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The Real Truth About Menopause Treatments | Dr. Mary Claire Haver

Episode 80, duration 1 hr 13 mins
Episode 80

The Real Truth About Menopause Treatments | Dr. Mary Claire Haver

Dr. Mary Claire Haver is board certified in Obstetrics and Gynecology and is a Certified Culinary Medicine Specialist from Tulane University. She is a Louisiana State University Medical Center graduate and completed her Obstetrics and Gynecology residency at the University of Texas Medical Branch (UTMB). She is also a Certified Menopause Specialist through The Menopause Society. Dr. Haver was a clinical professor at UTMB and The University of Texas Health Science Center at Houston. Dr. Haver has served as a Hospitalist, Associate Residency Director, and Assistant Professor in her career. In 2021 she opened Mary Claire Wellness, a clinic dedicated to caring for the menopausal patient. Dr. Haver developed The Galveston Diet, a three-pronged lifestyle plan that encourages fuel refocusing, intermittent fasting, and anti-inflammatory nutrition to manage hormonal symptoms, stabilize weight, and revitalize the body as it ages to provide benefits that will last a lifetime. Dr. Haver is working on her second book, The New Menopause, which will be released in the Spring of 2024.

The Real Truth About Menopause Treatments - Dr. Mary Claire Haver

In this episode we discuss:
– Is hormone therapy safe?
– Who is hormone replacement for?
– The top three tips to support your hormonal transitions.
– Which supplements you should use during perimenopause & menopause.

00:00:00 – The Inevitability of Menopause

00:05:01 – The W.H.I. and the Misinterpretation of Results

00:09:31 – The Link Between Progestogen and Breast Cancer Risk

00:14:24 – The Symptoms of Estrogen Depletion

00:18:44 – Hormone Delivery Options

00:22:55 – Hormonal Treatment After Menopause

00:27:35 – Progesterone and Estrogen in Hormone Therapy

00:31:58 – The Difference between Bioidentical and Synthetic Hormones

00:36:13 – Why isn’t This Standard of Care?

00:40:50 – The Complications of Menopause Treatment

00:45:28 – Hormones and Hair Loss

00:49:17 – What About Spironolactone?

00:54:52 – The Importance of Fiber and Vitamin D

00:59:15 – The Effects of Menopause on Body Composition

01:03:38 – Strength Over Skinny

01:08:27 – The Muscular Skeletal Unit in Menopause

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Dr. Gabrielle Lyon[0:00:01]

Welcome to the Dr. Gabrielle Lyon Show where I believe a healthy world is based on transparent conversations.

In today’s episode, I have a very lively conversation with Dr. Mary Claire Haver. She is a certified menopause specialist through the Menopause Society. She is board-certified in obstetrics and gynecology. She is a wealth of knowledge on everything perimenopause, menopause, and hormones. She was a clinical professor at UTMB and the University of Texas Health Science Center at Houston, which is a phenomenal institution. In fact, that’s where some of the early protein research came out of. In 2021, she opened Mary Claire Wellness, which is a clinic dedicated to caring for the menopausal patient.Because of that, she has gained so much knowledge. She has a very large social platform, and her mission is to change the conversation around menopause. She has a new book that will be released in the spring of 2024 called,The New Menopause. I have to tell you, I loved talking to Dr. Mary Claire.

In this episode, we discuss is it safe to use hormone therapy or not? Who should use it and who shouldn’t? What supplements should be used during hormonal transition phases, whether it is perimenopause or menopause, and finally, the top three tips to support your hormonal transitions. As always, if you liked the show, pleasetake a moment to like, subscribe, leave a rating. I do this as a labor of love. The goal is to bring you the experts whom I respect and I think are really adding to the conversation and changing the voice and direction of medicine.

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All right, Mary Claire Haver. I’m really excited to chat with you all things menopause. This is probably one of the most requested and common topics that we get over here, and you certainly are the expert. How long have you been an OB/GYN?

Dr. Mary Claire Haver  [0:06:40]

I started my residency in 1998, and I’ve been just focused on menopause care in practice since 2021. I opened my menopause clinic, but I’ve really been just digging deep since about eight years.

Dr. Gabrielle Lyon  [0:07:04]

It’s interesting that you say that you’ve really been digging deep because what that says to me is that in traditional OB/GYN residency and teaching that potentially hormonal replacement therapy and really managing hormones is not the standard of care in a way that potentially would focus on optimization. Would you say that’s right?

Dr. Mary Claire Haver  [0:07:26]

That’s 100% correct. In my role in my traditional OB/GYN career, I was also a program director. I was in charge of the education of the residents for about 10 years off and on while I was delivering babies, teaching medical students, and doing all the other things an academic professor does. Looking back on that, when we do obstetrics and gynecology, we have probably 55% to 60%, depending on whether the program is devoted to obstetrics, which is important, and everything else gets shoved into the gynecology box. That’s going to include pediatric gynecology, oncology, cervical cancer, uterine cancer, vulvar cancer, reproductive endocrinology, getting people pregnant, and some of the endocrine disorders associated with it. Menopause is just this tiny little sliver we did not have, and there aren’t many throughout the country. Menopause-focused clinics just got lumped in with gynecology.

In medical school, I think I had one hour of lecture if you had the same focus just on menopause. It was just the briefest overview. then in residency, it really was, we might have had six hours and four years of training in lectures devoted, particularly to menopause. My last year of training was when the Women’s Health Initiative was released, which basically stopped 90% of prescriptions for hormone replacement therapy for all women and just left this whole generation of women without the option of hormone replacement therapy.

Dr. Gabrielle Lyon  [0:09:02]

Let’s talk about that. The Women’s Health Initiative came out 23 years ago, and that is an example of what really can change the narrative when something gets enough press and people don’t dive into the literature and question what is being tested and what is then being extrapolated about that. Can you mention a little bit about, for our listeners who don’t know anything about the Women’s Health Initiative, what it is, what the outcomes should have been, and where it now has put us?

Dr. Mary Claire Haver  [0:09:36]

The Women’s Health Initiative was really exciting. We knew from anecdotal evidence and from observational studies that women who were on hormone replacement therapy actually had a lower incidence of cardiovascular disease and death from cardiovascular disease. We knew that their bones were stronger, and we knew that their general urinary systems would be more protected against atrophy and other diseases associated with that. But the focus of the study was really to use a randomized, controlled, placebo-controlled study of thousands of women where they divided the women into hormone replacement therapy in the form of estrogen and progesterone versus placebo if they had a uterus. If they didn’t have a uterus, usually because of a hysterectomy, they were given estrogen only with no progesterone.

