All About Menopause: Expert Advice from Dr. Mary Claire Haver - Part One

Dr. Thais Aliabadi:
Hi, I am Dr. Thais Aliabadi.

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Mary Alice Haney:
I'm Mary Alice Haney. On today's episode, we have Dr. Mary Claire Haver. Dr. Haver is a board-certified OBGYN, and a certified culinary medicine specialist. She's the expert on all things menopause. Want to know what to eat during menopause? Well, Dr. Haver literally wrote the book on it. She's the bestselling author of the Galveston Diet and has a new book out, which I can't wait to read, called, The New Menopause. Dr. Haver is leading the much-needed conversation about menopausal healthcare, and we're going to get into all of it with her on the show today. Stay tuned. This podcast is for educational and entertainment purposes only. It is not intended as a substitute for a physician's medical advice. You should regularly consult your medical provider in matters relating to your own health. Dr. Mary Claire Haver, we are so excited to have you on this show today. You are a board-certified OBGYN, a certified culinary medicine specialist, the author of the bestselling book, the Galveston Diet. You have a new book coming out soon called, The New Menopause, which I am so excited to read. You have a clinic dedicated to caring for patients going through menopause, and you have over 3 million followers on social media. My sister, who's an NP, is the first person that introduced me to you and she's like, you've got to watch Dr. Mary Claire on Instagram, she's so incredible. You talk to your patients directly, to all the women out in the world talking about menopause, and in this issue that's still so unknown and scary to so many women. So we're really just so excited to have you here. This is the famous Dr. Thais Aliabadi.
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Dr. Thais Aliabadi:
Not as famous as you. Nice to meet you. I'm so excited to have you here. Menopause hit me so hard after I was diagnosed with breast cancer and I ended up removing my ovaries. As a gynecologist, I've treated women with menopause for so many years, but when you yourself go through it's shocking, it's shocking. So I just want to talk about everything menopause with you. We want to learn how you treat patients and when you choose to do a hormone replacement, when you don't. So all questions related to menopause.
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Dr. Mary Claire Haver:
Let's do it.
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Mary Alice Haney:
I'd love to actually just back up a tiny bit and understand, how did this start? How did you decide to devote your career to menopause and perimenopause?
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Dr. Mary Claire Haver:
So I was in a large academic institution as a professor in OBGYN. I was a residency program director, I taught medical students. I had a large private practice through the hospital and was really happy doing that for a long time. My patients were aging along with me, we'd gotten pregnant together, had babies together. You start and you get all the new OB patients. Then I was noticing I in perimenopause was on birth control pills to treat polycystic ovarian syndrome and I did really well on them. I had no problems with them, and so most of my perimenopause was probably masked. Then my patients are starting to have this complaint over and over and over again, same kind of constellation of things. I'm gaining weight, I'm gaining weight in new places, I'm having trouble sleeping, I'm having all these issues. Honestly, in my OBGYN residency, we had, holding my fingers up, like the tiniest amount of menopause education. My last year of training was when the women's health initiative was released and we were all terrified to even discuss hormone therapy because of this supposed, what was reported at the time as this dramatic increased risk of breast cancer. So it really wasn't part of my practice to have much of a discussion like screening for menopausal symptoms, learning outside of the stereotypical hot flash and night sweats, that I didn't know that menopause could affect every organ system of our body. These symptoms could be much further reaching than genital, urinary, and osteoporosis. That's basically what I was taught. So my patients are having all these complaints. These are women I went to church with, I grocery shopped with, I ran marathons with. These are not random people. These are people I've taken care of for years and I lived and worked in a community with. Who were like, look, something has changed, I'm not okay, I can't. Their resilience has dropped to certain things and they can't put their finger on it, and I didn't have enough training at the time to really put this constellation of stuff together. I mean, you might have something similar in your training program, but we would have GYNE clinic, gynecological clinic and the upper-level residents would get all the charts first and they would screen them out for the surgery cases because they wanted to get their surgery numbers. Then everything left at the bottom were the interns. So here I am a new intern and we're getting the whiny gynes or the whiny women, the WWs is what we call them in Texas. Now I look back and I'm like, we were just taught to dismiss them, that they were a little bit emotional, and I mean, such a disservice when they were probably going through perimenopause and just didn't have the words to put with what was happening to them. So once I go through it, so I get off birth control pills at 48 years old to see where I was at hormonally, immediately was fully menopausal. Went from zero to 60 of just dramatic hot flashes, night sweats. At the same time, my brother had passed away and I was grieving his death and I was gas lighting myself that, oh, this must be grief and I'm not sleeping because of this and I'm having pain. There was probably a component to that, absolutely, but once the grief fog started lifting like six months later, I'm still miserable. Then I was like, wait, when was my last period? Oh my god, I'm in menopause. This is my job and I couldn't even figure it out for myself. So that's when I got curious. It really started, I was struggling with this new abdominal fat distribution. I was like, what is going on with this? I was calorically restricting, working out twice a day, still not able to get the weight loss to stick. My husband was like, your girls are watching. Now my oldest is 23, she's in med school, Maddie's 20, she's in college, but they were teenagers back then and they were watching me weigh myself multiple times a day, watching me complain about my weight, watching me really have all this almond mom kind of food tendencies. My husband's like, is this really what you want to model for the girls? You're smart, figure this out. So that began my journey into learning more about menopause and inflammation and body changes and the whole nine yards. So I start talking about it on social media and I mean, I wrote a book called The Galveston Diet, basically how a menopausal person could approach nutrition. I went back to school, got certified nutrition. Then the questions just exploded. Well, what about this? What about that? What about that? Instead of automatically dismissing them, I got curious and started digging in the research and found, wait a minute, brain fog. Wait a minute, cognition changes. Wait a minute, depression, anxiety. None of this was ever taught to me and not really put forth, you can probably agree, in our ABOG articles where we get recertified every year, there's almost never anything on menopause. You really have to seek out certification and training outside of our traditional OBGYN residencies. That's how this all happened.
