Beyond Hot Flashes: Thriving Through Menopause into Your Best Years - Transcript

Dr. Mary Claire Haver
Women live longer than men. Sure. But we spent 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, that's where the work needs to happen.

Dr. Mark Hyman
Before we jump into today's episode, I want to share a few ways you can go deeper on your health journey. While I wish I could work with everyone one on one, there just isn't enough time in the day. So I built several tools to help you take control of your health. If you're looking for guidance, education, and community, check out my private membership, the HymanHive, for live q and a's, exclusive content, and direct connection. For real time lab testing and personalized insights into your biology, visit Function Health.

You can also explore my curated doctor trusted supplements and health products at doctorhymen.com. And if you prefer to listen without any breaks, don't forget you can enjoy every episode of this podcast ad free with Hyman Plus. Just open Apple Podcasts and tap try free to start your seven day free trial. What happens during perimenopause? Well, a lot of things can happen.

Ovaries are not necessarily ovulating every month and you can have these things called anovulatory cycles. You might have less estrogen. You'll have less progesterone because that only happens when you ovulate and you get a sack on your ovary that's called the corpus lutein that produces progesterone. And that basically leads to these hormonal imbalances. That's the take home here.

And you can have low estrogen, high estrogen, low progesterone. Now, these, these sort of swings in hormones are, are often irregular and they're responsible for many of the menopausal symptoms, right? The hot flashes, night sweats, vaginal dryness, that comes with lower estrogen. The drop in progesterone can actually happen earlier than the drop in estrogen and that they result in anovulatory cycles. These are cycles where you just don't ovulate, right?

The egg doesn't come out. You kind of run out of eggs. You know, you're born with a certain number of eggs and they decline over time and eventually you kind of always get pooped out and you just don't produce an egg. And when you don't produce an egg, that leads to a drop in progesterone. And that progesterone drop leads to what we call unopposed estrogen.

So it's either an absolute or a relative increase in estrogen to progesterone that leads to all sorts of symptoms. And early on in the perimenopause, can get heavy periods, irregular periods, long periods where you don't have a period, then you have heavy clots. You can get fibroids and worsening PMS symptoms all because of this drop in progesterone. Also can lead to many, many other things as we mentioned in terms of sleep issues and mood issues and headaches and fatigue. And over time estrogen levels will drop, but sometimes they can actually be quite high.

And that's when you get breast tenderness, food retention, clotting, heavy bleeding, increased risk of uterine cancer. All those things happen in the perimenopause. What about testosterone? Well, testosterone levels also go down in women as they approach menopause due to aging and a natural decline in ovarian function, which is where half of their testosterone is produced. The rest is produced actually in the adrenal glands.

And this results in a loss of libido, sex drive, loss of energy, motivation. And these changes in hormones also have widespread effects on the rest of a woman's biological system. So what are the physiological changes that happen? Well, as women approach menopause, their hormone levels begin to decline and their risk of various diseases increase. So that's really important to know what your hormonal changes are and how to support them through diet and lifestyle before you get into too much trouble.

Now, sometimes simple lifestyle changes and some supplements might help. Herbs are very effective. Things like acupuncture can be effective. Exercise, stress reduction, sleep optimization, healthy diet, removing toxins. All those things help.

But sometimes you do need help, more help. You need what we call bio identical hormone replacement therapy. And what does that mean? Well, just means using hormones that are the same as your body's own hormones. Historically in medicine we've used something called Premarin, which stands for pregnant mare's urine, Premarin, pregnant mare's urine.

Gross, right? But that's what we use. And that's, those are highly conjugated estrogens that are very inflammatory, have increased cancer risk and cause all sorts of problems. So we don't want to use that. But we're going to talk more about how to use hormones, when to use hormones and the benefits and the pros and cons in a bit.

But first let's discuss what actually happens to a woman's body physiologically during this transition period. Well, first thing is bone density becomes a risk, right? Estrogen, as estrogen levels drop, your risk of bone loss goes up, right? Estrogen plays a key role in maintaining bone health by helping regulate bone remodeling. And that involves resorption or breakdown of the bone and old bone and creating new bone.

All that requires estrogen. So how does estrogen do this? Well, it increases the activity of a certain type of cells in your bone called osteoclasts. These are classes like breaking down, like an iconoclast. I mean, it breaks icons.

Right? So it's an osteoclast is a cell that is responsible for breaking down bone, which is normal. You wanna recycle old bone and build new bone. And it also decreases the activity of osteoblast cells that are responsible for new bone formation. So that's not a good scene.