Now we give progesterone; it’s mandatory when you’re giving estrogen when you have a uterus because it needs to protect the lining of the endometrium, and it’s optional for women who don’t have it. so that is clear. So the study, they recruit these patients; it’s a multimillion-dollar study; it’s the first true study focused on women in menopause that had ever been done. Finally, we’re getting money devoted to us. So when they chose the ages of patients, the outcome of the study was not breast cancer occurrence. It was heart disease. That was what they were looking for. Breast cancer plus or minus was just a secondary finding. The average age of the patient in the study was 63 years old, so what’s not your typical menopausal patient? So they were taking women who, at average age 63, had already been on the path to heart disease or breast cancer, and now we’re going to give them hormone replacement therapy.

They started recruiting patients, I think, in 1995, and the studies began in the late ’90s, when they actually started giving them the hormones versus placebo. What they found was that, in this particular population, the women who were given estrogen plus progesterone had a relative risk increase of breast cancer of about 25%. The authors got together—some of the authors, not even all of them—and decided to halt the study. They held a press conference at the Watergate Hotel in the ballroom, invited every national news outlet (this is before social media, so this is in 2002), and said estrogen causes breast cancer. All the authors didn’t even have a chance to review the data. We were getting phone calls like, Oh my God, what’s going on? Because ABC News, NBC News, this was the biggest health report in 2002. It was the number one news story about health. The headlines screamed, “Estrogen causes breast cancer.”

Well, the estrogen-only arm kept going because they didn’t have an increased risk of breast cancer. They stopped it about two and a half years later. But as the narrative continued, people were terrified. Now since that time, there’s been multiple studies that have come out that have looked at the data, reanalyzed it, reworked it, and we now know, but it hasn’t been publicized, which is just befuddling me that the women who were on estrogen only actually had a relative decreased risk of breast cancer, and it seems like it was the progestogen, Provera, that was the link to slightly increasing the risk.

You and I understand the statistics, and I still have to really think hard about them. That doesn’t mean absolute risk. The absolute risk was still very small. But everyone was so terrified, including the physicians, because we weren’t even given the study to review on our own until it came out months later. But everyone was off, everyone was terrified, and the narrative remains. Estrogen causes breast cancer.

I get questions on social media every single day. My doctor says no; my doctor says it’s going to give me a heart attack. My doctor says it’s going to give me breast cancer. We know that the American Heart Association came out in 2020 saying that for women who start estrogen replacement with or without progesterone, it’s a protective effect.

There’s something called the healthy cell hypothesis, where estrogen is better at prevention than cure. The longer your body is without estrogen, either exogenous, meaning hormone replacement therapy, or natural, the higher your risk of not only cardiovascular disease, death from cardiovascular disease, stroke, diabetes, hypertension, muscle mass loss, and sarcopenia, which we’re going to talk about. I mean, it’s really astounding. when You have a very protective benefit of estrogen therapy when you start young, when you start early in your menopausal journey, including perimenopause.

Dr. Gabrielle Lyon  [0:15:11]

Can you touch on the age? Basically, we think of menopause as this magical time when, all of a sudden, you haven’t had a period, but perimenopausal symptoms and probably the ebbs and flows happen significantly earlier than that last period.

Dr. Mary Claire Haver  [0:15:29]

My biggest frustration is how we define menopause. It’s completely arbitrary in medicine that you must go a year without a period before you’re menopausal. Your menopause and ovarian depletion begin in your 30s. It may not be clinically significant until your 40s. But your ovaries are not the same.

We’re born with all of our eggs; that’s just the way we were made. that quality and quantity decrease from birth. Actually, it starts decreasing in utero. We have our maximum ovarian levels of gonads, which turn out to be five months in utero. I can’t fix that. At birth, the function, the quality, and the quantity begin to decline.

Our body doesn’t notice it until we reach a certain threshold. By the time we are 30, we’re down to about 10% of our egg supply. By the time we’re 40, on average, we’re down to about 3%. The quality of those eggs is declining rapidly, and with that, the quality of our ovarian estrogen production is declining.

Because our bodies react so differently to estrogen decline, I might have hot flashes, Gabby; you may have night sweats; you may have sleep disruption; I may have musculoskeletal issues; you may have general urinary syndrome. I mean, in my book, we’ve identified about 70 symptoms associated with estrogen depletion. The earlier we counteract this, not only symptomatically, the bothersome symptoms are going to get better, but your overall health status is going to get better as well.

Dr. Gabrielle Lyon  [0:17:06]

I love that. Again, that is not routinely talked about. Typically, the standard is that what we hear about is that you should not start estrogen, specifically estrogen therapy, until someone is in menopause. For some reason, it is dangerous for a menstruating or intermittently menstruating woman to start estrogen. What I’m hearing from you is that, in fact, that’s not what the literature says, that is not helpful, and in fact, estrogen is protective. I guess for the clinicians listening, we have a whole range of individuals, we have the public, we have clinicians, and we have people that are just very astute in science. Would you say that there is a starting dose? I mean, obviously we look at labs, but have you found, because you’ve seen thousands of patients, that there’s a potential starting dose of estradiol for women that they seem to do well with, and also what delivery system?

Dr. Mary Claire Haver  [0:18:06]

We don’t know. There aren’t any studies right now that are looking specifically at perimenopause and symptomatic control. We just really have anecdotal and observational evidence. And so I can tell you what I do. If a woman is still intermittently cycling, or even if she’s cycling, she still has a monthly period, but she is clearly symptomatic, and I’ve done the blood work to rule out other conditions, I’ve looked at her thyroid, and I’ve looked at her nutritional status.

I’ve looked at the labs I need to do to make sure that this is not masquerading as perimenopause. It’s a diagnosis of exclusion at that point. A one-time blood test is not great at diagnosing perimenopause. I just listen to the patient and believe her. Okay, I believe you. For those patients, if she’s having heavy periods or acne, you don’t think that a higher dose is going to be well with controlling the heavy bleeding, controlling the acne, and controlling some of the side effects.

I will go with a higher dose, like in the birth control pill range of hormone therapy, because really the biggest difference between the birth control levels and the menopause hormone therapy levels is dose. The formulation is very different; we can talk about that later, but when we look at the continuum, birth control pills were developed to suppress ovulation so that she doesn’t get pregnant. Menopause hormone therapy doses were developed to control hot flashes, basically.

Where we need the levels for cardiovascular protection, bone protection, and muscle protection, those studies are ongoing right now. We don’t know. There’s some pretty good osteoporosis where it’s really low, but is that enough to protect your brain? Those studies are really starting to explode right now, and I’m very excited.

