The Truth About Your Biological Clock: Egg Quality, AMH and Fertility with Dr. Natalie Crawford

In this episode of unPAUSED, Dr. Mary Claire Haver sits down with Dr. Natalie Crawford, a double board certified obstetrician, gynecologist, and reproductive endocrinologist, and author of the new book The Fertility Formula. Both physicians open by sharing their own fertility journeys, including pregnancy losses and dismissal from the medical system, before turning to the science that most women are never given access to. Dr. Crawford challenges one of the most persistent myths in women's health: that the biological clock is about running out of eggs. It is not. It is about egg quality, and those are completely different problems with completely different solutions. She explains how inflammation damages the chromosomes and mitochondria inside eggs, how chronic inflammation can actually deplete the ovarian reserve by penetrating the ovarian vault, and why the standard message to women, hurry up or give up, is not supported by the science. Guest links Natalie Crawford, MD https://www.nataliecrawfordmd.com/ Natalie Crawford, MD https://www.instagram.com/nataliecrawfordmd/ (Instagram) Natalie Crawford, MD https://www.tiktok.com/@nataliecrawfordmd (TikTok) Natalie Crawford, MD https://www.threads.com/@nataliecrawfordmd (Threads) Natalie Crawford, MD https://www.facebook.com/nataliecrawfordmd/ (Facebook) Natalie Crawford, MD https://www.youtube.com/c/NatalieCrawfordMD (YouTube) Natalie Crawford, MD https://www.linkedin.com/in/natalie-crawford-md/ (LinkedIn) Books “The New Perimenopause,” https://thepauselife.com/pages/the-new-perimenopause-book by Dr. Mary Claire Haver “The New Menopause,” https://www.amazon.com/New-Menopause-Mary-Claire-Haver/dp/1785045547 by Dr. Mary Claire Haver “The Fertility Formula,” https://www.nataliecrawfordmd.com/book by Dr. Natalie Crawford https://thepauselife.com/blogs/the-unpaused-podcast/the-truth-about-your-biological-clock-egg-quality-amh-and-fertility-with-dr-natalie-crawford

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

• 0:00Dr. Mary Claire Haver?

  Because there was so much to cover with Dr. Natalie Crawford, we've broken down this episode into two parts. This is part one, and we will publish part two later this week.

• 0:09Speaker 01

  Fertility is a health marker. An entire issue of fertility and sterility was talking about how women who have infertility have higher risks later in life. Cardiovascular disease, cancer, metabolic syndrome, stroke, earlier death. Does infertility cause any of those? Absolutely not. But it is the predisposing state that puts you at risk for infertility. So chronic inflammation can cause infertility and puts you at risk for these other things. So I think it's really important because women specifically are brilliant, educated, and we can tolerate really hard news. But we have to know it to just dismiss it and say, that's too scary. I'm not going to tell Mary Claire that her infertility is going to cause her to be at risk for these diseases later because there's nothing she can do about it.

• 0:54Speaker 01

  Yeah, we can't rewind the clock and change the infertility, but we can change our entire health starting today.

• 0:58Dr. Mary Claire Haver?

  Yeah.

• 1:09Dr. 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 one of my favorite humans in medicine, and I want to tell you exactly why before I even say her name. I followed her on social media for years before I ever met her in person. Genuinely impressed by her ability to take the most complex reproductive medicine and make it accessible without losing an ounce of the science. That's harder than it looks. But here is what I understood once I actually got to know her. This is not a wellness influencer.

• 1:54Dr. Mary Claire Haver?

  This is a physician who lived the failure of the system and rebuilt herself around fixing it. And that is exactly why I identify with her the way that I do. Because I've lived it too. I have polycystic ovarian syndrome. I've had two miscarriages. I navigated intrauterine insemination and ovarian drilling to have my children. I am a board certified OB-GYN who had been practicing medicine for years through all of that, and I still did not have the full picture of what was happening in my own body. This is not a personal failure. This is a system that was never designed to give women this information. Before you think this episode may not be for you because you're past the fertility chapter, stay with me.

• 2:38Dr. Mary Claire Haver?

  What happens to your ovarian function in your 30s and 40s does not stay in your 30s and 40s. It shapes your perimenopause, your metabolic health, your brain, and your bones. The fertility story and the menopause story are the same story. Your biological clock is not about running out of time. It's about egg quality. Those are completely different problems with completely different solutions, and almost nobody is telling women that. Women are being told to hurry up when what they actually need is information about what they can do starting now, not in a panic at 38. So when today's guest, Dr. Natalie Crawford, a double board certified OB-GYN and reproductive endocrinologist,

• 3:20Dr. Mary Claire Haver?

  asked me to write the foreword for her new book, The Fertility Formula, I said yes before I finished reading the ask. I believe in this information with everything that I have. I love this book for every woman who was where I was. I especially love it for my daughters because the information they deserve to have about their own fertility should not have to wait until something goes wrong. I'm Dr. Mary Claire Haver, a board certified obstetrician and gynecologist and 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.

• 4:12Dr. Mary Claire Haver?

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• 4:57Dr. Mary Claire Haver?

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• 5:25Dr. Mary Claire Haver?

  Dr. Natalie Crawford.

• 5:27Speaker 01

  Hi, thank you so much for having me. I'm so excited.

• 5:30Dr. Mary Claire Haver?

  Welcome to Unhaused. I want to start with your fertility journey. I think that really grounds who you are. I talked about a little bit in the intro, but walk us through what happened to you.

• 5:43Speaker 01

  You know, a lot of people think I became a fertility doctor because of my own fertility journey. But the truth was, I was already on this path. And I'll preface this by saying it was really hard for me because going through infertility really made me start to doubt my abilities as a fertility doctor, which was wild, right? If I can't get myself pregnant, what does that mean about my ability to help get other people pregnant? And I was so unprepared for that going into my own family planning journey because we didn't talk about fertility. The mentality at the time was 100% just prevent, prevent, prevent, and then start trying and just hope everything works out.

• 6:20Dr. Mary Claire Haver?

  I'm sorry, there's another way?

• 6:21Speaker 01

  Wait, yeah, I mean, pull the goalie and try, right? And just see what happens. And then we had pregnancy loss after pregnancy loss. So after our first one, you'll relate to this, it's so clinical about it. We just had just how we're trained. I recited the statistics, went out of four pregnancies. It wasn't meant to be, probably genetically abnormal, no big deal. And I remember my husband feeling really upset about it, and I was the one who was so clinical about it. The second pregnancy loss, I was chief resident on labor and delivery. And I was further along, so I felt really confident. The lines got darker, everything was looking great. And I was working nights. And I was at Parkland, it was crazy busy residency program. I'm the single person in charge of who's having a delivery done.

• 7:06Speaker 01

  And I started cramping and bleeding in the bathroom and had to deal with it and get back to work. And I remember just really compartmentalizing it and delivering other people's babies while I was losing my own. And I was shocked, you know, driving home, the pain was so bad, pulled over the car and threw up. Sat there thinking, I've sat on the other side of the table with so many women who've gone through this, but it's physically and emotionally terrible. And feeling in my gut like something was wrong and going to my doctor then, after the second loss and saying, I've had two pregnancy losses, something's wrong. And was told, well, we don't do a workup until you've lost a third. Go fail more, try again, lose a pregnancy.

• 7:50Speaker 01

  Had no blood work done, told it was just must be bad luck. You know, and of course I followed instructions, right? I was really, I was in residency, so I was gonna listen to what was told to me and tried again and lost another pregnancy. And at this point, had the full workup done. Everything was normal. So it was unexplained pregnancy loss and I was told, just, just bad luck, keep trying or do IVF. And I was into my fertility fellowship now. Ended up having a fourth pregnancy loss. And then that's really where we kind of started saying, what do we do now? And it was an interesting time period for us because going through it yourself really makes you question your body.

• 8:33Speaker 01

  And sitting on the other side of the table, being dismissed, really makes you evaluate what it's like to be a patient in this world, especially as a woman. You've been through training, you know, I think a lot of people haven't too. There's this doubling impact of when you care for other people, how we put our health so low on the totem pole.

