What They Don't Tell You About Menopause

Marie Forleo: I don't feel like I used to feel.

Dr. Mary Haver: I don't think I'd be where I am today, had my own personal experience, been so horrible.

Marie Forleo: This is the wrong group of women to piss off like we have had it up to here.

Dr. Mary Haver: Oh my gosh, wait, we're doing this wrong.

Marie Forleo: What would you recommend for anyone listening right now who absolutely knows something's not right? World renowned menopause expert Doctor Mary Claire Haver is one of the most sought after doctors on the planet. A bestselling author and a social media powerhouse with over 3 million rallying behind her mission to revolutionize health care for menopausal women, she's helping women navigate their hormonal changes with science backed tools so they can advocate for their own health and happiness.

Marie Forleo: Proving to billions of women that while menopause is inevitable, suffering is not. 

Marie Forleo: So much to talk about. Myself, my team. Digging into your work, into your books. There were so many things that, just rocked me. One of them, in the US alone, one third of women are peri- or post-menopausal, and that most women will spend 30 years of our lives post-menopausal. 

Dr. Mary Haver: Exactly. 

Marie Forleo: Let's just go right for it. Why is menopause such an important topic for women? And why have you chosen to make this your life's work?

Dr. Mary Haver: I chose it. I chose to make it my life's work because we have such a lack of education and knowledge amongst myself, amongst our health care providers, amongst the general population. And as a menopausal woman at 55 years of age, I am the healthiest I've ever been. But had I taken the road recommended to me by what the societies and and you know, at the time that I went through menopause would have recommended I would not be as healthy as I am today.

Dr. Mary Haver: And knowing that all of the changes that happen in our body in relation to menopause, and knowing things that I can do to make my body healthier in response to this, I think is so critical because women are living longer than men, great. But they're living that life in poorer health than a man. So we live 20% of our lifespan in poor health and our male counterparts, when we're age matched.

Dr. Mary Haver: And a lot of that has to do with menopause changes. And that is my focus. That's where I think the future of medicine should be, is keeping us healthy in this last third of our lives.

Marie Forleo: I loved in your book you said I was a terrible menopause provider for years because there were huge gaps in my knowledge. And then you went on to tell the story about the WW, which I want you to tell. So, let's talk about that like in medical school, how did you spend most of your time? What were you learning and focusing on?

Dr. Mary Haver: So medical school you spend the first two years in what we call didactics. So book learning physiology, you know, organ systems and, you know, anatomy, you know, and we're terrified, you know, we're just, we can't believe we're there. We all have imposter syndrome 100%. And it's very competitive to get in. And you're so stressed out that you've, you know, climbed this mountain and now you have another mountain to climb.

Dr. Mary Haver: And but when I look back on what I learned in medical school about menopause in a four year curriculum, I think I got one hour of a lecture. Total. Wow. One hour. So then in the US, I go to do my residency. I fall in love with obstetrics and gynecology, women's health and I match it. My top program.

Dr. Mary Haver: I'm so excited. I'm so proud of everything I learned in that program. But there was a huge gap. Menopause. I maybe got six hours total in a four year curriculum, and that level of education and focus had not changed. I was a residency program director in charge of curriculum, like we get a curriculum from the American Board of OBGYN, that we must check all these boxes, this many surgeries, this many hours doing X, Y, and Z.

Dr. Mary Haver: And I know at least until 2018, what was required of residents. And there was not like a menopause module or a menopause clinic requirement. You know, we got a few lectures throughout the four years, maybe six hours total. Wow.

Marie Forleo: And, you know, I heard you say on one of your, IG posts, it's like, so much of the emphasis was on helping women get pregnant and stay pregnant. And yet there are millions, if not billions of us who will never have children, myself included. And so it's just, as I was going through all of your work, it's like, oh my God, how are we here in 2024 and just talking about this is wild.

Dr. Mary Haver: It, it took me losing my ability to reproduce, to really realize where the gaps are in how we train and educate health care providers in this country, and that the focus on women's health is not the health of women. The focus on women's health is keeping her pregnant, which is important. You know, so much. More than 50% of our training of a, as an obstetrician gynecologist is, so, obstetrical training is pregnancy, right?

Dr. Mary Haver: Helping a woman through pregnancy, a very dangerous time of her life for some women, you know, getting her through the process, delivering the baby safely, a little bit of postpartum care, that's probably 55, maybe 60% of our training in a four year curriculum. Then there's gynecology. And in that box toolbox, open that up. We've got reproductive endocrinology, helping people get pregnant, in general, we have GYN oncology, very, very important cancers of the female reproductive tract. We have pediatric gynecology. You know how things in the gynecological world can affect a child that we need to be able to address, and a smattering of other things. And then there's menopause, and it just gets shoved in this tiny, tiny little box.

Dr. Mary Haver: Now, I finished my training in 2002, and that timing is important. Up until that time, we were being taught about hormone replacement therapy, really only in the context of helping a woman with the most cliche symptoms of hot flashes and decreasing her risk of osteoporosis, and a little bit about genital urinary syndrome of menopause. Just touching on it.

Dr. Mary Haver: But nothing about, we were, I think I heard one, like they brought in like a guest speaker who talked about the cardiovascular system in menopause. And I was like, well, how's that related? You know, we're here to deliver babies. And then the Women's Health Initiative results were dropped at the end of my training program in July of 2002, and that was it.

Dr. Mary Haver: I was the last class of residents who was classically trained in anything to do with hormone therapy.

Marie Forleo: So tell people who are unfamiliar with that particular, what dropped, what happened then. I definitely want to hit on that WW.

Dr. Mary Haver: So finally, the National Institutes of Health was being headed by a woman. And under her guidance, which I think was magnificent, they decided, we knew for years that hormone therapy was helpful, you know, for a multitude of things, because of observational studies, we knew that women on hormone therapy had a lower risk of cardiovascular disease. We knew that women on hormone therapy had a lower all cause mortality.

Dr. Mary Haver: We knew that women on hormone therapy had lower osteoporosis and lower UTIs, and lower general urinary syndrome of menopause, but it hadn't been proven. Correlation is not causation. How do you do that? A randomized controlled study with placebo, okay. That is the gold standard. So finally, we're going to study aging women. We're going to study hormones. I mean, they're going to spend $1 billion on this study.

Dr. Mary Haver: This was amazing. So the outcome of the study was, does hormone replacement therapy truly prevent heart disease in a woman? So they recruited women between the ages of 50 and 79, but the average age was 62. The average age of menopause in the US is 51. So this is where things get important. So they recruit, they start in 1998 and they recruit the women, and then they start.

Dr. Mary Haver: They divide them into two groups: placebo. You get a fake pill, you know, and no one knows who's in what group. They excluded women with hot flashes. Why? Because then they would know if they got the placebo or not, because it had to be double blinded. So if you give a woman estrogen, her hot flashes will decrease or probably subside.

Dr. Mary Haver: So they had to exclude those patients. So, who suffers the most severely as far as health consequences for menopausal women who have severe hot flashes? So they're out of the study. So now we have women, we're down to like in 85%, women have hot flashes. So now we're down to about 15%, average age of 62. Half of them get hormones, half of them get placebo.

Dr. Mary Haver: If you have a uterus, you're given estrogen plus progesterone, which is safe. And then if you didn't have a uterus through hysterectomy, then you were getting estrogen only. So off they go, collecting data on these women and what they see is, there seems to be an increased risk of women who were on estrogen in the non placebo arm.

