Menopause Masterclass: When "Normal Labs" Are Lying to You

In this episode of unPAUSED, Dr. Mary Claire Haver delivers a solo masterclass on the lab work every woman in perimenopause, menopause, and post menopause should understand and request from her doctor. Dr. Haver explains why standard annual labs, built for a general population, routinely miss the specific hormonal, metabolic, cardiovascular, and bone related changes that happen during the menopause transition, and she walks through seven categories of testing that give a far more complete picture of a woman's health. She starts with an advanced lipid panel, explaining why LDL alone is not enough and why ApoB, Lp(a), and small dense LDL particles matter for women whose cardiovascular risk shifts as estrogen declines. She covers fasting glucose and fasting insulin together, showing how the HOMA IR score can reveal insulin resistance long before a diabetes diagnosis. She addresses bone health in depth, arguing that waiting until age 65 for a baseline DEXA scan is far too late given how much bone density can be lost in the years surrounding menopause, and she details safe vitamin D supplementation ranges and optimal target levels. Guest links: The ‘Pause Life https://thepauselife.com/?srsltid=AfmBOoqNHlkfDy6-ZvUItyvLEdJ28-COZ4zZJ_GWy3vXk_gKuSJIzU4S Dr. Mary Claire Haver https://www.instagram.com/drmaryclaire/?hl=en (Instagram) Dr. Mary Claire Haver https://www.youtube.com/@drmaryclaire (YouTube) The Pause Life by Dr. Mary Claire Haver https://www.facebook.com/drmaryclaire/?ref=PRODASH_UPSELL_xav_ig_profile_page_web (Facebook) The Menopause Quiz https://thepauselife.com/pages/new-menopause-quiz-lp (The Pause Life) The Menopause Empowerment Guide https://thepauselife.com/pages/menopause-empowerment-guide-sign-up (The Pause Life) Lab Test Checklist https://thepauselife.com/pages/lab-checklist-download (The Pause Life) Clinicians List https://thepauselife.com/pages/recommended-physicians?srsltid=AfmBOooHgFFAcEtlYaKhzCJxU2XrdF1TQpLy_-OLoSh6YcOmNNTYPZ-t (The Pause Life) Books “The New Menopause,” https://www.amazon.com/New-Menopause-Mary-Claire-Haver/dp/1785045547 by Dr. Mary Claire Haver “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/?_encoding=UTF8&pd_rd_w=Rqixj&content-id=amzn1.sym.3a079c4e-f938-40c9-a0ed-01ef0e9528e9&pf_rd_p=3a079c4e-f938-40c9-a0ed-01ef0e9528e9&pf_rd_r=137-6716336-1977900&pd_rd_wg=EY2rq&pd_rd_r=179df492-f1bd-47ab-b516-225a64060f2e by Dr. Mary Claire Haver For full show notes, please click here https://thepauselife.com/blogs/the-unpaused-podcast/menopause-masterclass-how-to-read-your-labs.

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

• 0:02Dr. Mary Claire Haver?

  On today's masterclass, I want to walk you through something practical, something you can take directly into your next doctor's appointment. Over the years, I've had countless conversations with women who felt like their labs were all coming back normal, but they still didn't feel well. Fatigue they could not explain, weight changes that did not respond to the things that used to work, brain fog, poor sleep. And when they asked their doctors what was going on, they were told their numbers looked fine. The problem, more often than not, was not the numbers. It was the numbers that were actually being checked. Standard annual labs are designed for a general population.

• 0:45Dr. Mary Claire Haver?

  They do a good job of screening for a lot of things, but they're not designed to capture what happened specifically to a woman's body during the menopausal transition. There are seven categories of testing that can give you and your clinician a much more complete picture of your cardiovascular health, your metabolic health, your bone health, your hormonal status, and your inflammatory baseline. And most women have never heard of them. So that's what this episode is about. I am going to walk you through each test, what to ask for, why it matters, and how to have a productive conversation with your doctor. These are not specialty tests. They are not out of reach.

• 1:30Dr. Mary Claire Haver?

  They are reasonable, evidence-based labs that any clinician can order. Knowing what to ask for is the first step, so let's start there. 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.

• 2:13Dr. 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.

• 2:38Dr. Mary Claire Haver?

  So let's talk about blood work and why the standard annual labs often miss the full menopausal picture. And don't panic, we are going to have links to the checklist in the show notes and also on our website at thepauselife.com. So your doctor probably runs a CBC and a CMP every year. That's a complete metabolic panel and a complete blood count. These labs are important. They check your liver, your kidneys, your red and white blood cells, and your basic electrolytes. I am not telling you to skip them at all. These are important. But what I'm telling you is they're not really designed to catch what a woman's body is doing during the menopause transition.

• 3:20Dr. Mary Claire Haver?

  They're designed for the general population, and that general population, for most of the history of clinical medicine, was assumed to be male and was not assumed to have any hormonal changes. We know from research that it takes 17 years for a clinical study to come out, to then make it through the guidelines, and then be regularly practiced in clinical practice. That means that what your doctor learned in medical school about cardiovascular risks, about bone loss, about women's insulin metabolism, was likely already a decade behind the science when they learned it. And it has continued to fall behind ever since.

• 4:02Dr. Mary Claire Haver?