So you get a double whammy with, more breakdown and less buildup. So when you actually in menopause or perimenopause, this combination of bone breakdown and reduced bone growth ultimately leads to a loss in bone density. You see, average, women lose about one to 2% of their bone density per year during perimenopause and menopause. And the rate of bone loss can be even higher in the first five to seven years after menopause. You really got to be on top of this.

Get your bone density checked early, check it regularly and find out what's going on so you don't get into trouble. We'll talk about how to keep your bone density up too. If you look at what happens, it can lead to up to 20% of loss of your total bone mass if you don't do something about it and we're going to talk about what to do about but involves taking the right supplements, vitamin D, exercise, strength training and so forth. And this loss of bone basically increases a woman's risk for osteoporosis and fractures if it's not managed with diet and exercise, particularly strength training. What else goes on?

Well, your risk of heart disease goes up, right? Heart disease and stroke are the leading cause of death in women. But the good news is in up to eighty percent of cases it's preventable with lifestyle and diet. I've seen studies that show over ninety percent of heart disease is preventable. So what's happening in a woman's body to increase her risk during menopause?

Well, estrogen plays a role that's protective in the cardiovascular system. It enhances the production of a really important molecule called No or nitric oxide. It's a vasodilator that helps relax and widen blood vessels and improves blood flow, which we know it works because that's how Viagra works, right? Increases nitric oxide. It also helps reduce inflammation, is really important because heart disease is an inflammatory disease.

And so basically there's all sorts of things. It also helps your blood vessel health and reduce your risk of high blood pressure. And so all these are great. And the inner lining of your blood vessels is really important. That's what produces nitric oxide.

And so that inner lining of your blood vessels is really in part regulated by estrogen. So when it's weak or damaged, that's when cholesterol gets stuck in the arteries and forms plaque that causes hardening of the arteries or atherosclerosis or heart disease. It also increases LDL, the good cholesterol, although there's really no good and bad. It's a little bit more nuanced than that. And it decreases triglycerides, which is awesome.

It also lowers LDL, which tends to be a problem for people. Now it decreases LDL cholesterol by enhancing the expression of something called LDL receptors in the liver. And that's good because these receptors basically suck up all the LDL, the excess LDL in your blood, and it reduces the risk of plaque buildup in the arteries, which is great. It also has antioxidant properties that help reduce oxidative stress and the oxidation of LDL cholesterol, which is what really causes heart disease. It's not just LDL, it's when it's oxidized or rancid and then it causes heart disease and blockage in the arteries.

So how does estrogen protect against oxidation of LDL? Activates genes that make major antioxidant enzymes, things like SOD or superoxide dismutase and glutathione peroxidase. And these are more powerful than any antioxidant you'll ever have taken a vitamin. And they're produced by your own body. Now these help neutralize free radicals.

They protect against oxidative damage or rusting. And it's awesome. And estrogen itself has direct antioxidant properties due to its chemical structure. We call it phenolic structure. Now the phenolic structure is similar to what we call polyphenols, which are basically these plant compounds are anti inflammatory that help neutralize these free radicals.

And there's these phytoestrogens, but I don't like that term because it kind of means that they're stimulating the estrogen receptor but they're actually modulating it in a beneficial way and they don't actually cause estrogenic effects, they just help modulate it in a good way. And there's one from soy for like, for example, genestine and dadzine, and they are found in soybeans. Now there's other plant compounds that also help like lignans is the type of plant phenolic with weak estrogen activity in the body. They're found guess where in flaxseeds. So they really help a lot in terms of the overall sort of hormonal balance.

So I highly recommend flaxseeds for women in general, for lots of things for constipation and for omega-3s and for particularly for helping with hormonal balance. Estrogen also impacts insulin sensitivity and glucose intolerance, meaning it helps regulate your blood sugar, which is key for preventing heart disease and maintaining your metabolic health. So estrogen plays a huge role in insulin sensitivity and keeping your metabolism healthy. It up regulates the expression of something called glucose transporters within ourselves, which is basically our muscle and fat tissue. So essentially, the ability to get glucose out of your blood depends in part on estrogen.

It also helps maintain muscle mass, is key for insulin sensitivity, and it influences accretion of something called adipokines. These are hormones released by fat cells by promoting subcutaneous fat storage rather than visceral fat. Now, the visceral fat is the dangerous fat. That's around our belly. That's linked to prediabetes, insulin resistance.

And when you lower estrogen levels during menopause, it increases the woman's susceptibility to insulin resistance and to weight gain, particularly around the belly. Women notice that. They get more little pudgy around the middle. That's because of this reduction in estrogen. And eventually it can even contribute to the risk of type two diabetes.