Dr. Mary Haver: They abruptly stopped the study. They call a press conference. And before the findings were even fully analyzed, they released this data. And it was kind of the first viral thing I can remember before the internet, because it was this press conference, it was on Good Morning America. It was on all the morning news shows. It was on CNN.

Dr. Mary Haver: It was on everything, every which way. And in the newspapers, it was the number one medical like, news story in 2002, estrogen causes breast cancer. And it scared the doctors. We weren't allowed to read the study for weeks. Months after that. It scared the doctors. It scared the people. 80% of women abruptly stopped their hormone therapy, threw it in the trash.

Dr. Mary Haver: Nancy Snyderman got on TV, who was a big medical reporter at the time and, you know, with the information she was given, rightly said, estrogen will kill women. We need to stop giving it in hormones, you know, we need to stop giving hormone therapy to, to postmenopausal women. It's dangerous. And that message, those findings have been mostly rescinded and, in multiple papers.

Dr. Mary Haver: But that information has not been disseminated. And when you look at the American board of OBGYN, where I get my yearly recertification, we have to read a set of articles of latest research and then answer questions to make sure we read them, and then we get our little certificate, okay, you're good for another year. There is almost never anything to do with menopause care.

Dr. Mary Haver: So here I am going through menopause, having horrific hot flashes, terrified to take hormone therapy because of my family history of cancer. And, but I'm like, you know what? I can't live like this. I have no option. I'm just going to have to take the risk because my quality of life is horrible and, you know, disrupted sleep. I didn't know my musculoskeletal pain at the time was, you know, I'm just like your basic OBGYN who's reluctantly going to try hormone therapy.

Dr. Mary Haver: And then I start reading and digging, and then I start researching because of the weight gain and the Galveston diet, how that all formed, more and more about menopause in general. And I'm seeing all these correlations between inflammation and cardiovascular disease. And I'm kind of remembering something from my residency. What happened with that? And so and then I start meeting other doctors through social media who are really talking about menopause and presenting all these studies.

Dr. Mary Haver: And I'm like, oh my gosh, wait, we're doing this wrong. Like, this is really, really helpful. Not only, you know, I'm just lucky that I didn't let myself menopause for too long, you know, have those cliche symptoms for that long. And someone asked me the other day, what if you would have been the 15% who really didn't notice much difference?

Dr. Mary Haver: Your period just stopped and you didn't have the hot flashes? You know, that terrifies me because I don't think I'd be where I am today in this menopause movement. Had my own personal experience been so horrible.

Marie Forleo: It's not so interesting. And I want to unpack that more when we get there.

Dr. Mary Haver: We’ll talk about the WW. I forgot.

Marie Forleo: Yeah, no, let's talk about that because I found it so startling, but not, to be quite honest with you. And, Yeah, if you can tell.

Dr. Mary Haver: So yeah, in my OBGYN training program, and I've talked to other doctors and there's other terms that are very used across the country that are very similar. It's not, wasn't just me. So we had a gynecology clinic and there would be a stack of about 80 charts every day, and there were upper levels and lower levels. So we have our fourth.

Dr. Mary Haver: We have four years of training. So at fourth years, very hierarchal. So the upper levels, they need their surgery numbers. So they're combing through the charts trying to find the surgeries. And then everything left is like vaginal discharge. You know you're just kind of like nuts and bolts of, of different things. And then there's the WW in this GYN clinic.

Dr. Mary Haver: And I was like, what's that, in the upper level would be a tall Texan guy in his white coat with his cowboy boots walking down the hall. He's like, yeah, you got a WW and Room 4, good luck with that. A WW stands for a whiny woman. And she was Caucasian. It was a triple WWW.

Marie Forleo: A whiny white woman. Oh wow.

Dr. Mary Haver: And she had a constellation of symptoms that you couldn't put your finger on. Some hot flashes. She was gaining weight, maybe some headaches. She was anxious. She was depressed. She was having brain fog. She was tired. And we were taught, it wasn't written in the textbooks. Don't get me wrong, my professors never said this. This was just kind of like this…Vibe? That was handed down. 

Marie Forleo: Yeah, it's cultural.

Dr. Mary Haver: There's not much you're going to be able to do for her. Pat her on the knee. Tell her it’s part of life, and we got to move on. We got to get to these surgeries. 

Marie Forleo: Wow. 

Dr. Mary Haver: And that, you know, I didn't think about that for a long time after my training. And I was reading something, researching something.

Dr. Mary Haver: And someone said whiny gyney. And that was another term to use, like on the East Coast. And I thought, oh my God, the WW. I forgot about that. Like when I think about the cultural perceptions, the kind of internalized misogyny that I had to confront in my own life and training, the, you know, perception of what menopause really was.

Dr. Mary Haver: I didn't know enough at the time to say, this is perimenopause or menopause, and that was a fact, you know, that kind of thinking was still pervasive, is still pervasive today. It's less tolerated. It's not said as openly, but I think that line of thinking is going to take a generation to train out of our physicians.

Marie Forleo: If not more. And I think it when you were talking about the internalized sense of it, too, because I remember, you know, I'm in my late 40s now, and in my mid 30s, I really started just paying attention to my numbers. And we'll talk about that. Want to get to, you know, knowing your numbers because it's so important. And, for a while everything was just coming back pretty normal. You know, I was like, okay, great. Everything's looking normal.

Marie Forleo: Hormones levels looking normal. La la la la la. And I just remember even starting to have conversations with my partner like, I, I don't feel like I used to feel and I love him and God bless him, he's like, well, you're putting a lot of pressure on yourself. I'm like, yeah.

Marie Forleo: But that's not new. Like, you know, like this isn't new. And so it's been like over these past probably over the past decade or so, where I keep feeling I'm like, something's not okay. Like something's different, something's not okay. And I have so many friends in the industry and I feel like I'm a fairly good communicator and I cannot tell you how much internally I've been, like up, but this must be a part of getting old.

Marie Forleo: Oh - well, you must not be as strong as you used to be. Like all of this kind of self punishing internal dialogue that I didn't grant myself necessarily, possibly to go like how much of this is actually chemical, how much of what's happening for me? And is there help out there? So that's why I just wanted, I wanted to talk about that because it's like from a cultural perspective in the medical system and our internalized versions of that as women, especially as ambitious women, which we have a lot of those folks who pay attention, listen to our show.

Marie Forleo: They're entrepreneurs, they're creators, they're taking care of everyone and everything and have been for decades. And now you get to a point in your life where you're in your late 30s or 40s or 50s, not only are you taking care of aging parents and a business and your family, and now your own health, the wheels start coming off right?

Dr. Mary Haver: And, it's so interesting you say that because that is kind of universal. When I sit across the desk from my patients and they are recounting, I'm like, tell me the last time everything was okay when you, you know, have things, have you increased stress in your life? No, I've managed this machine for years. When I started researching for The New Menopause, I would read these articles and it would be, women can have, you know, all these symptoms.

Dr. Mary Haver: But this is a terrible time in her life. She's doing all the things you said, the aging parents, the whatever. And by the time I got to the 15th article where they were budding, you know, putting psychological, you know, taking physical symptoms and assigning it a psychological reason, I threw the paper down. I said, enough is enough. This latest article from The Lancet that was published, you know, in March, again talked about, oh, but this is a tough time in a woman's life.

Dr. Mary Haver: And I think we're totally doing a disservice. Of course it is. But these are things that we have managed forever. And not allowing the, even the thought that the hormonal milieu that is changing inside of our bodies is affecting our ability to cope, I think is completely doing a disservice to women.