  So here's what the standard annual panel typically misses for women in perimenopause, menopause, and postmenopause. For women specifically, there are lipid particles that drive cardiovascular risk in estrogen-depleted women. We don't find these in premenopause. We really only find them in postmenopause for most women. It misses insulin resistance in the early stages. It misses bone loss before it fractures. It misses thyroid dysfunction that mimics almost every menopause symptom. It misses iron depletion from years of chronic, heavy vaginal bleeding. And it misses the hormonal picture entirely. Seven categories. That's what we're going to cover today.

• 4:47Dr. Mary Claire Haver?

  I'm going to tell you what to ask for, what the science says, and what to say to your doctor if you meet resistance. Okay, lab number one. This is an advanced lipid panel. So most of you are probably getting a total cholesterol, an LDL, which is considered the bad cholesterol, and an HDL, which is considered the good cholesterol. We want to continue to have those checked, but we want to add in a couple of more very, very, very important tests. We want to add in an LP little a. We want to add in an ApoB. And if you are in perimenopause, you may want to consider adding in small, dense LDL particles. And we'll go over each one and why.

• 5:29Dr. Mary Claire Haver?

  So it turns out, not all LDL particles are created equal. LP little a and ApoB are very, very specific particles that are directly linked to heart disease. So just having an LDL does raise a flag of concern, but more specifically related to your risk of atherosclerosis and cardiac disease is going to be the LP little a and the ApoB. And most of you have probably not had these two labs checked. Very, very recent studies have identified this small, dense LDL particle, which most women have never had measured. It goes up, not with aging, but only across the menopause transition.

• 6:11Dr. Mary Claire Haver?

  And some researchers are actually suggesting it could be the blood-related marker we need to make the diagnosis of perimenopause. And this is brand new. ApoB specifically tells you the total number of atherogenics, so particles that are most likely to lead to atherosclerosis, that are lining your blood vessels, not just their size, not just their weight, their actual number. It's really a more sensitive predictor of cardiovascular risk than the LDL alone. And it is a test that most of you have not been offered. And then there's LP little a. So it's lipoprotein, small a, which is usually in parentheses. This specific particle tends to be genetically inherited, though we do see a small increase

• 6:55Dr. Mary Claire Haver?

  across the menopause transition. The right time to have your LP little a checked is as early as possible, even as young adults. Fortunately, the American Heart Association has just updated their lipid screening guidelines to include ApoB and LP little a, especially in younger adults, especially in women. However, 17 years is what it could take to trickle down to your doctor's office. So it's good that you go prepared and understand that you probably should go ahead and ask for these tests. LP little a is special because it doesn't respond to diet. It doesn't respond to statins, and it is a very significant risk factor for cardiovascular disease.

• 7:37Dr. Mary Claire Haver?

  And it can be elevated even in the face of what looks like a normal cholesterol. So by not checking it, we are missing a serious risk factor for cardiovascular disease. So what's the menopause connection here? Turns out, estrogen plays a direct role in how your liver produces and clears cholesterol particles. When estrogen declines during perimenopause, LDL rises. I can remember when I started seeing only menopausal patients, sitting at my laptop every morning, being absolutely shocked by the number of patients who walked into my office with previously normal cholesterol levels, which were now elevated.

• 8:18Dr. Mary Claire Haver?

  One thing that was never taught to me in my medical school or residency is we can expect an average of an 18% increase in our total LDL levels across the menopause transition. So this actually happened to me as well. And my patients come in and they're frustrated and they're confused because they never had elevated cholesterol before. They've done nothing different. They haven't changed their diet. They haven't changed their exercise levels. And suddenly, they are facing elevated cardiovascular risk, and they couldn't figure out why. Now we know why. Estrogen is very important in our cholesterol levels and directly affects those levels and therefore modifying our cardiovascular disease risk.

• 9:00Dr. Mary Claire Haver?

  So one way to think about it is elevated cholesterol is not just an aging event, it is a hormonal event. And understanding this means that you're understanding your risk of cardiovascular disease on another level. And remember, cardiovascular disease risk is modifiable. Lab test number two, your blood sugar and your insulin. So in the complete metabolic panel, if you were fasting, you will know what your fasting glucose level is. That is a standard part of things that we measure. And we know that certain levels qualify you for diabetes, are not being diabetic. What it doesn't tell you is if you have insulin resistance. In order to make that measurement, we need to also have a fasting

• 9:45Dr. Mary Claire Haver?

  Insulin level from the serum at the same time, and then we can do a calculation. And fortunately, calculators are easily available online. It is called the HOMA IR score, the H O M A insulin resistance score. You can Google it, you can plug your numbers into a calculator, and you can see if you have levels of insulin resistance that are concerning or not. And just FYI, if your levels above two, you are insulin resistant. What that tells you is there is a continuum. So we have normal blood sugar, no risk of diabetes, no risk of insulin resistance on one end of the spectrum. On the other end of the spectrum, we have full diabetes. On the way there, we have insulin resistance, prediabetes, and then full diabetes.

• 10:29Dr. Mary Claire Haver?