What about your brain? Well, brain is important and research shows that estrogen has a very important role to play in your brain. It's a neuroprotective compound, meaning it protects your brain and it's involved in keeping the brain healthy and firing all cylinders. And how does it do that? Well, helps do it through reducing inflammation in the brain.

It modulates the activity of brain immune cells to maintain a healthy brain environment and enhances something called neuroplasticity, which is the ability to grow and strengthen neurons and the connections between neurons. It also influences the production of our neurotransmitters, serotonin, dopamine, which helps support mood and cognition. And so it upregulates BDNF, which is essentially like miracle growth for the brain, which promotes the survival growth and the differentiation of neurons and increases connections between them. So your brain's more connected and functional. Also, protects against something called amyloid beta build up and toxicity.

Now this is the protein amyloid that accumulates and forms plaque in the brains of people with Alzheimer's, which is why we've seen some data that estrogen is protective against Alzheimer's, is kind of cool. That means when estrogen levels decline, the opposite happens, right? Your brain gets more inflamed, you get more brain fog, maybe serotonin and dopamine decrease, which can lead to low motivation, maybe you make you anxious, your mood changes. Is that because you're crazy? It's because your hormones are changing.

Sadly, your risk of dementia goes up and your cognitive decline goes up. So it sounds kind of bummer, right? It's all bummer data. But actually, the reason I'm telling you is because you can do something about it. There's so much you can do about it to prevent all these things and to support your body during this whole time and minimize all these things.

So you can't just kind of go through and ignore it and pretend everything's happening fine and not pay attention. You got to pay attention and you got to take care of yourself, ladies, because here's the deal. Most women in this period of their life, perimenopause or menopause, it's called the sandwich generation. They're sandwiched between their parents and their kids, their teenage kids and their old aging parents. Plus they're probably in the middle of their career and there's a lot of stress.

So you gotta take care of yourself. You know, like that thing they say on the airplane when you're, you know, you put the oxygen mask on yourself first, then you put on your kid. That's kind of what you gotta do. And if you do that, then you can preserve your brain function. You can preserve your body.

You can protect your heart. You can feel good. You can continue to live a happy, healthy, thriving life. But the more proactive you are about it now, the easier the transition is going to be. Here's the problem with traditional medicine.

It just doesn't know how to deal with this very well. It's like, okay, take the pill until you're 50 and then we'll switch you to hormone replacement therapy. Well, that ain't the answer, right? Conventional docs don't take a proactive, preventive approach to help protect against bone loss, against muscle loss, especially. They don't really focus on preventing high blood pressure, heart disease or protecting your brain during this time.

I mean, basically you might get a platitude, well, just exercise and eat better and manage your sleep and stress. But that's not very helpful information. And that leaves a lot of women to suffer. The truth is they don't have to, right? They don't really have to.

So let's first talk about where conventional medicine gets the approach to hormone replacement therapy wrong, right? Often what they'll do is to wait until symptoms appear to do anything about it, which is often late. And even when they do, their interventions just don't support the transition. They just manage symptoms with SSRIs and hormone replacement therapy. I mean, they now have a drug for PMS.

It was called Prozac. They changed the name to Serapham, exactly the same drug, just to make it sound like it was for women, but it's kind of ridiculous. I mean, it's not a Prozac deficiency, right? There's, there's a change that happens. Sometimes hormones can be helpful and doctors will prescribe them, but they don't usually do it right.

They don't do the right kind of hormone therapy and they use conjugated or equine estrogen. That's horse estrogen I mentioned, the urine, pregnant marriage urine or estrogen. And that's been linked to a ton of problems, right? Initially hormone replacement was seen as highly beneficial based on some observational studies because they weren't really clinical trials. They just looked at populations and checked them over time.

And it the Nurses Health Study. And they found that, you know, we're 130,000 women. They fought for decades and seemed like the women who took the hormones did better, right? They had less heart disease, breast cancer, dementia, osteoporosis, everything seemed great. But it wasn't hormones that were doing that se.

It was really their lifestyle. We call it the health user effect. So there was a large trial, billion dollar study funded by the NIH called the Women's Health Initiative and kind of turned upside down these findings. Now this is a study of over one hundred and sixty thousand women who are postmenopausal who were either on combined estrogen, progesterone therapy or estrogen only. They use synthetic forms.

They use pregnant Mary's urine and they use synthetic form of progesterone or progestin, which is often very problematic. Now these results were published in a prestigious journal called the Journal of the American Medical Association. Essentially, showed that hormone replacement therapy actually increased the risk of heart attacks, breast cancer, strokes, dementia and blood clots. And they wound up discontinuing the study early because the results were so shocking and they didn't want to harm women further. That study caused a lot of problems because all of a sudden you got fifty million women overnight, boom, stopped hormone therapy and they were miserable.