• 8:50Dr. Mary Claire Haver?

  I had losses too, right? After fertility treatment, so like couldn't get pregnant, finally got pregnant. All my friends are having babies, right? I'm sure you were doing the same thing. And like you telling that story, I like, I'm like still in labor and delivery, like cramping and bleeding and like getting my coworker to come in the triage room with me. And putting the speculum in and she's saying your cervix, this doesn't look good, you know, and like laying on that table.

• 9:16Speaker 01

  Yeah.

• 9:17Dr. Mary Claire Haver?

  You know, and knowing I have to get back to work. There's no one to take my shift.

• 9:20Speaker 01

  Right. No, there's, there's no leaving work.

• 9:22Dr. Mary Claire Haver?

  And like I checked out and immediately walked over to the floor. They admitted me for pain control because it was so bad.

• 9:29Speaker 01

  Yeah.

• 9:29Dr. Mary Claire Haver?

  You know, and then I got IV Finnegan back when they still did that. And then I ended up with a vasculitis from that, you know, because the morphine made me so nauseated. I was vomiting everywhere. It's like it was yesterday.

• 9:41Speaker 01

  I know. I have two beautiful kids now, right? I had four pregnancy losses and two kids and I'm so thankful, but every time it's like the wound is still there. You never fully heal from it. And yet, yet women often suffer alone in silence. I mean, I didn't tell my friends until I had to, not because I didn't want to, but it got to a point where I didn't know how. And then how do you say, I lost my third pregnancy when they didn't know about the other ones?

• 10:07Dr. Mary Claire Haver?

  Mm hmm.

• 10:08Speaker 01

  It really became such an isolated time and it was so hard to go through it and really evaluate what kind of physician am I? Like, how have, how have I treated the people who've been going through this?

• 10:23Dr. Mary Claire Haver?

  Mm hmm.

• 10:23Speaker 01

  Right? Because it was so eye opening how painful it was, how emotionally it was, how I had one doctor tell me, well, you weren't that far along. Like when I was grieving about it, that dismissive made me feel like I didn't have a right to grieve it because other people had it worse. And yet it was such a terrible loss and it makes you doubt your body and your future. Did I do this to myself because of training? We know female physicians have double the rate of infertility. So it was a terrible experience that really, I can talk about it now because I'm looking back through the rear, rear view mirror.

• 10:57Dr. Mary Claire Haver?

  With two healthy kids at home.

• 10:58Speaker 01

  Yeah.

• 10:58Dr. Mary Claire Haver?

  Yeah.

• 10:58Speaker 01

  So I can talk about it now and know that these are the kids I'm supposed to have. And it really changed the trajectory of how I practice, what I'm passionate about and what I do. But I have to applaud the women who are sharing their fertility journeys in the moment, no matter what it is, their health journeys, right? Because I didn't do that.

• 11:17Dr. Mary Claire Haver?

  Yeah.

• 11:17Speaker 01

  There wasn't Instagram to share back then, but how raw and vulnerable that is because, like you and I, like we've been friends for a while, but now like connecting on a deeper level because we've been through this shared experience.

• 11:28Dr. Mary Claire Haver?

  And it's so common.

• 11:29Speaker 01

  It's so common. Yeah. One out of four pregnancies will end in a pregnancy loss and that rate increases as we get older.

• 11:34Dr. Mary Claire Haver?

  And then 10 years later, you find out why.

• 11:38Speaker 01

  Yeah. 10 years later, I ended up getting a diagnosis of celiac disease.

• 11:42Dr. Mary Claire Haver?

  And for our listeners.

• 11:43Speaker 01

  Oh, yeah.

• 11:43Dr. Mary Claire Haver?

  What is celiac disease?

• 11:45Speaker 01

  Fair. It's essentially an allergy to gluten. So gluten, which is in a lot of our amazingly delicious foods like breads and pastas, causes an allergic correction in your body. And for the most part, it's often diagnosed younger. Many people get diagnosed as a child because they don't gain weight, or they have GI problems that are really bad. And my diagnosis was really interesting, you know, back when I was trying to get pregnant and having all these pregnancy losses, everything was normal. We were told to do IVF. I was okay doing IVF, but I was a first year fellow and I was IVF fellow. That's how fellowship is. So after OB-GYN training, it's three years of fellowship. It's a year and a half of clinical work doing IVF and a year and a half of research. So I couldn't go through IVF while I was the

• 12:30Speaker 01

  one doing IVF. And then the weird way of the world, that was fine, right? So I said, okay, but if we're going to do IVF, what do I need to do to prepare my body? How do I get in the best place? We have the best chance of success. And I was told it doesn't matter. There's nothing you can do. IVF will take care of it. This is just bad luck. IVF will put odds in your favor. And that was really hard, like to believe, just when you think about all the questions you have. Am I eating the right thing? Am I running too much? You know, what about stress levels? And was really dismissed on all of it. But I knew some people had bad looking eggs and not all sperm quality was equal. So my husband and I really went on this journey of saying, what can we do to try to have the best eggs and sperm possible? And in that journey, learning about inflammation and learning

• 13:14Speaker 01

  about the research, which became a big passion of mine, but I did cut out gluten because I felt more inflamed. I would tell you, I felt fatigued when I had it, just like tired in the afternoon. And end up getting pregnant before we did IVF with my daughter and then stayed pregnant. And that's a whole journey too, right? Because that whole pregnancy, I was ready for the shoe to drop.

• 13:35Dr. Mary Claire Haver?

  Yeah.

• 13:36Speaker 01

  Whole time.

• 13:36Dr. Mary Claire Haver?

  Oh, God.

• 13:37Speaker 01

  I, you know, one of the things I tell my patients is infertility steals the joy and the naivety of pregnancy away. Right? Like, I didn't, I saw my friends as happy pregnant people. I got maternity photos a week before I was due because a photographer friend finally was like, you have to let me document this. You know, I was just like, something's gonna go wrong. And I remember when she was born, like, I'm gonna cry now, but I'm not a big crier. I, I'm medical training, a lot of ways, like puts, allows you to compartmentalize your feelings like really well very often. And when I held her, I, I sobbed. It was just like this thing I really didn't believe, even when she was inside of me, was going to happen.

• 14:14Dr. Mary Claire Haver?

  I used to go to the bathroom and I would wipe and I would hold the tissue out and I would look away and I'd be like, one, two, three, look.

• 14:24Speaker 01

  Like preparing yourself.

• 14:25Dr. Mary Claire Haver?

  I was preparing myself in case there was blood, like for months, you know?

• 14:30Speaker 01

  No, I've done it too.

• 14:31Dr. Mary Claire Haver?

  I mean, she's living proof that an ultrasound a day won't kill your baby because I had access and I just want.

• 14:37Speaker 01

  Same. I was in a fertility clinic and my daughter got an ultrasound every single day of her life.

• 14:42Dr. Mary Claire Haver?

  I just wanted to see her heartbeat to make sure she was real.

• 14:46Speaker 01

  I'm the same, right? And then you get like what physiologic discharge of pregnancy and I get be like, something's wet. I'm bleeding, right? Like I was, you know, realizing that we put these, you know, markers. Once I, once I get this happens, then I'll feel better and.

• 14:58Dr. Mary Claire Haver?

  Once you hit viability.

• 15:00Speaker 01

  And then you just worry about new things and new challenges. And then I got pregnant with my son, who, I love both my kids so much, but it was such a different experience with my son because I got pregnant with him postpartum. Cause I wasn't gonna go back on birth control. It took us years to get pregnant, all the pregnancy losses. I wasn't even sure if we'd be ready to ever go through that again mentally or emotionally. But I was still not eating gluten. We were still being very anti-inflammatory and I got pregnant with him. And it was a really different experience, not going through all the loss and being pregnant with him. And it really healed my heart in a really special way. But so it was wild to get the diagnosis of celiac 10 years later.

