Menopause Relief: Hormone Tips Every Woman Needs To Know with Dr. Mary Claire Haver - Transcript
Dr. Mark Hyman
Coming up on this episode of The Doctor's Farmacy.
Dr. Mary Claire Haver
But the data is clear that doctor Hemant, like, on mental health. Like, you are better off giving her balancing those hormones than giving her an SSRI. It is more effective for the perimenopausal patient with new onset mental health changes. I just refuse to let people suffer.
Dr. Mark Hyman
Before we jump into today's episode, I'd like to note that while I wish I could help everyone via my personal practice, there's simply not enough time for me to do this at this scale. And that's why I've been busy building several passion projects to help you better understand, well, you. If you're looking for data about your biology, check out function health for real time lab insights. If you're in need of deepening your knowledge around your health journey, check out my membership community, Hyman Hive. And if you're looking for curated and trusted supplements and health products for your routine, visit my website, supplement store, for a summary of my favorite and tested products.
Hi. I'm doctor Mark Hyman, a practicing physician and proponent of systems medicine, a framework to help you understand the why or the root cause of your symptoms. Welcome to The Doctor's Farmacy. Every week, I bring on interesting guests to discuss the latest topics in the field of functional medicine and do a deep dive on how these topics pertain to your health. In today's episode, I have some interesting discussions with other experts in the field.
So let's just jump right in. Welcome, Doctor Haver, to The Doctor's Farmacy podcast. It's so great to have you here with us today.
Dr. Mary Claire Haver
Thank you for having me.
Dr. Mark Hyman
You know, you are, now a shining light in the field of women's health and menopause. You you're everywhere. And, you're talking about things that often have been neglected and no and when we went to medical school, we we never learned that women were different than men. All the research was done on men. You know, and and so we really kind of had this whole field of neglected, suffering that I would call it, that women endured, without a lot of help.
And, it was like, take the pill or take Prempro, which which is Premen and Provera. And those are, like, the 2 kind of options. And, of course, I'm over simplifying, but it was it was basically that. Or if you have menstrual disorders, take the pill. If you have menopausal stuff, take Prempro.
And there was some, like that was kinda it. There was no discussion of diet, of lifestyle. You know, you have background in culinary medicine. You know, people didn't understand the complexities that happen in women's health and the role of of, insulin resistance, the role of inflammation, the role of the microbiome, the role of toxins and endocrine disruptors. Like, none of that was stuff we learned, and yet it it's so important.
And and so many women suffer unnecessarily from symptoms that have simple solutions. And what's so great about your work is that you help people really navigate that and talk, as a as a physician, but also as an obstetrician gynecologist in a deep way about about this. And you've also had, you know, your own personal experience as a woman, so that adds a lot of flavor. I mean, I'm just a guy, and, you know, I probably shouldn't be talking about this. But I I think, you know, my experience as as a physician was sort of shaped by my work at Canyon Ranch, where basically for almost 10 years, I worked taking care of people between the age of 35 60, which was sort of the majority of of women.
And and I learned a lot about issues, and it it sort of struck me that so many women were suffering needlessly from things like PMS and, you know, dysfunctional bleeding and menopausal symptoms and osteoporosis and mood changes and sexual dysfunction and just a whole bunch of stuff that just never got bare airtime in traditional medicine. So I kind of would love to sort of hear your perspective. You know, just taking us through kind of your let's call it your indoctrination. I'm not going to have brainwashing, but it's kind of brainwashing. You know, we learn a lot of good stuff in medical school, for sure, and it's the foundation.
But like like what? Where where did you get from from what you learned there to where you are now? And how did you so? Yeah. How did you kind of shift your perspective, and what was the sort of the things that kinda catalyze that change in thinking?
Dr. Mary Claire Haver
So I, again, traditionally trained super proud of everything I learned, but as I grew older and my patient population was growing with me, we're all becoming perimenopausal and menopausal together. You know, When I started out, I was having babies. My patients were having babies. You get all the new OB patients. In your early days in family medicine, you get that.
And then you you kinda get your set of patients and off we go together. So here we are mid thirties, early forties, and there's this litany of complaints that myself and my patients are starting to go through. And I thought back to my residency training where there's a very shameful story of I was a new intern with my little white coat in gynecology clinic, and the upper levels would run to the charts back when we had paper charts and shuffle through to find surgery cases. You know? They wanted the surgeries because they had to get their numbers to graduate, and then that kinda left everything else in gynecology for us.
So that was discharge and irregular periods and and, you know, all the things. And then the interns got the very end of the pile. And it's what my upper levels would call a w w. And I didn't know what that was. And they w w w.
So you're upper level w w, and so they call it a whiny woman. Oh, what's that? The chart, and no professor ever said it. Other parts of the country called it whiny dineys. So women are coming in with these multiple day complaints.
They're all somewhere in their late thirties to forties. They all have this kind of laundry list of very vague complaints, not sleeping, low libido, weight gain, you know, tummy fat, that's new, not, you know, just disrupted mood, disrupted relationships. And we were taught that, well, this is just something women go through, and there's not much we can do about it. And pat her on the knee and tell her to sleep better and lose weight and have some wine, and everything will be okay.
Dr. Mark Hyman
Have some wine. Well, that's gonna fix it. Yes. That's gonna make it a lot worse, actually.
Dr. Mary Claire Haver
So fast forward 20 years, and I'm sitting there, you know, and it clicks in my head. I'm like, I'm a whiny woman. These are whiny though, there's more there's more to it than this. So that's where I started opening my mind, changing my perspective, and realizing, doctor Ahmed, that there is a huge gap in my own knowledge and training, and I would have sworn 10 years before that I was a great menopause doctor. I made A's on on my test, blew the top off my boards, but I didn't know what I didn't know.
And so the more I dug and then started to grow on social media because I started talking about it, when 10,000 people tell you, my frozen shoulder started at, you know, right when my periods became disrupted in perimenopause, I don't blow them off. I go look. It turns out we have evidence for multi multiple organ systems that are really attributed to, you know, when the hormones start changing all these things that can go awry, not just hot flashes and night sweats.
Dr. Mark Hyman
I think you're so right about that. You know, one of the stats that just blew me away was that, you know, 75% of women have some degree of premenstrual syndrome or PMS. Right?
Dr. Mary Claire Haver
Oh, yeah.
Dr. Mark Hyman
And I said to my and I said to myself, you know, what's going on here? Like, this is not a design flaw. Like, whether you believe in, you know, we were evolved from whatever or god made us or whatever. It's nature's not that stupid. God's not that stupid.
Like, why are all these women suffering? It's not something universally attributable to being a woman. It's something going on in our environment that's driving these changes. And there's things that can be changed in women's behaviors and their environment and their diet and their lifestyle and toxins that will make a difference. And so I I kind of was like, it kinda made me angry to see all these women who had all these issues that were not being dealt with effectively.
So for you, when you when you kind of had this insight, what what was the the next step for you in kind of changing your your practice? How did you start to kind of shift in your head to kind of think about this differently? And what did you do differently? What did you learn to do that you stopped doing, and what are you doing now that you didn't do?
Dr. Mary Claire Haver
So cutting my toe in the water was my patience and my frustrations with what at the time I was calling the unexplained weight gain. Now I know it's a body composition change, but everybody was complaining of the same thing. And it was one of my besides the hot flashes, night sweats, and joint pain that I was having, my pain point having been a thin person most of my life and having that thin privilege, then all of a sudden not being able despite no changes in diet and exercise. Actually, I was doubling down on on really destructive behaviors probably, calorically restricting to ridiculous levels, you know, doubling down at the gym without any real results. And so finally, my it was my husband who's an engineer who thinks very you know?
And he's like, honey, your daughters are watching. So my kids were, you know, teenagers and preteens at the time. And he said, you know, you're getting up in the middle of the night to pee and I see you weigh yourself. You're, you know, this is not healthy. You're a scientist.
Figure this out. So I called the nutrition department at the university I was employed at, and I was I was I was their doctor. Right? So I called my friends, so I delivered all their kids and the PhDs. And I said, what is going on in menopause?
Everyone's complaining of this. You know? They led me down a rabbit hole of inflammation, how estrogen deprivation is related to inflammation. I've never been taught this information in my life. It was never in our CMEs.
It was not you know? Menopause was hot flashes, night sweats, generally urinary syndrome, and some osteoporosis. That's it. And I'm like, wait. This isn't my fault.
This isn't because I'm lazy. This isn't because you know? And they're like, oh, by the way, this visceral fat deposition is leading to cardiometabolic risk that you never had before. What's your cholesterol doing? You know?
And having come from I was a PCOS patient, had fertility treatments for my kids, you know, learned all that's where my toe in the nutrition space started because I was on these online forums. Like, I couldn't figure out couldn't take enough metformin to you know, I'm like, there's gotta be a better way, and that's where I learned about how nutrition is playing into this as well. And so, you know, starting to talk to my patients about it, them getting excited, you know, looking at changing our nutrition. Are you getting enough fiber? Are we getting you know, instead of counting calories, let's let's look at nutrients and see what happens.
And that led to, you know, the Galveston diet and then you know? But then the conversation just exploded around menopause in general.
Dr. Mark Hyman
Yeah. You know, it's interesting. I I wrote an article years ago because I think, you know, this sort of change in thinking happened to me too. And and I it was called the life cycles of women, and it was talking about all the change that happened at different periods of women's life, you know, when they're going through puberty, when they're in their twenties, their thirties, their forties, their fifties, their sixties. And, it really is different in every stage of a woman's cycle, and it's something that that, you know, is not well appreciated by women.
It's not appreciated by most doctors. And yet when you begin to understand the physiology and the biology of what happens, you can start to intervene and help people actually deal with some of the suffering. So so so your focus is mostly on menopause, but I'm sure you obviously dealt with PCOS, you've dealt with PMS, you've dealt with dysfunctional bleeding, and all these things that happen. What do you think are the biggest causes for this sort of epidemic of hormonal dysregulation and suffering that women have to go through that is, I would say, usually avoidable or preventable or or or treatable if if it's not?
Dr. Mary Claire Haver
Right. So, you know, definitely our nutrition. It it's so much of it is the quality of our nutrition, you know, too much caloric intake for a lot of for a lot of patients, you know, having when your body composition changes and you have these you're you're leading to increased insulin resistance, which directly affects the function, you know, the insulin receptors on the ovary, which leads to PCOS. So, you know, I think nutrition, exercise, how we kind of move, how we think, how we eat as a culture is really pointing to a lot of the disruptions that we're seeing.
Dr. Mark Hyman
Yeah. You know, Sydney, I don't know if this is true or not. It's just a it was just a kind of folklore, but, I've heard that in Japan, they never had a word for hot flashes. That just
Dr. Mary Claire Haver
Oh, they it's rare in Japan. Yeah. They have different symptoms, a lot more musculoskeletal, than we do. But, yeah, in in culture
Dr. Mark Hyman
a lot of soy and a lot of omega threes. They have less sugar. They have, you know, more more nutrient dense food. Right? So so maybe, you know, it's it's our ultra processed food that's driving a lot of the dysfunction in our microbiome and insulin and inflammation.
And and so these are these are things that that happen on the surface that most people don't realize, but that are actually driving a lot of hormonal dysregulation. So do you do you think that do you think you have a perspective on that?
Dr. Mary Claire Haver
I definitely know that culturally, you know, and and cultures tend to eat a certain way, tend to exercise. Of course, there's outliers and everything. We see a different catalog of symptoms. You know, people who live in the blue zone tend to have less obvious menopause symptoms. I mean, every woman is born with a finite set of eggs.
Right? And we're all gonna run out, and that's our menopause. And then we live 20 to 30 years without the, you know, benefit of the estradiol produced in our ovaries. But how our body reacts to that loss of estrogen, that's where, you know, in in my practice, we call it the menopause toolkit. Replacing hormones is is one prong there, and it's not for everyone.
But we, you know, we go hard on nutrition, movement, stress reduction, sleep optimization, things that they really didn't teach us in medical school.
Dr. Mark Hyman
Right. Right. And those are true. Those are key, and I think those can get you a lot of the way there. And and, you know, I think that that some things that also are relevant, there are things we're also not taught in medical school beside nutrition are things like environmental toxins and how they disrupt our hormones.
They're called endocrine disruptors or the microbiome and hormones. How have you sort of learned about those things in in relation to the sort of epidemic of hormonal dysregulation, including infertility, PCOS, and all these problems we're seeing?
Dr. Mary Claire Haver
I think we need so much more work in this area. You know, just like you said, putting Band Aids on everything without really looking for and I know this term is misused, but the root cause, you know, why is this happening to this woman? Like you said, god's not that mean. There's certainly outliers. But why is 20% of our population, 10 to 20% have PCOS, polycystic ovarian syndrome.
Why is that? We were not designed for this to happen this way. We were designed to have a very predictable monthly ebb and flow of hormones until perimenopause. And then you know? And so why is it that that's happening?
And I think we need so much more research in this area. I think it's a I think it's a traffic circle with environment, some toxins, you know, nutrition. Everything is feeding into this negative feedback cycle.
Dr. Mark Hyman
And so what are the ways in which these these various environmental factors affect women's hormones, and how how does it affect them in their thirties, forties, fifties? Can you kinda walk us through, how you think about this?
Dr. Mary Claire Haver
So when we reach perimenopause, we reach a critical threshold of the amount of eggs that we have, that the normal signals that come from the brain that tell the egg ovaries to ovulate, what doesn't happen in PCOS. Right? We almost become PCOS like in perimenopause because our our level of egg egg supply at 30, we're down to 10% of what we're born with. By 40, we're down to 3%. And so peri begins when the normal signals don't work anymore.