If someone is cycling yet needs symptomatic control due to other conditions, I would go with the higher dose. If she’s cycling and her periods are fine and she feels fine other than disruptive hot flashes and night sweats, I may shore her up with a very low dose of estradiol and 100 milligrams of oral micronized progesterone. That’s my lowest dose that I’ll go with for that.

I tend to stick with the FDA versions because of cost, and I know they work, and I know they’ve been studied. I do go outside, and I will compound if they need it. If I can’t find or try Duavee, they’re not tolerating progesterone; the rare patient really struggles with progesterone. Duavee is an FDA-approved non-progestin option that they might tolerate, but it’s very expensive.

Or I’ll talk to my compounder and get him to do that, and we’ll try some other options there. I do compound testosterone for my patients on a regular basis because I can’t find an FDA-approved option that I can get a pharmacist to fill.

Dr. Gabrielle Lyon  [0:21:04]

I love what you’re saying: basically, the dose in a birth control pill is really on the higher end, and the doses to control menopausal symptoms are on the lower end; it’s probably somewhere in between. It’s a sliding scale, which is fascinating. In my clinical practice, we treat menopause, and we do a lot of patches and things. I really like the patch because it can be covered under insurance, and we do know that it is standardized. Do you have a delivery system and also oral micronized progesterone? Do you like the patch versus potentially the cream?

Dr. Mary Claire Haver  [0:21:48]

I do. I love the patch because it’s continuous dosing, and they get this beautiful steady state. I feel like they’re covered. I have five strengths that I can go to for her. If she’s super symptomatic and very early in her menopause, I’m going to go with a higher dose patch. That’s where I’m going to start, maybe 0.75 or 0.1.

The problem is that it stops at 0.1, and I do have patients who need more. Either way, we’re doing two patches, and I’ve got to write a letter to their insurance company, which is no problem; that’s my job. Or we might end with a very small oral dose.

The reason why I tend to go towards the patch is that when we ingest anything orally, we have a first-pass effect on the liver. When that estrogen hits the liver, we do see a bump in clotting factors. According to the latest research, eight out of every 10,000 women will have a blood clot who would not have otherwise, and there are some pretty good studies that show that transdermal lowers overall inflammation versus oral.

Now there are some benefits to oral care, especially in some small lipid numbers, but when I look at the overall picture, I really go towards the patch for the vast majority of my patients. Is she allergic to the adhesive? Some patients have an allergic reaction to the adhesive, so I’m looking at compounding a cream or maybe trying an oral for her.

Dr. Gabrielle Lyon  [0:23:13]

One of the questions that we get a lot is: How fast should someone have a resolution of symptoms? If it is, let’s say, hot flashes, mood, or brain fog, how quickly will we see a turnaround of symptoms?

Dr. Mary Claire Haver  [0:23:28]

Hot flashes are the best I can go with because it’s really clear. Hot flashes, yes or no? Brain fog is a little tougher to quantify. But hot flashes, I will say if we’re not better in four weeks, because I know, of course, we always go to our own experience. It was a solid three weeks for me. I remember at week two going, is this going to work? Do I need a higher dose? All of a sudden, at week three, I was sleeping through the night.

So I tell my patients, let’s give it four weeks. We have to upregulate these receptors. It’s a process. It took you a while to get here. It’s going to take us a while to fix it. I know that when I went from, I started on CombiPatch, which I loved because it was so convenient and I didn’t have to remember to take anything at night, a secondary pill.

But in the study out of France, they looked at 80,000 women and looked at the different progestins and their association with neoplasia, and the oral micronized progesterone had the least association. It was small, but it was there. And with so much cancer in my family, I just thought, you know what? I’m going to err on the side of being cautious here, and I like having that bump of progesterone at night, so I switched to the oral micronized progesterone.

When I did that, I went from a CombiPatch 0.5 to a 0.5 estradiol patch. I started flashing within a month. I always warn my patients that when we’re switching from one modality to another, their bodies may absorb it differently. Just be aware, and let me know what your symptoms are. We may need to go up on your dose again or down.

Dr. Gabrielle Lyon  [0:25:03]

From a safety standpoint, the real issue with oral estrogens is just that slight bump in clotting factor. Now I have a question for you, and I think a lot of physicians and probably patients are also wondering. They typically say do not start any kind of hormonal treatment therapy if you are 10 years postmenopause. The way that I read into that is estrogen, progesterone– physicians seem to prescribe testosteronewhether they’re 10 years old or not. But could you speak to where the evidence for that is, and if, in fact, you feel that is a reasonable recommendation, or should we reconsider that?

Dr. Mary Claire Haver  [0:25:47]

I definitely think we should reconsider it on a case-by-case basis. I don’t think it should be a blanket recommendation for everyone. We know that if you start hormone replacement therapy within 10 years of your menopause, you will have cardiovascular protection and some neural protection, at least within five years of neurodegenerative disease. We lose some of that benefit as we age.

The longer your body goes without estrogen, the higher these risks are going to go, and estrogen may not be helpful. In advanced cases of these diseases, certain forms of estrogen might be harmful. Again, so when I have a patient who’s been menopausal for greater than 10 years and never had the benefit of HRT, it was never offered to her; she was scared for very legitimate reasons, but she is curious and wants to know.

We look at her cardiovascular history, her family history, I get a full lipid panel, I get ApoB, and I try to dig as deep as I can. I sometimes recommend that if their levels are up, we get a calcium score—a cardiac calcium score—to see. If she’s low-risk, I’m like, Hey, you’re probably going to benefit from this. I can’t promise you anything; the studies really weren’t done past this level.

But I do know it’s going to protect your bones; I do know it’s going to protect your genital and urinary systems; it’s probably going to protect your muscles and several other organ systems. If you want to consider this, I think it’s reasonable. But again, this is a case-by-case basis.

Same with neurodegenerative disease. I have patients who have a very significant family history of dementia, both young and their parents, and weren’t given the option and are now 10, 15, or 20 years old. We have decided for them that it might be too risky because the benefit of neural protection seems to be there, and that is their biggest fear.

What can I do? So we’re trying to maximize nutrition, so I send them to Lisa Mosconi to read her books on The XX Brain and the new book coming out, The Menopause Brain, which I’m so excited about. So really, it is a case-by-case basis. But I have patients absolutely convinced that I have started on estrogen-containing hormone therapy for the past 10 years postmenopause, with all those boxes checked and knowing that we’re going to review this every year.