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Dr. Thais Aliabadi:
That is so true, and I couldn't agree with you more. You're incredible. Do you mind starting from pre-menopause and educating our listeners on what pre-menopause is? When does it start? When by definition, what do we call menopause?
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Mary Alice Haney:
I also just want to note really quickly that what's so crazy as we talk about this is that the one thing that every single woman will go through in her life is menopause. The fact that as OBGYNs, you guys were literally not taught about the one thing that every woman will go through is just astounding to me, so.
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Dr. Mary Claire Haver:
We really had the very most basic of education, just skimming the surface. Part of that is, why is it the busy OB-GYN who is dumped with all the cardiological consequences, all the neurological consequences, all the orthopedic consequences. We have enough to do in our day-to-day jobs. In my menopause clinic I'm a little bit of a neurologist and a little bit of a cardiologist. So I really feel like menopause education needs to go across every specialty, all of them, and not just OB-GYN.
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Dr. Thais Aliabadi:
So let's start with pre or perimenopause.
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Dr. Mary Claire Haver:
Okay, so let's step it back even further. Let's explain why this happens to us as females versus males. So men, people with XY chromosomes with healthy testicles, from puberty till death, will make their genetic material fresh every single day. It's like a factory continuing. Females are born with all of our eggs, all of our ovaries. Like the brain, we're stuck with all of the tissue we're going to have, and it's got to last us until it goes away. Okay, so endocrine aging, the aging of our ovaries happens twice as fast as any other organ system in our body. We're born with all of our eggs, one to 2 million at birth. By the time we're 30, we're down to 10% of our egg supply. By the time we're 40, we're down to 3% of our egg supply on average.
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Mary Alice Haney:
Wait, say that again one more time.
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Dr. Mary Claire Haver:
Yeah, by the time we're 30, we're down to 10% of our egg supply. By the time we're 40, we're down to 3% of our egg supply. Menopause signifies we are out of eggs. The ovaries have shut down and there is no more sex hormone. Very, very little, nothing clinically significant hormone production coming from that factory. The factory is closed. So menopause in medicine is defined as no menstrual period for one year after the age of 45. I really think that does a disservice, it leaves out a lot of women who have IUDs and hysterectomies who don't have periods because no one's thinking, what's happening to me, and you don't have that period to judge it by. So average age of period stopping for a year is 51 in the United States, but normal, 95% of women will have this happen between the ages of 45 and 55. Perimenopause is somewhere around when you're hitting, we think about the 10% egg range, maybe 12, where the usual signals from the brain, the hypothalamus and pituitary gland that are telling the ovary each month ovulate, ovulate. Remember our hormone cycles pre-menopausal are this monthly EKG looking thing with an estrogen surge mid-cycle and a little bit of a wave towards the end, and then this massive dump of progesterone right at the end, and the whole thing bottoms out and starts over again. The signals that go... The ovary can't respond to the same level of signals somewhere in our 30s and 40s, and the brain has to work harder making more stimulatory hormones in order to get that egg to release and those hormones to surge. So we see delayed ovulations, massive surges in estrogen, big bottoming out. So your body starts noticing something's different here, and because every organ system is affected, the experience is very different from woman to woman, even from sister to sister.
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Dr. Thais Aliabadi:
Is that why you can't really test correctly?
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Dr. Mary Claire Haver:
It's really hard. A one-time, blood, urine or saliva test, looking at things over time is a lot better but we don't have a technology for that very well. I'd love to have like a CGM like we do for glucose, for hormone levels.
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Mary Alice Haney:
Let's create that. That'll be the next thing that we work on.