• 15:42Speaker 01

  And eye opening too, right? That it wasn't unexplained. It wasn't bad luck. There was actually a very definitive reason why one caused by the choices I was making because I didn't know. Nobody tested for it. Nobody talked about listening to your body for clues that it's responding abnormally to the world around you, or that your cellular or metabolic health isn't optimal. They just said, bad luck, do IVF. And IVF is incredible and magical, right? So I do want to frame that it's helped 17 million babies be born since its existence.

• 16:13Dr. Mary Claire Haver?

  That's wild.

• 16:14Speaker 01

  Incredible. So nothing against it. You know, I even think back and say, like, would I have had success, right? Like, my egg quality was obviously a huge piece of this puzzle and implantation when I was consuming gluten. And if I'd gone through IVF while still eating gluten, would I have had pregnancy loss, bad embryo development, all the things that were going on, right? Probably so. So these are things that we have to bring, you know, more forefront in the discussion.

• 16:40Dr. Mary Claire Haver?

  Right.

• 16:40Speaker 01

  So that women can be more educated and informed and a better advocate for their own health, because we really are not taught to do that.

• 16:48Dr. Mary Claire Haver?

  Talk to me about fail first and why that's a problem.

• 16:52Speaker 01

  The definition of infertility right now is trying to get pregnant for 12 months. And based on population data, right? Those are the prevalence of infertility, when the majority of people would be pregnant, and this is how they made that conclusion, that when this definition came about, 85% of people would be pregnant after one year of trying. So the 15% deserve to work up at that moment. Now, if we want to be very specific, 72% of people get pregnant in the first six months. So actually, the majority of people, if you're going to get pregnant without intervention, it actually happens in those first six months.

• 17:23Dr. Mary Claire Haver?

  Does age matter?

• 17:24Speaker 01

  Age does matter. It makes it harder to get pregnant as we get older. But we still see the same trend, meaning those first few months that you're trying, you have the highest rates, and then it starts to drop, meaning less and less get pregnant the longer you've been trying. And even when you're young, if you've been trying for a year, your odds of getting pregnant naturally are going to drop. Let's say you're 30 and you're starting for the first time, your odds of getting pregnant naturally would be about 20% per month. And if you've been trying for a year, those odds are now 4% to 5% per month. And you've been trying for two years, 2% to 3%. Importantly, two to three percent, four to five percent, those numbers aren't zero, but they're substantially lower, meaning something is more likely to go on. But we've seen rates of infertility are rising.

• 18:09Speaker 01

  Those are old stats back from when I first started training a decade ago. The rate of infertility, we used to say is one out of eight, which is what that population data gave us. And now it's one out of six. And if you're in the United States and you're trying to get pregnant for the first time, it's going to be one out of five couples will experience infertility. So 20%, that's a high number. If we couple that with the fact that many women are waiting longer to get pregnant, it is harder to get pregnant.

• 18:34Dr. Mary Claire Haver?

  Right. We've just, you know, we've talked about this earlier on the podcast, but we're now in a time period for the first time in history where more women over 40 are having babies than under 20.

• 18:45Speaker 01

  Yeah, we see less teen pregnancies, more women getting pregnant older. That's really reflective of societal change. But it does not make sense to say, I'm not even going to do testing on you until you failed and then we'll do the testing. Because what we're talking about here is the evaluation to see if certain parts of your reproductive system are intact. A pelvic ultrasound, checking your ovarian reserve or how many eggs you have, checking to see if your partner has sperm. And Claire, do you know how many people come to see me and they've been trying for more than a year? You know, a variety of ages. And then we go find out their partner has zero sperm. And think about looking back saying, my gosh, I just saw a couple like this. They've been trying for three years. Three years and he has zero sperm.

• 19:29Speaker 01

  So she looks at me, she goes, so those three years, all these months, we were trying and thinking about.

• 19:34Dr. Mary Claire Haver?

  The stress.

• 19:35Speaker 01

  All of it, yeah. We had a 0% chance of conceiving each one of those months. And I said, that's true, right? That's not fair. In addition to the fact that it takes time to work these problems up, I really think that as infertility is rising, as women are waiting to start families later, good for them. Chase big dreams, right? We need a more proactive approach. And this includes testing earlier.

• 20:00Dr. Mary Claire Haver?

  Okay.

• 20:00Speaker 01

  Right? A more kind of preventive care model. Let's make sure there's no problems before we just say, go give it a go and come back if it doesn't work.

• 20:15Dr. Mary Claire Haver?

  The word at the center of your book is inflammation.

• 20:19Speaker 01

  Yeah.

• 20:20Dr. Mary Claire Haver?

  And it's a buzzword on social media.

• 20:22Speaker 01

  Apparently it is.

• 20:24Dr. Mary Claire Haver?

  But tell us what inflammation actually does to the fertility system. So what is the fertility system, by the way? What does it take to get pregnant?

• 20:31Speaker 01

  Oh, lovely question. Many women don't really understand how, you know, the brain, ovaries, and uterus are really connected. Right? So the brain, I like to think about as central command station, interpreting hormone signals from your entire body. And then it's going to send out signals to allow you to ovulate. Right? And we want to think about the egg. It's going to allow an egg to grow. That egg is going to make estrogen. Estrogen talks back to the brain to communicate that a mature egg is there. And it's really specific. 200 picograms of estrogen for 50 hours is a signal high enough to get the brain to send out an LH surge to ovulate. And then you'll ovulate. And then the brain continues to send out LH to make progesterone. So the brain talks to the ovary. The ovary grows and egg makes hormones. Those hormones talk back to the brain, but also talk to the uterus and prepare it.

• 21:16Speaker 01

  Estrogen grows the lining. Progesterone then opens and closes the implantation window. We want to think about what it takes to get pregnant. We'll just say in women, we'll leave men out of it for a hot minute. We need, the brain has to be able to interpret hormone signals. So it has to be able to hear.

• 21:31Dr. Mary Claire Haver?

  When does that not happen?

• 21:32Speaker 01

  Yeah. So your brain doesn't see your ovaries. And I think this is a really important concept. It has no idea what is happening. It is relying on the signal. So let's imagine we're friends on walkie talkies. Right? If inflammation is static interference on the radio, the brain can't hear whatever signal the ovaries trying to send. And so it's going to misfire, send off abnormal signals. And that static can come from a few different things. So that static is most commonly coming in from chronic inflammation and from insulin resistance. And insulin resistance is one of the top causes of chronic inflammation that we can dive into. But essentially, inflammation is a normal part of your immune system. Right? You get a cut, your body heals, acute inflammation. And I'd like to preface and say,

• 22:17Speaker 01

  inflammation is actually really important in getting pregnant. When you ovulate. That follicle, the egg grows inside a follicle, it gets bigger, it ruptures, allows the egg out and has to reform. And so your inflammatory system comes and heals that little spot where you ovulated from. And in fact, if you take anti-inflammatory medication like NSAIDs, ibuprofen, Eli, Motrin, you'll prevent the follicle from rupturing. You'll get hormonal changes of ovulation, but you won't have an egg released. So that's really important because some women have middle schmerz, that middle pain. Yeah, who say, I can feel myself ovulating because they feel that cyst bursting or they feel when the ovary is heavy from that bigger follicle.

• 22:59Speaker 01

  And if you go take ibuprofen, when you feel that, you can prevent that follicle from actually allowing the egg to be released. So inflammation is important, but what's bad is the difference in chronic inflammation, right? So when the immune system is constantly activated, then we see a shift in how your body is going to respond because it's not meant to be exposed to that chronic inflammation. I explain it to patients as imagine there is a lever and we call this your inflammatory burden because inflammation is all around us. We're not going to go down to zero. But what we're trying to do is actively keep the lever as low as possible on any given day in the environment that we're in so that we have the resilience to respond to the night

• 23:41Speaker 01

  you get less sleep or the day that you do have a lot of stress or the crappy food you ate on the plane over. So we want to be able to have response to tolerate these acute inflammatory moments. But when you constantly have a burden that's up here, what starts to happen, it changes how your cells function on multiple ways. So static interference on the radio, the brain gets really worried, it can't hear signals, starts to not send out the signals that it needs. You also, chronic inflammation directly impacts the ovary profoundly. So the ovary now can't respond to the signal that's coming in. It also is going to damage the cells around the egg. So now the egg can't make the hormones it needs to. And it can get inside the egg and damage the chromosomes and the mitochondria.

