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  • Writer's picturePenn Smith

Menopause and HRT questions with Dr. Haver

Penn: Why should women in perimenopause/menopause consider taking HRT?

Dr. Haver: You might consider HRT if you're having severe side effects that are disruptive to your life, for example If you're having the classic symptoms of night sweats, sleep disruption, mental health disorders. But a lot of the symptoms women don't realize and even healthcare providers don't realize have a very strong menopause correlation, things like joint pain, muscle pain, skin changes, hair changes, nail changes, you know, there is not an organ system that is not affected in your body.

But what if you are one of the lucky small percentage of women who really don't notice any difference other than your periods stop one day and you feel fine? Well, we

know that menopause is an independent risk factor for cardiovascular disease as well as Alzheimer's and dementia. And it turns out that women who start hormone therapy early in their journey, meaning within perimenopause, or within the first five to 10 years of their period stopping will see a decreased risk of cardiovascular disease and neuro dementia as they age as well as stronger bones, you know, less chance of osteoporotic fracture which we really, really need to talk about this. You know, and what happens when you break a hip and your quality of life and your chance of death skyrockets - this is so preventable. And hormone therapy goes a long way for those chronic diseases.

Penn: Why are so many doctors so ill informed about HRT, why so much confusion, fear, uncertainty, and doubt around the topic of HRT?

Dr. Haver: I was part of that, and so I can really speak honestly about it. In 2002, the Women's Health Initiative study was abruptly ended, because they found that the estrogen and progesterone only arm had an increase or what they found to be an increased risk of breast cancer in the participants that took it.

That was a shot heard around the world. They went into a very famous ballroom and called a press conference. It was just a small handful of the dozens of investigators in this study. They brought in news cameras, this was before social media so 2002 and it was on every major news station, it was on all the morning talk shows, it was the biggest health story of 2002 - "estrogen causes breast cancer", and that abruptly stopped 80% of all hormone therapy prescriptions stopped future prescriptions of hormone therapy, and that kind of locked into people's minds. Now that study has been I don't want to say disproven, but those findings have been reexamined, walked back.. it was grossly overestimated. It was you know, so many things have been just removed from that study. We have learned some important things from it. I think it was an important study but but we we didn't have a news conference for that, you know, and in our continuing at least from the OBGYN world, which is my specialty. When we look at our CME every year - continuing medical education - in order to keep up our board certification. It's tonnes of stuff about fertility and getting pregnant and staying pregnant. And you know, pediatric gynecology. Lots of new groundbreaking surgical techniques, all important stuff, oncology, a lot of things on disparities amongst gender and race. And all these important things. There is never -almost never- a menopause article, which means there's no real research being done in menopause. There's a huge gap in how we were treating and training residents on how to take care of a menopausal patient.

Penn: I wonder though, if it'll shift now?

Dr. Haver: So just like in politics, I mean, a lot of this is political. Right? The money goes into research from the NIH National Institutes of Health. It's very, very political. We have to fight for it. And we have to prove we have to have numbers on our side, we have to show that interventions can actually make a difference in the quality of a and life the health and lifespan of a woman's life. And so this generation are generally I'm 54 I'll be 55 next month. We are not willing to take this anymore. We are not willing to go gracefully into older age, you know, whether you choose or not to have hormone therapy is as it sounds a personal decision your body, your right. But you deserve the informed conversation about it. And it's a big ship to course correct. And I mean it is it's going to take years but and we're on a bit of a wave right now. And I just pray that this is just not a tidal wave and people get with it, you are going to have to advocate for yourself, and you're going to have to fight in some instances, and I'm doing everything I can to spread resources and information on how to do that.

Penn: Okay, so what are the different options for HRT for women who live in the United States?

Dr. Haver: Great. I practice here in the US and I know some of your followers are in other countries. So I'm going to try to speak in kind of generic terms. So you can take this information back where you come from. Most of the research that has been done has been centered around hormone replacement. So let me give everybody a brief primer because I think it's important that you understand what menopause really is. It's not some magical mystical time in your life.