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Dr. Thais Aliabadi:
It'll be all over the place.
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Dr. Mary Claire Haver:
If I could invent something, it would be something to track hormone levels consistently over time so that we could say, okay, you're entering perimenopause. So that perimenopause transition from, something that's not right, things are starting to fail, to complete failure is seven to years. So do the math. Somewhere between the ages of 35 and 45, you will become perimenopausal. Now, there are things that we can do to speed that up, but there's not much we've learned to do yet. There's a lot of technology happening here and innovation and how to extend the shelf life of the ovary, but right now there's a lot of claims being made with supplements and all this stuff. Really, other than good health and supporting a nice healthy milieu, there's not much that we can do to push that genetically pre-programmed age of menopause further out.
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Dr. Thais Aliabadi:
Can you explain for our listeners what those symptoms of perimenopause?
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Dr. Mary Claire Haver:
Okay, so what we were taught in school and in training was hot flashes, right? Probably because we can't blame anything else on a hot flash besides tuberculosis, and that's not that common, right? So if a woman over 45 comes in with life-disrupting hot flashes, we pretty much know that that's related to her menopause journey. However-
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Mary Alice Haney:
Or, too much red wine at night.
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Dr. Mary Claire Haver:
Yeah, sleep disruptions related to hot sweats or not, okay, to hot flashes or not, you don't have to have a hot flash to have sleep disruption in menopause. Mental health changes, new onset depression, new onset anxiety, worsening pre-existing mental conditions all go up, we see a fourfold increase across the menopause transition. Drop down to the heart, palpitations both stemming from the thermoregulatory center, which can send signals to the heart, and the sinoatrial node on the heart becomes irritated. Estrogen is a really powerful anti-inflammatory hormone. When it goes away, estradiol, we see new onset inflammation in multiple organ systems. One of the biggest ones is in the musculoskeletal system. So 80% of women will have the musculoskeletal syndrome of menopause, which is basically musculoskeletal joint pain or adhesive capsulitis like we see in frozen shoulder, with no injury. You send them for an MRI, everything's clean, they don't see any injury, but they're having pain. A lot of us in this end of the world think that some of the chronic pain, chronic fatigue, and fibromyalgia is probably just perimenopause, if you look at the age and what's going on with their hormones. So in the genital urinary system now we have known about this for a long time, general urinary syndrome of menopause is basically atrophy. So the vagina, lots of estrogen receptors. When those aren't taken care of, we see that the walls of the vagina get thin, mucus production drops dramatically. The caliber of the vagina can shrink. We see a lot more infection and irritation. The bladder is totally affected, the urethra, so we see recurrent UTIs, sepsis, and all of this is so treatable. Osteoporosis, that's another one we've known about for a long time but a lot of women aren't aware that we can decrease your risk of an osteoporotic fracture by 50% with hormone therapy. The musculoskeletal system works together. So we reach our peak muscle mass and bone density usually in our thirties, most women. We begin a very gentle decline until we hit perimenopause and that accelerates. So we're seeing an increased risk of frailty, all of this is preventable, we are seeing osteoporosis. So if you develop an osteoporosis, 50% of women will have an osteoporotic fracture in their lifetime. This is preventable, and if it happens to your hip, you have a 30% chance of death after the age of 65 in the first year with surgery, without surgery, 70%. That year is marked with horrible decline.
Your asthma, so we see new onset of atypical asthma in perimenopause. We see tinnitus and vertigo, so I'm dying to find an ENT who will sit down and talk to me about this. We're seeing the gut completely changes through the perimenopause transition. So the gut microbiome changes, approaches that of a man. We lose diversity, we lose our good bugs, we lose lactobacillus, which is critical for keeping the vagina and the gut healthy. So all of these things change. We see bloating, headaches, migraines. God, I could go on and on and on.
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Dr. Thais Aliabadi:
Weight gain.
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Dr. Mary Claire Haver:
Weight gain, absolutely. Then body composition changes more than just weight gain because they've really looked at it. Women tend to gain weight as they age, but what's happening is where we're depositing fat changes dramatically. We stop becoming a pear and we move to an apple. So we start driving fat to the intra-abdominal cavity in the form of visceral fat. Listen, curves are beautiful, embrace them. That's your subcutaneous fat that's probably genetic and don't ever feel like you have body dysmorphia because you have curves, but the intra-abdominal fat that turns us into apples is dangerous. This is the fat that is linked to hypertension, diabetes, stroke, and chronic disease. We see a massive acceleration of deposition there just from being menopausal.
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Dr. Thais Aliabadi:
What about hair loss?