Dr. Gabrielle Lyon  [0:28:12]

Where does the data stand right now? Because of the Women’s Health Initiative, it seemed as if estrogen alone was okay. Where are we at now? Do we never give estrogen without progesterone? Is it age-dependent? Is it uterine-dependent? Where are we at with the combination therapy?

Dr. Mary Claire Haver  [0:28:36]

Combo therapy is mandatory with the uterus. But if you have a Mirena-containing IUD, so your uterus is protected there, or you’ve had a hysterectomy, which is a huge percent of our patient population, is progesterone optional? At first, I said, “No, you don’t need it.” But as the literature is expanding and as I’m talking to patients and myself, it’s very helpful for sleep. It’s very helpful for anxiety, especially racing thoughts at night. There are some benefits to continuous progesterone. When I’m starting my patients, I’m telling them if they’re really sleep deprived, I’m like, let’s try this now. We can always pull back or take it off, but there’s probably some benefit here that we haven’t recognized. Where all this evolved was that estrogen was the hormone. It’s the only thing we cared about, and we were just trying to stop hot flashes in menopause. We really weren’t looking at everything else. Oh, and that Feminine Forever book, oh my God, which was kind of a get your sexy back.

Dr. Gabrielle Lyon  [0:29:41]

Hey, what is that, Feminine Forever? I have never heard of that book.Well, we’re definitely reading your book, but I’ve never heard of Feminine Forever.

Dr. Mary Claire Haver  [0:29:53]

The whole first wave of estrogen was this book by New York physician OB/GYN, and it was called Feminine Forever. He was giving estrogen alone to everyone, and man, they were feeling great. It was kind of a get-your-wife-back, like the husbands were reading it, and look, they weren’t having vaginal atrophy as much. Women were going for it. Husbands were getting their wives on it. All these women were just rushing to estrogen, which had benefits. They felt great. They were sleeping. I mean, yeah, okay. But the whole premise was really ick. Instead of from a health benefit, it was this get your wife back in bed with you benefit.

But what they found was that a certain percentage of the population was developing endometrial hyperplasia and cancer from unopposed estrogen. Well, that’s very fixable by giving a woman uterine progesterone. As long as you do that with the uterus, you’re not going to increase your risk of endometrial hyperplasia or cancer.

So then it was like, well, only if you have a uterus do you need this progesterone. Well, it has benefits and can be taken very safely. There are multiple progestogens on the market. Let’s touch on that. We have progesterone, which is what our body makes naturally. And then we have progesterones, which are chemically synthesized in the lab, which are converted to progesterones. They bind to the receptor, and they actually work really well.

But especially Provera, which is medroxyprogesterone acetate, that’s the one that actually has a significantly increased risk. Yes, the absolute risk is low, but there is an increased risk with Provera versus an oral micronized progesterone or some of the transdermal progesterones that are safer.

So in the WHI, they only studied two hormones, Premarin, which is conjugated equine estrogen, so they do some pretty sketchy stuff on pregnant mares and pregnant horses and extract their urine, and then there’s about 10 estrogen-esque components to it. Premarin was used forever. That was the standard. At the time, it was not unreasonable for the WHI to use Premarin. That was the number-one prescribed estrogen-containing product on the market.

Then the progestin that they used was medroxyprogesterone acetate; it was cheap and easy. At the time, there wasn’t a progesterone that was easily absorbed through the gut; it had very low bioavailability. We fixed that problem with micronized progesterone. They micronized it, it’s absorbed, and it works great. Okay, but that wasn’t available when the WHI came out.

It’s all very complicated and layered, but the FDA is still lumping all estrogens into one group and all progestogens into one group when really these risks are stratified based on which ones we take. In my practice and that of most people I know who are practicing good menopausal medicine, we’re pretty much sticking to estradiol and progesterone. We’re trying to keep it as close to what the body made as possible. It turns out that those have the lowest association with risk compared to the more synthetic options.

Dr. Gabrielle Lyon  [0:33:10]

Oh, that’s interesting. What is the difference between bioidentical and synthetic?

Dr. Mary Claire Haver  [0:33:16]

You have to think of it the way the body produces it. There’s a lot of misinformation and misunderstanding around the term “body identical” or “bio identical.” In the UK, they have body identical and bio identical. I choose not to go that route here in the US. We have things that are made in the lab that bind to the same receptors as things that are processed in a lab but come from a more natural product. At the end of the day, you have to go to the lab to make all this stuff. I don’t care what that woman says; you can’t just rub yams on yourself and expect to have any clinical therapeutic benefit. Bless your heart if you think that works for you.

Dr. Gabrielle Lyon  [0:33:55]

You might take an orange but other than that–

Dr. Mary Claire Haver  [0:34:01]

It takes a lot of processing in the lab. Yams are used to make the micronized progesterone, but it is an intense chemical procedure to get it to something that your body can absorb on a regular basis. Synthetic means they just start with background chemicals, and they end up with something that will bind to an estrogen receptor. That is ethanol estradiol, typically, which works great and is in most birth control pills. We have millions of women in your database on birth control pills and their safety and efficacy. They’re getting a bad rap, I think, for bad reasons. But I have used them for years. I use them for my patients to keep them from getting pregnant, to protect them from heavy bleeding, acne, and different medical reasons, and I stand by them to this day. The ethanol estradiol is not my favorite menopause hormone therapy dose because we don’t have any data on it. I stick with estradiol.

Dr. Gabrielle Lyon  [0:34:59]

It’s just really helpful to hear you talk about this and break a lot of this down. I know that everybody listening is going to want to have you back on. In terms of the changes that individuals expect to see in their labs, you mentioned that you have a pretty robust cardiovascular profile; you look at lipids; you look at ApoB. What are some of the changes and why? When estrogen declines, do we see these changes in lipid profiles?

Dr. Mary Claire Haver  [0:35:32]

We see a pretty significant increase, probably at 75% to 80% of my patients will have an unexplained increase in their LDLs and a decrease in their HDL, so their protective cholesterol goes down and their bad cholesterol, including the micronized particles, go up. It’s very frustrating for my patients. They are furious. I’ve done nothing. I’ve done nothing different. I’ve not changed my diet or exercise. I’ve been eating the same. There’s a huge subset of doctors out there who want to immediately put them on statins. I understand the reasoning for that. But when the American Heart Association said it loud and clear, statins do not, in a woman, yes, in a man, they do help decrease the risk of cardiovascular disease and deaths from cardiovascular disease, but they do not in a woman. The most effective therapy for decreasing the risk of cardiovascular disease and death is early and appropriate form of hormone replacement therapy.