We are born with our ovaries intact and all of our eggs. Men are different. The testicles make sperm every day fresh, right? They're constantly recreating new gametes. We are born with all of ours. And they began deteriorating, we are in the womb at five months, so 20 weeks of pregnancy, they start dying off, okay. And that dying off process, it doesn't matter when you go through puberty or if you've had birth control or contraception doesn't matter. Okay, we start ovulating a puberty we stop ovulating at the end of menopause. We stop ovulating when we run out of eggs. When you spit out your last viable egg, you are done and there's no bringing it back. When we talk about treatment of menopause symptoms, the number one treatment that's gonna work the vast majority of the time for the most amount of people is to give you back what those ovaries made. Okay, so what is ovaries make? Estrogen.

When we talk about hormone "balance", that's a lot of marketing. Remember, it's pulsatile. estrogen production in your normal reproductive years goes up and down each month, right? In a normal cycle. It's not everybody has normal cycles. And then following the estrogens peak, we have a progesterone peak. Okay, so our ovaries mostly make estrogen/ progesterone, we do make some testosterone- we make about 10% of what a man makes. Half of that comes from the ovaries. The other half comes from the adrenal gland. So when we talk about hormone replacement for a woman we talk about estrogen plus or minus progesterone.

And then in a separate conversation, we can talk about testosterone, but let's focus on estrogen because that's really when we're talking about bone health, mental health. You know what the studies are showing? It's all on estrogen replacement. So there's multiple forms of estrogen on the market in the US.

I have a book coming out about this. So for everyone, but you know, the big first one that came out was Premarin, which was from a pregnant mare and that pulled the estrogens out of their urine. There's about 10 different estrogens in there. It was used forever. It's still on the market today. I never prescribe it. One because I have better options. I feel like two because I don't like ethically what they do to the horses- you can research that on your own. So I prescribe estradiol- that is my number one go-to for my patients unless she can't tolerate it. We have to look for something else. Okay? Estradiol is what your ovaries made. So in the another marketing term, you need to kind of tiptoe around is body identical or bio identical. In the US, it means different things to different people. So I try to use language around "I'm trying to give you back what your ovaries used to make in the same chemical compound". So there's also ethanol estradiol which is synthetic and it is what is in the majority of birth control pills. I do see a push for oral contraception going to pure estradiol. These pills have been around forever and that's another ship to course correct. So for menopause therapy. Now the difference between a birth control pill and menopause hormone therapy is dosage. In birth control pills, we have to suppress ovulation so you don't spit an egg out and you don't get pregnant. Right? Menopause hormone therapy is a fraction of that dose. We're just trying to give you enough to keep you healthy. Not to not to suppress ovulation that isn't happening anymore. Okay, so when we talk about progesterone, again, I tried to stick to oral micronized progesterone, which is the safest way to deliver progesterone. There's a great study that came out of France about 80,000 patients as far as breast cancer and they looked at different types of progestins in the different menopausal hormone therapies and the chances that they would be associated with breast cancer. And it's an observational study, but the oral micronized progesterone which happens to be body identical, had the lowest risk so that's kind of like the go to - estrodiol plus progesterone. So how can we get it in your body? Tons of options there as well. We can do oral or non oral when we do non oral that could be transmucosal like a troche or something through the vagina, a cream or you can do transdermal again creams and patches and a gel. I try to stick to FDA approved options for a number of reasons. Number one, I know what's in it- it's got an 80% chance when they test it (to be accurate). It's exactly what they say it is number two and then when you do that for compounding it's only about a 40 to 50% chance, there's a lot of leeway, you know and there's they're not doing third party. There's no third party testing in compounding, it depends on the quality of the pharmacy that you're getting. So, oral in estrogen carries an increased risk of blood clots and potential blood pressure elevations, we can negate that risk and take you back to your baseline with a transdermal option with a non oral option. So your creams or gels, anything that goes through the skin or the mucosa are going to have lower risk for those conditions. So for that reason, I stick with a patch usually for estradiol is my preferred method. Progesterone creams can be compounded but it's a very large molecule they very erratic absorption through the skin. No one in my world feels like a progesterone cream is going to be enough to protect the lining of the uterus from endometrial cancer.

Penn: How are HRT estrogen and progesterone made?

Dr. Haver: it's if it's estradiol, it's usually a plant derivative. But everything goes to a lab... so don't think that there's nothing synthetic going on. But it's usually coming from something high in phytoestrogens like soy or yams where they basically take the phytoestrogen and break bonds and make new bonds to create estradiol which is body identical.

Penn: Should a person use HRT if they have zero menopause issues - never had a hot flash no night sweats, no weight gain, skin is plump, etc.

