Menopause Symptoms and Solutions with Dr. Mary Claire Haver - Part Two

Mary Alice Haney:
Welcome back to part two of our conversation with Dr. Mary Claire Haver, the go-to expert on all things menopause. If you missed part one, Dr. Haver covered everything from the early signs of perimenopause to the essential do's and don'ts of hormone replacement therapy. Today, we're diving straight into Dr. Haver strategies for managing menopause symptoms. Let's jump right back into it. Thanks for tuning in to She MD. 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.
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‍Dr. Thais Aliabadi:
I just want to make that very clear to our listeners that bioidentical, there's still pharmacists working on these formulations and you really need to talk to a physician before using them.

Mary Alice Haney:
Yes, and some compounded pharmacies are not as good as others, so that's also really important.

Dr. Thais Aliabadi:
True.

Dr. Mary Claire Haver:
The nice thing about when the testing is done, it's interesting, the FDA got so concerned over this compounded bioidentical stuff, they went to the top 12 compounding labs, including Biote, and they tested the products. They went in as secret shoppers, ordered a bunch of stuff, then ran it through the testing. There was a 34% discordance in what they said was in the product and what was actually in it. Then when you do FDA, they have to test them regularly. That's part of why you get an FDA seal of approval and they're 2%. Now again, I don't have a great option for women who need testosterone, so I have a couple of local compounders that I trust, that I know, they know I'm coming after them if they mess it up. But there's just more room for error in compounding.

Dr. Thais Aliabadi:
Just like you when I want to start patients on hormone replacement, I start them on estradiol patch because I want to bypass the risk of blood clot. There's more increased risk of blood clot if you take estrogen as a pill form. But the progesterone, like you said, micronized progesterone is very safe for an average patient with hot flashes, some sleep disturbances. What dose of estradiol patch do you start them on and how do you follow them?

Dr. Mary Claire Haver:
Younger, more symptomatic, I go higher in the estradiol. Like a 0.75, I want to have that wiggle room to go up a little bit. I do have the occasional patient, especially my POI patients, because premature ovarian. If you're younger than 40 and listening to this, forget all ... you need to be given levels that are going to put you at a premenopausal range, not a post-menopausal range to protect your health. I have one 28-year-old with POI who's on 2.1 patches to get her levels.

Dr. Thais Aliabadi:
Explain what POI is.

Dr. Mary Claire Haver:
Premature ovarian insufficiency. About 1% of the population will go through menopause well before the average age. Remember, 40 to 45 is early, has its own health risks. Before 40 is usually something to do with autoimmune disease and inflammation. We really have to be very, very vigilant with those patients to protect them from stroke, diabetes, osteoporosis, and all the things that we are at risk for, but we had 20 extra years of estrogen on board to protect us.

Mary Alice Haney:
How do you know if you are taking too much estrogen?

Dr. Mary Claire Haver:
Typically, your hot flashes go away, but the one thing about the patch is you have more breakthrough bleeding, which is annoying, it's a nuisance. It does not mean anything is wrong with you. But higher estrogen levels tend to give you more breakthrough bleeding. Most of it resolves on its own. We don't start a workup until it happens for six months. It does not mean anything is wrong, it's just an annoying side effect. More likely with higher estrogen, breast tenderness, headaches, just feeling a lot of gut, sometimes bloating and we'll back off on the estrogen a little bit. For bleeding, sometimes you can just increase the progesterone and that'll take care of the bleeding. Again, it's a little bit of an art and a science.

Mary Alice Haney:
I'm somebody that if I take a vitamin, I think, well, if I'm supposed to take 50 milligrams, maybe I'm going to take 200 milligrams, so I would-

Dr. Mary Claire Haver:
You don't want to do that.

Mary Alice Haney:
I may want to put on five patches on. Can you give yourself cancer by putting on too many patches of hormones?

