Hi there. Great to be with you here on the Oprah podcast, whether you are in perimenopause or menopause or post-menopause. So that means millions of you. I have the book for you. It's called The Book of Menopause: Real Talk, Real Science, Real Strategies for Your Next Chapter. And believe me, it's the next chapter. The editors at Oprah Daily have curated the most crucial information that we've all learned over the years about menopause from doctors and from psychologists and from all of the health experts. Joining me in the tea house is the editorial director of Oprah Daily, Pilar Guzman. Hello, Pilar.
Hello. You and I know that anytime we've talked about menopause on Oprah Daily, I mean, we were one of the first to start this conversation several years ago. I think the New York Times had done an article and then we did a whole conversation about it in the Hearst building in New York. And anytime we talk about it, it actually becomes the most read content. Women are in real need of, I think, reliable information and also what we've seen from Oprah Daily, in need of community. So what have you been hearing from women?
I think the storytelling, the sharing of people's experiences has been this incredible accelerator. You know, there is the research, there is the journalism, there is the storytelling that we do as a brand, but then the women themselves talking to each other and talking to us and sharing their symptoms and sharing their experiences has been this incredible groundswell. Did you notice that there has been a moment of breakthrough when like there was before and now there's this moment where it seems that more women are open to talking about it?
Absolutely. And I think it is not unlike the Me Too movement where it takes a few brave souls to kind of break the ice and break the silence and normalize the conversation. And I think part of it is that it still felt very shameful for a really long time until recently. I mean, 20 years ago when you went through menopause and tried to get people to come on the show, they wouldn't do it. And now nobody, particularly anybody famous, wanted to say they were going through it. Yeah. And so it's like a Naomi Watts who kind of, you know, broke the ice and then
Halle Berry. Exactly. Drew.
Yeah. Yeah. And Maria Shriver, and you know, and then it emboldens others to share their stories and to normalize it and to feel okay about it and not feel so alone.
Yeah. Well, I share my own story in the book. I was around, so you can find my story in this book, Menopause: Real Talk, Real Science. And I was around 48 when I started experiencing heart palpitations. And I went to, as I say in this book, I went to five different doctors, I mean one after the other after the other, and none of them had answers. And it wasn't until I picked up a book at the office that I learned that what I was experiencing, having these heart palpitations and sleeplessness, were indications of menopause. So, what was it like for you?
Well, I didn't have heart palpitations, but I had sleepless nights. My mind was racing. I had more than usual anxiety. I'm a little prone to anxiety, but there was more than normal. And I went to the doctor and I have a wonderful OB/GYN who I really trust, delivered both my children. And she said, 'Oh, let's do, let's, you know, your levels are fine.' We did the bloods and the levels were fine, but I said, 'No,' I pushed back and I got hormones. But I think a lot of women don't feel brave enough to sort of push back against the advice of their doctors. And I think she has even changed her tune in the last few years since that first visit when I first came to her about that. But I think about all the women who don't feel emboldened to say, 'Wait a minute.'
Yeah. The moment their doctors say, 'No, you shouldn't,' which I've had doctors who said, 'No, you shouldn't do hormones.' The moment you hear that, you're just like, 'Oh, okay.' Okay.
Well, women spend 41%, that's nearly half of their lives in the post-reproductive state, you all. And even though I have to say I've been talking and talking and talking about this for a few years now, there's still so much that you all don't know, that a lot of people don't know. And why do you think that is?
I think there's still a lag in education in medical schools. I mean, you will talk to some of the experts we'll have on today. I think, you know, they will tell you that they didn't even learn this in medical school. So there is a lag in, you know, midlife women's health education even among doctors. And then of course there was the famous Women's Health Initiative which set it back by, you know, two decades essentially.
That's right. And so many women suffered because of that.
Because of that misrepresented study, actually.
So many women did. So Congress just recently held its first ever hearing on menopause, calling for more research, more education. So, does that mean that the tides are finally beginning to turn, do you think?
I am cautiously optimistic that the answer is yes. But we cannot take our foot off of the gas pedal in terms of continuing to tell stories, continuing to write stories, continuing to put pressure on government, on our own doctors. I think even just our individual advocacy is so important when we go into the doctor's office and demand something else and actually will leave a practice if there's even a whiff of resistance. And I actually encourage women to call if they're interviewing a new doctor or they're going to see a new doctor, make sure that they are open, if they are of age, that they're open to hormone therapy because many doctors are still resistant. If you have an older doctor, they're going to be resistant because they're still basing it on the misrepresented study.