  You can make lifestyle changes, nutrition changes, add in possibly more fiber supplements, et cetera, to help control the insulin resistance that you have so that you never run high blood sugars as you would as a prediabetic or a diabetic. The earlier you know these numbers, the earlier you know your risk, the more likely you are to intervene and decrease that risk overall. Insulin resistance can remain silent for years until you're diagnosed with full diabetes. Your fasting glucose can look perfectly normal while you're insulin resistant. Your hemoglobin A1C can look perfectly normal while you're insulin resistant. Now, A1C is a number that we also recommend checking in all of our patients. Hemoglobin A1C measures the amount of glucose

• 11:13Dr. Mary Claire Haver?

  that is attached to your red blood cells, little glucose chains coming off the end. And what it really represents is what your blood sugars have been averaging over about six weeks. So it's really a long tail look at what your blood sugars have been doing, rather than this very narrow window that we got while you were fasting. It's a very, very important test. And there are levels that tell you if you are prediabetic or fully diabetic. And A1C is often used to track someone's diabetes control while they're starting on medications. So specifically for the HOMA IR score, it's calculated from, again, fasting glucose and your fasting insulin together. And a normal fasting glucose with a high insulin level means your pancreas is working overtime

• 11:56Dr. Mary Claire Haver?

  to keep that glucose in range. That is insulin resistance. It's exactly the metabolic picture I see consistently in menopause. So what happens in the menopause transition? Insulin resistance increases. A woman's risk of insulin resistance doubles to triples across the menopause transition with no changes in diet and exercise. So that is why this is a test we constantly check so we can be counseling our patients appropriately. So what is the menopause connection here in insulin resistance? So bear with me here, a little bit of science. Estrogen directly influences something, a receptor called GLUT4, G L U T four, which is a transporter that moves glucose into your muscle cells.

• 12:39Dr. Mary Claire Haver?

  When estrogen drops, the GLUT4 activity declines, so it becomes harder for your body to pull in glucose into the muscle. Therefore, the glucose stays in the bloodstream outside of the cell, thus raising your blood sugar level. And then, of course, your pancreas will raise the insulin level in order to force that more glucose inside of those cells. Over time, our cells stop responding. So in plain terms, and I did this for a long time, if your blood sugar is normal, your doctor may tell you that you have nothing to worry about, your sugar is normal, your A1C is normal. And they're missing a key part of the picture. We can pick up insulin resistance before you ever become prediabetes. And you can start making those nutrition changes,

• 13:22Dr. Mary Claire Haver?

  exercise changes, supplement changes in order to combat this. Okay, let's move on to bone health. Lord have mercy. Okay, so a couple of labs to ask for are going to be your baseline DEXA scan, which is a bone density scan, and your vitamin D level. So the current standard recommendation, which no one who deals with osteoporosis on a medical basis, you know, who is an osteoporosis expert, thinks that this is a good idea. This is an insurance decision and really not serving patients all that well. But the recommendation is to get a baseline DEXA scan at the age of 65. And I want to talk to you about why that is absolutely too late for the majority of us.

• 14:05Dr. Mary Claire Haver?

  Bone loss begins somewhere in our 30s. Okay, females are expected to reach peak bone density somewhere in their late 20s to 30s. It stabilizes for a bit, and then we have an age-related decline. Bone is something, if you don't understand, that is turns over on a regular basis. Meaning, we have cells that are chewing up older bone, and right behind them, cells, osteoblasts and osteoclasts are chewing up old bone and laying down new, fresh bone behind it. This is called remodeling. This is an absolutely normal process. This is why, when we break a bone, all we have to do is set it, line up the bone ends together, if it's a simple fracture, and the bones will heal itself with this osteoblast,

• 14:49Dr. Mary Claire Haver?

  osteoclast activity. The rate at which we lay down new bone and the rate at which we chew up bone changes across the menopause transition, especially in peri-menopause. The fastest rate of bone loss, the rate of bone loss, is in peri-menopause, not post-menopause. So we reach our maximum bone density, we start having age-related decline, then we hit menopause, and the whole thing starts accelerating. By the time we're 65, most of us will have a significant amount of bone loss. And if you didn't have a high starting point, you may already be osteoporotic. So in our clinic, we are recommending having bone density checked as early as possible. I mean, I have patients in their 30s and 40s

• 15:34Dr. Mary Claire Haver?

  who have, you know, risk factors. We are getting bone density scans on, and some of them are coming back with low bone density. You can lose up to 20% of your bone mass in the first five to seven years past menopause. So you start that rate of acceleration, and then the bones start, you start having deterioration of your bone strength. By the time your DEXA scan is ordered at age 65, that maximum loss may have already closed, and the opportunity to intervene aggressively has shut whatsoever. Now, to be clear, we have studies showing women gaining bone strength at every age, even in their 70s and 80s. It is possible, it just gets harder. So if we can intervene younger, start the lifestyle changes younger,

• 16:19Dr. Mary Claire Haver?

  perhaps start the pharmacology and the medication younger, I think we can ameliorate what is now becoming an epidemic of osteoporosis and frailty. Right now, in the United States, 50% of women can expect to have an osteoporotic fracture before they die. Okay? And if that fracture is your hip within the first year, if you were surgically repaired, if you have a successful surgical repair of your fractured hip, due to the complications of that surgery, you have a 29% chance of death in that first year, from blood clots, from sepsis, from other complications. Okay? If you don't have surgery, if you can't afford the surgery, or you're not well enough to survive the surgery, they decide it's not worth it,

• 17:04Dr. Mary Claire Haver?

  up to 80% of women will not make it past that first year. So avoiding fracture risk is huge here. Hanging on to your bone density is huge. Not waiting until 65 is critical. Now, if you have risk factors for osteoporosis, like a significant family history, like a history of a prior fracture of a long bone, like chronic steroid use, like being very thin, a low BMI, being a smoker, having fair skin and light eyes, that will sometimes qualify you to have it done sooner rather than waiting until 65. So estrogen is the primary regulator of osteoclastic activity. Osteoclasts, remember, are the Pac-Man cells. They're chewing up the bone.