Marie Forleo: I was thinking about that this morning when I was preparing so we could have this conversation, and it was really funny. And walking around my coffee, I'm like, you know, knowing myself and knowing my group of friends in this kind of age range, late 30s, 40s, 50s, I'm like, this is the wrong group of women to piss off. Like we have had it up to here.

Marie Forleo: We're exhausted. We don't have the resiliency like we will, I'll just speak for myself like, can't take it, do you know what I mean? It's like, not one more thing. So I, I just found myself cheering at so many of, and for those of you who don't follow, follow Dr. Mary on Instagram, you have to, because your shares are incredible. But it's like, there are chemical reasons for how you're feeling right now and you don't have to suffer.

Dr. Mary Haver: And you don't have to do an intrinsic psychological process. 

Marie Forleo: Yes. And you're not getting weak and you're not just quote unquote. I mean, everyone's getting older, and I want to get to some of the things, like some of the distinctions between chronological age and endocrinological age in a little bit. But I heard you talk, heard you talk about, about estrogen deprivation. So how do we know we might be experiencing this?

Marie Forleo: And also, if you can just walk us through those three phases of perimenopause, menopause and postmenopause, because most of us have had no education on this whatsoever.

Dr. Mary Haver: Sure. So the best place to start when we talk about the phases of menopause is to start embryologically. Females and males are very different. And as far as our sex hormone production and our gonads are so, you know, females have ovaries, males have testes. Everybody realizes that. But what most females, what most of us don't know, humans don't know, is we're born with all of our eggs.

Dr. Mary Haver: They form when we're five months in utero. They finish forming inside of our mothers, and we start losing them from that point. So we lose the amount and we lose the quality.

Marie Forleo: Wow. Okay, I never heard that before.

Dr. Mary Haver: By the time we're born, we have about 1 to 2 million eggs. That's got to last us as long as they last. By the time we're 30, so we start ovulating, each month we lose about 11,000, okay? And we lose them as children, while we're children. Then we're not out yet. And we go through puberty and we begin the ovulation process.

Dr. Mary Haver: If we're healthy, then at about age 30, we are down to 10% of our eggs supply. And by the age of 40, we are down to 3%. Menopause is the complete senescence of that ability to ovulate. We've basically run out of eggs that are functional and they're not coming back. And so when you think of it that way, you're like, oh, so we're cruising along in our 20s.

Dr. Mary Haver: Everything's going right. Our hormones look like an EKG. Basically we have this rise of estrogen mid-cycle. Then that's followed by a rise in progesterone that drops off. When estrogen rises, we thicken up the lining of the uterus. And then the progesterone decidualizes. It kind of coils the blood vessels inside of those glands. And then they shut when the progesterone drops off and the whole thing starts over again each month in preparation for pregnancy.

Dr. Mary Haver: That's what on an evolutionary basis, that's why it's there. Whereas males make their stuff fresh every day until they die, usually, you know, it gets harder for them to propagate children, but they can do it, you know, if they try hard enough. So menopause represents, you know, from a medical standpoint, it's defined as one year after the last menstrual period, easy kind of -

Dr. Mary Haver: Pinning the tail on that donkey's pretty easy. What it represents is the loss of the production of estradiol and progesterone from the ovaries and some testosterone from the ovaries. Okay. So the disruption in the force. So we're going along each month as we reach some kind of critical level of quality in a quantity, that process starts going awry.

Dr. Mary Haver: We end up in a zone of chaos and that's perimenopause. And it's about 7 to 10 years. So the brain, the hypothalamus, the gland in the brain is constantly testing the blood, has a little monitor inside, some little chemicals. You know, that's checking for estrogen levels. And when it sees that they're low it gives out a signal called GNRH to the pituitary gland to say again in the brain, tell the ovaries to get working.

Dr. Mary Haver: We need more estrogen. So the pituitary makes something called luteinizing hormone in follicular stimulating hormone LH and FSH, which basically talk to the ovary, bind to the ovary, the theca lutein cells around those eggs and say, produce estrogen, testosterone, and then finally progesterone after ovulation, estrogen levels go up, the brain quiets down. We're happy. We're good.

Dr. Mary Haver: Okay. But when the air quality drops and the number of eggs drop, that gets harder and harder. The ovary can't respond like it used to. So the brain's like, hey, step it up, I need more. And then you get surges of these hormones that say, ovary, get in gear. Let's do this. You get these loop ovulations, these late ovulations where you'll have these massive dumps of LH and FSH, but then finally you get this boom production of estrogen.

Dr. Mary Haver: We see in perimenopause these dramatic highs and lows of estradiol production followed by kind of ehhhh progesterone. And that's the zone of chaos. So in perimenopause, remember we have estrogen receptors all over our body. And most women are like, something's not right. It could be brain fog. It could be mental health changes. You know we're we know pinning the tail on the easy donkey is period disruption.

Dr. Mary Haver: And that period disruption could look like anything. Too heavy, too light, too regular. Not regular. They're missing. They're coming too soon. They're so heavy I can't stand it. I'm anemic. They're so light I can't find them anymore, you know? So, it's called dysfunctional uterine bleeding, and it could look like absolutely anything, right? 90% of us will have dysfunctional uterine bleeding on our path to menopause.

Dr. Mary Haver: So muscles, musculoskeletal symptoms. Your gut microbiome completely changes. How you process glucose changes, your lipids change. I mean, there's not an organ system or a metabolic function that is left unchanged from this very natural process. So how that it's expressed in our bodies is different from woman to woman. And we're not training our health care providers about perimenopause at all or how to recognize it.

Dr. Mary Haver: They know menopause. No more periods. We're done. Right. But they're not seeing this huge picture of the metabolic changes, cardiovascular changes.

Marie Forleo: 7 to 10 years is so big. And I'm just thinking to myself, like I'm just kind of tracing back over the past, let's say 6 or 7 years, and I can again even hear internally kind of my own bias and going, oh no, not yet, not yet. And feeling.

Dr. Mary Haver: The same.

Marie Forleo: Experiences of anxiety and depression that I had never experienced in my life. And I've talked about this on the show before that honestly, Mary, it was scary. Like I was experiencing my own life in such darkness that I, and I knew from a logical perspective there was no reason for it. Like on paper, I was like, she's good.

Marie Forleo: Like I, business good, I have great, like, right. Nothing made sense. 

Dr. Mary Haver: So imagine if you somewhere in your 30s, you go in for your annual visit and your doctor screened you for those things and gave you a little bit of education around what might happen. So that you weren't so petrified when this constellation of symptoms lined up.

Marie Forleo: Yes. 

Dr. Mary Haver: That you knew this might be perimenopause. Let me go in and talk to my doctor again. I might need some other tests to rule out autoimmune disease or hypothyroidism because a lot of things have overlapping symptoms. How different would your experience have been?

Marie Forleo: Oh my gosh. I mean, enormously different. And you know, my journey kind of progressed to where, and I may be getting these terms wrong, but I'm just going to explain it from a, my own internal perspective, where I started having so much physical pain in my body. And this was during the pandemic, that my best friend who lives peacefully with cancer, she's like, you need to go, you need, you need to go get this checked out. And like, there's no way, no, I'm fine, I'm fine, you know? And finally, we discovered that I had all of these enormous tumors growing outside of my uterus. Like, one was the size of a grapefruit, and it was push, and it was just a mess. And I opted to, you know.

Dr. Mary Haver: Hysterectomy.

