How to Navigate Menopause & Perimenopause for Maximum Health & Vitality | Dr. Mary Claire Haver

In this episode, my guest is Dr. Mary Claire Haver, M. D., a board-certified OB/GYN and an expert on women’s health and menopause. We discuss the biology and symptoms of perimenopause and menopause and their effects on body composition, cardiometabolic health, mental health, and longevity. She explains the lifestyle factors, including nutrition, resistance training, sleep, and supplements, that can better prepare women for and improve symptoms of both perimenopause and menopause. We also discuss hormone replacement therapy (HRT) and whether HRT impacts the incidence of breast cancer or can affect cardiovascular health. We also discuss contraception, cellulite, polycystic ovary syndrome (PCOS), and how to reduce the risk of osteoporosis. This episode is rich in actionable information related to what is known about menopause and perimenopause and the stages before, allowing women of all ages to best navigate these life stages. For show notes, including referenced articles and additional resources, please visit hubermanlab.com. Thank you to our sponsors AG1: https://drinkag1.com/huberman AeroPress: https://aeropress.com/huberman Eight Sleep: https://eightsleep.com/huberman BetterHelp: https://betterhelp.com/huberman InsideTracker: https://insidetracker.com/huberman Timestamps 00:00:00 Dr. Mary Claire Haver 00:02:04 Sponsors: AeroPress, Eight Sleep & BetterHelp 00:06:26 Menopause, Age of Onset 00:09:50 Perimenopause, Hormones & “Zone of Chaos” 00:14:42 Perimenopause, Estrogen & Mental Health 00:20:04 Perimenopause Symptoms; Tool: Lifestyle Factors & Ovarian Health 00:25:26 Early Menopause, Premature Ovarian Failure; Estrogen Therapy 00:29:42 Sponsor: AG1 00:31:31 Contraception, Transdermal, IUDs; Menopause Onset, Freezing Eggs 00:38:18 Women’s Health: Misconceptions & Research 00:45:01 Tool: Diet, Preparing for Peri-/Menopause; Visceral Fat 00:48:31 Tools: Body Composition, Muscle & Menopause, Protein Intake 00:51:42 Menopause: Genetics, Symptoms; Tools: Waist-to-Hip Ratio; Gut Microbiome 00:58:22 Galveston vs. Mediterranean Diet, Fasting, Tool: Building Muscle 01:05:18 Sponsor: InsideTracker 01:06:29 Hot Flashes; Estrogen Hormone Replacement Therapy (HRT), Breast Cancer Risk & Cognition 01:15:36 Estrogen HRT, Cardiovascular Disease, Blood Clotting; “Meno-posse” 01:24:00 Estrogen & Testosterone: Starting HRT & Ranges 01:30:36 Other Hormones, Thyroid & DHEA; Local Treatment, Urinary Symptoms 01:37:57 OB/GYN Medical Education & Menopause 01:41:30 Supplements, Fiber, Tools: Osteoporosis “Prevention Pack” 01:46:53 Collagen, Cellulite, Bone Density 01:51:42 HRT, Vertigo, Tinnitus, Dry Eye; Conditions Precluding HRT 01:55:27 Polycystic Ovary Syndrome (PCOS) & Treatment; GLP-1, Addictive Behaviors 02:01:55 Post-menopause & HRT, Sustained HRT Usage 02:04:58 Mental Health, Perimenopause vs. Menopause; Sleep Disruptions, Alcohol 02:09:09 Male Support; Rekindle Libido 02:12:46 HRT Rash Side-Effect; Acupuncture; Visceral Fat 02:16:24 Zero-Cost Support, Spotify & Apple Reviews, YouTube Feedback, Sponsors, Social Media, Neural Network Newsletter Disclaimer Learn more about your ad choices. Visit megaphone.fm/adchoices

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

• 0:00Andrew D. Huberman?

  Welcome to the Huberman Lab Podcast, where we discuss science and science-based tools for everyday life.

• 0:09Andrew D. Huberman?

  I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. My guest today is Dr. Marie Claire Haver. Dr. Marie Claire Haver is a board-certified OB-GYN and an expert in perimenopause, menopause, and all aspects of female-specific health. During today's episode, Dr. Haver explains exactly what perimenopause and menopause represent in terms of their underlying psychology and biology, and the specific actions that all women can and should take in order to navigate these stages in optimal health. She also describes the things that all women should know and do long before perimenopause arrives, in order to best navigate perimenopause and menopause once they arrive.

• 0:53Andrew D. Huberman?

  We discuss specific nutritional practices, supplementation practices, as well as conversations that you should have with your mother and with your physician, in particular, your OB-GYN, not just as perimenopause and menopause approach, but at every developmental stage. A fair amount of our discussion centers around hormone replacement therapy, not just for estrogen, but for testosterone in women as well, and the many misconceptions and controversies that exist around hormone replacement therapy for menopause. Dr. Haver explains how the specific timing in which hormone therapy is initiated plays a key role in whether or not the hormone therapy is beneficial for women or not. And of course, today's discussion gets into ways to offset some of the more common difficulties

• 1:35Andrew D. Huberman?

  associated with menopause, including sleep issues, hot flashes, inflammation, and more. By the end of today's episode, you will have a clear picture from Dr. Marie Claire Haver about what perimenopause and menopause actually represent, the best way to approach perimenopause and menopause, and the various considerations around hormone therapy and lifestyle choices that can allow any woman to approach the years of perimenopause and menopause and beyond with the utmost vitality and wellness. Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is, however, part of my desire and effort to bring zero cost to consumer information about science and science-related tools to the general public.

• 2:17Andrew D. Huberman?

  In keeping with that theme, I'd like to thank the sponsors of today's podcast. Our first sponsor is Aeropress. Aeropress is like a French press, but a French press that always brews the perfect cup of coffee, meaning no bitterness and excellent taste. Aeropress achieves this because it uses a very short contact time between the hot water and the coffee, and that short contact time also means that you can brew an excellent cup of coffee very quickly. The whole thing only takes about three minutes. I started using an Aeropress over 10 years ago. I first learned about it from a guy named Alan Adler, who's a former Stanford engineer and inventor. I'm a big fan of Adler's inventions, and when I heard he developed a coffee maker, the Aeropress, I tried it and I found that indeed it makes the best possible tasting cup of coffee. And I'm not alone in my love of the Aeropress.

• 3:02Andrew D. Huberman?

  With over 55,000 five-star reviews, Aeropress is the best-reviewed coffee press in the world. I'm also excited to share that Aeropress has just released a brand-new Aeropress that brews and packs into its own travel tumbler. This new Aeropress, called the Aeropress Go Plus, makes brewing coffee when traveling incredibly easy. The design is really clever. The entire Aeropress unit packs really nicely into a custom Aeropress travel thermos that's small enough that it can fit into your carry-on or any form of luggage. And with it, you can make an excellent cup of coffee anywhere. All you need is some ground coffee and hot water. Indeed, I've even used it on the plane, in hotels, of course. Basically, I take it with me anywhere I need a great tasting cup of coffee. And with Father's Day coming up, it makes for a great Father's Day gift.

• 3:44Andrew D. Huberman?

  If you'd like to try Aeropress, you can go to aeropress.com/huberman to get 20% off. Aeropress currently ships in the USA, Canada, and to over 60 countries around the world. Again, that's aeropress.com/huberman. Today's episode is also brought to us by Eight Sleep. Eight Sleep makes smart mattress covers with cooling, heating, and sleep-tracking capacity. Now, I've spoken many times before on this podcast about the critical need for us to get adequate amounts of quality sleep each night. One of the best ways to ensure a great night's sleep is to control the temperature of your sleeping environment, and that's because in order to fall and stay deeply, Your body temperature actually has to drop by about one to three degrees. And in order to wake up feeling refreshed and energized,

• 4:26Andrew D. Huberman?

  your body temperature actually has to increase by about one to three degrees. Eight Sleep makes it incredibly easy to control the temperature of your sleeping environment by allowing you to program the temperature of your mattress cover at the beginning, middle, and end of the night. Eight Sleep also tracks your sleep with very high precision. It will tell you how much slow wave sleep you're getting, how much rapid eye movement sleep you're getting, each of which is critical for different aspects of physical and emotional recovery during sleep. And that allows you to dial in the exact temperature parameters to really ensure that you get the best possible night's sleep. I've been sleeping on an Eight Sleep mattress cover for well over three years now, and it has completely transformed my sleep for the better. Eight Sleep recently launched their newest generation pod cover, the Pod4 Ultra.

• 5:09Andrew D. Huberman?

  The Pod4 Ultra has improved cooling and heating capacity, higher fidelity sleep tracking technology, and it also has snoring detection that remarkably will automatically lift your head a few degrees to improve your airflow and stop your snoring. If you'd like to try an Eight Sleep mattress cover, you can go to eightsleep.com/huberman to save $350 off their Pod4 Ultra. Eight Sleep currently ships to the USA, Canada, UK, select countries in the EU, and Australia. Again, that's eightsleep.com/huberman. Today's episode is also brought to us by BetterHelp. BetterHelp offers professional therapy with a licensed therapist, carried out completely online. I've been going to therapy for over 30 years. Initially, I didn't have a choice. It was a condition of being allowed back in high school.

• 5:54Andrew D. Huberman?

  But soon I realized that quality therapy can be extremely valuable. And I now consider doing therapy as important as getting regular exercise, including cardiovascular exercise and resistance training, which of course I also do every week. Therapy, provided it's with a therapist with whom you have excellent rapport and feel supported by, and from whom you can gain valuable insights, can be immensely valuable because it leads to healthier thought patterns and actions related to your personal and professional life. In fact, I see doing quality therapy as a powerful way to direct your focus and attention toward what really matters. If you'd like to try BetterHelp, you can go to betterhelp.com/huberman to get 10% off your first month. Again, that's betterhelp.com/huberman. And now for my discussion with Dr. Mary Claire Haver.

• 6:38Andrew D. Huberman?

  Dr. Mary Claire Haver, welcome.

• 6:41Speaker 01

  Thanks for having me.

• 6:42Andrew D. Huberman?

  Delighted to have you here and to learn about menopause and other aspects of women's health.

• 6:49Andrew D. Huberman?

  There's a lot happening in this area right now.

• 6:51Speaker 01

  Yeah.

• 6:52Andrew D. Huberman?

  And you are at the center of what I understand is a new direction for the understanding and treatment of menopause.

• 7:00Speaker 01

  That's what we hope.

• 7:01Andrew D. Huberman?

  And related themes like perimenopause.

• 7:03Speaker 01

  Yeah.

• 7:04Andrew D. Huberman?

  And the many important aspects of female health that stem from it, like cardiovascular disease, osteoporosis.

• 7:10Speaker 01

  Right.

• 7:10Andrew D. Huberman?

  And so on. So we will get into all of that today. But just to kick things off, how do we define menopause?

• 7:17Speaker 01

  So the medical definition of menopause, which I have a huge problem with, is one year after the final menstrual period. And the reason why I have a problem with it is not everyone has a menstrual period. What if you've had a hysterectomy? What if you have an IUD? What if you've had an ablation or something that's suppressing your periods? PCOS? So for a lot of women and even clinicians, they are struggling to like, find that diagnosis because it doesn't fit everything. What it represents is something much bigger. Menopause is also one day of your life. It is that one day, exactly one year after your last period. But it represents the end of your ovarian function.

• 8:00Speaker 01

  Some of us call it ovarian failure, ovarian senescence. But basically, what separates males and females is, many things separate us. But in my world, we are born with all of our eggs. We have one to two million at birth. By the time we're 30, most of us are down to about 10%, maybe 120,000. By the time we're 40, we're down to 3% of our egg supply. And the quality is declining as well. So menopause is when you have no more eggs left and therefore no more sex hormone or very little sex hormone production from the ovaries. So estradiol levels will decline, less than 1% of your reproductive years. Your progesterone levels will decline as well.

• 8:45Speaker 01

  Testosterone declines for sure, but we have other ways to produce it. So it's somewhere 50% or less than your healthiest years.

• 8:52Andrew D. Huberman?

  So is it fair to say that we need a redefinition of what menopause is?

• 8:57Speaker 01

  I think so. I think defining it as the presence or absence of a period is a mistake.

• 9:03Andrew D. Huberman?

  Is there any consensus about the quote unquote typical age of onset for menopause? And is it changing? You know, I hear a lot about how the onset of puberty is shifting earlier in females and

• 9:18Andrew D. Huberman?

  Given that puberty, at least by some definitions, relates to the onset of menses, one could imagine that menopause would be shifting earlier as well.

• 9:27Speaker 01

  So, the things that determine when we have puberty or not are different than the things that determine when we run out of eggs. Right now, in the US, it's the average age of that one-year-after-year cycle, so menopause, that one day, is about 51 to 52 years old. However, normal is still 45 to 55, and there's a big variation. You know, that curve's pretty wide. Perimenopause begins seven to 10 years before that last menstrual period.

• 10:02Andrew D. Huberman?

  Wow, okay. And I say "wow" because it's the first time I've ever heard a specific number tacked to this word, "perimenopause." Maybe we could talk a little bit about perimenopause?

• 10:13Speaker 01

  Sure.

• 10:14Andrew D. Huberman?

  Since it sounds like it represents a transition phase

• 10:18Speaker 01

  Yeah.

• 10:19Andrew D. Huberman?

  into official menopause.

• 10:21Speaker 01

  Right.

• 10:22Andrew D. Huberman?

  However one chooses to define that. What are some of the, I don't know if I should call them symptoms?

• 10:27Speaker 01

  Sure.

• 10:28Andrew D. Huberman?

  Or I should just...

• 10:29Speaker 01

  Well, let me do, let me walk you through the endocrinology, and then we can go through symptoms, so you understand. So, in a normal, healthy menstrual cycle, before menopause ever becomes an issue, the female hormone cycle is a very EKG-like, reproducible, monthly rise and fall of estrogen, progesterone, and then the brain hormones, LH, FSH, and then GnRH. So, the way it works is our brain, in the hypothalamus, is sensing for, has a little sensor in the blood, looking for estradiol levels. And when they get low, it sends GnRH down to the pituitary, saying, "Hey, tell the ovaries to start trying to ovulate, so we can get more estrogen on board." The process of ovulation is what drives up our estrogen levels. Okay?

• 11:13Speaker 01

  So, pituitary sends out the pulses of LH and FSH, which then lead to ovulation. When we reach, in perimenopause, the beginning of perimenopause, that critical level of egg supply, those signals don't work as well. We start becoming resistant to the LH and FSH pulsatile surges. So...

• 11:35Speaker 01

  The brain's like, hey, I told you we need more estradiol. And the pituitary is like, I sent the signal. And the brain's like, send more. So we get much higher pulses of FSH. And then finally, the ovary kind of, ugh, is able to get that egg out. But sometimes it's delayed. So we have the timing of that monthly predictable cycle goes awry. Sometimes the periods are closer together. Sometimes they're further apart. But also, the estrogen and progesterone levels start changing dramatically. We see much higher surges of estradiol than we ever had in our pre-productive years, and then much lower levels underneath. So we end up with this very volatile curve and not predictable at all. We call it, in our world, the zone of chaos.

• 12:19Speaker 01

  So it is literal hormonal chaos. What used to look like this, you know, every month is now just insane and very, very, very unpredictable. That is why we don't have a good blood test in perimenopause to make the diagnosis. Those of us in the menopause use symptoms usually to make the diagnosis, and we rule out other conditions that might overlap. So perimenopause, basically, critical threshold. It's a downward trend overall of estradiol, but it is a very chaotic, you know, race till you flatline and bottom out.

• 12:52Andrew D. Huberman?

  I see. So for those listening, your description of the, kind of, the amplitude of the estrogen surge, it gets much greater in this perimenopause phase. You also mentioned that follicle stimulating hormone, which comes from the pituitary, has to be, or somehow is upregulated in this phase. Because, I don't know, is it that the receptors for FSH are somehow not responsive? At the level of the ovary, do we know what's happening to the ovary? Is it, obviously, the signal's getting there. It's not effective, so then the brain is kicking out more FSH. Is it that the ovary is some-

• 13:26Speaker 01

  So the egg quality is poor. And then around each germ cell is the thicelluline cells, which is actually where the estradiol, the whole pathway going from, you know, actually testosterone's converted to estradiol. So that whole pathway, you know, it still will respond, but the cells are just old, you know, is the way that it's been explained to me. And from what I've read, I think we need a lot more research in this area because that is how we're going to help women, I think, longer term, is understanding that process better. But, you know, all I learned in school 25 years ago was it's the transition to menopause. The end. You know, the whole endocrinological process, I didn't learn until about two years ago.

• 14:05Andrew D. Huberman?

  And my guess is, just based on my understanding of the only recent trend toward emphasizing studies of both female and male, even just mice in mouse models, which is where generally this stuff originates, and then it shifts into humans once certain targets are identified. Only recently has the NIH insisted that there be female mice in the studies of mice. I mean, it's been a few years now, but that's a, you know, sex as a biological variable is, is actually a requirement in most grant applications, unless, of course, there's a specific reason to study only one or the other sex of mice.

• 14:42Andrew D. Huberman?

  So you can imagine that the dearth of research in this area is due to a long desert of absence of studies into what is perimenopause.

• 14:54Speaker 01

  Right.

• 14:54Andrew D. Huberman?

  So for women who are in the age range of perimenopause, or who are thinking about this, are there things that they can do in order to either upregulate the sensitivity of the ovary to FSH, or to somehow prolong this period of perimenopause? And I should also say, what are some reasons why they would want to do that?