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Dr. Mary Claire Haver:
Hair loss. So there's female pattern hair loss and there's male pattern hair loss, and there's iatrogenic hair loss, and all of these can happen through the menopause transition. Some women will suffer from higher androgens and it has to do with steroid hormone binding globulin and how when your estrogen levels drop, we don't make as much binding hormone. So the androgens, the activity of our androgens can increase. So you'll see acne, chin hairs, losing hair in places you want it. Male pattern baldness, I know your listeners, I'm pointing to my temples as more of the temporal baldness. Female pattern hair loss is not related to higher activity of androgens and we see our parts widening. So that could be hormones, it could be genetics. Hair loss is complicated, but we definitely see an acceleration. So it's important to understand why you're losing the hair because the treatment options will differ a little bit based on what the cause is.
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Dr. Thais Aliabadi:
The last symptom that I noticed is skin thinning.
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Dr. Mary Claire Haver:
Yes, so we lose about 30% of our collagen. You don't have to tell a perimenopausal woman-
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Mary Alice Haney:
Oh, joy.

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Dr. Mary Claire Haver:
... A menopausal woman, this through the... We lose elastin and we lose transepidermal water loss increases through the menopause. So all of that combines with dry skin, itchy skin. We also see a lot of nerve inflammation, especially under the skin. So formication, feeling like ants are crawling on your skin. People have horrible itchy ears. That's another one I see quite a bit. Just scratching all night long and when there's no infection or dermatitis, we see that a lot in menopause too.
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Mary Alice Haney:
So what do you do about these symptoms? So you get somebody that comes in. By the way, I went in, no hot flashes, I'm 51 years old, six months ago, actually it was about eight months ago before I met Thais. I was just peeing all the time. I was like, I have a UTI, I'm peeing all the time and I had no other symptoms. He's like, you're in perimenopause. I still had my period, so there's all of these things that nobody tells you about.
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Dr. Mary Claire Haver:
I forgot. Yeah, the urgent continence and the stressing.
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Mary Alice Haney:
Oh my god, I was peeing all the time all over myself, it was terrible. So what do you do when someone comes into your office with these symptoms?
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Dr. Mary Claire Haver:
Okay, so when I approach a patient in menopause, I have the menopause toolkit. Okay, so it's comprehensive care. Most of my patients are coming to me, fix these two or three symptoms, 6, 7, 8, whatever it is, that are affecting my life right now, but I'm looking down the road. I'm looking at my mom, I'm looking at my aunties, and I don't want that life. I don't want to be frail and I don't want to have cognitive deficits. I don't want to have dementia. What can I do? Let me tell you, the march to those diseases, sarcopenia, frailty, and dementia, accelerates when we lose our estrogen. So hormone therapy is going to go a long way. So we start a discussion around lifestyle, nutrition. I have a background in nutrition, I'm able to do nutritional counseling. I have a body scanner in my office, I measure muscle mass and visceral fat. I do very directed counseling around that. So nutrition and movement. I was a cardio queen in the '80s and '90s. I worked out to be thin, full disclosure. I worked out to look a certain way and I assume that was healthy. This is as a physician. If I could go back and talk to my 30 5-year-old self, I would tell her to pick up some weights and eat some protein because I was just trying to be skinny and I was successful at it, therefore, I was healthy. I probably chipped away at my bone and muscle strength ridiculously for a cosmetic way to look. When genetically, I probably never have a chance of being obese. I was just wanting to be ultra thin. So I think a lot of us grew up with that mentality and so I'm having to do a lot of counseling around resistance training, keeping our muscle strong, that will keep our bones strong.
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Mary Alice Haney:
You just mentioned, do you start hormone therapy in perimenopause then?
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Dr. Mary Claire Haver:
So we have a discussion around each patient individually around the risks and benefits of hormone replacement therapy. I think that through my training and in most of my practice in general, the risks of hormone therapy we're grossly overestimated and the benefits were grossly underestimated. I did not know anything about cardiovascular prevention, I did not know we could use for genital urinary prevention of GSM and recurrent UTIs. That kind of information was just not put forth and I apologize to my patients back then that I did not do the work to really get out there and hustle and dig through the research to find, but I'm trying to make up for that now and writing books so you can educate yourself. Advocate for your own self at your appointments because a lot of docs were like me. I was great at delivering babies, I was an amazing obstetrician, I was great at gynecologic surgery, but there was definitely a huge gap in my education for menopause.
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Mary Alice Haney:
Are you taking time to treat yourself? It's okay, honestly, we all should do it. I love to get a pedicure and opt for an extra 10-minute foot massage at the end. I love to close my bedroom door and just try and take a 20-minute nap. Sometimes I even opt for that extra legroom seat on the plane. Well, if you treat yourself to the top options with everything in life, why settle when finding a doctor? It is your health, after all. Enter ZocDoc, the place where you can find and book tens of thousands of top-tier doctors all with verified patient reviews. So don't settle, go for the best and find the doctor for you. With ZocDoc, you've got more options than you know. ZocDoc is a free app and website where you can search and compare highly rated in-network doctors near you and instantly book appointments with them online. Once you find the doc you want, you can book them immediately. No more waiting awkwardly on hold with a receptionist. These docs all have verified reviews from actual, real patients. You can filter specifically for ones who take your insurance, are located near you, and treat basically any condition you're searching for. The typical wait time to see a doctor booked on ZocDoc is between just 24 to 72 hours. That's it. You can even score same-day appointments.