Right? And it led to a shift in their recommendations around hormone therapy being very much anti hormone therapy. The problem was that they didn't really get into the nuances and they didn't look at the type of hormone, dosage of the hormone, the method of application, is it a pill, is it topical, timing of hormones. It's really subtle and personalized. The truth is that, hormone therapy can be used and I would like to call it hormone optimization therapy because you don't want to overdose.

You want to do the right forms. You want to do bio identical forms and women who actually begin hormone therapy within six to nine years after menopause can start to benefit from the therapy. But starting it too late after menopause may increase risk. So you got to be careful about when to start. Now hormone therapy may also help women in perimenopause and helps to reduce symptoms and provide relief.

But you've gotta be very specific and personalized based on the symptoms and the form and the type of hormones used really matter. What should we actually know from the Women's Health Initiative, which was a randomized controlled trial? And what do we know now that's different on the intervening twenty two 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 misunderstood information or misinformation. So, WHI, you know, they started enrolling patients in the late 90s. 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, all right, 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 used Premin and Imprepro, which at the time were the two top, that wasn't unusual at the time. Those were the two commercially available formulations that they did. So that's one problem.

They used one formulation. You know, the Premarin, they didn't have a uterus, and Imprepro if they didn't, 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 enroll the patients, get started. In the Premarin and Provera arm, they did notice a very slight 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. That was 2002 is when I graduated. And it, like you said, it was this massively disrupted, it was the top news medical news story of 02/2002.

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 breast cancer. So now, but that notion just went crazy. No one would prescribe it after. Everyone was terrified.

Those data points have been refuted, as you know, throughout multiple studies throughout time, but we're just having a hard time getting the world to catch up to this. But in

Dr. Mark Hyman
Was forms it of hormones that caused some of the increased

Dr. Mary Claire Haver
hormones? Right. So, Levy and Simon and Levy just published the contemporary view of hormone therapy. 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 problem starts for females. So the longer my body is away from estrogen, the more likely I am I had to have a stroke, 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 have 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 protective benefits, you probably should start within ten years of your menopause. Do you want the neurologically protected benefits for decreased Alzheimer's and dementia? You need to start within the first five to ten years.

Lisa Moscone has new data published on this just this week in Nature. Probably it's a bigger window than we thought. It will always protect your bones. It's always going to protect your general urinary system. It's always going to 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 going to take hormones and go about

Dr. Mark Hyman
my diet. Yeah, you did. Perfect. No. You said that already.

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 poorer 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. I think, you know, as I was sort of learning about the women's health initiative, I actually already had kind of gotten a little bit biased because I'd read this book about bioidentical 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, was used in that original women's health study, that actually has to be metabolized by the liver and it actually increases inflammation, CO reactive protein, increases triglycerides, increases your risk of breast cancer, I think because of its effect on alcohol metabolism and lots of things. So if you drink a glass of wine, hormone levels would jack up really high.

I think there's a lot of problems with that, but now that topical or bioidentical hormones seem to be better tolerated, more effective, are you worried at all about them? Would be concerned that there is some unknown risks 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, you know, not in the estradiol world. Okay? Does it look like it's actually protective 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 with lots of data coming out from Europe and other places, but they're all using different progestogens. What I want to see is a head to head of estradiol plus my oral micronized progesterone. And let's follow those women, you know, for twenty, thirty years, and see who lives longer, what the risk of breast cancer is, etc. But you know, what's happening is bikini medicine in my world where women are little

Dr. Mark Hyman
So bikini

Dr. Mary Claire Haver
the only thing we need to worry about in women's health is the bikini area, the breasts and everything out of 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 stat, 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 our options out there. So, oh, 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 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, she's going through 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, that's what I do in my clinic. I'm going to 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 talked 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. Okay? But what about the woman who kind of luckily the fifteen percent 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 For that's

Dr. Mark Hyman
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? Is this something that all women should do after menopause? Is this something we should kind of 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, four to maybe eight percent 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 enter this change.

And, you know, before you're you washed 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.

Dr. Mark Hyman
So

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- Right.

Dr. Mary Claire Haver
Would see your cancer would be said, 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, and know- Restocked. PE. Yes. Yeah. Some really contraindications.

Dr. Mark Hyman
Yeah. 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 smell and 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, oh, wow. This is a different me. Right?

This is a whole new experience.

Dr. Mary Claire Haver
That is what I see in my clinic and that is what the menopause sees. You know, we have this little friend group 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's fun. And so, 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. You

Dr. Mark Hyman
know? Yeah.