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Dr. Gabrielle Lyon  [0:36:31]

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It’s not the standard of care right now. You will go and you will see these changes in lipids, and you would think that the initial response is different because the one thing that is different is the decrease in estrogen, but again, that is not considered the standard of care, which is a mistake.

Dr. Mary Claire Haver  [0:39:49]

It’s a mistake. I think the AHA clearly says it, but it takes so long for the standard of care to change, and I’m not willing to wait. I’m not willing to let my patients suffer when I can intervene the best way I know how.

Dr. Gabrielle Lyon  [0:40:05]

I love that about you, Mary Claire. I just have so much respect for you. Let me ask you this in terms of dosing. I’d love for you to speak about a way of thinking about it collectively. When we’re dosing estrogen, are we also thinking about, are we seeing an improvement in the lipid profile? Are we seeing a particular change in FSH? Could you speak to that? Are we looking for that at a certain number? What is it like when we’re guiding therapy, assuming that a woman is beginning to feel better? I can think of one patient who feels better on a very low dose of estrogen, and I am continuously encouraging her to potentially increase her dose because I’d like to see a change in her lipid profile, but we’re not there yet. I’m curious as to where you look for particular markers, specifically not insulin but FSH, in these lipid profiles.

Dr. Mary Claire Haver  [0:41:03]

I’m following FSH long-term with my patients. Symptomatically, I’m following symptoms; does she feel better, etc.? Like you, I use a toolkit when I’m treating my patients. Hormone therapy is one small tool in the toolkit. We are working hard on nutrition, exercise, stress reduction, and sleep optimization; all of this must work together. If I’m just relying on hormone therapy, I’m doing a disservice to my patients. When I see a resolution and supplementation, so when a patient comes in with elevated cholesterol, I’m talking about increasing fiber in her diet, considering something like berberine. We take a look at her nutritional profile, we look at her exercise, we look at her sleep patterns, and then we’re following the lipids throughout overall. My clinic started in 2021, so we’re at year two right now. I haven’t increased my estrogen dose based on lipids yet. I’ve seen a dramatic improvement, but it takes a toolkit. It’s not just HRT.

Dr. Gabrielle Lyon  [0:42:19]

I haven’t either, but I always think is there a way that we could better target just these cardio protective mechanisms with very specific dosing or levels? And again, it’s interesting, you don’t follow FSH. I think that’s very telling for a lot of people that it truly is about how the individual feels, and then potentially secondary outcomes or secondary markers that we’re looking at. Do you look at a progesterone estrogen ratio? There’s a lot of discussion about that. Do you look at these ratios?

Dr. Mary Claire Haver  [0:42:52]

In perimenopause? No.

Dr. Gabrielle Lyon  [0:42:56]

I don’t either. Finally, somebody said no. I talked to a lot of experts, and they’ll always tell me that they look at this.

Dr. Mary Claire Haver  [0:43:02]

No. What day of the cycleare you? I’m like, no. My God, no.A thousand times no.

Dr. Gabrielle Lyon  [0:43:09]

I feel very supported in this moment because people will say, well, don’t you look at these ratios? I’m thinking, first of all, the half-lifeof progesterone is so low.

Dr. Mary Claire Haver  [0:43:18]

No. What day of the cycle are you? If they understood anything about ovarian endocrinology. The term estrogen dominance has become a darling of profiteers who are stepping so far out of the scope of their practice and really are–

Dr. Gabrielle Lyon  [0:43:35]

I’m laughing because it’s so true. It’s so true.

Dr. Mary Claire Haver  [0:43:38]

–leveraging pseudoscienceto sell whatever supplement they’re trying to sell.Now this is a doctor who sell supplements right here, so full disclosure. It just befuddles me, and God bless these women. We have this entire vulnerable subset of our population, which is every single woman over the age of 35, who doesn’t know where to turn, who is desperate, who is miserable, who is suffering, who is on this path to an earlier death with lower quality of life, who is just trying to do her best, who is falling prey to this, and I am sick of it. I’m all for, we’re all learning, Gabby. I learn through you, you learn from me. I mean, this is the Wild West, okay? But there are practitioners out there who are talking the most nonsense nonsensical, and at this point, I am not checking estrogen progesterone ratios. I am just treating the patient. I know what’s happening.

Dr. Gabrielle Lyon  [0:44:36]

I think what this really comes down to is that there’s all this complicated protocol. If people are making it really complicated, and I think that I’m speaking to a provider and the patient, if you are going to a provider that is making things incredibly complicated, changing your dosing every third day, all of these weird protocols, then in my professional opinion, this is not the right provider. Things do not have to be complicated to be effective. You don’t need these very fancy ratios. You do have to understand what your baseline levels are and how they’re improving. How is this person feeling? I absolutely agree with Mary Claire; there’s a lot of predatory-esque behavior by potentially very well-meaning individuals who are creating a narrative that is ultimately confusing and very poor science. That is not intellectual integrity. You guys have to understand that.

Dr. Mary Claire Haver  [0:45:34]

I think it’s ultimately harmful. I think it’s very expensive, and menopause care doesn’t have to be complicated or expensive.

Dr. Gabrielle Lyon  [0:45:45]

Let’s talk about hair loss and perimenopause or menopause.

Dr. Mary Claire Haver  [0:45:49]

I’ve been touching my hair constantly.

Dr. Gabrielle Lyon  [0:45:51]

Can we talk about that, please? What is a woman to do? What are some of these treatments? Are we talking about minoxidil? Are we talking about topical? Are we talking about spironolactone? What is a woman to do when all of a sudden, she runs her hair through her formerly gorgeous locks, and all of a sudden, the drain is clogged, and it looks like there is Mr. It?

Dr. Mary Claire Haver  [0:46:15]

There is an aging component to hair loss because we’re getting older and our hair follicle’s structure is changing, but there’s definitely a hormonal component as well. There’s a nutritional component that could be there; vitamin deficiencies can cause it. Hyperthyroidism and hypothyroidism can cause it. Hair loss is complicated. So first, your physician should dive in to make sure we’re not missing something else. You could have multiple things that are causing this for you. It may require a visit to a dermatologist. There’s also infection and autoimmune disease, and the list goes on and on. Make sure that you’re not rushing. I think it’s okay for most people to try minoxidil over the counter. It’s not harmful; it’s topical. If that’s not helping, you need to get in to see a specialist, someone like you and I who dives into this or a dermatologist to help rule out some of the other conditions.

Dr. Gabrielle Lyon  [0:47:23]

And a topical, you’re talking about?