• 15:14Speaker 01

  Right.

• 15:15Andrew D. Huberman?

  You know, obviously, this is part of the, of the arc of maturation of the female reproductive axis, but of course, that alone is not a reason to not try and, I guess we say, optimize it for one's well-being.

• 15:29Speaker 01

  So, we don't know. When you, the best way I can highlight why we don't know, or where the dollars are going for research, you know, we go to PubMed, and you type in the word pregnancy, 1.1 million articles come up. Type in the word menopause, it's down to 97,000.

• 15:45Andrew D. Huberman?

  Really?

• 15:46Speaker 01

  You type in the word perimenopause, and I checked this like two weeks ago, and it was like 6,400 and something.

• 15:53Speaker 01

  Yeah.

• 15:53Andrew D. Huberman?

  That is surprising.

• 15:55Speaker 01

  So.

• 15:55Andrew D. Huberman?

  Or maybe it shouldn't be surprising, given what we were just talking about in terms of.

• 15:59Speaker 01

  So as far as like, why those cells are becoming resistant and what's happening at the level of the receptor, I think we need a lot more research in this area. I think it's starting to happen because women are realizing there's a demand now because the older you are, when you go through menopause, the healthier you are for cardiometabolic disease. It's the loss of estrogen that accelerates our path to those diseases.

• 16:24Andrew D. Huberman?

  So are there clinical signs of perimenopause?

• 16:27Speaker 01

  Mm hmm.

• 16:28Andrew D. Huberman?

  That either directly or indirectly relate to these bigger surges in FSH?

• 16:33Speaker 01

  Mm hmm.

• 16:34Andrew D. Huberman?

  And these larger amplitude estrogen surges?

• 16:38Speaker 01

  The two best documented and studied are mental health changes. The brain does not like the chaos of, and the neurotransmitters are very, very sensitive to estrogen and progesterone and even testosterone. And so we see aberrations in serotonin and orbinephrine and in dopamine as the levels start becoming chaotic. So we have at least a 40% increase of mental health disorders in, and SSRI use doubles across the menopause transition, across perimenopause. And now the data is showing that women who are given hormone therapy in their perimenopause have a lower incidence of new onset depression.

• 17:21Speaker 01

  And now the neuroscientists are saying, hey, for these women who are developing depression in perimenopause, giving them estrogen is better than an SSRI. They're going to have a better outcome.

• 17:33Andrew D. Huberman?

  I think most people don't realize how rich the brain and rest of the nervous system are with hormone receptors, in particular estrogen receptors. And as you mentioned, testosterone receptors as well, androgen receptors.

• 17:48Speaker 01

  Mm hmm.

• 17:49Andrew D. Huberman?

  And the often direct relationship between estrogen and the neuromodulators such as serotonin, dopamine, epinephrine, acetylcholine.

• 17:58Speaker 01

  GABA for progesterone.

• 18:00Andrew D. Huberman?

  Yeah, it's interesting during neural development, which is where I started off, which was neural embryonic development. The hormones exert these widespread roles in defining even which neurons will express certain neurotransmitters. And then somehow, the field of neuroscience has only recently gotten on board the idea that this intimate relationship between hormones and neurotransmitters is something to consider in essentially every aspect of brain health.

• 18:30Speaker 01

  Right.

• 18:31Andrew D. Huberman?

  Not just cognition, but maintenance of neurons and offsetting neurodegeneration and so on. I mention that only so that people, I think, typically think of hormones as something, sure, there's a signal from the brain, but that hormones are mostly of the body, when in fact, hormones play an absolutely crucial role within the brain. So you mentioned that during perimenopause, there are symptoms that are, I guess, are mainly reflected as shifts in mental health.

• 19:01Speaker 01

  Yeah.

• 19:01Andrew D. Huberman?

  So is this women suddenly feeling kind of less optimistic? Is it like, what's the sort of constellation of psychological shifts that can occur?

• 19:13Speaker 01

  So we see increasing anxiety. We see definitely loss of executive functioning, so new onset of ADD type symptoms. We see, of course, the cognitive, you know, what we call brain fog in lay terminology, which is cognitive, you know, so they lose their words. They're not able to do the calculations at work, like their executive functioning ability in their jobs is huge. Like, one in five women will quit their jobs because of menopause symptoms.

• 19:41Andrew D. Huberman?

  That's an outrageous number.

• 19:45Speaker 01

  Yeah, and the economic impact is huge. And so now companies are starting to get on board, and this is the time of our lives when the kids are grown, for a lot of us, you know, and we're trying, we're ready to lean into our positions and really get into leadership, and we have all this experience. And now we can't, you know, and now all of a sudden, these, and their confidence is just wrecked. So, and then the depression, and they're not sleeping, and like, it's this horrible feedback cycle that they end up in, that we end up in.

• 20:09Andrew D. Huberman?

  Yeah, I wasn't aware that one in five is striking.

• 20:12Speaker 01

  That came out of the UK, but they're starting to like crunch the numbers here in the US, and it's looking very similar.

• 20:18Andrew D. Huberman?

  I know we're going to get into actionable tools later as it relates to menopause, but as long as we're discussing this phase of perimenopause, what are some of the basic things that women could A, pay attention to? We don't want to make people hypervigilant to the point of anxiety, but certainly, given the frequency and given the implications, it's important for them to pay attention to this phase. And then, some of the things that they can do to either behaviorally or perhaps through other tools, offset some of these changes?

• 20:49Speaker 01

  Dysfunctional uterine bleeding, which is abnormal periods. So, and again, nothing's off the table. It could be heavy periods, menarasia, too frequent, too few, skipping. It's really, really chaotic. And, but a lot of women are suffering horribly from really debilitating periods, either through the volume of blood loss or they're having cramps and really, and so 90% of us will have that as a symptom. Fatigue is a huge one. A lot of them, the symptoms are kind of vague and can be attributed to a lot of other things. In our, in my, what we call the menopause chat group,

• 21:32Speaker 01

  we have a lot of theories about a lot of conditions like fibromyalgia and the irritable bladder syndromes and that probably just perimenopause and menopause. And doctors didn't know how to make that diagnosis. And so, musculoskeletal system takes a huge hit through the transition. So, all of a sudden, you have no injury and you're having hip pain, joint pain, back pain. You go to the doctor and you get an x-ray, you do whatever, work up, and they can't find anything wrong. Palpitations are huge. It is a vasomotor symptom. So, along with hot flashes, palpitations. So, a woman will walk into the emergency rooms sweating profusely, horrible palpitations, she's anxiety, and they'll tell her she's having a panic attack. They'll work her up, everything's negative, and just say, "Well, it's a panic attack." Go home.

• 22:17Speaker 01

  And no one knew to connect the dots and figure out that this woman was in her menopause transition and this is how her body was expressing it. It's complicated because we have sex hormone receptors, as you do, in every organ system of our body. And when these levels start going chaotic... It can present in so many different ways. And so when the patients come to me, I'm doing blood work, not a lot of hormone levels because they're not super helpful, but I am doing thyroid workups and autoimmune workups and looking for nutritional deficiencies and anemia and different things because I don't want to miss those things and just pin everything on perimenopause.

• 22:55Andrew D. Huberman?

  Are there lifestyle factors that can offset some of this?

• 22:58Speaker 01

  It's not a perfect correlation, but the healthier you are, so anti-inflammatory diet, you know, Mediterranean-esque, Galverson diet-esque, you know, nutrition pattern, um, regular exercise, good sleep habits, you know, all the pillars of health, the healthier you are when you hit perimenopause, the better the course is going to be for you. They're looking at extending the life of the ovary with pharmacology. We know what can shut it down faster. So we have kind of a genetic predetermined age of when you're going to lose all your eggs, but we can speed that up. So if you smoke, you're going to go through menopause sooner than your twin would have if she didn't smoke. Okay. If you don't have children and you ovulate regularly, then

• 23:40Speaker 01

  the more you ovulate, the faster you run through your egg supply. Okay.

• 23:44Andrew D. Huberman?

  Interesting. I, I wasn't aware of those data. That's, I, I don't know that most people are aware of those.

• 23:49Speaker 01

  No, if you have a hysterectomy and you leave your ovaries behind, I didn't, I didn't ever counsel my patients about this. You lose four years off the life of your ovaries. If you have a tubal ligation, you usually lose a year and a half. Huge genetic disparity. So African Americans tend to go through a year and a half sooner. And then there's Caucasians in the middle and then Asian family tend to go through later and they're not sure why, you know, a year, two years. So there are, if you have chemotherapy, if you have surgery, if you have any inflammatory process in the abdomen, irritable bowel or endometriosis, you're going to lose some of the life of the ovary.

• 24:23Andrew D. Huberman?

  You mentioned smoking. Are there any data on vaping?

• 24:26Speaker 01

  Not yet. I haven't seen any. There might be out there. I just haven't seen it yet.

• 24:29Andrew D. Huberman?

  No, I'm guessing if they're out there, they're not prominent, or you would have seen them. I'm curious about vaping because a lot of people are vaping instead of smoking. And hopefully, people are neither vaping nor smoking because it seems that we had an expert in vaping on the podcast recently from Stanford, and it seems that there's nothing great about it.

• 24:48Speaker 01

  Right.

• 24:48Andrew D. Huberman?

  And there may be some things really bad about it. But I was just curious, given that a number of young women, and men for that matter, are vaping nowadays.

• 24:57Speaker 01

  I think we probably need-

• 24:58Andrew D. Huberman?

  And whereas smoking rates have gone way, way down.

• 24:59Speaker 01

  Another 10 years before we'd be able to, you know, see when those women are going through menopause. You know, because vaping, I think vaping is younger, the younger generation, like my kids.

• 25:11Andrew D. Huberman?

  People in their 20s and 30s.

• 25:13Speaker 01

  10 to vape. So we're, you know, we're 20 years out from seeing how it's going to affect them.

• 25:17Andrew D. Huberman?

  Is there any evidence that alcohol can impact perimenopause?

• 25:21Speaker 01

  I haven't seen any, but I can't imagine that, you know, heavy use of alcohol would prolong the life of the ovary in any way. So.

• 25:28Andrew D. Huberman?

  And we know that any use of alcohol has some potential role in disrupting sleep.

• 25:32Speaker 01

  Oh, 100%.

• 25:33Andrew D. Huberman?

  And presumably, like everything else, if you disrupt sleep, you disrupt things for the worst.

• 25:38Speaker 01

  Everything.

• 25:38Andrew D. Huberman?

  Got it. So you mentioned rough ages for onset of menopause, 51, but anywhere from 45 to 55. And that perimenopause is defined as a period about seven years prior to that?

• 25:53Speaker 01

  Seven to 10, yeah.

• 25:55Andrew D. Huberman?

  What's the earliest you've ever had a patient come in who entered menopause? What's the latest you've ever seen?

• 26:01Speaker 01

  My personal patient, 27, and she came in just a couple of months ago. So she had a special condition we call premature ovarian failure. And she had found me on social media and wanted to come just to make sure she was doing everything right. And so, early menopause is defined as between the ages of 40 and 45. And then premature menopause or premature ovarian insufficiency, it's not a complete failure for most women, but it is very, very low, is any time before the age of 40. So this patient- Kind of got kicked around for two years, went to her doctor, no periods, horrible hot flashes. Again, she was 25 and it was not on his radar.

• 26:43Speaker 01

  And he never tested her for menopause. And it took her, you know, 18 months to get the diagnosis. And so the longer your body is away from estrogen, the higher the risk factor. And it's been all over the news this week where we know that untreated premature ovarian insufficiency has a earlier death. So they have higher cardiovascular disease, diabetes, stroke, all because estrogen is so protective and they have to go so long without it. We can negate most of those risks by giving her aggressive hormone therapy early. So she came in to make sure she was on the right dose because in premature ovarian failure, we don't want to give them menopause hormone therapy doses. They're too low. We want to get her more like she would have, which is three to four times the amount of

• 27:28Speaker 01

  estrogen as a reproductive aged woman. And so, and she wanted to have a period so she would seem like her friends. You know, it was an emotional thing for her, which I totally respect. And so, so we were doing cyclical progesterone for her so that she would have a withdrawal bleed and feel like she was normal.

• 27:48Andrew D. Huberman?

  Basic question, but I'm curious, so I'll ask. Given that levels of estrogen change so much naturally during the course of the ovulation cycle, menstrual cycle. With estrogen therapy, is it a constant dose or it's modulated by week to week?

• 28:05Speaker 01

  Yeah.

• 28:05Andrew D. Huberman?

  Or day to day?

• 28:06Speaker 01

  Good question. So there are some formulas. So, and when we look at hormonal contraception, so the biggest difference between contraceptive doses and menopause hormone therapy doses, they're both based in estrogen and progesterone mostly. Okay? The hormone therapy was developed to stop a hot flash for decades. Menopause was defined by the presence or absence of, you know, severe menopause was defined by hot flashes or not. They did nothing else. And so they developed the formulations with enough estrogen to stop hot flashes. Birth control was developed to stop ovulation. You don't ovulate, you don't get pregnant. And it's, but the difference between low dose birth control pill and higher dose menopause

• 28:50Speaker 01

  hormone therapy is not that far away. And so. That a lot of people don't understand. Now, the types of estrogen we use in birth control are a little bit different. Most birth control is ethanol estradiol, which is one of the synthetics. We have literally millions and millions of women's year data on it. We know its safety profile. I think we're not counseling patients adequately about birth control as far as what it does to their testosterone and what it can do to, you know, "Oh, it's fine. It's safe." I took it for years, but I think we need to do a better job as a specialty on counseling women, but I do think it's a good medication. And then on menopause hormone therapy, you know, it's much lower dose. It does not suppress ovulation. So in perimenopause, it's a little bit of the Wild West. Which one we're going

• 29:32Speaker 01

  to use? How high do we want to go? Do we need to suppress her ovulation because she's got acne or horrible periods or cramps or something where I want to suppress that ovulation to help her? Or can I give her menopause hormone therapy doses, which in effect, think of the hypothalamus, I'm giving her just enough estrogen to calm the brain down and tell them everything's okay. We're not going to get those big peaks and drops. And if she still ovulates, that's okay, too.

• 29:55Andrew D. Huberman?

  As many of you know, I've been taking AG1 for more than 10 years now. So I'm delighted that they're sponsoring this podcast. To be clear, I don't take AG1 because they're a sponsor. Rather, they are a sponsor because I take AG1. In fact, I take AG1 once and often twice every single day, and I've done that since starting way back in 2012. There is so much conflicting information out there nowadays about what proper nutrition is. But here's what there seems to be a general consensus on. Whether you're an omnivore, a carnivore, a vegetarian, or a vegan, I think it's generally agreed that you should get most of your food from unprocessed or minimally processed sources, which allows you to eat enough but not overeat, get plenty of vitamins and minerals, probiotics, and

• 30:37Andrew D. Huberman?

  micronutrients that we all need for physical and mental health. Now, I personally am an omnivore, and I strive to get most of my food from unprocessed or minimally processed sources. But the reason I still take AG1 once and often twice every day is that it ensures I get all of those vitamins, minerals, probiotics, et cetera. But it also has adaptogens to help me cope with stress. It's basically a nutritional insurance policy meant to augment, not replace, quality food. So by drinking a serving of AG1 in In the morning and again in the afternoon or evening, I cover all of my foundational nutritional needs. And I, like so many other people that take AG1, report feeling much better in a number of important ways, such as energy levels, digestion, sleep, and more. So while many

• 31:19Andrew D. Huberman?

  supplements out there are really directed towards obtaining one specific outcome, AG1 is foundational nutrition designed to support all aspects of well-being related to mental health and physical health. If you'd like to try AG1, you can go to drinkag1.com/huberman to claim a special offer. They'll give you five free travel packs with your order plus a year's supply of vitamin D3 K2. Again, that's drinkag1.com/huberman. As long as we're on the topic of birth control, earlier you mentioned that the IUD, and presumably this is some form of the IUD, not necessarily copper IUD, can disrupt or stop A period. A period. Maybe we could talk a little bit about the different forms of birth

• 32:02Andrew D. Huberman?

  control. IUD, the pill, quote unquote, old term, but I think most people know what we're referring to when we say that. The ring, and on and on. Sure. What is your stance on these different forms of birth control as it relates to their safety? You know, I guess about a year and a half ago, I hosted a female physician guest on this podcast, and both sides of the birth control issue were touched on. One, the relationship to potential inhibition of certain forms of cancers, but then also the potential for certain side effects, maybe even cancers. And so, you know, it seems like it can play out both ways, and this is a very heated topic. Yeah.

• 32:46Andrew D. Huberman?

  In fact, so much so that I learned that if one is going to post a clip of any of this on social media, it almost makes sense to have them in the same post, because we actually did both of them. We did a post where it was more about the pros of birth control and then the cons of birth control. Right. As stated through the words of this very same clinician. So, we will be sure to, so for anyone listening, whichever Answer comes first. Stay tuned for the next answer because my understanding is that it's not a black and white issue.