So, how do you believe we begin to just eradicate a lot of the shame that women have around menopause? You know, we've written about it consistently on O Magazine, on Oprah Daily. I've talked about it, but I can't believe that people are still like embarrassed about it.
I feel the same way. And I think social media helps a lot.
and this is where social media is a force of good because you hear lots of women, women who you admire, powerful women and regular women. And I think the more you hear it, the more the shame goes away. I think, you know, in some ways, storytelling is the antidote to shame.
I agree. You know, the minute we circle
storytelling is the antidote to everything because storytelling allows you to know you're not the only one that's ever gone through anything.
Yep.
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Well, Dr. Mary Claire Haver is an OB/GYN and certified menopause practitioner. She's a regular contributor to O Daily and a big contributor to this menopause book and the author of the New York Times bestselling books, The New Menopause and The New Perimenopause. Dr. Haver, thanks for being here. Great to see you again. What's happening with our hormones during perimenopause? Because so many women are experiencing that at an early age. It starts like in their 30s now.
Yeah. So if the average age of menopause is 51 in the United States, but we have a pretty big window of when that might happen. So that's just average. We're looking 46 to 55. Now back that up 7 to 10 years when perimenopause begins. And as far as what hormones are doing, I wish I could tell you it was this slow, beautiful, gentle decline till the end of ovarian function. But actually, it's a roller coaster, something we've named the zone of chaos. So on the way out, as the ovaries deplete their egg supply, the brain is working harder and harder to try to get the hormones out of the ovaries, and that is causing very erratic shifts in our hormone levels. So estrogen levels can get higher than they were in your entire life outside of pregnancy. And we see crashes in progesterone. And so that really manifests early on in our 30s and 40s. We see the brain symptoms first typically, not the hot flashes. Those come towards the end of perimenopause. We start seeing sleep disruption. We see mental health changes like Pilar was talking about, and we see brain fog. So those are usually when I'm really trying to dig in to see, are these symptoms going to be perimenopausal in the patient, those are the ones I start focusing on early.
And explain why hormone therapy is an effective... Well, first of all, you need to explain, I keep saying the misrepresented Women's Health Initiative. Can you explain that? That is what set us on a course of everybody having such great fear about it. And I think a lot of women weren't even around or thinking about that Women's Health Initiative at the time that it came out, but are living or experiencing the results of it because their doctors, their mothers, their aunts all saying, 'No, no, no hormones.' So let's talk about what happened with the Women's Health Initiative and why.
Sure. So, we knew from observational data in the 80s and 90s that women on hormone therapy, and that was about 38 to 40% of the population, seemed to have lower rates of heart attacks, they seemed to live a little bit longer. We knew that their bones would be stronger. But as far as the heart disease question, it was, well, are these women healthier and wealthier and just have a better lifestyle and that's contributing to their decrease because they can afford hormone therapy, they can afford to go to the doctor, the time, the money, the access, or is this really hormone therapy? So that's what the Women's Health Initiative set out to study. If we put women on hormones versus placebo, is this decreased risk of heart attacks due to the medication or just due to lifestyle? So the average age of the woman in the study was 63 years old. Much older than a typical woman would be starting menopause therapy. We had two arms. If you had a uterus, you got estrogen plus a progesterone. If you didn't have a uterus, you got estrogen only. And they started collecting data. They collected so many lifestyle factors. They collected heart disease data, breast cancer data. And what they saw was an early signal that in the estrogen and progesterone group only, there was a very small signal, not great, that there was an increased risk of breast cancer. What happened was they called a press conference and announced to the world that hormone therapy causes breast cancer versus placebo. We got a 26% increase in breast cancer and that's why we stopped the trial. But that really wasn't the entire story. This was an older population. They didn't have mammograms before starting hormone therapy. We didn't know how many of these women may have had an early breast cancer before they started hormone therapy. And we didn't see that signal, this didn't make the news, in the estrogen-only arm. So it terrified women. It went viral before the internet. Right. It was the number one.
Everybody just dropped their medications the next day. Everybody just literally...