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Dr. Mary Claire Haver:
Let's go back to the hormone replacement therapy. So I'm a 51 and a half year old who's going through menopause, or let's start there. I haven't had a period for a year. I come to your office. The way I approach my patients, I usually treat symptoms, not blood levels. So I listen to patients and if someone only has vaginal dryness, I'll treat that, if someone has depression, I might try an antidepressant first. In my specific practice because I went through breast cancer, so obviously I'm a little PTSD with breast cancer risk. Please educate us on patients who have a high lifetime risk of breast cancer and patients who have been diagnosed with breast cancer and they're on these medications, anti-estrogens like Tamoxifen or Arimidex, and they come to you with symptoms of menopause. How would you treat these patients?
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Dr. Mary Claire Haver:
So every patient can use vaginal estrogen without any worry of recurrence, there's zero. I mean, we have multiple studies looking at that. So immediately I launch into not only treating a symptom but the protective benefits since eventually they're going to head there, especially if they're on an aromatase inhibitor or something that's lowering whatever estrogens they have even further, because they're going to suffer more.
When estrogen is through life is taken off the table for them through a contraindication or just a personal choice, we have to go hard on the other pillars of health and nutrition, the other pharmacology to treat their symptoms. If she doesn't have any, what's changed in the last two years since I started the research for the new book is, especially since the American Heart Association has come out very strong here. If they're of the right age, once we took that WHI data and stratified it by age, we have some protective benefits of decreasing your risk of cardiovascular disease, decreasing your risk of dementia, if you start early enough. So it's a very nuanced conversation depending on what her stage is in menopause, what her concurrent disease. We don't want to put estrogen on top of cardiovascular disease or dementia, so those are not going to be candidates. We have to look at other ways to protect her bone. You can do vaginal estrogen for everyone, but other ways to protect her organ systems outside of giving her back the estradiol.
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Mary Alice Haney:
What is early enough? I see that a lot in the research, which is, it's the protective for your brain.
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Dr. Mary Claire Haver:
For cardiovascular disease, the American Heart Association, when they stratified the data from the WHI, found that the greatest cardiovascular protective benefit. So if you start hormone therapy within 10 years of your menopause or before the age of 60, you will have a lower risk of death from cardiovascular disease. It's actually better than a statin for prevention of a primary heart attack. It's about a 50% decrease per year, versus women who can't take it.
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Dr. Thais Aliabadi:
Let's take an average American going through menopause or post menopause, recently post menopausal women. I come to your office and counsel me on HRT.
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Dr. Mary Claire Haver:
So I would look at your family history. So say you have no contraindications and nothing in your history that would make me worry that you have existing cardiovascular disease or existing dementia. So you're otherwise healthy. I would say, okay, we know that if you're having hot flashes and you're having symptoms, this is the gold standard of treatment for vasomotor symptoms. It also appears to be preventative for osteoporotic disease. You'll have about a 50% decreased risk of an osteoporotic fracture. You will also have a much lower incidence of recurrent UTIs in menopause, as well as keeping your vagina healthy and resilient to trauma. It will make sexual activity much better. You'll have a decreased risk of urgency and frequency of urination, and you will have less stress incontinence because the tissue is just healthier in general. You will probably have it if you're in the first five years of your menopause, we can clearly show that you will have a decreased risk of cognitive disorders and dementia if you're otherwise healthy. So that's where I start. Then we talk about formulations, different ways of delivering it into the body, how we will track her progress. Again, I do symptoms as you do, rather than arbitrary blood levels. We also have a discussion around testosterone and what potential benefits would be there as well. So remember that our sex hormones are the same as men's, estrogen, progesterone, and testosterone. We actually have more testosterone in our bodies than estrogen, and it's the precursor. So in the factories that make estradiol, the step before estradiol is testosterone. So we have plenty of that on board. When we go through menopause, we lose roughly 50% of that capability. We still have an adrenal pathway that works okay, so but our estradiol will drop less than 1% of our pre menopausal levels, to give you some idea. So when we talk about hormone replacement, I always start with estrogen and its benefits. If you have a uterus, you must have progesterone. However, it's optional if you've had a hysterectomy or you have an IUD, but a lot of my patients are really happy with progesterone, especially if they still struggle with sleep or nighttime anxiety, it seems to have a very calming effect there. So lots of my patients who don't absolutely have to have progesterone, we're choosing to give it to them for those sleep and nighttime anxiety benefits. Testosterone has been studied, it's absolutely great studies to show that it does help with hypoactive sexual desire disorder in a menopausal woman. Those studies have been done. Unfortunately, the FDA has not gotten around to approving a formulation for women. So we have two options for testosterone. One is to give them the men's version and they use 10% of the amount that a man would get, or to do a compounded version. Texas it's really hard to get the pharmacist here to give them the men's version that nothing, no one likes to get involved in healthcare better than a Texas state legislator or a pharmacist. So I'll have testosterone compounded for most of my patients in a cream form. Off label and when you talk to the sexual medicine specialist, they really are very, very, very pro-testosterone in women. I'm using it off label, so again, I have a monitor and my patients get bone densities, if they're coming in with osteopenia, osteoporosis, or sarcopenia, I am absolutely recommending testosterone. They still have to eat the protein, they still have to do the resistance training, but it does seem to have a synergistic effect.