We become resistant. Now we could definitely make that worse with. We know, you know, if you have inflammation in the abdomen through surgery, chemo, radiation, you know, that definitely helps. If you are insulin resistant and not managed with diet, that will definitely contribute to how your ovaries are gonna respond to this environment and how they're gonna produce the hormones. I have less training and stuff on the exact toxins.
I know the usual things like radiation and chemo will affect, but if those things affect, certainly others might affect as well.
Dr. Mark Hyman
Yeah. There was a a book I read years ago called Hormonal Chaos by Theo Kollmer. It was sort of like a silent spring book. I encourage you to check it out because it it really describes how, you know, she was a sort of research scientist who was looking at what was going on in animal populations and the ways in which these these pesticides and plastics and so forth that we're all poisoned with are are endocrine disruptors are causing abnormal genders and hermaphroditism and infertility and, you know, trouble with with all sorts of populations from frogs to birds to alligators. And it was fascinating, and I kind of got me to really think about it.
The the the thing that I I think that happens with this this changes in the eggs and the cycles and the hormones is interesting because as as in I'm practicing, what I would notice, we often we would have high levels of estrogen and low levels of progesterone. They would have an what we call anovulatory cycles. This is, like, what you get in in PSOS where you don't ovulate and recycle, and then you don't make progesterone, which is what happens in the second half of your cycle. And that was sort of the thing that led to a lot of these symptoms of fluid retention and breast tenderness and menstrual migraines and then heavy bleeding and irregular cycles, and it's just this big kind of almost continuum of hormonal dysfunction. And and, you know, I I I wonder sort of what your perspective is on this this sort of phenomena that I I think is a lot.
You know, in the world of functional medicine, we talk about estrogen dominance or estrogen excess or imbalance, and it's it's not it could be in a relative or excess relative or absolute imbalance between estrogen and progesterone, and and that seems to what's led to a lot of the symptoms. And a lot of the toxins and a lot of the dietary things drive an increase in estrogen. Right? So these are estrogen mimicking toxins, and then sugar causes fat deposition, which leads to excess estrogen produced in this in the fat tissue. So can you kind of walk us through what is this whole phenomena?
How should we think about it, and what can women start to do to kind of address it?
Dr. Mary Claire Haver
I think you hit the nail on the head of the these are most of the what you would call estrogen dominance is chronic inovulation or ovo ovulation, meaning you're just not getting that monthly ovulation cycle going. And so, you know, in PCOS and peri, people will ovulate in PCOS occasionally. Right? It's very, very similar in multiple levels to what a woman's gonna go through in perimenopause as far as where her hormones are. So we have, you know, much higher levels of FSH because the brain is constantly trying to get that egg out, you know, to get those estradiol levels up.
So that spurt in FSH will then give you these much higher estradiol levels than a regular ovulating woman would have. And then after ovulation, the progesterone never quite gets to where it used to be. So, yeah, she has this whole cascade of symptoms, heavy periods, light periods, no periods, too many period. You know, everything's on the table as far as her cycles. Breasts become enlarged, fluid retention, you know, gut micro microbiome becomes disrupted.
And, you know, treatment options through that really vary from patient to patient. There is no one size fits all. So this is where I think a lot of patients are getting frustration. A, they're not being offered any treatment at all because you haven't had a not had a period for a year, you know, or they're just, you know, occasionally a birth control pill might be helpful in certain situations, but it should not be I don't think the panacea go to for all peri and and PCOS patients. By, you know, our lack of training and education around how nutrition, how diet, looking at what she's eating, when she's eating, how she's eating, how she's moving, making sure, you know, she's getting the right kind of exercise.
Most of my practice focuses on, you know, 35 plus in that perimenopause to menopause range. And, you know, we're plotting out a course to decrease the risk of osteoporosis and sarcopenia. You know, so that's where my exercise recommendations are going. More heavy lifting, less intense cardio, you know, more zone 2 training, and how, you know, we can balance her her hormone levels through this transition so she's not suffering.
Dr. Mark Hyman
So there's things that raise estrogen, and there's things that kinda reduce ovulation. So it's sort of like working on both ends of that. Right? And, you know, traditional a traditional OBGYN will typically just give women, if they're premenopausal, the birth control pill, and if they're That's
Dr. Mary Claire Haver
what they're trying to do.
Dr. Mark Hyman
Yes. We're trying to do. It's like and yet, you know, if they're not looking for contraception and then we can discuss the pros and cons of the pill. But, you know, it it may not be the best therapy because it comes with risks and also side effects. So, you know, one of one of the things that, you know, I I one of the things I I did when I was early on in this field was, like, 1996.
I met a guy named John Lee. Have you ever heard about this guy? And and he wrote this book, and it interesting to get your perspective on this. He wrote a book called What Your Doctor May Not Tell You About Menopause.
Dr. Mary Claire Haver
And I I've heard of the book, but I haven't read it.
Dr. Mark Hyman
Great book. And it and it I heard him speak, and and I was like, this is interesting. Let me try this out. And essentially, he was talking about the use of low dose topical progesterone or sometimes oral progesterone as a way to help a lot of women with all these symptoms that happen, whether it's pain.
Dr. Mary Claire Haver
In perimenopause, it's very effective.
Dr. Mark Hyman
Perimenopause. Yeah. Yeah. For sleep, for hot you know, for just heavy bleeding, for fibroids, all this stuff that that, you know and it it was that's something I learned in medical school. So how do you think about this whole sort of approach of using progesterone, and is it safe?
Is it effective? Is is what should we be concerned about, and and how do we sort of know when to use it?
Dr. Mary Claire Haver
Great question. I really, really like it in early perimenopause, especially if she's still kind of cycling regularly, but her she's having disrupted sleep. I love it for sleep. I love it for regular and heavy periods. It does wonders.
Traditionally trained, you don't need progesterone if you've had a hysterectomy. You know? However, I use it all the time, because the what it does for the brain in sleep is amazing. And there's new data coming out looking at you know, we have a 40% increased risk of mental health disorders through perimenopause when she was completely either worsening or new onset of mostly anxiety and depression. And progesterone can be very helpful here.
Also, a low dose estrogen, can be really helpful here as well even if she's still ovulating, something like a low dose estradiol patch just to kind of shore her up through those dips. You know? That's how I explain it to her. Now for as far as how I prescribe progesterone, transdermal so we have progestogens, which is the big category, right, of all of our progesterone type medications. We have progestins, which are quote synthetic, you know, and I like having options, but I usually do oral micronized progesterone.
The topical progesterones are natural, but it's a really big molecule. And there's not great data showing we get enough penetration through the skin if you're giving estrogen at the same time to protect the lining of the uterus. And I, like, really like giving that pill at night for sleep. My patients love it. They really you know, especially if their sleep disrupted outside of hot flashes, they it it and and and my personal bias, it is the best thing I've ever done for myself is the progesterone at night.
Dr. Mark Hyman
It's kind of a miracle. It was kind of a miracle pill Yeah. And a miracle drug that I I never learned about really using in medical school other than in combination with Premarin. And and the and the and the synthetic form of it called Provera, which my joke was it made women fat, hairy, and depressed because it's had a lot of side effects. You know?
And and
Dr. Mary Claire Haver
Yeah. Not many of us in in the modern menopause space use Provera, you know, very, very rarely. I pretty much just use progesterone. You know? I'm trying to get the patient as close to what our ovaries used to make as possible.
You know? I don't love the term body identical, but it is body identical. So But I think it
Dr. Mark Hyman
it that's a really important point. So use stuff that your body knows what to do with, and it doesn't have all these untoward effects. Like, you know, and I think, you know, the the thing you said, I just wanna don't wanna skip over it is that you you're doing something that's really unusual in women's health. You're you're actually combining topical low dose estradiol or the most common form of estrogen with oral or even topical progesterone. And you're doing it before they end their menstrual cycles, before they
Dr. Mary Claire Haver
end the
Dr. Mark Hyman
definition of menopause, which is really kind of a little bit heretical. It's like taking care
Dr. Mary Claire Haver
of to let people suffer. I Yeah.
Dr. Mark Hyman
That's it.
Dr. Mary Claire Haver
Right? Not only, but the data is clear that doctor Hemant, like, on mental health, like, you are better off giving her, balancing those hormones than giving her an SSRI. It is more effective for the perimenopausal patient with new onset mental health changes. So and then the cardiovascular data is looking good. Like, if we can get this thing shored up before she completely transitions, she is going to do better in multiple aspects of her life.
Why are we waiting till people are symptomatic? Why are we waiting until they have osteoporosis? Why are we waiting until they have general urinary syndrome? Well, with this, we could be preventative.
Dr. Mark Hyman
What what do you mean? That's what we learned to do in medical school. Wait till someone's sick and then give me a drug. I don't know what you're talking about. So totally clear why we do this.
I mean, it you're what you're saying is is sounds so common sense, but it's often sort of, not how we how we learned and how we practice. And I think, you know, what you're talking about is is is is something that's so rewarding because for anybody listening out there who's a woman or who lives with a woman, you understand it's it's not always fun. And and there are solutions, but often the the solutions are not getting to the people who need them because of the way in which traditional medicine is is practiced and how we're trained. And yet the solutions are relatively simple, very inexpensive, and very effective. I mean, I I would say other than, like, delivering a baby, which is so fun and a positive experience, you know, giving someone hormones and having their life turn around is, like, one of the most satisfying things as a doctor.
Right? Because you're just
Dr. Mary Claire Haver
A 100% agree.
Dr. Mark Hyman
Just like you they all of a sudden they're having symptoms. Their sex drive comes back. Their energy comes back. They're they're don't have mood changes. They have all these benefits, you know, that that occur.
And and, you know, we went through this period. I want to sort of come back to this because there's a reason that we've sort of shied away from hormones and women are suffering is that is that hormones kind of had a good rep and then a bad rep. And now they're coming back to having a better rep. And I I think there's a historical reason for that, which was a nurse's health study that was an observational study that didn't prove cause and effect. But the women who seem to take hormones did better than women who didn't.
So it was like, you gotta take them. And I remember a woman in my practice, who said, I couldn't at Kenya Ranch, she said, if if if, if I don't take hormones, my doctor says it's malpractice. If you don't prescribe hormones, it's malpractice. And that was the nurses health study. And then then then it shifted all in, like, 2,002.
There was a nurses health study, and it was like I went to the Women's Health Initiative, which is a big study of $1,000,000,000 and a 100 and, I don't know, 20, 40,000 people, women. And it kinda gave us some country data. And that meant, like, 50,000,000 women overnight stopped taking it, and it led to sort of a catastrophe. So can you walk us through, like, what should we actually know from the Women's Health Initiative, which is a randomized controlled trial? And what do we know now that's different in the intervening 22 years that has changed our thinking?
Dr. Mary Claire Haver
So this was one of the probably the best cases of something going viral before social media and, you know, kind of this path of of misunderstood information or misinformation. So WHI, you know, they started enrolling patients in the late nineties. We knew from observational data that women on HRT tended to have less heart attacks and die from heart attacks less. And so they said, alright. Well, is it just because women on HRT are healthier and wealthier?
Is this an artifact, or can we prove this with a randomized control study? First time aging women had ever been studied with that level of, and they use Premen and Prempro, which at the time were the 2 top it that wasn't unusual at the time. Those were the 2 commercially available formulations that they did. So that's one problem. They use one formulation.
You know, the Premarin, if they had a if they didn't have a uterus and then Premra, if they did, versus placebo. Average age so the outcome of the study was not safety. It was measured, but that was not the primary aim. The primary aim was to see if they would get cardiovascular disease or not. So they started with a much older population.
This is key. The average age of the study was 63. They enrolled the patients, get started. In the Permian and Provera arm, they did notice a very slight relative, relative risk increase of breast cancer in that population, not in the estrogen only arm. They called a press conference.
They didn't release the study data at the Watergate Hotel, and it was on the cover of every newspaper, every news story. I remember I was my chief year of training. I was 2002 is when I graduated. And it like you said, it was this massively disruptive. It was the top news medical news story of 2,002, and it said estrogen causes breast cancer.
Well, turns out the estrogen only arm kept going, and they didn't see an increased risk of breast cancer. So now you know? But that notion just went crazy. No one would prescribe it after. Everyone was terrified.
Those those data points have been refuted, as you know, throughout multiple studies throughout time, but we're just having a hard time, like, getting the world to catch up to this. But But in general
Dr. Mark Hyman
Was it the forms of hormones that caused some of the increased
Dr. Mary Claire Haver
growth in the So, you know, Levy and, Simon and Levy just published, like, the contemporary view of of hormone therapy. You know, formulation matters, type matters, age matters. We have a window of opportunity for protection for cardiovascular disease. And, basically, it's the time away from estrogen where the problems start for for females. So the longer my body is away from estrogen, the more likely I am I had to have a stroke of cardiovascular disease, diabetes, the whole every cardiometabolic disease.
Estrogen is protective. Once those diseases start, estrogen is great at prevention, not a cure for some of these things. And so the older women in the study didn't see a cardiovascular benefit because they probably already had heart disease. They missed their window of opportunity because they started older. Their acceleration of their diseases had already occurred.
So now we know. If you want the cardiovascular prevent protected benefits, you probably should start within 10 years of your menopause. If you want the neurologically protected benefits for decreased Alzheimer's and dementia, you need to start within the 1st 5 to 10 years. Lisa Moscone has new data published on this just this week in Nature. Probably it's a bigger window than we thought.