• 24:24Speaker 01

  And then to double down more, inflammation is one of the few things that can get into what I like to call the vaults inside the ovary. You know, you and I have the same favorite graph talking about how many eggs you're born with and how many exist when at birth and when you start puberty. Because we know we're born with all our eggs, we run out of them over time. And I like to think about them as in that vault inside the ovary. And every month you have a little group coming out of the vault. Very few things can get into the vault. Most of us are born with a number and we just lose over time. But chronic inflammation gets inside the vault. And so when we are exposed to chronic inflammation, not only does it damage our eggs, changes our ovarian response, changes our brain's interpretation response. It actually decreases the number of eggs we have inside the vault. So we run out of eggs faster.

• 25:07Dr. Mary Claire Haver?

  How does inflammation impact us, you know, once we're past the fertility age?

• 25:11Speaker 01

  Exactly the same way, right? You and I are very passionate that the ovary is the most interesting part of our body and so important for your health. So we want to think about inflammation, just as you're trying to get pregnant. Ovarian health and hormone function and being able to interpret your body's signals is all interfered by inflammation. And then especially once we get into perimenopause, menopause, we don't have that reliable, high estrogen, which is anti-inflammatory. We start to feel the burden of this inflammation even more. So it's even more important anytime we have this hormonal change, that we are moving the levers where we can. So that we can feel the best that we can, but also so that our ovaries can function in the best way that they can.

• 25:54Speaker 01

  We don't even make it harder for them as they're already getting to a place where they're starting to have less eggs.

• 26:00Dr. Mary Claire Haver?

  You say something in the book that, and I want to reiterate this, you talked about luck. And you say, and this is a quote, fertility is not a matter of luck. I was taught, you know, I trained a few years before you, that a huge percentage of it was just bad luck, right? We knew that there were some chromosomal abnormalities and some genetic things. But outside of that, there was no discussion around

• 26:25Speaker 01

  I know.

• 26:26Dr. Mary Claire Haver?

  diet, nutrition, exercise, stress reduction, sleep, and how all of that could affect your fertility. I mean, it's a miracle I got pregnant in the middle of a residency program.

• 26:34Speaker 01

  Same.

• 26:35Dr. Mary Claire Haver?

  You know, and not, not a shock that I lost pregnancies during that same time. And so to continue the quote, it is the net sum choices you make throughout your life. What does that mean?

• 26:45Speaker 01

  So there's no one single choice that's going to get you pregnant or prevent a pregnancy. But we really start thinking about how chronic inflammation can impact us in so many different ways. It really does impact our ability to get pregnant. And if we want to think about luck even more, you don't control luck at all. But we know if you have intercourse the day you ovulate, you have significantly higher chance than if you have intercourse two days after ovulation when the chances are zero. That's not luck, that's knowledge. We also want to think about the fact that all of these different lifestyle factors significantly increase inflammation. And we have a plethora of data that it can take you longer to get pregnant and you can have worse outcomes with IVF. It's none of this data's all or nothing, right?

• 27:30Speaker 01

  So if you smoke cigarettes, am I going to sit here and say you can't get pregnant?

• 27:33Dr. Mary Claire Haver?

  No way.

• 27:33Speaker 01

  No, but can I say it will be harder for you? You'll have more miscarriage, more genetic abnormalities. You'll actually go into menopause earlier, right? You'll have higher rate of preterm birth, all the complications that come from, we'll say, one exposure. And this is an interesting example because everybody accepted cigarette smoking was really bad really quickly. But there's so many other things that cause inflammation that are also harmful to our body and sometimes in multiple ways, that we are more hesitant as a community to accept. The biggest pushback I get is that it's fear mongering or that it causes blame. And here's what I have to say, because I went through it and you did too. Fertility is a health marker. An entire issue of fertility and sterility was talking about how women who have infertility have higher risks later in life. Cardiovascular disease.

• 28:19Speaker 01

  Cancer, metabolic syndrome, stroke, earlier death. Does infertility cause any of those? Absolutely not. But it is the predisposing state that puts you at risk for infertility. So chronic inflammation can cause infertility and puts you at risk for these other things. So I think it's really important because women specifically are brilliant, educated, and we can tolerate really hard news. But we have to know it to just dismiss it and say, that's too scary. I'm not going to tell Mary Claire that her infertility is going to cause her to be at risk for these diseases later because there's nothing she can do about it. Yeah, we can't rewind the clock and change the infertility, but we can change our entire health starting today. Yeah, and we deserve to have that knowledge. And I think women really, fertility is a nice time, right?

• 29:04Speaker 01

  It's a health marker, not just getting pregnant, it's a state of your body's health. But it's often the first time in a young woman's life that she is trying something outside the norm, right? We go through this weird phase where you see a pediatrician, and then you go off to college, and then maybe you see an OB-GYN and get some birth control. But you don't usually have any medical problems that get diagnosed before then. So suddenly you're at this position, if you're not getting pregnant, it's the first red flag your body might be waving. You know, especially if you haven't learned to track your cycles or listen to your cycle for a clue.

• 29:38Dr. Mary Claire Haver?

  Talk to me about infertility in general. You mentioned men. So if a couple comes to you and they've tried for a year and they're not pregnant, how much of it is female? And I want people to understand this. You know, how much is female, how much is male factor?

• 29:52Speaker 01

  Fifty percent of infertility is female, fifty percent is male.

• 29:55Dr. Mary Claire Haver?

  Do you guys hear this?

• 29:56Speaker 01

  Fifty fifty. If we want to be actually more specific, one third is only a female factor, one third is only a male factor, and one third has combined factors, both female and male. And that's important too, because I often have women come in and say, well, then why is it always the woman who goes first to go get evaluated? Well, because healthcare is not female centric, right? It is always placing blame on the woman. Women have always carried the burden of the pregnancy, of the gestation, of the health of that baby. But sperm health contributes to the placenta, right? You have higher risk. This placental disease, preeclampsia, earlier birth, based on the help of the sperm. That's what part of what the sperm genome contributes to. So men have to be a part of this discussion and the good news for them

• 30:41Speaker 01

  is that sperm is constantly made every single day, right? 1,500 sperm a second. And so men are packaging up brand new DNA in the sperm. It gives us incredible opportunity to make a change that might seem like not very much and have completely different sperm counts. Sperm are highly sensitive. So unlike women where your eggs do have some resilience and there's not one single change that will usually make it or break it. For men, one single decision can actually destroy your sperm counts. Now, the good news is it's often reversible.

• 31:11Dr. Mary Claire Haver?

  Yeah.

• 31:11Speaker 01

  But let's use cannabis, everybody's favorite, right? So cannabis use can decrease.

• 31:16Dr. Mary Claire Haver?

  That would be marijuana if you don't know what cannabis is.

• 31:18Speaker 01

  Marijuana and including in edibles, right? THC. So we see a lot of.

• 31:23Dr. Mary Claire Haver?

  So you don't have to smoke it?

• 31:24Speaker 01

  You don't have to smoke it. So it's not the act of smoking. It's actually what it's doing inside your body. And it does cause inflammation. It also impacts brain function and testicular function. So men have lower production of sperm and testosterone because sperm and testosterone are made together. The brain signals them. And then also, and more concerning, we see increase in fragmentation of the DNA inside the sperm head. So it's impacting how the DNA is packaged. If a man is using cannabis in any form, so say he's smoking weed, his partner has a significantly higher rate of pregnancy loss, even if she's never around it at all. Talk about one single decision that is impacting your fertility. And every time I say this, people will say, well, I smoked all this pot and I have babies.

• 32:07Speaker 01

  And there's always going to be individualized experience and that's great. But this is even more important if you are, they'll say you're older. So you're starting to try for your family older. We don't want to waste time and then find this out and then have to wait three months for sperm to regenerate. Being more proactive and I love this talk of trimester zero. Like what can we do before we get pregnant, the three months beforehand? That's the lifespan of sperm. And we do see that eggs are most sensitive in the 60 days before they ovulate. So when I see a couple who says, well, we want to be pregnant soon, but not yet. This is an incredible opportunity to say, let's take these three months, do the opposite of what we did, which was just try.