Dr. Mary Claire Haver:
You definitely can give yourself a lot of breast tenderness, maybe some headaches, some gut disturbances if you trip in a vat of estrogen cream or something or to put too many patches on.

Dr. Thais Aliabadi:
I just want to also tell you don't put too many patches on. One way I follow my patients, I always do a pelvic ultrasound once a year on all my post-menopausal women. You want the endometrial echo complex or the lining inside the uterus to be less than four millimeters. Sometimes, I see these patients who are either on unopposed estrogen or they're not taking their progesterone regularly and I can immediately tell by looking at the lining of their uterus. I just want to clarify one thing for our listeners. When you first start hormone replacement therapy, it is normal to have irregular bleeding. I usually might give them about four to six months. But if you're a post-menopausal woman and you've been on hormone replacement for more than few months and you have breakthrough bleeding-

Dr. Mary Claire Haver:
New onset, yeah.

Dr. Thais Aliabadi:
... You need to see a doctor because we still need to do a biopsy of the lining of the uterus to make sure you don't have atypical cells. I want to make sure that our listeners don't think just bleeding is always normal with hormone replacement. It is normal when you first start, but after that, if you start bleeding, we call it postmenopausal bleeding and it needs to be evaluated by a gynecologist.

Dr. Mary Claire Haver:
I tell my patients "Any bleeding I want to know," especially if she's postmenopausal and has not bled for a year. I have a whole sheet on this, "Let me know so we can document it, but be reassured X, Y, and Z. But you always need to let us know."

Mary Alice Haney:
I have a few questions from our listeners for you. Do you prescribe Loestrin to perimenopausal women or transdermal HRT? Do you ever prescribe Loestrin?

Dr. Mary Claire Haver:
Yes to both. If the patient needs contraception, if she's perimenopausal, she can still get pregnant and if she doesn't want to be pregnant and is looking for contraception, this is a conversation we have. Remember the biggest difference between birth control pills, birth control pills were developed to stop ovulation so you don't get pregnant. Menopause hormone therapy was developed to stop a hot flash. The biggest difference between the two is dose and there's low dose birth control pills and high dose MHT and they're very close to each other. So there's not a huge difference. Now formulations do matter, do change quite a bit between the two. That's more to do with big pharma than anything. But so Lo Loestrin, a patient needs contraception or she's having dysfunctional uterine bleeding and we worked her up and everything's normal and we need to control this bleeding, this may be a good option for her. We have lots of options. We're going to talk about IUDs and different things, but for a lot of patients this going higher dose and we suppress her ovulation, she's having acne or signs of high androgen. Suppressing ovulation can be really handy here in these last few months to get her through till the finish line, till full menopause. Occasionally, yes, but I'm also using menopause hormone therapy dosages in perimenopause as well. It really just depends on the patient and her symptom profile.

Dr. Thais Aliabadi:
I want to add one thing. Loestrin for our listeners is a birth control pill. You can use Loestrin for a young woman, you can use it for perimenopausal woman. When we get close to menopause, our periods start becoming irregular as she was explaining. By starting someone on a birth control pill, you can regulate their period. Like she explained, if they have acne, hair loss, all of that, you can use these birth controls to treat their symptoms. I always describe menopause to my patients, like crossing a river. You can either pull your pants up and just go straight into the river, you get tossed from one side to the other until you get to the other side. Or you can go on birth control or hormone replacement and it's like a bridge that takes you from one side of the river to the other side. Both options are good. Dr. Haven, you can comment on this. When you, when I start a perimenopausal woman on hormone replacement, I tend to cycle them once a month versus doing continuous because they are still having periods, so I cycle them and as they go through menopause then it's not important to cycle them as much. But birth control pills do make them regular. Both options are available.

Mary Alice Haney:
Do you have your patients get a DEXA scan before 65?