If it will always protect your bones. It's always gonna protect your general urinary system. It's always gonna protect your muscles. You know? But you still have to do the work.
So I never want anyone any of your listeners to think, oh, I'm just gonna take hormones and go about my
Dr. Mark Hyman
day and I'll
Dr. Mary Claire Haver
be perfect. No.
Dr. Mark Hyman
You said that exercise.
Dr. Mary Claire Haver
No. You must exercise. You must eat right. You know, this is a tool in the toolkit so that because here's the fact of the matter. Women live longer than men.
Sure. Okay? But we spend 20% of our lives in poor health than our male counterparts, and that's not okay. And that's the gender health gap. And that's where we have all this is where the work needs to happen.
Dr. Mark Hyman
Yeah. I think this is so essential. And I think, you know, as I was sort of learning about the women's health initiative, I I actually already had kind of gotten a little bit biased because I'd read this book about bio identical hormones, about using hormones that were the same as your body's own hormones to bind the same receptors that have less side effects. Like, Premarin, which was used in that original women's health study, that actually has to be metabolized by the liver, and it it actually increases inflammation. It's a reactive protein, increases triglycerides, affects increases your your risk of of breast cancer, I think, because of its effect on alcohol metabolism and lots of things.
So if you drink a glass of wine, your your hormone levels would jack up really high. So I think there was a lot of problems with that. But now the topical or bio identical hormones seem to be better tolerated, more effective. Are you worried at all about them that you would be concerned that there is some un unknown risk that we haven't determined from the research yet about whether or not these actually may increase breast cancer risk or ovarian cancer risk.
Dr. Mary Claire Haver
Not in the estrogen family. Not if you stick to a you know, not in not in the estradiol world. Okay? It doesn't look like it's actually protected for breast cancer, especially if you start young. The progestin seem to be where there's a lot of variation.
And, you know, these studies are being done. We have lots of data coming out from Europe and other places, but they're all using different progestogens. What I wanna see is a head to head of estradiol plus my oral mycorrhizeprogesterone, and let's follow those women, you know, for 20, 30 years and see who lives longer, what the risk of breast cancer is, etcetera. But, you know, what's happening is bikini medicine in my world where women are little men with the bikini medicine. So the only thing we need to worry about in women's health is the bikini area, the breasts and everything under the bikini.
And so, you know, the bikini bottom, and it's like you said, we're not testing these drugs, you know, cardiovascular drugs on men. So let's take a statin. You know? My cholesterol went up through the menopause transition. I've been able to get it back down with HRT and diet, okay, very successfully.
But my doctor recommended a statin. There is no data to suggest that statins decrease the primary risk of a heart attack in women. HRT does, and that was actually Premarin, like, not the best of of our options out there. So, I could go on and on about this.
Dr. Mark Hyman
No. It's good. It's good. It's good. I think it's good because I think, you know, we we, we we have to sort of empower women with the knowledge that we have now and not be stuck in this old story that we shouldn't do it.
Now the question I have really is is if if you're going through, no menopause and you have no symptoms and you're good, should you take hormones?
Dr. Mary Claire Haver
I would have a balanced conversation with that patient, and that's what I do in my clinic. I'm gonna talk to her about even though it's not recommended by the societies yet, except for the American Heart Association well, they're a little bit on the fence, but I talk to her about the known protective benefits of hormone therapy, her bones, her brain, her heart, if she's in the right window of opportunity. And I'll let her make a decision for herself. We'll talk about the risks, her family history, her needs, her wants. What's happening is the old menopause was HRT only for the shortest time, the lowest dose, only if you have severe symptoms and you're gonna jump off a roof.
Okay? But what about the woman who kind of luckily, the 15% who don't have the cliche symptoms? But I also say, what's your cholesterol? How's your insulin resistance? How's your joint pain?
Because those symptoms are just now being recognized as part of the hormone deficiency that's going on.
Dr. Mark Hyman
For sure.
Dr. Mary Claire Haver
And maybe we can help those things.
Dr. Mark Hyman
Yeah. And so so to flip the question upside down a little bit, if if a woman starts on hormones, is this something they should stay on long term, and and is this something that all women should do after menopause? Is this something we should kinda move towards thinking that all women should be done, or is this more of a personalized approach?
Dr. Mary Claire Haver
I definitely think it's personalized. I definitely right now in the US, 4 to maybe 8% of women who are eligible are on HRT, And people are saying that's over medicalized, and I think that's ridiculous. We're just allowing your body to work in the fashion that it used to work before you went through this change and, you know, before your you lost your eggs. And so I think every woman deserves that conversation and to be allowed to make a decision for herself. And then if she decides to do it, we re I review it every year with them.
How are you doing? How are you feeling? Have we developed any new medical problems? But it is absolutely possible that a woman could enjoy benefits of hormone therapy until she dies. I might die with an estradiol patch off.
Dr. Mark Hyman
I understand.
Dr. Mary Claire Haver
And let you know? And but that's my personal choice combined with my knowledge level and and my family history.
Dr. Mark Hyman
So I'm hearing the subtext, unless someone has significant reasons not to, like breast cancer risk or they've had breast cancer and is contraindicated, or ovarian cancer or uterine cancer, which are hormone dependent cancers that do flourish in the case of
Dr. Mary Claire Haver
That would feed your cancer would be fed. Yeah.
Dr. Mark Hyman
Right. It seems like what you're
Dr. Mary Claire Haver
A severe liver disease, a recent blood clot, you know, your Yeah. And, you know, a recent DVT or PE. Yeah. So a pulmonary contraindications. Of course.
Yeah.
Dr. Mark Hyman
Mhmm. But for pretty much everybody else, what I'm hearing you say is it's a good idea.
Dr. Mary Claire Haver
It's something to consider, and it is something I discuss with every single patient.
Dr. Mark Hyman
Yeah. The other thing is, you know, women might have a sort of, like, the frog in cold water that gets turned up slowly, and they don't know they're boiling to death. Like, the changes can happen and be subtle, and you think this is just a normal aging. But then you get them on hormones, like, wow. This is a different me.
Right? And this is a whole new whole new experience.
Dr. Mary Claire Haver
That is what I see in my clinic, and that is what the menopause you know, we have this little friend group of of clinicians, and we're multidisciplinary. The menopause. And we text all day long. We share patient stories and ask questions and articles, and, you know, it it's fun. And so, you know, it's retrospective.
It's all these women saying, oh my gosh. I didn't realize that. My tinnitus, tinnitus, my vertigo, my palpitations went away. Mhmm. You know?
Dr. Mark Hyman
Yeah. Yeah. Yeah. Yeah.
Dr. Mary Claire Haver
It's pretty exciting. It's exciting stuff.
Dr. Mark Hyman
So let's talk about testing. You know, you know, what I found is is hormones fluctuate greatly. And, you know, when I was sort of in medical school, I was saying, no. Don't worry about testing so much because they're all over the place, and, you know, you you only wanna test after they've stopped having their period to confirm they're in menopause. How do you see testing hormones in women, and and when should women start testing?
What should they be testing? And if you're checking hormones, does it matter when in the cycle you're chest testing? Like, should it be day 1 to 3 or day 18 to 23 to see what's happening with ovulation? How do you sort of think about this?
Dr. Mary Claire Haver
I I here's my fantasy, is that we have a CGM type thing, a continuous h a CHM, a continuous hormone monitor. You know? Why not? Why not? There's actually I talked to someone who's trying to develop one where you start having symptoms, you pop that bad boy on, you follow yourself for a couple of months.
It's tracking all the things, your estrogen, your progesterone, whatever. But, you know, we we have these kind of poor panaceas for that right now in the form of, you know, you need to do testing over multiple days. It's it's hard to to read. And so the way I diagnose perimenopause is I talk to the patient. I absolutely believe her.
I do a lot of blood work to rule out other things like autoimmune disease, hypothyroidism, inflammatory disorders, nutrition. But, like, a spot hormone test because of all that crazy chaos is not gonna help me that much. Certainly, if I can't use her period to help kinda guide me a little bit, I'm doing hormone testing, you know, to see, is she really postmenopausal and we missed it? Because we don't have a period to judge. But I, you know, I don't have a great, you know, easy blood urine saliva test that I think is a 100% reliable.
I really just listen to the patient, believe her, go there with her, you know, make sure nothing else is going on or overlapping with all the blood work, and then we just drive into treatment.
Dr. Mark Hyman
Well, it's interesting. For for, you know, premenopausal women, I think, you know, who are having a lot of symptoms. I always found that if I checked hormones sort of in the second half of the cycle, like the 18 to 23 of a normal 20 day cycle, that I could see what's going on with their ovulation because their progesterone would often be low.
Dr. Mary Claire Haver
Progesterone would be low.
Dr. Mark Hyman
And their estrogen would be really high. And that would kinda give me a lot of clues about what's going on. And then I might just try progesterone with those women, or I might try that and a tiny bit of estrogen. And and that seemed to be a a good sort of indicator. Is it is it is that a good practice?
Dr. Mary Claire Haver
That's very reasonable. You know, if if you can get it on day 18, just with modern you know, we are lucky in the type of clinics we have, but sometimes, you know, the access that patients have to that kind of thing is is is pretty limited. Yes. But I I think, you know, a really high estrogen with a really low progesterone is classic inovulation, right, or allivo ovulation. Or it that's either peri or PCOS for us.
And, you know, giving your progesterone often is miraculous. Those patients are so happy.
Dr. Mark Hyman
You can obviously see the ratio of LH and FSH change where you get high LH and low FSH, which is often correlated with PCOS, and we see that too. So it's kind of a what about, you know, early on in the cycle? When is it indicated to do testing day 1 to 3? You know? So typically most of the what what what
Dr. Mary Claire Haver
I learned for that was for fertility. And, interestingly, you know, we've fertility does a lot of work with AMH and
Dr. Mark Hyman
Anti malarian hormone?
Dr. Mary Claire Haver
Anti malarian hormone. They're actually looking at analogs of that or block or I think they're blockers. These there's 2 biotech companies that I know are working on, you know, medications that work with AMH to extend the life of the ovary because it seems that rise in AMH is accelerating the the loss of the follicles in menopause. And if they can figure out a way to block that process, they think they can extend the life of the ovary so that we have we can enjoy more of our natural estrogen. But, again, that's all in theory, and they're testing it in apple juice.
Dr. Mark Hyman
Measure AMH, this it should be lower in in order to indicate better fertility. When it's higher, it
Dr. Mary Claire Haver
might be a little bit better. Longer you have a longer time until you're menopausal. So I think there's there's a lot of work to be done there in the menopause space, so I'm excited to see what's coming in the future for that.
Dr. Mark Hyman
Let's talk about sex. I think, you know, one of the things that We
Dr. Mary Claire Haver
didn't talk about testosterone yet.
Dr. Mark Hyman
No. That's what I wanna get into. So, you know, you know, you you've said before that, and I this is sort of well known if you're a physician, is it maybe not actually for most doctors is that testosterone, absolute testosterone levels are higher than estrogen and production levels in women.
Dr. Mary Claire Haver
In women. It's the precursor to estradiol down the, you know, down the down the pathway to create estradiol. Testosterone's the last step before we aromatize it to estradiol. So, yeah, our natural testosterone levels are actually higher in picograms per deciliter than our estradiol levels, but then we lose those too.
Dr. Mark Hyman
Yeah. And there's a lot of reasons for for libido issues and sexual dysfunction in women. I once heard this woman, Susan Love, who wrote a book about women's health years ago. She was quite amazing, and she said the biggest sex organ for women is between their ears. And I think there's a lot a lot of truth in that, but but also women have vaginal dryness.
They have lower testosterone. They have arousal dysfunction. There's all sorts of stuff that gets kinda chronic.
Dr. Mary Claire Haver
Vagabrio dysfunction. Yeah.
Dr. Mark Hyman
Yeah. And, you know, and men got Viagra and all this stuff, but women kind of don't really seem to get have this addressed very effectively. And what I found is it's it can be really effectively addressed by you know, addressing overall lifestyle issues and relationship issues, obviously, but sometimes using testosterone can be very effective. And it also is great for bone health and mood and energy and focus and has a lot of benefits. So, I I'm curious about your perspective about the use of testosterone and how you use it, how you prescribe it.
You know, I I one of the things I I I learned was that you could use it topically on the clitoris, and you can get it compounded. And women use a couple of drops every night. Over a few weeks, it really increases their arousal, orgasm. And I I I think it worked because the women I prescribed it for would always call me back for refills, so I figured that it was working either way.
Dr. Mary Claire Haver
Yeah. So my friend so in our menopause, we have, 3 or 4 urologists who are females. You know, they're in Ishwish, the sexual what medicine wellness conference, and they love topical testosterone in the vulva, especially if they're having it's there's so many testosterone receptors in that lower, in the introitus as well. They love it for the clitoris too. So, like, doing that if you look at the vulva, that they call it 12 to 6 when you apply the the cream, and they have it specially compounded for that.
They're huge fans of that. Especially if they have GSM, generally urinary syndrome of menopause, a combination of estrogen and testosterone, or the DHEA, which gets converted down the pathway to both, is is helpful. So I love testosterone. I'm a huge fan. Clearly, the data for HSDD, hypoactive sexual desire disorder, which is the organ between our head.
Dr. Mark Hyman
Oh my god.
Dr. Mary Claire Haver
You know? But, you know, does she have a good relationship with PTSD? Names. Yeah. Is she having pain?
