GLP-1s, Hormones, and Why You Can't Calorie-Count Your Way Out of Menopause with Dr. Michelle Gordon

In this episode of unPAUSED, Dr. Mary Claire Haver sits down with Dr. Michelle Gordon, a board certified obesity medicine physician and diplomate of the American College of Lifestyle Medicine, with surgical fellowships from the American College of Surgeons and the American College of Osteopathic Surgeons. Through her practice Thrive Span Medical, she works with midlife women across 39 states whose metabolic and hormonal symptoms have been dismissed as normal aging. Dr. Gordon opens by dismantling the calories in, calories out framework, not as a vague wellness talking point but on a physiological level. She explains why biology determines the burn rate, why fat oxidation drops by 32% in perimenopause, why visceral fat accumulation accelerates when estrogen declines, and why insulin resistance and leptin resistance make it nearly impossible for midlife women to lose weight through willpower alone. She also covers how sleep deprivation compounds all of it, creating a cycle of cravings, brain fog, and weight gain that most women are navigating without any clinical support. Guest links: Michelle E. Gordon, DO https://www.linkedin.com/in/drmichellegordon/ (LinkedIn) Dr. Michelle Gordon https://www.instagram.com/doctormichellegordon/ (Instagram) Dr. Gordon, Obesity Medicine https://drmichellegordon.substack.com/?utm_source=ig&utm_medium=social&utm_content=link_in_bio&fbclid=PAZXh0bgNhZW0CMTEAc3J0YwZhcHBfaWQMMjU2MjgxMDQwNTU4AAGnquYRddl_IhUjsfGwSq3CvSHsXhiBCnwGd5mzyftKY6nFFPpE5poJiJXUECU_aem_bPanlz1tlGRuzicXT8ET7w&utm_id=97760_v0_s00_e0_tv3_a1denngnzju5f5 (Substack) Dr. Michelle Gordon https://www.facebook.com/drmichellegordon/ (Facebook) Dr. Michelle Gordon https://drmichellegordon.com/ Dr. Michelle Gordon https://www.tiktok.com/@drgordonmichelle (TikTok) Dr. Michelle Gordon https://drgordon.me/?utm_source=ig&utm_medium=social&utm_content=link_in_bio&fbclid=PAZXh0bgNhZW0CMTEAc3J0YwZhcHBfaWQMMjU2MjgxMDQwNTU4AAGnfSi0rzRPQzOZzoNPCh0-y9oKfiRBDM42_zIZl--9UbH6DzcrfErcMT4dbdk_aem_Ao3Ndf43BKVYkQ_wfkzkaw Dr. Michelle Gordon https://www.youtube.com/@drmichellegordon (YouTube) Books: “The New Perimenopause: An Evidence-Based Guide to Surviving the Zone of Chaos and Feeling Like Yourself Again,” https://www.amazon.com/New-Perimenopause-Evidence-Based-Surviving-Yourself/dp/0593736613 by Dr. Mary Claire Haver “The New Menopause,” https://www.amazon.com/New-Menopause-Mary-Claire-Haver/dp/1785045547 by Dr. Mary Claire Haver Weightless: A Doctor's Guide to GLP-1 Medications, Sustainable Weight Loss, and the Health You Deserve,” https://www.amazon.com/Weightless-Doctors-Medications-Sustainable-Deserve/dp/0593981200 by Dr. Rocio Salas-Whalen For full show notes, please click here https://thepauselife.com/blogs/the-unpaused-podcast/glp-1s-hormones-and-why-you-cant-calorie-count-your-way-out-of-menopause-with-dr-michelle-gordon.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Speaker 00

  Weight gain in midlife women is physiological and predictable. We know this now. The burn rate goes down and you can't out calorie, count yourself out of it. It's going to happen. It's predictable. We can work on it. Resistance training. I mean, that's, that's the number one longevity hack and sleep.

• 0:22Dr. Mary Claire Haver?

  Yeah.

• 0:22Speaker 00

  And fiber. You don't have to white knuckle through it. If, if, if you start gaining weight and you, you rapid, rapidly the weight comes on and all you're doing is thinking about food and you're craving food. We have medication, medication that can help now. And the other thing I want to say to the women is that if, if your doctor dismisses you, go get another doctor. There's a million doctors in this country. You don't have to go to a doctor that makes you feel like crap.

• 0:46Dr. Mary Claire Haver?

  Yeah.

• 0:57Dr. Mary Claire Haver?

  The views and opinions expressed on UnPaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. Today's guest is someone I've found the way I find many of the best medical communicators. I was scrolling on social media and came across a video where she was explaining why calories in, calories out does not work for many midlife women. Not in the vague wellness-y way, in a physiological, mechanistic, this is what's actually happening in your body way. And I thought, this is someone who gets it.

• 1:39Dr. Mary Claire Haver?

  I was watching her dismantle a medical myth in plain, precise, clinical language and I thought, she has got to be a guest on UnPaused. Dr. Michelle Gordon is board certified in three disciplines: general surgery, obesity medicine, and lifestyle medicine. She spent 15 years building and running a multimillion dollar surgical practice and she was good at it. Then she walked away from it because she kept seeing the same thing over and over. Women arriving for surgical intervention after years of being dismissed, minimized, and told their symptoms were stress or aging or their own fault. By the time the system paid attention, the damage was already done.

• 2:20Dr. Mary Claire Haver?

  She left this thriving surgical practice because she was tired of seeing women arrive already broken. She wanted to intervene earlier. Her practice focuses on weight, hormones, metabolism, sleep, and brain health in midlife women. She works with high performing women who cannot afford to lose their edge and need clinical clarity without judgment. Today, we're doing a deep dive into why midlife weight gain happens, why eat less, move more stops working, and what GLP-1 therapy actually looks like when it's done right for a perimenopausal or menopausal woman. The connection between metabolism and brain health, and what the future of obesity medicine in menopause should look like. I'm Dr.

• 3:02Dr. Mary Claire Haver?

  Mary Claire Haver, a board certified obstetrician and gynecologist and a certified menopause practitioner. I'm also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to UnPaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life. So, Dr. Michelle Gordon, welcome to UnPaused.

• 3:34Speaker 00

  Thanks for having me. I'm really excited to be here.

• 3:37Dr. Mary Claire Haver?

  More and more information about weight management, GLP-1s, and how that can all incorporate successfully into a clinical practice is one of the top requests that we get, so our audience is super excited to have you here.

• 3:49Speaker 00

  Yay.

• 3:50Dr. Mary Claire Haver?

  But you didn't start out doing this.

• 3:51Speaker 00

  No.

• 3:52Dr. Mary Claire Haver?

  No.

• 3:53Speaker 00

  I didn't.

• 3:54Dr. Mary Claire Haver?

  You were a general surgeon?

• 3:55Speaker 00

  General surgeon. I like to say I was a general surgeon for 20 years because it was five years of

• 3:58Dr. Mary Claire Haver?

  Residency, yeah.

• 3:59Speaker 00

  Residency. But yeah, no, I did acute care general surgery. That's what I found I liked. And then in the pandemic, things got really weird.

• 4:08Dr. Mary Claire Haver?

  Yeah.

• 4:09Speaker 00

  And I didn't like it anymore. And I just stopped all of it and started looking at other things. So I took this time off. I was really unsure of where I wanted to be, thinking I was going to leave medicine altogether.

• 4:22Dr. Mary Claire Haver?

  Yeah.

• 4:23Speaker 00

  I'm a surgeon.

• 4:24Dr. Mary Claire Haver?

  Yeah.

• 4:25Speaker 00

  Okay? We forget medicine. So I had to learn a lot, and that was probably one of the harder board exams I've ever taken. But I passed it in 2023, and then I started practicing. And learning about obesity as a chronic disease was eye opening for me.

• 4:39Dr. Mary Claire Haver?

  Yeah. When I was learning about Obesity as a chronic disease, that was such a kind of a mind blowing, you know, concept to me because what I had been taught in all of my training was this was a willpower issue. This was a personality disorder. This was a thermodynamics problem. My first video I saw of you that really got, maybe I've seen something before, but like the one was you debunking the thermodynamics equation to the gym bros on your page. You had a quote from somebody up there and I was like, and you did it in such a great way and you use science.

• 5:16Speaker 00

  The, the problem I think with the thermodynamics argument is yes, you are not going to lose weight if you're not in a calorie deficit. I have never, ever, ever said that that wasn't true. The issue is that all thermodynamics experiments, for the most part, are based on static engines. And biology determines the burn rate. And that's the difference. And in a perimenopausal woman, which, you know, of course, the, the research hasn't really been given to women's health. So we don't really know a whole lot. But what we do know is that women are not small men.

• 5:51Dr. Mary Claire Haver?

  Exactly.

• 5:52Speaker 00

  Very, very different biology.

• 5:54Dr. Mary Claire Haver?

  You talked about women showing up in your office when you were a surgeon and they were already broken. They'd missed all these windows of opportunity for intervention. What did already broken look like?

• 6:06Speaker 00

  Well, I was an acute care general surgeon. So people come to the ER, they're already broken. For the most part, but the best example of that was a woman in her 60s who came to the ER with, with belly pain and septic shock. She'd lost her granddaughter about a week before. And it was obvious that something was very broken inside of her. And when I got her to the operating room, there was a clean hole in the sigmoid colon and the belly was full of stool. And she just sat there and endured it. She was obese. And she endured it because women put themselves last. We're taught that from the beginning. And she might've survived if she had come earlier, right? But by the time we got her

• 6:48Speaker 00

  to the OR, it was too late. That's what already broken looks like.

• 6:52Dr. Mary Claire Haver?

  Yeah. You have a phrase that I love. I mentioned in, in the opening, "You help women who cannot afford to lose their edge."

• 7:02Dr. Mary Claire Haver?

  I have the same subset of patients, I think, coming to see me. A lot of them are very high functioning, you know, in their jobs, in their day to day lives. Not all of them are employed, but they are literally managing multiple things and all of a sudden they've lost that ability. Are you seeing the same thing in your clinic?

• 7:19Speaker 00

  I do. What's happening is the women who come to me are high powered leaders, CEOs or entrepreneurs. A lot of entrepreneurs come to me and they're women who have always met their goals. And all of a sudden, either they're not able to think the way they used to, or they're, they're really upset because they've always met their goals and they can't lose weight. Or they lead a team and they can't get to the edge of their brains and their team is noticing and they wonder if there's something wrong with them.

• 7:52Dr. Mary Claire Haver?

  And we'll get into some of the specifics, but what happens with the majority of those patients in your practice?

• 7:57Speaker 00

  Well, usually we treat them with estrogen. Estrogen is amazing. That will help. I have one patient in my practice now who had a TBI.

• 8:06Dr. Mary Claire Haver?

  And for our listeners, a TBI?