Dr. Mary Claire Haver
It's pretty exciting. It's exciting stuff.

Dr. Mark Hyman
So let's talk about testing. Know, what I found is hormones fluctuate greatly. When I was in medical research, know don't worry about testing so much because they're all over the place and you only want to test after they've stopped having their period to confirm they're in menopause. How do you see testing hormones in women and when should women start testing? What should they be testing?

If you're checking hormones, does it matter when in the cycle your chest testing will actually be day one to three or day eighteen to twenty three 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 CHM, continuous hormone monitor. 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 months, it's tracking all the things, your estrogen, your progesterone, whatever. But you know, 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 hard 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, of all that crazy chaos, is not gonna help me that much. Certainly if I can't use her period to help kind of guide me a little bit, I'm doing hormone testing, you know, to see is she really post menopausal 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

Dr. Mark Hyman
treatment. For pre menopausal women, think, 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 day eighteen to twenty three of a normal twenty day cycle, that I could see what's going on with their ovulation because their progesterone would often be low. And their estrogen would be And really that would kind of give me a lot of clues about what's going on. Then I might just try progesterone with those women, or I might try that and a tiny bit of estrogen.

And that seemed to be a good sort of indicator. Is that a good practice?

Dr. Mary Claire Haver
That's very reasonable. If you can get it on day 18, just with modern 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 pretty limited. Yes, but I think, you know, a really high estrogen with a really low progesterone is classic inovulation, right? Or oligoovulation, or that's either peri or PCOS for us. And, you know, giving her progesterone often is miraculous.

Those patients are so happy.

Dr. Mark Hyman
You can always see the ratio of LH and FSH change, where you get high LH and low FSH, which is often correlated with PCOS. We see that So it's kind of like What about early on in the cycle? When is it indicated to do testing day one to three?

Dr. Mary Claire Haver
It What for or for I learned that was for fertility. And interestingly, you know, fertility does a lot of work with AMH and Antimalarium hormone? Antimalarium hormone. They're actually looking at analogs of that or I think they're blockers. These there's two biotech companies that I know are working on, you know, medications that work with AMH to extend the life of the Because it seems that rise in AMH is accelerating 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 ovaries so that we can enjoy more of our natural estrogen. But again, that's all in theory and they're testing it

Dr. Mark Hyman
in house. If you measure AMH, it should be lower in in order to indicate better fertility. When it's higher

Dr. Mary Claire Haver
Right. Which means 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

Dr. Mary Claire Haver
We didn't talk about testosterone yet.

Dr. Mark Hyman
No. That's what I want get into. So, you know, you know, you've said before that, and this is sort of well known if you're a physician, is that maybe not actually, doctors, is that testosterone, absolute testosterone levels are higher than estrogen and prejudicial levels in women.

Dr. Mary Claire Haver
In women. It's a precursor to estradiol 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 of truth in that. But but also women have vaginal dryness, they have lower testosterone, they have arousal dysfunction, they have all sorts of stuff

Dr. Mary Claire Haver
that gets kinda Orgasmic dysfunction.

Dr. Mark Hyman
Yeah. And, you know, 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 that it can be really effectively addressed by 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'm curious about your perspective about these 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. If 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 worth it.

Yeah.

Dr. Mary Claire Haver
So my friend so in our menopause, we have, three or four urologists who are females, you know, and they're in ISHWISH, the sexual medicine wellness conference, and they love topical testosterone in the vulva, especially if they're having, 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 six when you apply the cream and they have it specially compounded so 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 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 heart.

Dr. Mark Hyman
Oh my god.

Dr. Mary Claire Haver
It's that, you know, does she have a good relationship

Dr. Mark Hyman
with Doctors like to give these names.

Dr. Mary Claire Haver
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 got to fix that. 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. Have a monitor in my office for black muscle mass and visceral fat. I have an InBody scanner, electrical impedance scanner. So if she's coming in and she's had a bone density and she's got low bone mass and she's sarcopenic, you know, I'm 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 got to eat the protein and lift the weights and do all the things as well.

That testosterone can be additive in that.

Dr. Mark Hyman
And you use it topically? Or how do you use it?

Dr. Mary Claire Haver
I do. So yeah, the only on Daconoate is, and it's not even approved in The US, safe, you know, for the liver toxicity part of it. So testosterone therapy should be trans mucosal or transdermal for safety reasons. And then in The US, there's no FDA approved formulation for women. So in some states than others, it's easier to get.

Sometimes you can do the male version of like T stem gel, and you have 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 a pharmacist, will go around the block and do 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?