Dr. Mary Claire Haver  [0:47:29]

Go see someone who has some expertise in this area. But don’t let them blow you off and say, well, there’s nothing we can do because there’s absolutely stuff that you can do. What I wouldn’t do is rush something like PRP or any of these really expensive therapies and treatments until we know what’s causing it, because this may not be that helpful to you, and it may be a simple vitamin deficiency that needs to be corrected. Make sure that your vitamin D levels are adequate and that you don’t have an iron deficiency. These are the top two nutritional things that I do a deep dive into there. Do we all need the expensive $90 a month vitamin? I don’t think so.

Dr. Gabrielle Lyon  [0:48:17]

I want to piggyback off of what she mentioned. Iron, I totally agree; ferritin, I think I’d like to see it above 75, certainly for hair growth. We check a ceruloplasma, we check a form of copper in the blood, and that definitely can relate to hair loss. But I just wanted to mention that.

Dr. Mary Claire Haver  [0:48:52]

Hormonally, what can we do? There are hormones that can contribute to hair loss when you receive excessive amounts of them. We have to talk about steroid hormone-binding globulin. SHBG is a protein created in the liver, and it is the car that our sex hormones ride in when they float through the bloodstream. When they’re in the car, they’re inactive. They don’t work very well. But they’re just bound, so they can float around. Your overall levels may not change, but the activity of those levels may change. Testosterone is bad for female hair because the higher your testosterone level three, the more likely you are to have acne and male-pattern baldness, so this is the hair loss here on the sides typically. When your part is getting wider in the middle, that is more of a female pattern type of hair loss, and those are treated very differently. If you are someone who is noticing this male pattern here, which happened to me a little bit–

Dr. Gabrielle Lyon  [0:50:09]

For those of you who are not watching and listening, she’s addressing her temples. Basically, male-pattern baldness would be the temple recession. By the way, I will say some individuals are sensitive to testosterone, whereas other women—I have women on testosterone—are not sensitive at all. Maybe they have low DHT receptors, but you guys will know nearly immediately if you are one of those individuals. She was also mentioning the top, the widening part—that’s female pattern baldness.

Dr. Mary Claire Haver  [0:50:43]

Right, in general, and you can have both. When I have a patient who comes to me or who’s on testosterone and she’s seeing some loss here, we’re going to try to decrease that dose. When we go through menopause, our estrogen levels decline. Estrogen stimulates the production of that binding hormone, so we see more activity from our androgens. Just going through menopause can contribute to male-pattern baldness because your testosterone level hasn’t changed that much, and you may have even declined the overall level, but the activity of that level has increased. If you’re one of those women who is sensitive to DHT or has high DHT receptors, then you’re going to see that. Acne is another thing; you’re growing hair where you don’t want it, and you’re losing hair where you–

Dr. Gabrielle Lyon  [0:51:32]

She means the chin—the stray eyebrow hair on your chin. Let me ask you this: do you ever recommend spironolactone? I’ve looked in the literature, and I feel extremely torn about it. I’m going to tell you why so you can really help redirect my thinking. Spironolactone has been used at 100 mg to 200 mg for acne and hair loss. In the literature, it seems mixed. Some of it will say it is primarily addressed in the receptors, and it doesn’t have a significant systemic response because the last thing that I want to do is tank someone’s testosterone. I would love for you to educate me. Is that okay? Will it reduce a woman’s blood level of testosterone, where potentially she might have an impact on her sex drive, etc., versus just her hair or skin?

Dr. Mary Claire Haver  [0:52:31]

again, the jury is still out. We know it helps with acne and we know it helps with hair loss, but at what cost?you might be sacrificing your desire and drive because we are lowering the ability of testosterone to bind to the receptor. we’re not sure. it doesn’t seem like it’s lowering your blood levels of testosterone, it’s lowering its ability to function. women on long term spironolactone–so Kelly Casperson with You Are Not Broken is really my  go to for this kind of stuff. we’re seeing clitoral atrophy, decreased sensation in the area on women on long term spironolactone. for those patients who are doing well on it otherwise, they’re using topical testosterone  in the clitoral area,in the vulva to try to help build that tissue back up. But again, you’re robbing Peter to pay Paul in some of these conditions. Now, I’m moving more towards an oral minoxidil for my patients.

Dr. Gabrielle Lyon  [0:53:36]

What dosedo you like to utilize?

Dr. Mary Claire Haver  [0:53:39]

The study have gone up to 5,I’m a little scared. I start with 1.

Dr. Gabrielle Lyon  [0:53:43]

I can share.

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we start low, but we typically land on around 3mg for women. We have found that around 3mg, and it takes a couple of months.

Dr. Mary Claire Haver  [0:55:14]

I’m starting with 1. It’s something new that I’m trying because so many of my patients are ending up on testosterone due to not only the sexual wellness benefits but also the sleep, the mental clarity, and the brain fog. It seems to be helpful across the board, and I am just going right off the recommendations, and I’m using it for my patients who have low muscle mass.

I’m going for it. I have the ability in my clinic to measure muscle mass. I can’t afford the DEXA yet; getting there. But I have the body scan, and I have the medical grade, so I feel like it’s a pretty good substitute for a DEXA. When I’m seeing their muscle mass range is less than the 98th percentile, I’m off-label recommending testosterone for that as well.

Full disclosure: I wasn’t on it. I’ve been skinny my whole life. I don’t have a lot of muscle mass, and I’m fighting and fighting. I was like, you know what, I’m going to try it.

The added benefit? I did not expect my drive to increase. I didn’t think I had a problem. I thought we were okay. We’re just a normal married-for-30-years couple. It seems like there’s a little more interest in that area at our house, and everyone’s happy. It was like a bonus. I would not have classified myself as having a hypoactive sexual desire disorder. No one is swinging from the chandeliers at my house, but it’s better. That has been something I didn’t realize, and so I tell my patients this, and everyone’s happy.

Dr. Gabrielle Lyon  [0:57:06]

I absolutely love that. I think eventually, for muscle mass, they are going to make something called D3-creatine available. It’s deuterated creatine; you’ll take a pill, you’ll pee it out, you’ll be able to measure it, and you’ll be able to actually see exactly how much muscle mass an individual has. It’s been validated. It’s just not available to practitioners yet, and I’m really hoping that it will be in the next handful of years, because that would be extraordinary. What about supplementation? Do you think that there’s evidence for certain supplements? I think for a very long time, people would talk about black cohosh; they would talk about Schisandra berry. Is there evidence to support the utilization?