You know, we're ruling out all the other causes, making sure she has a stable relationship with a partner who she used to have a good libido with or, you know, layman's term libido. Making sure she's not having pain. We gotta fix that. And, so all those things are addressed. And then testosterone really does seem to be helpful for the hypoactive desire issues, so the brain parts for females.
Also, I use it off label if my patients come in. I have a monitor in my office for for muscle mass and and visceral fat. I have an InBody scanner, electrical impedance scanner. So if she's coming in and she's she's had a bone density and she's got low bone mass and she's sarcopenic, you know, I am recommending it off label because the data is very promising in combination with we know that women with higher just natural testosterone levels have less of those diseases. So I'm just trying to help her, but she's gotta eat the protein and lift the weights and do all the things as well.
And and that testosterone can be, additive in that.
Dr. Mark Hyman
And you use it topically, or how do you use it? Through
Dr. Mary Claire Haver
the skin or So yeah. For the only on ducanoy is, and it's not even approved in the US. It's safe, you know, for the liver toxicity part of it. So testosterone therapy should be transmucosal or transdermal, for safety reasons. And then in the US, there's no FDA approved, you know, formulation for women.
So in some states than others, it's easier to get sometimes you can do the male version of, like, t T Stem gel, and you but it's hard to dose. You know, it's like a pea size amount or so most of my patients, because Texas, we really have a hard time getting the t stem from the pharmacist, will go around the block and do a compounded cream. So I'll do a transdermal testosterone cream for the patients, and we'll kind of dose adjust, you know, based on her levels and her symptoms.
Dr. Mark Hyman
And it doesn't cause women to grow mustaches and beards and
Dr. Mary Claire Haver
If you stay in a physiologic range, if you don't overdose her, sure. If I give her enough, she will grow all sorts of things. But I I try to keep my patients in a healthy physiologic range.
Dr. Mark Hyman
I think that's so important. That is such a key statement, and it is to use hormones in a way that kind of matches your normal physiologic state for optimal health, not an excess amount. I mean, you see these muscle heads in gyms that have huge levels of anabolic hormones that this is our super physiological, and there there are serious consequences that. But if you're keeping people in an optimum range, it it actually works. And I I think, again, this is one of those areas that has been neglected for women that is so important to be addressed.
And again, even that there isn't an FDA approved formulation that you have to go hustle around and try to get this prescription covered or go to a compounding pharmacy, it just doesn't make any sense. Right?
Dr. Mary Claire Haver
Exactly. It's so frustrating as a as a clinician that I can't. It's so complicated sometimes to help my patients get what they need just to feel normal again.
Dr. Mark Hyman
Yeah. I think I think we're we're kind of hopefully coming out of the dark ages of women's health. I don't know if we are, but it feels like there's a lot of people out there not talking about it. There's you. There's people like Sarah Godfrey.
There's others. You know, my friend, Gabrielle Lyon, are all kind of advocating for kind of a a new way of thinking about women's health. You know, it wasn't something I intended to go into, but it just became something that I was very much immersed in because of the population that I was dealing with. And I just learned so much from my patients and, you know, often the the best source of learning is listening and asking what's going on with them, them telling you, and then learning about the condition and how to sort of adjust your your treatment to match that. And I I think, you know, it's been a dark period because because of the women's health initiative, there's been such a fear and such a resistance to hormone therapy across the medical disciplines, and and now it seems like it's shifting.
Is this just on the fringe, or do you think this is changing within, traditional obstetrics in gynecology?
Dr. Mary Claire Haver
I definitely see it changing. I see, like, in the American ABOG, American Board of OB GYN, the Council on Resident Education. I was a program director for, like, 10 years. So they are pushing to have a menopause curriculum. I see, you know, more and more people contacting me, other clinicians who are like, help me.
Help me. I wanna learn more. You know? The the rate of people signing up to get certified by the menopause society is skyrocketing. You know?
I think people are becoming aware mostly due to social media platforms, the news, you know, and patients. This generation of menopausal and perimenopausal woman is not putting up with it. She knows there's a better life for her, that she doesn't have to suffer, and she wants more information.
Dr. Mark Hyman
So what's what's on the horizon? Like, what's what are we kinda looking at in terms of, you know, new advancements in medicine, in nutrition, supplements, in other therapies that could help with with women's health and hormones and menopause. Is so you're kind of on leading edge, and you're hearing about things that are emerging. What what are you excited about?
Dr. Mary Claire Haver
Well, I talked about the, you know, the the ways to, like, improve the shelf life of your ovary naturally to, like, hang on to the follicles that you have for as long as possible. So that's one of the most exciting things too. You know, my daughter is a medical student. She's a she just started her 2nd year, like, this
Dr. Mark Hyman
Mine too.
Dr. Mary Claire Haver
And yeah. We're in their 4th year. It's really exciting. And, she just seeing her class and how excited they are about learning more about menopause and aging women, males and females, you know, all the people in her class, how into this that they are, and they see the tide changing. I'm like, this is the next generation.
You know, they're gonna be doing my surgery in 20 years. Like and that that what I see is other medical society really starting to put a toe in the water and study the aging woman outside of what a man does, and, like, how that's just gonna broaden our understanding so that we can close that health gap between men and women.
Dr. Mark Hyman
Yeah. That's great. I mean, I I think I think, you know, there's some kinda cool therapies out there that I've seen, like certain things for arousal disorder like Vyleesi. There's other drugs out there that
Dr. Mary Claire Haver
are and Vyleesi are pretty pretty cool. So, yeah, Vyleesi, for HSDD. Yeah. So there's 2 FDA approved medications for the treatment of hypoactive sexual desire disorder. They are they were studied in premenopausal patients, but we are using them off label for menopausal patients.
So Vyleesi is a medication that works on melanocortin in the brain. And it's an injection you give your yeah. Yeah. So injection you give yourself 30 minutes before, you know, activity. And when it works, it works great.
Like, the patients absolutely love it. And, similar to how Viagra would work because you need a certain time before the medicine kicks in and and the arousal, you know, begins. So and then Adi is a medication you take every day, and it works at the level of nerve receptors in the brain. I'm changing god. Is it dopamine?
I can't remember. I should know this. And so that's a medication you take every day, like a vitamin to just kind of shore up your level so you're more interested and ready when the opportunity presents itself to you.
Dr. Mark Hyman
No. That's great. It's great. I mean, I think, it's about time. And and I think I think the other thing I wanted to sort of just before we wrap, I wanted to talk to you about PMS because in my experience, seeing women in this sort of transitional period, it gets worse.
Like, it may not be bad in their twenties and then in their late thirties, forties, it starts to accelerate, and they get premeds from migraines. They get flu retention. They get breast tenderness. They get, you know, mood changes. They get sleep disruption.
And it to me, it's sort of like almost like kinda squishes up against the sort of whole perimenopausal phenomena because it's often related to this imbalance with that you get in hormones from the lack of ovulation every cycle. And and I'm curious about how you how you approach that and what you think
Dr. Mary Claire Haver
about that. I know from her history, if she had severe PMS symptoms, and we go to go through what those were, that these tend to become accelerated when she hits perimenopause. That whatever pathology was causing that, you know, how her body responded to that hormonal milieu in her this is gonna like, especially if she has depression or anxiety, you know, she had to be treated for that. We know that we I need to be on the lookout in peri, that this may be the first sign of her perimenopause that she has sudden worsening of these symptoms. And I'm going in for I'm going in for hormone therapy very quickly on this.
Dr. Mark Hyman
So as a treatment for PMS, you use hormone therapy?
Dr. Mary Claire Haver
So it's been a so now I you know, not doing a lot of premenopausal patients now. But back in the day, we kinda had 2 options, like squash her hormones with birth control pills, and for some, that gave them symptomatic control, or do an SSRI, either every day or just
Dr. Mark Hyman
Otherwise known as Prozac. 2 2
Dr. Mary Claire Haver
2 weeks out of the month, you know, when her PMS symptoms would have been the worst. But as far as, like, any real research as to why the hell this is happening other than you're just a woman, we we got we got work to do.
Dr. Mark Hyman
Yeah. I mean, from my experience as a functional medicine doctor, it it seems pretty clear that it's it's a it relates to a lot of the lifestyle factors, environmental factors, toxins, diet, the gut microbiome that are all modifiable. And then by fixing all these things, get people nutritional status up, get them big b 6, magnesium, a lot of the things that help omega 3 fats. A few supplements often can really be helpful. In fact, I had a a cocktail that they don't make anymore, but it was a cocktail of Chinese herbs that's from perimenopause and hormone imbalance and PMS and magnesium, taurine, and b 6, which all help with estrogen excess and metabolism.
And it would be like a miracle pill for this. Also, I use chasteberry, which is a an herb. Bitext can be helpful. And
Dr. Mary Claire Haver
then and
Dr. Mark Hyman
then, you know, sometimes giving even a little bit of progesterone can be really magical for these women, even topical or or more if they need a little more. And and and so it's sort of it's really about getting the whole person healthy. And I think, you know, it's easy to think of jumping to hormones. But I think what you said before is really important that it's not about just jumping to hormones. It's about understanding the full panel of phenomena that are driving these changes and then working on those, what you're eating, exercise, stress, sleep, nutritional status, your gut health, all these things will help to regulate your hormones because they're influenced by all these things.
And that's that's sort of they're not just randomly going haywire. There's reasons for it. It's not like I said, a design flaw. And so we can actually really do a lot of good for people by helping them do that. And by the way, the side effects of all those things work for every other known disease.
So
Dr. Mary Claire Haver
Right. And so we I well, I give a lecture to medical students or residents. You know? Thank god programs are inviting me, and I and I go through the menopause toolkit, and we talk about the big 6, insulin resistance, cardiovascular disease, and how menopause plays in here. Then I'm like, you're gonna see the same things repeated.
25 grams more fiber in your diet per day. Lower your you know, get adequate sleep. You know, I'm like, this all these things work for all these diseases. Right? And so you're gonna see a pattern here, and there's a reason for it.
Dr. Mark Hyman
Yes. Like, there's one diet for preventing cancer that causes heart disease, and other diets that's for heart disease that causes diabetes, and other diet for diabetes that causes dementia. No. No. It's like the basic principles of running and operating a human being are pretty the same.
Right? In your car, you need oil, you need gas, you need air in your tires. Like, it's not that complicated, but it's, again, stuff that we just don't know anything about. I mean, my daughter's in medical school, and I said, Rachel, how how much you learn about nutrition? Nothing.
I learned about fatty acids and amino acids, and I'm like, what are you gonna take for lunch? What are you gonna eat for lunch? Right? And then I said, well, what about your microbiome? Well, not really.
How about toxins? Well, now not not not about that either. They're like, wow. You know, it's even though, you know, the science is out there, and it's not hard to find. You just go to the, you know, the Internet.
You go to PubMed and search for anything, and you'll find it, and you'll find what data on there.
Dr. Mary Claire Haver
My daughter got her undergrad in nutrition science.
Dr. Mark Hyman
Oh, wow.
Dr. Mary Claire Haver
And she was gonna become a registered dietitian, and then, like, halfway through, she's like, mom, I think I wanna take the MCAT. And I was like, go for it. You know, she thought she could be more effective with her nutrition background going to an MD than than an RD. It's more more of her interest level. So, yeah, she talk about you know, whenever I talk about nutrition, she can't she follows every word and double checks me and is throwing articles at me.
She's really fun having her, you know, double triple check everything I say.
Dr. Mark Hyman
Yeah. Well, yeah, they're, they're they're good to kinda keep you on your feet. Right?
Dr. Mary Claire Haver
Yeah.
Dr. Mark Hyman
Yeah. So if you could kinda have a final word to women out there who are struggling with menopause and menopausal symptoms, perimenopause, PMS, like, what what kind of sort of would you advise them as a sort of an overall sort of menopause framework and strategy? Kinda how how do you kind of
Dr. Mary Claire Haver
Menopause is is inevitable for all of us and and but suffering is not. And you can live your best life. I am almost 56. I am the healthiest, happiest, best relationships, beautiful sleep. You know, multiple reasons for that.
It's not just the estrogen patch I'm wearing. And I want everyone to feel the way that I feel right now. You know, I want everyone to enjoy the life that I have. You know? And it's I changed everything when I hit menopause.
I changed how I ate, how I thought, how I stress released. I gave up a lovely job that I cared about that was killing me. You know?
Dr. Mark Hyman
And Right.
Dr. Mary Claire Haver
You know? So I I I and I want that for everyone. And so, you know, finding a menopause educated provider, you know, to help guide you through this and be your partner through this transition is gonna be key.
Dr. Mark Hyman
Well, thanks for your advocacy and your work and your insights. You you have a wealth of resources. Your new book, is is really tremendous. It's really
Dr. Mary Claire Haver
Thank you.
Dr. Mark Hyman
Kind of lays out a map. It's for women. It's called the new menopause, the latest research and best treatments for a healthier, better life. You can find everywhere you get books. You also have a great website.
Right? And, it's
Dr. Mary Claire Haver
Thank you.
Dr. Mark Hyman
Maybe share with that as to everybody. Yeah. And a pause live.
Dr. Mary Claire Haver
Yeah. It's the pause live.
Dr. Mark Hyman
The pause live. The pause live. That's great. Yeah. That's great.
Dr. Mary Claire Haver
I wanted to put a positive spin.
Dr. Mark Hyman
Great. And so I think it's it's just great that you're out there talking about this because it's not enough people particularly from, you know, more of a traditional academic background who who really understand this and are helping people through it. So thank you, and, it's great to great to hear that you and I come to the same conclusions after 30 years of practice. So Yeah. I really appreciate your work, and thanks for joining us on The Doctor's Farmacy.