Dr. Mary Claire Haver
Doctor. If you stay in a physiologic cream, you don't overdose her, sure, if I give her enough, she will grow all sorts of things. But 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 and gyms that have huge levels of anabolic hormones that this is our super physiological, and there there are serious consequences to that. But if you're keeping people at an optimum range, it actually works. 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. Really doesn't. It's so frustrating as 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 now 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 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, and 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.

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 now it seems like it's shifting. Is this just on the fringe or do you think this is changing within traditional obstetrics and gynecology?

Dr. Mary Claire Haver
I definitely see it changing. I see, like, in the American ABOG, American Board of OBGYN, the Council on Resident Education, I was a program director for, ten 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 want to learn more. You know, the rate of people signing up to get certified by the menopause society is skyrocketing.

You know, 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. She doesn't have to suffer, and she wants more information.

Dr. Mark Hyman
Love you to talk about this case that you shared a little bit earlier with me about this 52 year old woman who had allergies, migraines, weight gain over eight years, lost her parents. It's a really great case. Talks about how we think about people going through this phase of life differently. Yeah. So I want to by the way, before you do, I just want to say it doesn't matter what phase of life you're in as a woman, whether you're a teenager going through hormonal changes in your twenties, thirties, forties, fifties, sixties and beyond.

We take care of all of it. We're just sort of focusing a little bit on menopause now, but this applies across the board. And we, you know, have different issues at different ages. But looking at the life cycles of women is really a core part of what we do.

Dr. Cindy Geyer
I agree. And I think, as I mentioned before, it's a window of opportunity. It's often the symptoms that bring you into the to talk to the functional medicine practitioner, but it opens the door for a conversation about everything. Yeah. Which is really important.

I'm going to look back on this. So this is somebody who didn't come to me initially for menopause, but she happened to be in the menopause transition. She was 52. I think her last menstrual period was about six months before she came to see me. And she had this history of allergies and migraines.

So just so you know, I'm going to talk as I go through this. One of the things that comes up for me with allergies and migraines is thinking about the role of histamine in some of her symptomatology. The last eight years, so as she's entered the menopause transition, her weight's been going up. And she had what's a very common occurrence. She lost both of her parents, unfortunately.

Her partner had a serious health issue. So there's been a lot of added stress. And face it, mortality was right in front of her. So that can bring up a lot of things about, Oh my gosh, what does it mean to be getting older? And what's gonna happen for me?

She'd also noticed in the last three years, was starting to have some hot flashes and sleep disruption, brain fog, which she in particular linked to more sugar and carbohydrate intake. At the same time, was craving more of those foods as she was more stressed. A little bit of a vicious cycle. And we started her really on a nutrition plan while we were gathering some of the data. And her original nutrition plan was kind of what we talked about.

Whole food plant based diet, minimizing those processed carbohydrates, even trying a low histamine diet to see if we could sort of clear the decks and what would happen with her allergies and her migraines. Recommended doing a sleep study, some breath based practices, which we know have shown some evidence for reducing the hot flashes. It's just helping support her with all the stuff that she's been dealing with. And then when we got her labs back, her estrogen was not measurable, so she's not making any at all. Some women will make a little bit.

She had some yeast overgrowth. Had some mark in her gut. We had some elevated markers and it also showed up in her stool test. And she had intestinal methane overgrowth as well, which was probably playing a big role with some of her digestive issues and this estrobilone that we talked about.

Dr. Mark Hyman
Yeah.

Dr. Cindy Geyer
And she was showing some evidence of increased intestinal permeability. Her LDL particles were higher than we wanted to see it.

Dr. Mark Hyman
So she had bad bugs growing her gut, too much yeast, too many bugs in the wrong spot. She got bloating and she had leaky gut and all these things were causing allergies, inflammation, and making everything worse.

Dr. Cindy Geyer
Yes. So it wasn't just the hormones. Yeah. Yeah. And I think that's a really important piece

Dr. Mary Claire Haver
of cannabis.

Dr. Mark Hyman
But Bina, I don't want ask you this, your experience too, Cindy. Like, what I found is that that if I start with all these other things, the hormones often get in the line that actually the hormones are often screwed up as a downstream consequence of other upstream causes. Yes. It's not usually the hormones themselves or the issue. Right?

I think about it like we all have hormones. They all should be working. Why aren't they working? It's like if you have a toxin like mercury, that's a bad thing. If you have a parasite, that's something that's an upstream cause.

Right. But if you have screwed up hormones, it's usually the consequence of something else that's screwing them up. It's not a primary thing. Can

Dr. Cindy Geyer
be. It can be. It can

Dr. Mark Hyman
be.