They were calling their doctor in a panic. I remember I was a chief resident. So my last year of my training program, we were giving hormone therapy. It was expected to have that conversation with a patient. And then it was like full stop. She's terrified of breast cancer. We don't want to give her breast cancer. And it took off like wildfire. And everyone was terrified. And all meaningful training in menopause stopped at that point, too.
Education around menopause. I mean, it was just...
Yeah. And so it wasn't until I saw Sharon Malone speak in 2023 that I realized what the implications of the WHI actually were. I was still operating under the, well, hormone therapy might give her breast cancer, so we really want to look at alternatives. It's the last thing we're going to consider when she's having very disruptive hot flashes. No discussion around bone density preservation. No discussion around mental health or any of the other things we know the full body effects of estrogen loss can do.
Wow. So it was that late in 2023 with Sharon Malone. You were one of those doctors who was tentative about it.
Yeah. Very tentative. And I remember sitting in the audience in tears. Like, how did I not know this? I am board certified. I get recertified every year. I read all the journals. I check all the boxes. And no one had put this information in front of me to say it's actually really, really safe for the vast majority of patients. It's going to be a huge benefit versus the risk. Every woman deserves the conversation. And just seeing it dismantled and taken down made me realize how much of a gap I had in my own education and knowledge and how I had really not been of full service to my patients.
Well, so let's switch gears today. Dr. Haver, today you say that the GLP-1s and hormone therapy are a game-changing duo for menopause belly fat.
So, great point. And we know that women on hormone therapy have less accumulation of visceral fat versus those not on hormone therapy. So, visceral fat for your listeners is the very special fat that wraps around our organs. So, I had for years had patients going through the menopause transition saying, 'Something's happening in my belly. It's bigger. I've changed nothing in diet and exercise.' And they would in their little paper gowns at a well-woman kind of grab their tummies and like, 'Mary Claire, what's happening here?' And I'd just be like, 'Work out more, eat less. Things get harder as we get older, etc.' Never knowing that there was a hormonal component attributed here. When we add in the GLP-1, they work synergistically together. So, there was a recent study that came out looking at women on just a GLP-1 versus GLP-1 plus menopause hormone therapy, they lost 30% more weight.
In that study, and when we look at body composition changes, it's the type of weight that we're looking at. So, they're losing visceral fat, that belly fat, which is inflammatory, dangerous, leads to heart disease, diabetes, stroke, versus just subcutaneous fat. So all around the board, I mean, and in my clinical practice, it really is a game changer for my patients combining the two.
And what are the benefits of hormone therapy other than it easing hot flashes or allowing you to sleep at night? I mean, I didn't sleep for two years and then I had a click of estrogen and the lights went on. I mean, the sky got clearer. I no longer felt like I was moving behind a veil. So all of that was worth it to me. But now I hear that there are actually improvements for your heart, for inflammation, for other things.
So we have four FDA-approved reasons: hot flashes, premature menopause, preservation of bone density in a postmenopausal patient, and for the genitourinary system. But we have estrogen receptors throughout the body. So our patients are telling us in observational data, brain fog is better. If your hot flashes are waking you up, it absolutely will help with sleep. When sleep gets better, as you know, everything gets better.
Yes. And so we also know musculoskeletal symptoms can get better. Of course, the genitourinary system, things like vaginal dryness, recurrent UTI. There's a big push on social media to really spread the knowledge about the safety of vaginal estrogen and how you can safely use it with your systemic estrogen as well, and you probably should, to decrease the rate of vaginal dryness, painful sex, anorgasmia. Like patients will come in and say, 'I'm struggling with orgasm. It's taking longer. I can't have them anymore. I want to have them because the tissue is changing down there.' So, estrogen can go a long way there as well.
Wow. Wow. And you say osteoporosis is a silent threat to women after 40. And so, what can we be doing to protect our bones?
Great question. So the biggest rate of bone loss actually begins in perimenopause and waiting till 65 for when that insurance-approved first bone density scan, I think is a mistake. You know, we start asking to screen our patients in perimenopause. We want to know what the baseline is. And so what can we do? Hormone therapy is FDA approved for prevention. So that's one thing. But I think lifestyle is key here. And a lot of women don't understand, especially if they're on a GLP-1, right? You must eat adequate protein. So, we need a stimulus for the bone and we need to feed the bone. The bone needs calcium. The bone needs vitamin D. The bone needs protein. Okay? And the stimulus is going to be movement, especially resistance training. The most effective way to protect your bones by moving your body is weight training and jumping.