• 17:47Dr. Mary Claire Haver?

  That estrogen tends to keep that rate in check. And when estrogen drops, the osteoclast activity accelerates. So, and let's talk about vitamin D. If your vitamin D is low, and let me tell you, I check a vitamin D level on every single one of my patients, and 80% in our patient population have low to suboptimal vitamin D levels. You know, besides the LDL, this is something else that floored me when I was checking labs. Like, wow, all of these patients have such low vitamin D levels. There's reasons for this. We avoid the sun, we're trying to protect our skin for very good reasons. We also have a tougher time absorbing it. It's really, really hard for a woman in the US to get enough vitamin D absorbed through her diet. So through just food alone.

• 18:31Dr. Mary Claire Haver?

  So it's very, very common that we have patients supplementing. How much do you supplement? Well, it depends on what your levels are. We have prescription-strength vitamin D, which is 50,000 international units that we give weekly. We tend to give that for a shorter period of time, perhaps, you know, 10 weeks to 12 weeks. And then in our clinic, we recheck a vitamin D level. But you can safely supplement up to 4,000 international units, I use, of vitamin D per day without worries of toxicity. Flip side, you can become toxic on vitamin D. I have only heard of vitamin D toxicity, however, in people who were given the prescription strength, that 50,000 IU level every week, and were never taken off of it.

• 19:15Dr. Mary Claire Haver?

  So, again, there's nuance here. It's important to be monitored. But if you're just doing over-the-counter supplementation, it is considered safe to do 4,000 international units or less per day without having to worry about toxicity and constantly getting your lab levels checked. Everybody wants to know, what should my vitamin D levels be? So depending on the lab, the cutoff for deficiency, and deficiency is bad. Deficiency is like rickets, risk, okay? Is less than 30 to 40. However, ideal in our clinic is considered to be 60 to 100. So that's the goal, the window we're shooting for with our patients, is 60 to 100 to be considered optimal, which is different than deficient.

• 19:59Dr. Mary Claire Haver?

  Okay, so in plain terms, waiting until 65 to have a bone density is like checking the smoke detectors when the house is already on fire. Most women in this country are not diagnosed with osteoporosis until they are fractured. So do not wait until you fracture. This is something that is so important. Frailty is the, one of the biggest reasons women are admitted to long-term care facilities in the United States. And if your goal is to avoid frailty at all costs, we have lots and lots of podcasts, you know, before me that talk about how to keep your bones strong, how to keep your muscles strong. But like, knowing your numbers, understanding what your personal risks are, knowing your family history, taking control of your diet,

• 20:43Dr. Mary Claire Haver?

  looking at your vitamin D levels, is just going to be so important.

• 20:54Dr. Mary Claire Haver?

  All right, lab number four, the thyroid chart. All right, what you should ask for, a TSH, a free T4, and a free T3, which is optional if the clinical picture really warrants one. So thyroid dysfunction, which 10% of us at least have, it's probably higher, and perimenopause, which 100% of us, if we live long enough, will go through, share almost every symptom. So how do we know the difference? Blood work. Fatigue, brain fog, weight gain, hair loss, mood swings, depression, palpitations. If you do not rule out hypothyroidism, you cannot be confident that what you are treating

• 21:39Dr. Mary Claire Haver?

  is the hormonal picture of perimenopause, rather than a completely separate and very treatable condition, or both. TSH alone is often not sufficient. In most clinical labs, a TSH is the screening test, and then they might do a reflex T4, which is the active thyroid hormone. It can be in range while the free T3 and free T4, the actual active hormones are low. So we send them on everyone. I don't want to miss a certain segment of the population. If your symptoms are persistent and your TSH is normal, asking for at least a free T4 is a very reasonable next step with your clinician. So don't skip your thyroid testing. It is the other shoe that always needs to drop in a menopausal workup. You should not skip it.

• 22:23Dr. Mary Claire Haver?