Dr. Cindy Geyer
It can be. But you're

Dr. Mark Hyman
to an insulin producing insulin as a tumor. Or you could have, you know, I don't know what else. You could have a lot of things. Have a cortisol producing tumor and have Cushing's. So there's a lot of things that obviously aren't what you're doing.

Dr. Cindy Geyer
Right.

Dr. Mark Hyman
But for the most part, a lot of it I see is downstream. Is that your experience?

Dr. Cindy Geyer
It is, and I will say with the exception of menopause. Because while a lot of women get better, there's still a subset that the estrogen itself being so low can be playing a role with some those Yeah, because there's a documented change in Yeah, those

Dr. Mark Hyman
like 85 year old women are not having hot flashes. True. And they have low estrogen. True. Right?

So what's going on?

Dr. Cindy Geyer
Oh, that's true. That's true. Actually, about fifteen percent of them will continue to have

Dr. Mark Hyman
Oh boy. So we

Dr. Cindy Geyer
don't know what's going on with those women. One other thing that showed up for her, she had some common nutrient deficiencies. Her B12 was low, her vitamin D was low. And we mentioned about vitamin D playing a role as actually a hormone as well. So we targeted all those things, and she was feeling better, especially the brain fog and fatigue.

So that responded really well to the nutrition approaches in addressing her gut.

Dr. Mark Hyman
So you basically fixed your gut, gut elimination diet, and healed the microbiome, which is a core part of what we do in functional medicine. And whatever you've got, it's kind of usually plays a role, whether it's heart disease or diabetes or cancer, or allergies or autoimmune disease, or autism, or ADD, or hormonal issues. Really have to look at the gut as a central feature. So you're saying just by getting rid of the bad bugs, getting rid of the bad foods, put her on foods that healed her gut, things that healed her leaky gut, she improved.

Dr. Cindy Geyer
And supporting her nutritionally, nutritionally. Absolutely. And got better, allergies got My Yeah.

Dr. Mark Hyman
So, Cindy, we did all these things. You did all these incredible things. You diagnosed her with all these imbalances. We corrected them, and we do this kind of work at the Ultra Wellness Center. Do a deep dive.

We find all these things that need to get corrected. We correct them, and people's health just dramatically improves. But sometimes, you know, with the hormone issue, you need to use hormones. And it's not that they're bad or good. And I think we get into this binary thinking in medicine.

It's good, it's bad. It's good, it's bad. And the truth is it's got to be personalized. Right. And it's different for everybody.

And there are some rules and principles that I think we follow in functional medicine around prescribing hormones, which I want to get into. But tell us the rest of the story with this woman. You got her mostly better, then she was still having very low estrogen.

Dr. Mary Claire Haver
Right.

Dr. Mark Hyman
What did you do?

Dr. Cindy Geyer
She came back in about three months later and articulated that she was feeling better. Brain fog, the fatigue, her migraines, her allergies, they were all better. But it's interesting, the hot flashes were continuing and her sleep was being more affected. So she now came back saying, You know what? I think I do want to try hormones.

We had this conversation back and forth. And of course, you're going to do your due diligence. Before prescribing hormones, you want to make sure that she's up to date with her mammogram. There's no concern there, that she hasn't had any dysfunctional bleeding, that it raises a red flag and you want to make sure that there's no hyperplasia or anything going

Dr. Mark Hyman
You have heavy bleeding in the perimenopausal area where you get like precancerous stuff in the uterus, and you can check that with a vaginal ultrasound. Right. Right.

Dr. Cindy Geyer
Right. And she didn't have any of that. So we decided And now we

Dr. Mark Hyman
have something really cool. Do a liquid biopsy, which we didn't have years ago, which is essentially the ability to track cancers through a blood test. It looks at fragments of cell free DNA we where can actually see, Oh gee, well maybe we should screen and see, not just with a mammogram, misses a lot, but actually a gallery test, looks at liquid biopsy. Then you go, Gee, I'm pretty comfortable this person is not having some latent cancer, and I'm going to throw some estrogen on it and give her a problem.

Dr. Cindy Geyer
Right. So we decided to try hormones. And my general thinking about hormones, that term bio identical created a lot of confusion back in the day. But my favorite way to do it is to use a patch, which has a lot of customizable doses, and it's an estradiol that is pharmacologically exactly the same as what your own ovaries would have produced before menopause. I like it because it's convenient.

You put it on twice a week. It gives you a steady amount of estrogen. Like I said, there's a range of doses. Because she's symptomatic, I'm going to start with a mid level dose. We started with a mid level dose for her.

Because she has her uterus, she does need progesterone because progesterone's going to protect over stimulation or over thickening of that lining of the uterus. And we can also take advantage of progesterone because it has some calming sedating effects and give it at night, so it might also help her sleep.