Dr. Mary Claire Haver:
I recommend it strongly. Fortunately in the Houston area, we have these DexaFit centers for $99. They can go and pay out of pocket and not only have a bone density done, but it'll also give them visceral fat and muscle mass estimates. They don't pay me to say this, but insurance typically without severe risk factors won't cover it until 65. I really believe this is too late. All the orthopedic surgeons think it's too late. I want to know, I went and had mine done at 55 and fortunately everything looks good. All my osteoporosis prevention kit is working, but that is something I do recommend.

Dr. Thais Aliabadi:
In my practice. I start as soon as they hit menopause. At 50, I had osteopenia. I have family history of osteoporosis. I think 65 is absolutely too late. That's the guideline for insurance companies. If your doctor does not want to give you an order for bone density and you're 54, 53 and you've gone through menopause, I think it's important to ask for it.

Dr. Mary Claire Haver:
Do both of you do a calcium CT score?

Dr. Thais Aliabadi:
I do, yes.

Dr. Mary Claire Haver:
I do. Again, I don't want to put estrogen on top of disease. If I'm worried, if her cholesterol's elevated, or Apo B or LP a, the markers for cardiovascular disease are elevated, I will recommend, "Let's go ahead and get one of these before we start estrogen and just so that we don't exacerbate potential disease that's already there." Fortunately, we're getting those paid for. Insurance is really covering those if they have the cholesterol profile.

Dr. Thais Aliabadi:
I think for a coronary calcium scan, you can start at age 45 and you can do it every five years. Like she said, insurance will cover it. By 50, I definitely want a baseline coronary calcium scan. It's good for all women to have a cardiologist. I do order it because sometimes my patients, I'm sure you see it too, they come from a cardiologist and they're like, "No, no, no. I did everything with my cardiologist." I'm like, "Well, you're 55. Have you had a coronary calcium scan? No, well go back to your cardiologist, ask for a coronary calcium scan." Coronary calcium scans are a CT scan of the heart and they basically predict your risk of heart attack for the next five years, so it's important. I have my patients get a baseline at 45, but then again, I tend to be on the more aggressive side of the spectrum when it comes to screening. But definitely by 50 they should have a baseline coronary calcium scan.

Mary Alice Haney:
Dr. Haver, what supplements do you recommend to women that are perimenopause and menopausal and are they different?

Dr. Mary Claire Haver:
No, they're not different. Good health is good health. Of my patient population, I get a vitamin D on everyone. 80% are horribly deficient, not just low. They're like no. I recommend 4,000. I use a vitamin D as a daily maintenance level. If I need to give them prescription strength, if they come in really low, we'll do that for 12 weeks, then go into maintenance and recheck in a few months. Myself, I have to once a year, once every two years, take the prescription strength because I just dwindle down over time despite my best efforts. I am recommending fiber. I have my patients track their fiber intake. The average fiber intake in the US for women is about 12 grams per day and we need at least 25 for optimum health. I'll recommend a fiber, get your fiber from food, supplement if you can't get it, if you have intolerances or whatever. I am recommending collagen, especially if she's osteopenic. There's a specific collagen called Fortibone that was studied looking at improving bone density over five ... Well, it took five years, but that's how fast bones grow. Then, I do a deep dive, I do an iron study. I'm looking for nutritional markers in my blood work with my patients. What I'm not doing a lot of is hormones, because I believe her and so I don't need to prove that she's menopausal.

Dr. Thais Aliabadi:
Can you explain, especially having had breast cancer for breast cancer prevention, we want the vitamin D levels to be above 65.

Dr. Mary Claire Haver:
Above 60, 65. Yeah.

Dr. Thais Aliabadi:
For a lot of women they show up with vitamin D's 8, 10, 12. Can you please explain to them the prescription vitamin D that we use?