  So lab number five, the iron and anemia panel. Iron anemia panel. Okay, what do you want to ask for? Your ferritin, that is the stored iron. Okay, this is what you usually are missing. This is not included in the basic annual labs. They might get an iron level, maybe, if you're anemic. So, but here's what happens. Iron is stored typically in our bone marrow, and then we have iron floating around in our blood. Your body will steal from the bone marrow to keep the iron levels normal. While the storage is dropping, dropping, dropping, your iron levels will look normal, and you will not become anemic. Once your ferritin levels get critically low, then your serum iron will drop, which

• 23:04Dr. Mary Claire Haver?

  will then lead to a microcytic anemia. So why wait until you're anemic? Why not check the ferritin level and see what your stores are doing? It's a way better way to determine who is running low on iron. Why do we run low on iron in perimenopause? Why would that happen? Maybe because you're not getting enough in your diet. That's a very important part, but usually that's not the problem. 90% of us, nine zero, almost all, will develop dysfunctional uterine bleeding in perimenopause, especially late perimenopause. You've heard me talk about the zone of chaos. You've heard me talk ad nauseam about what the zone of chaos does to our brains, our

• 23:48Dr. Mary Claire Haver?

  mental health, our ability to sleep. The zone of chaos also wreaks havoc in our endometrial lining, where the blood is made for our periods. Quite often, a huge percentage of us will develop heavy, irregular vaginal bleeding from the hormonal changes associated with perimenopause, which will then steal from our iron stores in the bone marrow, leading to a decreased ferritin. Here's what happened in the last few years. The deficient ferritin level used to be 15. They doubled it to 30. All of a sudden, another like 45 million people in the world, or whatever the numbers

• 24:28Dr. Mary Claire Haver?

  were, became iron deficient from this ferritin level, being doubled, because they didn't understand the mechanics of it. So I love science, because we learn more, science changes. But if, you know, you've never had a ferritin level checked, and you're still, at least if you're still having periods, especially if you have fatigue, you're not sleeping, your hair is falling out, you deserve to know what your ferritin levels are, and if you have restless legs. So how do we correct a low ferritin? We give you ferritin, and there's two ways to do it. We can give you an IV iron infusion, which is usually done in an infusion center. So there's not like a shot they can give you. It is something they actually have to do an IV into your bloodstream. I've had it done.

• 25:12Dr. Mary Claire Haver?

  I had low ferritin in perimenopause when my periods were getting out of control, and I was having horrible fatigue. I couldn't climb the stairs at work without gasping. And I used to be a runner. I'm like, this was not normal for me. We checked iron, my ferritin had tanked. I got an iron transfusion, and I felt like a normal person again for a very long time. It is something I think we're missing in a lot of women, since this heavy bleeding is so common and is like the calling card of late perimenopause, that we owe it to women to have this checked on a regular basis. You can also take oral iron. Now, that can be tricky for some women. It can cause constipation and some GI distress. Fortunately, we have options that are enterically coded and pass through the stomach without

• 25:55Dr. Mary Claire Haver?

  causing as much distress, something you really need to talk to your clinician about. But I often are recommending to patients to go back to their PCP and request an iron transfusion. An iron transfusion is something you can discuss with your doctor if you have low ferritin, and for most with regular insurance, it should be covered if your ferritin levels are critically low, and it's worth pursuing. It works much faster than taking weeks and weeks and weeks of oral iron. So in general, low ferritin will cause fatigue. It can cause cognitive slowing. It can cause difficulty exercising. All of this happened to me. It can also cause hair thinning. Every one of those symptoms is also on the perimenopause symptom list. So we don't want to miss a nutritional deficiency and think that everything is not perimenopause, by the way.

• 26:40Dr. Mary Claire Haver?

  By listening to me, you may think that, but so many of these symptoms overlap that this is why we get all of this blood work, because all of these things can be happening at the same time to a woman. Lab number six, hormones. So what to ask for? Estradiol, and there's a very specific estradiol. You want the high sensitivity. It's the LC/MS. Okay, you don't want a plain estradiol. You really want the high sensitivity one, especially when the menstrual pattern is not available. So if you are over the age of 45, and you have not had a period for one year, that is the clinical definition of menopause. So who would I check an estradiol level on? Certainly, if you don't, if you've never had regular periods, and I can't say your

• 27:24Dr. Mary Claire Haver?

  period is gone for a year, therefore you're menopausal, I'm going to check it. If you have a Mirena or a progesterone containing IUD that has major periods, go away. Absolutely. If you have some kind of hypothalamic suppression or you're nursing, I might check it. If you've had a hysterectomy, uterus is gone, or you were born without a uterus, I would check an estradiol level in order to help me understand the transition for you. Now, you've heard me talk earlier. If I have a patient who is postmenopausal on hormone therapy, especially on a transdermal hormone therapy, like the gel, or the spray, or the patch, we have such variable levels of absorption of this particular medication, and I'm worried about, and you're worried about your bone density.

• 28:05Dr. Mary Claire Haver?

  For these patients, I am often recommending and checking an estradiol level just to see what their absorption is. Are they absorbing enough to protect her bones? Another hormone level you might want to consider is your testosterone level. Now, who would I check a testosterone level? I actually check it in everyone. It's part of the standard blood work that we do. Who do I treat if it's low? I am treating women with hypoactive sexual desire disorder, HSDD, or what laypeople would call low libido. Now, we don't have a therapeutic range. No one has done that study to say, if your, if your testosterone level is between 60 and 80, you should have perfect libido. That is not how libido works.

• 28:47Dr. Mary Claire Haver?