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Mary Alice Haney:
What are the symptoms of low testosterone?
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Dr. Mary Claire Haver:
Well, everything's tanking at once for a woman, but one thing that giving her estrogen and progesterone typically won't do a lot for her if she has a hypoactive sexual desire disorder.
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Mary Alice Haney:
But what does that mean? Does that mean, because my friends that are taking testosterone are taking it because they have no sexual desire.
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Dr. Mary Claire Haver:
Right, and so when we look at female sexual function and dysfunction, it's five buckets that a woman may struggle and she could have overlapping. So one is a relationship disorder. If you don't feel supported, loved by your partner, then a lot of women struggle with getting your brain to say this is a good idea. I can't fix that with medication. The last thing I want to do actually is give someone medicine that's going to make them want to have sex with someone they hate. I mean, it's up to them, but it just seems to defeat the purpose.
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Mary Alice Haney:
Yeah, exactly. That seems like a good point.
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Dr. Mary Claire Haver:
Yeah, so sometimes the patients say, no, I hate him. I'm like, okay, well that's probably part of the issue here. Pain, if she's having pain usually from atrophy or there's some other vulvar conditions, we got to fix that first. We must treat the pain because the brain is not going to want to do something that is not pleasurable that's supposed to be pleasurable. So that's also orgasmic dysfunction. So if a patient is primarily hypo-orgasmic, she's never had an orgasm in her life, do you know that's 10 to 15% of women?
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Mary Alice Haney:
Wow.
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Dr. Mary Claire Haver:
If that happened to 10 to 15% of men, it would be a national emergency.
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Mary Alice Haney:
It would be a total national emergency.
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Dr. Mary Claire Haver:
But we just calmly accept it as life and move on. There's very little studies or treatment. You really have to go to someone who's so focused on that to find help. Then there's arousal disorders. Arousal disorders are like you have the desire but nothing's happening in the pelvis. Sometimes that is a nerve conduction disorder or poor blood flow to the area. Vaginal Viagra can actually be helpful there because it'll dilate the blood vessels in the pelvis and help blood flow get to where it needs to get to, but that's fairly rare. But most women have primary hypoactive sexual desire disorder. They used to have great desire, they still love their partner, they want to want to do it. I think we also need to normalize not wanting it and being okay with it. That's not a problem, it has to cause distress, if it doesn't cause you distress, we don't need to treat it. So a sexual desire mismatch is a whole nother conversation where one person's up here and the other person's way down here. There's some great books on the subject, Come as You Are by Emily Nagoski, and Kelly Casperson's podcast, You are Not Broken, is fantastic. So it's a very complicated discussion, very nuanced. I screen for it, before they even hit the door, they're filling out a screening protocol for that because I can immediately launch into the conversation.
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Dr. Thais Aliabadi:
Let me ask you a question. Can you talk about testosterone pellets? Because they're irreversible, they're different than the cream or the sublingual drops, and I see a lot of hair loss with it. As a menopausal woman, you already have hair loss and these patients get these pellets and they come in with really high blood levels of testosterone and then I start treating them with anti-testosterone to fix the hair loss that goes with the pellet. So can you comment on that for us?
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Dr. Mary Claire Haver:
Biote is the main company that makes the testosterone pellets and they were developed for men for hypogonadism, for treating hypogonadism. It became a billion-dollar industry and the physicians make a lot of money inserting them. So what we're seeing in our community here and you're probably seeing the same thing, is this poor woman whose menopausal is desperate. She's going in and no one gets... And you can put estrogen in those pellets, but you must take oral progesterone, at least most of those docs know that, that's what they're teaching through Biote. They're dying, they want anything and this is the only person they can find to help them. They're like, here, take these pellets. They're not discussing the other FDA-approved options. It's pellets or nothing in a lot of these clinics, and that's one of the huge problems I have. It makes the doctors the most money, so ethically, I just think it's terrible. I went and signed up for Biote to see why the hell these women are all being overdosed. Do you know in their paperwork they recommend frequently checking blood levels and running her between 150 to 250. 236 is a low normal male range. So they're routinely recommending giving super-physiologic doses of testosterone. The higher you go, the more likely you're going to have unwanted side effects. When you were 25 years old and your sexual peak, you were like, yes, all the time, whenever that age was, your testosterone level was probably no more than 70. We don't have to go that high to restore sexual function. The higher you go, the more likely you are to have the hair, the chin, the beard, the acne, and the hair loss. But it is in their paperwork to overdose the patient. I see patients coming in the three, four and 500 range. I'm like, you're transitioning.
