but it's going to help so many women.

Please share, Dr. Haver, where can women connect with you? Where can they buy your book and everything?

[Mary Claire Haver, M.D] (37:21 - 37:45)
So all of our social media at Dr. Mary Claire. So D-R-M-A-R-Y-C-L-A-I-R-E. And then on our website is the pause life.com.

And we have tonnes of free resources. We have menopause quiz, we have blogs, we have resources, we have free downloadables, you know, questions to ask your doctor, what labs should you be considering, you know, at your next visit, how to discuss these labs with your doctor.

[Angela Foster] (37:46 - 39:11)
Thank you so much, Dr. Haver. It's been amazing to have you on and we will link to all of that in the description. Thank you so much.

I hope today's episode inspired you on your journey to vibrant health and high performance. Make sure you check out the show notes for a summary of all the important links to everything we talked about. And if you enjoyed this episode, hit the follow button and share it with a friend on social media or leave a review over on Apple podcasts.

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Perimenopause isn't the waiting room for menopause. It is its own biological storm. Here's what it does to your body, and exactly what to do about it.
In this episode I'm joined by Dr. Mary Claire Haver, board-certified OB-GYN and Menopause Society certified practitioner, and we break down exactly why women in this transition feel like they've lost themselves and how to get back and live their best life.

WHAT YOU WILL LEARN
• Why do you feel fine one day and awful the next in perimenopause
• What is the "zone of chaos" and why your brain feels it first
• Why anxiety, brain fog and sleep disruption are the first signs of perimenopause
• Does estrogen work better than antidepressants for mood
• When to start hormone therapy and where to begin
• How long can you stay on HRT
• Why belly fat increases in perimenopause and how to address it
• How the gut microbiome changes through the menopause transition
• Which supplements actually help women over 40: creatine, vitamin D, fiber and more
• What vaginal estrogen does and why most women need it