Marie Forleo: Exactly. So they left my ovaries intact, you know, was not a, not a fun thing. And it was just. And then that kind of sent me on this journey which I want to talk to you about. A friend of mine, you know, checked in on me and she's like, have you done a Dutch test? I'm super curious to hear your…

Marie Forleo: And it was just, you know, I had done all this blood work before, and it was like, hormone stable, hormone stable. She's like, yeah. Now it's really important. We really have to keep an eye on this so that you can feel the best that you can feel. And I was like, why are we not talking with women in their 20s and 30s to start understanding their baseline of how they feel their strongest and their best.

Marie Forleo: And I know not everyone feels their strongest and best, but still, just to have some type of baseline so that when we start to enter, what did you call it of chaos?

Dr. Mary Haver: Zone of chaos.

Marie Forleo: Zone of chaos. Where I'm like, oh my God, I've been living in the - so many of my friends, too. We talk about like, what the hell is going on?

Dr. Mary Haver: So do you know that there is a disruption of blood flow to the ovary after hysterectomy? Now, hysterectomies are needed, you know, or were you counseled that you would go through menopause 3 to 4 years sooner than you would have naturally? 

Marie Forleo: No. 

Dr. Mary Haver: To be on the lookout for those things?.

Marie Forleo: No. Absolutely not.

Dr. Mary Haver: So now your, you know, average age is 51 normal’s 45 to 55. You have to back all of that up four years for you.

Marie Forleo: Yeah. Yeah. No it was like, okay. And it's like, well you know mostly the conversation was around, whether or not I felt like I was like, are you sure you don't want to have kids? And I've always been sure, since I was born, I was like, that's not my path in life. And so I was like, so, you know, from that point of view.

Marie Forleo: But it didn't go far beyond that. If I'm just going to be really honest. And so, yeah. And so now it's like, you know, we'll, we'll talk offline. But it's like, okay, well.

Marie Forleo: All of these other things, I just went through this whole gastro thing and I'm like, okay, getting that back online. But it's like a full time. It feels like another full time job to keep myself in my strongest, healthiest state in addition to all the other stuff. And I'm like, no wonder women are frustrated and exhausted and like, I can't do this.

Marie Forleo: Tell me your opinion. or just your thoughts about it, because we have to start knowing our numbers. And one of the things that I think has been so frustrating for me, and I don't know if the tests really exist because it's a moving target, you know, you're talking about with men.

Dr. Mary Haver: So, that's part of the problem that, you know, medicine loves a blood test. You know, a doctor loves a blood test. Yes or no? Check the box. And because of this chaotic fluctuation, we don't have a one time blood, urine, or saliva test that is clearly therapeutic. You know, diagnostic rather, of being able to diagnose the perimenopause transition.

Dr. Mary Haver: Right now, it is a literal diagnosis of exclusion. One, the doctor needs to know that's a thing. And needs to know the group of symptoms that it might be. There's been a scoring system around, a symptom scoring system that has nothing to do with your periods. They never even ask about your periods. It's all about mental health changes, gastrointestinal changes, skin changes.

Dr. Mary Haver: You know, general urinary changes and the likelihood that this is related to perimenopause and it's validated. It's been out since 2008. I'd never heard of it until I dug into the research. I now use it in my clinic, but someone who's menopause educated should be able to tell if you're perimenopause with a conversation. Bloodwork, I do extensive blood work, but I'm ruling out those other conditions, nutritional deficiencies, looking for inflammation markers.

Dr. Mary Haver: You know, because in my clinic it's a 360. You know, we do nutritional counseling, exercise. You know, I cover everything and of course, hormones, you know, whether or not she wants hormone therapy as part of that conversation, but it's that big. Yeah. You know.

Marie Forleo: What did you experience personally, like did you have an experience with perimenopause where you started feeling that?

Dr. Mary Haver: Not so much.

Marie Forleo: Not so much.

Dr. Mary Haver: I had polycystic ovarian syndrome, so I had an endocrinological disorder. I'd had my whole reproductive life. That's why I had fertility treatments to have my children. And in order to mask that, you know, I couldn't lose weight because I was already thin. I had thin PCOS, and that's a tougher nut. You know, at the time, treatment was really diet, which I had covered.

Dr. Mary Haver: And then to suppress, you know, the hormones with birth control pills, which worked really well for me. I know they don't work for everyone, but I did really, really well on them. So I was cruising along in my 40s, on, and I would just get my periods. I would just continuously, I didn't know that I was treating my perimenopause at the time.

Dr. Mary Haver: And so at about age 48, I decided, okay, let's, I talked to my practitioner and we said, let's get off the pill and see where you are. Well, if you know, if you start, if you're skipping still, because I was PCOS, I didn't have regular periods. We'll check your hormones and see if you're fully menopausal yet. So I stopped taking them and at the exact same time, my brother Bob, this was 2015.

Dr. Mary Haver: He had been ill for a long time. He had end stage liver failure from HIV, and he got really sick, got hospitalized with a stroke. So I rush home. We end up doing his end of life care and then, you know, spent two weeks at home grieving, you know, helping him towards his death and then grieving and then going, having to go right back to work because, you know, how much time we get off for bereavement, like nothing.

Dr. Mary Haver: They gave me a week. And so of course, did I get therapy? No. Did I do counseling? No. Did I do anything other than just go back to work and try to cope? Yes. I wasn't taking the pills anymore, so I'm attributing all of the symptoms I'm having to grief, which probably was contributing. Definitely. I wasn't sleeping, I was having horrific hot flashes, horrible joint pain.

Dr. Mary Haver: My nutritional… went out the window. I was just coping. I was in survival mode. I was filling myself with processed carbohydrates as a way to numb the pain. I would cry the whole way. I go to the work, you know, be the best doctor, cry the 40 minute drive home, cathartic, get get home stuff my face with gold, “my kids” goldfish crackers and, and then, like, start making dinner and try to be a good mom and wife and so through that process, I didn't realize I was in menopause.

Dr. Mary Haver: And then finally, when the grief started lifting, I realized, wait, when was my last period? Wait, why am I not sleeping? Wait, these are hot flashes. I was like, oh my God, I'm menopausal. I guessed that myself. This is my job. And so I reluctantly have a conversation with my practitioner. I think I need hormones, I can't, I can't live like this.

Dr. Mary Haver: I'm not sleeping. And she's like, you know, we really worry about breast cancer with your family. Because I've lost a brother to leukemia. And another one to esophageal cancer. Well, he had been diagnosed by then. So like, and I have all of my mother's family and all of my father's family have had cancer, like 90% of them. And, you know, I didn't know that WHI findings had been rescinded.

Dr. Mary Haver: I didn't, you know, no one had put those articles in front of me as part of my continuing medical education, and I didn't know enough to dig and look. So I reluctantly decided to start hormone therapy. So I really was like, truly, you know, without estrogen for six months, maybe. So then, I'm also like dealing with the weight gain from not doing exercise and nutrition.

Dr. Mary Haver: And I decide, okay, girl, get back to your, you know, usual workout habits, workout less, eat more, which I would. I told my patient for 20 years and it wasn't working. It, it didn't work for me anymore. And I was like, it has to, it has to. I can't be - I couldn't have been lying to these patients all these years.

Dr. Mary Haver: So I am calorically restricting to, I think, 900 calories a day. I mean, it had to work. Yeah, I'm doubling down in my gym. My home gym. No, I mean I'd lose a little bit and then it's bounced right back on all the tricks that I was doing to, like, get back into my jeans, you know, after babies and all that not work, not working.

Dr. Mary Haver: So that's when I was like, my husband was going on a trip and I was like, when you get back, you're going to have the wife you deserve. And he's like, babe, I love you. This is crazy talk. Like, you look great, I don't care. I don't care about whatever you're worried about. But like your ,your daughters are watching.

