How to Navigate Menopause & Perimenopause for Maximum Health & Vitality | Dr. Mary Claire Haver
Dr. Mary Claire Haver, a board-certified OB/GYN, discusses perimenopause and menopause, covering hormonal changes, symptoms, and the critical role of lifestyle (nutrition, exercise, sleep) and hormone therapy in optimizing women's health and longevity through these stages.
Deep Dive Analysis
18 Topic Outline
Redefining Menopause: Beyond the Last Period
Perimenopause: The Zone of Hormonal Chaos
Impact of Perimenopause on Mental Health & Cognition
Early Menopause, Premature Ovarian Failure & Estrogen Therapy
Contraception Options and Their Impact on Ovarian Life
Underrepresentation of Women's Health Research & Funding
Nutrition Strategies for Perimenopause and Menopause
Body Composition Changes: Muscle Loss & Visceral Fat Gain
Gut Microbiome Shifts During Menopause Transition
Understanding Hot Flashes and Vasomotor Symptoms
Hormone Replacement Therapy (HRT): Misconceptions and Benefits
Timing Hypothesis for HRT and Cardiovascular Health
Estrogen, Testosterone, and Other Hormones in HRT
Local Hormone Treatments for Genital Urinary Syndrome
OB/GYN Medical Education Gaps in Menopause Care
Non-Hormonal Strategies for Bone Density & Overall Health
Conditions Precluding HRT & Polycystic Ovary Syndrome (PCOS)
Sustained HRT Usage and Long-Term Benefits
6 Key Concepts
Menopause
Medically defined as one year after the final menstrual period, menopause represents the end of ovarian function and the cessation of significant sex hormone production from the ovaries, particularly estradiol and progesterone. This definition is problematic as it doesn't account for women without periods.
Perimenopause
This transition phase begins 7 to 10 years before the final menstrual period. It is characterized by hormonal chaos, with much higher surges and lower drops of estrogen and progesterone, leading to unpredictable cycles and a range of symptoms due to the ovary's decreased responsiveness to brain signals.
Visceral Fat
This is fat that wraps around internal organs, distinct from subcutaneous fat. Its accumulation significantly increases during the menopause transition, rising from about 8% of total fat in premenopausal women to 23% in postmenopausal women, even without changes in diet or exercise, and is a harbinger of chronic disease.
Timing Hypothesis (HRT)
This concept highlights that the age at which hormone therapy is initiated significantly impacts its benefits. Starting HRT between ages 50-59 is associated with a 50% decreased risk of cardiovascular disease and death, suggesting estrogen is more effective for prevention than cure.
Genital Urinary Syndrome of Menopause (GSM)
This syndrome encompasses symptoms affecting the vulva, vagina, and lower urinary tract due to declining estrogen and testosterone levels. It includes thinning tissue, loss of elasticity, decreased mucus production, and increased risk of UTIs, and affects nearly all women in menopause.
Hypoactive Sexual Desire Disorder (HSDD)
This is a sexual dysfunction characterized by a persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activity. In menopausal women, it is often linked to declining testosterone levels and can be addressed with testosterone therapy.
8 Questions Answered
Menopause is medically defined as one year after the final menstrual period, but this definition is problematic because it doesn't apply to women who don't have periods due to hysterectomy, IUDs, or other conditions, making diagnosis difficult.
The earliest signs of perimenopause often include mental health changes like increased anxiety, loss of executive functioning (brain fog), new onset ADD-type symptoms, and dysfunctional uterine bleeding (abnormal periods).
Forms of birth control that suppress ovulation can slightly delay the onset of menopause, potentially by about nine months after several years of use, because they prevent the monthly loss of thousands of eggs associated with ovulation.
Menopause leads to significant body composition changes, including accelerated muscle loss and a substantial increase in visceral fat, which is fat wrapped around internal organs and is a major risk factor for chronic diseases.