Dr. Mary Claire Haver:
Prescription vitamin D, it's a vitamin D3 and it is 50,000 typically is what we'll prescribe. You want to take that once a week. Now, in the days you're not taking that 50,000, you can take your 4,000 daily dose. It's just a really hard nutrient to get through food. It's fatty fish, but just most Americans don't eat a ton of that and mushrooms has quite a bit. Unless you're eating like a pound of mushrooms a day, it's really hard. We're protecting our skin, rightly so from the sun. The more pigmented you are, the less chance the sun has a chance to penetrate and create that natural vitamin D, so we see low vitamin D levels in women of color much more than, way more than Caucasian too, but I'm especially vigilant with my patients who are women of color.

Mary Alice Haney:
What about hair loss? What do you recommend to women that are suffering for hair loss?

Dr. Mary Claire Haver:
Sure. I'm checking iron levels, I'm checking nutrition. Shoring up any nutritional deficiencies, vitamin D, et cetera.

Dr. Thais Aliabadi:
Go over that with us. Go over those supplements one by one.

Dr. Mary Claire Haver:
Well for hair, so I usually start with minoxidil. If it's obviously male pattern baldness, we're doing anti-androgens, and then I'm doing minoxidil. I used to exclusively recommend the topical minoxidil, but now I'm moved into oral minoxidil. I used topical minoxidil for years, but it just got so hard, the hair math of what day was I going to wash it and I have to do the minoxidil and wash it out and it has to be clean to put the color, because I have gray hair. It just became this math I couldn't do anymore. Then one of my derm friends was like, "Why don't you do an oral? You just don't have to think about it." I was like, "Oh." Now I'm recommending oral minoxidil for my patients with female pattern baldness or just generalized genetic hair loss.

Dr. Thais Aliabadi:
Do you start at 0.5 or do you start them at 2.5?

Dr. Mary Claire Haver:
The lowest prescription strength is 2.5 and I have them cut it in half to start. Minoxidil also, red light therapy can be really helpful. Those machines can be a little bit pricey, but saving to invest in that, it improves the blood flow to the area and improves the health of the scalp, which will improve the hair growth typically. Different dermatologists are doing stuff with PRP injections in the head, again improving the health of the scalp overall, decreasing inflammation. Certainly, a visit to a dermatologist to get a workup for this is warranted, especially if you have patchy hair loss, that could be an infection. I have a 45-minute YouTube video on this because it is so complicated and nuanced.

Dr. Thais Aliabadi:
We'll link to that too.

Mary Alice Haney:
Do you ever prescribe dutasteride if a minoxidil fails?

Dr. Mary Claire Haver:
I haven't gotten to that yet. Sometimes, I'll do an anti-androgen and if it's obvious that they're coming in off of a pellet and they're at 400 and 500, like you said, I'll do that. But typically if we just let that pellet ride out and they're postmenopausal, perimenopause is when we can see a lot of the new onset. Their testosterone levels are normal, but the free testosterone is higher because the SHPG is lower, that tends to level out post menopause. But yeah, most of my patients do pretty well. I've done it in one patient who was just absolutely resistant, but I was like, "At this point, we need to see a dermatologist. I want to make sure you're getting worked up properly."

Dr. Thais Aliabadi:
Going back to hair loss, which blood levels do you check for patients with hair loss?

Dr. Mary Claire Haver:
Well, I'm doing CBC, CMP, a vitamin D.

Dr. Thais Aliabadi:
Iron, you mentioned,

Dr. Mary Claire Haver:
Full iron studies. Yeah, ferritin, transferrin. That's a sneaky one that will get in there. Then sometimes just inflammation. I'm sending high sensitivity, C reactive protein. Again, they're nonspecific, but it just lets me know something's happening though I don't know the exact cause. I always, if their general inflammation levels are high, we're going nutrition first, fiber, anti-inflammatory, packing foods, leafy greens, legume, seeds, nuts, grains, whole grains if they can tolerate them and working with nutrition first to see if we can bring those levels down. Then hormone therapy, it just really works.

Mary Alice Haney:
You've mentioned gut health and how that changes during peri. Do you do a postbiotic, a prebiotic? What do you recommend?