• 8:08Speaker 00

  Traumatic brain injury.

• 8:09Dr. Mary Claire Haver?

  Okay.

• 8:10Speaker 00

  That she's recovering from and it's been a while, but I put her on estrogen and within a week, I said, I said to her, just, I think yesterday I saw her and I said, are you able to get closer to the edge of your brain now? Because that's a big problem. People who've had traumatic brain injuries just feel like it's, everything's just right there, but they just can't get there. And she's like, you know, my thinking has cleared up a little bit.

• 8:31Dr. Mary Claire Haver?

  Amazing.

• 8:32Speaker 00

  I have another one that I saw yesterday as well, who I had just started her on testosterone, 0.5 milligrams, really small dose, like lowest dose. She said, this is the first time in years I didn't take any Advil for a week.

• 8:45Dr. Mary Claire Haver?

  Wow.

• 8:46Speaker 00

  No pain. I was, I was like, this is miraculous.

• 8:50Dr. Mary Claire Haver?

  Yeah.

• 8:50Speaker 00

  Because when you take hormones, when you feel crappy and you take hormones, it, it does feel like a miracle.

• 8:55Dr. Mary Claire Haver?

  It's a, you know, estrogen in its natural state, pumped out of the ovaries, has this amazing anti-inflammatory property. And then when you outlive the life of your ovary, that goes away and it just unmask so much musculoskeletal pain, inflammation, etc.

• 9:11Dr. Mary Claire Haver?

  So being able to ameliorate that in in part with hormone therapy is one of my favorite parts of my job.

• 9:19Speaker 00

  It's so nice to see women come back to themselves. And I don't know if you know this, but I've I've got survey data from over 16,000 women. And one of the things that that they've said over and over is I feel like an alien is beamed down, taking control of my body, mind, emotion, and mood. Why, you know, why do I just not feel like myself?

• 9:39Dr. Mary Claire Haver?

  Yeah. Did you see that paper last year? It was presented at Menopause Society meeting, which I did virtually. And it was a woman who wrote a paper called, I Just Don't Feel Like Myself in Perimenopause, and really quantified it, like now we can use that as a medical term. And now I like use that all the time on social media because it's now considered a medical term that a woman has just, she doesn't feel like herself. And that often is the first sign.

• 10:04Speaker 00

  Right.

• 10:05Dr. Mary Claire Haver?

  Let's talk about calories in, calories out. Is that the biggest thing you had to kind of rethink through once you left surgical practice and got into lifestyle and obesity medicine?

• 10:16Speaker 00

  I wouldn't say it's the biggest thing I had to work through. I think what really brought that on for me was posting on social media and seeing the pushback from gym bros more than anything else.

• 10:25Dr. Mary Claire Haver?

  Been through this exact arc.

• 10:27Speaker 00

  You know, talking, talking about lipotoxic toxicity and how obesity is a disease of inflammation. And when, when I was on TikTok and posting, I would, I would post like a, a text post. And the comment, I had to turn off comments. They were so awful. Just, you know, put down the fork, bra, thermodynamics, bra. And so it, it makes for a real easy way to attack the standard that men think about. And then when I start to get into the conversations with the, with the people who actually watch my videos, I'm like, you know, this is for the women. Women are not small men. And we've been treated like small men our whole lives. Or like we are a servant to men, or they're for men's pleasure only.

• 11:12Speaker 00

  And what we think and what, who we are doesn't matter.

• 11:16Dr. Mary Claire Haver?

  Right. I also.

• 11:19Dr. Mary Claire Haver?

  Had to learn how to really believe women and get out of the bias and that was kind of built into the system of women tend to just be emotional. I mean, and I was taught that women tend to somaticize psychological problems. It's not clear if it's not on the checklist that we gave you, then, well, she's just a little bit crazy.

• 11:39Speaker 00

  Yeah. What did you say on Mel Robbins, whiny woman?

• 11:42Dr. Mary Claire Haver?

  Whiny woman. I mean, that was my intern year. The WW, well, she was Caucasian. So it was a WWW, whiny white woman. And so they coded in it because we still had handwritten charts. That's how old I am.

• 11:52Speaker 00

  Right.

• 11:52Dr. Mary Claire Haver?

  It was like a little WW and that was like a little signal that she's, she's midlife. She has multiple vague complaints. Can't put your finger on it. Labs look okay. She's still having a few periods. Like she's not menopausal. We did not have a framework in how to treat this woman.

• 12:07Speaker 00

  Right. And it didn't matter. It didn't matter because it was a woman.

• 12:11Dr. Mary Claire Haver?

  Yeah, exactly.

• 12:12Speaker 00

  And I think the biggest problem is that women dismiss other women as well.

• 12:16Dr. Mary Claire Haver?

  They do. They do. I see, you know, in the comments in social media a lot, there's a lot of blaming of male clinicians. We got some great male clinicians out there.

• 12:27Speaker 00

  There's some great ones out there.

• 12:27Dr. Mary Claire Haver?

  And this is not a gender issue, you know? Sadly, I was one of those females who did tend to dismiss when I couldn't figure it out. Well, it must be something psychological I'm missing. Until my patients and I all got to that age and I'm like, all these women I hang out with outside of the office are not crazy. Like I know them. I shop with them. We run together. We have mommy groups. You know, they pick up my kids when I'm running late at the hospital. Like, she's not crazy. Like this is, this is real.

• 12:54Speaker 00

  Yeah.

• 12:55Dr. Mary Claire Haver?

  And she's not gaining weight because she's constantly going through the drive through.

• 12:58Speaker 00

  Right. And I think women are not believed. Like it's, it's a, it, women and girls are not believed. I mean, it, it's more of a systemic problem than just in medicine.

• 13:10Dr. Mary Claire Haver?

  Oh, totally. You're in there fighting, fighting the good fight in the clinics across from the patients, day to day, seeing the success, seeing the new tools available to patients, you know, and really helping change your patients' lives.

• 13:21Speaker 00

  Right.

• 13:21Dr. Mary Claire Haver?

  But, you know, you don't have to fight this battle on social media.

• 13:24Speaker 00

  No, but I, I'm trying to reach the woman who has been dieting since she was eight.

• 13:30Dr. Mary Claire Haver?

  What do you want to tell her? If she can't drive to northern New York and come find you?

• 13:34Speaker 00

  Well, I have a virtual clinic.

• 13:37Speaker 00

  And I have 39 licenses, so, so I can treat a lot of people. But, so here's the thing. The metabolic chaos that goes on in women is just very different. And obesity has its own set of inflammatory markers, inflammation. And the woman who has been to the doctor and the doctor just says, eat less, move more.

• 14:00Dr. Mary Claire Haver?

  Yeah, why, why does this fail her?

• 14:02Speaker 00

  Because she's already got so much inflammation that fat oxidation isn't happening the way that we would expect. I mean, even in perimenopause, you must know this because you just wrote the book, but in perimenopause, fat oxidation goes down by 32%, right? So a woman who does the same things, exercises the same, or even starts doing more, will gain weight because hormones. Right? And that's where put down the fork bra doesn't work. We have to work on the resistance. We have to work on insulin resistance and leptin resistance and the brain. The brain will pathologically cause someone to feel more hungry through perimenopause.

• 14:41Dr. Mary Claire Haver?

  Yeah. So what is insulin resistance? For our listeners who may not understand, it's a term being tossed about quite a bit now.

• 14:47Speaker 00

  Yeah, so it's, it's a really interesting problem. It's not something that you're born with, although there are some genetic predispositions. But in midlife women, estrogen is responsible for how the body responds to insulin, right? And I can't imagine, because you just wrote that book. And you must have read so many papers on, on how insulin and estrogen.

• 15:09Dr. Mary Claire Haver?

  Yes.

• 15:10Speaker 00

  Interact.

• 15:10Dr. Mary Claire Haver?

  Less than you would think, because when you look at the volume of research around perimenopause, I have to kind of look at the postmenopausal data and make inferences backwards.

• 15:22Speaker 00

  Wow. That's frustrating, but maybe we'll get some more than 11% of the NIH budget for women's health.

• 15:28Dr. Mary Claire Haver?

  We'll see.

• 15:30Speaker 00

  Maybe. So what happens when estrogen declines is there's more visceral fat accumulation. So fat moves from around the hips to visceral, right? And that

• 15:39Dr. Mary Claire Haver?

  And for our listeners visceral intra-abdominal cavity, so inside our tummy or what we call belly fat.

• 15:44Speaker 00

  Right. Well, we also have, remember, we have the omentum.

• 15:47Dr. Mary Claire Haver?

  Yeah.

• 15:47Speaker 00

  Right? And the omentum's job is to clean up in the abdomen. And I can't tell you how many times I took out an appendix and had to do a partial omentectomy just because the

• 15:56Dr. Mary Claire Haver?

  It was wrapped around there.

• 15:57Speaker 00

  Was doing its job. And that gets bigger. The omentum gets bigger than mesentery, which is the fat that

• 16:03Dr. Mary Claire Haver?

  Between our bowels.

• 16:03Speaker 00

  Right. Well, it's where the blood vessels are living. That gets bigger. And then, of course, anything around the organs. But when we talk about visceral fat, I think we're mostly talking about increased volume of omentum and mesentery. But that's active endocrine organ, right? And so it starts releasing some inflammatory cytokines. And then with that, the fatty acids go up. Fatty acids go through the portal vein in the liver, which is where most of our blood comes back. Right? And there's a reaction there that causes us to have less sensitivity to insulin because of the increase in the fatty acids. It's not all sugar. You'd think it would be all sugar, but it's not.

• 16:46Speaker 00

  And that's where, you know, the biology is just so complex. As the pancreas tries to

• 16:53Dr. Mary Claire Haver?

  Compensate.

• 16:55Speaker 00

  As the sugar goes up, it's like puts up more and more, but the body doesn't react as well. And that's insulin resistance.

• 17:02Dr. Mary Claire Haver?

  And then you mentioned leptin. So what is leptin's a hormone?

• 17:06Speaker 00

  Yeah.

• 17:06Dr. Mary Claire Haver?

  And what does leptin do?

• 17:08Speaker 00

  It is responsible for satiety.

• 17:11Dr. Mary Claire Haver?

  And satiety is feeling full?

• 17:13Speaker 00

  Feeling full. Yeah. It's the thing that makes you full. And we know from bariatric surgery studies, right? That leptin resistance goes down with bariatric surgery. And ghrelin

• 17:24Dr. Mary Claire Haver?

  Another hormone, ghrelin.

• 17:25Speaker 00

  Ghrelin's the one that makes you feel hungry. Yeah. And that sensitivity goes up in bariatric surgery. We have lots of data on bariatric surgery, but we don't have enough on weight loss. In people who lose weight, the hormonal changes don't last.