  Okay, but for a big percentage of patients, you know, 50% or greater, we will see improvement of their libido, especially in postmenopausal patients, with testosterone therapy. It's, it's pretty awesome for patients. But if you're in perimenopause, what do we do? If you're in perimenopause, a single FSH or estradiol level is not going to be helpful in determining if you're in perimenopause. Remember the zone of chaos. We have talked about this multiple times on this podcast. Your hormones are fluctuating. LH, FSH, estradiol, and progesterone are no longer in a predictable pattern. The whole hallmark of perimenopause is the zone of chaos.

• 29:29Dr. Mary Claire Haver?

  So these one-time blood tests, saliva tests, urine tests are not diagnostic. If your doctor is treating you based on these, I want you to take a step back and say, hey, are these tests really necessary? Especially if they're asking for you to pay out of pocket hundreds of dollars for things like the Dutch test. We don't use them in our clinic. I can diagnose perimenopause without it very, very successfully. So buyer beware. Testosterone, on the flip side, doesn't fluctuate in perimenopause and doesn't crash in postmenopause. It is a more, just like men, a steady state, age-related decline. That is a hormone you can reliably check throughout a woman's life to give you an idea of the clinical picture.

• 30:14Dr. Mary Claire Haver?

  Lab number seven, and this is one of the more controversial ones, and we'll get into it. Your level of chronic inflammation. So you may want to consider asking for a high sensitivity C-reactive protein, or an erythromocyte sedimentation rate, ESR, which is optional. So estrogen, as it turns out, has tremendous anti-inflammatory properties throughout the body. And when estrogen declines, we know that most women will develop some type of chronic low-grade inflammation. And we can see this reflected in their high sensitivity C-reactive protein. This is the most sensitive blood marker that we have of systemic inflammation, and you know, this is a really easy and inexpensive blood test to follow.

• 30:59Dr. Mary Claire Haver?

  Here's the problem with the CRP. It's not specific, meaning I can't tell you why you're inflamed. It might be menopause from estrogen withdrawal. It might be from some other chronic inflammatory process going on in your body. So I can't get an elevated CRP, which, you know, high sensitivity CRP, which a lot of my patients have, and say, oh, obviously, this is from your liver, or this is from gut health, or this is from where. I'm like, listen, something is inflaming. It might be menopause. Let's make these lifestyle changes. Let's make these diet changes. Let's do everything we can and, you know, get all this other blood work, see if we can rule out other inflammatory conditions like autoimmune disease, et cetera. And then we go from there. And that works quite well in our clinic.

• 31:41Dr. Mary Claire Haver?

  So in plain language, back to the alarm system that we're trying to fix in someone's house, think of a high sensitivity C-reactive protein as your body's inflammation alarm. It doesn't tell you where the fire is, but it tells you that the smoke detector is going off, and we need to go figure out what's going on in the body.

• 32:08Dr. Mary Claire Haver?

  So again, these are very basic. We do more labs in our clinic, but I wanted you to have this seven basic labs that are super easy to discuss and not unreasonable for your clinician to offer. But this next section, I want to talk about what to do and what to say when you don't think you're being heard by your clinician or doctor. I want to walk you through 12 common dismissals and give you the exact language to respond. These are not confrontational scripts. These are things that you, as my listeners, you as my social media followers, have come to me and said, these are the things that my clinician has said to me when I voiced my concerns. So I wanted to give you language that you could

• 32:52Dr. Mary Claire Haver?

  use that might open their mind to the possibility that something else might be going on. Because remember, this is not one doctor out to get you. This is not one doctor who's a jerk or doesn't care, or you know, this is a system that is overwhelmed, a group of clinicians that are largely overworked, forced to fit you into a 10-minute slot while they're trying to take care of every health problem that you've got going on. I'm trying to give you the best shot that you have to get what you need out of this clinical visit. Remember also that you may not be able to get this all done at once. This may have to take more than one visit, and that's okay. So when your doctor says, you go in complaining of fatigue,

• 33:33Dr. Mary Claire Haver?

  or I can't sleep, or I'm gaining weight, or I'm having muscle aches or joint pains, and they say, this is just a part of getting older. What do you say? Your response can be something like, I understand that aging brings changes, but what I'm experiencing is interfering with my daily life. I'd like to talk about where the hormone shifts might be contributing and what we can do to help me feel better. What do you do when the doctor says, this is probably just stress or lifestyle-related? What can you say? All right, stress may play a role, but these symptoms feel that they might be hormonal. I'd like to look

• 34:17Dr. Mary Claire Haver?

  into whether perimenopause or menopause could be part of what's going on and discuss my options for managing it. What to do when you're told, you're too young for perimenopause? Again, remember, menopause and perimenopause education is severely lacking. If your doctor comes at you with this response, most likely, they have not been adequately educated in modern menopause medicine. And that's not their fault. That is the fault of the medical system leaving us behind and expecting us to behave like small men and not taking into account this like robust hormonal change that we go through. Your response, you're

• 34:58Dr. Mary Claire Haver?

  not old enough for menopause yet. Well, I've learned that perimenopause often starts in the 40s or sometimes younger. These symptoms line up, and I'd like to take a closer look at where I am in the menopause transition. Here's another key. There is a validated perimenopausal scoring system called the Menopause Quiz. We have it on our website. It's 100% free. You can go in, take the quiz. It's been absolutely validated. It will spit out your results that you can then take to your doctor with the list of symptoms and their severity and the chance that this constellation of symptoms is related to your menopause. One more tool for you to go in, help yourself feel validated, and give talking points

• 35:41Dr. Mary Claire Haver?

  to your clinician to help get the process started, for them to take you seriously in what's going on. What to say when regular periods are used to dismiss your symptoms? You're still having periods, so it can't be menopause. Your response, I know that hormone fluctuation can cause symptoms long before the periods stop. I'd like to talk about perimenopause and whether these changes could be playing a role in how I'm feeling. What to say when birth control is offered without a discussion? Now, let's be clear. I use birth control pills in certain situations. They are an important tool in the toolkit.