Dr. Mary Claire Haver:
Remember in the health of the gut, the prebiotic is soluble fiber. We're doing fiber supplements, we're doing lots of fiber rich foods. That usually takes care of that. If you think about how big fiber molecules are, the little bit of prebiotic they put in a pill is not enough. We need 35 grams really of fiber per day for optimum health, 25 is the cutoff for before that you're deficient. If there's half a gram and a little pill that's with your probiotic ...
Now, probiotics are the actual microbe, lactobacillus and ... God, actinomycetes, lots of species in there. I do recommend for most women, there's some great studies done in menopausal women who were obese, with hypertension of just adding a probiotic usually in the lactobacillus species seems to really help with their gut health and lower their blood pressure and decrease the risk of visceral fat. I tell my patients, "Listen, if you're getting something rich naturally in probiotics every day, like yogurt, kimchi, miso, you're probably okay getting that through food." Actually, most of your nutrients should come from food, "But if you're struggling, then utilizing a probiotic can be really helpful."

Mary Alice Haney:
There's so many out there. How do you find the best one?

Dr. Mary Claire Haver:
Like any supplement, you need to find somebody with third party testing because you can put anything in a capsule and sell it, no one's checking. You need to have someone who's big enough to do the third party testing on their own. When looking for a probiotic, I'm like billions is better, the more the better, because we lose a lot in the digestive process. So to get enough live ones to hit the gut is going to take a billion to start with. Then you want to get one that's varied. The female gut microbiome is really diverse. Just doing one or two species is probably not enough. You want to get one that has multiple species in it.

Mary Alice Haney:
What do you think about metformin?

Dr. Mary Claire Haver:
Well, if you have ... Oh, that's a double-edged sword. Metformin as a preventative measure?

Mary Alice Haney:
Yes.

Dr. Mary Claire Haver:
I haven't seen, it has its own complications. There's problems with metformin if you're not careful. If you are pre-diabetic though, so if you are wearing a glucose monitor, if you've had your HOMA-IR score, that's another thing I check is the HOMA-IR score. It's looking at a ratio of your fasting insulin and your fasting glucose level. If their HOMA-IR score is elevated, well first we start with nutrition and if we can't get it under control, we start talking about metformin. Now there's some studies done, but most of those people recommending it, they're not studying women. They're looking at studies done on 25-year-old male athletes, so I'm very protective of our population and I'm really, really diving into the studies that are done on women and showing health in women.
One of the most dramatic examples of this is the data on statins. A woman flips over 200 and a doctor rushes to put her on a statin. Statins have never been shown to decrease the risk of a primary heart attack in women, only in men, yet we recommend it to women all the time. I'm like, not to say that if you have familial hypercholesterolemia or some other really, just the woman who has a menopausal elevation in cholesterol, which we see in 80% of patients by the way. Not addressing that through other means first, actual bile acid sequesterants, the old medications we used to use are probably better for women at primary prevention of a heart attack than a statin.

Dr. Thais Aliabadi:
Can you talk to us about sleep? I know we touched on progesterone helping women go to sleep. What else do you prescribe if someone does not want to take progesterone or can't take progesterone?

Dr. Mary Claire Haver:
We really start with the sleep hygiene, being very focused on the temperature, all the things we know from the sleep medicine specialist, the temperature of the room, limiting the stimulus before limiting stimulants that you would take before bed. Really prioritizing your sleep environment, the sleep time, turning off the phone, not having that blue light stimulation before you go to bed. The chill pads have been found to be helpful. Say hormones are off the table for you, so you really have to maximize what's waking you up? Is it having to go pee? Is it a hot flash? Is it anxiety? Utilizing behavioral therapy for anxiety, chill pads for the bed, cooling the room down, having a fan and ice water available, not drinking liquids so close to bedtime to limit the time you have to get up and go to the bathroom, if she's waking up with urgent continence. Getting on medication for that, we can do some of the oxybutynin and those medications. They're not my favorite, but if everything else is off the table, that sometimes can help her sleep at night.