• 17:42Speaker 00

  We don't have, we don't have the data. We think that maybe five years staying at a lower weight, maybe. But the body always tries to go back.

• 17:49Dr. Mary Claire Haver?

  Yeah.

• 17:49Speaker 00

  That is survival. And so we're fighting against Survival and the way that we evolved.

• 17:58Dr. Mary Claire Haver?

  In bariatric surgery, yeah.

• 17:59Speaker 00

  And not just bariatric surgery, in any time you want to lose weight. Right? Bariatric surgery is really interesting. I almost became a bariatric surgeon. I studied bariatric surgery and decided I didn't want to do it because I thought the relapse rate was too high. And now I understand why. I never understood why until I started studying obesity medicine. Bariatric surgery, about 25 to 35% of patients will regain.

• 18:24Dr. Mary Claire Haver?

  Yeah.

• 18:25Speaker 00

  Most won't because there is a permanent hormonal change that happens when you permanently change the anatomy. But bariatric surgery comes with its own problems.

• 18:33Dr. Mary Claire Haver?

  Yeah, I've had a lot of post bariatric surgery pregnancy patients and they were complicated. We managed them, but it was, you know, it creates a different body.

• 18:43Speaker 00

  Right.

• 18:44Dr. Mary Claire Haver?

  And that creates its own set of complications to deal with, especially when you're dealing with another human growing inside of a body that's been changed.

• 18:52Speaker 00

  Right.

• 18:57Dr. Mary Claire Haver?

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• 20:09Dr. Mary Claire Haver?

  Tell me about muscle loss, calories in, calories out. And we have this age-related loss of muscle. Why is muscle so important for maintaining our weight?

• 20:19Speaker 00

  There's insulin receptors in muscle, right? So muscle is longevity. If you don't have a lot of muscle, it's you're going to be more frail, without question. That's just the way it is. So when somebody loses weight, right? It's the patient who loses weight will lose about 10 to 15% of what they lose will be muscle. The data show that a patient on GLP-1 will lose just maybe a little bit more, 20 to 25% max. Now, we have, if you watch social media, oh, 40 to 60% of the weight you lose is muscle. That's not true, as long as you make sure that the patient is eating enough protein. And weightlifting is an adjunct. Protein is the number one, which I was really surprised about.

• 21:04Speaker 00

  I was at Obesity Week 2025, and there was a paper that was presented about weight muscle loss specifically with semaglutide. And that was for every 10 kilogram of weight loss, it was 2 to 2.5 kilograms. So it's not as much as we thought. Yeah, up to 25%.

• 21:21Dr. Mary Claire Haver?

  You know, our patients in perimenopause and menopause, we see a doubling, sometimes tripling of sleep disruption.

• 21:28Speaker 00

  Sure.

• 21:28Dr. Mary Claire Haver?

  Of sleep disorders across the transition. How is that affecting her weight potentially?

• 21:33Speaker 00

  Well, as you know, in perimenopause, follicle stimulating hormone increase, right? And that disrupts sleep. But I hear from these women in my practice who are waking up 10, 12 times a night. I have a woman who she had an elective hysterectomy, total hysterectomy, because her mother had breast cancer. It was never given hormones. And she didn't have breast cancer. And I've just put her on hormones. And her sleep is improving, which is crazy because she's never had a good night's sleep since that time. But what happens with sleep deprivation is it leads to brain fog.

• 22:04Speaker 00

  Then there's worsening insulin sensitivity. Okay. And this then because of loss of sleep, there's cravings.

• 22:13Dr. Mary Claire Haver?

  Yeah.

• 22:13Speaker 00

  Right?

• 22:14Dr. Mary Claire Haver?

  Yeah.

• 22:14Speaker 00

  You don't have a choice. This is all like subconsciously wired and the, the brain will preferentially go toward high calorie foods.

• 22:25Dr. Mary Claire Haver?

  Comfort foods.

• 22:26Speaker 00

  It could be fats, it could be carbs, but a lot of times the brain runs more on carbs. So it, it can, you know, chips or whatever, but the cycle with the cravings can lead to weight gain. But then you also, when you throw perimenopause in the mix and the decreased fat oxidation, you know, it's with decreased sleep, sleep, decreased sleep leads to brain fog.

• 22:44Dr. Mary Claire Haver?

  Mm hmm.

• 22:45Speaker 00

  Okay. I mean, it's just.

• 22:46Dr. Mary Claire Haver?

  You just end up in a negative feedback.

• 22:47Speaker 00

  Oh, it's terrible.

• 22:48Dr. Mary Claire Haver?

  I describe it as a traffic circle going the wrong way around, you know?

• 22:51Speaker 00

  I love it.

• 22:52Dr. Mary Claire Haver?

  Where, where you've got sleep, you've got loss of hormones is kind of in the middle. And then that affects your sleep, which affects how you store fat, which affects your hunger. It is nearly impossible to break. Like if a perimenopausal, menopausal woman eats the same and works out the same, her visceral fat level will double to triple with doing nothing different.

• 23:12Speaker 00

  Right.

• 23:13Dr. Mary Claire Haver?

  Just from the hormone changes and all the downstream dominoes that fall.

• 23:16Speaker 00

  Right. But it's calories in, calories out.

• 23:18Dr. Mary Claire Haver?

  Yeah. Calories are important, brah.

• 23:20Speaker 00

  Yeah.

• 23:21Dr. Mary Claire Haver?

  It's not the only thing. It's not the only thing. I have a daughter in medical school, so I'm seeing what the new kids are being taught. They're definitely treating obesity as a chronic disease.

• 23:29Speaker 00

  Great.

• 23:30Dr. Mary Claire Haver?

  Yes. They are, they are not stigmatizing patients with, you know, high fat levels nearly as much as I was kind of taught to do. But I think we have a whole generation of physicians still practicing who are struggling to get that message. Were you seeing this in, in your clinical practice? By the time my patients get to us, you know, and they're primarily coming for a menopause, but many of them are struggling with weight. And so once we kind of tend to their menopause, then we'll start introducing GLP-1s into practice.

• 24:01Speaker 00

  So, I mean, women who come to me are women who have either been mismanaged or have gone to an online place and gotten medicine and then, you know, weren't really just kind of left to their.

• 24:12Dr. Mary Claire Haver?

  No body composition, no.

• 24:13Speaker 00

  Yeah, yeah. And so when they come to me, they, most of them are usually on a GLP-1 and have been dieting since they were eight. So it's, it's a much more difficult metabolic picture when I'm dealing with.

• 24:27Dr. Mary Claire Haver?

  Let's talk specifically about GLP-1 therapy.

• 24:30Speaker 00

  Okay.

• 24:31Dr. Mary Claire Haver?

  And I get this question all the time on social media. Is it okay? Like, they're asking for permission for me to use a GLP-1 for my menopause waking.

• 24:41Speaker 00

  Depends.

• 24:42Dr. Mary Claire Haver?

  So who's a good candidate? Who's not?

• 24:44Speaker 00

  So the guidelines are as follows. BMI, I know BMI is trash, but that's what we have, of 27 with a comorbidity. Comorbidity, including high cholesterol, sleep apnea, high blood pressure, prediabetes, diabetes, for the most part. So that's BMI. Or BMI of 30 or higher. Okay. Those are all candidates for GLP-1.

• 25:06Dr. Mary Claire Haver?

  So 27 plus 1?

• 25:07Speaker 00

  Right.

• 25:08Dr. Mary Claire Haver?

  Or 30 plus?

• 25:09Speaker 00

  There are some guidelines that say 25 plus 1. For me, it really depends on the patient.

• 25:13Dr. Mary Claire Haver?

  Same.

• 25:14Speaker 00

  Let me tell you who GLP-1s are not for.

• 25:16Dr. Mary Claire Haver?

  Please.

• 25:16Speaker 00

  Okay.

• 25:17Dr. Mary Claire Haver?

  Be clear.

• 25:19Speaker 00

  They are not for someone who wants to lose 10 or 15 pounds for a wedding. They're not a temporary fix. Obesity is a chronic relapsing disease. There's no world where we would tell someone, hey, you know, you can take this asthma inhaler for two times and then you got to get off it. We're going to get you off it. And so the biggest issue is changing the narrative around what obesity really is. And even, even if it was behavior that caused it, it's still there. It's, it's still active endocrine organ that is causing inflammation throughout your body. And so what I love about GLP-1 is it makes it so that you're not hungry when you're trying to starve.

• 26:01Speaker 00

  I mean, you don't have to fight against your biology to get to a normal weight. I'm a GLP-1 patient.

• 26:07Dr. Mary Claire Haver?

  Yeah, yeah. My patients talk about when they go on a GLP-1, something unlocks in their brain. Did you feel that?

• 26:16Speaker 00

  I don't know, because I had been on a weight loss journey. I mean, at my highest, I was over 220. Okay. I'm 5'6". I gained weight with pregnancy, was never able to lose it. Right? So I gave birth in 1993. My son's going to be 30, 33 next month. And I was, I was never able to lose it. I would exercise my butt off and get down to maybe 15 pounds heavier than where I am now. But then I just couldn't maintain it because it was, you know, it was restrictive and so much exercise. And, and then I went into surgical residency for getting it.

• 26:48Dr. Mary Claire Haver?

  Right.

• 26:49Speaker 00

  So for me, I was on a journey, working with a coach, losing weight, doing great, tracking my food. And then I got bored in obesity medicine and started treating patients. Six months into treating patients, I went to Obesity Week. And one of the presenters said this about Terzepatide specifically. It prevents diabetes. It prevents 10 types of obesity-related cancers. It prevents, we think, Alzheimer's. It has longevity benefits. And for me, that was the click. It's like, oh, I don't have to really fight with my body. I'm gonna try this. I'm gonna try it as an experiment and see. And so I started in December of 2024. I mean, I didn't lose that much. I also didn't go to the max dose.

• 27:34Speaker 00

  So I stayed at five milligrams for a long time and went up to maybe eight and a half, nine. But I got down.

• 27:40Dr. Mary Claire Haver?

  And this is semaglutide?

• 27:41Speaker 00

  No, Terzepatide, 30-ish pounds. Okay, I'm by pre-pregnancy weight. I haven't seen this weight since 1992. So for me, the biggest thing is I don't have to worry about what I eat.

• 27:53Dr. Mary Claire Haver?

  Yeah.

• 27:53Speaker 00

  Other than the protein. Like, I gotta make sure I get enough protein.

• 27:55Dr. Mary Claire Haver?

  You clear the brain space.

• 27:57Speaker 00

  Yeah, I mean, I still track. I still make sure I eat enough or don't eat too much.

• 28:02Dr. Mary Claire Haver?

  So you have a patient coming in, decides she's a good candidate.

• 28:07Speaker 00

  Yeah.

• 28:07Dr. Mary Claire Haver?