• 33:18Speaker 01

  I think the best form of birth control is a vasectomy. And so much of contraception is dumped in a female's lap, you know, in a committed relationship. And I can't tell you the comments I've heard when a patient comes to me and she wants to get X, Y, and Z simply for contraception. She's absolutely perfectly healthy. There's nothing wrong with her. She just doesn't want to be pregnant. And I'm like, okay, you're done. You know, she's completed her family. She's out, you know. And I'm like, tell your partner to get a vasectomy or he won't do that, you know. So now all of the risk and the onus goes on her. And so we go through the options of surgical, like, you know, tubal ligation, which is basically blocking the tube. So when I, you know, talk to my teenagers, I'm like,

• 34:02Speaker 01

  here's how you not get pregnant. A, you don't have sex. Well, if that's not an option, then we have to either block the sperm, stop the egg from coming out, or stop the place where they communicate, which is the fallopian tube. And so when we look at the different forms of hormonal contraception, which are meant to stop ovulation, suppress ovulation, because they're telling the brain, we have enough estrogen and progesterone on board, quiet down so it doesn't send those signals to the ovary, right? And so that can come in a pill form, a patch form, a ring form, and they each have their own pros, cons, risks, benefits. You know, transdermal has less risk of blood clots versus oral has a higher risk of blood clotting, any form of estrogen. So we talk about that. We look at their family history, or if they have MTHFR, any of the clotting genes, you know, then we counsel

• 34:46Speaker 01

  directly. Versus the IUD, the IUDs create an inflammatory environment in the uterus that blocks and it creates a plug in the cervix so that the sperm can't get through. And then if any do get through, it's a toxic environment in the uterine cavity for the sperm. So that's really how those IUDs work. Some IUDs are coated with progesterone or progestin, not progesterone or progestogen. And those end up decidualizing the endometrium, so thinning that lining from that constant progesterone to the point where you stop bleeding. So a lot of my patients really loved that option of being amenorrheic, no periods, just for the convenience of it. But they were still ovulating in the background.

• 35:28Speaker 01

  So we're not suppressing their natural cycles, just their periods.

• 35:32Andrew D. Huberman?

  I see. And is there any evidence that the use of any form of birth control can disrupt the timing or the availability of, I realize availability of eggs is a very clinically naive, biologically naive statement, but basically what I'm saying, can it, can any of them accelerate the onset of perimenopause? Can they delay the onset of perimenopause?

• 35:54Speaker 01

  They will delay the onset a little bit. You know, it's, it's maybe a year if you use it for a long time, from what the data shows. So women who suppress ovulation, we lose about 11,000 eggs each month with the ovulation process to get one out. 11,000 race to the finish line and only one makes it, but we lose about 11,000 in the process. So women who are constantly, you know, for a long time suppressing ovulation will have a slightly older age of menopause had they not done that.

• 36:24Andrew D. Huberman?

  When you say slightly older, what's the longest extension of?

• 36:27Speaker 01

  The best I could see in the data was maybe nine months.

• 36:31Andrew D. Huberman?

  Okay, from nine months use of birth control?

• 36:34Speaker 01

  No, no, no. So, so maybe like five to 10 year use. I have to look at the data again to be, you know, I'd have to look that one up, but it was several years.

• 36:41Andrew D. Huberman?

  Got it.

• 36:43Speaker 01

  To, to gain an extra maybe nine months, maybe a year of ovarian life.

• 36:48Andrew D. Huberman?

  I see. And nowadays, at least if people have the means, there's some trend, if you will, toward freezing one's eggs. This might be a good opportunity to just state something that came up before when we had Dr. Natalie Crawford on the podcast to talk about female fertility. I think surprising to many people was

• 37:12Andrew D. Huberman?

  Her statement that, not because it's controversial, but because we just don't hear this often enough, that harvesting eggs for freezing or for IVF does not diminish the pool of eggs that one would have, meaning you're losing them each month.

• 37:30Speaker 01

  Right.

• 37:30Andrew D. Huberman?

  Anyway.

• 37:31Speaker 01

  Yeah, and so they're only pulling out 10, 12 maybe in a cycle. And when you're losing 11,000 with an ovulation, so it really isn't going to affect when you go through menopause.

• 37:43Andrew D. Huberman?

  Such a crucial thing for people to hear.

• 37:45Speaker 01

  Yeah.

• 37:46Andrew D. Huberman?

  I think there were a number of comments when we posted that clip on social media and people, women, saying, wow, I didn't realize that harvesting eggs would not somehow shift the onset of menopause earlier. And so for the record, we are not saying that. We're saying it does not. And very interesting that the use of birth control, but I'm guessing only forms of birth control that suppress ovulation.

• 38:12Speaker 01

  Yeah.

• 38:13Andrew D. Huberman?

  Can delay the onset of perimenopause, menopause by about nine months maximum.

• 38:17Speaker 01

  Maximum.

• 38:18Andrew D. Huberman?

  So things like the copper IUD.

• 38:20Speaker 01

  That won't affect it.

• 38:21Andrew D. Huberman?

  Right, which prevent pregnancy by creating a unfavorable environment for the sperm rather than disrupting ovulation in any way will not presumably extend perimenopause, menopause. Okay, just want to make sure we're crystal clear for people. You're being very clear, but I want to make sure that I'm clear on it and then reiterate because this can be kind of tricky territory. I think there are a lot of assumptions about this stuff and there's a lot of lore out there. Why do you think that is? Is that because of the lack of solid research and communication in this area?

• 38:48Speaker 01

  I think so.

• 38:49Andrew D. Huberman?

  Or is it something else? You know, I think that these are tricky topics for discussion often because we hear all this stuff, like birth control pills disrupt one's ability to get pregnant when they come off, or we just learned that it can delay the onset of perimenopause, which by extension means there's a greater window for pregnancy if one thinks about it that way. But why do you think it's so, such a tangled discussion out there?

• 39:18Speaker 01

  I think just the way that society views pregnancy and female health and.

• 39:27Speaker 01

  You know, at least, you know, I live on the internet now. You know, this new life has brought me life on the internet and this what the algorithms are showing me.

• 39:36Andrew D. Huberman?

  It's a very friendly thing.

• 39:37Speaker 01

  Everyone loves you.

• 39:39Andrew D. Huberman?

  It's a great, listen, it's what you're doing is so important. And I understand the the statement behind that statement, I think. But it's so important because it people are getting the opportunity to learn about really critical public health and female health issues in a way that just was inaccessible before.

• 40:00Speaker 01

  Yeah, it is. And I, I, it's good and bad. You know, there's a lot of lore and misinformation that's getting propagated. And I feel like as a specialty, you know, as a women's health specialist, we did this to ourselves. You know, we have not properly educated ourselves. We have not spent the money, the research, really, you know, championed women after reproduction. When you look at the dollars and and the research and where it goes in women's health. I mean, women's health just gets a little sliver of all the NIH funding. When you look at all NIH funding and what goes to menopause, it's point oh three percent. Less than half a percent. This is one third of a woman's life. And when you look at, God, McKinsey and Company just just published a report where they pulled

• 40:45Speaker 01

  680 studies on like chronic diseases, diabetes, hypertension, cardiovascular disease. And they looked at how they had, they were women included in the studies, but how many presented the data for the different sexes? Like what happened to men versus what happened to women? It was only 50% of the articles actually did sex specific differences and how this medication affected this process or whatever. And then the ones that did, 30% of women had poorer outcomes. And and the other, and on the flip side, 10% of men had poorer outcomes. And these things aren't just being brought to light. So the the lack of recognition of sex specific differences in chronic disease and how menopause kind of plays into all that, I think, is where the future needs to go.

• 41:28Speaker 01

  So we deserve as much good health as everyone else. Because, yes, we're living longer than men, but 20 to 25% of that life is in poorer health.

• 41:37Andrew D. Huberman?

  Wow, that's a really significant statement. I mean, I think that the National Institutes of Health has been terrific in establishing new institutes within it. They even have a complementary health institute now. There's the National Eye Institute. There's, you know, cancer here. Is there a plan, or one would hope, for a dedicated institute for women's health?

• 42:01Speaker 01

  There's a push. So, there was one piece of legislation that got pushed through. The Bidens signed it, and it was $100 million for women's health, and that got chopped up very quickly. Menopause did get a little piece of it, because we're also really struggling with endometriosis and, you know, a lot of the female-specific uterine diseases and PCOS and things. And so, we need more funding there as well. And then, there's another bill that just got, that's the one Halle Berry was like, on TV talking about, another bill for $250 million. That bill includes language for education of providers. So, we have a whole generation of providers. Like, I graduated my residency training the

• 42:44Speaker 01

  year the WHOI came out. So, all, we had very little, like, real clinically significant menopause education, and then we knew about HRT, and we were giving it in clinic, if she was coming in with severe hot flashes. But, that got taken off the table after the WHOI, and then we have a whole genera, like, all menopause education basically stopped after that.

• 43:04Andrew D. Huberman?

  So, WHOI, Women's Health Initiative, HRT, no, that's okay, just so that people are on board, hormone replacement therapy. Yeah, it's, it's a, well, we can encourage the expansion of research in these areas and with this discussion. And certainly, I was on NIH panels for years as a regular member in the Eye Institute. And what I've noticed with NIH is that they are very responsive to the public call for growth of research in particular areas. You know, it can take time. It's government, after all, and they need funding. There's a finite amount of funding. But, but I think that rarely do I ever get into legislature-based things. But, if you are somebody who cares about

• 43:49Andrew D. Huberman?

  more funding in a given area of research, it's actually very straightforward what to do. You call your congressman, or senator, and you tell them, literally, you leave a message. I find this kind of interesting. And so, it's kind of like what we learned in social studies and...

• 44:04Andrew D. Huberman?

  In elementary school, but you call your, you call your Senator or your governor and you leave a message and you say, hey, you know, there's this issue that impacts a ton of people and it's really important. And the next time it comes up, when budgeting comes up in Washington, it's really important. And if you hear about a bill, you can call and support a bill. And believe it or not, some of that stuff actually translates to more funding in a given area. In fact, the Brain Initiative, which unfortunately had its budget cut significantly recently, maybe put that funding back. But, you know, arose from the, I believe it was the child of two neuroscience professors up at University

• 44:46Andrew D. Huberman?

  of Wisconsin. I'm probably going to get some details wrong, but so the Khalils are the, are the professors, as I recall, and their son overheard all these conversations growing up about the importance of brain science and then eventually pushed through government channels for more money for brain research. And then we had a long phase of pretty, pretty substantial research and then it was cut. So these things, but it persists. And so these things really matter. It can impact it. So, and maybe we should send them a clip of your statements on this podcast. Getting back to kind of things that people can control. So for people who are heading into perimenopause or who are in the perimenopause phase, aside from the typical things that we hear about fortunately a lot these days,

• 45:27Andrew D. Huberman?

  like getting adequate sleep, getting exercise, nutrition, maybe we could touch a little bit on nutrition in a moment. You mentioned Mediterranean diet, Galveston diet, things that are going to promote overall health.

• 45:39Speaker 01

  Right.

• 45:39Andrew D. Huberman?

  Are there any things that people can do, maybe even take, that would improve their outcomes in this phase? Like I've heard of people, and I have no bias here or even knowledge of the research on this, if there is any people taking, for instance, grape seed extract or people trying to do a number of things to reduce inflammation, kind of general themes around self-care and wellness these days. But what are sort of the five or six that come to mind, perhaps as like the things that can move the levers in the right direction?

• 46:09Speaker 01

  What I would tell my 35-year-old self, you know, who just kind of went into this obliviously. And what I know now is

• 46:17Speaker 01

  Your diet is probably one of the most important things that determines your level of inflammation and then estrogen is a really powerful anti-inflammatory hormone and we lose that protection when we go through, we start losing it through the transition. So whatever you can do in the other areas, especially with nutrition, sleep, stress reduction, we need to do it. So fiber, we are not getting enough fiber in our diet. In the Western diet, I think it's, most women are getting 10 to 12 grams per day and we need at least 25 and the health benefits tend to max out around 30, 32 grams per day. So focusing on foods that are rich in fiber. Fiber is feeding the gut microbiome, slowing down glucose absorption, you know, glucose levels, sugar absorption into the bloodstream. It is slowing down the rate of, you know, certain parts of transit and pulling more

• 47:02Speaker 01

  water into the gut. There's nothing bad about it, right? The foods that are rich in fiber have a lot of other stuff that's good for you too. Co-factors, vitamins, minerals, nutrient, you know, just, they're just so healthful. And then anthocyanins, you know, just find things that crunch that are, and get as many colors as you can, you know, green, red, purple, yellow, every color represents a phytochemical that is going to be good for you in different areas of your body and try to keep it as varied as possible. We're not getting enough protein and I have to thank Dr. Gabrielle Lyon, you know, really helping me focus in on that. You know, when I first wrote Galveston Diet, to be honest and transparent, it was for weight loss and, you know, I was frustrated with my weight gain and that was the pain point my patients had and that was my pain

• 47:45Speaker 01

  point, but I didn't realize it represented something much more sinister than, than just the way I looked, you know, the visceral fat gain. And so, learning about visceral fat and what it really means, and that is for your listeners, the fat that wraps around our internal organs. It's a very different fat than the subcutaneous fat. And, you know, a pre-menopausal woman, so we age matched and looked at visceral fat levels, measuring it with the DEXA scanners, you have about 8% of your fat as visceral as a pre-menopausal person and then when you go through the transition, it's 23% with no changes in diet and exercise.

• 48:20Andrew D. Huberman?

  The visceral fat is not something that gets enough attention. I think everyone thinks about subcutaneous fat because of its relationship to aesthetics.

• 48:26Speaker 01

  It's cosmetically distressing, but really, yeah.

• 48:29Andrew D. Huberman?

  And one doesn't want too much of it for health reasons either, but the, it's the intravisceral fat that... At least by my understanding is really the most problematic for our health.

• 48:40Speaker 01

  It's a harbinger of chronic disease, so.

• 48:44Andrew D. Huberman?

  I read that weight gain is one of the primary symptoms of menopause itself.

• 48:50Speaker 01

  Yeah, so you have to be careful how you think about that. When we plot weight gain versus age, it's a very straightforward linear curve, and menopause does not seem to affect that. What is happening is a body composition change. We are losing muscle and we are gaining visceral fat. And so, and you might be gaining some because subcutaneous fat, but those are kind of the key things that are happening. And so that's really when I'm counseling patients, what I'm focusing on, because I have a body scanner in my office where I can tell them what their level of visceral fat is in their muscle mass. And so we, bone and muscle, that musculoskeletal unit works together. And so we see this acceleration of muscle loss, which controls our basal metabolic rate, which determines our resistance to insulin,

• 49:34Speaker 01

  which, you know, so it's just, that's the organ of longevity. That's what I've learned from Dr. Lyon, you know, and everything we can do to hang on to it and build is so important. So protein, going back to the original point, protein intake is key, and women by and large are getting 50 to 60 grams of protein per day, and we really probably need 80, 100, 120, depending on our body composition.

• 49:59Andrew D. Huberman?

  Yeah, thanks for mentioning Dr. Gabrielle Lyon. She's doing what I view as just-

• 50:03Speaker 01

  Beautiful work in the world.

• 50:04Andrew D. Huberman?

  Yeah, terrific work, really promoting women's health and health generally. I know she's now, I believe is exploring advanced training in urology for males as well. And so, you know, it's only fair to credit her with really expanding into these different areas, but especially this idea that we need-

• 50:28Andrew D. Huberman?

  And women, perhaps in particular, from what I understand, she'll be on the podcast soon, so we'll get more of an understanding, at least one gram of quality protein per pound of lean body mass, maybe even per pound of body weight per day in order to optimize their health.

• 50:43Speaker 01

  Yeah, she's definitely on the higher end. The WHO, the Women's Health Initiative, some of my favorite data, it's not all bad, it's data, was looking at frailty scores and protein intake in women. And what they found was women who were having 1.5 to 1.7. So basically, it was the higher their protein intake, the less likely they were to be frail. The end. And they were reaching, it was kind of peaking out somewhere around 1.5 to 1.7 grams per kilogram of lean body mass. And most women are getting, the FDA recommends .8.

• 51:19Andrew D. Huberman?

  Wow. And source of protein also important, high quality.

• 51:24Speaker 01

  Right, right. You need all the amino acids.

• 51:25Andrew D. Huberman?

  Very interesting. Now, that's in menopause, but presumably also...

• 51:32Speaker 01

  So, starting those habits in peri, just getting that laid down and getting those habits laid down are going to set you up for a much better post-menopause, a much healthier post-menopause. And we have to stop defining menopause by your hot flashes. It may or may not make your hot flashes better, and we have great medications for that, if it's disruptive. But I'm talking about your cardiometabolic disease risk.

• 51:55Andrew D. Huberman?

  I meant to ask this earlier, so forgive me for leaping back briefly, but is there any value in knowing the age at which your mother went into menopause?

• 52:05Speaker 01

  Yes.

• 52:06Andrew D. Huberman?

  As a metric, or a sensor, rather, as a window into whether or not you will go into menopause at more or less the same age?

• 52:14Speaker 01

  Yes. Of course, it's not one-to-one. We get half of our DNA from our fathers. But I always ask, and there is a, the latest data that looked at it, genetics is the biggest factor that determines when you're going to go through menopause. So knowing when your mothers, your aunts went through, and if there were any medical conditions associated with that, is huge.

• 52:37Andrew D. Huberman?

  Okay, so now we're talking not so much about peri-menopause, but also menopause itself. What is the typical constellation of symptoms as one...

• 52:48Andrew D. Huberman?

  Enters menopause, like, right at the beginning? And then, does that constellation of symptoms change as one, you know, a year, two years, three years into menopause?

• 52:56Speaker 01

  So, it's almost 100% with body composition changes, like, very, very close. You know, that visceral fat is tough to beat. It's beatable, but it takes a lot of work, you know?