Dr. Thais Aliabadi:
What about supplements for sleep, like magnesium, melatonin?

Dr. Mary Claire Haver:
Of course, yeah. There are certain, especially magnesium that can be really calming. Magnesium L-threonate is my favorite for this, it's what I take. It's been studied in SSRI resistant depression. It really crosses the blood brain barrier, probably one of the best. Glycinates, probably okay. There's some that stay in the gut and cause diarrhea and that's why we use them for bowel preps and milk of magnesia and all that. Others get into the bloodstream but don't seem to get into the brain very well, so they're good for people with low magnesium, but L-threonate has some great studies. NeuroMag or Magtein are the brand names for those. That's what I recommend for sleep.

Dr. Thais Aliabadi:
What dosage of magno?

Dr. Mary Claire Haver:
260 milligrams in the early evening.

Dr. Thais Aliabadi:
Excellent. What about melatonin?

Dr. Mary Claire Haver:
Melatonin I think is good for short term. The sleep medicine specialist, you develop tolerance and they're not recommending melatonin for long-term use.

Mary Alice Haney:
The dosing is too high. You're finding that they're dosing people so high that your body doesn't even create that level of melatonin.

Dr. Thais Aliabadi:
What do you tell women who come to your office and ask you for Ambien?

Dr. Mary Claire Haver:
Really, really special cases. I have had to get people off of Ambien from being addiction. It's a benzodiazepine and you develop tolerance. Certainly, if she came in with some horrific event or my husband who worked overseas at a 12- hour time difference would use it on the shift changes. He worked 30 on, 30 off, so he'd use it for a day or two to help shift his clock. That's why Ambien was developed, was for astronauts to get in their different time zones. But no one is recommending long-term use of benzodiazepines for anything. Short-term use is fine. It's something to help you through a difficult time, but long-term use absolutely not.

Mary Alice Haney:
What about Trazodone?

Dr. Mary Claire Haver:
Again, another addictive substance.

Dr. Thais Aliabadi:
Same, the same.

Dr. Mary Claire Haver:
Short-term use is fine, but you really want to be cautious because your body will develop tolerance and you'll need more and more to get the same effect.

Dr. Thais Aliabadi:
Also, the day after the next morning you're not feeling well, you're going to feel tired. Some patients get depressed, their mood goes down, their energy level is down, they're sleepier, so I don't recommend it.

Dr. Mary Claire Haver:
A lot of my patients were self-medicating with Benadryl or Tylenol PM to help them sleep. Again, same thing happens. They have a hangover the next day, they're really struggling. Now, there's studies coming out saying increased dementia with people using-

Mary Alice Haney:
Oh yeah, with brain health.

Dr. Mary Claire Haver:
Yeah, brain health long-term.

Mary Alice Haney:
We talked about this briefly, but if someone comes in for vaginal dryness, because that's a real symptom for peri and menopausal women.

Dr. Mary Claire Haver:
Calling card, yeah,

Mary Alice Haney:
Will you just talk the step by step? What do you do? I come in, I say "I have vaginal dryness." What do you recommend?

Dr. Mary Claire Haver:
Say, "Are you using a lubricant?" And we'll talk about different types of lubricant. Even with that, I recommend a lubricant for everyone at this age, regardless of whether you think you have dryness or not. I just think it makes everything more fun, but it's preventative for some patients. If she comes in with a complaint, again, this is something I screen for before they hit the door, immediate discussion around vaginal estrogen.
Now, if it scares her or she doesn't want to do estrogen for whatever reason, we have a couple of options. There's an oral ospemifene that you can take, I don't love it. It has a lot of side effects and if I can convince her for vaginal estrogen, but there is Intrarosa. Intrarosa is intra vaginal DHEA. The sexual medicine specialists love it because it really does work to keep the vaginal, vulvar, and bladder tissue healthy through probably creating some estrogen through the pathway, but it also creates some testosterone down there and they love it for that. They feel like it gives them better sexual benefit.