Dr. Mark Hyman
Like the body's natural Valium.

Dr. Cindy Geyer
Yeah. Yeah. Yeah, absolutely. So that's what we did. We started her on a pack.

Dr. Mark Hyman
And was that an oral progesterone?

Dr. Cindy Geyer
The progesterone is oral. For her it was.

Dr. Mark Hyman
It's not just the progesterone that we used to prescribe, Provera.

Dr. Cindy Geyer
Right.

Dr. Mark Hyman
And my joke with that one, it's called methoxy progesterone. It makes women fat, hairy, and depressed. And it does. It's horrible. In fact, it makes people eat more.

They use it during cancer treatment to get people to Yes. Eat And so when cancer patients are starving and losing weight, they give them this to increase their appetite.

Dr. Cindy Geyer
Yep. Yeah. And we can talk about that because I think the women's health initiative, which prompted everybody to throw their hormones in the garbage, One of the downsides of it, or one of the potential flaws of it, two of them actually, most of the women were in their 60s, so they're a decade past the average age of menopause. And physiologically, women are in a different place then. They might not get the same tissue responsiveness to estrogen.

And they used Premarin, which is conjugated equine estrogens.

Dr. Mark Hyman
Horse estrogen.

Dr. Cindy Geyer
Horse estrogen.

Dr. Mark Hyman
Yeah. I mean, but it means pregnant mares Premarin. That's actually how they got the name. It's forget it from pregnant mares, and then they concentrate it. And it's horse estrogen, which is very different than ours, it's very inflammatory And and quite

Dr. Cindy Geyer
when it's given by mouth, it goes through the liver and creates higher C reactive protein inflammation markers, higher clotting factors. It worse insulin resistance instead of better insulin resistance.

Dr. Mark Hyman
Higher triglycerides.

Dr. Cindy Geyer
Higher triglycerides. So all of the things that were blamed on estrogen and hormones may have been more a function of the older age group of the women when they started and the formulation and the route of administration.

Dr. Mark Hyman
Yeah. So they used basically the wrong kind of estrogen and the wrong kind of progesterone.

Dr. Cindy Geyer
And the wrong route of administration.

Dr. Mark Hyman
And the wrong route of administration. Yeah. So yeah, sort of the philosophy we use basically is use as little as possible for a short time as possible for with form of the hormone that's same as your body makes and give it bypassing your liver through your skin, hopefully, or under the tongue or there's a million ways to do it. But basically, it's doing it mostly trying to mimic nature. Right.

Right? And not overdoing it and not underdoing it.

Dr. Cindy Geyer
Right. So that brings up another point, right? It is not common practice once you put somebody on hormones to follow-up blood levels.

Dr. Mark Hyman
Amazing.

Dr. Cindy Geyer
You know what, and for me, I It's

Dr. Mark Hyman
like giving a person a blood pressure pill and not checking their blood pressure. Exactly. Or you're someone a cholesterol pill and not checking their cholesterol.

Dr. Cindy Geyer
So we wanna see, does it help the symptoms? But we also want to see, well, what is your blood level? Because that can help you gauge. For example, if I start at a given dose of a patch and she comes back and she's still having hot flashes, how well is she absorbing that patch? Is it enough to get a measurable rise in her estrogen or not?

Because then that can guide the dosing. I also, just from trying to thread the needle of risk and benefit, I don't believe in supplementing somebody's estrogen to the level it was when she was in her 20s. We're trying to get the benefits, but not really drive too much estrogen so we mitigate risk.

Dr. Mark Hyman
Yeah. And, you know, I don't view this any, but I often will check estrogen metabolites on women who are Yes. Taking So I can assess whether or not they're producing toxic estrogens. I will often look at their genetics. She mentioned genetic testing.

There's genetics around estrogen metabolism. We can look at like COMT and other hormones, methylation hormones, methylation pathways like MTHFR. Basically, English, that means we can check various enzymes that are involved in detoxifying estrogen and whether they're working well or not. Then we can use science to find the right cofactor for that enzyme, which is a nutrient. Right?

And so we can start to build a very scientific way of of personalizing here. This is where all medicine is going. Right. We're all going to be doing this. Right now, sadly, very few people get this.

It's really why we we do the work we do at the Ultra Wellness Center to give people the chance to get access to the future of medicine now. And the good news is people get better. It's just amazing to see these stories that you're telling are so satisfying because people have all these symptoms, not just menopause, like allergies, migraines, gut issues like this woman had. And we're able to get all that sorted and then get her back on track. And people can come back and basically have a resolution to a lot of these really difficult problems that we don't have good solutions for in traditional medicine.

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