Dr. Mary Claire Haver
Thanks for having me.
Dr. Mark Hyman
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Coming up on this episode of The Doctor's Farmacy.
Dr. Mary Claire Haver
But the data is clear that doctor Hemant, like, on mental health. Like, you are better off giving her balancing those hormones than giving her an SSRI. It is more effective for the perimenopausal patient with new onset mental health changes. I just refuse to let people suffer.
Dr. Mark Hyman
Before we jump into today's episode, I'd like to note that while I wish I could help everyone via my personal practice, there's simply not enough time for me to do this at this scale. And that's why I've been busy building several passion projects to help you better understand, well, you. If you're looking for data about your biology, check out function health for real time lab insights. If you're in need of deepening your knowledge around your health journey, check out my membership community, Hyman Hive. And if you're looking for curated and trusted supplements and health products for your routine, visit my website, supplement store, for a summary of my favorite and tested products.
Hi. I'm doctor Mark Hyman, a practicing physician and proponent of systems medicine, a framework to help you understand the why or the root cause of your symptoms. Welcome to The Doctor's Farmacy. Every week, I bring on interesting guests to discuss the latest topics in the field of functional medicine and do a deep dive on how these topics pertain to your health. In today's episode, I have some interesting discussions with other experts in the field.
So let's just jump right in. Welcome, Doctor Haver, to The Doctor's Farmacy podcast. It's so great to have you here with us today.
Dr. Mary Claire Haver
Thank you for having me.
Dr. Mark Hyman
You know, you are, now a shining light in the field of women's health and menopause. You you're everywhere. And, you're talking about things that often have been neglected and no and when we went to medical school, we we never learned that women were different than men. All the research was done on men. You know, and and so we really kind of had this whole field of neglected, suffering that I would call it, that women endured, without a lot of help.
And, it was like, take the pill or take Prempro, which which is Premen and Provera. And those are, like, the 2 kind of options. And, of course, I'm over simplifying, but it was it was basically that. Or if you have menstrual disorders, take the pill. If you have menopausal stuff, take Prempro.
And there was some, like that was kinda it. There was no discussion of diet, of lifestyle. You know, you have background in culinary medicine. You know, people didn't understand the complexities that happen in women's health and the role of of, insulin resistance, the role of inflammation, the role of the microbiome, the role of toxins and endocrine disruptors. Like, none of that was stuff we learned, and yet it it's so important.
And and so many women suffer unnecessarily from symptoms that have simple solutions. And what's so great about your work is that you help people really navigate that and talk, as a as a physician, but also as an obstetrician gynecologist in a deep way about about this. And you've also had, you know, your own personal experience as a woman, so that adds a lot of flavor. I mean, I'm just a guy, and, you know, I probably shouldn't be talking about this. But I I think, you know, my experience as as a physician was sort of shaped by my work at Canyon Ranch, where basically for almost 10 years, I worked taking care of people between the age of 35 60, which was sort of the majority of of women.
And and I learned a lot about issues, and it it sort of struck me that so many women were suffering needlessly from things like PMS and, you know, dysfunctional bleeding and menopausal symptoms and osteoporosis and mood changes and sexual dysfunction and just a whole bunch of stuff that just never got bare airtime in traditional medicine. So I kind of would love to sort of hear your perspective. You know, just taking us through kind of your let's call it your indoctrination. I'm not going to have brainwashing, but it's kind of brainwashing. You know, we learn a lot of good stuff in medical school, for sure, and it's the foundation.
But like like what? Where where did you get from from what you learned there to where you are now? And how did you so? Yeah. How did you kind of shift your perspective, and what was the sort of the things that kinda catalyze that change in thinking?
Dr. Mary Claire Haver
So I, again, traditionally trained super proud of everything I learned, but as I grew older and my patient population was growing with me, we're all becoming perimenopausal and menopausal together. You know, When I started out, I was having babies. My patients were having babies. You get all the new OB patients. In your early days in family medicine, you get that.
And then you you kinda get your set of patients and off we go together. So here we are mid thirties, early forties, and there's this litany of complaints that myself and my patients are starting to go through. And I thought back to my residency training where there's a very shameful story of I was a new intern with my little white coat in gynecology clinic, and the upper levels would run to the charts back when we had paper charts and shuffle through to find surgery cases. You know? They wanted the surgeries because they had to get their numbers to graduate, and then that kinda left everything else in gynecology for us.
So that was discharge and irregular periods and and, you know, all the things. And then the interns got the very end of the pile. And it's what my upper levels would call a w w. And I didn't know what that was. And they w w w.
So you're upper level w w, and so they call it a whiny woman. Oh, what's that? The chart, and no professor ever said it. Other parts of the country called it whiny dineys. So women are coming in with these multiple day complaints.
They're all somewhere in their late thirties to forties. They all have this kind of laundry list of very vague complaints, not sleeping, low libido, weight gain, you know, tummy fat, that's new, not, you know, just disrupted mood, disrupted relationships. And we were taught that, well, this is just something women go through, and there's not much we can do about it. And pat her on the knee and tell her to sleep better and lose weight and have some wine, and everything will be okay.
Dr. Mark Hyman
Have some wine. Well, that's gonna fix it. Yes. That's gonna make it a lot worse, actually.
Dr. Mary Claire Haver
So fast forward 20 years, and I'm sitting there, you know, and it clicks in my head. I'm like, I'm a whiny woman. These are whiny though, there's more there's more to it than this. So that's where I started opening my mind, changing my perspective, and realizing, doctor Ahmed, that there is a huge gap in my own knowledge and training, and I would have sworn 10 years before that I was a great menopause doctor. I made A's on on my test, blew the top off my boards, but I didn't know what I didn't know.
And so the more I dug and then started to grow on social media because I started talking about it, when 10,000 people tell you, my frozen shoulder started at, you know, right when my periods became disrupted in perimenopause, I don't blow them off. I go look. It turns out we have evidence for multi multiple organ systems that are really attributed to, you know, when the hormones start changing all these things that can go awry, not just hot flashes and night sweats.
Dr. Mark Hyman
I think you're so right about that. You know, one of the stats that just blew me away was that, you know, 75% of women have some degree of premenstrual syndrome or PMS. Right?
Dr. Mary Claire Haver
Oh, yeah.
Dr. Mark Hyman
And I said to my and I said to myself, you know, what's going on here? Like, this is not a design flaw. Like, whether you believe in, you know, we were evolved from whatever or god made us or whatever. It's nature's not that stupid. God's not that stupid.
Like, why are all these women suffering? It's not something universally attributable to being a woman. It's something going on in our environment that's driving these changes. And there's things that can be changed in women's behaviors and their environment and their diet and their lifestyle and toxins that will make a difference. And so I I kind of was like, it kinda made me angry to see all these women who had all these issues that were not being dealt with effectively.
So for you, when you when you kind of had this insight, what what was the the next step for you in kind of changing your your practice? How did you start to kind of shift in your head to kind of think about this differently? And what did you do differently? What did you learn to do that you stopped doing, and what are you doing now that you didn't do?
Dr. Mary Claire Haver
So cutting my toe in the water was my patience and my frustrations with what at the time I was calling the unexplained weight gain. Now I know it's a body composition change, but everybody was complaining of the same thing. And it was one of my besides the hot flashes, night sweats, and joint pain that I was having, my pain point having been a thin person most of my life and having that thin privilege, then all of a sudden not being able despite no changes in diet and exercise. Actually, I was doubling down on on really destructive behaviors probably, calorically restricting to ridiculous levels, you know, doubling down at the gym without any real results. And so finally, my it was my husband who's an engineer who thinks very you know?
And he's like, honey, your daughters are watching. So my kids were, you know, teenagers and preteens at the time. And he said, you know, you're getting up in the middle of the night to pee and I see you weigh yourself. You're, you know, this is not healthy. You're a scientist.
Figure this out. So I called the nutrition department at the university I was employed at, and I was I was I was their doctor. Right? So I called my friends, so I delivered all their kids and the PhDs. And I said, what is going on in menopause?
Everyone's complaining of this. You know? They led me down a rabbit hole of inflammation, how estrogen deprivation is related to inflammation. I've never been taught this information in my life. It was never in our CMEs.
It was not you know? Menopause was hot flashes, night sweats, generally urinary syndrome, and some osteoporosis. That's it. And I'm like, wait. This isn't my fault.
This isn't because I'm lazy. This isn't because you know? And they're like, oh, by the way, this visceral fat deposition is leading to cardiometabolic risk that you never had before. What's your cholesterol doing? You know?
And having come from I was a PCOS patient, had fertility treatments for my kids, you know, learned all that's where my toe in the nutrition space started because I was on these online forums. Like, I couldn't figure out couldn't take enough metformin to you know, I'm like, there's gotta be a better way, and that's where I learned about how nutrition is playing into this as well. And so, you know, starting to talk to my patients about it, them getting excited, you know, looking at changing our nutrition. Are you getting enough fiber? Are we getting you know, instead of counting calories, let's let's look at nutrients and see what happens.
And that led to, you know, the Galveston diet and then you know? But then the conversation just exploded around menopause in general.
Dr. Mark Hyman
Yeah. You know, it's interesting. I I wrote an article years ago because I think, you know, this sort of change in thinking happened to me too. And and I it was called the life cycles of women, and it was talking about all the change that happened at different periods of women's life, you know, when they're going through puberty, when they're in their twenties, their thirties, their forties, their fifties, their sixties. And, it really is different in every stage of a woman's cycle, and it's something that that, you know, is not well appreciated by women.
It's not appreciated by most doctors. And yet when you begin to understand the physiology and the biology of what happens, you can start to intervene and help people actually deal with some of the suffering. So so so your focus is mostly on menopause, but I'm sure you obviously dealt with PCOS, you've dealt with PMS, you've dealt with dysfunctional bleeding, and all these things that happen. What do you think are the biggest causes for this sort of epidemic of hormonal dysregulation and suffering that women have to go through that is, I would say, usually avoidable or preventable or or or treatable if if it's not?
Dr. Mary Claire Haver
Right. So, you know, definitely our nutrition. It it's so much of it is the quality of our nutrition, you know, too much caloric intake for a lot of for a lot of patients, you know, having when your body composition changes and you have these you're you're leading to increased insulin resistance, which directly affects the function, you know, the insulin receptors on the ovary, which leads to PCOS. So, you know, I think nutrition, exercise, how we kind of move, how we think, how we eat as a culture is really pointing to a lot of the disruptions that we're seeing.
Dr. Mark Hyman
Yeah. You know, Sydney, I don't know if this is true or not. It's just a it was just a kind of folklore, but, I've heard that in Japan, they never had a word for hot flashes. That just
Dr. Mary Claire Haver
Oh, they it's rare in Japan. Yeah. They have different symptoms, a lot more musculoskeletal, than we do. But, yeah, in in culture
Dr. Mark Hyman
a lot of soy and a lot of omega threes. They have less sugar. They have, you know, more more nutrient dense food. Right? So so maybe, you know, it's it's our ultra processed food that's driving a lot of the dysfunction in our microbiome and insulin and inflammation.
And and so these are these are things that that happen on the surface that most people don't realize, but that are actually driving a lot of hormonal dysregulation. So do you do you think that do you think you have a perspective on that?
Dr. Mary Claire Haver
I definitely know that culturally, you know, and and cultures tend to eat a certain way, tend to exercise. Of course, there's outliers and everything. We see a different catalog of symptoms. You know, people who live in the blue zone tend to have less obvious menopause symptoms. I mean, every woman is born with a finite set of eggs.
Right? And we're all gonna run out, and that's our menopause. And then we live 20 to 30 years without the, you know, benefit of the estradiol produced in our ovaries. But how our body reacts to that loss of estrogen, that's where, you know, in in my practice, we call it the menopause toolkit. Replacing hormones is is one prong there, and it's not for everyone.
But we, you know, we go hard on nutrition, movement, stress reduction, sleep optimization, things that they really didn't teach us in medical school.
Dr. Mark Hyman
Right. Right. And those are true. Those are key, and I think those can get you a lot of the way there. And and, you know, I think that that some things that also are relevant, there are things we're also not taught in medical school beside nutrition are things like environmental toxins and how they disrupt our hormones.
They're called endocrine disruptors or the microbiome and hormones. How have you sort of learned about those things in in relation to the sort of epidemic of hormonal dysregulation, including infertility, PCOS, and all these problems we're seeing?
Dr. Mary Claire Haver
I think we need so much more work in this area. You know, just like you said, putting Band Aids on everything without really looking for and I know this term is misused, but the root cause, you know, why is this happening to this woman? Like you said, god's not that mean. There's certainly outliers. But why is 20% of our population, 10 to 20% have PCOS, polycystic ovarian syndrome.
Why is that? We were not designed for this to happen this way. We were designed to have a very predictable monthly ebb and flow of hormones until perimenopause. And then you know? And so why is it that that's happening?
And I think we need so much more research in this area. I think it's a I think it's a traffic circle with environment, some toxins, you know, nutrition. Everything is feeding into this negative feedback cycle.
Dr. Mark Hyman
And so what are the ways in which these these various environmental factors affect women's hormones, and how how does it affect them in their thirties, forties, fifties? Can you kinda walk us through, how you think about this?
Dr. Mary Claire Haver
So when we reach perimenopause, we reach a critical threshold of the amount of eggs that we have, that the normal signals that come from the brain that tell the egg ovaries to ovulate, what doesn't happen in PCOS. Right? We almost become PCOS like in perimenopause because our our level of egg egg supply at 30, we're down to 10% of what we're born with. By 40, we're down to 3%. And so peri begins when the normal signals don't work anymore.