• 53:06Andrew D. Huberman?

  Do people know if they have visceral fat? I mean, there's their scanning approaches to look at it.

• 53:10Speaker 01

  So, gold, you know, of course, the gold standard is a DEXA or even an MRI, but no one can afford that. So, we have, like, what I have in my office is the in-body scanner, so it's electrical impedance scanner, and it's, it's pretty good.

• 53:22Andrew D. Huberman?

  So, you stand on the scale, hold the handles?

• 53:24Speaker 01

  I have the medical, I have the highest-grade one for my patients. And most people doing what I do, you know, utilizing a body scanner, use that one. But, you can use the waist-tip ratio. And so, the waist-tip ratio is a better measure of your risk of metabolic health than your weight or your BMI. So, it's so simple. You take a tape measure and a calculator, you can do it in your head, but you measure the smallest part of your waist. And if you don't have a small waist, if it goes out, then just use your belly button. Just use something you can measure again.

• 53:53Andrew D. Huberman?

  Are people sucking in, or are they relaxed?

• 53:54Speaker 01

  You should be relaxed. And I tell my patients, you know, do it first thing in the morning when your bladder's empty and you're not bloated, and, you know, and then, the widest part of your hips. It's not perfect, but it's better than your weight or your BMI.

• 54:06Andrew D. Huberman?

  So, widest part of the hips with people, feet, feet, parallel, standing together?

• 54:10Speaker 01

  Yeah, just parallel, standing up straight.

• 54:11Andrew D. Huberman?

  Because people are gonna go try this, right?

• 54:13Speaker 01

  And so, I only know the data for women, so forgive me, but for a female, if it's less than 0.7, then your chance of having clinically significant aberrations in visceral fat are low. And then, if it's greater than one, you likely have higher levels of visceral fat. And so, in clinic, or when I was coaching online for Galveston Diet, we were using the waist-tip ratio as one of the, you know, measures for their success.

• 54:43Andrew D. Huberman?

  When measuring the waist? Which point along the waist? Is it right at the navel? Is it?

• 54:48Speaker 01

  It's just wherever you're smallest. So, that's kind of different for different women. So, I would just say, look in the mirror. Wherever your hourglass goes in is where you want to kind of stick to. But, if you don't have that kind of a waist, and you have a wider waist, just pick the belly button, because you always know you can go back to that level. You know, that's, because we're tracking them over time.

• 55:07Andrew D. Huberman?

  Great, those are very useful recommendations. And how often should people do that?

• 55:13Speaker 01

  You know, you should never weigh yourself every day. You shouldn't do this every day. We were having patients do it, or you know, our followers do it once a month.

• 55:19Andrew D. Huberman?

  So, changes in body composition, as measured by DEXA or impedance, or if you don't have access to that, waist to hip ratio. What are some of the other symptoms of menopause?

• 55:30Speaker 01

  Fatigue, fatigue, multiple causes for the fatigue. A lot of sleep disruption. Sleep disruption is another huge thing. So, all of a sudden, you're struggling to go to sleep, or you're having middle of the night awakenings and not able to go back to bed.

• 55:43Andrew D. Huberman?

  That are new and different from previous?

• 55:46Speaker 01

  New and different than before, right.

• 55:48Andrew D. Huberman?

  I see.

• 55:48Speaker 01

  There was a recent study that came out, and most of my patients in hindsight say, "I knew something wasn't right." Or, "Something was different, something had changed, but I couldn't put my finger on it." And they just had a study come out saying, something's... Then when they looked at what that means, what does "I'm not feeling like myself" mean? And it was psychological changes. So, you lose resilience, you're suddenly more irritable, you're suddenly not able to like, go with the punches, or do, you know, you're not adjusting as well to change that you used to. You're snapping at your kids more, your partner, or you're, you know, you're getting frustrated at work, you know? It's just very kind of subtle, and it takes going through it and then looking back to say, "Yeah, I really said maybe about 47 that something was changing,

• 56:33Speaker 01

  and I just thought I was just stressed out, or whatever, and then now I can see that was the beginning of the pattern." So, menstrual changes, as we talked about. You know, the big highlights, vertigo, tinnitus ringing in the ears, skin changes, so dry skin, itchy skin, feeling like you're having crawling under the skin, big gut changes, so nuance up bloating, you're kind of eating all the same things, and your gut's just not handling things like it used to. So, the Zoe Nutrition Study took 1,100 women and did stool samples through menopause, through the perimenopause, menopause transition, and saw the changes in the gut microbiome from the loss of the sex hormones. And basically, we went from what was typical female microbiome to that of a male.

• 57:18Speaker 01

  Through the transition.

• 57:20Andrew D. Huberman?

  Is there any direct evidence that supplementing the gut microbiome, and here I don't necessarily mean pills and powders.

• 57:28Speaker 01

  Right.

• 57:29Andrew D. Huberman?

  My understanding is that getting enough fiber.

• 57:31Speaker 01

  Yeah.

• 57:32Andrew D. Huberman?

  And low sugar fermented foods can also support the gut microbiome.

• 57:36Speaker 01

  Yes.

• 57:37Andrew D. Huberman?

  Things like sauerkraut kimchi.

• 57:39Speaker 01

  Miso.

• 57:40Andrew D. Huberman?

  Pheffer miso.

• 57:41Speaker 01

  Plain yogurt, just straight up, nothing added.

• 57:44Andrew D. Huberman?

  Yeah, so is there evidence that supporting the gut microbiome can make this stage of menopause more, I guess, reduce some of the symptoms of menopause?

• 57:54Speaker 01

  So, the best I could find was, most of them are done with supplements, because those are easier to measure than handing someone a cup of yogurt.

• 58:01Andrew D. Huberman?

  Right, and you know which bacteria you're providing.

• 58:03Speaker 01

  So, they did lactobacillus and looked, and bifidobacterium, I think, and saw that women who were obese and hypertensive and menopausal, and they had visceral fat decrease and blood pressure improvements versus placebo. Also, it's hard to do placebo studies with food, you know, so.

• 58:21Andrew D. Huberman?

  Right.

• 58:22Speaker 01

  But they do, and then in the retrospective studies, they can look at dietary patterns. And women who ate rich foods fermented and lots of yogurt, you know, Mediterranean-type diets, have better symptoms overall.

• 58:35Andrew D. Huberman?

  What's the difference between the Mediterranean diet and the Galveston diet?

• 58:38Speaker 01

  So, when I, so I got my culinary medicine certification, I was frustrated.

• 58:45Andrew D. Huberman?

  Culinary medicine?

• 58:46Speaker 01

  Yeah, so I was frustrated in, when I was working, because I didn't know anything about nutrition, and suddenly, like, everything I was trying to tell my patients was based on, like, the one lecture I got in medical school, and, you know, good nutrition was like porn, you know it when you see it, you know, the Supreme Court definition of pornography. And so, you know, the best I'd ever gotten was the gestational diabetic diet, and it was the Xerox things with, you know, I was in the deep, I was in Texas, so it had, like, tortillas and stuff on it, and it had been copied so many times, you could barely read it anymore, and that was the diet. We would, that was the only nutrition I'd ever, like, hand it to a patient. And so, I'm like, eat healthy. And so, I'm like, I gotta do better than this, I don't know enough. And so, we had a guest speaker for A O, Alpha Omega Alpha, which is the honor society for

• 59:27Speaker 01

  medical school, and I was one of the advisors, so, and it was this guy, Tim Harlan, who Had started this culinary medicine movement and it was basically nutrition for doctors. And he developed this like online program and I had to go to New Orleans for a lab and San Antonio for a lab and work in kitchens where you were learning how to counsel patients, how to cook, and also basically like getting a little minor in nutrition. So it was the best thing I've ever done.

• 59:53Andrew D. Huberman?

  Yeah, I was gonna say, very cool.

• 59:54Speaker 01

  I mean, I learned about allergies and like all this stuff, you know, food allergies and things that I just didn't know and just basic nutritional principles, like what it takes to build a healthy body and what, you know, I knew about quasiorcore and like severe deficiencies, but not good, basic nutrition. And so, you know, they talked heavily about Mediterranean, they talked a lot about the fad diets and stuff, but you know, the principles of the Mediterranean, I was like, I want to teach this to my patients, but they're not going to eat a lot of Greek yogurt or they're probably not going to eat a lot of feta, you know, like, how can I kind of take these blocks and make it more Americanized? So that was kind of like the brainchild for me around Galverson Diet was, let me like create something, and I really was into fasting at the time, too. So I was like, let me put this fasting thing together with, you know, good nutritional

• 1:00:36Speaker 01

  anti-inflammatory principles and talk about the things we know are probably you should, you know, not having a whole lot of, you know, processed foods and high sugars and stuff and, and explain it in a way and how it's affecting their menopause and like, how can she approach her nutrition? And that's how Galverson Diet was born. It was for my patients and then I gave it to my girlfriends and then they started sharing it and I talked about it one day on Facebook and the world exploded.

• 1:00:57Andrew D. Huberman?

  In the best way.

• 1:00:57Speaker 01

  In the best way, yeah. It led me here.

• 1:00:59Andrew D. Huberman?

  Right, right. And we all benefit. What is the evidence that fasting can be beneficial or detrimental to perimenopause?

• 1:01:10Speaker 01

  Yeah, so the jury's kind of still out on that one. I was really liked the data that, you know, I think it was Mark Mattson had done on neurodegenerative disease and, and using fasting as a tool there and lowering inflammation levels. So I was like, this is amazing, this is great, because so much about menopause is pro-inflammatory, you know?

• 1:01:30Andrew D. Huberman?

  Is this intermittent fasting?

• 1:01:31Speaker 01

  Intermittent fasting, yeah. So he was basically doing sixteen eight, you know, and, you know, very scheduled intermittent fasting. And so that was something I was coaching my followers about, you know, consider this, try this, this might be something to help lower inflammation. I pulled back on that because it's really hard to get enough protein in for a lot of women, especially if they came in at sixty and now I'm telling them to double their protein. You know, and then giving them an eight hour window to do it. They're like, I'm walking around knowing on a chicken breast all day, you know, this is hard.

• 1:02:01Andrew D. Huberman?

  Right. And metabolizing protein is its own work.

• 1:02:04Speaker 01

  Right. And so you have to spread it out throughout the day, you know, and a lot of that work was done at UTMB, where I did my undergrad, I mean, my residency and where I taught for years. And so I was friendly with the nutrition department there. I was getting all excited about everything. And they're like, you know, I went to several of their conferences and like talking about breaking up protein intake into nuggets throughout the day because most women have very little protein with breakfast, maybe wheat gluten in their toast, and then have a little bit at lunch and then kind of stack their protein at night. And they're still not getting enough, but they're overdoing it in their evening meal. That's their big protein meal. And so like teaching them to kind of, you know, what I was teaching in Galveston Diet was you need to have a healthy fat, a good, healthy carb and a protein with every meal and snack that you eat, you know.

• 1:02:48Andrew D. Huberman?

  Why do you think that protein has not been emphasized enough until recently?

• 1:02:55Speaker 01

  I think because we didn't understand it, you know, we didn't understand how important muscle was. And I mean, we knew that protein intake was important for muscle, but muscle was for bodybuilders and not for women. I lived my whole life up until about five years ago, eating to be thin and moving to be thin. That thin was the only measurement of health that I needed to worry about. And what I did was chip away at my bone and muscle strength. And thank God I don't have osteopenia yet. You know, I've hopefully have reversed whatever trend I was on and I'm naturally low muscle. So now it's just a battle to try to hang on to what little I have and build some.

• 1:03:32Andrew D. Huberman?

  And you're new resistance training.

• 1:03:34Speaker 01

  Yeah, yeah, yeah. Now.

• 1:03:36Andrew D. Huberman?

  Three days a week, three days a week.

• 1:03:37Speaker 01

  Three to four days a week. Yeah, I'm resistance training, much less cardio. I was running marathons. And it was a great social thing with my girlfriends, but you know, everything I did was cardio. I taught step aerobics. You know, the only weights I did were maybe in Zumba, maybe one or two pounds, you know. So, and that was better than being on the couch. I mean, I loved the community and doing that, but you know, for me to like stay out of the nursing home, which was my ultimate goal for as long as possible, I need to pick up some weights and heavy weights. And so that's where my focus has changed.

• 1:04:06Andrew D. Huberman?

  Isn't it interesting that it wasn't until recently that it was only bodybuilders and football players and people preparing for military or a specific sport would resistance train. And now we are told that everybody, male, female, young, old, should resistance train.

• 1:04:23Speaker 01

  Absolutely.

• 1:04:24Andrew D. Huberman?

  Probably three times a week.

• 1:04:25Speaker 01

  Yeah. And my generation is struggling because we don't know how to do it. And so I'm, you know, and I'm not a personal trainer. I don't pretend, you know, I hire one to help me develop a program so that I don't hurt myself and that I can get stronger, you know, progressive loads. So, you know, and again, Dr. Lyon, such a huge proponent of that. And so what I try to do publicly is show my workouts so that people, I normalize it and people see me doing it and they're like, well, she can do it, then I can do it.

• 1:04:52Andrew D. Huberman?

  That's great. Super inspiring. And it really helps cross that threshold where people, as you said, they don't know how. It's scary.

• 1:04:59Speaker 01

  Right.

• 1:04:59Andrew D. Huberman?

  For people who have resistance trained for a long time, they go into a gym, they know how all that stuff works. But for those that don't, it's

• 1:05:05Speaker 01

  You're wandering around like, what does this one do?

• 1:05:06Andrew D. Huberman?

  Yeah, it's intimidating for a whole bunch of reasons. Well, thank you for putting that content out. Both the prescription, if you will, but also the example that one can go about it. So I'm guessing if you could go back 20 years, you would have started resistance training earlier and eating more

• 1:05:21Speaker 01

  Yeah, strong over skinny, nutrition over calories and, and stop looking, trying to look a certain way, you know. You're undermining your future health by doing that.

• 1:05:31Andrew D. Huberman?

  I'd like to take a quick break and acknowledge our sponsor, InsideTracker. InsideTracker is a personalized nutrition platform that analyzes data from your blood and DNA to help you better understand your body and help you reach your health goals. Now, I've long been a believer in getting regular blood work done for the simple reason that many of the factors that impact your immediate and long-term health can only be analyzed from a quality blood test. Now, a major problem with a lot of blood tests out there is that you get information back about metabolic factors and hormones and lipids and so forth, but you don't know what to do with that information. With InsideTracker, they make it very easy to know what to do with those numbers because they have a personalized platform that allows you to see the levels of those metabolic factors, lipids, hormones, et cetera.

• 1:06:15Andrew D. Huberman?

  And they give you specific directives that you can follow related to nutrition, behavioral modification, supplementation, and more that can help you bring those numbers into the ranges that are optimal for you. If you'd like to try InsideTracker, you can go to insidetracker.com/huberman to get 10% off their new membership program. InsideTracker membership offers significantly reduced prices on InsideTracker's comprehensive blood panels. Again, that's insidetracker.com/huberman to get 10% off. So, what are some other symptoms of menopause? You mentioned body composition changes. The one that we hear about the most, for some reason, I don't know, is hot flashes.

• 1:06:53Speaker 01

  Yeah, so I think hot flashes, so in medicine, we call it a vasomotor symptom. So, we have a dysregulation of the thermoregulatory center in the hypothalamus and that the thermostat gets reset, basically. And so, what happens is we have this vasodilation of, it starts in the core typically for most women, somewhere in the chest, neck area, and you feel this heat. I can probably trigger one just by talking about it. And it goes up into the neck and out into the extremities, and then you just start profusely sweating from all the blood vessels dilating. And then it could last minutes to a second, but for some women, it's preceded by sometimes

• 1:07:34Speaker 01

  palpitations, sometimes by this intense feeling of dysphoria, you know, this intense sadness feeling, and then it just kind of passes. But, you know, say you're, you know, wherever you are in your life, whatever you're doing, all of a sudden, you're just like sweating profusely in the middle of some important area of your life, work, you know, whatever your jobs are in your life. And it's disruptive. If it happens at night, you don't sleep. And for some women, it's severe where they're having multiple ones a day.

• 1:08:01Andrew D. Huberman?

  And when anytime you disrupt sleep, then daytime is far worse.

• 1:08:04Speaker 01

  Yeah.

• 1:08:05Andrew D. Huberman?

  Regulation of everything.

• 1:08:06Speaker 01

  You, yeah, you stress differently, you, you know, everything changes. And so when my patients come in, the first questions we ask are sleep. And that's the first thing we work on is, is, you know, what can we do to get your sleep better?

• 1:08:19Andrew D. Huberman?

  What can be done for hot flashes, aside from the things that you've already described to offset menopause?

• 1:08:24Speaker 01

  So, the goal, absolute goal standard is hormone therapy, is like giving your body back the estrogen, which will re- get your serotonin levels back to where they were, and leave that thermoregulatory center alone. So it's back to where it used to be.

• 1:08:37Andrew D. Huberman?

  Let's talk about hormone therapy.

• 1:08:39Speaker 01

  Sure.

• 1:08:39Andrew D. Huberman?

  It's a bit of a controversial topic.

• 1:08:41Speaker 01

  For no reason.

• 1:08:42Andrew D. Huberman?

  Yeah, I, I was gonna say, I don't know why.

• 1:08:44Speaker 01

  Yeah, it's demonized. It, it got such a bad rap, and we need to, to, it's just some of the, was the worst misinformation campaign in the history of medicine.