• 32:47Dr. Mary Claire Haver?

  Right.

• 32:47Speaker 01

  But let's actually prepare and try to decrease inflammation as much as possible so that we have the best egg and sperm quality leading into this pregnancy attempt.

• 32:55Dr. Mary Claire Haver?

  Okay. We'll dig into some of the particulars around that.

• 33:00Dr. Mary Claire Haver?

  Welcome back to another Midi Pause. I'm Dr. Mary Claire Haver, host of UnPaused. When it comes to your skin, there is no one-size-fits-all solution. Key hormones like estrogen and testosterone fluctuate during various life stages and can have a variety of effects on your skin, especially during midlife. When estrogen declines in perimenopause and menopause, you may notice changes. It's all normal and natural. The good news is Midi Health offers effective skin treatments for visible signs of shifting hormones. Midi's science-backed solutions can help nourish, revive, and protect your skin now and for years to come. The loss of estrogen during menopause accelerates the aging process faster

• 33:43Dr. Mary Claire Haver?

  than anything you've experienced up to this point. We can expect to lose 30% of our collagen in the first five years of menopause. Yes, you heard that right, 30%. I see this all the time in my patients and have experienced it personally. Women will say, "My skin just doesn't look like it used to," or "Nothing I'm using is working anymore," and they're right, because hormonally changing skin needs a different approach than what worked in our 30s and 40s. Many skincare ingredients, including vitamins A, B, and C, are commonly used in routines focused on supporting skin during midlife. Some studies have shown that topical Estriol cream may significantly improve signs of aging. We know estrogen plays a

• 34:27Dr. Mary Claire Haver?

  key role in skin health, things like hydration, elasticity, and collagen production, and supporting that can make a real difference. Midi offers an Estriol Plus Face Cream, which is designed specifically for this stage of life. Progress starts with a personal plan. Booking your first virtual visit with Midi Health takes less than 10 minutes. It's important to talk with a clinician who really understands what you're experiencing. That's personalized care. Midi Health is setting a new standard for healthcare. As the nation's fastest-growing women's telehealth company, Midi provides accessible, insurance-covered services. Midi fills the critical health gaps women face in perimenopause and menopause. If you

• 35:11Dr. Mary Claire Haver?

  want a clinician in your corner who understands what your body and skin need right now, that's exactly what Midi is there for. Go to joinmidi.com. Join m-i-d-i dot com and connect with one of their clinicians today.

• 35:28Dr. Mary Claire Haver?

  Let's talk about the biological clock.

• 35:29Speaker 01

  Oh, yes.

• 35:30Dr. Mary Claire Haver?

  Because the data is really different than what most women have been told or not told. You say that fertility is often capped 10 years before menopause because of egg quality. But what does that mean?

• 35:41Speaker 01

  Yeah, most women think that there's this magic cliff at age 35.

• 35:45Dr. Mary Claire Haver?

  Yep.

• 35:46Speaker 01

  I asked them to-

• 35:46Dr. Mary Claire Haver?

  I was taught that. I was advanced maternal age.

• 35:48Speaker 01

  Yes. And if I ask them to explain why, most women think it's because they're almost out of eggs. The number of patients I have who schedule an appointment for me because it's their 35th birthday has passed. That's the number one appointment type I see. Hey, I'm 35, so I'm infertile now, or I'm almost out of eggs. The majority of women are nowhere close to out of eggs at age 35. If we go back to my favorite analogy, the vault, right? You're born with all your eggs. Every month, a group of them comes out of the vault. One is randomly chosen to ovulate, the rest of them die, and the next month you have another group. Now, when you are younger, the vault is more full, more eggs come out every month. As the vault starts to get emptier, fewer eggs come out every month. So imagine there's a bouncer at the room trying to keep the room at the right amount of people.

• 36:32Speaker 01

  Someone's really crowded, he's shoving more out, and as it starts to get empty, he doesn't want as many people to leave. An average 30-year-old would have 20 eggs coming out of the vault. So she would ovulate one and 19 would die. So much loss. An average 40-year-old would have eight eggs coming out of the vault. One would ovulate, seven would die. Yes, count does go down. And for all of us, we will reach a threshold where we are out of eggs. And you can go through that earlier. So we can have premature ovarian failure. That does happen. But what happens and is more profoundly impactful for our fertility is that since our eggs are inside our body our entire life, they absorb the wear and tear of the world around us. And we see a change to both the genetic normalcy of our eggs and the egg function or quality or health.

• 37:16Speaker 01

  Think about mitochondrial function, the ability of the egg to make hormones and do all of its other function. What we know, and I like to tell my patients, imagine your chromosomes are like kindergartners in alphabetical order. Because female chromosomes are 46 XX. So inside your egg, they're held 23X, 23X, held apart by these myotic- Spindles proteins, held apart by little proteins. And they stay that way from when you're born. They're frozen. Until you ovulate. This is the wildest thing. Yeah. So then when you ovulate, they split apart and half of them go into the egg. The problem here, when you're 20, your proteins are really strong, so most of them are in the correct spot. But when you're 40, absorbing that wear and tear, a lot of these proteins have broken down. So your chromosomes don't split normally. They've gotten out of line.

• 38:01Speaker 01

  It's like if I've asked the kindergarteners to stand there for 40 years instead of 20 years. And then to make matters worse, this is another place where inflammation doubles down. Because inflammation impacts egg function, mitochondrial health directly. But also, imagine it's like bringing puppies into the room of your chromosomes. Like the kids get out of order, directly impacting those proteins, holding your chromosomes in a perfect position. So it does get harder because of this egg quality, genetic normalcy and egg competency. But it's not usually at age 35. At age 35, about half your eggs are genetically normal and half are not. It's really important for somebody to know, I don't have a test for egg quality right now. I cannot test the function of your eggs. Okay?

• 38:44Speaker 01

  I can test genetics of the egg, once it's been made into an embryo, an IVF. And we use that data to extrapolate the percentage of genetically normal eggs at any given age. So 50/50 at age 35. Well, at age 30, it was about 60 to 70% normal, so it has dropped. But you still have a good egg count. Most women at age 35 will have around 14, 15 eggs outside the vault. So 50% of that's still a really good number. The problem is that number starts to more rapidly drop as we get older. So at 38, it's more like 30, 40%. And then at 40, it's more like 20, 25%. So we start to see a more profound drop after age 38 in the number of eggs that are genetically normal.

• 39:29Speaker 01

  Now, not all 38-year-olds are created equal, and this is important too. As a population, we get more metabolically unhealthy as we get older. So there is both tincture of time, but the lifestyle choices and inflammation add up a lot. And I think it's important in this discussion, and you'll probably ask. But we should talk about ovarian reserve tests and how that play into the biological clock. Yeah. So most people think, oh, egg count is the end of the puzzle. And there is a test for how many eggs that you have, and it's pretty controversial, shockingly to me. When we think about this, I don't know when we'll run out of eggs. But I can evaluate the eggs outside the vault. I can't see inside the vault, so I don't know. But if in general, when the vault's more full, it sends out more.

• 40:13Speaker 01

  If I test the eggs outside the vault, I can at least get an idea what's inside. So I like to think about these tests of ovarian reserve as putting you in a category. Are you normal for your age, above average, below average, critically low?

• 40:25Dr. Mary Claire Haver?

  What is that test?

• 40:26Speaker 01

  There's a couple of different, but the best one is an AMH.

• 40:29Dr. Mary Claire Haver?

  AMH.

• 40:29Speaker 01

  Antimalarian hormone. AMH is made from the granulosa cells. The cells that surround every follicle. So more eggs in, more eggs out, more AMH. The body's not perfect. So again, the 30 year old with 20 eggs outside the vault, we can see a 25% variation month to month. So she might have 21 month, then 16, 22. And if I point checked in AMH each of those months, it would fluctuate. However, it would all stay within her category. So that's why we don't want to think about a point value. Because women do get really freaked out, rightly so. We don't understand the test. And let's say you had one that was 2.5 and then a year later it's 1.5. You're going to do the mental math and say, man, I'm going to be out of eggs in a few years. And that's not reality because it does hop back and forth.