  You know, for her GLP-1. Walk us through what the options are. What's available commercially right now for you to prescribe to a patient? What are the differences in them? How are they given?

• 28:17Speaker 00

  Okay. What is currently available? We have liraglutide. I don't prescribe it. It's a daily injection. It's Saxenda, same thing, right? It's GLP-1, but it's daily. Decent weight loss, 12 to 15%. Not bad, but it's a daily injection and that will cause needle fatigue fast.

• 28:35Dr. Mary Claire Haver?

  Okay.

• 28:36Speaker 00

  We have semaglutide. Good drug, high side effect profile.

• 28:40Dr. Mary Claire Haver?

  For example, what are the side effects?

• 28:41Speaker 00

  Nausea, gastrointestinal. That's the biggest one.

• 28:44Dr. Mary Claire Haver?

  That's what we see in our clinical practice, too. Very, very high side effect profile.

• 28:48Speaker 00

  I do find, though, that men tolerate semaglutide better than women. You don't treat men, right?

• 28:53Dr. Mary Claire Haver?

  No.

• 28:54Speaker 00

  Yeah. So in the men, men, I will always start on semaglutide first. And then if they don't tolerate it, I'll switch them. But women, women don't tolerate it as well. Because we're different. We're not small men.

• 29:04Dr. Mary Claire Haver?

  Turns out, right? We just through trial and error have now pretty much exclusively do terzepatide.

• 29:11Speaker 00

  Yeah, yeah.

• 29:11Dr. Mary Claire Haver?

  For the side, just to avoid the side effects. Our patients tolerate it better in general. There's a few that come in on it, want better management. They're happy with it. We keep them on it. But if we're doing a new start, we're pretty much doing terzepatide.

• 29:25Speaker 00

  Yeah, I really like terzepatide. I started with terzepatide. I never had any major side effects. I get a little bit of nausea. I'm very careful about constipation. As a surgeon especially. So my, my cocktail for constipation is magnesium oxide. Some people do better with magnesium citrate, but for the most part, if I, if I have a patient who says that they're constipated, it's magnesium oxide and it works. It's great. It might cause some diarrhea in the morning, but it's a lot better than being constipated.

• 29:55Dr. Mary Claire Haver?

  Yeah.

• 29:55Speaker 00

  In my opinion. So semaglutide will come in 0.25 and now up to 7.2 milligrams. I haven't prescribed 7.2 yet, but it's like a huge jump. It's from 2.4 to 7.2, which I don't know how, I would never want to do that. I would want to step somebody up.

• 30:12Dr. Mary Claire Haver?

  Yeah, start slow.

• 30:12Speaker 00

  But I don't know, I haven't talked to Norvo, so I don't know what the, how to step somebody up to that. But I'm pretty sure it, you can go from, from 2.4 to 7.2, which seems scary to me.

• 30:23Dr. Mary Claire Haver?

  Wow.

• 30:24Speaker 00

  Yeah.

• 30:24Dr. Mary Claire Haver?

  What about terzepatide? How do you dose that?

• 30:27Speaker 00

  Terzepatide is 2.5 to 15 milligrams.

• 30:30Dr. Mary Claire Haver?

  Another big jump.

• 30:31Speaker 00

  Yeah, yeah. But you dose it small and slow. I love using vials.

• 30:37Dr. Mary Claire Haver?

  So do we.

• 30:38Speaker 00

  Okay.

• 30:38Dr. Mary Claire Haver?

  I like having that ability to control the dose.

• 30:41Speaker 00

  Yeah. So there might be somebody who can't take a 2.5. They just, they just get too sick from it. And we'll start them on a much lower dose. The Zepbound vials come in 50 units per vial. And so we might start them on 20 units or 30 units instead and, and work that way. I have very few patients who are on max dose of, of terzepatide. Appetite. It is never my goal to take somebody to the max dose. I, I want to get somebody to the dose that works, where they're feeling good, able to live their life. And losing weight, of course, but we don't want to lose weight too fast.

• 31:15Dr. Mary Claire Haver?

  Right.

• 31:16Speaker 00

  Because the data, the data tell us that if you lose weight too fast, you're at risk for, especially for women, more osteoporosis and muscle mass loss. I mean, we know that from bariatric studies, that there's a lot more muscle mass loss in rapid weight loss. So we don't want that. And also, with rapid weight loss, there's the, the gallbladder risk.

• 31:35Dr. Mary Claire Haver?

  Yeah.

• 31:35Speaker 00

  Gallstones, acute cholecystitis.

• 31:37Dr. Mary Claire Haver?

  So how do you counsel? You get these patients and we decide she's a good candidate. You pick the medication, you start her on the dose. What other counseling are you giving her?

• 31:47Speaker 00

  Oh, well, about the medicine specifically?

• 31:50Dr. Mary Claire Haver?

  Well, about lifestyle.

• 31:51Speaker 00

  Lifestyle.

• 31:52Dr. Mary Claire Haver?

  I'm your patient. Walk me through this.

• 31:53Speaker 00

  So we're going to.

• 31:54Dr. Mary Claire Haver?

  So I have my shots. I'm ready.

• 31:55Speaker 00

  Yeah. No, you don't have your shots yet. We're going to find out what your history is first. What is your relationship to food? What is your lifestyle like?

• 32:02Dr. Mary Claire Haver?

  Why is that important?

• 32:03Speaker 00

  Well, because if you're somebody who has always been afraid to eat a carb, we're going to talk about eating carbs. That's really important. I'm really big on understanding what somebody's relationship is to food. You know, some patients in my practice who won't step on a scale. They would just want to base it on how their clothes fit. That's fine. I think it's very important to meet patients where they are. We're going to talk about how your sleep is, what's your sex drive like? What's your mood and motivation? How willing are you to partner with me in helping you reach your goals? Right? And then what are your goals? What do you want? And how fast do you want it? Because is it realistic to think that you're going to lose 20 pounds in a month? Those are really important things. So I need to get to know you. And we're going to talk about

• 32:47Speaker 00

  protein. The only thing that you have to, you have to track is protein. That's all I care about to start.

• 32:52Dr. Mary Claire Haver?

  Okay. How much protein?

• 32:53Speaker 00

  The data say one gram per pound of ideal body weight. Almost nobody can get that.

• 32:58Dr. Mary Claire Haver?

  So yeah, like that's a lot. For example, if you're 120 pounds, ideal body weight, 140 pounds, that's 140 grams of protein.

• 33:05Speaker 00

  Every single day.

• 33:05Dr. Mary Claire Haver?

  Most women are in reality, eating 50 to 60.

• 33:09Speaker 00

  Yeah.

• 33:09Dr. Mary Claire Haver?

  Maybe.

• 33:10Speaker 00

  Yeah.

• 33:10Dr. Mary Claire Haver?

  And that. That is so like more than doubling. That is a lot of protein.

• 33:15Speaker 00

  It's a lot of protein.

• 33:16Dr. Mary Claire Haver?

  How do you, how do you teach them to scale? Or do you teach them to scale?

• 33:18Speaker 00

  Well, we, again, you have to start people where they are and we start finding high protein foods. Right? The only thing I care about is getting 30 grams of protein in the morning. I don't care about timing, but I want you to get 30 grams of protein in the morning.

• 33:29Dr. Mary Claire Haver?

  Why?

• 33:29Speaker 00

  Because that's going to keep you full and it's going to fuel your brain and it's going to help you get through the day. That's the number one thing. And it's funny because when I have patients who start doing that and like, oh, I feel so much better during the day when I do that.

• 33:42Dr. Mary Claire Haver?

  Yeah.

• 33:42Speaker 00

  Right? And I've seen videos that you did where you're like getting 50, 60 grams of protein first thing in the morning.

• 33:47Dr. Mary Claire Haver?

  I like efficiency and I'm a very busy girl. And so I've concocted this shake that I make that hits so many of my nutritional goals at once. So we tell patients to track their protein and their fiber.

• 34:00Speaker 00

  Yeah.

• 34:01Dr. Mary Claire Haver?

  For satiety and all the health benefits. So the shake has a scoop of protein powder, of course. Um, it has Greek yogurt. I have no dairy issues and that gives me another 20 grams there. I have a like hemp chia flax, you know, mix that I throw in there for omega threes. The Greek yogurt also has probiotics.

• 34:21Speaker 00

  Of course.

• 34:21Dr. Mary Claire Haver?

  I put an extra scoop of fiber and I do put a little collagen that's a specific for skin and bone, which we create. And so, you know, I put frozen berries for anthocyanins and, you know, vitamins, minerals, nutrients and fiber. And shake that whole thing up and add a little water because the berries are frozen. And it's delicious. It's probably 700 calories. Yeah, it is 700 calories and, but it has 50 grams of protein-ish and probably 20 grams of fiber. And it takes me three, four hours to get through it. So I take it down to the gym. I get my workout in and then I work on the treadmill in my walking desk.

• 34:55Speaker 00

  Ah.

• 34:56Dr. Mary Claire Haver?

  And take all my Zoom calls for business there. And, you know, that's my morning. That gets me till noon, one o'clock. And that is how I start my day usually when I'm at home.

• 35:05Speaker 00

  That's great. I usually tell patients that, you know, they have to start tracking their protein. I do tell them 25 to 45 grams of fiber. But that's, that's hard. It's hard to get.

• 35:13Dr. Mary Claire Haver?

  It's hard if you've not done it. So.

• 35:15Speaker 00

  So I, but you have to really ramp up the fiber slowly.

• 35:18Dr. Mary Claire Haver?

  Oh, yeah.

• 35:19Speaker 00

  If you ramp the fiber too fast, you're going to have, you're going to have the scoots. So we don't, we don't want that. But what? What I do is, is if they really have a hard time eating food and getting protein in from real food, then I say, let's, let's find a powder that you like. There's some clear protein powders you can put in water. There's, there's just, there's a lot of options

• 35:41Dr. Mary Claire Haver?

  out there. And there's more coming.

• 35:42Speaker 00

  Yeah. I, I like Greek yogurt. I like,

• 35:45Dr. Mary Claire Haver?

  I do too.

• 35:46Speaker 00

  I like the Oikos protein shots, the 10 grams of protein and 60 calories. I usually have a couple of those in the morning. And, and I'm also a big sourdough bread fan. So I make my own sourdough.

• 35:56Dr. Mary Claire Haver?

  Oh, for your probiotics, yeah.

• 35:58Speaker 00

  Every morning I'll have a slice of sourdough bread and some, and some like kefir kind of thing. And that, that'll get me to 25 or 30 grams of protein.

• 36:05Dr. Mary Claire Haver?

  Awesome. Okay. So what about, do you prescribe hormone therapy?

• 36:10Speaker 00

  Yeah, I do.

• 36:11Dr. Mary Claire Haver?