Dr. Haver: Yeah, so that's a great question. Look at your family history. If you have a strong history of neuro dementia, Alzheimer's if you know you have the Alzheimer's gene, there's a great study you should read that looked at women who has the APOE gene for Alzheimer's who were on hormone replacement therapy or birth control pills and perimenopause. They had higher brain volumes and higher cognitive scores than their counterparts who weren't on hormones in menopause, so it seems estrogen Is protective against certain diseases, especially if you've got a strong family history of cardiovascular disease or your cholesterol is coming up out of nowhere. You haven't changed your diet, you exercise and all of a sudden you're you know, so menopause must be it... you may miss out on the cardiovascular and cognitive benefits. Now that being said, people who have severe symptoms have higher health risks. Okay, so if you're a super flasher you are higher risk of stroke, and I was a super flasher.

Penn: Did a study or something just came out recently about the correlation between night sweats and severe night sweats and heart attack? Or maybe this has been out for a long time. Maybe I just read it...gosh, I remember my mom going through it and it's interesting because my mom was definitely in that age bracket of the WHI. But luckily she had a really fantastic doctor and she stayed on HRT until her breast cancer diagnosis which was when she was like 71. That's when she got off of estrogen and it's funny. Funny is the wrong word again, but I read the book estrogen matters, which is amazing, and I recommend it to everyone. But it's almost, and I might be interpreting it wrong, it's almost like estrogen would be protective post breast cancer as well, except for of course that's a conversation with her oncologist etc, but it's been so demonized. It's incredible.

Dr. Haver: So with the WHI there were two arms. Basically, there were women who had uteruses and women who had had hysterectomy. Okay, two groups. The women who had uteruses were further divided into two subgroups. One of them got Prem-Pro (Estrogrn+progest), okay, and the other one got placebo. And with no uterus, you don't need the progestin so they just got Premarin. Okay, and off they went. The Premarin only group had a decreased 20 to 30% (I forget the numbers) risk of breast cancer, new onset of breast cancer, and those that were diagnosed had a lower stage and a higher survival rate. Okay. For Prem-pro, they did see an increased risk. It went from 4 out of 1000 women per year to five out of 1000. So that's the difference between absolute risk and relative risk. What got sent out in the papers was estrogen causes breast cancer (no, it's progestins). And that it had a 25% increased risk... that is a relative increased risk. large populations, you know, your individual risk was .08%!! When we talk about female cancers, there's no association actually, birth control pills, a history of birth control pill use is protective against most ovarian cancers. Okay, so that takes your risk down. We know from the WHI that any estrogen use is protective against colon cancer. They never talked about that. Okay? We know that estrogen and progesterone arm only had an increased risk of breast cancer and it was modest at best. There's no increased risk within five years of use. Okay, the first five years are free. And then for uterine cancer, meaning endometrial cancer, so I'm not talking about a sarcoma. I'm talking about the most common gynecologic cancer you know is endometriosis and cervical, but and no associated with cervical cancer. That's a virus right? And so the lining of the uterus that endometrium, if you give a woman with a uterus unopposed estrogen meaning estrogen alone, no progesterone, you will predispose her to endometrial cancer. Okay, so those of you who are getting estrogen in any form, and you're getting a progesterone cream, you need to call your doctor immediately and ask to be switched to an oral pill because the creams are not going to be absorbed enough to give you that protection of the lining of the uterus. You're putting yourself at risk for cancer.

Penn: I've heard that doctors should never give oral estrogen because it increases the risk of clots, Is that true?

Dr. Haver: So there is a modest risk with oral estrogen but there is no increased risk of clotting with transdermal. This is what happens - anything we ingest orally, any medication, any food goes through stomach intestines, right? And then the portal circulation, there's special veins that go from the gut to the liver. Everything gets taken to the liver for processing that is a normal part of our metabolism. When that bump of oestrogen that you took orally hits the liver, it can upregulate your clotting factors. And so 7 out of 10,000 women without MTHFR (you know without any inborn clotting defects), will have a blood clot that wouldn't have. So vaginal estrogen doesn't do it, transdermal estrogen doesn't do it. Not to say you're never going to have a clot. You're still a woman with veins. But transdermal/transmucosal are not going to increase you over your baseline. So there's so many women who are under the impression that they've had a clot or they're carrying whatever genetic protein, see, whatever, that they cannot ever do HRT... you shouldn't do oral estrogen, although the risk is still very low 7 out of 10,000. But for that reason, I usually prescribe transdermal- Is it essential for all women who supplement with estrogen to also take progesterone? Absolutely if you have a uterus. If you don't have a uterus I usually start my patients on estrogen only and see how they do if they're still having difficulty with sleep, racing thoughts, anxiety etc then we may add in some nighttime progesterone for that.