Mary Alice Haney:
Thank you. I know that every woman listening really wanted to know that.

Dr. Thais Aliabadi:
I just want to add one more thing that I use in my office is a CO2 laser of the vagina, especially for women who, like you said, there are a lot of women, especially with breast cancer who are scared to use estrogen even though we have no data that shows that it's unsafe to use. If you have had the diagnosis of breast cancer, you are allowed to use vaginal estrogen. Nothing works better than vaginal estrogen, but there's a CO2 laser of the vagina that women can try. You do it every six weeks for three times. A combination of that with the lubricant, with the vaginal estrogen makes a big difference.

Mary Alice Haney:
Well, you have given so much time today to us. Is she not the best?

Dr. Thais Aliabadi:
You're incredible.

Mary Alice Haney:
Literally.

Dr. Thais Aliabadi:
Your patients are so lucky to have you. Nobody talks about menopause. That's why you have so many followers and you're so knowledgeable and it's really enjoyable to listen to.

Mary Alice Haney:
The new menopause book is coming out. It's called The New Menopause. When's it coming out?

Dr. Mary Claire Haver:
April 30th. Everywhere you buy books. It's ready for pre-order now.

Mary Alice Haney:
Okay, everywhere you buy books. We're going to link to it on our site.

Dr. Mary Claire Haver:
It really is like the girlfriend's guide, what to expect when you're never going to expect again.

Mary Alice Haney:
No, I love it.

Dr. Mary Claire Haver:
I really wanted a comprehensive guide for patients and to include all of the body organ systems.

Mary Alice Haney:
Dr. Haver, we're going to have links to a lot of the things that you talked about. We're going to have links to your site, to pre-order your book. We also do ask all of our guests to give us five things, five tips. If you could give women five tips, it could be a supplement, it could be an exercise, it could be eat protein. What were the five things that every woman listening to right now who's in perimenopause or menopause that you would recommend?

Dr. Mary Claire Haver:
Number one is make sure with your exercise you're doing some significant resistance training, strength training. You really have to do progressive load to keep those muscles strong, because your body's trying to tear them down just through the aging process. Number two, know your family history. Know what your risks are. Be very, very focused on how you want to avoid those risks in the future and try to find a [inaudible 00:29:04] in your healthcare. I know it's hard to find a menopause provider. I'm screaming from the rooftops trying to get more training and education in our programs, but we're probably a generation away from you being able to walk into just any OBGYN's office and get an informed conversation around your menopause care. Number three, educate yourself as to what menopause really is and the organ system so you're not blindsided when these things start happening to you. Just knowing and being aware is not creating hysteria. It is creating a knowledge base. Talk about menopause, share your experiences with your friends, your family, so that we destigmatize this and we normalize it and it just becomes a normal part of life and not something to be feared or where we can expect this dramatic what's happening now, this dramatic changes and hastening our way to certain disease processes.
Make sure you're getting enough fiber in your diet. Most of us aren't doing it and it goes such a long way. People with high fiber diets have less cardiovascular disease, less dementia, watch your alcohol intake. I used it as a drug all through COVID to soothe the drama, but it so affects my sleep. Women in menopause do not tolerate alcohol the same as they did before, and it really doesn't have any health benefits that are worth talking about. Limiting alcohol conception really is going to go a long way for you.

Dr. Thais Aliabadi:
You are incredible. Thank you so much.

Mary Alice Haney:
This was honestly, I've been wanting to meet you for so long and I follow you on Instagram and I can't wait to read your new book. You really are, you're helping so many women. Your voice and your platform is shining light on an area that is not talked about enough. We really appreciate you being here, Mary Claire.

Dr. Mary Claire Haver:
So happy to be here. Thanks guys.

Mary Alice Haney:
Remember, if you want to be your own health advocate, a good place to start is by following us on social media at She MD 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. We'll see you next time on She MD.