Dr. Mary Haver: I had two girls who were teenagers at the time. They're watching you disparage the way you look. They're watching you - I was the, I’m an almond mom at that point. You know, I was, I was doing all these crazy eating behaviors, showing them negative self-talk in front of them, all the bad things. And it really like was sobering for me.

Dr. Mary Haver: So being a type A physician decided, like, all right, I'm going to fix this. And he's like, you're smart. Figure this out. It's not working. It's not working. You got to do something different. What do you tell the kids when the behaviors you have are not working? You must change your behavior. And okay, so I call the nutrition scientists at the university I was employed at and was like, what is going on in menopause?

Dr. Mary Haver: Why are me and all my patients at this age? Because remember, I'm aging with my patients. And were all complaining of the same thing. My girlfriends and you know, we're marathon runners. We're super healthy. We're fit. You know, I'm finally getting back into those habits. And I don't look the same, which is distressing me. I wasn't thinking about the cardiovascular disease risk at all.

Dr. Mary Haver: The other stuff that was happening inside of me, I just didn't like how I looked in clothes. 

Marie Forleo: Yeah, dude. We're vain. 

Dr. Mary Haver: Totally normal. And so they start pointing me in the, in the line of all this research on nutrition and inflammation and then menopause and inflammation and this is all new stuff. And I'm like, oh my God. Okay, okay, I loved, I dug into fasting, Mark Madsen's research. So then everything when I first put a toe in the water for menopause was really about weight gain. 

Dr. Mary Haver: Talking about that on social media. And then all of a sudden like, women were like you know what. Wait I'm not, I'm not lazy, I'm not crazy. I'm like no, this is a thing. And so that's where my social media presence started really growing is like the open conversations I was having with my own struggles, hormone therapy…

Dr. Mary Haver: And then I'm learning about, whoa, these test, these, these studies. Well, isn't it dangerous? Not really. Actually. Studies have been rescinded. I'm making friends with other menopause doctors online. They're sharing articles with me. Then my menopause window got a lot bigger. Because, you know, I'm growing, growing, growing, and people are asking more and more questions. Not about weight gain, about frozen shoulder, about, palpitations, about musculoskeletal pain, about frozen shoulder, about, you know, could this be related when 10,000 women ask you the same question?

Dr. Mary Haver: I'm curious. So I started digging into the literature instead of saying, no, no, no, no, no, no. Can't be that, can't be that and realize menopause is much bigger than we thought. Sure, nutrition is important. It's probably the most important thing for our overall long term health. And some nutritional changes will likely affect like, how many hot flushes you have. But like, this is way bigger than just stamping out a pesky hot flash.

Marie Forleo: I have to say this. So for everyone, this book, I feel like it's like the Menopause Bible. That's how I felt when I was reading this, because I'm like, I'm finally getting the education that I didn't know I needed. And I think one of the things that's so brilliant that you've done is the entire big toolkit, which is kind of the back half of the book.

Marie Forleo: It's like, hey, if you have any of these dozens and dozens and dozens and dozens of potential symptoms, here are evidence based ideas, strategies that you can try to help alleviate outside of…um, what's it called? I always want to call it HRT because our… 

Dr. Mary Haver: Pharmacology.

Marie Forleo: Yes.

Dr. Mary Haver: You know, we talk about pharmacological ways that you can adjust to these symptoms. But the big six of what I call the visceral fat, the cardiovascular, the cholesterol, you know, the things that are going to mess you up later on. 

Marie Forleo: Yeah. 

Dr. Mary Haver: Are mostly you know, HRT does have a definite you know, it gives you an advantage there, but it's not going to take care of your nutrition; it’s not going to take care of your movement for you. Those are all important.

Marie Forleo: Yes. Okay. So I'm curious here from you personally when you, because you are,  are you still doing HRT and what is that, what was that like?

Dr. Mary Haver: Probably die within a sterile patch on.

Marie Forleo: Yeah. You know, my mom, actually, one of the reasons it was interesting, like every woman on my mom's side of the family had hysterectomies. And I remember my mom was the one, she had it, and I felt like when you were telling the story about when you were in training, and it was like looking for the surgeries.

Marie Forleo: This was like in the 80s, and it felt like when women were getting hysterectomies, like they were just like, you need one. You need this. 

Dr. Mary Haver: It's time. You don't need that anymore, right? We're removing people's organs.

Marie Forleo: Right. And so I remember distinctly, it's like, you know, when a memory and your family gets burned in your brain of my mom, like, moaning and wailing in so much pain. And she was so angry. It actually stopped her from going to the doctor for, like, 30 years. We still have her. I almost lost her a few times last year.

Marie Forleo: That's a whole other story. But I remember she went on estrogen and she told me she was like, changed my life. It changed her life. And so we had never really had the conversation again. You know, that was a conversation I think I had with her in my late teens, but not now. And so what was your experience?

Marie Forleo: Did it take a few months for you to start experiencing, like what was that like? 

Dr. Mary Haver: So the hot flashes I remember, like at week two thinking, is this going to work? Is this going to work? Is this going to work? Then all of a sudden by like three weeks, three and a half, by week four, I was sleeping through the night every night. 

Marie Forleo: Wow. 

Dr. Mary Haver: And you know, waking up like Cinderella, like, oh, the rainbow and the birds chirping and like being like, oh my God.

Marie Forleo: I can just hear so many women in the audience crying now, you know what I mean? Just like, is that possible again? 

Dr. Mary Haver: You know, and again I, because I have a uterus still…

Marie Forleo: Yes. 

Dr. Mary Haver: I had to have progesterone. I didn't start testosterone until probably six months ago. And I'm also using topical estrogen. So I have replaced my hormones right now for ways. So I'm doing a systemic estrogen for the cardiovascular benefits of course, for the symptom reduction.

Dr. Mary Haver: For the cognitive benefits. You know I happened to get there in the right window of opportunity for both cardiovascular and neural protection. I'm doing it to protect my bones and I'm doing it to protect my general urinary system.

Marie Forleo: Let's talk about that. What is that window of opportunity especially for, cognitive function? Because again, I know the reason that folks listen to me is I have the same kind of flavor of crazy as many of them do. We're ambitious and we've got lots of stuff that we want to do. And the moment, for me, I get really frustrated with me if I don't feel the level of sharpness that I have been accustomed to for most of my life, it's really hard to… so what, what is that? What is that window?

Dr. Mary Haver: When most women will have some degree and for a large amount of us, a significant degree of decrease of cognition. The brain is rewiring through this senescence time period. Estrogen is very, very, very active in the brain. Progesterone is active in the brain. And turns out testosterone is likely active for women and for all humans. You know, we all have the same three hormones, by the way.

Dr. Mary Haver: We just have them in different levels. And so, if you look at Lisa Masconi's work and her book The Menopause Brain is fantastic. Highly recommend. Read, especially if you have Alzheimer's and dementia in your family, you know, and you're worried. She's got some great strategies. Also highly nutrition based on ways that you can decrease your risk. But anyway, but just to let your listeners know, this is expected, this is going to happen, and it doesn't necessarily signal the path to dementia.

Dr. Mary Haver: Most of it will eventually return if you're not on the dementia pathway. but, you know, remember that Alzheimer's is a disease that begins in midlife, that we don't have symptoms until we're older. These processes are starting now for us. And when we look at the WHI data, when we look at the swan studies and these big, big databases where women were studied, it looks like for certain, the longer, the older you are at menopause, naturally, the less your risk of cognitive disorders is as you age. Estrogen is very protective in the brain. The earlier you go through menopause, the more likely you are now. It's not a 1 to 1 correlation at all. You know, women who have premature menopause don't automatically go and have dementia, but they're higher risk. Okay, so, great study out of the British Medical Journal.