• 41:13Speaker 01

  So it's not telling us that you are fertile. It's not telling us you will have any problem getting pregnant or that you won't. But it is an important data piece telling me how many eggs you have right now. And that's important because even if your ovaries still function and everything else is perfectly normal. If you have low ovarian reserve, my big question is, why? Why? Right? Because you might get a diagnosis. Maybe you have an autoimmune disease. Maybe you have Hashimoto's. Maybe you have endometriosis. Maybe you have a toxic exposure that you could change, right? Maybe you stop smoking cigarettes when you get this data. So it might impact your health right now, regardless of children. But also it might impact your family plan immensely.

• 41:57Speaker 01

  And so this is why it's kind of crazy that it goes against ACOG's recommendation.

• 42:01Dr. Mary Claire Haver?

  And to be clear, ACOG is American College of OB-GYN and they do not recommend doing AMH testing.

• 42:08Speaker 01

  Outside of, are you a candidate for IVF?

• 42:10Dr. Mary Claire Haver?

  Right?

• 42:11Speaker 01

  Correct. They don't recommend AMH outside of an infertility evaluation. The problem here is that

• 42:17Dr. Mary Claire Haver?

  But you do it.

• 42:18Speaker 01

  I do it. And I, and I tell everybody they should do it. I tell all my OB-GYN colleagues too. I said, if you sit across the table from a woman and you ask, are you trying to get pregnant? No. What birth control do you want? The next question should be, do you want kids one day? Should we test your ovarian reserve? And here is why. ACOG says that it's too distressing for a woman to find out she has

• 42:39Dr. Mary Claire Haver?

  Stop.

• 42:39Speaker 01

  Too stressful, too distressing for a woman

• 42:41Dr. Mary Claire Haver?

  Stop.

• 42:42Speaker 01

  To find out she has low ovarian reserve if she's not trying to get pregnant because it does not mean you can't get pregnant.

• 42:48Dr. Mary Claire Haver?

  Natalie.

• 42:49Speaker 01

  That's why it's the

• 42:50Dr. Mary Claire Haver?

  What?

• 42:50Speaker 01

  Literally the thesis of the whole book. Can't make decisions on data you don't know. And so they are taking agency away from women out of the presumption.

• 42:58Dr. Mary Claire Haver?

  We can't handle the truth?

• 42:59Speaker 01

  That the data you are going to get is too stressful and that you won't make different decisions about it. But women will make different decisions based on this data every single day. And it's not ACOG's decision about what you do. It should be yours.

• 43:11Dr. Mary Claire Haver?

  Yours.

• 43:12Speaker 01

  Women will, there are a group of women who will run out of eggs and they will sit across from me and here's the conversation we have. One, why, right? So we're going to do the why, do an evaluation. But two, if you have a low egg count, you will go through menopause early. You have less time to grow your family. You will have fewer eggs with IVF and egg freezing. So that'll be an uphill battle. Therefore, the sooner you do it, the easier it will be because quality will be more in your favor. And controlling the lifestyle factors because it's even more important because you don't have as many eggs to work with. So of course you want to decrease inflammation and have the best quality possible.

• 43:49Dr. Mary Claire Haver?

  You know, and I'm thinking of the downstream effects of osteoporosis

• 43:52Speaker 01

  Of course.

• 43:53Dr. Mary Claire Haver?

  And cardiovascular disease and all the things we know that POI puts you at risk for.

• 43:57Speaker 01

  If you know you're at risk for going into ovarian failure early, right?

• 44:00Dr. Mary Claire Haver?

  Right.

• 44:01Speaker 01

  From a family planning lens alone, you might Try sooner. Maybe you have a partner and you are waiting for this perfect career moment, but you're faced with, that may not happen for me, or maybe I won't have the size family I want if I don't start now. Maybe you will freeze eggs, maybe you will freeze embryos, maybe you'll get pregnant on your own with a sperm donor. Maybe you'll do none of those things, but you will say, I got to make the decision. I didn't let time make it for me. And then to your point, if you don't know something's going to happen in your future, you will go through years of feeling like crap until you get that diagnosis versus women. I say, your AMH is low, your AMH is under one and you are 30. I will tell a woman, there is no way you're going to go through menopause at 51, 52.

• 44:43Speaker 01

  Like this, you're not going to make it. You are already in a low account at a really young age. You're not going to go through menopause tomorrow, but you should know when you start having these symptoms, you are the candidate who peri-menopause will strike in your 30s. You will need earlier hormone replacement therapy if you do not want to have earlier onset of dementia, heart disease, osteoporosis. But women are not even given that opportunity to think about, think about the years of preventive care of bone building they could be doing, of how they could restructure their entire life, let alone children.

• 45:14Dr. Mary Claire Haver?

  I treat the downstream of all of this.

• 45:16Speaker 01

  You know, and I see the epidemic of frailty and osteoporosis we have in this country and dementia. A thousand percent. So we are sitting at the opportunity, I know you agree with me, someone say this.

• 45:28Speaker 01

  I strongly believe that as a physician, my job is not to be the gatekeeper of you getting data about your body. I do not believe that in this calendar year of 2026, where we have easy access to technology, lab draws and tests. I also think you are smart enough to understand how I'm helping you interpret it. Right? Yeah. AMH is a complicated test, but it's one example. But you very well may make different decisions now and in the future based off of it. And at the end of the day, that should be your right to make.

• 45:57Dr. Mary Claire Haver?

  How much is an AMH?

• 45:59Speaker 01

  $79 if your insurance does not cover it. Right? Cheap. This is crazy.

• 46:04Dr. Mary Claire Haver?

  So for women who have had a child in their late 30s, early 40s, and I stopped doing obstetrics in 2018, I was still delivering babies, but just in a hospital setting. Now that we have this, you know, older cohort of women having children, we're rolling right from postpartum into peri-menopause.

• 46:24Speaker 01

  Yes.

• 46:24Dr. Mary Claire Haver?

  And are you, how are you counseling those patients?

• 46:27Speaker 01

  This is a great question because so many women.

• 46:32Speaker 01

  Are just not given basic information, even if their doctor knows or thinks it across from them. And this is one thing I stress to people is just one phrase like,

• 46:42Speaker 01

  "Hey, Mary Claire, your egg count is low." So after you go through growing this baby for nine months and recovering postpartum, you may not resume ovulating again. You may be in menopause or perimenopause, and this is what you should look out for. That sentence took me less than one minute to say and completely changes how you think about your postpartum experience and will allow you to not dismiss yourself, gaslight yourself from your symptoms, because we all know postpartum is a crazy time. But you'll be able to get care earlier because you've had that nugget of information. So I really believe as healthcare professionals, we have to start empowering patients when we have the data in front of them. So any woman who's older, if you're 40 and older, you may come out of that pregnancy because you're still losing eggs all of those months.

• 47:27Speaker 01

  There's nothing we can do yet that can slow down the rate of loss of eggs from the vault. So while you are pregnant, while you are breastfeeding, while you are postpartum, you are still losing them. You are getting into those lower counts of your eggs. So as you have children earlier, we need to be more mindful about, "Oh, I'm not breastfeeding anymore. My period hasn't coming back, and I still feel these estrogen low symptoms." You know, I try to tell my patients, and I sit in a unique space because I don't, I haven't delivered a baby now since 2013, but I get to see them when they're early pregnant and, you know, a year before them. But I get to tell them, "Hey, your egg count's so low that if you stop breastfeeding, your period doesn't come back, and you still feel like you did initially postpartum." Like, do not pass go.

• 48:11Speaker 01

  Like, go call your OB-GYN. This could be perimenopause or menopause. You need to get an evaluation because we know the sooner we get them on hormone therapy, the better their postpartum experience is going to be.

• 48:22Dr. Mary Claire Haver?