Yeah. Okay. More than jumping, but I will definitely do the weight training. Yes. [laughter] That's fantastic. Thank you, Dr. Haver. It's always so great speaking with you.
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I want to bring in neuroscientist and director of the Women's Brain Initiative at Weill Cornell Medicine New York-Presbyterian Hospital. Also the author of the New York Times bestseller, The Menopause Brain, Dr. Lisa Mosconi. It's so nice to see you here. So nice to see you.
Hello. It's so good to see you. Thank you so much for having me. Hi to her.
So, you've described menopause as a renovation project on the brain. Explain how women's brains change during menopause.
Yes, I think that's a beautiful way to think of menopause and also very graceful in some ways. And so most people associate menopause with the function of the ovaries, which is fair enough, but in reality, menopause is a neurologically active phase. It impacts the brain as surely as it does the ovaries. And I think many women intuitively know that. We have so many women in midlife coming to the clinic saying, 'Something is going on with my brain,' and then we start talking about symptoms. And when women say, and what you were saying with Mary Claire, hot flashes, night sweats, insomnia, depression, irritability, anxiety, brain fog, memory lapses, those are all possible symptoms of menopause that have nothing to do with the function of the ovaries, but they come from the brain. Those are neurological symptoms that come from the ways that menopause can change the brain. So I think that the notion that menopause is a renovation project on the brain is very appropriate. It takes some of the fear out of the word menopause, to your point before, and it's very important to understand also as women that the hormones that we think of as sex hormones like estrogen, progesterone, those are actually brain hormones as well. They serve very important functionalities in the brain. So when they decline after menopause, the brain needs to shift gears and adjust to a different hormonal environment. But the important thing to realize is that the brain has the ability to adjust and to just carry on. The ovaries may close down shop, but the brain needs to keep working. And I find that to be really a sign of resilience and plasticity that we don't quite celebrate enough and we don't appreciate enough. And then of course the symptoms are no picnic. So those need to be addressed. But both things are really important to appreciate.
What is happening when we're having brain fog? You know, we're talking about how up to half of women report brain fog. So what is actually happening in our brain?
So brain fog is one of the most common symptoms of menopause and one of those that we really don't talk about but that is potentially even more disruptive to women than hot flashes and night sweats. In clinical terms, we talk about cognitive fatigue or mental fatigue, which I find to be a really good way to capture the experience that so many women have, that they're tired, that it takes them longer to do things. They have trouble multitasking. They have trouble with their memory. They have trouble even coming up with words. Right.
Right. The word fumbles can be very disruptive. What is happening...
And concentrating too, right? Concentrating.
Because I remember when I was going through it and during perimenopause, I didn't know that that's what I was experiencing, but you know, as much as I love to read, I couldn't finish a chapter. I couldn't like finish a chapter.
And that is very upsetting to so many women. We need our brains to function, right? We need our brains to feel good also for quality of life. And we have so many women come into the clinic with brain fog. I run an Alzheimer's prevention program and we have so many women in midlife come to us with this brain fog really worried that number one, they could be going crazy. That would come up over and over. 'I think I'm going crazy. I think I'm losing my mind.' Or brain tumors. So many women coming to us saying, 'There's something wrong with my brain. I'm so worried that I'm having a brain tumor' or even more so, early-onset dementia. So the symptoms, this brain fog, the women can experience can be so severe and so debilitating to really prompt serious concerns about mental health and brain health. So I would like all women to know that brain fog can happen for many different reasons. Menopause being one of them. It needs to be taken seriously without panicking. If it is menopause, and we can do all sorts of tests to understand where it's coming from and what to do about it. If it is menopause, very often it goes away. It's temporary and it should go away when the transition is complete.
If the symptoms persist or interfere with daily life...
Or you're given therapy for it.
You're given hormone therapy for it. It can go away, because my brain fog went away with estrogen and progesterone.
That is very important information I think and something that we're looking into more thoroughly right now. It's tricky to measure brain fog and some clinical trials have shown that estrogen therapy can preserve cognition. We do need to better understand if it can also bring it back, like you were saying. For you, it works so beautifully. For some women, it doesn't. So we really need to understand who responds and why and then generate recommendations for all women.