The initial interpretation of the Women's Health Initiative (WHI) study, which suggested HRT increased breast cancer risk, was flawed due to an older study population. More recent data suggests that if HRT is started between ages 50-59, it can decrease the risk of cardiovascular disease and death, and estrogen itself is not carcinogenic.
Yes, there's still value in discussing HRT. While the maximum cardiovascular benefit may be lost, HRT can continue to protect bones, the genital urinary system, and skin. A doctor should assess cardiovascular risk factors before initiation.
Sleep disruptions, often caused by vasomotor symptoms or racing thoughts, can be improved by controlling hot flashes with HRT and taking oral progesterone at night due to its GABA-ergic effects. Reducing alcohol intake is also crucial, as tolerance decreases significantly post-menopause.
Decreased libido (hypoactive sexual desire disorder) is common due to hormonal changes. Testosterone therapy, often compounded as a transdermal cream, is frequently chosen by patients for its effectiveness and cost-efficiency, after ruling out other issues like pain or relationship problems.
39 Actionable Insights
1. Consider Hormone Replacement Therapy
Engage in an informed conversation with your doctor about hormone therapy (HRT) as it is the ‘absolute gold standard’ for managing menopause symptoms and offers significant protective benefits for long-term health. Every woman deserves to understand her options and make her own choice regarding HRT.
2. Start HRT in Opportunity Window
If considering hormone therapy, aim to start it between ages 50-59 or within 10 years of menopause onset, as this ’timing hypothesis is key’ for maximizing cardiovascular protection and cognitive benefits. Estrogen is more effective at prevention than cure, and earlier initiation leads to better outcomes for heart health and brain function.
3. Regular Resistance Training
Engage in resistance training three to four days a week to combat the accelerated loss of muscle and bone strength that occurs with aging and menopause. This is crucial for maintaining strength, controlling basal metabolic rate, and supporting overall longevity.
4. Prioritize High Protein Intake
Increase your daily protein intake to 80-120 grams, depending on body composition, and distribute it throughout the day, rather than stacking it at night. Adequate protein is essential for building and maintaining muscle mass, which is vital for metabolic health and insulin sensitivity.
5. Utilize Vaginal Estrogen Therapy
Consider using vaginal estrogen, as it is safe and effective for treating genital urinary syndrome of menopause (GSM), preventing recurrent UTIs, and helping with urge incontinence. It improves tissue health in the genitourinary system without systemic absorption.
6. Wear a Weighted Vest for Bone Health
Incorporate a weighted vest, starting at 10% of your body weight, into daily activities like walking or chores to stimulate the musculoskeletal system. This practice can significantly improve bone density and help prevent osteoporosis.
7. Adopt Healthy Lifestyle Early
Embrace an anti-inflammatory diet (Mediterranean-esque), regular exercise, and good sleep habits long before perimenopause begins. The healthier you are entering this transition, the better your overall course will be.
8. Increase Daily Fiber Intake
Aim for 25-32 grams of fiber per day by focusing on fiber-rich foods, as most women consume only 10-12 grams. Fiber supports a healthy gut microbiome, slows glucose absorption, and helps lower inflammation, which is crucial as estrogen’s anti-inflammatory protection declines.
9. Explore Female Testosterone Therapy
Discuss testosterone therapy with your doctor for issues like hypoactive sexual desire disorder (HSDD), osteoporosis, osteopenia, or sarcopenia. While off-label for women, it can improve libido, bone density, muscle strength, and cognitive clarity.
10. Use Progesterone for Sleep
If experiencing middle-of-the-night awakenings or racing thoughts, take oral progesterone at night before bed. Progesterone, likely through its effects on GABA, can help settle the brain and promote better sleep.
11. Limit Alcohol for Sleep
Reduce or eliminate alcohol consumption, especially if you are in perimenopause or menopause, as women often cannot tolerate it as they used to. Alcohol significantly disrupts sleep, leading to awakenings and other sleep disturbances.
12. Know Family Menopause History
Inquire about the age your mother and aunts went through menopause, as genetics is the biggest factor determining your own menopause age. This information can provide valuable insight into your likely timeline.