We become resistant. Now we could definitely make that worse with. We know, you know, if you have inflammation in the abdomen through surgery, chemo, radiation, you know, that definitely helps. If you are insulin resistant and not managed with diet, that will definitely contribute to how your ovaries are gonna respond to this environment and how they're gonna produce the hormones. I have less training and stuff on the exact toxins.
I know the usual things like radiation and chemo will affect, but if those things affect, certainly others might affect as well.
Dr. Mark Hyman
Yeah. There was a a book I read years ago called Hormonal Chaos by Theo Kollmer. It was sort of like a silent spring book. I encourage you to check it out because it it really describes how, you know, she was a sort of research scientist who was looking at what was going on in animal populations and the ways in which these these pesticides and plastics and so forth that we're all poisoned with are are endocrine disruptors are causing abnormal genders and hermaphroditism and infertility and, you know, trouble with with all sorts of populations from frogs to birds to alligators. And it was fascinating, and I kind of got me to really think about it.
The the the thing that I I think that happens with this this changes in the eggs and the cycles and the hormones is interesting because as as in I'm practicing, what I would notice, we often we would have high levels of estrogen and low levels of progesterone. They would have an what we call anovulatory cycles. This is, like, what you get in in PSOS where you don't ovulate and recycle, and then you don't make progesterone, which is what happens in the second half of your cycle. And that was sort of the thing that led to a lot of these symptoms of fluid retention and breast tenderness and menstrual migraines and then heavy bleeding and irregular cycles, and it's just this big kind of almost continuum of hormonal dysfunction. And and, you know, I I I wonder sort of what your perspective is on this this sort of phenomena that I I think is a lot.
You know, in the world of functional medicine, we talk about estrogen dominance or estrogen excess or imbalance, and it's it's not it could be in a relative or excess relative or absolute imbalance between estrogen and progesterone, and and that seems to what's led to a lot of the symptoms. And a lot of the toxins and a lot of the dietary things drive an increase in estrogen. Right? So these are estrogen mimicking toxins, and then sugar causes fat deposition, which leads to excess estrogen produced in this in the fat tissue. So can you kind of walk us through what is this whole phenomena?
How should we think about it, and what can women start to do to kind of address it?
Dr. Mary Claire Haver
I think you hit the nail on the head of the these are most of the what you would call estrogen dominance is chronic inovulation or ovo ovulation, meaning you're just not getting that monthly ovulation cycle going. And so, you know, in PCOS and peri, people will ovulate in PCOS occasionally. Right? It's very, very similar in multiple levels to what a woman's gonna go through in perimenopause as far as where her hormones are. So we have, you know, much higher levels of FSH because the brain is constantly trying to get that egg out, you know, to get those estradiol levels up.
So that spurt in FSH will then give you these much higher estradiol levels than a regular ovulating woman would have. And then after ovulation, the progesterone never quite gets to where it used to be. So, yeah, she has this whole cascade of symptoms, heavy periods, light periods, no periods, too many period. You know, everything's on the table as far as her cycles. Breasts become enlarged, fluid retention, you know, gut micro microbiome becomes disrupted.
And, you know, treatment options through that really vary from patient to patient. There is no one size fits all. So this is where I think a lot of patients are getting frustration. A, they're not being offered any treatment at all because you haven't had a not had a period for a year, you know, or they're just, you know, occasionally a birth control pill might be helpful in certain situations, but it should not be I don't think the panacea go to for all peri and and PCOS patients. By, you know, our lack of training and education around how nutrition, how diet, looking at what she's eating, when she's eating, how she's eating, how she's moving, making sure, you know, she's getting the right kind of exercise.
Most of my practice focuses on, you know, 35 plus in that perimenopause to menopause range. And, you know, we're plotting out a course to decrease the risk of osteoporosis and sarcopenia. You know, so that's where my exercise recommendations are going. More heavy lifting, less intense cardio, you know, more zone 2 training, and how, you know, we can balance her her hormone levels through this transition so she's not suffering.
Dr. Mark Hyman
So there's things that raise estrogen, and there's things that kinda reduce ovulation. So it's sort of like working on both ends of that. Right? And, you know, traditional a traditional OBGYN will typically just give women, if they're premenopausal, the birth control pill, and if they're That's
Dr. Mary Claire Haver
what they're trying to do.
Dr. Mark Hyman
Yes. We're trying to do. It's like and yet, you know, if they're not looking for contraception and then we can discuss the pros and cons of the pill. But, you know, it it may not be the best therapy because it comes with risks and also side effects. So, you know, one of one of the things that, you know, I I one of the things I I did when I was early on in this field was, like, 1996.
I met a guy named John Lee. Have you ever heard about this guy? And and he wrote this book, and it interesting to get your perspective on this. He wrote a book called What Your Doctor May Not Tell You About Menopause.
Dr. Mary Claire Haver
And I I've heard of the book, but I haven't read it.
Dr. Mark Hyman
Great book. And it and it I heard him speak, and and I was like, this is interesting. Let me try this out. And essentially, he was talking about the use of low dose topical progesterone or sometimes oral progesterone as a way to help a lot of women with all these symptoms that happen, whether it's pain.
Dr. Mary Claire Haver
In perimenopause, it's very effective.
Dr. Mark Hyman
Perimenopause. Yeah. Yeah. For sleep, for hot you know, for just heavy bleeding, for fibroids, all this stuff that that, you know and it it was that's something I learned in medical school. So how do you think about this whole sort of approach of using progesterone, and is it safe?
Is it effective? Is is what should we be concerned about, and and how do we sort of know when to use it?
Dr. Mary Claire Haver
Great question. I really, really like it in early perimenopause, especially if she's still kind of cycling regularly, but her she's having disrupted sleep. I love it for sleep. I love it for regular and heavy periods. It does wonders.
Traditionally trained, you don't need progesterone if you've had a hysterectomy. You know? However, I use it all the time, because the what it does for the brain in sleep is amazing. And there's new data coming out looking at you know, we have a 40% increased risk of mental health disorders through perimenopause when she was completely either worsening or new onset of mostly anxiety and depression. And progesterone can be very helpful here.
Also, a low dose estrogen, can be really helpful here as well even if she's still ovulating, something like a low dose estradiol patch just to kind of shore her up through those dips. You know? That's how I explain it to her. Now for as far as how I prescribe progesterone, transdermal so we have progestogens, which is the big category, right, of all of our progesterone type medications. We have progestins, which are quote synthetic, you know, and I like having options, but I usually do oral micronized progesterone.
The topical progesterones are natural, but it's a really big molecule. And there's not great data showing we get enough penetration through the skin if you're giving estrogen at the same time to protect the lining of the uterus. And I, like, really like giving that pill at night for sleep. My patients love it. They really you know, especially if their sleep disrupted outside of hot flashes, they it it and and and my personal bias, it is the best thing I've ever done for myself is the progesterone at night.
Dr. Mark Hyman
It's kind of a miracle. It was kind of a miracle pill Yeah. And a miracle drug that I I never learned about really using in medical school other than in combination with Premarin. And and the and the and the synthetic form of it called Provera, which my joke was it made women fat, hairy, and depressed because it's had a lot of side effects. You know?
And and
Dr. Mary Claire Haver
Yeah. Not many of us in in the modern menopause space use Provera, you know, very, very rarely. I pretty much just use progesterone. You know? I'm trying to get the patient as close to what our ovaries used to make as possible.
You know? I don't love the term body identical, but it is body identical. So But I think it
Dr. Mark Hyman
it that's a really important point. So use stuff that your body knows what to do with, and it doesn't have all these untoward effects. Like, you know, and I think, you know, the the thing you said, I just wanna don't wanna skip over it is that you you're doing something that's really unusual in women's health. You're you're actually combining topical low dose estradiol or the most common form of estrogen with oral or even topical progesterone. And you're doing it before they end their menstrual cycles, before they
Dr. Mary Claire Haver
end the
Dr. Mark Hyman
definition of menopause, which is really kind of a little bit heretical. It's like taking care
Dr. Mary Claire Haver
of to let people suffer. I Yeah.
Dr. Mark Hyman
That's it.
Dr. Mary Claire Haver
Right? Not only, but the data is clear that doctor Hemant, like, on mental health, like, you are better off giving her, balancing those hormones than giving her an SSRI. It is more effective for the perimenopausal patient with new onset mental health changes. So and then the cardiovascular data is looking good. Like, if we can get this thing shored up before she completely transitions, she is going to do better in multiple aspects of her life.
Why are we waiting till people are symptomatic? Why are we waiting until they have osteoporosis? Why are we waiting until they have general urinary syndrome? Well, with this, we could be preventative.
Dr. Mark Hyman
What what do you mean? That's what we learned to do in medical school. Wait till someone's sick and then give me a drug. I don't know what you're talking about. So totally clear why we do this.
I mean, it you're what you're saying is is sounds so common sense, but it's often sort of, not how we how we learned and how we practice. And I think, you know, what you're talking about is is is is something that's so rewarding because for anybody listening out there who's a woman or who lives with a woman, you understand it's it's not always fun. And and there are solutions, but often the the solutions are not getting to the people who need them because of the way in which traditional medicine is is practiced and how we're trained. And yet the solutions are relatively simple, very inexpensive, and very effective. I mean, I I would say other than, like, delivering a baby, which is so fun and a positive experience, you know, giving someone hormones and having their life turn around is, like, one of the most satisfying things as a doctor.
Right? Because you're just
Dr. Mary Claire Haver
A 100% agree.
Dr. Mark Hyman
Just like you they all of a sudden they're having symptoms. Their sex drive comes back. Their energy comes back. They're they're don't have mood changes. They have all these benefits, you know, that that occur.
And and, you know, we went through this period. I want to sort of come back to this because there's a reason that we've sort of shied away from hormones and women are suffering is that is that hormones kind of had a good rep and then a bad rep. And now they're coming back to having a better rep. And I I think there's a historical reason for that, which was a nurse's health study that was an observational study that didn't prove cause and effect. But the women who seem to take hormones did better than women who didn't.
So it was like, you gotta take them. And I remember a woman in my practice, who said, I couldn't at Kenya Ranch, she said, if if if, if I don't take hormones, my doctor says it's malpractice. If you don't prescribe hormones, it's malpractice. And that was the nurses health study. And then then then it shifted all in, like, 2,002.
There was a nurses health study, and it was like I went to the Women's Health Initiative, which is a big study of $1,000,000,000 and a 100 and, I don't know, 20, 40,000 people, women. And it kinda gave us some country data. And that meant, like, 50,000,000 women overnight stopped taking it, and it led to sort of a catastrophe. So can you walk us through, like, what should we actually know from the Women's Health Initiative, which is a randomized controlled trial? And what do we know now that's different in the intervening 22 years that has changed our thinking?
Dr. Mary Claire Haver
So this was one of the probably the best cases of something going viral before social media and, you know, kind of this path of of misunderstood information or misinformation. So WHI, you know, they started enrolling patients in the late nineties. We knew from observational data that women on HRT tended to have less heart attacks and die from heart attacks less. And so they said, alright. Well, is it just because women on HRT are healthier and wealthier?
Is this an artifact, or can we prove this with a randomized control study? First time aging women had ever been studied with that level of, and they use Premen and Prempro, which at the time were the 2 top it that wasn't unusual at the time. Those were the 2 commercially available formulations that they did. So that's one problem. They use one formulation.
You know, the Premarin, if they had a if they didn't have a uterus and then Premra, if they did, versus placebo. Average age so the outcome of the study was not safety. It was measured, but that was not the primary aim. The primary aim was to see if they would get cardiovascular disease or not. So they started with a much older population.
This is key. The average age of the study was 63. They enrolled the patients, get started. In the Permian and Provera arm, they did notice a very slight relative, relative risk increase of breast cancer in that population, not in the estrogen only arm. They called a press conference.
They didn't release the study data at the Watergate Hotel, and it was on the cover of every newspaper, every news story. I remember I was my chief year of training. I was 2002 is when I graduated. And it like you said, it was this massively disruptive. It was the top news medical news story of 2,002, and it said estrogen causes breast cancer.
Well, turns out the estrogen only arm kept going, and they didn't see an increased risk of breast cancer. So now you know? But that notion just went crazy. No one would prescribe it after. Everyone was terrified.
Those those data points have been refuted, as you know, throughout multiple studies throughout time, but we're just having a hard time, like, getting the world to catch up to this. But But in general
Dr. Mark Hyman
Was it the forms of hormones that caused some of the increased
Dr. Mary Claire Haver
growth in the So, you know, Levy and, Simon and Levy just published, like, the contemporary view of of hormone therapy. You know, formulation matters, type matters, age matters. We have a window of opportunity for protection for cardiovascular disease. And, basically, it's the time away from estrogen where the problems start for for females. So the longer my body is away from estrogen, the more likely I am I had to have a stroke of cardiovascular disease, diabetes, the whole every cardiometabolic disease.
Estrogen is protective. Once those diseases start, estrogen is great at prevention, not a cure for some of these things. And so the older women in the study didn't see a cardiovascular benefit because they probably already had heart disease. They missed their window of opportunity because they started older. Their acceleration of their diseases had already occurred.
So now we know. If you want the cardiovascular prevent protected benefits, you probably should start within 10 years of your menopause. If you want the neurologically protected benefits for decreased Alzheimer's and dementia, you need to start within the 1st 5 to 10 years. Lisa Moscone has new data published on this just this week in Nature. Probably it's a bigger window than we thought.
If it will always protect your bones. It's always gonna protect your general urinary system. It's always gonna protect your muscles. You know? But you still have to do the work.