Dr. Mary Haver: First time I've seen data on estrogen presented this way. They looked at lifetime exposure to estrogen, both natural and HRT. So age of menopause minus puberty plus any years that she had on hormone therapy and the risk of cognitive disorders with that. And it was pretty much a, you know, correlation. The longer you're exposed to estrogen, the lower your risk of cognitive disorders.

Marie Forleo: That's amazing.

Dr. Mary Haver: Yeah. And dementia.

Marie Forleo: That's amazing.

Dr. Mary Haver: So and I'm like that's out of a database. So that's data that's been sitting around. Someone just pulled the numbers. Let's do that for blood pressure. 

Marie Forleo: Yes. 

Dr. Mary Haver: Let's do that for cholesterol. Let's do that for cardiovascular disease. And look at it that way. So, starting HRT within at least the first five years of your, seems to be protective for both Alzheimer's and for other forms of neuro dementia.

Marie Forleo: So that's incredible. You know, when I had my hysterectomy and then I just started feeling really nervous, to be quite honest with you, because I didn't know who I can trust.

Dr. Mary Haver: Yeah.

Marie Forleo: And it just felt like it was like, I don't know, you know? And I started talking with girlfriends, of course, and I feel like I have a little bit of an advantage because based on what I do, I get to talk with really smart people like you. So I have a network of smart docs who I can start reaching out to.

Marie Forleo: What would you recommend for anyone listening right now who absolutely knows in her heart something's not right, right? Shit's going off the rails and is perhaps whether her doctor, for whatever reason, she doesn't feel a high degree of trust. Right? That, that this is the right person. Where can she start to look?

Dr. Mary Haver: It is not reasonable. And I think it's terrible that you can expect to go into your lovely, trusted OBGYN who delivered your babies and has done your contraceptive management and whatever else you needed to be menopause informed. I was that doctor. I did my best with what I knew, but I did not nearly know enough. So it's finding someone who is menopause informed, and it might be an internal medicine doctor.

Dr. Mary Haver: It could be a family medicine doctor; it could be an OBGYN. So one place to try is The Menopause Society has a certification process. Right now there's only 1200 of us trying to take care of every menopausal person in the world. And you don't have to be an OBGYN to get menopause certified. So that's one place and it's still not a guarantee.

Marie Forleo: And that's something people can Google.

Dr. Mary Haver: Yeah, you can look up. You can go to menopause.org and look up certif… And they only certify twice a year. So there's another crop coming out in June. So we're getting there. There is, on my website I have testimonials from patients all over the world who have said, look, I've got I found someone who was amazing. And so we have that information kind of consolidated into a database on our website.

Dr. Mary Haver: That's another place. Call ahead. Call ask.

Marie Forleo: Yes. What should the questions be? Because I feel like for me, even though again, I consider myself a fairly good communicator, not having either scripts or the questions to ask, or if there's any kind of red flags things, because I'll tell you my experience.

Dr. Mary Haver: Will the doctor have a conversation with me about the risks and benefits of hormone therapy to treat my menopause?

Marie Forleo: Say that one more time.

Dr. Mary Haver: Will the doctor be willing to have a conversation with me about the risks and benefits of hormone therapy to treat my menopause?

Marie Forleo: And if it's anything but a yes, we keep on moving.

Dr. Mary Haver: That's it. Not every woman will choose it. Yep, not every woman is a candidate, but 100% of us need the conversation and the education. 

Marie Forleo: Yes. So, you know, there's different forms of HRT. Can you walk us through some of those options?

Dr. Mary Haver: Sure. So we look at the formulations. So, the types of hormones. So the human body for sex hormones makes estrogens, makes progesterone, and makes androgens. Those are the you know, I call it male type. We all have them okay. Estrogens are estradiol. That's what our ovaries make. That's the one we most of us know. Estrone is a weaker estrogen.

Dr. Mary Haver: It's produced in fat cells and peripheral conversion and different cells, usually fat cells. And the precursors usually start in the adrenal gland there. And we make androgens both in the ovary and in the adrenal, through the adrenal pathways as well. When we talk about hormone therapy in general, we're talking about estrogen. Most of the research, the studies, the, you know, emphasis is on estrogen.

Dr. Mary Haver: We give progesterone to protect the lining of the uterus from unopposed estrogen. So if you have a uterus, you must take a progestogen. Mandatory.

Marie Forleo: What if you're people like me who don't?

Dr. Mary Haver: So it's optional. But I'll tell you why I recommend it. 

Marie Forleo: Okay. 

Dr. Mary Haver: And then there's androgens, which would mostly testosterone, is what most people would understand. So in traditional HRT, it's estrogen based. And when we talk about risk benefit and, you know, cancer, it's usually the conversations around estrogen plus or minus the progestin. So in the WHI study, which they only looked at Premarin, plus or minus Provera which is conjugated equine estrogen and progesterone acetate, that was the only formulations they studied, which was not unreasonable because that was the number one prescribed product on the market.

Dr. Mary Haver: Other stuff was available but harder to get. Or you know, and Premarin was part of the study. They paid, you know. So here, use our drug. Which, yes. Okay. So it turns out that the estrogen only arm, the women who had had hysterectomy, who only got estrogen, had a 30% decreased risk of breast cancer and a higher survival if they did get it.

Marie Forleo: Wow. 

Dr. Mary Haver: Yeah. And when they reanalyzed the data, there was, it was only the estrogen plus progesterone arm, and it was .8% per year absolute risk. 

Marie Forleo: Wow. 

Dr. Mary Haver: What got reported was the relative risk it went from. And I hope I get the numbers right, like five out of a thousand per year to six out of 1000 per year.

Dr. Mary Haver: Five out of the thousand per year was the baseline risk placebo. Women get breast cancer because they have breasts. That are active and have a lot of you know, glands in them. and then that went to six. So a 25% increase of relative risk. So a lot of people don't understand statistics. I really have to put on my thinking cap when I think about it.

Dr. Mary Haver: But that's, that's a relative population risk versus an absolute risk. What is my risk? So I'll have one extra case per thousand per year if I take this hormone therapy. And even then there's some debate over if that's actually accurate. So, you know, it's much, much less. But we took that option of that discussion away from women, which I think is outrageous.

Marie Forleo: Absolutely. It is outrageous.

Dr. Mary Haver: There was no longer shared decision making. It was a no. Chin up, Buttercup. We're only going to give this to you if you're suffering severely from the cliche symptoms, and only for the shortest time possible.

Marie Forleo: You know, you would think even from an economic perspective. And listen, I'm a person who loves money, and I believe in capitalism, and I like all of that. It was like you would think that our society, from a pure productivity economic GOP perspective.

Dr. Mary Haver: It's a cost savings. Polypharmacy for, you know, Celebrex to treat your muscle and joint pain, cholesterol, statin. Let me talk about statins. I'm gonna blow your mind here in a minute. Statin and anti-anxiety and antidepressant. So, so let's look at absolute numbers. So another thing that the, there's been this talk of over medicalization of menopause it's not a disease.

Dr. Mary Haver: Why are we putting all these people on… That is the most misogynistic, paternalistic, horrible thing I've ever heard. 5% of women in the U.S. right now are on hormone therapy who could be on it. Menopausal women.Yet. 25%, 20%. But, you know, if we go from ten who are on SSRIs to a 20 through the menopause transition, we double and then that goes up to 25 by age 60.