Penn: If someone is in menopause, officially ie no cycle for over a year, is it safe to take progesterone alone without taking estradiol for its benefits such as sleep, etc?

Dr. Haver: So why are you not starting on estrogen? I mean, progesterone is what in the studies caused the breast cancer not the estrogen. So if you think you're doing this, I mean, yes, it can be helpful. Absolutely. And it's very safe, you can do estrogen without. You can't do estrogen without progesterone if you have a uterus now, but if you have a Mirena IUD or, you know, an IUD with progesterone in it, you're covered you don't need the extra progesterone, you're okay. A lot of breast cancer patients or people super high risk with genetic defects or choosing HRT with the IUDs because they're not getting the systemic progesterone that's higher risk and they can protect the lining of the uterus. Okay. Yes, you can do progesterone as far as there's no blood clots are anything but the progestins is more likely to be related to breast cancer than estrogen.

Penn: Okay, vaginal estrogen. Why would I need to take vaginal oestrogen on top of regular HRT

Dr. Haver: Because you have a vagina? The more the merrier. If, for a lot of women, they're not getting enough penetration of the tissues in the vagina, the bladder, the bladder neck from their systemic estrogen quite often, especially if they're sexually active. I've got to add vaginal estrogen to really get that tissue absorption and anyone can use vaginal estrogen. If you have breast cancer right now, you can do vaginal estrogen, and it just kills me that women were denied this and then having horrific vaginal atrophy, you know, from their tamoxifen and other treatments and they're just like miserable and they can't have sex. It's just nightmare. And you know, that is completely treatable very safely with vaginal oestrogen.

Penn: Why is it that if you're using a facial cream with estradiol in it that that is not systemic, but you can use transdermal gel or whatever and it IS systematic?. What's the difference?

Dr. Haver:

Yeah, great question. So the devil's in the dose, just trying to penetrate that top layer skin. That's all you're doing, right? Get to those receptors right in the skin. It's a micro dose compared to what is in those systemic preparations. Okay. Devil's in the dose so think about it- when I'm trying to explain to patients I'm like, it's like the cortisone 10 you pick up you know, cream that you can get from the grocery store versus a you know, clobetasol, that's like a match and a blowtorch.

Penn: Can HRT reverse existing hair decline or just slow new decline?

Dr. Haver:

It depends. So hair loss has multiple reasons. There could be nutrition, deficiencies, genetics, hormones, stress, the PTSD kind of hair loss that we all went through and COVID and so it depends. I have a whole YouTube video about hair loss like medical reasons and different treatments. You know, everything from red light to PRP, so if it is hormonally related, it can help. What happens in menopause is we end up with sometimes male pattern baldness, and what happens is, our estrogen levels greatly decline. And our steroid hormone binding globulin declines as well. That is the little car you know, it's a protein that holds on to our sex hormones and they transport through the bloodstream, and so when they're free, they're active when when they're bound they're not active. So when SHBG drops, your estrogen production drops. There's no estrogen anyway, but your testosterone you're still making some in the adrenal gland and it becomes more active because it's unbound, so testosterone starts for some of us acting here (on the hairline). So I really think everybody could benefit if you're losing hair thinning hair from Rogaine, you know, doesn't matter what the hair loss is from - Rogaine, or minoxidil can be helpful. It's something I've used for years regularly. Finally, finally, finally getting it all back (my hair). And hormone therapy, you know, really being kinder to your hair. I've really tried to be less aggressive with hair techniques and straightening and different things.

Penn: What's the cause of waking between 2 and 4am nightly? Let's talk about that because boy, that's the thing.