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Dr. Thais Aliabadi:
Yes, that's exactly, and unfortunately as an OB-GYN, there's nothing you can do. I cannot go in there and get those pellets out. So, be careful. That's why I'm so glad you did this because I see it all the time. These patients come in with levels in the 400s, there's almost male pattern baldness, facial hair. Then I start throwing anti-testosterones at them just to fix it. So I'm glad we talked about that.
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Dr. Mary Claire Haver:
Yeah, I mean, I think they can be done ethically, they're just not. They're sold as this great way to make ancillary income, which a lot of physicians are struggling. I see why this happened, I see the perfect storm. Women are desperate, doctors are desperate, here we're going to fix everybody and everything, but unfortunately, they're not used ethically.
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Dr. Thais Aliabadi:
Just to close the loop, if you have a patient with low sex drive, what do you prescribe? I know you said the cream. Can you tell us?‍

Dr. Mary Claire Haver:
So I'm typically doing a testosterone cypionate powder that's mixed into a cream, that's what I'm telling the pharmacist to cook up for me. I start at five milligrams per deciliter and we give them five milligrams per day basically. In the patients where we check, they stay in nice physiological, the high normal ranges, so 50 to 70. Now, sometimes they don't absorb well and we have to go up. The nice thing about most of the compound is they come in these click or pumps and we can do a little extra and see how they do. Again, I'm treating the patient, treating her symptoms, trying to get her to a place where she's happy. So without turning her into a teenage boy.
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Mary Alice Haney:
So can you guys both talk to me then about, because I think there's still so much confusion. You go in there, it's recommended that you do hormone replacement therapy. Is it a patch? Is it 0.5? Is it one? Do you have to have progesterone?
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Dr. Mary Claire Haver:
Great, great. Okay, so this is the art, not the science, because we don't have physiologic ranges we shoot for. So we're treating symptoms. So here's how I approach it. When I look at how to deliver a progesterone, 100%, unless she has an intolerance, I'm going oral micronized progesterone. It has the best safety profile, it's been studied all over Europe. Big study just came out of Korea just showing no increased risk of breast cancer. So I'm like, nothing, not even a hint, not a whiff. So I'm like, that's my go-to. It's cheap, it's generic, it's so easy.

Dr. Thais Aliabadi
You do 100 micrograms.‍

Dr. Mary Claire Haver:
I start with 100 and we can go up to 300. So depending on sleep, I'm usually using sleep as my guide. Now, if she's going on a, again, there's an art, not a science. So I usually for estrogen, we have oral and non-oral. So oral works great, they have great, great, great results. However, increased risk of clotting. So I tend to stick to the non-oral forms. Usually a patch because I have five strengths I can choose from and I can go up and down and it's really affordable for my patients, so affordability is key. So I used to love the CombiPatch, but it's $230 a month depending on, and that's just out of a lot of patient's range. So between oral micronitrized progesterone and an estradiol generic patch, I can get them for maybe 50, 35 to $50 a month for their HRT. Then they can go spend that extra money on something else that'll make them happy.

Dr. Thais Aliabadi:
Can you please explain also why they need progesterone? If you have a uterus and you take unopposed estrogen, you are at an increased risk of developing uterine cancer. So in order-

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Dr. Mary Claire Haver:
To negate that risk, yeah, we have to give progesterone. Yeah, so the uterus is a muscle bag on the outside with fibrous and muscle tissue. Then the inside is what we call the endometrium, which is glandular tissue where our periods are made each month and where the babies grow. Okay, if you ever get pregnant. So that endometrium is very sensitive to estrogen and if we just gave you estrogen without the opposing progesterone, the lining keeps thickening, keeps growing, the cells keep dividing, and eventually women might develop hyperplasia or possibly endometrial cancer. So there are conditions naturally where women don't ovulate regularly that put them at increased risk for this. So by giving you progesterone either cyclically or daily, we can negate that risk and just take it off the table.
Turns out there's other benefits like I talked about earlier to progesterone. So good for sleep. I'm prejudice, I'm very biased, I love mine for sleep.
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Mary Alice Haney:
I actually had noticed that right away when I started taking progesterone. I was like, it was almost, it just calms me at night.