  Yeah. The combination seems to be magical for my patients, GLP-1 and HRT. And the data backs it up. There are good studies now showing both for semaglutide and tirzepatide, that the patients on HRT plus one or the other will lose more weight than on the medication alone.

• 36:29Speaker 00

  Well, yes.

• 36:30Dr. Mary Claire Haver?

  On a GLP-1 alone.

• 36:30Speaker 00

  And women lose more weight on a GLP-1. When they, they pulled a couple of metal analysis and the data show us that women lose more weight than men on GLP-1s. Probably we're thinking because of estrogen. But yeah, I do, I do prescribe them together, but not always. Some women come to me and just want to see if they feel better and see if they can lose weight on hormones. I think it's very important to meet patients where they are, like I said, and we have to know what their goals are. Right? So part of evidence-based care is based on the patient's wishes. And if the patient isn't ready to start, that's fine.

• 37:06Dr. Mary Claire Haver?

  Yeah, we don't start them together. We almost always start hormones, because we're a menopause clinic.

• 37:12Speaker 00

  Yeah.

• 37:12Dr. Mary Claire Haver?

  And then see how they do. And there are few patients who that's all they needed. And that with lifestyle, they're doing great. Why add something else? That leads me to the next question. This is all controversy, but I see it constantly on social media. Microdosing, giving GLP-1s to patients who don't have a weight problem for the anti-inflammatory benefits. Where do you stand on that?

• 37:34Speaker 00

  Well, it's not something I practice. I think that it's an area of study. I think that there's a lot of benefit for people with, say, rheumatoid arthritis, for example, who would take a small dose, maybe a one milligram of tirzepatide, and find that it really helps. It's

• 37:50Speaker 00

  We just, it's like, it's like any other drug. Let's say you were going to take sermorulin, for example, right? We have no data. And, and so I can't in good conscience prescribe it.

• 38:01Dr. Mary Claire Haver?

  And for our listeners, sermorulin is the growth hormone ana-

• 38:04Speaker 00

  Yeah, it's a growth hormone analog that you can get at, at, you know, functional medicine clinics and that sort of thing. There's a lot of untested peptides that, that, that are kind of getting hawked by people on social media, BP157 and the CHU, whatever.

• 38:19Dr. Mary Claire Haver?

  We don't, we don't do any of that.

• 38:20Speaker 00

  No, no, no, I don't either. I, I, I have worked for, you know, some big telehealth clinics that do sell that stuff. And I won't prescribe it because I have not seen the data for it.

• 38:31Dr. Mary Claire Haver?

  Yeah.

• 38:32Speaker 00

  There's just no data. So why would I want to be a party to an experiment that isn't being controlled?

• 38:39Dr. Mary Claire Haver?

  There's no human data. None.

• 38:42Speaker 00

  It's very, very sparse.

• 38:43Dr. Mary Claire Haver?

  But to be clear, GLP-1s are a peptide. Insulin is a peptide.

• 38:46Speaker 00

  Yeah, yes.

• 38:47Dr. Mary Claire Haver?

  Like, we use peptides that are studied in humans and show benefits, so.

• 38:51Speaker 00

  Absolutely. I, I, I'm not against peptides. I'm against unstudied peptides that haven't been FDA approved.

• 39:05Dr. Mary Claire Haver?

  When your patients come to you, what, what labs are you running? Do you have a general panel? Do you wait till they get there?

• 39:13Speaker 00

  Yeah, I, I do, but I don't delay treatment for labs. I usually will, you know, meet with the patient. I'll see what their needs are. Again, remember, most of them are already on a GLP-1. Some of them may not be on hormones, but they're on a GLP-1. So I get baseline labs. So a good, a good portion of my patients have had bariatric surgery.

• 39:29Dr. Mary Claire Haver?

  Okay.

• 39:29Speaker 00

  And have had regain. And the problem with bariatric surgery is many patients forget that they had it and get lost to follow-up. And anyone who's had bariatric surgery-

• 39:39Dr. Mary Claire Haver?

  You're nutritionally deficient, yeah.

• 39:41Speaker 00

  It does not matter which kind, right? You had a VSG, or you've had a RUY, or a duodenal switch. You are at risk for iron, thiamine, all the Bs. And, you know, if you get tingling limbs, you probably have a B vitamin deficiency. And so it's really common for somebody who's had regain to come to me and say, you know, I want- A GLP-1 and I'm like, but are you taking your bariatric multivitamin? And they're like, no. So that's important. So I test for micronutrients. I only do that once. I'll do cholesterol, you know, basic stuff and then usually

• 40:12Dr. Mary Claire Haver?

  CBC, so blood count, basic metabolic panel.

• 40:16Speaker 00

  Fasting insulin. The other thing I do is inflammatory markers.

• 40:20Dr. Mary Claire Haver?

  Which ones?

• 40:20Speaker 00

  CRP, HOMOIR, that, that kind of thing. And then we work on it.

• 40:25Dr. Mary Claire Haver?

  Yeah.

• 40:25Speaker 00

  And of course, DEXA, but I don't require, usually the labs and the

• 40:30Dr. Mary Claire Haver?

  For our listeners, DEXA is a bone density scan, the DEXA scan.

• 40:34Speaker 00

  Yeah.

• 40:35Dr. Mary Claire Haver?

  Do you do any body composition measurements?

• 40:37Speaker 00

  In the office? Or I don't, I'm virtual.

• 40:40Dr. Mary Claire Haver?

  You do a lot of virtual, yeah. So how do you do?

• 40:42Speaker 00

  I just use that.

• 40:43Dr. Mary Claire Haver?

  No, I use DEXA. You use DEXA?

• 40:44Speaker 00

  I use DEXA.

• 40:45Dr. Mary Claire Haver?

  Excellent.

• 40:45Speaker 00

  Dex is probably, I think it's the gold standard.

• 40:47Dr. Mary Claire Haver?

  It's a gold standard, yeah.

• 40:48Speaker 00

  So I use DEXA and that I do within three months. Now, some patients that come to me have already had it and then we just follow. And then I'll do one every three to six months, depending on the patient.

• 40:58Dr. Mary Claire Haver?

  We try to standardize it. So they all come in fasting, empty their bladder before, you know, we try to get them in eight hour fast. They have a similar baseline status between scans.

• 41:08Speaker 00

  Sure.

• 41:08Dr. Mary Claire Haver?

  And we don't like hang a solid number on it. We're just looking for trends. What does informed consent look like?

• 41:13Speaker 00

  Well, I have a big contract I send to the patients that I paid a lawyer to make, right?

• 41:19Dr. Mary Claire Haver?

  Yeah.

• 41:20Speaker 00

  Yeah. I mean, we have to, right? But informed consent for GLP-1 specifically. So we talk about a few things. The number one thing I tell patients is that we're treating a chronic disease and that this chronic disease is something that we have to treat for life. So I look at GLP-1 as a forever medication. Not something that we're going to talk about coming off of, not that I won't talk to you about it. But if you do decide you want to come off it, we're going to monitor very, very closely. It's not going to be like, you know, I'm going to let you come off and send you off into the, into the void by yourself. But we talk about common side effects, nausea, vomiting, diarrhea, constipation, abdominal pain.

• 42:02Speaker 00

  It usually happens when you try too fast or if somebody's like a super responder and doesn't tolerate the starting dose, which can happen.

• 42:09Dr. Mary Claire Haver?

  Yeah.

• 42:10Speaker 00

  Then there's some other things that we have to be careful about and explain. If somebody's had a history of pancreatitis, not gallstone pancreatitis, because usually gallstone pancreatitis is resolved after surgery.

• 42:25Dr. Mary Claire Haver?

  Yeah, once you get rid of the gallstones.

• 42:27Speaker 00

  For somebody who's had idiopathic pancreatitis, then we have to be cautious. Somebody who's had gastroparesis, cautious, right? And then I do warn patients that if they get blurry vision, to discontinue use and go see an ophthalmologist right away, because there is a type of neuritis that's been linked, I'm not sure, but enough, enough that I've had a couple of patients with blurry vision that I sent to ophthalmology. They were fine, but just to be careful.

• 42:54Dr. Mary Claire Haver?

  Right.

• 42:54Speaker 00

  So those are, those are the things I really talk about. Bowel obstruction is something else that can happen. And I haven't had a patient with any of the major side effects. But the, the rodent studies showed that bowel obstruction can happen. And then we have some, some absolute contraindications. Pregnancy, breastfeeding, absolute contraindications. We don't know what this does to a fetus.

• 43:21Dr. Mary Claire Haver?

  No.

• 43:22Speaker 00

  Right? So, I mean, I've had plenty of patients who got pregnant while they were on it, but it's not a fertility tool that I would recommend. We just don't have data, so we want to never do it. And if you're breastfeeding, no, it's a big no-no. If somebody wants to get pregnant, I tell them, stop. Two months before, it's got to be out of your system. Because the half-life is five days, that means it's still in your system 30 days later.

• 43:47Dr. Mary Claire Haver?

  Yeah.

• 43:47Speaker 00

  Right? So we want to make sure that, that it's, that it's discontinued. And then when you're done breastfeeding, if you want to get back on it, then come on back. Most of my patients are done having children. I mean, let's face it.

• 43:57Dr. Mary Claire Haver?

  Right. So are mine.

• 43:59Speaker 00

  Yeah. But then absolute, other absolute contraindications include family history of multiple endocrine neoplasia type 2. With that comes something called medullary thyroid carcinoma. Other thyroid carcinomas, not a contraindication.

• 44:12Dr. Mary Claire Haver?

  Okay.

• 44:13Speaker 00

  It's the medullary thyroid carcinoma, and that only showed in rat studies or rodent studies.

• 44:19Dr. Mary Claire Haver?

  Haven't seen it in humans yet.

• 44:20Speaker 00

  We have not seen it in humans, but it's enough to make it, and EMN2 is really rare.

• 44:24Dr. Mary Claire Haver?

  Yeah. I've never seen a patient with it, but I've read about it. I know how to answer the question on the test.

• 44:28Speaker 00

  Right. That's why longitudinal care and having a relationship with a physician makes a huge difference. So somebody who's willing to Look at the big picture and make sure that you're eating enough protein and that you're going to the gym. Or, you know, it doesn't necessarily have, some people hate lifting weights. And I've had some patients say, every time I go to the gym, I get angry. Right? So we have to find something that you will like to do because the best exercise is one you'll do. If you hate it, you're not going to keep doing it. You're just going to be fighting yourself.

• 45:01Dr. Mary Claire Haver?

  Do you counsel someone differently if they have low bone density versus normal bone density?

• 45:06Speaker 00

  You know, it's not something I've had to treat yet. So I will say that, you know, somebody with low bone density, I mean, I usually send them off to a specialist. That's, that's not my area of specialty.

• 45:16Dr. Mary Claire Haver?