Dr. Mary Haver: The world is fine with that. That's not overmedicalization? 20… one out of four women is on an SSRI, but probably we would have lessened that risk of her developing a mental health issue if we would have had her on hormone therapy? So we can just give her… an oral estradiol is $3, by the way. So when we look at the economic impact of, plus they're quitting their jobs.

Dr. Mary Haver: Leaving teaching positions, nursing positions. You know, the traditional female jobs at the height of their careers. And who's suffering? Us. 

Marie Forleo: Yes.

Dr. Mary Haver: All of patients and students.

Marie Forleo: The wisdom that we're losing, right. The experience that we're losing, the leadership that we're losing. Because understandably, women are. Again, it's like you want to put your fucking head through a wall because you're like, I cannot take this. 

Dr. Mary Haver: The loss of confidence. I mean, it's, I say this and I don't say it lightly. I have an hour with a new patient who comes in and she pulls out a huge questionnaire. We do mental health screening. You know, before she gets to the door, we do a validated menopause score. We do a sexual desire score, you know, sexual function score, all of that.

Dr. Mary Haver: So I know all that before she hits the door, it takes her 20 to 30 minutes to unpack her menopause trauma. For me to validate her, that she's not crazy. And then we launch into therapeutic options.

Marie Forleo: I believe It.

Marie Forleo: Because we have so much backlog of being dismissed and just told, no. There’s nothing you can do.

Dr. Mary Haver: There's nothing you can do.

Dr. Mary Haver: You’re just getting older. And that's true. You are getting older.

Marie Forleo: Yes. You know, and I thought that there was something, just fascinating that I read. It was the rate at which our ovaries age is twice as fast as for every other organ system in the body. I had never heard that before. And it's like, so this is real. 

Dr. Mary Haver: Endocrine aging versus…

Marie Forleo: Chronological aging.

Dr. Mary Haver: Yeah. And it doesn’t really happen. Men have some, some senescence of there. But it's like a 1% decline each year. It's not the chaotic, you know.

Marie Forleo: The zone of chaos.

Dr. Mary Haver: The drama of perimenopause and then dropping to less than 1%. It's very different.

Marie Forleo: So let me go here with you for a minute because I loved in the book there's a lot of sections about knowing your numbers. And again, I feel like these past few years for me, I'm like, this is another full time job of understanding my biometrics, of understanding from personalized medicine standpoint, all the things I need to do to keep this thing running and tight and right and cute and strong and healthy and all that.

Marie Forleo: What are some of, because again, you're very comprehensive in here. But if a woman wants to start keeping an eye and knowing her numbers, can you give us any top lines of some of the kind of top tests? And again, we know about bone density. There's going to be a whole range of things. 

Dr. Mary Haver: Cholesterol, cholesterol. You need to know your cholesterol because it's going to rise, even if you're in, with no changes in diet and exercise, the loss of estrogen will, will change the way that your liver processes, you know, and you will end up with a lower HDL and a higher LDL, a more, a less favorable lipid profile that is more likely to contribute to future cardiac disease.

Marie Forleo: And how about in, in terms of hormone testing as it is, I know we kind of, we're talking about that for a minute, but I don't know if I ever got really clear of your just your viewpoint on the Dutch, or what we could do.

Dr. Mary Haver: Don't find, I don't use the Dutch test. I don't find it helpful. 

Marie Forleo: Okay. 

Dr. Mary Haver: I don't really do much hormone testing unless I'm not in. If she's had a hysterectomy or an ablation or has a marine IUD and I can't use her periods as a guide, then I'm kind of checking FSH to an estradiol. If a patient comes in and we are struggling to get her therapeutic on her medication, I'm worried she's not absorbing LSN and estradiol.

Dr. Mary Haver: There's some interesting new data coming out looking at risk of hyperlipidemia and, and checking FSH levels. FSH, remember, is that hormone that the brain gets says, hey, give me more. Using FSH to track if she's truly getting enough estrogen to get her cholesterol in check. So, really exciting new data to come with that. So I'm starting to send a few of those whose cholesterol, like their hot flashes, are gone.

Dr. Mary Haver: But I'm, we're struggling to get her cholesterol down. And so I'm experimenting with that with my patients. And she understands that we're just, we're just kind of throwing stuff at the wall right now. 

Marie Forleo: Yeah. 

Dr. Mary Haver: So we're still kind of, another zone of chaos is treatment. Is you know, we don't have therapeutic ranges established. They look like they might be different for different people.

Dr. Mary Haver: Meaning if my level is 50 and I'm feeling great, my hot flashes are in check, my cholesterol is in check. All the things. Everything's kind of running back to the normal aging process. But your level is 50 and you're in the gutter still. Nothing's better. 

Marie Forleo: Yeah. Yeah. 

Dr. Mary Haver:  So we, we don't have, those might vary from person to person. So we don't really know what your therapeutic level is going to be. And remember, I can't say let's get a baseline at 25 because it's an EKG. Each month we have our baseline. We surge with ovulation. It goes back to baseline. So we don't really know what those levels are going to be. So like, if someone has premature menopause, I know I want to get her up to 100.

Dr. Mary Haver: We've kind of established that those are premenopausal levels, but in, no one is suggesting in post menopause that we go to premenopausal levels. It's almost that same kind of like, oh, we don't want to give her just enough to keep the hot flashes at bay. But is that the best thing? Is that really going to keep her as healthy as possible?

Dr. Mary Haver: We don't know yet. That's where the research needs to come in.

Marie Forleo: It's fascinating, and I'm so happy that we're having this conversation because even for me personally, it's helping me set myself at ease. You know, I'm, as a type A person, I like control, I like clarity, I like specificity, and this is part of what's been so utterly frustrating for me. I'm like, well, just, you know, for me, it's like, tell me a target to hit, I can hit it, you know what I mean? I need something to go for me.

Dr. Mary Haver: Gimme a check box.

Marie Forleo: Give me a check box, tell me what I need to do, and then I'll do it. And this is. And just this conversation alone, just understanding, like, okay, so we don't have tests to know the numbers per se. We're only just starting to throw some spaghetti at the wall. And it is so individualized, which makes it critical that you're working with a provider or someone that can be with you on this journey, so that you can keep reporting back, right, and keep testing and looking at cholesterol level.

Marie Forleo: Let's talk about bone density for a moment, because I loved when I saw on your IG, I love working out. So I was a former Nike Elite dance athlete. Fitness has been a huge part of my life, and I've been having so much fun the last six months.

Dr. Mary Haver: You have great biceps. 

Marie Forleo: I’ve got some good guns, listen, I’m Jersey, it's like the gun show. Jersey Shore's like, come on. Anyhow.

Marie Forleo: Strength training. One of the most important things we can do. Let's talk about that.

Dr. Mary Haver: Yeah. So, you know, I have this, talk that I give about what I would tell my 35 year old self, and nutrition over calories, and strong over skinny or like the top two things. I was a cardio queen. I was running marathons with my girlfriends. Everything was about looking a certain way. I knew, skinny was fit, you know?

Dr. Mary Haver: And there's, you know, thinner people do tend to be a bit healthier. But like this relentless focus on staying thin and that, that somehow gave me a health advantage. It's better than obesity, you know, but I was chipping away at my bone and muscle strength, only focusing on cardio. Women didn't lift weights. That was not a thing when I grew up, you know, not not in general. And then the ones who did, I was like, what are you doing in the gym? I don't know, I was on the cardio machines. Right? That is so wrong. You know, we reach our maximum. Naturally. Our natural peaks in both bone and muscle strength are usually in our 20s or 30s.