• 36:24Dr. Mary Claire Haver?

  Like, it's a form of hormone therapy. Using that level of hormones, which is very different than menopause hormone therapy, think of menopause hormone therapy as a microdose compared to what we're giving you in a birth control pill. But if you need contraception in perimenopause, or if you need cycle control, birth control pills can be magical for some of the hormonally related changes that are going on with your periods during perimenopause. It worked for me, great. So remember, they're not the devil, but it shouldn't, you know, if you're not have, if you don't need contraception, you're not having heavy periods, you might be a better candidate for just plain menopause hormone therapy and perimenopause. But again, lack of training, lack of education, most clinicians aren't comfortable doing that

• 37:08Dr. Mary Claire Haver?

  because they never learned about it. Okay, what do you say? I'm open to discussing different approaches, but I'd like to understand the difference between hormonal contraception and hormone therapy for perimenopause, and which option might best address my symptoms and long-term health. When hormone therapy is refused automatically, I would say run here, but I'm going to give you some words. Doctor says, hormones are too risky. I don't recommend them. Your response, I've read the current research and know that hormone therapy is safe and effective for most women when started at the right time. I'd like to go over whether it might be a good option for me based on my personal risk factors.

• 37:50Dr. Mary Claire Haver?

  Pro tip here, you can download the Menopause Society Guidelines that were updated in 2022 for menopause hormone therapy and hand them to your doctor. That might be the first time they've ever seen them in their lives. Remember, the Menopause Society is an elective society. The American College of OB-GYN does not recognize the Menopause Society or their guidelines yet. So I am a board-certified obstetrician gynecologist. I'm very proud of my training, but I did recognize, as I became a menopausal person, that there was a humongous gap in my knowledge and education. I sought out my own education through the Menopause Society. That's not common. So you can actually provide a source of education for your doctor and

• 38:33Dr. Mary Claire Haver?

  hand those guidelines over and hopefully teach them something and make them feel more comfortable in offering this to you. When mood symptoms are labeled as just garden variety depression with no hormonal component, okay? Doctor, this sounds like anxiety or depression. Let's try an antidepressant. Not 100% unreasonable, but what we know now is that the mood changes associated, this is mostly in perimenopause, the chaos of the hormone changes in perimenopause are directly related to anxiety and depression. And there's some very recent studies that are excellent that have shown that giving these women menopause hormone therapy, and these women were given transdermal options,

• 39:14Dr. Mary Claire Haver?

  they saw better improvement in their mental health than with an SSRI. Now, these were new diagnoses of anxiety and depression in perimenopause, or there were women who were previously well-controlled on an SSRI, their symptoms were absolutely controlled, they were on medication, and rather than upping their medication or adding a second agent in that same family, they were given menopause hormone therapy, transdermal, and they did beautifully, beautifully well. So your response, I'm open to addressing mood changes, but I'd like to explore whether shifting hormones might be contributing. Can we look at the bigger picture, including hormone levels in perimenopause, before we start there?

• 39:53Dr. Mary Claire Haver?

  When your symptoms are called normal, this one drives me crazy. Okay, normal means common. Not that it's not pathologic, not that it's acceptable. I mean, presbyopia as we age is normal, you know, being farsighted becomes normal. We can't see the menus anymore at a restaurant. We struggle to read. This is a normal change. Normal, meaning it's so, so, so common and happens to most people. Normal does not mean there's nothing to do. So the doctor says, every woman goes through this. It's just a part of life. Your response, I know menopause is universal, but it doesn't mean that I have to suffer through it. These symptoms are affecting my quality of life, and I'd like support in exploring what can

• 40:37Dr. Mary Claire Haver?

  be done. When a bone density scan is refused, you don't need a bone scan yet. You're too young, you say. I understand the standard recommendation is to start at 65, but I know that bone loss can begin during perimenopause, rapid acceleration of my bone loss. With my age, my symptoms, and my risk factors, I'd like to proactively assess my bone health now rather than wait for a fracture. When symptoms are dismissed as not menopause from your doctor, that's not really a menopause symptom. Again, this is a function of a lack in training of education. The only three areas I was taught, and I was taught nothing in medical school.

• 41:20Dr. Mary Claire Haver?