  It's rare, you know, sarcopenic obesity, I don't see a lot in my clinic because we do the body scans. But it's the thinner patients that are struggling because the heavier body that they had, that was actually protective because their bones and muscles were working harder for the heavier weight that they were carrying around. So we, I don't see so much of that in the obese patient.

• 45:33Speaker 00

  There's a few things you have to work on from a lifestyle perspective.

• 45:36Dr. Mary Claire Haver?

  Okay.

• 45:36Speaker 00

  Right? You've got to work on the, the diet. You've got to work on the movement. You've got to work on the self-concept. Self-concept is huge when it comes to obesity. Remember, a lot of women will gain weight because they don't want to be noticed. And then what happens is they realize that it's not healthy anymore for them to do that. And they want to lose weight, but then they start to get noticed again. And if they've had any sort of trauma in their life, that can be triggering. So getting the self-concept, and usually I'll tell a woman who is at the beginning of her journey to get used to how you look in the mirror and start really loving who you are now. There's, there's a lot to that, working

• 46:20Speaker 00

  with not hating the, the person in the mirror. It's a lot easier to get yourself to do something when you're not hating yourself.

• 46:28Dr. Mary Claire Haver?

  Yeah. The number one patient stop is gastrointestinal side effects. So we talked a little bit about constipation and magnesium oxide, you know, to help manage that. What are you backing off on dose? Like, how are you managing some of these other symptoms?

• 46:43Speaker 00

  Well, I use Drazepatide, first of all. That's the number one thing. But yeah, I usually find that if somebody has a lot of nausea, that's usually a cue to back off on the dose a little bit. Most of the time, if it's, if it's really bad, we can give them Zofran. Just remember the Zofran is going to make any constipation worse. You need to be careful. But also ginger. Ginger works?

• 47:04Dr. Mary Claire Haver?

  It's a nausea, anti-nausea.

• 47:05Speaker 00

  For nausea. And so I usually say, start with ginger. Let's see how you do and, and kind of move from there. And when I was working for the big telehealth clinic, I probably had 15,000 some odd interactions and I wrote maybe 20 Zofran prescriptions.

• 47:19Dr. Mary Claire Haver?

  How often are you following up on your patients? Like, how often are you monitoring? What does that look like? So that you get them started, off they go. When do you see them back?

• 47:28Speaker 00

  It's a medical partnership, right? So in the beginning, I see them a lot.

• 47:32Dr. Mary Claire Haver?

  Okay.

• 47:32Speaker 00

  About weekly. And then as things start to stabilize, it'll be every other week, but never less than once a month.

• 47:38Dr. Mary Claire Haver?

  So, once they reach their goal weight, what do you do? Do you take them off?

• 47:42Speaker 00

  No, it's a chronic disease.

• 47:44Dr. Mary Claire Haver?

  Do you back up on the dose?

• 47:46Speaker 00

  It depends. What, my philosophy about, about these medications is they're a lever, right? If you're a woman who wants to gain muscle, then we got to back your dose off so you can eat. Because if you, if you don't eat, you're not going to build muscle. It's really hard to build muscle when you're in a calorie deficit. That's almost impossible. It's really hard. And so I tell women, look, here's what we're going to do now. I'm going to drop you down to a lower dose. You're going to be hungry, or maybe, and you're going to lift heavy. And then, once we've done that build phase, maybe three months, let's, let's do a cut and we'll raise your dose and watch. This is exactly what bodybuilders do without it.

• 48:26Dr. Mary Claire Haver?

  Yeah, that's how they get ready for competition.

• 48:28Speaker 00

  Yeah.

• 48:28Dr. Mary Claire Haver?

  For patients who are not losing weight on a GLP-1, does that ever happen?

• 48:32Speaker 00

  It can. About, about 20% of patients lose less than 5%.

• 48:36Dr. Mary Claire Haver?

  Wow.

• 48:37Speaker 00

  That's what the data show. The thing is, is that that doesn't mean that it's not working, that it's not doing things behind the scenes to regulate blood sugar or even, even give you cardiovascular benefits. I mean, that was the biggest takeaway from the SELECT trial, but it's just what came to my mind is that regardless of weight loss, there's cardioprotective benefits.

• 48:57Dr. Mary Claire Haver?

  You mentioned the SELECT trial. Tell us, tell our listeners in lay terms, please, a little bit about it and why it was important.

• 49:03Speaker 00

  Yeah, so they looked at cardiovascular benefits with semaglutide in particular. And I think the biggest takeaway is that cardiovascular benefits. Are there regardless of weight loss?

• 49:14Dr. Mary Claire Haver?

  Wow.

• 49:15Speaker 00

  That was my biggest takeaway from it. Cardioprotective regardless of weight loss, patients in the trial with less than 5% weight loss still benefited.

• 49:22Dr. Mary Claire Haver?

  Wow.

• 49:23Speaker 00

  That's huge.

• 49:23Dr. Mary Claire Haver?

  What are those benefits? Like, what would that look like? Were they measuring, I don't know, cholesterol?

• 49:28Speaker 00

  No, 20% lower major adverse cardiovascular events.

• 49:31Dr. Mary Claire Haver?

  So they were just looking for heart attacks?

• 49:32Speaker 00

  Yeah, but these were, they only enrolled people who already had cardiovascular disease.

• 49:36Dr. Mary Claire Haver?

  Okay.

• 49:36Speaker 00

  So we don't know what it's going to be like in terms of cardio protection.

• 49:39Dr. Mary Claire Haver?

  So someone who had had a heart attack or had, you know?

• 49:43Speaker 00

  Yeah, somebody, anybody that already had it. And it was a 20% reduction in major adverse cardiovascular events. And so because of this trial, this is when the American College of Cardiology said, we have to treat obesity first. That is what brought them around.

• 49:56Dr. Mary Claire Haver?

  That's amazing.

• 49:57Speaker 00

  That's what brought them around to saying that obesity is a chronic disease. Because before that, it was all, you know, bro-science.

• 50:06Speaker 00

  But I think, I think also, it's really important to, going back to SELECT, is that we don't know what all of the anti-inflammatory benefits are of this medication, right?

• 50:16Dr. Mary Claire Haver?

  I give you that.

• 50:17Speaker 00

  And so what we can, what we can say is that obesity is inflammatory disease, hypertension is an inflammatory disease, diabetes. So if we can mitigate that inflammation, we may see a decrease in chronic disease across the board.

• 50:32Dr. Mary Claire Haver?

  I agree. Okay, let's talk about weight regain data. So people stop GLP-1s, they gain the weight back?

• 50:38Speaker 00

  They do. In the first year, it's 2/3 of the weight they lost. So that's why we don't stop. Just, just like any other medicine. What happens when you stop taking insulin, when you're a diabetic and you're insulin dependent? The reason why I love this data is because it is the biggest evidence we have for obesity is a chronic disease, a chronic relapsing disease, that when you stop the stimulus, the weight comes back. And some people are able to stop and maintain.

• 51:05Dr. Mary Claire Haver?

  I have, but not many.

• 51:06Speaker 00

  No. I don't know what the data are, but I can say that, for the most part, the brain will take you back. Because GLP-1 works not just on, you know, not just on the stomach, but it works on the, on the brain, the receptors of-

• 51:18Dr. Mary Claire Haver?

  Let's talk about that, because I think our listeners are really curious. How does this medicine work? Work. Why, where in the brain is it working?

• 51:24Speaker 00

  It works on dopamine signaling. Okay. So there's this, there's this thing that can happen with it. That's not truly a side effect because it hasn't been described enough called anhedonia. Have you seen that?

• 51:35Dr. Mary Claire Haver?

  Couple of times.

• 51:36Speaker 00

  Yeah. Yeah. So I call it the I don't give a shits.

• 51:39Dr. Mary Claire Haver?

  Loss of joy in daily things. So like a patient's complaint, you know, I've lost my libido. I don't want to go shopping. I'm not depressed, but things aren't making me happy anymore.

• 51:50Speaker 00

  Right. This is where I think that there's a good amount of research potential in addiction for these medications, especially at higher doses because of dopamine signaling.

• 52:04Speaker 00

  But if somebody gets all of their dopamine from food, and I was like that. So when I first started, I was like, why do I feel so crappy? Why do I just like, ugh? And I don't know how else to explain. It was just very blah. And I realized that it was because I wasn't able to get that

• 52:21Dr. Mary Claire Haver?

  That hit.

• 52:22Speaker 00

  From food. I just had to change the story about it. And then I was okay. That was fine for me, but that's not going to work for everyone. I'm, I'm somebody who, who spends a lot of time constructing stories to make my life mean something. And so when I changed the meaning, because I knew the medicine was working, it had to work for me. So I had to change that story. But there is that problem that some people just really feel crappy on it. And that to me is a signal that we just got to dial it down. And when it comes to weight loss, it didn't, you didn't gain weight in three months. Why expect that you're going to lose all the weight you gained in three months? I think it's very important to remember that we are treating a chronic disease and it, and we have to be patient. It all takes time.

• 53:08Dr. Mary Claire Haver?

  Let's move on to sleep.

• 53:09Speaker 00

  Okay.

• 53:10Dr. Mary Claire Haver?

  So my patients complain so much. And, and for me, I have to protect my sleep with my life.

• 53:16Speaker 00

  Sleep is important.

• 53:17Dr. Mary Claire Haver?

  With my life. Otherwise, I can't take it for granted. I can't expect to be able to have alcohol and sleep the same. And my little mean ring tells me, you know, like there are things like when I have caffeine, when I work out, like all of this will affect. Not just the hours I'm sleeping, but you know, we had a couple of sleep medicine specialists on recently who really talk about the architecture of sleep. So what are you seeing in your clinical practice for sleep and your patients?

• 53:45Speaker 00

  Well, oftentimes I'll see patients who have not, you know, they're perimenopausal and they're not sleeping. And, you know, those, those patients are usually pretty easy to treat. If you give them progesterone, they can sleep through the night, right? Again, it's increased follicle stimulating hormone, and then the sex hormones decrease and the sleep architecture just gets all messed up. But, you know, again, one to 12 times per night, the sleep deprivation then leads to the brain fog where difficulty finding words, and then cravings, and then weight gain, and then it's all back to that whole cycle again. Yeah.

• 54:16Dr. Mary Claire Haver?

  Are you finding that GLP-1s are helping with sleep at all?

• 54:20Speaker 00

  Some patients find that they help with sleep, but some paradoxically find that they don't sleep well if they take it before bed. It's so individualized.

• 54:27Dr. Mary Claire Haver?

  Right. So if you have a patient coming in and her main complaint is brain fog, what are you thinking? Like what's?

• 54:34Speaker 00

  Is she obese?

• 54:35Dr. Mary Claire Haver?

  Uh, sure.

• 54:36Speaker 00

  Okay. So we're going to treat-

• 54:38Dr. Mary Claire Haver?