So I never want anyone any of your listeners to think, oh, I'm just gonna take hormones and go about my
Dr. Mark Hyman
day and I'll
Dr. Mary Claire Haver
be perfect. No.
Dr. Mark Hyman
You said that exercise.
Dr. Mary Claire Haver
No. You must exercise. You must eat right. You know, this is a tool in the toolkit so that because here's the fact of the matter. Women live longer than men.
Sure. Okay? But we spend 20% of our lives in poor health than our male counterparts, and that's not okay. And that's the gender health gap. And that's where we have all this is where the work needs to happen.
Dr. Mark Hyman
Yeah. I think this is so essential. And I think, you know, as I was sort of learning about the women's health initiative, I I actually already had kind of gotten a little bit biased because I'd read this book about bio identical hormones, about using hormones that were the same as your body's own hormones to bind the same receptors that have less side effects. Like, Premarin, which was used in that original women's health study, that actually has to be metabolized by the liver, and it it actually increases inflammation. It's a reactive protein, increases triglycerides, affects increases your your risk of of breast cancer, I think, because of its effect on alcohol metabolism and lots of things.
So if you drink a glass of wine, your your hormone levels would jack up really high. So I think there was a lot of problems with that. But now the topical or bio identical hormones seem to be better tolerated, more effective. Are you worried at all about them that you would be concerned that there is some un unknown risk that we haven't determined from the research yet about whether or not these actually may increase breast cancer risk or ovarian cancer risk.
Dr. Mary Claire Haver
Not in the estrogen family. Not if you stick to a you know, not in not in the estradiol world. Okay? It doesn't look like it's actually protected for breast cancer, especially if you start young. The progestin seem to be where there's a lot of variation.
And, you know, these studies are being done. We have lots of data coming out from Europe and other places, but they're all using different progestogens. What I wanna see is a head to head of estradiol plus my oral mycorrhizeprogesterone, and let's follow those women, you know, for 20, 30 years and see who lives longer, what the risk of breast cancer is, etcetera. But, you know, what's happening is bikini medicine in my world where women are little men with the bikini medicine. So the only thing we need to worry about in women's health is the bikini area, the breasts and everything under the bikini.
And so, you know, the bikini bottom, and it's like you said, we're not testing these drugs, you know, cardiovascular drugs on men. So let's take a statin. You know? My cholesterol went up through the menopause transition. I've been able to get it back down with HRT and diet, okay, very successfully.
But my doctor recommended a statin. There is no data to suggest that statins decrease the primary risk of a heart attack in women. HRT does, and that was actually Premarin, like, not the best of of our options out there. So, I could go on and on about this.
Dr. Mark Hyman
No. It's good. It's good. It's good. I think it's good because I think, you know, we we, we we have to sort of empower women with the knowledge that we have now and not be stuck in this old story that we shouldn't do it.
Now the question I have really is is if if you're going through, no menopause and you have no symptoms and you're good, should you take hormones?
Dr. Mary Claire Haver
I would have a balanced conversation with that patient, and that's what I do in my clinic. I'm gonna talk to her about even though it's not recommended by the societies yet, except for the American Heart Association well, they're a little bit on the fence, but I talk to her about the known protective benefits of hormone therapy, her bones, her brain, her heart, if she's in the right window of opportunity. And I'll let her make a decision for herself. We'll talk about the risks, her family history, her needs, her wants. What's happening is the old menopause was HRT only for the shortest time, the lowest dose, only if you have severe symptoms and you're gonna jump off a roof.
Okay? But what about the woman who kind of luckily, the 15% who don't have the cliche symptoms? But I also say, what's your cholesterol? How's your insulin resistance? How's your joint pain?
Because those symptoms are just now being recognized as part of the hormone deficiency that's going on.
Dr. Mark Hyman
For sure.
Dr. Mary Claire Haver
And maybe we can help those things.
Dr. Mark Hyman
Yeah. And so so to flip the question upside down a little bit, if if a woman starts on hormones, is this something they should stay on long term, and and is this something that all women should do after menopause? Is this something we should kinda move towards thinking that all women should be done, or is this more of a personalized approach?
Dr. Mary Claire Haver
I definitely think it's personalized. I definitely right now in the US, 4 to maybe 8% of women who are eligible are on HRT, And people are saying that's over medicalized, and I think that's ridiculous. We're just allowing your body to work in the fashion that it used to work before you went through this change and, you know, before your you lost your eggs. And so I think every woman deserves that conversation and to be allowed to make a decision for herself. And then if she decides to do it, we re I review it every year with them.
How are you doing? How are you feeling? Have we developed any new medical problems? But it is absolutely possible that a woman could enjoy benefits of hormone therapy until she dies. I might die with an estradiol patch off.
Dr. Mark Hyman
I understand.
Dr. Mary Claire Haver
And let you know? And but that's my personal choice combined with my knowledge level and and my family history.
Dr. Mark Hyman
So I'm hearing the subtext, unless someone has significant reasons not to, like breast cancer risk or they've had breast cancer and is contraindicated, or ovarian cancer or uterine cancer, which are hormone dependent cancers that do flourish in the case of
Dr. Mary Claire Haver
That would feed your cancer would be fed. Yeah.
Dr. Mark Hyman
Right. It seems like what you're
Dr. Mary Claire Haver
A severe liver disease, a recent blood clot, you know, your Yeah. And, you know, a recent DVT or PE. Yeah. So a pulmonary contraindications. Of course.
Yeah.
Dr. Mark Hyman
Mhmm. But for pretty much everybody else, what I'm hearing you say is it's a good idea.
Dr. Mary Claire Haver
It's something to consider, and it is something I discuss with every single patient.
Dr. Mark Hyman
Yeah. The other thing is, you know, women might have a sort of, like, the frog in cold water that gets turned up slowly, and they don't know they're boiling to death. Like, the changes can happen and be subtle, and you think this is just a normal aging. But then you get them on hormones, like, wow. This is a different me.
Right? And this is a whole new whole new experience.
Dr. Mary Claire Haver
That is what I see in my clinic, and that is what the menopause you know, we have this little friend group of of clinicians, and we're multidisciplinary. The menopause. And we text all day long. We share patient stories and ask questions and articles, and, you know, it it's fun. And so, you know, it's retrospective.
It's all these women saying, oh my gosh. I didn't realize that. My tinnitus, tinnitus, my vertigo, my palpitations went away. Mhmm. You know?
Dr. Mark Hyman
Yeah. Yeah. Yeah. Yeah.
Dr. Mary Claire Haver
It's pretty exciting. It's exciting stuff.
Dr. Mark Hyman
So let's talk about testing. You know, you know, what I found is is hormones fluctuate greatly. And, you know, when I was sort of in medical school, I was saying, no. Don't worry about testing so much because they're all over the place, and, you know, you you only wanna test after they've stopped having their period to confirm they're in menopause. How do you see testing hormones in women, and and when should women start testing?
What should they be testing? And if you're checking hormones, does it matter when in the cycle you're chest testing? Like, should it be day 1 to 3 or day 18 to 23 to see what's happening with ovulation? How do you sort of think about this?
Dr. Mary Claire Haver
I I here's my fantasy, is that we have a CGM type thing, a continuous h a CHM, a continuous hormone monitor. You know? Why not? Why not? There's actually I talked to someone who's trying to develop one where you start having symptoms, you pop that bad boy on, you follow yourself for a couple of months.
It's tracking all the things, your estrogen, your progesterone, whatever. But, you know, we we have these kind of poor panaceas for that right now in the form of, you know, you need to do testing over multiple days. It's it's hard to to read. And so the way I diagnose perimenopause is I talk to the patient. I absolutely believe her.
I do a lot of blood work to rule out other things like autoimmune disease, hypothyroidism, inflammatory disorders, nutrition. But, like, a spot hormone test because of all that crazy chaos is not gonna help me that much. Certainly, if I can't use her period to help kinda guide me a little bit, I'm doing hormone testing, you know, to see, is she really postmenopausal and we missed it? Because we don't have a period to judge. But I, you know, I don't have a great, you know, easy blood urine saliva test that I think is a 100% reliable.
I really just listen to the patient, believe her, go there with her, you know, make sure nothing else is going on or overlapping with all the blood work, and then we just drive into treatment.
Dr. Mark Hyman
Well, it's interesting. For for, you know, premenopausal women, I think, you know, who are having a lot of symptoms. I always found that if I checked hormones sort of in the second half of the cycle, like the 18 to 23 of a normal 20 day cycle, that I could see what's going on with their ovulation because their progesterone would often be low.
Dr. Mary Claire Haver
Progesterone would be low.
Dr. Mark Hyman
And their estrogen would be really high. And that would kinda give me a lot of clues about what's going on. And then I might just try progesterone with those women, or I might try that and a tiny bit of estrogen. And and that seemed to be a a good sort of indicator. Is it is it is that a good practice?
Dr. Mary Claire Haver
That's very reasonable. You know, if if you can get it on day 18, just with modern you know, we are lucky in the type of clinics we have, but sometimes, you know, the access that patients have to that kind of thing is is is pretty limited. Yes. But I I think, you know, a really high estrogen with a really low progesterone is classic inovulation, right, or allivo ovulation. Or it that's either peri or PCOS for us.
And, you know, giving your progesterone often is miraculous. Those patients are so happy.
Dr. Mark Hyman
You can obviously see the ratio of LH and FSH change where you get high LH and low FSH, which is often correlated with PCOS, and we see that too. So it's kind of a what about, you know, early on in the cycle? When is it indicated to do testing day 1 to 3? You know? So typically most of the what what what
Dr. Mary Claire Haver
I learned for that was for fertility. And, interestingly, you know, we've fertility does a lot of work with AMH and
Dr. Mark Hyman
Anti malarian hormone?
Dr. Mary Claire Haver
Anti malarian hormone. They're actually looking at analogs of that or block or I think they're blockers. These there's 2 biotech companies that I know are working on, you know, medications that work with AMH to extend the life of the ovary because it seems that rise in AMH is accelerating the the loss of the follicles in menopause. And if they can figure out a way to block that process, they think they can extend the life of the ovary so that we have we can enjoy more of our natural estrogen. But, again, that's all in theory, and they're testing it in apple juice.
Dr. Mark Hyman
Measure AMH, this it should be lower in in order to indicate better fertility. When it's higher, it
Dr. Mary Claire Haver
might be a little bit better. Longer you have a longer time until you're menopausal. So I think there's there's a lot of work to be done there in the menopause space, so I'm excited to see what's coming in the future for that.
Dr. Mark Hyman
Let's talk about sex. I think, you know, one of the things that We
Dr. Mary Claire Haver
didn't talk about testosterone yet.
Dr. Mark Hyman
No. That's what I wanna get into. So, you know, you know, you you've said before that, and I this is sort of well known if you're a physician, is it maybe not actually for most doctors is that testosterone, absolute testosterone levels are higher than estrogen and production levels in women.
Dr. Mary Claire Haver
In women. It's the precursor to estradiol down the, you know, down the down the pathway to create estradiol. Testosterone's the last step before we aromatize it to estradiol. So, yeah, our natural testosterone levels are actually higher in picograms per deciliter than our estradiol levels, but then we lose those too.
Dr. Mark Hyman
Yeah. And there's a lot of reasons for for libido issues and sexual dysfunction in women. I once heard this woman, Susan Love, who wrote a book about women's health years ago. She was quite amazing, and she said the biggest sex organ for women is between their ears. And I think there's a lot a lot of truth in that, but but also women have vaginal dryness.
They have lower testosterone. They have arousal dysfunction. There's all sorts of stuff that gets kinda chronic.
Dr. Mary Claire Haver
Vagabrio dysfunction. Yeah.
Dr. Mark Hyman
Yeah. And, you know, and men got Viagra and all this stuff, but women kind of don't really seem to get have this addressed very effectively. And what I found is it's it can be really effectively addressed by you know, addressing overall lifestyle issues and relationship issues, obviously, but sometimes using testosterone can be very effective. And it also is great for bone health and mood and energy and focus and has a lot of benefits. So, I I'm curious about your perspective about the use of testosterone and how you use it, how you prescribe it.
You know, I I one of the things I I I learned was that you could use it topically on the clitoris, and you can get it compounded. And women use a couple of drops every night. Over a few weeks, it really increases their arousal, orgasm. And I I I think it worked because the women I prescribed it for would always call me back for refills, so I figured that it was working either way.
Dr. Mary Claire Haver
Yeah. So my friend so in our menopause, we have, 3 or 4 urologists who are females. You know, they're in Ishwish, the sexual what medicine wellness conference, and they love topical testosterone in the vulva, especially if they're having it's there's so many testosterone receptors in that lower, in the introitus as well. They love it for the clitoris too. So, like, doing that if you look at the vulva, that they call it 12 to 6 when you apply the the cream, and they have it specially compounded for that.
They're huge fans of that. Especially if they have GSM, generally urinary syndrome of menopause, a combination of estrogen and testosterone, or the DHEA, which gets converted down the pathway to both, is is helpful. So I love testosterone. I'm a huge fan. Clearly, the data for HSDD, hypoactive sexual desire disorder, which is the organ between our head.
Dr. Mark Hyman
Oh my god.
Dr. Mary Claire Haver
You know? But, you know, does she have a good relationship with PTSD? Names. Yeah. Is she having pain?
You know, we're ruling out all the other causes, making sure she has a stable relationship with a partner who she used to have a good libido with or, you know, layman's term libido. Making sure she's not having pain. We gotta fix that. And, so all those things are addressed. And then testosterone really does seem to be helpful for the hypoactive desire issues, so the brain parts for females.