• 1:08:53Andrew D. Huberman?

  Well, that's a bold statement, but I believe you. The, um, the way I understand it is that there was this large scale hormone therapy trial.

• 1:09:02Speaker 01

  Mm-hmm.

• 1:09:03Andrew D. Huberman?

  Um, and the interpretation of that trial was something different than we now believe.

• 1:09:10Speaker 01

  Right.

• 1:09:10Andrew D. Huberman?

  As a medical community.

• 1:09:12Speaker 01

  The initial, so it was really groundbreaking at the time. Aging women were finally being studied. We knew from observational data that women on hormone therapy, probably 40% of the population of females eligible were on HRT. Okay, so very large amount. So the women who were given hormone therapy had lower incidence of cardiovascular disease, older ages of cardiovascular disease, lower death from cardiovascular disease. Some people argued that that was an artifact of healthier, wealthier women get HRT, because they go to the doctor. Okay, so this is just because they're healthier, that they have less cardiovascular disease. So let's prove it. What do you do that with? A randomized controlled trial. So flaws in the study. So they take, I think there were 11,000-ish women in the estrogen-only arm

• 1:09:56Speaker 01

  because they'd had hysterectomy. So for your listeners, if you have a uterus and you're getting estrogen, you must have a progestin with it to protect the lining of the uterus from endometrial cancer. As long as you give an adequate progestin, you're fine. Okay? But if you don't have uterus, progesterone is not mandatory. So the women who had had hysterectomy got estrogen only or placebo. And the estrogen at the time was Primorin, which was the number one prescription for HRT at the time. So nothing weird about that.

• 1:10:25Andrew D. Huberman?

  So it's just synthetic estradiol?

• 1:10:27Speaker 01

  Actually, no. Primorin is, is, Primorin stands for pregnant mare urine. It is actually very natural. They take pregnant horses and extract the estrogens from their urine. Because they're pregnant and they were secreting a lot of it. And it was cheap and easy. And I have a lot of ethical issues about how they do that, but, and I don't prescribe it, but that's what was done at the time. So.

• 1:10:47Andrew D. Huberman?

  I've seen horses urinate, they urinate a lot.

• 1:10:50Speaker 01

  There are dozens, like a racehorse, sorry. There's dozens of estrogens in that comp, but the main one is estradiol. So then there, the other group who had uteruses were given Primpro, which is Primorin plus Provera and, or placebo. So off we go. They recruit 11,000 and then I think 15,000 in the other arm. Huge study. It was like a billion dollar study. Like, we're so excited this is happening. This started when I was in med school. And then they start recruiting patients and then, you know, everyone's taking their meds. They excluded women with hot flashes.

• 1:11:25Andrew D. Huberman?

  What?

• 1:11:26Speaker 01

  Because if your hot flashes go away, you know that you didn't get the placebo.

• 1:11:32Andrew D. Huberman?

  Ah.

• 1:11:33Speaker 01

  So they excluded women with hot flashes. Problem number one.

• 1:11:35Andrew D. Huberman?

  Yeah, that's a big problem.

• 1:11:37Speaker 01

  Now, the end outcome, the, what they were trying to measure was cardiovascular disease. So they started with an older population. The average age was 63.

• 1:11:46Andrew D. Huberman?

  Whereas the typical onset of menopause is?

• 1:11:48Speaker 01

  51.

• 1:11:49Andrew D. Huberman?

  Wow.

• 1:11:49Speaker 01

  So these women had been menopausal, you know, on average for 10, 12, 13 years. So time away from estrogen is when disease starts, accelerates, right? Okay, so put them on their meds, start measuring. In the estrogen plus progestin arm, they saw a non statistically significant increased risk of breast cancer. And it was this, the relative risk, relative, now you know what this is, but your, many of your listeners may not, was 25%. And, and I hope I get the numbers right. It was four out of 1,000 women per year to five out of 1,000 women per year.

• 1:12:28Speaker 01

  Okay, so placebo arm was four. So we have breasts, we are females, we get breast cancer, about four out of a thousand women per year, and that increased to five. In the estrogen-only arm, there was a 30% decreased risk of breast cancer.

• 1:12:41Andrew D. Huberman?

  Regardless of the average age.

• 1:12:44Speaker 01

  And they kept that arm going.

• 1:12:45Andrew D. Huberman?

  Right, because it's randomized, so presumably the average age for the other group is roughly 61 as well.

• 1:12:51Speaker 01

  Yeah, they were matched, so in their 60s as well. So they call a press conference at the Watergate Hotel.

• 1:12:57Andrew D. Huberman?

  The Watergate Hotel of all places.

• 1:12:58Speaker 01

  To announce the findings. They hadn't even published the data yet. No one had had a chance to read it. And the head researchers called this press conference and say estrogen causes breast cancer.

• 1:13:10Andrew D. Huberman?

  Exogenous estrogen from these.

• 1:13:14Speaker 01

  Yes, yes. And they said it's a 25% increased risk. But the absolute risk was like 0.8% per year. But that didn't get, that's not a headline thing. So on every, like ABC, NBC, CBS, all the morning shows, nightly news, every major magazine, it was the number one medical news story of 2002, that estrogen was bad, and it caused cancer, and da-da-da. The estrogen-only arm kept going, and they found after a couple more years, a slightly increased risk of stroke, so they stopped the study. The effects on cardiovascular disease were neutral, but there was lower colon cancer in both groups, but no one talked about that. So, the American Heart Association in 2020 went and looked at, they looked at

• 1:13:58Speaker 01

  ages. So there were younger women who were given HRT, and what they found was if you started hormone therapy between the ages of 50 to 59, you had a 50% decreased risk of cardiovascular disease and death from cardiovascular disease and all-cause mortality.

• 1:14:12Andrew D. Huberman?

  Wow, so age at which you start matters.

• 1:14:15Speaker 01

  Matters. Estrogen, so that's where there's something called the healthy cell hypothesis, or, and so basically estrogen is better at prevention than cure. And it's very protective, especially in the entima of the coronary arteries. So taking that estrogen away, we lose that protection. Once the disease builds up, there's some worry that adding estrogen, once you've developed atherosclerosis or plaque, might loosen the plaque, especially in that first year. So which led for some people maybe to have a slightly increased risk of stroke. So when my patients come in, we are talking about these differences. It doesn't mean that after 60, you might not have cardiovascular benefit. We start losing the benefit. So it's the timing hypothesis is key.

• 1:14:58Speaker 01

  And it's the years away from estrogen. That's the problem. There's a great study in the British Medical Journal. They looked at years of reproductive life plus HRT and looked at cognition scores and saw that the longer your body is exposed to estrogen in any form, like whether natural cycles or exogenous estrogen of any form, and it was estradiol in that study, actually, then you had higher cognition scores, healthier brains.

• 1:15:31Andrew D. Huberman?

  Which at a just very, you know, top contour level makes total sense, given that estrogen is neuroprotective. I realize it might not be neuroprotective in every instance and every neuron in the brain, but it's generally neuroprotective.

• 1:15:42Speaker 01

  Generally neuroprotective, yeah.

• 1:15:43Andrew D. Huberman?

  And decline in estrogen is correlated with neurodegeneration, which does not mean it's causal. I have to ask, when they announced this study at the Watergate Hotel, of all places, and the conclusion that they put forth was that estrogen therapies can increase rates of cancer. I have to wonder if that had something to do with, what I understand is a sort of party line around cancers and breast cancers in particular, which is that you want to quote unquote, "block" the estrogen receptor. You want to get in there and put, give Tamoxifen, or nowadays, I'm sure there are other drugs that are more effective, to block the estrogen receptor. It all seems to pile up on the side of a story that says, you know, estrogen and estrogen

• 1:16:26Andrew D. Huberman?

  binding to the estrogen receptor is pro-cancerous, which obviously, I think you're telling us in a indirect and direct way now, and we'll go further into, is simply not the case.

• 1:16:37Speaker 01

  If you take a healthy breast cell and dump it at a Petri dish and then marinate it with some estrogen, it's not teratogen, I mean, it's not carcinogenic. Estrogen is not carcinogenic. We live with it our whole lives. If it was in pregnancy, for those of us who are ever pregnant, when our estrogen levels skyrocket, we would see this into uptick in breast cancer, and we don't.

• 1:16:56Andrew D. Huberman?

  In fact, I think there's some evidence for the opposite, that getting pregnant prior to age 40, is it true that that's protective against certain forms of breast cancer?

• 1:17:06Speaker 01

  That seems to be somewhat protective for certain forms of breast cancer, yeah. So, we have this whole generation of physicians who really weren't taught much about menopause, don't understand the protective benefits of estrogen and menopause's effect on metabolic disease, and they have this mentality of estrogen is bad, and so a woman walks into her, today, 2023, they looked at the data, she goes into her doctor complaining of menopausal symptoms, which right now are still only recognized as genital urinary syndrome of menopause, hot flashes, night sweats, you know, the very cliche symptoms. Documents in the charts, she's having whatever. Only 10% are offered any therapy, and they're most likely four to one to be offered an antidepressant. That is where it stands today. That is what

• 1:17:50Speaker 01

  we are fighting against, is not every woman will choose HRT, but every woman deserves an informed conversation about it, and let her make her choice. You know, if you believe the WHI data, which there are some problems there, the risk is small, okay? But, did you talk to her about cardiovascular disease, and diabetes, and insulin resistance, and her cholesterol? Because those things go up through the menopause transition with no changes in diet and exercise. And those are all, you know, you're more, even with the diagnosis of breast cancer, the most likely thing a woman is going to die from is cardiovascular disease, a heart attack or a stroke. So, framing it like that, I think is where we

• 1:18:31Speaker 01

  need to head. And the other thing is, you know, I was a great OB-GYN in so many areas of what I did. Why should this all be dumped in the lap of the poor, busy OB GYN who's running around the hospital, doing pap smears, trying to deliver babies, surgery and all the things? This should be required education for all, everyone in medical school. We are females and we're not little men with breasts and uteruses. We react differently to medications, disease, disease burden. And that's not been studied adequately and that's where the push needs to go. It's bigger than just hot flashes.

• 1:19:03Andrew D. Huberman?

  Do you think that one solution is to deepen the medical school curriculum?

• 1:19:10Speaker 01

  Absolutely. And more, and I hate saying women's health, because everyone thinks breasts and uterus, right? And reproduction. It's the health of women. And we're not addressing it differently than the health of a man. And we're different. And so that, I think, is where we need to head.

• 1:19:29Andrew D. Huberman?

  Given that it's half of the population,

• 1:19:30Speaker 01

  Yeah.

• 1:19:31Andrew D. Huberman?

  one would imagine that the best thing to do is to make the core curriculum of medical students expand to include this, as opposed to making it a specialty.

• 1:19:40Speaker 01

  I think so.

• 1:19:41Andrew D. Huberman?

  Does that mean a fifth year of medical school? I'm not kidding. I mean, I guess.

• 1:19:46Speaker 01

  Maybe. I mean, people said, well, you'd have to extend the OB GYN residency. I'm like, no. Any specialist who touches a female should understand how that female, I mean, the starkest example is cardiovascular disease. You know, how much longer we have to wait in the ED, how much more likely we are to die in the hospital setting from a heart attack, because we don't present the same symptoms as men do. And it's just, the default has always been how it happens to the basic, you know, really Caucasian male. And so, at least in the US. And so, because we respond differently, because we wait longer, because our symptoms are considered to be psychologically induced, less than biologically induced. And so, women are dying at higher rates. When you look at the data on statins.

• 1:20:33Speaker 01

  You get high cholesterol, so 80% of women will have abnormal cholesterol levels through the menopause transition if they were normal before, okay?

• 1:20:40Andrew D. Huberman?

  So elevated LDL?

• 1:20:41Speaker 01

  LDL and lowering HDL. So now they are at higher risk for cardiovascular disease. Automatically, a PCP will offer her a statin. Okay, that is standard of care. Do you know that the American Heart Association published in 2020 that statins have never been shown to decrease their primary heart attack in a woman? Secondary, yes, but no primary prevention, and it does not decrease the risk of death from cardiovascular disease.

• 1:21:03Andrew D. Huberman?

  I did not know that.

• 1:21:05Speaker 01

  Yeah. Yet we're routine, you know what does? HRT. If given in the right window of opportunity.

• 1:21:11Andrew D. Huberman?

  How is the HRT, in this case estrogen HRT, given? Is it a patch? Is it injections? Is it a pill?

• 1:21:20Speaker 01

  Yeah, great question. All the above. So we have, I like to break it down into oral and non-oral forms. So everything oral we ingest goes into the gut, the liver, the hepatic system will pick up the portal vein and take everything to the liver for processing. When that bump of estrogen hits the liver, we can see a slight increase in some of our clotting factors. So for that reason, I tend to go with the non-oral formulations to avoid that risk, especially if she has any family history of clotting or personal history of clotting. You know, we're going to go with a non-oral form.

• 1:21:52Andrew D. Huberman?

  So these are things like elevations in factor V Leiden?

• 1:21:55Speaker 01

  MTHFR, if she's had a history of a blood clot, we are not going with an oral estrogen formulation.

• 1:22:00Andrew D. Huberman?

  And for people that haven't had a history of a blood clot, my understanding, which admittedly is very sparse, is that you can do a genetic test just by blood draw to see whether or not you have two normal copies of the gene for factor V Leiden. Some people are heterozygotes, so they're more at risk of presumably bleeding in that case, all right? But in other words...

• 1:22:24Andrew D. Huberman?

  Can people go into this knowing whether or not they're more or less at risk from taking estrogen?

• 1:22:31Speaker 01

  So I don't think that there's a high enough for that reason because we're not routinely screening for these things unless they have a family history. I'm going with non-oral estrogen as a primary product for my patients because I can just skip that worry.

• 1:22:46Andrew D. Huberman?

  So a patch typically?

• 1:22:47Speaker 01

  So typically transdermal. So a patch, there's Eva Miss spray, there's FDA-approved options of a patch, there's gels, there's a ring, there's a spray, and there is a vaginal ring, which I love, love, love because it's so you put it in for three months and it treats, you know, you get a two for one, you get a local treatment in the vagina as well as systemic treatment as well. It's just really expensive and typically not covered by insurance on the first tier. So very few of my patients can afford it. There are some injectables, which no one in the menopause uses.

• 1:23:20Andrew D. Huberman?

  The menopause.

• 1:23:21Speaker 01

  Yeah.

• 1:23:22Andrew D. Huberman?

  What a great.

• 1:23:22Speaker 01

  There are also pellet.

• 1:23:23Andrew D. Huberman?

  The meniverse and the menopause. Are those terms that you coined? I love it.

• 1:23:27Speaker 01

  I think I did, yeah.

• 1:23:28Andrew D. Huberman?

  Great. All right. You heard it here.

• 1:23:30Speaker 01

  So the menopause is a group of healthcare professionals who are from multiple specialties. We have cardiologists, orthopedic surgeon, internal medicine, Dr. Lyon is a member, and we have a big group chat and we all support each other. We support each other's books and research and we send articles back and forth and we support each other on social, but we also band it together to kind of negate one of the bigger publications on menopause than when the Lancet published. It's a whole nother discussion. But, you know, we are fighting for equity in menopause care and women's health.

• 1:24:05Andrew D. Huberman?

  Great. Nothing succeeds like a group.

• 1:24:07Speaker 01

  It's like the old menopause versus the new menopause.

• 1:24:09Andrew D. Huberman?

  I love it. Love it. So.

• 1:24:14Andrew D. Huberman?

  Hormone therapy to increase estrogen, how does it make women feel psychologically, physically? What are some of the positive changes that can occur, aside from just offsetting some of the negative? And I want to make sure that I remember to ask, what if a woman has been in menopause for, you know, has passed that point? Because as you said, it's a day. So they passed that point a year earlier, two years earlier, three years earlier. Given the results of this first study, which, as you explained, are problematic and their interpretation, the way it was interpreted, as opposed to...

• 1:24:48Speaker 01

  Initially, yeah.

• 1:24:49Andrew D. Huberman?

  Yep. What's too long? Should women, should women start estrogen therapy in their 40s, just in, just to, you know, smooth the transition?

• 1:25:00Speaker 01

  Maybe. We need more studies in this area. Like, should we just, the minute we figure out, like, I would love, like, I wear a glucose monitor. I have insulin resistance, so I...

• 1:25:10Andrew D. Huberman?

  For those listening, it's just, it looks like a little button-sized sticker on the back of the arm.

• 1:25:14Speaker 01

  I would love to develop one to track estrogen levels, starting in your 30s, just see where you're at. You know, start seeing, are you having aberrations in your cycle? And we can start the perimenopause journey and talking about, should we begin supporting? I think there's a tremendous amount opportunity for research in this area. But typically, we are not starting patients until they're very symptomatic, if they're perimenopausal, or they're postmenopausal. So, in general.

• 1:25:42Andrew D. Huberman?

  So if a woman is in her, let's say, late 30s, she is anticipating perimenopause, or maybe is in perimenopause, and wants to start low-dose hormone replacement therapy? I think it's something worth mentioning, that not all, you know, presumably the dosages are tailored, and then blood, so a given dose is tried, blood is drawn, you measure estradiol.

• 1:26:08Speaker 01

  So we're not, we don't have established levels of, like, therapeutic ranges of estradiol. What we've found is that when we do that, so far, I think we have some opportunity here. If my level's 50 and your level's 50, I could feel like I'm on top of the world. My symptoms are gone. You still need more. So we are titrating from symptoms.