  One of the statistics that shocked me and I didn't realize until I read this recently was how much bone we actually lose during pregnancy and postpartum from the hypoestrogenic state. Well, and postpartum, really. And that younger patients bounce back. Their bones will rebuild. It's just a blip. Unless you go right from postpartum to perimenopause and now you have a double acceleration. So when I now have patients who had babies in their 40s, I am getting a bone density go.

• 48:52Speaker 01

  Well, that's another test, very similar to AMH, and this is more in your world than mine. But like, do you, should you really have to wait till 65 to get a bone density?

• 48:59Dr. Mary Claire Haver?

  I think 45.

• 49:00Speaker 01

  That's how I had my celiac diagnosis. So I ended up having peripheral neuropathy develop. And that was enough to get my attention, right? Cause you know, I mean,

• 49:10Dr. Mary Claire Haver?

  And to our listeners, what is peripheral neuropathy?

• 49:12Speaker 01

  If you think about your hands or your feet going asleep, I had my fingers and my toes were both asleep. And it just didn't get better. And in fact, it was kind of getting worse, like growing up like a stocking. And I was like, I can't do my job. What's going on? This was bad enough to get me in. And I had some other very vague symptoms, right? I felt fatigued. I was like really afternoon sleepy. I felt kind of bloated, but you know, I'm over 40 at this time. Like, these are the things that happen. And I go into my doctor and in the evaluation of this, they get a full body MRI. I mean, almost a full body MRI. They were really afraid I had MS. So I get an MRI and I didn't have multiple sclerosis, luckily. But the radiologist, I had a really good radiologist, I guess, because they said this patient needs a DEXA.

• 49:54Speaker 01

  Her bones don't look dense enough on an MRI. So I got a DEXA done and I was osteopenic at the age of 41, which is not what you should be, right? For the listener, the current recommendation is not to get a bone density scan until you're age 65.

• 50:09Dr. Mary Claire Haver?

  Unless you have severe risk factors.

• 50:11Speaker 01

  Yeah. So I would not have fallen into that category and have risk factors. My lovely PCP, who's an incredible family physician, said, you know, instead of just, oh, well, so this is highly abnormal, right? Something's going on causing both of these things. This is not a coincidence, right? I strongly believe that for a lot of things. We also have these little symptoms that don't seem like much, but when you put them all together, it's not coincidental, like something is really happening in your body. And then ended up getting the diagnosis that I wasn't absorbing and it was celiac. And cut gluten out of my diet, worked really hard to rebuild my bones. And I sent Vonda a screenshot of my latest DEXA where I no longer have osteopenia.

• 50:49Dr. Mary Claire Haver?

  Dr. Vonda, right?

• 50:50Speaker 01

  Yes, and I was, because it is very hard to build backbone after you're 40. And so It's not impossible, but it is work. Living proof that it's not impossible, but you have to make active choices. Again, you have, but you have to know the data about your body to be in a position where you can know what choices to make and to prioritize doing it. And that's really what you and I both share. It's what the book is about, too. How do you empower people with knowledge that they can be an advocate? Like you deserve information about your body. You have to know what's normal. So you can sit there when things are abnormal. And really, we have to relearn how to have agency over ourself. Because when we've been dismissed, we start to dismiss our own symptoms. And then we have to get really sick. You have to not feel your fingers before you go to the doctor.

• 51:35Speaker 01

  Because the mild symptoms, we don't trust our body anymore. Talk to me about a period. Let's go back to our younger listeners. Cause I, I know that our listeners will start sending this to their daughters. You know, most of my listeners are past fertility age. Well, you have a whole, you have a whole new group of perimenopause. So, yeah, I mean, we, for daughters, for, especially in the perimenopause phase. That's when a lot of women actually learn about their periods for the first time. And so you say our periods are a vital sign. Vital sign. What does that mean? It's telling you so much about your body. So let's, let's do the menstrual cycle in one minute. Okay. Okay. You've got the group of eggs coming out of your vault. Each egg grows inside a follicle.

• 52:16Speaker 01

  The brain is going to send out the signal FSH, follicle stimulating hormone. It's actually named for what happens in women. Men have FSH too. Does a different job, right? FSH and LH help control sperm production. So FSH in women get an egg to grow. As the egg grows, gets bigger, makes estrogen. That estrogen is going to talk back to the brain. This is called the follicular phase, first half of the cycle. From when you start your period until when you ovulate. Estrogen dominant, meaning you only have estrogen, no progesterone. This is going to be of varying lengths depending on how many eggs that you have. When estrogen is at its peak, going to talk back to the brain. Brain will send out a surge of LH, luteinizing hormone. But the follicle rupture, like we talked about, and that's ovulation.

• 53:00Speaker 01

  And then that same follicle will reform and become known as the corpus luteum, a cyst that will make progesterone. And this is going to be the luteal phase driven by the corpus luteum and LH or luteinizing hormone from the brain. Progesterone will be made in pulses. Corpus luteum cannot live for more than two weeks, so it will die and you'll get a period. The exception there is if you get pregnant, when you get pregnant, the pregnancy hormone HCG and LH share a receptor on that corpus luteum stimulate more progesterone. But what's really interesting is that it's not just when your period comes that's important. I mean, it is, but really learning about ovulation and how long your follicular and luteal phases are, because your body is meant to give you a lot of information about your

• 53:44Speaker 01

  hormones based on your menstrual cycle. Yet, when did you learn to track your cycle?

• 53:49Dr. Mary Claire Haver?

  Never. I mean, I, no, I was Catholic. I'm Catholic. And so I went through pre-cana, which is preparation for marriage.

• 53:58Speaker 01

  Yes.

• 53:59Dr. Mary Claire Haver?

  And they briefly mentioned, you know, natural family planning and tracking cycles. And they brought in a couple who were doing that. Well, I was an OB-GYN. Like, I was like, yeah, yeah, yeah, whatever. That was the first time like I'd heard it. I'd heard it. And then when I did my fertility rotation, like, kind of

• 54:14Speaker 01

  A little.

• 54:14Dr. Mary Claire Haver?

  A little bit mentioned, but really.

• 54:17Speaker 01

  We're not ever really taught about this. And we live in an interesting space with technology. And I think a few things are important for people to know. When you're using an app, that is your marking cycle day one. And this app is telling you, this is your fertile window. The fertile window is defined as the five days before and then the day you ovulate. That's because the egg can live for 24 hours, but sperm can live in the female body for up to five days. The app is detecting this fertile window and your ovulation date purely by what's called the calendar method. It's assuming your luteal phase is 14 days in length, subtracting it, plopping it on a calendar. It is only correct 20% of the time. So it's a wrong vast majority of the time. Yet, many women are using that

• 54:59Speaker 01

  to do their period tracking, using it to try to conceive, which can be a problem. But more than that, we have lost the leverage of using our cycle as a tool. And what I mean by that is if I want people to think about ovulation on a spectrum, we tend to think about it as, are you ovulating or not? But there is a quality to your ovulation that's giving us subtle clues about how the brain and ovary are communicating. So one of the first stages of ovulatory dysfunction is a short luteal phase. The corpus luteum cannot live as long as it needs to, either because its foundation wasn't good, the follicle it came from wasn't strong enough, didn't have a good foundation for the house, or the brain's not sending out enough signals, probably because there's interference on the radio. So having a luteal phase that's

• 55:42Speaker 01

  less than 11 days in length is called a short luteal phase. That's one of the first warning signs if something's going on. But if you're just tracking cycle day one on your app, you're never going to be notified of that. The other opportunity is when your follicular phase is either really short or really long. This is often a reflection of how many eggs you have. So if you have a high egg count, and think about it in the disease state, PCOS or polycystic ovarian syndrome, one of the things that happens then is you're born with a high egg count. So your vault is sending out more eggs every month, which is fine, but your brain doesn't know this and sends out its normal amount of FSH, so it's getting diluted. So an average PCOS patient, if you don't have as strong of a signal, you need a longer signal. It takes longer time to see FSH before your

• 56:26Speaker 01

  egg will kick off. So you tend to see those longer cycles that are spaced out, but it's the follicular phase that's really long. So follicular phase that's longer than 20 days is not normal, no matter what your luteal phase is. Similarly, if your follicular phase is really short, we tend to see this as your egg count gets lower. So one of the first signs we see clinically of reproductive aging or having a low egg count would be that your cycles have shortened. I used to have 28 day cycles and now they're 24, 25, exactly. And specifically, if we look at it and it's the follicular phase that's shortening, because now instead of 20 eggs, you have 10. Each egg is now getting double the signal, so it starts growing faster. That becomes harder to get pregnant as well because the lining's not having as much estrogen to grow as thick of a uterine lining,

• 57:11Speaker 01

  and you're probably timing things wrong based on some of your apps. So having an abnormal follicular phase is giving you insight as well. And then we do start to see just the irregularity, the not being able to predict. You should be able to have that calendar and put your finger on it and be within a couple days of when your period comes. And I see a lot of patients who have irregularly regular cycles, like not skipping full months, but maybe to be four weeks, maybe to be five weeks. Like, we don't really know when it's coming. And it should be tighter control. When the brain and ovary can really communicate, it is a very synchronized clock.