13. Track Waist-to-Hip Ratio Monthly
Measure your waist-to-hip ratio monthly (waist at smallest part, hips at widest part, relaxed) as a better indicator of metabolic health risk than weight or BMI. A ratio less than 0.7 for women indicates lower visceral fat, while greater than 1 suggests higher levels.
14. Choose Non-Oral Estrogen Forms
If considering estrogen therapy, opt for non-oral formulations like patches, gels, or sprays, especially if you have a family or personal history of blood clots. Non-oral delivery bypasses liver metabolism, reducing the slight increase in clotting factors associated with oral estrogen.
15. Continue HRT Indefinitely if Healthy
If you started hormone replacement therapy early in menopause, remain healthy, and have no contraindications, you can continue it indefinitely. HRT provides ongoing protection for bones, the genitourinary system, and skin.
16. Evaluate Abnormal Uterine Bleeding
If you experience dysfunctional uterine bleeding (heavy, frequent, or unusual bleeding), consult a gynecologist for evaluation before starting hormone therapy. This is crucial to rule out cancer or other underlying conditions.
17. Avoid HRT with Specific Conditions
Do not start hormone replacement therapy if you have known hormone-sensitive cancer, are actively being treated for a blood clot, or have severe liver disease. These conditions are contraindications due to potential risks or impaired hormone metabolism.
18. Support Loved Ones Through Menopause
Educate yourself about perimenopause and menopause to understand the profound physical and mental changes your loved one may be experiencing. Offer support, attend appointments, and be a partner through this transition to maintain a healthy relationship.
19. Take Daily Creatine Monohydrate
Consider supplementing with 5 grams of creatine monohydrate daily, as studies in women have shown benefits for muscle and bone health. This supports the musculoskeletal system, which is critical for longevity.
20. Consider Bioactive Collagen Supplement
Explore specific bioactive collagen supplements (e.g., Verisol, Fortabone) that have shown promise in improving bone density and reducing the appearance of wrinkles and cellulite in menopausal women. While not a complete protein, it may offer targeted benefits.
21. Supplement with Vitamin D
Address potential Vitamin D deficiency, as 80% of patients are often deficient and struggle with absorption. Supplementation is important for overall health.
22. Apply Topical Estriol for Skin
Use a topical estriol cream on your face to help slow the rapid loss of collagen and improve elastin concentrations in the skin, which commonly occurs in the first five years of menopause. This can help maintain skin health and appearance.
23. Use Vaginal DHEA for Sexual Health
Consider prescription vaginal DHEA preparations like Enterosa, which locally convert to testosterone and estrogen. This can improve vulvar health and sexual function, particularly for patients who may have limited HRT options, such as those with breast cancer.
24. Testosterone for Low Libido
If experiencing hypoactive sexual desire disorder (HSDD), where libido has significantly decreased, testosterone therapy can be a beneficial option. It works at the brain level to help restore sexual drive.
25. Vaginal Estrogen for Painful Sex
If experiencing pain, tearing, or fragility during sexual activity due to loss of elasticity and moisture, vaginal estrogen therapy can help. It improves tissue health and reduces discomfort.
26. Topical Sildenafil for Arousal
For arousal disorders where blood flow to the genital area is diminished, topical sildenafil (Viagra) can be a helpful treatment. It can improve blood flow and enhance arousal symptoms.
27. Address Relationship Issues for Libido
Recognize that relationship dynamics can significantly impact libido and sexual function. Ensuring you feel loved and supported by your partner is fundamental for sexual desire.
28. Combine GLP-1s with Protein & Training
If prescribed GLP-1 medications like Ozempic or Mounjaro, prioritize adequate protein intake and resistance training. This strategy helps mitigate potential muscle loss associated with these medications, supporting long-term health.
29. Discuss Contraception with GLP-1 Patients
If you are a female patient taking GLP-1 medications and do not wish to become pregnant, discuss contraception with your prescriber. These medications can restore ovulation in women who previously had difficulty conceiving, leading to unexpected pregnancies.