  The only areas I was taught that menopause could possibly affect. Your periods would stop. Your bones will disintegrate. Your general urinary system will suffer. That's it. Nothing about the musculoskeletal system, the metabolic system, brain health, mental health. Nothing, nothing, nothing. We're still struggling to teach that. Okay. Again, not an individual doctor's fault. This is a systemic problem. So what do you say? From what I've read, perimenopause and menopause can affect multiple systems, including sleep, cognition, metabolism, and joints. I'd like to consider whether my symptoms might be connected to hormonal changes. And then when weight gain gets the diet talk,

• 42:04Dr. Mary Claire Haver?

  you probably just need to eat less and move more. And those words sadly came out of my mouth to women in perimenopause and menopause more times than I can count. It is what we standardly teach our students. I think understanding around obesity has improved. I know my daughter's not being taught that. She's a third year medical student. She is taught about the multifactorial causation of obesity and weight gain amongst women, amongst all patients, and that it's much more complicated than just a simple calories in, calories out. But a lot of doctors who are older in training only got the message of this is a moral problem. This is a laziness problem. This is a, you're just not moving enough and you're eating too much problem.

• 42:47Dr. Mary Claire Haver?

  And your response can be, I've made lifestyle changes and I'm still struggling. I've read that perimenopause can impact metabolism, insulin resistance, and body composition. I'd like to explore what else can be contributing. And when you're told, this is my favorite. There's nothing we can do. This too shall pass. Your response. I understand that these changes are part of a transition, but that doesn't mean that I have to go through this unsupported. I'd like to work together on ways to improve how I feel right now. So these scripts are also available on the checklist. Don't worry, you can take them into your doctor's office and then you can just run your finger down to the responses and, and pick out the one that makes the most sense to you at the time.

• 43:31Dr. Mary Claire Haver?

  I'm not expecting you to memorize these or to have them, be scribbling them down after the podcast. We are going to have these available to you. Of course, they're on our website at thepauselife.com under the lab checklist, and they're going to be linked in the show notes as well. So here's what I really want you to take from this episode. These labs exist. The science behind them exists. The clinical knowledge to interpret them exists. What has not always existed is the woman in the room who knew how to ask, or the medical system that recognizes menopause's impact outside of the reproductive system. This is you now. Okay. Print out the checklist.

• 44:13Dr. Mary Claire Haver?

  Go to the website, download it, go to the show notes, download it. Bring it to your next appointment. Go through it with your clinician. Push back a little bit if you need to. Use the scripts. And if your provider will not engage with you on these questions, that is important information too. And there are menopause informed practitioners who will. How do you find them? How do you find someone who is educated in how to take care of a menopausal patient? On our website, we have a clinicians list. This is a list of clinicians that you guys, my followers, my supporters, you know, our email list has through their good graces, gone and written testimonials on clinicians that they have found locally. We've organized them and there's over a thousand.

• 44:58Dr. Mary Claire Haver?

  We've organized them by city and state. So hopefully that will be of some benefit to you. Second resource, the menopause society has a list of certified providers. So if you join the menopause society, you get on a big list. But if you pass the test, which I think is important, you want to find someone who is certified by the menopause society. So you've not only are a member, but you've actually studied and took the test. Also, Dr. Heather Hirsch and Dr. Rachel Rubin have excellent clinical courses to teach people how to take care of menopausal patients and how to prescribe. There are other resources out there as well. And then there is also telehealth. There are some really great telehealth options. We do have those listed on our website as well. And these are telehealth companies that were built to just serve menopausal women. They saw a gap.

• 45:42Dr. Mary Claire Haver?

  They saw a need and they decided to build a system around it to help support women in perimenopause and menopause. So menopause is inevitable. Okay. If we are lucky to live long enough, you are going to go through menopause, perimenopause, and then menopause. More women will go through menopause than get pregnant and, and bear children. Suffering through menopause uninformed and unsupported is no longer acceptable. We're done accepting this. You deserve the full clinical picture of your own body. So go get it. And here's what I want to leave you on with a note of hope. I am post-menopausal. I've been fully menopausal for at least 10 years. You, you want my life. I am living my best life. I've never had better relationships. I've never had better boundaries. I've never been healthier.

• 46:27Dr. Mary Claire Haver?

  Okay. I have better muscle strength, better bone density that I've had in 10 years, and a better outlook on life. I've gotten therapy when I need it. I've totally changed my nutrition. I've totally changed my exercise habits. I'm having better sex. Like, I'm going to say it out loud. I'm having way better sex. And there's multiple layers to that. Yes, I'm on testosterone. That definitely helped. But I'm also thinking about it differently, like thinking about putting me first. Like, the best thing about my life is I've lost my filter. I am simply putting myself first and taking care of Mary Claire first. I am able to take so much better care of everyone in my world around me. I've also learned to put up boundaries on people I don't need to be taken care of, who can take care of themselves.

• 47:09Dr. Mary Claire Haver?

  So all of this is possible and there is light at the end of the tunnel. I don't want anyone to be scared of menopause or afraid or feel like it's something to fear. It is absolutely not. But you deserve to be educated and supported through it so you can come out of this with flying colors and feel like I do every day. So thank you for spending time with me. I really, really hope this episode is useful and that these resources are going to help you. Please, if you found this helpful, send it to a woman who needs it. That could be your sister, your best friend, a cousin, a coworker. By sharing these episodes, we can share the education and knowledge so that we can all take menopause out of the closet, out of the dark, and into the light where it belongs.

• 47:53Dr. Mary Claire Haver?

  You can find full episodes of UnPaused on YouTube at Dr. Mary Claire. 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 wherever you buy books. UnPaused is presented by Odyssey in conjunction with Podpeople.