• 57:44Dr. Mary Claire Haver?

  So what would a healthy period look like? You know, when you're, someone listening out there, like, how do I know if I'm normal and I need to worry about this?

• 57:53Speaker 01

  The vast majority of people are gonna have cycles that are going to range between 26 to 32 days, and it should come within one to two days of normal. But you should track your ovulation, and the way you can do that can be with what we call fertility awareness methods. And this can be your basal body temperature, based on the fact that after you ovulate, the corpus luteum makes progesterone. Progesterone raises your core body temperature. So if you see your body temperature rise by 0.4 degrees Fahrenheit. I used to hate this, right? In transparency, early days of fertility doctor, these were, you know, mercury thermometers, special graph paper, and it's highly influenced.

• 58:28Dr. Mary Claire Haver?

  I did all of that.

• 58:29Speaker 01

  I did too. I hated it as a patient as well. This is where tech has been great, because with wearables, we have increased sensitivity, checking data points multiple times throughout the day. So Oura Ring, Apple Watch, Whoop, natural cycles have put us in a position where we can really target ovulation really nicely. And so that's a nice one. Even if you don't want to get pregnant, you just want to leverage your period as a vital sign, because if you know when you're ovulating, you can then flag, oh, my luteal phase is short. That could be thyroid, that could be prolactin, I could be running too much. My brain could have a signal that's off. So you start going down this short luteal phase pathway, because something's off. You now use your period as a vital sign. But if you were just looking at if it's coming regularly, it would still be coming every

• 59:14Speaker 01

  26 days. It's knowing that the luteal phase was short, that's really kind of clue you in. The other ways to track ovulation for somebody to know is gonna be, one can be also with cervical mucus. As estrogen raises, the cervical mucus, the cervix is the entry to the uterus, and it has this mucus barrier to prevent anything from getting inside, except when you ovulate, when of course we want sperm to be able to go through. It becomes sticky, stretchy, like an egg white. The key here is to wipe first. Many women will sit down, go to the bathroom, and it's so stretchy, you can just fall in the toilet. So wipe first, look. You know it when you see it. It looks just like a stretchy egg white. The last day of type four cervical mucus is considered ovulation day. And the third option is urinary hormone measurement, so LH testing,

• 59:59Speaker 01

  which can be an ovulation predictor kit.

• 1:00:00Dr. Mary Claire Haver?

  It did all that too?

• 1:00:01Speaker 01

  Exactly. And so you ovulate the day after you have a positive LH surge. So this is going to allow you not just to know, are my cycles regular? But are the phases of my cycle really normal? And leveraging that cycle is a true vital sign. And the other piece as we have to mention is you shouldn't bleed through your clothes. And your periods shouldn't be so painful that they prevent you from doing things that you want to do in your life.

• 1:00:23Dr. Mary Claire Haver?

  I tell patients, your cycle should never disrupt your life.

• 1:00:26Speaker 01

  It should not. You should know it's there.

• 1:00:28Dr. Mary Claire Haver?

  Yeah, right. Like with stuff you buy at the grocery store, you know, like you should, it should never be an issue in your mind that you can't do something.

• 1:00:36Speaker 01

  Yeah, you're going to cancel plans with friends where you're going to bleed through your clothes. I mean, I have, I have a physician friend who's a doctor, right? And she said, oh, well, I can't wear this because I'll be on my period. So I'll be bleeding through my clothes all day. And I'd be like, time out, stop. Like, that's not normal. Lo and behold, she had uterine fibroids that were never diagnosed and got them diagnosed, got them removed and then doing great. So even physicians, right, have, we're just, there's so much stigma with menstruation that we feel like we just have to tolerate whatever's given to us. And we assume that we don't tolerate it as well as everybody else.

• 1:01:09Dr. Mary Claire Haver?

  Right.

• 1:01:10Speaker 01

  Instead of really being told, no, if you bleed through your clothes, that's not normal. And I believe you and we need to see why. If your pain is so bad that you're missing out on things, that's not normal and we should evaluate why. If you have pain, so you can't have intercourse, not normal, right? We need to evaluate why and what is going on. So I love the discussion where we are talking about what a normal cycle is because it should be something that isn't so disruptive and isn't adding the stress or the strain to your life. And shouldn't be something that you just hate when it comes every month.

• 1:01:44Dr. Mary Claire Haver?

  You in the introduction of fertility formula, I mean, like for those watching on video. She matches her book, by the way. When it comes to your health, hormones and fertility, you deserve to be the one in control of your future. What is, what does it feel like when that happens? I never had that opportunity.

• 1:02:02Speaker 01

  I didn't either, really, right? And in fact, thinking about the damage I've done to my own body, all these years of inflammation, undiagnosed celiac, you know, I don't like it, but I, I like knowing now. You can handle any deck of cards that I put in front of you, but you need to know what cards you have. And that's really what this is about. It's not about doing some perfect checklist. It's about living your life with intention and knowing that you're in the position where you're making the choices you make from a place of knowledge, instead of just letting things happen around you.

• 1:02:38Dr. Mary Claire Haver?

  Okay. In your book, you say the single biggest thing a woman can do for her hormonal health is not found in a pill.

• 1:02:43Speaker 01

  Yeah.

• 1:02:44Dr. Mary Claire Haver?

  But in how she structures her day. What does that mean?

• 1:02:46Speaker 01

  This all goes to decreasing inflammation.

• 1:02:48Dr. Mary Claire Haver?

  Mm hmm.

• 1:02:49Speaker 01

  And so I think about the, the five different pillars that I like to talk about are sleep, stress, exercise, food and toxins. And I often group sleep, stress and exercise together as the foundation of your day. Cause whether you realize it or not, you've made a choice on all of those. It's not, are you going to be stressed? But what are you going to do when you experience that stressful encounter? What type of exercise, if any, are you going to do today? How much sleep are you going to get? And it's not always perfect. It's a moving lever. But the point is all five of these categories control the excess inflammation that we are exposed to every single day. And when we add that lever up, we know there's going to be damage to our cells and to our body and our health and our fertility. So

• 1:03:32Speaker 01

  thinking about actively working with whatever each day is giving you, how do I decrease this lever more? And that really starts to think about prioritizing our own health also, right? Women tend to be bad about that until it's gone from us.

• 1:03:45Dr. Mary Claire Haver?

  Mm hmm.

• 1:03:45Speaker 01

  But giving women the opportunity to say, no, how I structure my life, these choices that I'm making, I want to do this in a way that is going to cultivate a more anti-inflammatory lifestyle.

• 1:03:57Dr. Mary Claire Haver?

  Dr. Crawford's new book, The Fertility Formula, is available now wherever you buy books. You can find her on Instagram, YouTube, and Threads at @NatalieCrawfordMD, also on her website, nataliecrawfordmd.com. 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

• 1:04:38Dr. Mary Claire Haver?

  a review and be sure to share the show with the women you love. We would be so grateful. You can find full episodes on YouTube at Dr. Mary Claire. 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.