  Most are.

• 54:38Speaker 00

  Yeah. Yeah. We're going to treat the obesity with a GLP-1. And I'm gonna find out what other symptoms are going on. You know, she's, she's 43, right? She's waking up at 3 a.m. progesterone. All right. Progesterone, and maybe even low dose estrogen, depending on her mood.

• 54:58Dr. Mary Claire Haver?

  True. The, the data out of Australia is clear. You know, new onset mental health with anxiety, your transdermal estrogens are going to be-

• 55:06Speaker 00

  It's, it's like a miracle.

• 55:07Dr. Mary Claire Haver?

  Your best bet.

• 55:08Speaker 00

  But also, we've got to look at the thyroid.

• 55:10Dr. Mary Claire Haver?

  True.

• 55:11Speaker 00

  I mean, somebody with brain fog-

• 55:12Dr. Mary Claire Haver?

  That's standard on my panel. Like, like, they, they get that before they even come through the door.

• 55:16Speaker 00

  I had one patient who had had a progesterone IUD placed, and she was really tired, really tired, really tired. And I said, well, maybe it's that IUD. And then I looked at her TSH, which was 50. I was like, oh, we need to treat your thyroid. Let's do that first.

• 55:28Dr. Mary Claire Haver?

  So we talked about semaglutide, the main GLP-1 that's being used. Tresepatide is different because it's the GLP-1 plus.

• 55:36Speaker 00

  Yeah, it's got insulin neotropic polypeptide.

• 55:39Dr. Mary Claire Haver?

  Yeah. And then there's something new on the horizon. Are you excited about it?

• 55:43Speaker 00

  I am so excited. Retachritide.

• 55:45Dr. Mary Claire Haver?

  Retachritide, okay.

• 55:46Speaker 00

  GLP-1, GIP, and glucagon.

• 55:49Dr. Mary Claire Haver?

  Okay, so it's like, it's like tirzepatide plus glucagon.

• 55:52Speaker 00

  Plus glucagon.

• 55:52Dr. Mary Claire Haver?

  Basically. Why would that?

• 55:54Speaker 00

  Glucagon ups your fatty acid oxidation.

• 55:57Dr. Mary Claire Haver?

  Okay.

• 55:57Speaker 00

  So fatty, fatty acid oxidation with more muscle preservation.

• 56:01Dr. Mary Claire Haver?

  Okay.

• 56:02Speaker 00

  And the, the phase two trials look amazing. They're still enrolling for phase three. And what's really interesting for me, because I'm on Reddit, there's a subreddit called Reddit. And the results that people are getting, and this, it's amazing.

• 56:15Dr. Mary Claire Haver?

  So when you say results, is this just weight loss? What are we talking about?

• 56:18Speaker 00

  Oh, weight loss, body composition, you know.

• 56:21Dr. Mary Claire Haver?

  Muscle preservation.

• 56:22Speaker 00

  But it's, it's mostly men. And remember, if you're taking, if you're taking retachritide now, retachritide now, you're using something that is not FDA approved, that is gray market, that is.

• 56:35Dr. Mary Claire Haver?

  People are taking it?

• 56:36Speaker 00

  Oh, yeah.

• 56:37Dr. Mary Claire Haver?

  I had no idea.

• 56:38Speaker 00

  Oh, yeah. And it's.

• 56:39Dr. Mary Claire Haver?

  I'm just waiting for it to drop.

• 56:41Speaker 00

  No, no, no, no.

• 56:42Dr. Mary Claire Haver?

  From the FDA.

• 56:42Speaker 00

  Now, research grade is available. You could take it now, just like all the other peptides. I really want to make, use caution there, because it's, you don't know what's in it.

• 56:51Dr. Mary Claire Haver?

  No.

• 56:52Speaker 00

  You don't know what's in it. As opposed to my friends in the compounding world, who will compound tirzepatide and will compound semaglutide. And if you're using a reputable compounding pharmacy, then, you know, I don't necessarily have a problem with that, as long as the pharmacy is good.

• 57:10Dr. Mary Claire Haver?

  Mm hmm.

• 57:11Speaker 00

  And usually it's because of cost.

• 57:12Dr. Mary Claire Haver?

  Mm hmm.

• 57:13Speaker 00

  But I haven't seen, I haven't seen appreciable differences.

• 57:17Dr. Mary Claire Haver?

  In outcomes?

• 57:17Speaker 00

  In outcomes.

• 57:18Dr. Mary Claire Haver?

  Between the.

• 57:19Speaker 00

  Between the compound and the name brand.

• 57:20Dr. Mary Claire Haver?

  Right.

• 57:21Speaker 00

  I haven't.

• 57:21Dr. Mary Claire Haver?

  Okay.

• 57:22Speaker 00

  So I don't, I can't, I can't say anything bad about it.

• 57:25Dr. Mary Claire Haver?

  Injection barrier. What if a woman won't inject herself? Do you have patients? I don't. They will, they will not get an IV. They will have a baby at home. They will, but they will inject themselves with a GI. That is how strong the pull to lose weight is?

• 57:40Speaker 00

  There's a greater conversation to be had about.

• 57:45Speaker 00

  The, the standards of beauty for women.

• 57:47Dr. Mary Claire Haver?

  Mm hmm.

• 57:48Speaker 00

  Like, what are they really based on?

• 57:51Dr. Mary Claire Haver?

  14 year old.

• 57:53Speaker 00

  12 year old.

• 57:53Dr. Mary Claire Haver?

  Post adolescent.

• 57:54Speaker 00

  Not even post adolescent, I mean, pubescent. But I think, I think it's important. So we've got, we've got strong social pull to be thin. But at what cost? And that's the problem. And, you know, seeing some of the celebrities that are really emaciated now, going back to that 90s heroin chic is scary. So the, the question was needle fatigue, right? Or, or being willing to give, give yourself a shot. I've had a couple of patients who are really afraid. They'll find auto injectors. So they'll get their compound or they'll get their vials from Eli Lilly and they'll use an auto injector because they're just afraid to put a needle in themselves. I'm a surgeon and I'm afraid of needles.

• 58:33Dr. Mary Claire Haver?

  Really?

• 58:34Speaker 00

  I, I, man, when I needed to get a shot, I would run the other way. So I took Depo Brevara for a little while and my nurse was going to give it to me and I just ran to the other side. I'm just, I, I am afraid of needles, but I inject myself every week. It's slow.

• 58:47Dr. Mary Claire Haver?

  Now, what about the new oral therapies that are coming down the pipe right now?

• 58:51Speaker 00

  I haven't had to prescribe those yet.

• 58:53Dr. Mary Claire Haver?

  Me neither.

• 58:54Speaker 00

  So we have Wegovy now that's at 25 milligrams, 15% body mass reduction. Okay. Wrapped in snack. Okay, don't ask me what that means, but it's wrapped in a special molecule so it won't get destroyed by the liver.

• 59:06Dr. Mary Claire Haver?

  In the gut.

• 59:07Speaker 00

  Yeah. That's proprietary and I think it's very important that anyone who is offering a compounded version of oral Wegovy, the, the coating is patented and you're not going to get that.

• 59:20Dr. Mary Claire Haver?

  Okay.

• 59:21Speaker 00

  And so what we've found is that there's, oral, oral forms don't work, but this one does.

• 59:27Dr. Mary Claire Haver?

  Okay. Because it's coated to.

• 59:28Speaker 00

  Yeah, it's got a special.

• 59:29Dr. Mary Claire Haver?

  Basically make it through without being destroyed by the gastric juices.

• 59:33Speaker 00

  But then we have a couple of interesting ones coming down the pipe, right? Orforglipron. And the R1, what is that? Orforglipron is really exciting because it has almost equal.

• 59:45Dr. Mary Claire Haver?

  Weight loss.

• 59:46Speaker 00

  Weight loss to semaglutide without, without having to worry about eating around it. So that's, that's going to be an interesting one if, when it gets approved. We might see that a lot more frequently. And then the other one, what's that other one?

• 1:00:00Dr. Mary Claire Haver?

  Uh, danuglipron?

• 1:00:02Speaker 00

  Oh, more side effects, tolerability challenges. These agents are really interesting because. Anything oral, you know, remember, everything goes through the liver, right?

• 1:00:11Dr. Mary Claire Haver?

  Right, right.

• 1:00:11Speaker 00

  Everything gets destroyed by the liver and the stomach. These, these agents actually kind of permeate the barrier and go into the bloodstream that way. So they're, they're really interesting agents.

• 1:00:21Dr. Mary Claire Haver?

  Wow. So they're kind of skipping that first class effect of the liver?

• 1:00:24Speaker 00

  They're, they're not peptides. They're these small molecules that resist enzymatic degradation.

• 1:00:30Dr. Mary Claire Haver?

  Okay, that's cool.

• 1:00:31Speaker 00

  Super cool.

• 1:00:31Dr. Mary Claire Haver?

  Well, we'll see. You know, my patients are super happy on their injections and do not want to stop.

• 1:00:35Speaker 00

  I haven't had anybody like, well, ask for an oral, I mean.

• 1:00:39Dr. Mary Claire Haver?

  They're like, it's working. I'm tolerating this. Like, why would I stop this?

• 1:00:42Speaker 00

  Exactly.

• 1:00:43Dr. Mary Claire Haver?

  You know, I'm very happy with my results and I don't want to switch to anything else. Giving myself an injection is not a problem. Now, if the cost came down significantly, that may tempt some patients.

• 1:00:52Speaker 00

  Well, cost is coming down. Semaglutide is off.

• 1:00:56Dr. Mary Claire Haver?

  Oh, since we've been prescribing it, it's down like 80%.

• 1:01:00Speaker 00

  Right, but also the, the patents are expired in Asia.

• 1:01:04Dr. Mary Claire Haver?

  Oh, wow.

• 1:01:04Speaker 00

  Let's say you go to India, they're, they're, you can get it for 30 bucks now.

• 1:01:08Dr. Mary Claire Haver?

  Amazing.

• 1:01:08Speaker 00

  Or maybe 15.

• 1:01:09Dr. Mary Claire Haver?

  Okay.

• 1:01:09Speaker 00

  So, I mean, I'm not going to make a trip to India like every month, but I'm just saying it's going to get cheaper.

• 1:01:16Dr. Mary Claire Haver?

  So the studies were not powered to look at menopause, but we're doing it, you're doing it. All my, you know, the whole menopause, most of them are prescribing it to some degree, HRT plus. And it's a game changer.

• 1:01:28Speaker 00

  I think it is, yeah.

• 1:01:29Dr. Mary Claire Haver?

  A total game changer on multiple levels, not just on what she weighs, but her inflammation, her sleep, her joint pain, her, you know, the combination really seems to be unlocking something and really giving her her life back.