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Dr. Mary Claire Haver:
I have to get under the covers like the minute I take it.
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Mary Alice Haney:
Me too, me too.
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Dr. Mary Claire Haver:
... because I'll be like-
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Mary Alice Haney:
[inaudible 00:39:43]. So one more quick question for those of us that are not as educated as you two, if you start, so the average woman comes in and to get the benefits of the heart and the brain, you're going to try to start in perimenopause?
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Dr. Mary Claire Haver:
Or early menopause, yeah.

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Mary Alice Haney:
Or early menopause. Then how long do you stay on it? Do you stay on it after menopause? What's too long to be on hormone replacement therapy?
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Dr. Mary Claire Haver:
There's no age at which you have to come off. Once you start those cardiovascular benefits, they can continue as long as you don't have cardiovascular disease. So it is a potential, if I stay healthy, I will stay, I die with an estradiol patch on, and constantly protecting my brain, my bones, as much as I can get out of this thing. So now eventually, if you develop cognition issues permanent, if you are on the road to dementia or you develop cardiovascular disease or you develop a hormone sensitive cancer, then we must stop. There are absolute contraindications that we have to be aware of, but there's no longer an age at which you have to stop.

Dr. Thais Aliabadi:
You're not concerned about the risk of stroke past 75?
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Dr. Mary Claire Haver:
So there is an increase. So when you talk to Avrum Bluming and the people who really dig into the data, they feel like when you add the estrogen to pre-existing disease through the action of nitric oxide, the sticky platelets or the thrombotic strokes in the brain are more about sticky platelets than an actual clot. So he feels like the women, first of all, the stroke studies were mostly done in high dose birth control pills in younger patients. The doses we use in menopause hormone therapy are micro doses compared to that, or just like 10, 15, 20%, maybe 50 in the early years. So I do think about it. I don't have a patient in her 70s still on hormone therapy. Most of the time many other medical conditions pop up, but it is a conversation that I have that after a certain time it might, because of the sticky platelets and your vessels are starting to deteriorate, we may be making that risk worse.
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Dr. Thais Aliabadi:
Amazing. I have an important question for you. Can you talk to us about hormone replacement therapy through a traditional pharmacy versus bioidentical hormones?
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Dr. Mary Claire Haver:
Compounded, yeah. So we have to understand what bioidentical means. So when you say bioidentical to your listeners, you just think estradiol, that is what the ovaries made. Now, there are a couple of other bioidentical by that definition, hormones that our bodies can make. One is estrone, that is what is converted in our fat cells typically, or in the periphery in our other organ systems. Two, estrogen, it's a weak estrogen. It's a little bit pro-inflammatory. We don't like to have large amounts of that floating, but it does become the dominant in our menopause, which is why we think some of the disease states pop up then. Then we have estriol, which is made in our placenta and they have synthesized that it is a natural estrogen. But again, it's not anything I'm giving a menopausal patient. It hasn't been shown to be helpful. Why would I want to make her feel like she's pregnant? Then there's [inaudible 00:42:52]... Well, let's see. There's one that's a fetal estrogen that has just been synthesized and it's in one... Drug companies love them, hate them, they have to make money, and so they come up with these new concoctions and claim that they're better. So Estetrol, I think is what it's called. Now. When you look at, the ovary makes more than just estradiol. There's all these little minor, minor, minor estrogens out there that may have little duties but we don't make those, [inaudible 00:43:18]. And so mostly we say, when we say bioidentical, we mean estradiol. Now the compounding, so you can get those from an FDA from a regular pharmacy, that's what I take. Now, the compounders are sometimes giving biassed and triassed. Now that's a combination of estrone and estriol, the two ones I spoke about earlier. I don't have a clinical indication for that. Any claims that they're superior, they're safer, they work better, are bunk. There is no data to support that. Do buyer beware, they're trying to sell you something or make claims that their product is superior when it's just not.
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Dr. Thais Aliabadi:
Oh my God, I love you for this because one misconception from my patients is, I'm sure you get the same, they think if it's bioidentical, it's coming from some plant in someone's backyard. So
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Dr. Mary Claire Haver:
Often the precursor is yams. But you can't roll in a bed of yams and get any hormones, that's not how it works. You have to put in a lab and do a lot of chemical processing to it. So there's a lot of misunderstanding. And the Wild Yam cream, throw that in the trash.
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Mary Alice Haney:
Stay tuned for part two of our conversation with Dr. Mary Claire Haver and her No Nonsense Guide to Menopause. You won't want to miss it. And remember, if you want to own your own health, a good place to start is by following us on social media, at SheMD podcast, and by subscribing to our show on YouTube or wherever you get your podcasts. If you want to own your own health, check out Dr. Haver's Tips on our website, shemdpodcast.com.