• 1:26:27Andrew D. Huberman?

  I see.

• 1:26:27Speaker 01

  Yeah.

• 1:26:28Andrew D. Huberman?

  Interesting. So it's similar to what is done, similar-ish with testosterone replacement therapy, which these days, you know, I sort of half joke that the, you can change out the R in testosterone replacement because a lot of people are, a lot of men are taking testosterone not as a replacement, meaning their levels are not lower than 300 milligrams per deciliter, which is kind of lower range. They're sort of low, middle, and they're trying to get high, you know, higher range. But hormone replacement therapy, as I understand it, has never been strictly, in men or women, strictly for people who are out of range. That it, in theory, it can be to optimize, reduce symptoms.

• 1:27:09Speaker 01

  Right.

• 1:27:09Andrew D. Huberman?

  And to optimize well-being.

• 1:27:11Speaker 01

  Right.

• 1:27:12Andrew D. Huberman?

  And I don't know if the medical establishment wants it used that way, but certainly in the case of testosterone replacement therapy in men, it's being used that way, quite often, in fact.

• 1:27:21Speaker 01

  So the, we don't have established therapeutic ranges for estradiol. If she's POI, premature ovarian insufficiency, we know we want to get her to 100 or around 100 or higher in picograms per deciliter. And, but in the menopausal patient, we're rarely checking levels, but I do think we have an opportunity to learn a lot more now that we're able to track, how is it, how does it affect your cholesterol? We need to look at those numbers. Like, what's the optimal dose for cholesterol? What's the optimal dose for cardiovascular disease? All we, all these studies have looked at was, was she on it or not? So that's where I think the opportunities can come.

• 1:27:59Andrew D. Huberman?

  So if a woman goes on hormone replacement therapy, how often is she coming in for blood draws? Or are you just, you know?

• 1:28:05Speaker 01

  Well, it depends. Like testosterone, we tend to check more often. There's, we don't have an FDA-approved option for women for testosterone. And so, no. So we either try to get her T-STEM, or she's finding someone to insert a pellet or something, and there's, there's other issues with that. What I do in Texas, it's really hard. The pharmacists do not like to do the T-STEM for patients, and I've even been...

• 1:28:29Andrew D. Huberman?

  T-STEM?

• 1:28:30Speaker 01

  T-STEM is the gel, you know?

• 1:28:33Speaker 01

  And I end up compounding it in a cream and do a transdermal cream for the patients, but there's such variable absorption, we do tend to check more levels of that just to may try to get her therapeutic. So what for women at peak dose is somewhere in a healthy female, you know, 35 to 70. And it's so, so I had a woman coming in with signs of hyperandrogenism, you know, she's, you know, deep voice, hair growth, whatever, acne, and I'm going to check a level. If it's above 90 for females, I need to look for a tumor. Like that's too high. Okay. Or PCOS, it can get that high, certainly above 200, that's, that's outrageous. So I'm trying to get my patients, you know, 60, 50, 70, but if she's like 50 and her,

• 1:29:15Speaker 01

  she's got her libido back and she feels great and everything's wonderful, then I'm hold, you know, because the higher we go, the more likely you are to have side effects. So you're losing hair, you know, temporal hair loss, voice deepening, acne, new chin hair, you know, losing hair where you want it, gaining hair where you don't want it. This is how I explain it to patients.

• 1:29:33Andrew D. Huberman?

  And so when you say 50, that's 50 nanograms per deciliter. I think many people, including myself, were surprised to learn that women actually have higher levels of testosterone than they do estrogen.

• 1:29:46Speaker 01

  Mm hmm. And absolute ranges, yeah.

• 1:29:48Andrew D. Huberman?

  Right, in absolute ranges.

• 1:29:49Speaker 01

  And I can tell you right now, your natural level of estradiol is higher than mine. Now, I'm, I supplement, but you know, like when I go through menopause, your residual estradiol is now higher than a postmenopausal woman.

• 1:30:01Andrew D. Huberman?

  So this is the estradiol that I have because testosterone was aromatized into, into estrogen.

• 1:30:07Speaker 01

  Yeah.

• 1:30:08Andrew D. Huberman?

  Interesting, interesting. So much is breaking down around the, the old stereotypes.

• 1:30:13Speaker 01

  Right. The man hormone and female hormone. Like testosterone's a human hormone.

• 1:30:17Andrew D. Huberman?

  Right.

• 1:30:18Speaker 01

  Estrogen's a human hormone.

• 1:30:19Andrew D. Huberman?

  And they exist in, in both biological sexes. Yeah, it's, it, it's sometimes unfortunate that compounds in the body get names like steroid hormones, because then people hear steroids.

• 1:30:30Speaker 01

  Yeah.

• 1:30:31Andrew D. Huberman?

  And then it has a gravitational pull toward anabolic steroid use or. Even the word fat, you know, it's like, you know, dietary fat versus subcutaneous fat versus visceral fat.

• 1:30:43Speaker 01

  Visceral fat, yeah.

• 1:30:44Andrew D. Huberman?

  We need better nomenclature to avoid a lot of the confusion that exists out there. What are some of the other hormones that can be reduced and can possibly be replaced by hormone therapy? Like progestins, you know, are there, is there a role for, you know, adjusting things like prolactin? Or is there, is there a role for other hormones in what sure is to be a multifactorial thing? I mean, I think menopause is a process, not an event.

• 1:31:12Speaker 01

  Hypogonadism for females, right? And so we know that, you know, because the pituitary and hypothalamus are involved and that GnRH, you know, there's some cross-reactivity. So for example, hypothyroidism. When I have a patient who's on her, and doing well on hormone therapy for her thyroid, so she's on T324, whatever she's on, I'm like, listen, you know, we need to recheck your thyroid levels in six weeks because giving you back estrogen is gonna mess with a little bit of that feedback cycle. So we need to make sure you're still therapeutic. So I think we've got more work to do with some of the other hormones. But when we talk about replacement in menopause, we are mostly looking at your estrogens, your androgens, and your progesterone.

• 1:31:57Speaker 01

  So the formulations can differ. But we, you know, there's a lot of misunderstanding around what is bioto-identical versus synthetic. And I think a lot of cottage industries in this little bubble that we had for 23 years where doctors were afraid to prescribe hormone therapy and then women were desperate for care. We had some little cottage industries of people I think were well-meaning and trying to help, but kind of developed terminology that really isn't medically specific, like estrogen dominance, you know, and what that really is. And so that is not a term that is in any medical journal. It's kind of something coined, I think, from a well-meaning provider trying to explain what's happening in perimenopause, that you're having more estrogen produced than progesterone than you used to have. So PCO patients do the same thing.

• 1:32:41Speaker 01

  You know, there's multiple reasons for that to happen. So when we talk about, you know, in the miniverse of what we're trying to replace, we all agree that we stick pretty much with estradiol. We're just trying to give you back the water you were drinking. So I want to get as close to what your body used to make because that's what the receptors like. I'm trying to give you progesterone, you know, rather than a synthetic. Not that they're all demonized. Progesterone doesn't work for everyone. I'm glad I have options. And then for your androgens, we pretty much just do testosterone and we do a transdermal again, because the oral can be hepatotoxic unless it's on Decanoate, which isn't available in the US. But there's no FDA approved option for women, so it's not covered by insurance.

• 1:33:23Speaker 01

  We know it works for hypoactive sexual desire disorder, what your follow was, what we call libido. We think, we know it has.

• 1:33:30Andrew D. Huberman?

  Testosterone does.

• 1:33:31Speaker 01

  Yeah. Women at the highest quartile of testosterone have better bone density and stronger muscles. So I'm using it off label for my patients who come in with osteoporosis, osteopenia or sarcopenia. I'm using it off label and telling them, this is a probably a, it's not a Hail Mary. We think it works, but we don't have, you know, it's not approved for that yet, yet. We know it has receptors in the brain. My patients are saying that they're more clarity of thought, they're sleeping better. They really, really like the testosterone. So there's, you know, DHEA is a great vaginal preparation for DHEA called Intrarosa. And then the receptors there will start converting it into both testosterone and estradiol, you know, through the process. And so the sexual medicine docs really like Intrarosa, especially for breast cancer patients

• 1:34:15Speaker 01

  because they get that little boost of testosterone in the vulva.

• 1:34:18Andrew D. Huberman?

  Intrarosa?

• 1:34:19Speaker 01

  Intrarosa is the brand name. I think it's Prosterone?

• 1:34:23Andrew D. Huberman?

  And this is a prescription drug?

• 1:34:24Speaker 01

  Yeah, these are prescriptions.

• 1:34:25Andrew D. Huberman?

  So Intrarosa is prescription DHEA?

• 1:34:28Speaker 01

  Specifically formulated for the vagina.

• 1:34:30Andrew D. Huberman?

  Got it. Which sits further upstream to the production of testosterone and estrogen.

• 1:34:35Speaker 01

  Right. And so fortunately, the, what's left in the vagina is able to, you know, plug that guy in and get it to produce both testosterone and estradiol, which testosterone is the immediate precursor. We have to aromatize it, right? To make estradiol in females as well.

• 1:34:49Andrew D. Huberman?

  These local effects on tissues are interesting. I, they make perfect sense if the highest concentration is at the site of release from the, from the patch or the gel or the whatever, the, you said intravaginal, what is it? It's like a capsule?

• 1:35:05Speaker 01

  I think the Prosterone is a. Insert, like a little gel looking, not a gel, but a, um, I forget what the binding material is, but it's like a little insert you put in.

• 1:35:15Andrew D. Huberman?

  Okay, so the local effects, because I guess, you know, it stands to reason that the highest concentrations can be at the side of the thing that's releasing the hormone, but then it also goes systemic by getting into the bloodstream.

• 1:35:25Speaker 01

  Actually, so the, the local formulations, the Prosterone and the, um, the Intrarosa and as well as the Estradiol formulated for the vagina, do not absorb systemically. They're so low dose, there has not been clinically significant tissue absorption. I have a formulation for my face as well.

• 1:35:43Andrew D. Huberman?

  So it's a cream?

• 1:35:44Speaker 01

  A cream that I put on my face, it's Estriol. And so there's some decent studies with Estriol, but we lose 30% of our collagen. It's a very big pain point for women when they go through menopause, that we lose so much collagen so quickly in the first five years of menopause. And so we can slow that process down, we can't stop it completely, we can slow it down by using a topical estrogen and the topical really seems to help with the elastin concentrations as well.

• 1:36:06Andrew D. Huberman?

  Interesting, so you, you will often prescribe a lot of local treatments for hormone replacement?

• 1:36:11Speaker 01

  Yes, and really it's so safe, so we can take breast cancer off the table, all the discussion around blood clots and everything, everyone can use vaginal estrogen and they should, and I'll tell you why.

• 1:36:20Andrew D. Huberman?

  Starting at what age relative to menopause?

• 1:36:22Speaker 01

  You know, the old menopause thoughts is do not give vaginal estrogen until she's symptomatic. Now, all of us will become symptomatic from GSM, so that's genital urinary syndrome of menopause, so from the pubic bone all the way to the sacrum, all of that tissue is heavily, you know, tied to estrogen to testosterone. And when those levels decline, we see thinning of the tissue, loss of elasticity, loss of mucus production, as well as the health of the urethra. And so UTIs, like the best treatment for recurrent UTIs in a menopausal patient is vaginal estrogen.

• 1:36:51Andrew D. Huberman?

  Interesting.

• 1:36:52Speaker 01

  Not recurrent antibiotics.

• 1:36:53Andrew D. Huberman?

  And what about, um?

• 1:36:55Speaker 01

  So it's preventative.

• 1:36:56Andrew D. Huberman?

  Very interesting.

• 1:36:56Speaker 01

  And we can probably keep 50% of women out of the ER and out of urosepsis if we gave them all prophylactic vaginal estrogen. All these ladies in nursing homes should be on vaginal estrogen. So, just to protect them from getting urosepsis.

• 1:37:11Andrew D. Huberman?

  Interesting. What about like urinary incontinence and some of these other symptoms that are associated with more elasticity, presumably more elasticity of tissue in that region?

• 1:37:22Speaker 01

  If you're early in a, so we have stress incontinence and then we have overactive bladder urgent incontinence. And so it definitely helps with urgent incontinence. It relax, you know, it helps to relax and decrease the inflammation in the wall of the bladder. So thumbs up there. So people are getting up at night and having that urge to go. But stress incontinence is an anatomical problem. We've lost, you know, the sling that holds up the urethra in the female fails, right, from herniation and poor tissue health. We can build up that health and we, you know, there's physical therapy, there's lots of options. And you, you know, no uro-gynecologist wants to take a woman to the OR to do a lift if she's not estrogenized. They're all going to get vaginal estrogen, pre, you know, through healing and then forever

• 1:38:07Speaker 01

  to keep the tissue healthy.

• 1:38:08Andrew D. Huberman?

  Everything that we've been talking about for about the last 15 or 20 minutes seems to go directly opposite this large-scale study that was discussed at the Watergate Hotel. Is your read that the medical establishment, in particular the OB-GYNs in the US and in other countries, understand now that that study was flawed to some extent in its design?

• 1:38:35Speaker 01

  No.

• 1:38:36Andrew D. Huberman?

  Or is what we're talking about here like really cutting edge? I mean, if we were to gather a roomful of 1,000 OB-GYNs trained in various decades and put them there?

• 1:38:44Speaker 01

  I think maybe 10% would have any idea. But here's why, and I'm going to call out the American Board of OB-GYN directly on this. We take our board certification exams every year in our specialty, as every specialty does, and they give us a set of articles of the cutting-edge newest research. And it's divided into categories: obstetrics, office practice, gynecology, GYN surgery, pediatrics, oncology. You know, there is no menopause.

• 1:39:08Speaker 01

  Category, nothing. So I went back over like 10 years of all my green journals and looked at how many articles were anything to do with menopause and it was less than 1%. So they were not systematically trying to put the latest menopause information in front of us. They don't even recognize the menopause society as a like entity.

• 1:39:33Andrew D. Huberman?

  Well, now they have to contend with the menopausey.

• 1:39:36Speaker 01

  They do.

• 1:39:37Andrew D. Huberman?

  And you

• 1:39:38Speaker 01

  They might, you might see me banned from the ABO, but you know what?

• 1:39:41Andrew D. Huberman?

  No, no, no.

• 1:39:41Speaker 01

  I'm so proud of what I learned. I learned amazing things. I am a boss at delivering a baby, at taking care of a pregnant patient. I am great at pediatric gynecology. I was so good with adolescents. Where I failed and where this, I let the system let me fail was in the care of a woman after reproduction, outside of surgery, outside of her surgical needs.

• 1:40:01Andrew D. Huberman?

  Well, I have to imagine that, given the medical profession is interested in the well-being of people and in, for sake of the discussion today, women, that they will be grateful that now you, you have a microphone, many microphones in various contexts. So that is surprising to me, however. I would think that, given the exciting findings around hormone replacement therapy and the, I'm kind of obvious, at least when you described them to me, obvious flaws in these earlier studies of, you know, starting hormone replacement therapy when women are already 61, when they've already accumulated, in many cases, some health, health issues that it would be kind of obvious.

• 1:40:44Speaker 01

  You missed, missed the ability to, to measure the protective benefits. So, but fortunately, we've got great studies coming out of like the Danish data, the Scandinavian data, that are really looking at this again and showing the protective benefits. So.

• 1:41:01Andrew D. Huberman?

  Is it generally the case that the studies out of Europe and Scandinavia are more forward thinking?

• 1:41:06Speaker 01

  It depends. You know, some of the most forward-thinking, shockingly, is come out of Asia, a lot out of China. And I asked my husband, he's worked there before, and he said, There's as many researchers in China that are female as male. It's not like they have a big stay-at-home culture. You know, they're not, women are expected to work and they're getting PhDs and they're doing the research. And so, and he thinks, in his, in of one, you know, his humble opinion, and he's an engineer, you know, that, that's, I was like, why do you think? You've worked over there. He goes, I think because there's just as many women who are writing the papers as men.

• 1:41:41Andrew D. Huberman?

  Interesting take. I like it. It makes good sense. What are the various things that people can do in terms of non-hormone replacement therapies that can support them through, really into and through perimenopause and menopause? We talked about nutrition earlier. Maybe we could touch on that a little bit more. We talked about behaviors, resistance training, maintaining, maybe even increasing muscle mass. There's no pressure to include them, but what about the very supplements that we hear about that can touch on, or we are told can touch on these hormone pathways? Things like DIMM, things like grape seed extract, things like, you know, evening primrose.

• 1:42:22Speaker 01

  I don't, I don't think they're harmful, but there's just not robust data to really support. So Menopause Society went and looked at all of them, even soy and everything. And they just, outside of cognitive behavioral therapy, which can be helpful, but is not a menopause cure, they didn't find much in the supplement world that would stop. Remember, we're defining menopause as hot flashes and general urinary syndrome of menopause. So, you know, when I'm recommending supplements to patients, I do think there's some okay data on turmeric for maybe hot flashes, but I'm not saying to take that instead of replacing the estrogen your body is, is missing greatly. I like the anti-inflammatory benefits of, of, you know, of that supplement. I'm recommending fiber.

• 1:43:07Speaker 01

  Eighty percent of my patients are deficient in vitamin D and struggling to get it absorbed. You know, I'm recommending creatine.

• 1:43:15Speaker 01

  For muscle, I am recommending, there's a specific bioactive collagen that was studied in menopausal women with osteoporosis where they saw improvement in bone density. So I'm recommending a weighted vest. Great studies elderly women, but saw improvements in bone density. And I'm like, why do we wait until we're osteoporotic to make the diagnosis?