Also, I use it off label if my patients come in. I have a monitor in my office for for muscle mass and and visceral fat. I have an InBody scanner, electrical impedance scanner. So if she's coming in and she's she's had a bone density and she's got low bone mass and she's sarcopenic, you know, I am recommending it off label because the data is very promising in combination with we know that women with higher just natural testosterone levels have less of those diseases. So I'm just trying to help her, but she's gotta eat the protein and lift the weights and do all the things as well.
And and that testosterone can be, additive in that.
Dr. Mark Hyman
And you use it topically, or how do you use it? Through
Dr. Mary Claire Haver
the skin or So yeah. For the only on ducanoy is, and it's not even approved in the US. It's safe, you know, for the liver toxicity part of it. So testosterone therapy should be transmucosal or transdermal, for safety reasons. And then in the US, there's no FDA approved, you know, formulation for women.
So in some states than others, it's easier to get sometimes you can do the male version of, like, t T Stem gel, and you but it's hard to dose. You know, it's like a pea size amount or so most of my patients, because Texas, we really have a hard time getting the t stem from the pharmacist, will go around the block and do a compounded cream. So I'll do a transdermal testosterone cream for the patients, and we'll kind of dose adjust, you know, based on her levels and her symptoms.
Dr. Mark Hyman
And it doesn't cause women to grow mustaches and beards and
Dr. Mary Claire Haver
If you stay in a physiologic range, if you don't overdose her, sure. If I give her enough, she will grow all sorts of things. But I I try to keep my patients in a healthy physiologic range.
Dr. Mark Hyman
I think that's so important. That is such a key statement, and it is to use hormones in a way that kind of matches your normal physiologic state for optimal health, not an excess amount. I mean, you see these muscle heads in gyms that have huge levels of anabolic hormones that this is our super physiological, and there there are serious consequences that. But if you're keeping people in an optimum range, it it actually works. And I I think, again, this is one of those areas that has been neglected for women that is so important to be addressed.
And again, even that there isn't an FDA approved formulation that you have to go hustle around and try to get this prescription covered or go to a compounding pharmacy, it just doesn't make any sense. Right?
Dr. Mary Claire Haver
Exactly. It's so frustrating as a as a clinician that I can't. It's so complicated sometimes to help my patients get what they need just to feel normal again.
Dr. Mark Hyman
Yeah. I think I think we're we're kind of hopefully coming out of the dark ages of women's health. I don't know if we are, but it feels like there's a lot of people out there not talking about it. There's you. There's people like Sarah Godfrey.
There's others. You know, my friend, Gabrielle Lyon, are all kind of advocating for kind of a a new way of thinking about women's health. You know, it wasn't something I intended to go into, but it just became something that I was very much immersed in because of the population that I was dealing with. And I just learned so much from my patients and, you know, often the the best source of learning is listening and asking what's going on with them, them telling you, and then learning about the condition and how to sort of adjust your your treatment to match that. And I I think, you know, it's been a dark period because because of the women's health initiative, there's been such a fear and such a resistance to hormone therapy across the medical disciplines, and and now it seems like it's shifting.
Is this just on the fringe, or do you think this is changing within, traditional obstetrics in gynecology?
Dr. Mary Claire Haver
I definitely see it changing. I see, like, in the American ABOG, American Board of OB GYN, the Council on Resident Education. I was a program director for, like, 10 years. So they are pushing to have a menopause curriculum. I see, you know, more and more people contacting me, other clinicians who are like, help me.
Help me. I wanna learn more. You know? The the rate of people signing up to get certified by the menopause society is skyrocketing. You know?
I think people are becoming aware mostly due to social media platforms, the news, you know, and patients. This generation of menopausal and perimenopausal woman is not putting up with it. She knows there's a better life for her, that she doesn't have to suffer, and she wants more information.
Dr. Mark Hyman
So what's what's on the horizon? Like, what's what are we kinda looking at in terms of, you know, new advancements in medicine, in nutrition, supplements, in other therapies that could help with with women's health and hormones and menopause. Is so you're kind of on leading edge, and you're hearing about things that are emerging. What what are you excited about?
Dr. Mary Claire Haver
Well, I talked about the, you know, the the ways to, like, improve the shelf life of your ovary naturally to, like, hang on to the follicles that you have for as long as possible. So that's one of the most exciting things too. You know, my daughter is a medical student. She's a she just started her 2nd year, like, this
Dr. Mark Hyman
Mine too.
Dr. Mary Claire Haver
And yeah. We're in their 4th year. It's really exciting. And, she just seeing her class and how excited they are about learning more about menopause and aging women, males and females, you know, all the people in her class, how into this that they are, and they see the tide changing. I'm like, this is the next generation.
You know, they're gonna be doing my surgery in 20 years. Like and that that what I see is other medical society really starting to put a toe in the water and study the aging woman outside of what a man does, and, like, how that's just gonna broaden our understanding so that we can close that health gap between men and women.
Dr. Mark Hyman
Yeah. That's great. I mean, I I think I think, you know, there's some kinda cool therapies out there that I've seen, like certain things for arousal disorder like Vyleesi. There's other drugs out there that
Dr. Mary Claire Haver
are and Vyleesi are pretty pretty cool. So, yeah, Vyleesi, for HSDD. Yeah. So there's 2 FDA approved medications for the treatment of hypoactive sexual desire disorder. They are they were studied in premenopausal patients, but we are using them off label for menopausal patients.
So Vyleesi is a medication that works on melanocortin in the brain. And it's an injection you give your yeah. Yeah. So injection you give yourself 30 minutes before, you know, activity. And when it works, it works great.
Like, the patients absolutely love it. And, similar to how Viagra would work because you need a certain time before the medicine kicks in and and the arousal, you know, begins. So and then Adi is a medication you take every day, and it works at the level of nerve receptors in the brain. I'm changing god. Is it dopamine?
I can't remember. I should know this. And so that's a medication you take every day, like a vitamin to just kind of shore up your level so you're more interested and ready when the opportunity presents itself to you.
Dr. Mark Hyman
No. That's great. It's great. I mean, I think, it's about time. And and I think I think the other thing I wanted to sort of just before we wrap, I wanted to talk to you about PMS because in my experience, seeing women in this sort of transitional period, it gets worse.
Like, it may not be bad in their twenties and then in their late thirties, forties, it starts to accelerate, and they get premeds from migraines. They get flu retention. They get breast tenderness. They get, you know, mood changes. They get sleep disruption.
And it to me, it's sort of like almost like kinda squishes up against the sort of whole perimenopausal phenomena because it's often related to this imbalance with that you get in hormones from the lack of ovulation every cycle. And and I'm curious about how you how you approach that and what you think
Dr. Mary Claire Haver
about that. I know from her history, if she had severe PMS symptoms, and we go to go through what those were, that these tend to become accelerated when she hits perimenopause. That whatever pathology was causing that, you know, how her body responded to that hormonal milieu in her this is gonna like, especially if she has depression or anxiety, you know, she had to be treated for that. We know that we I need to be on the lookout in peri, that this may be the first sign of her perimenopause that she has sudden worsening of these symptoms. And I'm going in for I'm going in for hormone therapy very quickly on this.
Dr. Mark Hyman
So as a treatment for PMS, you use hormone therapy?
Dr. Mary Claire Haver
So it's been a so now I you know, not doing a lot of premenopausal patients now. But back in the day, we kinda had 2 options, like squash her hormones with birth control pills, and for some, that gave them symptomatic control, or do an SSRI, either every day or just
Dr. Mark Hyman
Otherwise known as Prozac. 2 2
Dr. Mary Claire Haver
2 weeks out of the month, you know, when her PMS symptoms would have been the worst. But as far as, like, any real research as to why the hell this is happening other than you're just a woman, we we got we got work to do.
Dr. Mark Hyman
Yeah. I mean, from my experience as a functional medicine doctor, it it seems pretty clear that it's it's a it relates to a lot of the lifestyle factors, environmental factors, toxins, diet, the gut microbiome that are all modifiable. And then by fixing all these things, get people nutritional status up, get them big b 6, magnesium, a lot of the things that help omega 3 fats. A few supplements often can really be helpful. In fact, I had a a cocktail that they don't make anymore, but it was a cocktail of Chinese herbs that's from perimenopause and hormone imbalance and PMS and magnesium, taurine, and b 6, which all help with estrogen excess and metabolism.
And it would be like a miracle pill for this. Also, I use chasteberry, which is a an herb. Bitext can be helpful. And
Dr. Mary Claire Haver
then and
Dr. Mark Hyman
then, you know, sometimes giving even a little bit of progesterone can be really magical for these women, even topical or or more if they need a little more. And and and so it's sort of it's really about getting the whole person healthy. And I think, you know, it's easy to think of jumping to hormones. But I think what you said before is really important that it's not about just jumping to hormones. It's about understanding the full panel of phenomena that are driving these changes and then working on those, what you're eating, exercise, stress, sleep, nutritional status, your gut health, all these things will help to regulate your hormones because they're influenced by all these things.
And that's that's sort of they're not just randomly going haywire. There's reasons for it. It's not like I said, a design flaw. And so we can actually really do a lot of good for people by helping them do that. And by the way, the side effects of all those things work for every other known disease.
So
Dr. Mary Claire Haver
Right. And so we I well, I give a lecture to medical students or residents. You know? Thank god programs are inviting me, and I and I go through the menopause toolkit, and we talk about the big 6, insulin resistance, cardiovascular disease, and how menopause plays in here. Then I'm like, you're gonna see the same things repeated.
25 grams more fiber in your diet per day. Lower your you know, get adequate sleep. You know, I'm like, this all these things work for all these diseases. Right? And so you're gonna see a pattern here, and there's a reason for it.
Dr. Mark Hyman
Yes. Like, there's one diet for preventing cancer that causes heart disease, and other diets that's for heart disease that causes diabetes, and other diet for diabetes that causes dementia. No. No. It's like the basic principles of running and operating a human being are pretty the same.
Right? In your car, you need oil, you need gas, you need air in your tires. Like, it's not that complicated, but it's, again, stuff that we just don't know anything about. I mean, my daughter's in medical school, and I said, Rachel, how how much you learn about nutrition? Nothing.
I learned about fatty acids and amino acids, and I'm like, what are you gonna take for lunch? What are you gonna eat for lunch? Right? And then I said, well, what about your microbiome? Well, not really.
How about toxins? Well, now not not not about that either. They're like, wow. You know, it's even though, you know, the science is out there, and it's not hard to find. You just go to the, you know, the Internet.
You go to PubMed and search for anything, and you'll find it, and you'll find what data on there.
Dr. Mary Claire Haver
My daughter got her undergrad in nutrition science.
Dr. Mark Hyman
Oh, wow.
Dr. Mary Claire Haver
And she was gonna become a registered dietitian, and then, like, halfway through, she's like, mom, I think I wanna take the MCAT. And I was like, go for it. You know, she thought she could be more effective with her nutrition background going to an MD than than an RD. It's more more of her interest level. So, yeah, she talk about you know, whenever I talk about nutrition, she can't she follows every word and double checks me and is throwing articles at me.
She's really fun having her, you know, double triple check everything I say.
Dr. Mark Hyman
Yeah. Well, yeah, they're, they're they're good to kinda keep you on your feet. Right?
Dr. Mary Claire Haver
Yeah.
Dr. Mark Hyman
Yeah. So if you could kinda have a final word to women out there who are struggling with menopause and menopausal symptoms, perimenopause, PMS, like, what what kind of sort of would you advise them as a sort of an overall sort of menopause framework and strategy? Kinda how how do you kind of
Dr. Mary Claire Haver
Menopause is is inevitable for all of us and and but suffering is not. And you can live your best life. I am almost 56. I am the healthiest, happiest, best relationships, beautiful sleep. You know, multiple reasons for that.
It's not just the estrogen patch I'm wearing. And I want everyone to feel the way that I feel right now. You know, I want everyone to enjoy the life that I have. You know? And it's I changed everything when I hit menopause.
I changed how I ate, how I thought, how I stress released. I gave up a lovely job that I cared about that was killing me. You know?
Dr. Mark Hyman
And Right.
Dr. Mary Claire Haver
You know? So I I I and I want that for everyone. And so, you know, finding a menopause educated provider, you know, to help guide you through this and be your partner through this transition is gonna be key.
Dr. Mark Hyman
Well, thanks for your advocacy and your work and your insights. You you have a wealth of resources. Your new book, is is really tremendous. It's really
Dr. Mary Claire Haver
Thank you.
Dr. Mark Hyman
Kind of lays out a map. It's for women. It's called the new menopause, the latest research and best treatments for a healthier, better life. You can find everywhere you get books. You also have a great website.
Right? And, it's
Dr. Mary Claire Haver
Thank you.
Dr. Mark Hyman
Maybe share with that as to everybody. Yeah. And a pause live.
Dr. Mary Claire Haver
Yeah. It's the pause live.
Dr. Mark Hyman
The pause live. The pause live. That's great. Yeah. That's great.
Dr. Mary Claire Haver
I wanted to put a positive spin.
Dr. Mark Hyman
Great. And so I think it's it's just great that you're out there talking about this because it's not enough people particularly from, you know, more of a traditional academic background who who really understand this and are helping people through it. So thank you, and, it's great to great to hear that you and I come to the same conclusions after 30 years of practice. So Yeah. I really appreciate your work, and thanks for joining us on The Doctor's Farmacy.
Dr. Mary Claire Haver
Thanks for having me.
Dr. Mark Hyman
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