Dr. Mary Claire Haver  [0:57:55]

when I have my toolkit for my patients, and we’re looking across the spectrum, we’ve got to stop defining menopause by hot flashes and night sweats. I’m looking at every organ system for her. So when I’m talking about supplementationand what estrogen deprivation is doing to your body, number one supplement is going to be fiber. women are on the struggle bus trying to get adequate amounts of fiber in their diet per day. the average American woman is getting 10 to 12.

Dr. Gabrielle Lyon  [0:58:31]

Why should they get fiber?

Dr. Mary Claire Haver  [0:58:34]

Fiber decreases the rate of absorption of glucose into our bloodstream soit’s going to stabilize our insulin levels better. Number two, it feeds our gut microbiome. if you’re not paying attention to the studies exploding around the gut, which was completely dismissed 10 years ago and now it’s everything, the health of our gut microbiome and how important it is to our mental health, how our heart functions. the gut microbiome approaches that of a man when you go through menopause, it totally changes. The microbiome changes.

Dr. Gabrielle Lyon  [0:59:07]

I actually did not know that. I had no idea. So I potentially have a malegut microbiome?

Dr. Mary Claire Haver  [0:59:12]

It’s so crazy. This is one of the places where oral estrogen might be better than transdermal. We need a lot more studies. I can see a point where we have some very low-dose oral estrogen with some transdermal. What we’re really seeing is that we just need to extend the shelf life of the ovary. We have to figure out how to do that, and people are working on that. That’s the best way.

Oral estrogen may be a little bit better for the gut microbiome because that’s where it’s headed. That’s where it goes first, and estrogen in the gut does change things. I’m not on it. For that reason, I’m doing everything else to support my gut, including fiber.

The number two supplement is vitamin D. 85% of my patients are deficient in vitamin D. That hormone has receptors in every organ system of our body; it goes hand in hand with estrogen. You can safely supplement without worrying about toxicity, though you may need more than 4000 international units a day.

My supplement I’ve created for my patients and followers has 4000 IU. I’m going to push it to the highest level that you can do safely. We throw in some omega-3s with it and vitamin K for absorption. that I think most women should be on. It’s almost impossible to get it naturally at our age due to decreased absorption through the gut.

It is the rare patient I see who, without supplementation, has a normal vitamin D level. Vitamin D helps with sleep, cholesterol, and all the other things, so we have to start with the basics.

As far as the claims of Ashwagandha and all these phytoestrogens, phytoestrogens can be helpful, but when the randomized controlled studies were looked at versus placebo, it’s just mixed. You might have an anecdotal patient who sees some relief, but it’s not going to replace estradiol.

I’m only having these discussions if a patient has an absolute contraindication to estrogen replacement, and then we’re having to look for other ways to support her. But remember, Ashwagandha is likely not going to support your brain, your bones, or your genital urinary system. It might help with hot flashes a little bit and maybe some brain fog.

Dr. Gabrielle Lyon  [1:01:42]

Let’s mention one thing that I think is crazy to think about: an individual could supplement with all of these things as long as they want. The reality is that at some point, a woman is going to go through menopause, and no amount of ashwagandha, no amount of chaste tree berry, no amount of any of these herbs, vitamins, minerals, or nutrients is going to take away that biological change. It’s just the way that it’s going to be.

Dr. Mary Claire Haver  [1:02:16]

Right, and we haven’t figured out medically how to stop that process, and it begins at birth. One, we have to stop defining. I have so many sweet patients or followers who are like that, but I never went through menopause. I didn’t have any hot flashes. We have to stop defining. My periods just stopped. I’m like, well, great. Super flashers have a higher risk of cardiovascular disease and neurodegenerative disease, so that’s wonderful for you. But it doesn’t mean that, in the background, your cholesterol profile is not starting to tank. You’re losing muscle mass, I promise, if you’re not doing something about it. All of these things are happening that are contributing to your decline. I’m not saying you’re never going to die. But I’m saying that you want those last 10 years to be as functional as possible, and if you’re not paying attention to what menopause is doing to your body, you’re going to suffer more than you need to.

Dr. Gabrielle Lyon  [1:03:12]

Yeah, absolutely true. Now I know that this is not a treatment for body composition changes; this hormonal replacement therapy just currently is not. Do you see a change in the positive When individuals are going through perimenopause or menopause and they begin hormone replacement therapy, do you see an alteration and improvement in body composition with estrogen, progesterone, and testosterone?

Dr. Mary Claire Haver  [1:03:39]

I do. I absolutely do. Again, I have a machine to measure it. Now again, we are all also addressing nutrition and all the other things in the toolkit. But I am seeing dramatic decreases in visceral fat with my patients. I don’t know what’s the biggest factor for them. Again, we have individual genetic expressions here, and we’re treating everything that we can at once. But we know from observational studies that women who are given the option of HRT early, especially in perimenopause, through their transition and into full menopause, have lower visceral fat than women who were not.

Dr. Gabrielle Lyon  [1:04:22]

Where do you think the future of menopause and hormone replacement therapy is going?

Dr. Mary Claire Haver  [1:04:30]

There are so many ways. I hope that we’re going to have more options for patients as far as dosages and delivery systems. What I would love to see is a vaginal ring that is affordable and that we have an estrogen, progesterone, and testosterone option. I guess number one is an FDA-approved option for testosterone for women. The problem with progesterone, as it is, is that progesterone in its natural form is the best way to give it to your body, as far as we can tell, and we don’t have a great non-oral option for that yet. The progesterone molecule is huge, and it’s really difficult to get it to pass through the skin. Until we can find a micronized way to get it through the skin and get it to a sustainable level, we’re going to have to go with oral.

So I think the first step is an affordable estradiol ring. Because really, we’re treating the vagina, the general urinary system, and systemically all in one, so you don’t need a separate vaginal cream. I think the top priority is getting an FDA-approved testosterone option for women. That’s going to be number one, and then getting it into more formulations so we have more options to offer patients that are tolerable to them and getting way more studies on other organ systems outside of just hot flashes and seeing what the dose optimizations are for that. We don’t know yet.

Dr. Gabrielle Lyon  [1:06:00]

I know. Isn’t it amazing that in 2023 or 2024, we still don’t know the optimal dosage for different organ systems? I mean, it is pretty mind-blowing.

Dr. Mary Claire Haver  [1:06:14]

No. We’re guessing.

Dr. Gabrielle Lyon  [1:06:18]

It’s wild. When you think about training and exercise, do you find that women seem to respond better to high-intensity interval training or strength training? Obviously, many people have continued to engage in cardiovascular activity. But do you find that in your clinical practice, there’s one way in which people really move the needle?