• 1:43:33Andrew D. Huberman?

  Yeah, this is interesting. So weighted vest.

• 1:43:35Speaker 01

  A weighted vest. They looked at creatine weighted vest vibratory training in nursing home dwellings. So they were kind of a population where they couldn't go anywhere.

• 1:43:43Andrew D. Huberman?

  Vibratory training is the shake plate?

• 1:43:44Speaker 01

  Uh huh, the shake plate. And so, you know, anything that stimulates that musculoskeletal unit will, will send the signal to get stronger. You know, what most women don't realize, I mean, they know about osteoporosis, right? And they don't want to have it, but they don't understand that like your habits in your 30s and 40s are going to put you on that path. And that your body's going to fight to lose muscle and bone naturally through the aging process and accelerated with menopause. It doesn't have to be that way, but you have to do the work, you know? And, and there's some hacks. And so I love the weighted vest for a hack. I'm like, do the dishes with it on, go walk the dog, you know, like.

• 1:44:18Andrew D. Huberman?

  How heavy?

• 1:44:19Speaker 01

  So you want, in the nursing home, they started at 10% of their body weight. So I'm like 10 pounds, 12 pounds, start with that. So now my husband's obsessed and we have six of them and they go from eight to 35 pounds, you know? So I have different weights that I wear. Like if I'm doing leg day, I'll put the heavier one on so I don't have to hold as heavy.

• 1:44:35Andrew D. Huberman?

  So you'll use a weight vest when you're doing leg day?

• 1:44:38Speaker 01

  Mm-hmm.

• 1:44:39Andrew D. Huberman?

  Wow.

• 1:44:40Speaker 01

  So I can't, because I don't have great grip strength and, you know, and so it'll help me be able to squat heavier, you know? But now I'm getting better. I've got the bar going, so I'm, I'm getting there, you know?

• 1:44:49Andrew D. Huberman?

  I'm going to tell my sister and my mom this.

• 1:44:50Speaker 01

  Yeah, and you know.

• 1:44:51Andrew D. Huberman?

  I've got my sister, yeah, doing some resistance training.

• 1:44:54Speaker 01

  And it's just a cheat. I'm so, it's so cute on social because they'll post and tag me and they're walking their dog and they're doing whatever with their weighted vest on. And now in Galveston where I live, you can't go, you see it all over the sea while everyone's walking with their weighted vest.

• 1:45:08Andrew D. Huberman?

  I love it. And it's hot down there a lot of the year.

• 1:45:10Speaker 01

  Yeah, it's warm.

• 1:45:10Andrew D. Huberman?

  So no excuses, people outside of Texas, or in Texas for that matter. But my experience is that people in Texas don't tend to make excuses. Anyway, that's, uh, said like a real Californian here. We were talking about this a little bit earlier and, uh, female-specific weight vests?

• 1:45:26Speaker 01

  I would love to develop one because the ones were made for men and they're okay. But if you have larger breasts, it's hard where the snaps are to get it on right. And I know there's a big trend with rucking, but that puts all the weight on your back. And I really like the weighted vest because I feel, and this is my opinion really, but that, you know, the reason why it's helping with their bone density is it's putting the weight on the entire axial skeleton rather than just the muscles on your back. So we're putting the force more evenly supported.

• 1:45:53Andrew D. Huberman?

  Yeah.

• 1:45:54Speaker 01

  And so, but some of my followers have written in and said they're struggling because they have larger breasts and how to get this around. I'm like, I gotta make one that's gonna accommodate, you know, have longer, you know, to strap down here underneath the breasts, so.

• 1:46:07Andrew D. Huberman?

  Yes, someone should develop that. You should develop that. Not that you don't already have enough on your plate already. Along the topic, I like rucking. It is sort of backloaded, you know, by definition. Some of the weight vests that are out there are evenly distributed in a way that makes them pretty comfortable. They're not all loaded up up front like, like a special operator or something would wear. So I, positive effects of, of the weight vest would be increased bone density. You're, you're doing more work.

• 1:46:35Speaker 01

  A little more calories, right. You're getting stronger. But I'm, I'm, I coach to it, you know, with my followers for this is part of my osteoporosis prevention pack.

• 1:46:44Andrew D. Huberman?

  Love it. Are you willing to share a few other things that are in the prevention pack?

• 1:46:48Speaker 01

  You know, eating adequate protein, doing resistance training, wearing your weighted vest, creatine, five grams a day where most of the studies were done in, in the women.

• 1:46:55Andrew D. Huberman?

  Creatine monohydrate.

• 1:46:56Speaker 01

  Monohydrate, yeah. And then, um, the, that collagen, consider that collagen. Full disclosure, I do sell that one, but, um, really good investment, I think.

• 1:47:06Andrew D. Huberman?

  Maybe we could talk about collagen for a moment.

• 1:47:10Andrew D. Huberman?

  It's a complete protein?

• 1:47:12Speaker 01

  No.

• 1:47:13Andrew D. Huberman?

  No.

• 1:47:13Speaker 01

  No, it's missing one, I think, one or two amino acids. So it's not a complete protein. Um, it's better than none. So I do like include my collagen in my protein intake for the day because I eat all animal-based protein, pretty much. So I figure I'm, I'm covered my bases to have, you know, 10% of it coming, which is missing two amino acids. Or I think it's one valine. I have to look it up, so.

• 1:47:36Andrew D. Huberman?

  And what are the specific effects of a quality collagen?

• 1:47:38Speaker 01

  So, you know, there's a lot of controversy there. I've seen the videos. It is broken down into its component amino acids, you know, through the digestion process. But the first ones I looked at were totally for vanity. I was changing bathing, I was trying on bathing suits with my daughter, who was a little girl at the time. And I was complaining about the appearance of my cellulite, even thin people have cellulite. And she's like, Mommy, it doesn't look that bad. And I, you know, scientist in me was like, goes on PubMed and starts looking up articles on, on cellulite and how to decrease the appearance of it. And so I found these articles on something called Verasol. And it was a collagen made in Germany. And they'd studied, actually done like really high-quality studies, like laser measuring wrinkles and cellulite.

• 1:48:23Andrew D. Huberman?

  Germans are precise.

• 1:48:23Speaker 01

  And they, and it looked, they had positive outcomes. I'm like, well, it won't hurt me. So I ordered, so I Googled, where do I find this Verasol collagen? I find this company, I order it. And then one day I talked about it on the internet. And the company called me and said, would you please let us know when you do that? Because they sold out of their supply for like three months. So the same like manufacturer of that particular Verasol made this Fortabone, did the studies, five years doing bone density scans on these women. It was a small study, but they saw improvements. We know what happens to bone density if you do nothing. It goes down. These went up. And I thought, okay, I want to do, and I want to offer this to people. Like, if not them, me, this is a high-quality product.

• 1:49:07Speaker 01

  I can, you know, and that, so that's part of my, um, what I offer to people or what I recommend. You can get it anywhere. Other people sell it, not just me.

• 1:49:16Andrew D. Huberman?

  Great. So. I'm perplexed. This isn't a challenge, but I'm perplexed. Would a protein that's not a complete protein be beneficial for a body organ like skin, whereas the complete proteins don't seem to do it on their own? Nobody knows. Okay.

• 1:49:34Speaker 01

  I don't know. Are they not studying the right thing? Are they not really looking at it? So, I don't know.

• 1:49:40Andrew D. Huberman?

  It's great when I hear, I don't know, the scientist in me says, great area for exploration. Because we don't really believe, in fact, we don't believe that amino acids that are derived from a particular body part target that tissue. We've heard this argument before. Dr. Lane Norton and I have both gone on record publicly saying there is basically zero, not basically, delete the basically, there is zero evidence that when you ingest heart, let's say you like eating liver or heart or skeletal muscle, that somehow the amino acids are selectively trafficked to the organ of the heart or the liver or the skeletal muscle. There's no evidence of that whatsoever. Certainly not in humans. If

• 1:50:22Andrew D. Huberman?

  there is evidence, I'm sure they'll let us know in the comment section on YouTube and let us know. But yeah, it's perplexing why collagen would have a selectively beneficial effect on skin.

• 1:50:33Speaker 01

  They didn't study it versus a steak. You know, they just, they just looked at bone density if they took this product every day for five years and what happened. And they weren't, you know, they weren't having tremendous cardiometabolic disease. They weren't on bone building medications. They weren't on HRT. So, you know, they did a pretty clean, so there's, you know, not a huge study, but it was interesting. And I thought, okay, you know, I don't want to break because if I break my hip, well, 50% of women will have an osteoporotic fracture before they die.

• 1:51:02Andrew D. Huberman?

  50%?

• 1:51:03Speaker 01

  50.

• 1:51:04Andrew D. Huberman?

  What about men? Do we know? Just by way of comparison?

• 1:51:06Speaker 01

  I think it's 25.

• 1:51:07Andrew D. Huberman?

  Wow.

• 1:51:08Speaker 01

  But don't quote me on that. I need to look that one up. So, it's about half. Okay? And then hip fracture, if you break that hip. If over the age of 65, you have a, your one year mortality with surgical repair is 30%. If you, if you're not healthy enough to have the repair, you can't afford to have it, it's 79.

• 1:51:27Andrew D. Huberman?

  Goodness.

• 1:51:28Speaker 01

  So that's what we're trying to avoid is that, you know? And the tremendous, if you've seen the women who have tremendous osteoporosis in their spine and just how their lives are so hard and how much pain they live in every single day. You know, this, a lot of this is avoidable with aggressive, you know, being aggressive and intentional about this. And HRT can be a huge part of that as well.

• 1:51:55Andrew D. Huberman?

  What I'm about to ask is a little bit outside the box, but I feel fair asking, given that, um, you know, I'm not a clinician, but I have some background and certainly understanding of neurodegenerative conditions of the eye and vision. Have you ever observed in your patients that when they get on hormone replacement therapy for menopause, that things that are typically associated with aging, like diminished visual function, um, hearing, you mentioned tinnitus, also called tinnitus, I understand, but tinnitus, I think is, we'll do both, tinnitus, tinnitus, tomato, tomato.

• 1:52:27Speaker 01

  And E and T corrected me and said tinnitus.

• 1:52:28Andrew D. Huberman?

  We'll do both. Here that, that they, um, they report seeing better, hearing better, and any kind of sensory improvement or offset of sensory loss?

• 1:52:38Speaker 01

  So we know the data is clear on dry eye and how that can affect. But how it affects like the optic nerve, you know, we know that estrogen is anti-inflammatory. So any kind of like inflammatory condition in and around the eye does tend to get better, but we need, you know, probably more data in this area. For hearing, most of the research is around tinnitus and vertigo. So the, the rate of which the crystals break off in the ear accelerates in menopause and people on HRT have less vertigo, new vertigo than they would have had before. And I forget what the pathophysiology, I wrote it in the book, but I can't think of

• 1:53:17Speaker 01

  it right now, um, what the physiology was behind why tinnitus increases in, um, menopause, but it's due to the estrogen levels declining.

• 1:53:26Andrew D. Huberman?

  You mentioned dry eye. A lot of people might hear dry eye and think, oh, no big deal. But actually, dry eye is one of the most frustrating things, um, to have. And it's a, um, I believe a many billions of dollars a year industry to find treatments for dry eye. So does estrogen replacement therapy improve dry eye?

• 1:53:46Speaker 01

  It does seem to. They have less incidence. Most of the studies are just retroactive and they're looking at the incidence of those things on women on HRT for other reasons or not. And they just see, especially like frozen shoulders, the best data there, I think. And what they see is a decreased risk of occurrence. And then if they do have it, they have a shorter duration and easier course, you know, easier to treat if they're on HRT.

• 1:54:08Andrew D. Huberman?

  Fantastic. So what are some of the cases where a woman can't or shouldn't do hormone replacement therapy? And here we're using hormone replacement therapy as kind of a proxy for estrogen therapy?

• 1:54:22Speaker 01

  Yeah. So any hormone sensitive cancer, A. One of the things a lot of women don't understand, if you have dysfunctional uterine bleeding that has not been evaluated, you should not start hormone therapy because we don't know if it's cancer. So if you're having really heavy, especially if they're heavy bleeding, clots out of nowhere, you know, something unusual about the volume or the frequency of your bleeding, you need to go see a gynecologist and get that evaluated before you start hormone therapy. Okay? It may not be anything cancerous or tumors. It might just be the hormone changes, but that needs to be evaluated. If known breast cancer, no. If you're actively having a blood clot that you're being treated for, they're saying, let's hold off until that therapy

• 1:55:01Speaker 01

  is over. Even if you've had a hormone sensitive cancer, including breast cancer, depending on the stage, the type, and it's a very nuanced conversation, does not mean that you were automatically disqualified for hormone therapy after your treatment. So that is one of the biggest misconceptions out there. If you have really severe liver disease, I'm not talking about mild fatty liver disease. Lots of menopausal women have that. And it does tend to get better with HRT. If you have severe liver disease, that is where estrogen begins to be metabolized. And so you could have abnormal metabolism. You don't want that. So that's going to keep you from being a candidate.

• 1:55:40Andrew D. Huberman?

  Why do you think we're seeing, or at least hearing about, in my case, PCOS, Polycystic ovarian syndrome, so much more? Is it because people are aware? Is it because?

• 1:55:51Speaker 01

  I think two reasons. One, the obesity epidemic had led to more PCOS. That is definitely a risk factor for, you know, insulin resistance is usually the main path of physiologic cause behind PCOS. And I'm a PCOS, then PCOS sufferer. So I had it my whole reproductive life.

• 1:56:10Andrew D. Huberman?

  But you're not obese at all?

• 1:56:12Speaker 01

  No, no, they missed it forever. I was just stressed out medical student.

• 1:56:16Andrew D. Huberman?

  Which can potentially cause PCOS?

• 1:56:18Speaker 01

  With acne. Yeah, I mean, you can have, PCOS is a symptom of something biologically aberrant. Turns out I'm insulin resistant, which is why, you know, even though I'm thin. And so we've had higher, increasing levels of obesity, which is a risk factor for that. Also, people are talking about it and writing books about it. Karen Tang just published, it's not hysteria, it's not hysteria. And she's a gynecologic surgeon, does a lot of work around endometriosis. So she has like huge chapters on PCOS and how to advocate for yourself and, you know, all about the disease process so people understand.

• 1:56:54Andrew D. Huberman?

  Interesting. What are some of the primary treatments for PCOS? Is it going to be blocking androgens?

• 1:56:58Speaker 01

  So, yes. And so for me, you know, in all my training, it was always put them on birth control because it will suppress ovulation and suppress the overproduction of androgens in their system. So I was a very happy birth control patient because I was thin. For the obese patients, if we can help them lose weight, it does tend to, they start ovulating again. And so now with the new GLP-1s, a lot of PCOS will probably resolve itself. And they'll start ovulating again and go back to normal cycles. That's the pregnancies that are happening from GLP-1s.

• 1:57:35Andrew D. Huberman?

  I see. So GLP-1 associated pregnancy.

• 1:57:37Speaker 01

  GLP-1 babies, yeah.

• 1:57:38Andrew D. Huberman?

  GLP-1 babies.

• 1:57:39Speaker 01

  We saw a surge of that when all the patients, the obese patients, were getting the gastric bypasses. Then they get pregnant. And so we were advising them to not be pregnant until their weight was stable for a year after surgery because of the medical implications of nutrition and pregnancy. But they were getting, you know, they were so excited and cute and now their libido's up and, and they're, you know, getting pregnant and never really needed contraception before and just assumed they'd still have trouble. And so now they're ovulating and getting pregnant and we're seeing the same thing with GLP-1. So anyone listening out there who's prescribing a GLP-1, please talk to your female patients about contraception if they don't want to be pregnant.

• 1:58:17Andrew D. Huberman?

  Very interesting and admittedly unforeseen implications of GLP-1. As long as we're there.

• 1:58:24Speaker 01

  Sure.

• 1:58:24Andrew D. Huberman?

  What are your thoughts on Ozempic, Monjaro?

• 1:58:27Speaker 01

  I think that they can be a really important tool for a lot of patients. I don't think they're for everyone. I don't think people are being counseled adequately, a lot of them. I mean, in my area outside of Galveston where I live, there are med spas giving out GLP-1s. And as far as I can tell, they're just giving them the meds and sending them out the door. I've had patients coming in on it who were never counseled about the potential for muscle loss. So when I look at a patient's health, I look at a 30-year plan, right? And so they come in with a lifelong history usually of, of having a weight problem and a fat problem and, and here's this medication that's going to take the food noise away and help them focus on the habits that are going to keep them healthy longer. So I do have patients that I've prescribed it to. We have a very long discussion about adequate protein

• 1:59:11Speaker 01

  intake, resistance training. You know, I have a way to measure their muscle mass. We are tracking that every month for them, every month to six weeks while they're, you know, on the medication. So women who are on HRT with a GLP-1 have a 30% increase in weight loss.

• 1:59:28Andrew D. Huberman?

  Wow.

• 1:59:29Speaker 01

  Yeah.

• 1:59:29Andrew D. Huberman?

  Yeah, I appreciate that you mentioned that. The use of Ozempic monjaro is not mutually exclusive with resistance training and improved nutrition.

• 1:59:39Speaker 01

  No, I think it's

• 1:59:40Andrew D. Huberman?