Dr. Mary Haver: And we begin the aging decline. But for women, or those of us born with ovaries, that starts accelerating that muscle and bone loss through the menopause transition. And part of the reason why we gain weight and we change our body composition is, estrogen declines, we lose muscle by the bucket at that point, and we're losing bone strength.

Dr. Mary Haver: But muscle is what determines our basal metabolic rate. So the rate at which we burn calories, right. So no changes in diet and exercise. You're losing muscle. You're gaining fat. And we're starting to… estrogen is great at driving fat to the hips and thighs. And that pear shaped, the female. We start driving fat like men do. To the abdomen. To the abdominal cavity.

Dr. Mary Haver: And that fat represents increasing inflammation, increasing risk of cardiovascular disease, diabetes, stroke. And so to stop defining health so much as terms of just being a thin person, you want to be a strong person. 

Marie Forleo: 100%. And it feels so good. I've always felt like it's like the best pharmacy that I have access to. You know, my best own natural pharmacy. And it's amazing. I'll say, like, I have gained so much strength in the past six months where I used to again, I would always complain to Josh, my partner, I'll be like, I'm not as strong as I used to use to. He’s like, you always say that. I'm like, no, it's true. But now as I'm like, throwing up weight.

Dr. Mary Haver: Can gain muscle at any age. It's harder. 

Marie Forleo: But it feels fantastic.

Dr. Mary Haver: It feels fantastic. So I started testosterone because I have a body scanner in my office where I can measure muscle mass and visceral fat, and that, that guides my counseling as far as nutrition and exercise for patients. And I have low muscle mass and I still had low muscle mass, and I still had low muscle mass. And so I realize that I'm not eating enough protein, and I am not doing enough lifting.

Dr. Mary Haver: So I fix, you know, started fixing that. And I'm like, you know, as, as it stands today, medicine has only recognized that hyperactive, you know, that testosterone is helpful for menopausal women, for hyperactive sexual desire disorder. But we have a lot of observational studies that suggest it's great for bone strength. It's great for muscle strength. It's great for cognition.

Dr. Mary Haver: It's great. You know, we have testosterone receptors everywhere in the body. And the people who focus on sexual medicine are like, listen, we can't ignore this. We need to do more studies on this. So I started it for muscle mass. And it's, it's helping. I've put on a couple pounds of muscle. So yay me. I did not think I had a desire issue. I, we were fine.

Dr. Mary Haver: We. No one complained at my house. Everybody was okay with sexual desire. Yeah definitely an uptick in the area. 

Marie Forleo: Really? 

Dr. Mary Haver: Did not expect, like I knew we treated people for that. And it's something, you know, everyone's happier at our house and.

Marie Forleo: Josh is going to be like replaying this. Like, mmm.

Dr. Mary Haver: And I would miss it. 

Marie Forleo: Yes. 

Dr. Mary Haver: If it was gone. It wasn't like this overnight thing for me where I just had the sudden loss. So many of my patients are coming in being like, no, no, no. Five years ago it was great. You know, I mean we were, and I love him. You know, we talk about relationship disorders.

Dr. Mary Haver: We talk about orgasmic disorders. We talk about arousal disorders. You know, if you can rule all that out, it's pretty much hypoactive sexual desire and pain. Of course, if you have pain no one wants to do it. We have to fix that. Yeah. So yeah. So I was like, so I, it feels so good to be able to talk to patients about it and be like, I'm not talking chandeliers or I'm not 23 again.

Dr. Mary Haver: But there's definitely more interest in the area. And it's, it's made things better for us.

Marie Forleo: I love that, you know, I also really admire and appreciate you were talking about your menoposse. So tell us about what that means. 

Dr. Mary Haver: Welcome to the menoverse. 

Marie Forleo: Yes. 

Dr. Mary Haver: You are now our honorary member. And the menoposse is the name of our group chat on, a message chat through iMessage. And it's a collection of health care providers, doctors and or spark teachers who have focused their practice on menopause care. And these are the women I met at these, South by Southwest.

Dr. Mary Haver: I leave tomorrow, and we all share research articles back and forth. We support each other on social media. I called Corrine Menn who's a breast cancer survivor. I had a breast cancer survivor. I had a quick question about a patient. How do I direct her, you know, and so, and we're just always there and available for each other and so supportive and bringing each other to conferences and like, sharing the latest information.

Dr. Mary Haver: And it is the greatest group of women. And we have Avram Blooming wrote and Carol Tarvis wrote Estrogen Matters. And so we, his daughter does all his social media. So, you know, I call it a few, And A Few Good Men. And so, you know, we kind of have this, this amazing collection because you feel really alone.

Dr. Mary Haver: When I started doing this, I felt alone and I didn't feel like anybody else. Because you don't know what the algorithm shows you on social media. And I didn't know anyone else was talking about this. And then boop, there's another one and there's another one and there's another one. And so it's been this really wonderful thing because it helps me get through this process because there's so much backlash, there's so much pushback.

Dr. Mary Haver: There's so much of the medical establishment, which really was designed to help the basic white man, you know, and there's multiple books documenting this. You know, every woman knows she's been gaslit at the doctor, she's been dismissed, she's been ignored. And some something, you know, gynecologic pain is another huge thing we need to address. And so, you know, knowing that I've got this, the posse behind my back, and we're all going to stand together and support each other.

Dr. Mary Haver: And we don't all agree 100% on everything, but, you know, knowing that there's this respectful, kind, generous group of people who are all have the same goal as the health of women, different than women's health, right? Women's health sounds like reproduction and birth control. The health of women is like us all aging together as healthy as possible. I call it my nursing home prevention program.

Marie Forleo: I love this, my best friend and I, all the time, we talk about the scenarios, because we're like, look, statistics show it's you and I. Like that there's a high chance that if we fast forward and we're both blessed enough to be here, like, what are we going to do? And we literally talk about our plan. So I am so on board with this.

Marie Forleo: And I was thinking to myself, like how powerful that is and how grateful I am for the work that you're doing and for the menoposse, because we need to take better care of ourselves and take better care of women, because nobody's coming to save us. Right. And so we need to do this because I plan on being around for a long time, and I don't want to be frail.

Marie Forleo: I want to be strong. I want to go for as long as I'm blessed to be here. I want to be as spicy and as saucy and as strong as I possibly can, to keep doing the work that I love to do and to keep living an amazing life.

Dr. Mary Haver: And we are uncovering those strategies that work for most people that will decrease that risk.

Marie Forleo: Yes. You know, I want to read something before we wrap, and I want to ask you if there's any one message you want to leave women with, but this is just something beautiful that you wrote in an essay. So I'm gonna be reading your words to you. 

Marie Forleo: “If a woman in perimenopause or menopause isn't getting top notch care, it's a matter of life and death, really. There are issues that many women are attributing to ‘getting old’ while they scramble to be believed, get help, and thrive during what should be a powerful and exciting time in their lives. You are not a whiny woman. You are not crazy. And no one, especially your health care provider, should make you feel as if you are. You don't have to take it anymore. You have options for treatment and care.” Tearing up reading this.

Marie Forleo: “You're a person who deserves a beautiful, healthy menopause, one that's filled with strong muscles and bones, a clear mind, and a body free from pain and disease.”

Dr. Mary Haver: Yeah, and that's not happening today. Our grandmothers, my grandmother, spent five years in a bed at the end of her life, and she didn't want that, you know, and she didn't know the tools that might have been available to her to prevent that.

Marie Forleo: If there was one message that you'd want to leave our audience with, what would that be?

Dr. Mary Haver: That menopause is inevitable, and it's a natural process, but suffering through it is not.