Dr. Mary Claire Haver  [1:06:41]

It’s got to be strength training, but it’s really hard. There’s so much noise out there as to what’s optimal. There are so many predators out there who are preying on these poor women. They go in armed with everything I told them, and then these trainers are trying to negate everything I said. It’s so hard to let go of this skinny is where I’m headed. Strength over skinny is a really hard concept for people, given all of their lifetimes of mental beatdown on the number on the scale being the most important thing.

I can’t tell you the joy I have in some of my patients when I tell them that they’re not obese; they just have a lot of muscle, and we don’t even discuss their BMI. I never talk about BMI. We talk about muscle mass, fat mass, and visceral fat. Getting them to let go of burning calories as much as being strong over skinny is really tough, and the women who are able to cross that bridge and embrace it are seeing the biggest health gains.

Dr. Gabrielle Lyon  [1:07:50]

I completely agree with you. I wrote a book called Forever Strong, which is all about the fact that skeletal muscle is the organ of longevity. If you were to leave people with three pieces of advice for perimenopause and menopause, please tell me. I know it’s only three. Oh, and by the way, after you leave me with those three, I want to talk all about your new book because I cannot wait to get a copy. I’m still waiting for my copy, by the way.

Dr. Mary Claire Haver  [1:08:23]

I’ll be sending you something in the email very shortly. Number one, menopause is inevitable, Suffering is not. we don’t have a consistent way to train our health care providers as to menopause care. All I can do is arm you with things to advocate for yourself with evidence and data to advocate for yourself and at least point you in the direction of clinicians we know have been helpful to other of my followers, or those certified by the Menopause Society, which is not a guarantee on either direction, but it’s somewhere to start. You cannot assume that the wonderful OB/GYN who did all your well-woman care and delivered your babies and contraceptive management and took care of your infections and everything is going to have a clue or any time in their schedule to really devote themselves to menopause care. It’s almost impossible because I was that doctor for a long time. full disclosure, I was a terrible menopause provider for 15 years. Terrible. I’m ashamed. But I didn’t know what I didn’t know and I’m here to fix it. you may have some well-meaning provider who is still stuck in the 2000s as far as what they learned about menopause and I’m calling out clearly the American Board of OB/GYN because they are not putting for our yearly certification exams hardly any data for menopause studies to help us as a group of certified OB/GYNs stay up to date with the latest in research. They’re just not doing it, not in 2023.

Second advice, vitamin D and fiber. Nutrition first.

Dr. Gabrielle Lyon  [1:10:11]

Very important.Do you prioritize protein?

Dr. Mary Claire Haver  [1:10:15]

I do now. I mean, it was important. But as far as making it the top thing, my goal that I’m going to hit, which is prioritizing it in my meals, is something I’ve been doing since following you. I’ll be honest, my daughter, who’s a nutrition science major, is the one who made me start following you. She found you first. She’s now in medical school, by the way, and was absolutely like, Mama, you have got to follow this woman. So that is how I found you. She was sending me all your videos, and so it really helped me refocus my thought process on how important the musculoskeletal unit is in menopause and how we could just make a few simple changes to increase that level of protein intake, which can do so much good for a woman, especially at our age.

Dr. Gabrielle Lyon  [1:11:11]

Yes, that’s so wonderful. Tell me about your new book.Tell me all the details.

Dr. Mary Claire Haver  [1:11:20]

My first book was The Galveston Diet, named after my home, and it was a nutrition and wellness program for women in midlife and menopause. But that book exploded the conversation where people were like, yeah, that’s fine, but tell me more. What about this frozen shoulder? What about this vertigo? What about all these symptoms? It just took me down these rabbit holes. I realized there’s a lot more information I left on the table as far as the medical aspects of menopause. I feel like there’s a gap in what’s available, and I can fill that gap with another book.

The book is called The New Menopause, and it’s really something I hope gets into the hands of everyone 35 and older who is struggling, or their loved ones, to help them understand this process, what their loved one is going through, and how they can be supportive.

The first part is all about the history of menopause and how we’ve gotten to where we are, why women are dismissed, what’s going on in society as far as our views of how women age, and what our places in society are. Then I get into the medical aspects of menopause and what it actually is so that everyone understands what’s happening to the ovaries and organ systems when we lose estrogen, progesterone, and testosterone. Then we talk about medical hormone replacement therapy and what options are available. I do a deep dive into that so patients feel like they can have a conversation with their health care providers.

The last section is going organ system by organ system, what menopause can do, brain, bones, kidney, lungs, vertigo, dry skin, hair, teeth, and everything, and what the data has shown us so far and where the gaps are and so what HRT might be helpful for, what other things you can do, supplements, nutrition, exercise, sleep, and what we know that they help with. So, at least you have a starting point.

We’ve turned in the manuscript, and I could probably write eight more chapters, but we had to stop somewhere. I’m sure you felt the same way with your book. It’s really a labor of love. It’s really just a compilation of everything I talk about on social media every day in a readable format.

Dr. Gabrielle Lyon  [1:13:34]

When is it out, and where can people get it?

Dr. Mary Claire Haver  [1:13:36]

It will be released on April 30th. It’s available for pre-order now everywhere you buy books, so Amazon, Barnes & Noble, and wherever you buy books, you can find it and pre-order.

Dr. Gabrielle Lyon  [1:13:48]

I just want to mention to all my listeners that the pre-order really helps the author. Please, if you found this valuable, I love Mary Claire; I think she’s wonderful. I am going to be ordering a handful of copies for myself. Again, it takes a lot of effort and energy to write a book. When we preorder the book, it really helps the author. Let’s all give her our support and do that.

Mary Claire Haver, thank you so much for coming on. I’m very excited to share you with my audience. You are really an advocate for these changes for women. I know that it’s not always easy, and it certainly is not always easy being in the public eye and on social media. You are doing a wonderful job. Everybody needs to hear what you have to say, and I’m so grateful for you.

Dr. Mary Claire Haver  [1:14:45]

Thank you so much, and right back at you. If any of my followers are listening, please follow her on social media. Her book is fantastic. It is such a wonderful way to think about strength and longevity. Please support her by buying her book as well.

Dr. Gabrielle Lyon  [1:15:04]

You guys better be getting my book. Until next time, everybody. Thank you so much for joining us.

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The Dr. Gabrielle Lyon podcast and YouTube are for general information purposes only and do not constitute the practice of medicine, nursing, or other professional health care services, including the giving of medical advice. No patient-doctor relationship is formed. The use of information on this podcast YouTube or materials linked from the podcast or YouTube is at the user’s own risk. The content of this podcast is not intended to substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their health care professional for any such conditions. This is purely for entertainment and educational purposes only.