  The way it shows up on social media, it's sort of like people assume, well, you know, you gotta take great care of yourself and exercise. Well, great, but there are also a number of people that are carrying excess weight to the point where they are at risk of injury when they exercise.

• 1:59:52Speaker 01

  Mm hmm.

• 1:59:53Andrew D. Huberman?

  I mean, everyone's at risk of injury when they exercise. But what I'm hearing is that you basically take the view, whatever can get people in a kind of forward center of mass around management of blood insulin levels, et cetera. Because wasn't that the original FDA approval was for?

• 2:00:05Speaker 01

  Yeah.

• 2:00:06Andrew D. Huberman?

  Was it type 2 diabetes?

• 2:00:07Speaker 01

  Type 2 diabetes.

• 2:00:08Andrew D. Huberman?

  And there's also some data, as I recall, that Ozempic monjaro can reduce alcohol cravings.

• 2:00:14Speaker 01

  So, yeah, the reward center in the brain are the noise. So they're looking now, I guess, my friends who are like obesity medicine specialists and are all like reading every study that comes out, any kind of impulsive behavior or reward-seeking behavior, gaming, gambling, alcohol, you know, people are tending to do less of those behaviors because whatever's being blocked in the brain, and you know more about this than I do, seems to help with that, those drives.

• 2:00:44Andrew D. Huberman?

  That's interesting that the hypothalamus is a chock-a-block full of neurons associated with all sorts of drives and temperature regulation. You mentioned earlier, you know, the preoptic area of the hypothalamus involved in temperature regulation. And we've always viewed those as somewhat separate, but they're actually quite interconnected. And so I'm not entirely surprised that a drug that would reduce cravings for food might also reduce cravings for other things. It's gonna be really interesting to see what the science in the animal models and humans shows us over time.

• 2:01:14Speaker 01

  Over time.

• 2:01:15Andrew D. Huberman?

  It's definitely happening. I mean, this is, has it hit a trillion-dollar industry yet? It's probably hundreds of billions of dollars.

• 2:01:19Speaker 01

  I know that the majority of big research and funding is being funneled into this. Maybe not all for the right reasons, but the obesity medicine specialists who are kind of who I turn to for how do I do this? How do we do it right? How do I not hurt someone just to get them to lose weight? You know? And Are very excited because these new levels, they say it's like the iPhone 12, iPhone 13, like they're just going to get better and better with lower side effects, better profiles, you know, as time goes on. That we're going to look back at the Manjaro and these earlier meds and be like, oh my God, what were we doing, you know, because of the side effects?

• 2:01:59Andrew D. Huberman?

  Well, if nothing else, they're very interesting to pay attention to because it's clearly in the cultural zeitgeist right now. So every once in a while, when a guest for whom the topic is of immense interest is coming on the podcast, I'll put out a call on social media for questions. And so if you're willing, I'd like to just ask you a few of the audience questions. And we can treat these as rapid fire or as much depth as you like. First off, that many of the questions you've already answered, things like, what is the role for testosterone replacement therapy in women as opposed to just estrogen replacement therapy?

• 2:02:41Andrew D. Huberman?

  But one of the more common questions in here that we've touched on, but I think could deserve a bit more attention is, you know, if a woman is in her 60s and has already gone through menopause, is it appropriate for her to consider, or at least just talk to her doctor about hormone replacement therapy, or is she putting herself at risk?

• 2:03:00Speaker 01

  There's definitely worth the conversation. So if I have a patient who comes in and she's, she's more than 10 years past her menopause or over the age of 60 and has not been on HRT, then we start looking at risk factors for cardiovascular disease or stroke. And so we're looking at her blood pressure, her lipids, her, you know, cholesterol, triglycerides, and looking for things that are going to put her at higher risk. She's lost probably the maximum cardiovascular benefit, but we don't want to put estrogen on top of severe atherosclerotic disease. So if she has abnormal cholesterol, I'm going to send her for a calcium cardiac score. I want to see if there's calcified plaques around her heart.

• 2:03:43Speaker 01

  I may even, if, if stroke is a risk, we may even send her for an ultrasound, you know, looking at the intimal thickness of the carotid. So if those are normal or low risk, then we will talk about the benefits of what, what would the benefits be for her after the age of 60? Well, we've probably lost the best of the cardiovascular protection, but it will always protect her bones. It will always protect her genital urinary system. It will always protect her skin. I mean, there's things that estrogen will do for us forever. And so, and then let her make the decision, certainly if she's still symptomatic, meaning hot flashes or things we can easily identify that we know estrogen will help with. But, you know, that first 10-year window is kind of critical for the preventative benefits, but it doesn't mean she's not going

• 2:04:28Speaker 01

  to benefit forever. Now, when do we stop? Used to be, doctors make up numbers, three, 10 years, whatever. If she's been on it since early in her menopause and has not developed any of these diseases, and she wants to keep going, we're going to keep her on. I will probably die with my estradiol patch on, if I don't develop a reason to take it off, because I know it's protecting me in so many levels, and I want to keep that going.

• 2:04:54Andrew D. Huberman?

  In so many ways, it sounds very similar to testosterone replacement therapy in men. The idea is that people go on and don't-

• 2:05:00Speaker 01

  Yeah, well, you stop at 70. Why would you do that?

• 2:05:02Andrew D. Huberman?

  Right.

• 2:05:03Speaker 01

  You know, if you didn't develop a contraindication to it.

• 2:05:05Andrew D. Huberman?

  Very clear and potentially very actionable answer. Thank you. A number of the questions related to the relationship between menopause, hormone therapy, and mental health, or mental well-being. But let's just keep it simple for now and ask, what are the things that women can do in order to optimize their mental health in perimenopause and menopause? And that they can do to offset any mental health issues that might arise during perimenopause and menopause? And there's a reason why I asked about those two things separately. One is just to-

• 2:05:43Speaker 01

  Yeah, perimenopause is very different than menopause for mental health. So, great question. So, I just went to a menoposium, menopause conference in Chicago, and there was a whole section on mental health, and it was neuroscientists, psychiatrists, and menopause specialists, all up there discussing the latest data. It was so fascinating. And so, there really is a big difference as far as mental health for what's happening in perimenopause and what's happening post-menopause. And as we talked about earlier, in perimenopause, we have that hormonal zone of chaos. And we see this, you know, in the Australian data, it's a four times risk of mental health disorders, especially depression.

• 2:06:23Speaker 01

  And then in post-menopause, a lot of these things tend to stabilize or get better, probably because just the estrogen is bottomed out and the brain is not having to deal with these fluctuations. So, we think that the data is looking like the best treatment for the mental health issues in perimenopause is going to be estrogen for stabilization and not the traditional SSRIs, SNRIs, you know, the antidepressants and the anxiety meds.

• 2:06:55Andrew D. Huberman?

  Not incidentally, one of the more common questions was, in this case, very specifically worded, "I've been on HRT for five years and I'm 61. I feel great, but how long is it quote-unquote 'okay' to be on them? Seems like I hear conflicting opinions." Well, we just heard a very straightforward opinion from you. So, thank you for that.

• 2:07:11Speaker 01

  As long as you want to be, as long as you're still healthy.

• 2:07:13Andrew D. Huberman?

  "How can I stop waking up in the middle of the night? This is a problem since entering menopause."

• 2:07:20Speaker 01

  So, we see sleep disruptions definitely from, not only from the vasomotor symptoms, which will wake you up, okay? If we can get those under control, you know, your sleep function should not be affected by that. What we're seeing, though, is people, even with HRT, even with estrogen, are still having middle-of-the-night awakenings, or racing thoughts, or having, they get up to pee or something in the middle of the night and they can't go back to bed, usually because their brain is going on. What we found is that progestin, probably through the effects of GABA, is very effective at settling your brain down and allowing for sleep. So, I'm having my patients take their progesterone orally at night before they go to bed, and we're seeing better sleep with that. And

• 2:08:05Speaker 01

  that was also something covered in detail. I was so excited by the neuroscientist, that's part of her area of research, that they are showing clearly, and she can point to the neuroreceptors of where that's happening, that progesterone seems to be really protective for our sleep. Now, take hormones off the table. Sleep hygiene is still hugely important, and I need to see the studies to prove it, but I'm telling you, we do not tolerate alcohol like we did pre-menopausal.

• 2:08:33Speaker 01

  Women are in at least 90%. Every time I post about it online, I see thousands of comments of, "I quit, I had to give it up, I cannot sleep." And even in my own life, if I choose socially to have more than a glass of wine, I am giving up sleep. Like, it is a choice. I'm choosing not to sleep that night. I will wake up 2:23, 3:35, whatever time in the morning, sweating, and I'm like, you know, too much champagne at New Year's or whatever. So, you know, that is a choice, and it's something I counsel my patients about. Like, "You probably can't tolerate alcohol like you used to. Aging's a factor here. Our body composition changes, and there's probably something hormonally that's going on we don't understand yet. But like, you choose this, you're gonna choose not to sleep more than likely."

• 2:09:14Andrew D. Huberman?

  Interesting. I wonder whether or not estrogen modulates the alcohol dehydrogenase enzyme, but time will tell.

• 2:09:20Speaker 01

  Haven't seen the data yet, but I'm sure it's coming.

• 2:09:22Andrew D. Huberman?

  Here's an interesting one. How can men help their female loved ones navigate these stages?

• 2:09:28Speaker 01

  Yeah.

• 2:09:29Andrew D. Huberman?

  You get that question a lot?

• 2:09:30Speaker 01

  My, and it's, it's great. And it always comes on the, when I'm being interviewed by a male. You know, when I'm interviewed by a female, they're wonderful, but they, they have their own experience, and they have to talk about it. And that's fine. That's my job, you know, is women have to unpack their menopause trauma, to me. But the men are just so curious, and just have so many questions, and then, "How can I support a partner?" And, or my mom, or whomever in my life, who's, who's dealing with this. One is, is acknowledge that this is happening, and, and try to educate yourself. There's my book, other books. There's lots of information now on the internet about the subject. But she is going through a transition that is rocking her world more than likely, and is affecting her brain, her bones, her heart, her kidneys, her skin, her ability to relate, her ability to tolerate, and it's probably gonna affect your relationship in some way.

• 2:10:15Speaker 01

  Go there with her. Go to the appointments with her. Be there to advocate for her. You know, be a partner through this with her, because you will get her back. But it's gonna take, you know, changing the way that you address things.

• 2:10:26Andrew D. Huberman?

  A couple of questions about, quote, "How to rekindle libido."

• 2:10:30Speaker 01

  Oh, yeah.

• 2:10:31Andrew D. Huberman?

  This person in particular says, "It's packed its bags and moved out since I started menopause." They're reporting their individual experience, but you touched on testosterone therapy earlier.

• 2:10:41Speaker 01

  So, any woman in...

• 2:10:44Speaker 01

  Her menopause journey, at any time, there's a 50% sexual dysfunction rate. Meaning she's not happy with whatever's going on. Now, when we look at the buckets where sexual function fall into, we have orgasmic disorder. Now, in menopause, when we lose blood flow to the area, people can have delayed orgasms or less, um, the, the peak of the orgasm is lower, you know, less vibrant orgasms, for lack of a better word. Um, they have decreased blood flow to the area, they lose elasticity. So, pain is another bucket, you know, it hurts, the skin gets torn, it's very fragile, it's very friable. So vaginal estrogen therapy can help there. There is arousal disorders where you want to do it, but the blood's not getting where

• 2:11:28Speaker 01

  it needs to go, so you're not having all the arousal type symptoms. So sometimes Viagra, sildenafil, topical sildenafil can be helpful there. There, and, but the most common thing that women have is HSD, or of course, relationship disorder. You don't love your partner, you don't feel supported, it's going to be hard to, you know.

• 2:11:46Andrew D. Huberman?

  Relationship disorder.

• 2:11:47Speaker 01

  Yeah.

• 2:11:48Andrew D. Huberman?

  The official, the official term.

• 2:11:49Speaker 01

  So, but then HSDD is hypoactive sexual desire disorder. That's in the brain. And so, first thing I ask is, did you used to have a good libido or a drive? Yes, you know, and you have a good relationship with your partner, it doesn't hurt, you know, with the rule out the other things. That's where testosterone comes into play. That is, those patients, it does tend to help. There are two FDA-approved medications for libido. One is Vileci. It's an injection you give yourself and actually works for men as well, about 30 minutes before.

• 2:12:14Andrew D. Huberman?

  It's in the alpha melanocyte stimulating hormone pathway.

• 2:12:16Speaker 01

  Yeah, so melanocortin. And then there is, um, Addi, A D D Y I, works at the level, I think, of dopamine in the brain. So it's more in the family of SSRIs that, you know, so it affects neurotransmitter. And so, you take that every day. Um, and it works, it was only studied in pre-menopausal women, but it does, you know, it's modest, but it does seem to have an, an, an effect. So, but most of my patients, because Testosterone has so many other benefits and the cost to get it compounded in Texas is maybe 30 bucks a month. So it's really reasonable and the vial leasing and the addy can be very expensive and usually not covered by insurance. So because of cost and potential other effects, most of my patients choose testosterone if it's HSDD.

• 2:12:59Andrew D. Huberman?

  I see. This is a question about the side effects associated with estradiol hormone replacement therapy in this particular instance. The person says, what are the best alternatives to estradiol? I've tried tiny amounts and the side effects in this case, skin rashes and hives are what they are describing.

• 2:13:19Speaker 01

  So I wonder if it's the patch. So there's a certain percentage of patients who it's not the estradiol, it's actually the adhesive in the patch. They will have a reaction to it. So one is try an alternative form. Another thing that one of the members on my team saw in her chat group is they get the Flonase, a cortical nasal spray over the counter and they spray it on and let it dry. Then they put the patch on and it decreases the risk of the reaction to the glue. I don't know how if that lasts forever, but I thought that was a cool thing to know about. And but what I typically do for my patients is change them to an alternative form.

• 2:13:54Andrew D. Huberman?

  Interesting. Thank you for that. They went on to ask about trying a new supplement called EQUELE.

• 2:14:02Speaker 01

  I think I read about that one. Again, I don't know what's an EQUELE, but again, not really robust studies, but most of these things are not harmful, but you may just, it may be a little snake oil, you know, throwing your money away. Really, the thing that's going to fix the problem for most women is restoring your estradiol.

• 2:14:20Andrew D. Huberman?

  Yeah, because there were other questions about, you know, wild yam and things more in the supplement space as well as things like acupuncture and herbal medicine.

• 2:14:30Speaker 01

  So acupuncture can really be helpful. But again, it's hard to access and can be expensive for a lot of patients and it's not treating the root cause. But it definitely can help you deal with some of the symptoms and make you more comfortable.

• 2:14:44Andrew D. Huberman?

  And then last question, how best to attack, and here I'm quoting, attack the fat distribution problem at this time?

• 2:14:51Speaker 01

  Yeah, you need a multifactorial approach to visceral fat. So. Nutrition, exercise, women on HRT have less visceral fat. You know, those are kind of the key things. And, and the way you approach your nutrition with the exercise, with the stress reduction, getting those cortisol levels down are going to make you healthier in every other way as well.

• 2:15:11Andrew D. Huberman?

  Great. Well, Dr. Mary Claire, thank you so much for giving us just a wealth of knowledge about perimenopause, menopause, really explaining what those are clearly for the first time on this podcast. And really illustrating the things that people can do to think about these stages of life and to, I don't know if I should say tackle, or to dance with this stage of life, whatever term one prefers, in order to offset the negative effects. And it sounds like, in fact, it's very clear based on what you've told us, that there are real levers of control.

• 2:15:49Speaker 01

  Yeah.

• 2:15:50Andrew D. Huberman?

  Including hormone replacement therapy, but other things as well, nutrition, exercise. It sounds like when we put all these together, there's almost like a mindset around perimenopause and menopause that you are promoting, which is one of real agency, that this is not something that is going to bury us mentally and physically. That's something that really can be worked with. And I just want to say on behalf of myself, because I've learned so much from you here and the listeners and viewers of the podcast, thank you for the information today. Thank you for your clinical work. Thank you for your ongoing research into this area, for attending these conferences and learning so much about it so you can bring us the latest. And thanks for your public education efforts, because they are really making a tremendous

• 2:16:35Andrew D. Huberman?

  difference.

• 2:16:36Speaker 01

  Thank you.

• 2:16:37Andrew D. Huberman?

  Thank you for joining me for today's discussion with Dr. Mary Claire Haver. To learn more about her work, please see the link to her website in the show note caption, as well as the link to her terrific book, The New Menopause: Navigating Your Path Through Hormonal Change with Purpose, Power, and the Facts. If you're learning from and/or enjoying this podcast, please subscribe to our YouTube channel and follow us on both Spotify and Apple. That's a terrific, zero-cost way to support us. In addition, you can leave us up to a five-star review. Please also check out the sponsors mentioned at the beginning. And throughout today's episode, that's the best way to support this podcast. And if you have questions for me or comments about the podcast, or guests or topics that you'd like me to consider for the Huberman Lab podcast, please put those in the comments section on YouTube. I do read all the comments.

• 2:17:20Andrew D. Huberman?

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• 2:18:01Andrew D. Huberman?

  We have a foundational fitness protocol, all of which is available at completely zero cost. To sign up, you simply go to hubermanlab.com, go to the menu tab, scroll down to newsletter, and enter your email. And I should mention that we do not share your email with anybody. Thank you once again for joining me for today's discussion about perimenopause and menopause with Dr. Mary Claire Haver. And last, but certainly not least, thank you for your interest in science.