Dr. Haver: Middle of the night awakenings are one of the hallmarks of menopause, you know, people even who were good sleepers and then all of a sudden it's like 2 2 3 3 3, you know, and then you can't go back to bed, your heads racing, all of that. So if you're untreated for your menopause, you really want to consider hormone replacement therapy because if you're not sleeping, if the quality of your sleep is not great, you're going to suffer on multiple levels, your cortisol levels go up your stress on your heart goes up your ability to function and think during the day like you get in this really negative feedback cycle. And so HRT can be amazing. But even with HRT, like for myself, I have got to get the sleep hygiene down. Like I've made a funny video where I cut the shoulders out of my neck and you know, go sleeveless, and you know, chill that room down, get a chilling pad if you need make sure you got fans and cold water, you know, limit the times you have to get up and pee. So if that means restricting fluid intake after a certain time, do it, you know, get water at other times during the day I would not get reliant on a lot of sleep aids - you're not getting quality sleep when you do that. I mean occasional Ambien, occasional things, absolutely we all have you know. Other thing that I cannot do anymore is drink alcohol. Yeah, yeah, I if I choose to have wine, I am sacrificing my sleep and it is a conscious decision.

Penn: Will you hit on magnesium because I know you've done content on how important that is as well.

Dr. Haver: So we as it as a gender are not getting enough magnesium in our diets. And I don't look at males study so they have plenty of people that take care of them. So when I talk about studies I'm only looking at the ones on done on females and I try to do the ones only done on females and menopause- turns out we're not getting enough magnesium, we're not getting enough omega 3's, not getting a vitamin D. Magnesium has multiple functions in the body, including our brain. So there's reversing a deficit. Okay, when we talk about vitamins, we're trying to get you out of a deficit, okay? And then there's certain things that can be medicinal. So let me tell you what's not medicinal- like taking vitamin C. Vitamin C deficiency can lead to immune/immunocompromised, scurvy and all that stuff. Taking mega doses of vitamin C does not give you superpowers. It's not medicinal over the recommended daily amount. Okay. So magnesium is a little different magnesium we want to correct the deficit always but it can be medicinal certain forms can give you an added benefit in higher doses without being toxic. And so some of the things we know magnesium helps with is mental health, sleep, calming. So when my patients are coming in with sleep issues, even without HRT, I'm immediately going to magnesium L-threonate. It's the one that studied the most in mental health and in sleep.

Penn: Okay, so testosterone- I would love to know more about adding testosterone and what the benefits and side effects are.

Dr. Haver: So um, so you have to be careful. This is where I struggle a little bit with the biotech company because they make some very exaggerated claims that don't have a lot of clinical evidence to back them up and they're also recommending super physiologic dosages without clinical evidence. And so the higher you go physiologically, the more side effects you have, like, and if you want to grow beard - some women do, so I often ask a patient who comes in and I'll check her blood level and it's 350 400... that's transitioning. Right? Right. So if that's what you want, I'm 100% behind you, but I'm not the doctor for that, like transitioning from, you know, one gender to another. But when I put it to them that way, they're like, What?? I'm like, yeah, I try to dose my patients if they want it, and I'll talk to you why I give it. So in our most randiness sexual state, our testosterone levels were never higher than 70. That's high normal. If I had a person not on testosterone, a woman who came to me and her level was 100. I'm forced to look for a tumor, right? That's how high that is. So when I see a woman coming in, at 300/400 I'm like, Honey, are you okay? So hypoactive sexual desire disorder. It has been shown in a menopausal woman to be helpful. So remember, when we talk about sexual function, a woman or woman comes to my office and says, I'm not happy? If you're not having sex and you're happy? That's okay. But when we she says, I'm not happy, I miss it. I want to want to want it so you have to want to #1, okay, in order for me to help you. And so then we talk about the reasons and there's five buckets and they can overlap. So you don't have to be pigeonholed into one relationship disorder. If you don't feel you have a great relationship. This as someone who's supportive of you, this is a constant battle outside of the bedroom. It's completely within your right to not want to have sex with that person. You know to not have intimacy with them. I can't medicate that. Okay. Then we have desire, the brain arousal, the pelvis, orgasm disorders and then pain. Okay, if it hurts, we got to start there to fix the pain. Okay, now, desires what happens in the brain arousal is the physiologic response to a stimulus vagina elongates we have more mucus production that clitoris engorges ...all the things, okay. And then orgasmic and arousal disorders are totally separate treatments than testosterone. Testosterone seems to be good for a menopausal woman for desire. It doesn't work for everyone. Our desire is complicated. I joke I joke in my office that men's desire tends to be a light switch on and ours looks like the flight deck of the 747. I have a person who's in your area and wrote the book. You are not broken. If anyone is struggling with their sexual function. Please read that book before you go to some wackadoodle who's going to medicate you into oblivion? Okay, good. You're pursuing the right path. You know, further destroy your self confidence.

Penn: Okay, birth control, pregnancy and HRT. Is it okay to take a low form of birth control? So that estrogen doesn't deplete?

Dr. Haver: Yes. So especially in early perimenopause, she's symptomatic #1 and she needs contraception. That's my go to, you know, I'll do a very, very low dose. I'll try to find one with estrodiol but they aren't covered by insurance. If she's like been on a birth control pill in the past that her body did well with, we'll go back to that. But what I try to do is birth control pills early in the game and then we kind of transition to the more traditional menopausal doses as she gets further along.

Penn: The next question comes from somebody who's gained a lot of belly fat since approaching menopause. Is it her imagination? And what can she do about it?

Dr. Haver: So there are two things that are happening, and they're sometimes difficult to untangle. We're getting older, everything in our body, every cell in our bodies getting older. And then we're also having accelerated endocrine aging through menopause. And so that 1-2 combo is leading to increasing inflammation levels, and when our inflammatory markers go up, we drive more fat to the abdomen. Another phenomena that's happening is something called sarcopenia, which is the loss of muscle mass with age. Even though that scale is staying the same, unless you're having 1.5 grams of protein, you know, per kilogram of lean body mass per day and you're doing consistent resistance training with heavy weights you are losing muscle and replacing it with fat and then all of a sudden you're like What the hell's happened to my tummy?! And even the most discipline dieter you know, all of our lives we fought to be thin, right? To be smaller, and now I'm like, What in the hell?! We need to be stronger, Right? Yeah, let go with that. You know, you need to be healthy.

Penn: This is a question on HRT dosing and duration. I've seen studies that have shown that HRT has the most benefits for about 10 years from the start of menopause. Is that true?

Dr. Haver: The cardiovascular benefits, yes, the neurodegenerative benefits, yes. So those benefits don't go away when you stop. Okay? It depends on when you start. So it's called the healthy cell hypothesis. And I'm glad we brought this up, so estrogen is better about keeping a healthy cell healthy, than reversing a disease process once it gets started, and in some cases, can make it worse. And so if you start estrogen early enough, you will get those benefits and they will continue as long as you take it. But if you start more than about 10 years after your menopause, you've lost that potential benefit and you may even make a preexisting condition worse.

Penn: I know that there's a lot of people watching that are 10 years post menopause. Is there anything that they can do? So obviously, it's case by case but it does not mean just because you're 10 years or further post that you're just ixnay on this?

Dr. Haver: It's an individual decision. I sit down with my patients, we have a long discussion - ....I had a patient come in at 62, she had cardiac scan totally negative, no history of Alzheimer's or dementia in her family - completely healthy, functional, and she's like, "I want it for having flashes, I'm still having night sweats. I realize that I'm not going to get the cardiovascular benefits, but I'm certainly going to be able to sleep". And I was like, let's do it. Okay.

Penn: If I'm 42 and don't have any symptoms but want to prevent it symptoms, what would you recommend?

Dr. Haver: So we know that certain nutritional patterns, you have an easier time with symptomatology. Women who have more of the Mediterranean or Galveston diet (we're very similar to Mediterranean we're adding in fasting and micro nutrients basically), and so have less hot flashes and less symptomatology. We know less symptoms, less cardiovascular risk. And so turns out that just that diet alone helps with cardiovascular risk as well. So, you know, everybody in the interim wants a quick fix. And of course I do! If there was just one pill I could take that was like, make everything better, and I could just act feel 35 until I had a stroke at 90 and it was over. No, so that would be amazing. But it's all about habits. It's all about patterns. So adopting these habits and patterns as soon as possible will ease you through this transition and keep you as healthy as possible.

Penn: What is the best moment to start or even to start thinking about HRT?

Dr. Haver: The new book I'm writing is really a gift to a 35 year old. You know, before it even starts that you know what's happening. You're prepared just as you were prepare your child for puberty. You've probably already started having the conversations. You know, she's starting now. So that she's not blindsided. Like what's happening to our generation. We didn't know what the hell. You know, I always had irregular periods. I was off birth control pills. I was, you know, my brother just died. I was sweaty. You know, and it took me like a few months to be like "menopause!". You know, I was 49 years old. And so you know, I don't want another woman to go through that. I mean, I think we gaslight ourselves, you know, and so being informed, being prepared and as early as possible so that you're like, Okay, you have a plan in mind. Like, this is what I want to do. This is what I want to talk to my doctor about. Here's how I'm gonna arm myself with information. So that you know, the earlier you start and prepare, the better you're going to be.

Penn: Here's a question about testing for menopause and symptoms of menopause. I think that this is important to address... is that you don't have to test for menopause.

Dr. Haver: Perimenopause is a clinical diagnosis. You talk to the patient, you believe the patient. Now, I'll do bloodwork to make sure because a lot of things look like perimenopause, like PCOS or hypothyroidism or vitamin deficiencies depending on her symptoms. And so I'm testing for those things, but I rarely have to do a hormone test for perimenopause to make the diagnosis. Right because, again, remember it's pulsatile/fluctuating and in perimenopause the pulsatility goes crazy- you start having palpitations, and so a one time blood urine saliva test is rarely rarely going to be definitive. So you really have to understand the physiology of what's going on. And unfortunately, we're doing a terrible job of educating our providers. So they're relying on these companies who are trying to say, oh, take this test, spit in this thing, pee in this cup. And we're going to be able to tell you all this magical stuff about your body and there's just no validity there. So just save people money. You know, it's menopause. Sometimes I'll get the blood work just to prove okay, you're really done. Or if you have an IUD or an ablation or a hysterectomy, you don't have that period to guide. 95% of women will stop having a period between 45 to 55 years old. Perimenopause begins 7 to 10 years before that, so I know when they're walking in the door, right. When they're complaining xyz, I'm like there's a pretty good chance this constellation of symptoms is related to perimenopause. Let's treat.

Penn: Heart disease. What's the connection between heart disease and menopause?

Dr. Haver: So we know that the risks of cardiovascular disease go up with the menopause transition, it's linear. And so where we really enjoyed low cardiovascular disease risk pre menopause, it goes up to a little bit higher than a man's and right at the menopause transition, and so cholesterol all of a sudden, you're like going every year getting your lipids done and boom, you know, all of a sudden at 52 you've got high cholesterol. That's right. Your insulin resistance goes up, your inflammation markers go up, you know, all of those things. So, hormone therapy seems to be protective for a lot of that if you start early.

Penn: What is the link between osteoporosis and menopause? That's a huge question.

Dr. Haver: That's 100%. So we peak our bone density at around age 35 ish. And we start losing bone. So so we remodel bone every day of our lives. We are chewing up bone and laying down new bone like Pac Man, right? Chewing and pooping. So we chew faster and we poop slower. As we get older aging is a part of this. And then you hit menopause and it just ramps up. Right. And so HRT is one of the best preventative treatment measures for osteoporosis but bone density is related to muscle mass, right? musculo unit cannot be ignored. And weight bearing exercise is huge, huge, huge here. So if you had the grandma who looked like this, crumpled you know, you cannot take this for granted. Push to go pay for an out of pocket bone density test-it may be covered by your insurance. Know your numbers because once you get that diagnosis, everything's covered. And you know, all my friends who are orthopedic surgeons who are focusing on this are like this discussion needs to start in your 20s right, you know, kids lift weights.

Penn: Okay, last question for today. Side effects of HRT, are there any side effects of HRT?

Dr. Haver: Yeah, and they're annoying. It's annoying. So red flags with HRT- if you develop new onset headaches or any visual changes, that is a huge stop-now and call your doctor immediately. That is the brain thing going on? And that's very rare, but that is the things that annoy patients, scare patients- breast tenderness, usually self limited and I warn every single patient, you have a 40% chance you're going to have bleeding. Nothing's wrong with you. We are stimulating tissue that bleeds. Usually self limited. If it persists over a couple three months, we'll make some changes to the hormone levels to see if we can get this to stop, but you're not dying. It does not require a biopsy, workup, treatment, anything.


I cannot tell you how thankful I am that you are here today. I really appreciate your time and I know everyone is going to be "this is just fantastic information!" I can't wait for your new book, and maybe I can have you back after because I know you're gonna be pretty busy for a while. And I just I gotta say thank you and thank you so much for my community- you're a superstar in there. I am not kidding. It was like Dr. Haver?! And off to the races. So I really, really appreciate your time.

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