30. Avoid Smoking for Ovarian Health
Refrain from smoking, as it is known to accelerate the onset of menopause. Smoking can cause you to go through menopause sooner than you otherwise would, impacting long-term cardiometabolic health.
31. Manage Abdominal Inflammation
Be aware that any inflammatory process in the abdomen, such as irritable bowel disease or endometriosis, can accelerate the loss of ovarian life. Managing these conditions can help preserve ovarian function.
32. Understand Surgical Impact on Ovaries
Be informed that certain surgeries, like a hysterectomy (even if ovaries are left) or tubal ligation, can shorten the lifespan of your ovaries. A hysterectomy can reduce ovarian life by four years, and a tubal ligation by 1.5 years.
33. Suppress Ovulation to Delay Menopause
Using birth control methods that suppress ovulation for an extended period may slightly delay the onset of menopause. This is because fewer eggs are lost each month when ovulation is inhibited, potentially extending ovarian life by up to nine months.
34. Manage HRT Patch Skin Rash
If you experience a skin rash or hives from an estradiol patch, it may be due to the adhesive, not the hormone. Try an alternative non-oral form of estrogen or apply an over-the-counter cortico nasal spray to the skin and let it dry before applying the patch to reduce reaction.
35. Eat Varied Colorful Foods
Incorporate a wide variety of colorful fruits and vegetables into your diet, such as greens, reds, purples, and yellows. Each color represents different beneficial phytochemicals that support various aspects of your body’s health.
36. Evaluate Menopause Supplements Critically
Exercise caution with most over-the-counter menopause supplements, as many lack robust scientific data to support their efficacy in treating symptoms. While generally not harmful, they may not address the root cause of hormonal changes.
37. Optimize Sleep Temperature with 8Sleep
Utilize a smart mattress cover like 8Sleep to control your sleeping environment’s temperature. Programming the temperature to drop by 1-3 degrees for sleep and rise for waking can significantly improve sleep quality and duration.
38. Engage in Professional Therapy
Consider engaging in professional therapy with a licensed therapist to develop healthier thought patterns and actions. Quality therapy can be immensely valuable for personal and professional life, helping to direct focus toward what truly matters.
39. Use Aeropress for Coffee
Brew your coffee with an Aeropress to achieve a perfect cup without bitterness and with excellent taste, quickly. Its short contact time between water and coffee ensures a great brew in about three minutes, and the ‘Go Plus’ version is ideal for travel.
6 Key Quotes
What used to look like this every month is now just insane and very, very, very unpredictable. That is why we don't have a good blood test in perimenopause to make the diagnosis. Those of us in the menopause use symptoms usually to make the diagnosis and we rule out other conditions that might overlap. So perimenopause, basically critical threshold. It's a downward trend overall of estradiol, but it is a very chaotic race till you flatline and bottom out.
Dr. Mary Claire Haver
One in five women will quit their jobs because of menopause symptoms. That's an outrageous number.
Dr. Mary Claire Haver
In the U.S., it's the average age of that one year after your cycle. So menopause, that one day, is about 51 to 52 years old. However, normal is still 45 to 55.
Dr. Mary Claire Haver
The hormone therapy was developed to stop a hot flash for decades. Menopause was defined by the presence or absence of, you know, severe menopause was defined by hot flashes or not. They did nothing else.
Dr. Mary Claire Haver
We are females and we're not little men with breasts and uteruses. We react differently to medications, disease, disease burden, you know, and that's not been studied adequately.
Dr. Mary Claire Haver
I will probably die with my estradiol patch on if I don't develop a reason to take it off. Because I know it's protecting me in so many levels and I want to keep that going.
Dr. Mary Claire Haver
1 Protocols
Osteoporosis Prevention Pack
Dr. Mary Claire Haver- Eat adequate protein.
- Engage in regular resistance training.
- Wear a weighted vest (start with 10% of body weight, gradually increase).
- Take 5 grams of creatine monohydrate daily.
- Consider a bioactive collagen supplement (e.g., Fortabone).