• 1:01:41Speaker 00

  I agree. It, it's, to me, I mean, my personal feeling when I started taking this, I was, I write into my coach every week. I say, this drug is a fricking miracle.

• 1:01:51Dr. Mary Claire Haver?

  Yeah.

• 1:01:52Speaker 00

  Cause it, it really has helped me and, and it helps my patients. And one time I did a 10 day fast because I was a surgeon and I had to fast people all the time. I was like, let me see what it feels like to fast. And I like to have experience so that I can relate back to patients. And you know what happens after about five days without food? You start to feel really sad. And, and the reason I bring this up is that it's my experience with this medication. I understand. I struggled with obesity for 30 years plus. And understanding that it was a something, it wasn't something broken in me that I didn't have willpower. It was my metabolism that had changed was a game changer.

• 1:02:35Dr. Mary Claire Haver?

  Yeah, giving you, you back.

• 1:02:37Speaker 00

  Yeah, exactly.

• 1:02:38Dr. Mary Claire Haver?

  At your best self. Do you see a future? I mean, I'm doing it now. Where GLP one and menopausal hormone therapy kind of go hand in hand for a menopausal patient?

• 1:02:48Speaker 00

  I do, but not yet.

• 1:02:51Dr. Mary Claire Haver?

  Not yet.

• 1:02:52Speaker 00

  Probably, you know, we need, we need more research money. We need more data. We need to find out what's actually happening. We need to understand why the ovaries fail.

• 1:03:01Dr. Mary Claire Haver?

  People are looking at that, but only from a fertility standpoint, you know, or extending the life of the ovaries simply so she can stay pregnant or get pregnant later. I just want enough estrogen to keep my bones strong, lower my risk of heart disease, you know, and, and do keep my cognition humming the way it should be. You know, keep my general urinary system on point and let me go live my life.

• 1:03:24Speaker 00

  Exactly. I would love to understand why it is. I mean, it's, it can't just be because of fertility. There's got to be an evolutionary reason, but I intentionally didn't have a period all throughout my, through my residency. But then when I stopped the pill, I had, I got a fibroid up to here and had to have a urinary ablation. So it was, it was crazy. It was, I thought, I thought, well, I want to lose weight now because I was perimenopausal. Didn't know I was perimenopausal. And, and so I stopped the pill and then all of a sudden I was like,

• 1:03:51Dr. Mary Claire Haver?

  What is this math in my house?

• 1:03:53Speaker 00

  It's like, oh my God, I have cancer. Okay. So, so the question was more along the lines of, is it going to be standard care? Probably. But we need data and, and for that.

• 1:04:03Dr. Mary Claire Haver?

  Before the societies step up and like make guidelines. They, they, we're going to need the studies.

• 1:04:07Speaker 00

  Yeah. We need to, and I think that the studies need to be. They need to be, you know, free of commercial bias.

• 1:04:13Dr. Mary Claire Haver?

  True.

• 1:04:14Speaker 00

  And, you know, the, the, the problem is, is that there's no money in that. So how, you know, how do you get it done?

• 1:04:21Dr. Mary Claire Haver?

  Yeah.

• 1:04:22Speaker 00

  That's hard.

• 1:04:22Dr. Mary Claire Haver?

  So let's talk about the system and the fix and social media. There is a very loud contingent out there on social telling women that GLP-1s are a crutch, the easy way out, that they're cheating and you just need to try harder.

• 1:04:36Speaker 00

  Well, let's say that about Viagra.

• 1:04:39Dr. Mary Claire Haver?

  What do you say to that?

• 1:04:40Speaker 00

  No, really, I mean, would, would you say that about Viagra? Because Viagra was intentionally, uh, was, the first intention was to treat angina. Right? GLP-1s were first intended for diabetes. We found another use for them, to treat a chronic disease that wasn't a moral failing. The problem is, is that the residency system all by itself is broken. We, we, we destroy our doctors through residency. And it's almost like this same feeling when it comes to weight loss. Let's, you know, I had to suffer to lose weight, so because of that, so must you. Is it cheating? Not if you look at it as a chronic disease and you understand that it's a chronic disease. It's not for five pounds. It's not for 10 pounds.

• 1:05:24Speaker 00

  It's not to fit into a smaller clothes. You, you have to understand, we're looking at somebody who's had weight loss and weight regain and weight loss and weight regain over and over and over. By the time somebody's come to me, they've, they've tried and failed, tried and failed, tried and failed 20, 30, 40 times. This time it's going to be different. This time it's going to be different. And then inevitably it all comes back.

• 1:05:47Dr. Mary Claire Haver?

  If there's a clinician out there listening, um, you have this really unique background of, you know, 15 years as a practicing general surgeon. And then, you know, several years now, lifestyle, obesity medicine, totally just, you know, bringing women back their game medically, psychologically, you know, you're a part-time therapist probably as well. But if there's a clinician out there who is traditionally trained, the way we were trained, right? And hasn't, is, is hearing all this noise right now about how women are different than men, what actually menopause is doing, what, what message do you want them to hear?

• 1:06:23Speaker 00

  Well, I think it's, I think it's important that you understand that women navigate hormonal chaos from puberty to pregnancy. And then through the perimenopause and menopause transitions, our hormones are never stable. Men have stable hormones, for the most part. You know, they'll lose a little testosterone and we give it back to them. Right? It's, our hormones fluctuate because we 3D print humans. It's very important to remember that. We, we have this magical ability to create life. It's, it's really cool. Doctors don't understand that women are not small men. And I think that's, that's an important fact. Any woman who is presented to the doctor for weight loss has tried calories in, calories out, eat less, move more.

• 1:07:06Speaker 00

  They've really, they've really exhausted that. And a woman who continues to come back to the doctor in a system where she's been dismissed is persistent because she wants help. And I, I think that's important. And that woman who's sitting across from you as, as the person who hasn't, you know, maybe hasn't studied menopause or is starting to understand, you know, she's starved herself. She's counted her calories. She's exercised into oblivion. And she's probably been explained something by a man that she already knows more times than she's tried those things. So it's important that you meet her where she is and, and meet her with compassion and curiosity.

• 1:07:51Dr. Mary Claire Haver?

  Is there anything else you want to let, to the women listening out there who just feel like there's, they've just been gaslit, dismissed, and they're giving up? You know, this is what it is. What do you want to say to her?

• 1:08:02Speaker 00

  You're not broken. Midlife changes everything. Everything changes. It's your biology. No one told you it was coming either.

• 1:08:10Dr. Mary Claire Haver?

  Yeah.

• 1:08:11Speaker 00

  I mean, how many women have you spoken to that said, what the hell is happening to me?

• 1:08:15Dr. Mary Claire Haver?

  Thousands.

• 1:08:16Speaker 00

  Right? All of a sudden, I, I'm embarrassed, but I'm not embarrassed. It's a hot flash, right? But weight, weight gain in midlife women is physiological and predictable. We know this now. The burn rate goes down and you can't out calorie, count, count yourself out of it. It's going to happen. It's predictable. We can work on it. Resistance training. I mean, that's, that's the number one longevity hack. And sleep.

• 1:08:45Dr. Mary Claire Haver?

  Yeah.

• 1:08:46Speaker 00

  And fiber. You don't have to white knuckle through it. If, if, if you start gaining weight and you, you rapid, rapidly the weight comes on and all you're doing is thinking about food and you're craving food. We have medication, medication that can help now. And the other thing I want to say to the women is that if, if your doctor dismisses, you go get another doctor. There's a million doctors in this country. You don't have to go to a doctor that makes you feel like crap.

• 1:09:09Dr. Mary Claire Haver?

  Yeah, it's okay to fire them and, and find someone else.

• 1:09:12Speaker 00

  Absolutely.

• 1:09:13Dr. Mary Claire Haver?

  So if someone's starting a new start for GLP-1 and say she gets it from someone who hasn't given her a lot of information, what are your top three tips for her?

• 1:09:22Speaker 00

  So first one is don't go up too fast.

• 1:09:25Dr. Mary Claire Haver?

  Okay.

• 1:09:25Speaker 00

  It's not something that you want to race to the top. It's never a race to the top. It's a race to effectiveness, first of all. So when your, when your appetite and your cravings are managed, then stay at that dose as long as you can. Let's milk as much out of it as we possibly can. And then we'll step it up slowly.

• 1:09:42Dr. Mary Claire Haver?

  Good advice.

• 1:09:43Speaker 00

  Eat protein. Eat more protein than you think you can tolerate. It, it, it's the magic sauce for menopause and, and midlife. It's very important.

• 1:09:52Dr. Mary Claire Haver?

  One of the most important to me findings from the Women's Health Initiative, you know, they followed these women after they were off hormones for decades, right? And we're still collecting data.

• 1:10:01Speaker 00

  Mm hmm.

• 1:10:02Dr. Mary Claire Haver?

  Was when they looked at frailty scores, amount of protein in their diet was the most predictive measure.

• 1:10:10Speaker 00

  Wow.

• 1:10:10Dr. Mary Claire Haver?

  Of her chance of being frail was how much protein. So the women in the highest quartile of protein intake had the lowest frailty scores.

• 1:10:19Speaker 00

  Well, then.

• 1:10:19Dr. Mary Claire Haver?

  Regardless of their weight.

• 1:10:20Speaker 00

  Even more reason to eat more protein.

• 1:10:22Dr. Mary Claire Haver?

  Yeah.

• 1:10:23Speaker 00

  Gram of protein per pound of ideal body weight. And that's the start. That's really the start. And there's a lot you can learn from bodybuilders. Not the guys who are like doing T, but, but they do understand weight loss. They do. The, the problem is, is that most of them don't understand female biology.

• 1:10:40Dr. Mary Claire Haver?

  Yeah.

• 1:10:40Speaker 00

  So we have to take the good with the bad. But the third tip I would say is it's gotta be a slow process. You didn't get here overnight. You're not going to get there overnight. Enjoy every second of this journey and love yourself through it because no one shamed themselves into weight loss and felt good about it.

• 1:11:01Dr. Mary Claire Haver?

  Awesome. Well, Dr. Michelle Gordon, thank you for coming on UnPaused.

• 1:11:05Speaker 00

  Thanks for having me.

• 1:11:08Dr. Mary Claire Haver?

  You can find Dr. Gordon through her website at drmichellegordon.com or on Instagram at DrMichelleGordon. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at DrMaryClaire and get honest and accurate information on health, fitness, and navigating midlife at thepauselife.com. My new book, The New Perimenopause, is available now everywhere and anywhere you buy books and through our website. If you're loving this podcast, be sure to click Follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and be sure to share the show with the women you love. We would be so grateful. You can also find full episodes

• 1:11:48Dr. Mary Claire Haver?

  on YouTube at DrMaryClaire. UnPaused is presented by Odyssey in conjunction with Pod People. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on UnPaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment.