In 2023, 85 % women are complaining of menopausal symptoms, 10.5 % are receiving treatment or therapy. I mean, it would be as if your testicles truveled up and died at 51. That's the equivalent. Let's get started. Dr. Mary Claire Haver.

Renowned Menopause Expert. With more.

Than 2.

Million followers.

Helping countless women through their menopause experiences.

Menopause is inevitable, suffering is not. But a woman is more likely to be prescribed an antidepressant for her menopause than hormone therapy. Women by the thousands are like, Oh, my God, I had no idea. That's when I realized no one's talking about this. So here's their laundry list of symptoms. We've categorized about 70. So there's brain fog, changes in her sexual function, weight gain. But here's the scary things, and the studies have been done. We see either a new onset or worsening of depression, anxiety, bipolar, ADHD, risk for cardiovascular disease, and diabetes increases with current urinary tract infections, which is a major cause of death for women. They're suffering in silence. And I was one of those women. I want to see my grandkids one day. I want to watch these women I've raised grow up and be the women they're meant to be. And that choice might get taken away from me if I'm not careful. But there's lots of things that we can do. For example, we see a dramatic loss of muscle mass. Focus on strength training. This is going to determine your longevity as you age. Strength over skinny. And what about your diet?

I developed a program for my patients, and it's not rocket science. It's Whether.

You're a man or a woman, menopause is going to affect you because it's going to affect 50 % of our society. And there is 1.2 billion women being affected by menopause right now. And whether you're a man or a woman, most of us don't have the answers. How do we help? How do we talk about it? What is it? How does it affect the human body? If you're in a relationship with a woman that's in perimenopause, which can start at 30, up to a woman that is currently going through menopause in her 40s or 50s or 60s, what should you do to support her? What can she do to support herself? This subject of Menopause has exploded in public conversation, thankfully, but there's still so many unanswered questions. And that's why today I invited one of the leading voices on Menopause globally onto my show. Even as a man that won't go through Menopause myself but has a partner and a mom that certainly will, there's something that everyone can learn from this. And I implore all men who maybe clicked on this episode or were sent this link to listen. Please just listen because you can learn something too.

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Thank.

You. Dr.

Mary Claire Haver, why did you do what you do?

I started out in medicine the way most people do. I wanted to help people. And in our training and school, we get to have a little taste of all the different specialties. And my very last rotation in my third year was OB/GYN. And I really liked surgery. I really liked some of the surgical subspecialties, so I thought that would be my path. But then when I delivered my first baby and all that rush of emotion and dopamine and how beautiful that whole process was, I knew that that was going to be my calling. And so I did the traditional four-year residency and loved it and really did well and went into private practice. After about three years of doing the private practice route, I realized I missed being in academics. I wanted that ability to do research and be around students and teach as well as take care of patients. So I went back on as faculty and everything was going great. I was very successful. I was doing pap smears and babies and birth control and all the things that traditional OB-GYN does. And then I was aging as my patients were aging too.

And when I got to my 40s, I realized that there was a big gap in my education and knowledge around menopause. So I started researching. Most of my patients were coming in, the pain point was weight gain. And they were like, I'm not doing anything different. I'm working out. I haven't changed my diet. And that little voice in my head was like, Work out more, eat less. We tend to move less. I was just going with the script that had been handed to me for years that calories in, calories out is the only way. And in medicine in the US, we have very little background in nutrition. We learned nothing in medical school, very little in residency as far as what nutrition actually is and how it can affect our bodies. And so I started struggling with my own menopause. My patients were all struggling, and I decided to go back to school to learn more about nutrition because I felt like there was a big piece missing here because this weight gain was mostly centered around the midsection, and I was learning about visceral fat and subcutaneous fat and the differences and what's going on with our muscle mass.

And I'm like, There's a much bigger picture here than just calories in, calories out. So I enrolled at Tulane University in their culinary medicine program, and just my mind was blown by how much I didn't know as far as nutrition and inflammation and aging and how it all affects. But where was this menopause piece? So I took everything I learned, and I developed a little program for my patients, which became The Galveston Diet. And it really was just a passion project for me. And then I started talking about it on social media and realized that as my social media presence grew and the conversation got bigger and bigger that there were so many women suffering. Probably the majority of women in menopause were suffering not just from weight gain, but from musculoskeletal issues, mental health, brain fog, skin changes, hair changes, nail changes. And I just kept doing deeper and deeper dives and realizing no one's talking about this. No one's talking about the multiorgan system failure that a lot of women are going through, and they're suffering in silence, and physicians aren't helping, we're not trained. And so I thought it's really my kids who I have two daughters, one is 23, she's in medical school right now, and she's actually here with us.

And then the other is 20. And they were like, Mom, you've got the social media presence. You really need to use it for good. And that's where that conversation exploded for me on social media and where I realized by reading the comments what a much bigger picture, what was really happening in the menopause world and how we need to bring it to the forefront.

For people that don't understand menopause, they might think that it's a small issue affecting a small group of people, but how many women are affected currently by perimenopause, menopause, and postmenopause?

Sure. Right now, about a third of the female population of the world is in perimenopause. You do not, it's not optional. All of us go through it. And because we have such individual expressions of how it affects our bodies, what we know now is that there are estrogen receptors in every organ system of our body. And when those levels start declining, we see a very wide variety of a spectrum of syndrome where it used to just be thought it was a few hot flashes and some night sweats, maybe your sleep is disrupted, your genital urinary system is going to take a hit, your bones are going to get weaker. But what we know now is how much it's affecting our mental health, our capabilities, our skin, our bones, our kidneys, vertigo, tinnitus, frozen shoulder. Anytime I post about those on social media, the internet explodes. Women by the thousands are like, Oh, my God, I had no idea. Just the validation piece was so huge for them to make because they've been dismissed for so long and told it's all in their head.

If we think about from peri to post-menopause, what is that typical, and I know that's a tricky word to use, but what is the average typical age range? And then also what is the more possible age range? It could start.

Between this age and this age. In the US and in most of Europe, the average age of menopause, which means one year after your last menstrual period, is 51. Perimenopause, which is when your body recognizes there's some declining estrogen levels and you're beginning to be symptomatic, can start 7-10 years before that. So normal menopause is still 45-55. And so if you do the math and back that up 7-10 years, it is completely reasonable for a 35-year-old woman to begin to experience some of the symptoms of perimenopause.

Let's start with what is it? I would love you to explain this to me like I'm a 10-year-old, because I'm sure there's a lot of people that are both men and women that.

Aren't free. We're going to talk about gonads, right? What's gonads? Gonads are where are... In men, it's the testes, and where you're making your genetic material, where you're making sperm, right? And in a female, it's going to be ovaries, her ovaries. So the big differences between male and female and how that process happens is that males make their genetic material fresh constantly the minute they go through puberty until basically they die, unless they have some medical issue. Females, on the other hand, our eggs develop while we're in utero, in our mothers. So while we're in the womb, she's five months pregnant with us, we have our maximum eggs that we're ever going to have. And those are meant to last us until we go through menopause. And so they lay dormant until we go through puberty, and then they wake up again and we start ovulating. So we have this monthly in a healthy person cyclical hormones rise and ebb and flow with our cycles. Each month we have a period, you get pregnant, you don't get pregnant, and the whole process starts over again. Well, because we're born with that egg supply, through time, we're decreasing the amount and the quality of those eggs.

So when a woman hits the age of 30, she is down to about 10 % of the egg supply that she had at birth. And when she's 40, it's down to about 3 %. And it gets harder and harder for that ebb and flow of the natural hormones to do its job. And we start seeing fluctuations in her periods and then organ systems that are beginning to notice the lack of estrogen. Estrogen is a really powerful anti-inflammatory hormone in most of our body systems. So the musculoskeletal syndrome of menopause is really starting to be talked about quite a bit now. And we're looking at things like frozen shoulder, or thralges, generalized aches and pains. And most physicians aren't aware of this. Most know about hot flashes and night sweats and sleep disruption. But now that we're really opening the conversation as to how many organ systems are affected, we are seeing people coming out of the woodwork just so happy to know that they're not crazy and they're being validated.

And what's happening at these three stages? We have the perimenopausal stage, which is, from what I've understood there, when estrogen levels start to drop.

We start seeing disruptions in the forest. Instead of that nice monthly estrogen surge with ovulation and then the progesterone goes up, we start the elongation sometimes, or they even get closer together. I call it the zone of chaos. What used to be a very reproducible, dependable system starts failing. So some women will have irregular periods, meaning they're spacing out, they're skipping periods. Others will have really heavy periods like hemorrhagic almost. And again, the way the body reacts to this is very individualized from patient to patient. Doctors love something that follows a list, a checklist. We have all these complicated things we have to learn and we have these checklists, but menopause, it's like pinning the tail on a moving donkey. And in perimenopause, it's very, very chaotic. Estrogen surges, then it goes away for a while. Like a woman in perimenopause can feel completely fine for a few months, everything goes haywire, then she's fine again. And not only is her estrogen declining, her testosterone is declining as well. So we're seeing loss of muscle mass, we're seeing changes in her sexual function, we're seeing decreased strength. There's some really good studies showing how testosterone also affects our mental health and our cognition as well.

Why does this happen? From an.

Evolutionary or-The anthropologists have looked at this heavily, and there's only a couple of species in the world that go through menopause. Humans are one. There's a couple of species of whales, and I think they've now discovered one of the giraffes. Species of giraffes can do it. But by and large, most mammals will die while they're still ovulating. They're not going to go through a menopause. And so there's something called the grandmother hypothesis, where there was an evolutionary advantage for women to survive if she stopped the ability to have children at some point. Now, again, you have to temper this with humans have prolonged their lifespan and their lifespan because of modern medicine. So probably when we evolved, we weren't living this long. A woman my age was pretty rare. I'm 55. And so it's hard to say. I think we have outlived how we were genetically built. And so we're living longer and being forced to deal with the consequences of that.

So then the next stage is menopause.

Menopause itself is really that it's just really one day in your life. It's when you can throw the hammer down and say, I'm never going to ovulate again. I'm done. And so if a woman is over the age of 45 and she hasn't had a period for a year, that's the definition. Now it gets confusing because what if she's had a hysterectomy or doesn't bleed because of a surgery or an IUD or something? Well, then we can't use her periods to help judge, and that's when we start doing blood work. Work to see where she is in her menopause journey. And then post-menopause is the rest of your life. The hot flashes might go away, night sweats might go away, brain fog might get better. But pretty much everything else is going to continue to progress in a very linear fashion until you die without estrogen replacement.

To put it lightly, you seem somewhat dissatisfied with the current set of answers that the medical field, but just society at large are offering women in this peri-and post-menopausal phase of their life. I've sat here with a lot of women who are experiencing menopause at one stage or the other, and they also seem to be at a loss for answers. I was sat here two days ago with a very, very successful woman who has all the resources in the world, and she basically came in. This is someone that has all the answers. People come to her because she has the answers. And the one thing she doesn't seem to have answers on, in her own words, in her life at the moment, is menopause. She's rummaging around the internet, Googling things, finding contradictory information. And when you sat down, you had that same energy, you feel like women have been, dare I say, let down by a system.

I think the medical system is letting them down. I think society is letting them down. Our value and our worth. In medicine, I came through this wonderful training program. I'm very proud of what I learned. I'm very proud of the care that I gave, except I was a horrible menopause provider for probably 15 years. I knew what I knew. I relied on my training, and I didn't look outside of the traditional confines of training. This is such a systemic problem that... I'm going to tell you a story, and this is true, and it's embarrassing, but I think it needs to be said because I think it really highlights how women are treated in medicine. When I was in training, we had these upper-level residents. We have a hierarchy where you have different years of training. So it was in the early years, maybe my first year, and we had these clinics that we would run to take care of patients. And so we have the obstetrics, and we have gynecology as divisions in our training. So in gynecology, everything gets lumped together, Pediatrics, Menopause. We had no specific Menopause clinic. I maybe got six hours of lecture in a four-year curriculum.

And so we'd have these women coming in midlife, and they had multiple complaints. They didn't feel good. They weren't sleeping. They were gaining some weight. They were aching. Just this laundry list of things that were a little on the vague side. And my upper levels would say, Oh, gosh, good luck with that. You've got a www on your hands. And that was code. We never wrote that in the chart. This was not taught to me by faculty. This was just handed down in the lure of training. And a www was a whiny woman, and that was code. And now I know that she was perimenopausal, suffering from her list of symptoms of now, which we've categorized about 70. And they were frustrated because they didn't think they could help her. Now, remember the Women's Health Initiative, which was a study that was supposed to do a lot of good for women, it was originally designed and it was stopped in 2002. That was the end of my training program, was 2002. I come from one of the last groups of physicians in the US that were ever trained in hormone replacement therapy, and then the rug was pulled out from under us.

So the WHO, there were mistakes, there was misinformation in the reporting, and there was misinterpretation of the results. All of that has been walked back, relooked at. We know that for the vast majority of women, hormone replacement therapy is safe and effective and can give a woman her life back if she chooses to take it. But that option has been taken off the table for the vast majority of women. Recently I just saw the numbers. 85 % of women will come in complaining of what we know now. This was in 2023. Fda looked at the numbers. 85% women are complaining of menopausal symptoms. 10.5% are receiving treatment or therapy today.

Is there something in you that feels somewhat, even though you're a doctor, somewhat let down by the medical system or skeptical about the medical system for personal reasons?

Yeah, I'm one of those women. I thought I'd be one of those girlies who would just breeze through menopause because I was thin and thin meant healthy. I still... That mentality was alive and well when I trained and through most of my practice. I came through a very fat phobic training, and medicine as a whole is very biased against people's weight. So now that I've done a deep dive into nutrition and done a deep dive into menopause, and really sat there and listened to patients and realized that women who were gaining weight with menopause, they've done nothing different. They're still exercising. They're eating the same. The only thing that's changed for them is their hormones, and they're being categorically dismissed at multiple doctor's visits or worse. Here's their laundry list of symptoms. The root cause is menopause, but it's not recognized. And one medication could have taken care of everything, but they're going to seven, eight, nine different specialists on seven, eight, nine different medications to handle each symptom. Whereas all they needed was just to get her hormones back. She would feel amazing and be able to age the way she should.

When we talk about the potential health implications of women that are going through menopause, it's not just www. It's much more...

That's how she feels, though.

And that's how she's categorized probably by people around her. But there's real health consequences and life altering health consequences, lifespan reducing health consequences. What are those?

We know that a woman's risk and the studies have been done, it's not just aging. Of course, aging plays into this. But when you add in menopause as an independent risk factor, her risk for cardiovascular disease increases, her risk of diabetes increases, her insulin resistance starts going haywire immediately, your listeners and people who watch on YouTube will be shocked. I'm going to say, how many of their cholesterol levels shot up in their 30s and 40s with no changes in diet and exercise? We see cholesterol levels changing, skin, hair, teeth, the dental changes, the inner ear changes, the vertigo is incredible. The frozen shoulder is legion. What is frozen shoulder? Frozen shoulder is an adhesive capsulitis of the shoulder joint, and it is very common in menopause. So estrogen has this amazing anti-inflammatory effect, especially in our bones and joints and muscles. And frozen shoulder is super common, and it takes about two years of therapy to get it to break up. So the capsule that is right over the bone where the muscles attach becomes encapsulated and adhese and stuck. And so you have to get in there and break it up and do lots of training.

So a woman wouldn't be able to reach behind her back to do her bra. That's one of the things. Or you go to take a picture with your girlfriends, and you can't put your arm, or you can't lift your arm above here. That's one of the studies that I presented. A lot of the stuff I do on social, I'll present the studies because I like to have data, and I'll get 10,000 comments on, Oh, my God, that happened to me. That happened to me. That happened to me. Not that I can fix it, but at least they know this is something that it's not your fault. You didn't do anything. You're just estrogen levels dropped, which led to increasing inflammation in those joints.

And have they seen that there's a reduction in lifespan in women that go through menopause that aren't treated in a.

Certain way? We know that women on HRT have a lower all-cause mortality.

What's HRT?

Hormone replacement therapy or menopause hormone therapy. In the studies that have been done, the observational studies and in the WHOI, women who were on hormones, especially beginning early in their menopause. So estrogen, there is a window of opportunity for reduction of some of this burden of disease, and it is very starting in perimenopause or within the first ten years of your menopause. That's the sweet spot for being able to decrease your risk of diabetes, decrease your risk of cardiovascular disease and dementia. When we go beyond that, we start losing those benefits because estrogen is better at prevention than cure. And so my medical school daughter was like, Mom, I'm never going to be without estrogen. I'm going to start in perimenopause. I'm not going to be one of those women who's ever off estrogen. Of course, she's my daughter and listens to me on social media all day. So she's a little biased. But she says, Why can't we get to that point where we have no gaps in our estrogen supply? We just start starting in perimenopause. Offer it to all women. Not all women will choose it, and I support that. But we're not having the conversation and they're not being given the choice.

So what age with your daughter would you advise her to start hormone replacement therapy if she so chooses?

I would say we start checking levels and we start looking probably in late 30s, certainly if she starts having any symptoms out of the normal. She's living her best life, doing all the right things for her health, and all of a sudden, she's not sleeping well, or she's having aches and pains, or she's noticing changes in her body. Most women can tell you something was wrong. I couldn't put my finger on it, but I knew that something in me had changed, and I wasn't responding to things the same way. Their mental health had changed, or the way their gut had changed, or gut health. There's barely an organ system that's not affected by this.

I sometimes wonder because there's the person going through it and then there's those around them, and they might know themselves that something's wrong. The person that's going through perimenopause or menopause, but the people around them won't understand typically what's going on with that person. They might do the old www thing, or they might label them something else. They might misdiagnose it as another man's health predicament. I remember a woman in my life whose behavior changed around this age, and I didn't know about perimenopause or menopause. It's in hindsight now that I look back and go, Oh, my God. Everyone around this person thought they had bipolar or something.

Right. I mean, it's probably contributing to divorce rates, maybe in a good way at this time. One of the positive things I see about menopause is that women are cutting the things in their life that don't make sense anymore. They're not putting up with... As a society, we tend to take on everyone's burden and take on the emotional labor in a lot of relationships, take on the organizational labor. And I see because they're struggling so much with just staying afloat, they're able to just quickly say, No, I'm not doing this anymore. You need to pick up, do whichever relationship they're in. You need to pick up your end of the bargain here. Or I can't do all of the organizational labor, the emotional labor. And I have a patient who's a divorce attorney, and she said, I really think a significant percentage of this divorce is menopause, and either they're prioritizing what's important to them, or they're not getting the support that they need.

How can we give them the support that they need?

I think it's important that we talk about it. I encourage every single patient I have, all my followers on social media, tell your story. Tell your story to anyone who will listen. Tell your daughters. Tell your nieces. Tell your sons. Tell your loved ones. Make this a normal part of the conversation so that we see it coming, we understand what might happen, and that no one feels crazy and alone when they're going through it. And then we need to do a much better job in our medical system of providing support for these women in whatever way they need it, be it hormones, nonhormones, cognitive behavioral therapy. There's lots of things that we can do. Not just hormone therapy is not the cure all for everything. We have to support the whole toolkit. We have to prioritize our sleep, get the exercise that we need, focus on strength training. When a lot of us in my generation never did that, we were aerobics, focused on being thin and small. It's time to be strong. This muscle mass that you have is going to determine your longevity and your functionality as you age. And menopause is that loss of estrogen and testosterone is tearing our muscle units apart, which is leading to osteoporosis as well.

I want to go through that whole toolkit, but I also want to just, before we move there, understand why women don't sometimes communicate that they're going through perimenopause or menopause. Is there a stigma associated with.

Talking about it? Yeah, I think there's shame and stigma associated with aging, with females aging. And then you're layering on this loss of fertility. And in the medical field, when you look at funding in the US for research studies, women's health, I think it's 55 billion, the National Institutes of Health in the US, for all research studies. And that's outside of what pharma is funding. And women's health gets about 15 billion. And the majority of that is spent on getting people pregnant, keeping them pregnant, and fertility issues. Menopause gets, I think, 15 million. Jesus Christ. Yeah. It's like 0.03 %, if I did the math correctly, of all... Are we not as important as we were when we were fertile? Do our lives not matter? It's ridiculous to me. When we can intervene and help and give these women a longer life and a better quality of life.

And how many women is that? I know we said it has a fraction earlier on a percentage, but I think in your book, I read it's 1.2 billion women by the end of this year. There's what, 47 million new entrants into the peri-menopausal, post-menopausal category of RIA?

1.2 billion. Billion, right. And so many of them have no education at their fingertips, have nowhere to turn. 85% are going into their healthcare provider's office complaining, Help me, and being turned away. I'm leaving with more questions and answers, and only 10% are even having the discussion for hormone replacement therapy. And then if they're given it, they're so terrified because of the misrepresentation of the Women's Health Initiative, they're convinced they're going to get cancer. And that study has been completely dismantled and walked back. We have good information that came out of that study, but the thought that estrogen causes breast cancer is the worst thing that came out of that study because it's not true.

The mental health implications as well. I really want to get into the hormone replacement therapy and all that stuff. But the mental health implications for women, do we see an increase in depression and those and the consequences of.

Depression, I guess? Depression, anxiety, bipolar, the entire spectrum, ADHD. We see either a new onset or worsening of disease. I'm telling my patients or I'm telling people on social media, you may have done fine and done well with your depression on your SSRI. Don't be shocked if it is no longer working at that level. You either have to increase the dose. So no one right now is advocating for primary therapy of depression to be estrogen replacement. But we do know from the studies that it is a veryvery powerful adjunctive tool, and that it can be preventative for new-onset depression if you start in perimenopause. Women who start hormone therapy in perimenopause have a lower incidence of new-onset depression in their menopause.

Suicidality?

So I've looked at these numbers, and COVID is skewing things because we did see increased suicide rates, but we definitely see an uptick, especially in Caucasian women, not so much in women of color in the US in the perimenopause and menopause time frame.

Inflammation? What is inflammation? Sure.

So inflammation, there's chronic inflammation, and there's acute inflammation. So, acute inflammation is what we need to survive. It is the body's reaction to a foreign invader, basically, or to an injury or an illness. So you twist your ankle, right? And so we injure that tissue. These chemical messengers are spread from the injured tissue, which basically tells our immune system, send blood that way, send the white cells and the red cells and all the cells that are going to fight and heal this, you're going to swell, you're going to have pain that's going to keep you off of that joint so that it can heal. Acute inflammation also happens when we get viruses and other illnesses. Chronic inflammation is this low-grade, under-the-radar inflammation that's happening in the background. Autoimmune disease is a lot of chronic inflammation. But we also see aging itself. We can't change the fact we're aging, but menopause dramatically increases the amount of chronic inflammation that a female will go through just based on the lack of estrogen and testosterone in her body.

I'm trying to figure out why the lack of estrogen and the drop in estrogen causes inflammation.

It turns out estrogen is a really powerful anti-inflammatory hormone. We're just like removing that protective blanket, and now you're just aging faster because of it.

Okay, so we need to make sure that we reduce inflammation by any means necessary. That was the second component of the Galveston diet, anti-inflammation nutrition. If I wanted to have a low inflammation diet, you said there about the sugar, is there anything else that I've got to be aware of or avoid or choose in a supermarket?

Sure. I try to teach the principles in the form, let's add things in rather than restrict, because then we get into eating disorders. Keeping tabs on your added sugars, keeping those less than 25, but fiber. And that's one thing most people are not paying attention to. How much fiber are you getting in your diet per day? And most women are getting about 12 grams per day, and the minimum we should be getting is 25. Vitamin D is another huge one. About 85 % of my patients and women in menopause are vitamin D deficient. Not just low, I mean deficient. We are protecting our skin against sun damage, of course. We're staying indoors more. We're on our screens all the time, but we're also our guts changing, and our ability to absorb vitamin D is decreasing. So making sure that you are checking your vitamin D levels regularly and supplementing when you need to, or eating foods rich in vitamin D, that's another one.

And does vitamin D reduce inflammation? Yes.

Okay. So vitamin D is a vitamin, but it's also a hormone, and it has multiple functions in the body. And so vitamin D deficiencies are linked to lots of chronic diseases. You're more likely to have hypertension, diabetes, stroke, all of the top seven of 10 causes of death in women. And so keeping those... It's also mental health. It's lots of vitamin D receptors in the brain. And so first thing I do is check a vitamin D level on my patients when they come in.

So many of my nutrition-based or medical or doctors that I've spoken to on this show have spoken about fiber, especially in the last six months. People historically speak a lot about protein and all these kinds of things, but for some reason, everyone seems to be talking about fiber all of a sudden.

So fiber does lots of things for us. It slows down the absorption of glucose into the bloodstream, so that keeps our insulin levels lower over time. It feeds our gut microbiome, soluble fiber. There's two types of fiber. There's soluble and ins soluble. Insoluble is what when you mix up a fiber supplement, you see the stuff precipitate down to the bottom. That's the insoluble fiber. That's what pulls water into the gut and moves things quicker through the colon. Soluble fiber dissolves in water. That's the cloudy part. That is the food for our gut microbiome. That is the prebiotic. You don't need a prebiotic if you're getting enough fiber in your diet per day. And so keeping that gut microbiome fed and healthy and happy is going to do a multitude of things. That data is exploding right now in the research world as to where the gut microbiome, how to keep it healthy, and what organ system it affects. Then our gut microbes make these things called oxybutyrates, which are then absorbed into the bloodstream. And people who have high levels of oxybutyrates are actually healthier and have less coronary artery disease, less dementia, less everything.

So really nutrition. When I talk about the Menopause toolkit, hormone therapy is just one very small part of the puzzle. But nutrition should always be first. It doesn't matter how many hormones you take if you're not covering your nutritional basis the way you should.

What are some fiber-dense or fiber-rich foods that are in every supermarket?

Avocado, Chia seeds, nuts, berries, your cruciferous vegetables, things that are crunchy, that's fiber that's making the crunch, apples. There's so many. Don't find much fiber in lean meats or any, so it's going to be your fruits and veggies and seeds and nuts.

What about asparagas, tomatoes.

Spinach, celery? Asparagas, celery, yes. Tomato, not so much. Just think of things that the crunch is usually from the fiber. Okay.

Fasting.

I'm a fan. It's not for everyone. It's not a great way to lose weight. The data on weight loss is conflicting at best. You can eat a lot of things that will undo the goodness of fasting in your eating window if you're not careful. And so there's good data, though, on neuroinflammation and fasting and on systemic inflammation and fasting. So I recommend fasting for the systemic inflammatory benefits. And we do see some really nice lowering of insulin levels overall from fasting.

There's so many different types of fasting people talk about.

So when I'm teaching fasting to my students or to my patients, I recommend the 16:8. So that's where Mark Matt's in state. So that's 16 hours of fasting in a row, followed by about an eight-hour eating window. Now, again, it's individualized. Some people do great with a 14-hour fast, the 15-hour fast. 16 is just something to shoot for. And if someone's going to consider incorporating fasting into their life, give yourself about a six-week trial. Don't just try to go 16 hours without food if you've never done it before. Your body will adapt. And so the advice I got and what I do and what I teach now... So I used to break my fast about 6:00 in the morning before I exercise. So I pushed that window to 6:15. And I did that for three or four days until it felt normal, natural, I wasn't hungry. Then I moved it to 6:30. And then I just kept bumping that window out in 15-minute increments over weeks. And by week five, I remember sitting at my desk and I had my lunch ready to go. And I was still at the hospital at the time and saying, Oh, my God, I made it.

It's noon and I don't feel bad. So I had just slowly, slowly let my body adapt and adjust. And then I've been fasting since 2015, probably 2014. And it's just a normal, natural part of my life. I don't even think.

About it anymore. Have you noticed anytoday that you're on a diet, or are there any other side effects of that?

I do so many things. Yes, it's hard to tell. And so it's hard to tell. But initially, I do find when I'm fasting, the clarity of my thought is much better. I get much more work done. It's when I do my best research. It's when I do my best communicating with my followers. It is in the morning. Often if you follow me on social, I'm always in my pajamas with a cup of coffee while I'm getting ready for work because I just get so excited about something I learn and I want to share it with everyone. I do find that once I break my fast, the synapses tend to not work as quickly for me.

I was thinking about this too like an evolutionary lens, why fasting makes sense and why this narrative that we're meant to have breakfast, lunch and dinner, maybe breakfast.

At seven. That's a social construct. There's really not great science. Now, there are humans that will do better by eating meals more frequently. And that's why I say fasting is not for everyone, especially if it triggers an eating disorder. If you have diabetes or you have hypoglycemia, fasting may not be for you, but most people can do it successfully. And so I really encourage people to experiment with it and see how they do.

I was wondering if... I was trying to think through an evolutionary framework, and I was thinking about how in our hunter-gatherer past, we.

Would have - Meals were not available 24/7.

Yeah. And we would have needed a really focused brain to go out on the hunt. This explains why when we're.

Hungry, our.

Our brain working better. It almost seems like there's more oxygen or nutrients.

In the brain. The brain tends to work better using the ketones for fuel than glucose. The glucose is preferred fuel in the body. But when they did studies, they were animal studies, so take this with a grain of salt. But when they did their their mazes. Animals tended to get through the maze quicker and learn quicker when they were fasted rather than after they were fed. They're a little lazier.

Ketones, you can also use use as an energy source if you use the keto diet.

You can. But I think when Matson and those researchers were doing their research in Alzheimer's and dementia, there was no keto diet. They were just knowing that people were utilizing ketones for fuel, which is a normal natural process, we sleep. We burn through the glucose in our bloodstream, then we burn up what's in our liver and the gluconeogenesis, and then it switches to fat to burn for fuel. Now there's people who like to take exogenous ketones. I've never experimented with that. I don't have any any literature to support that use.

The third third component the Galveston diet is this idea of fuel refocus.

Right. That's looking at food, we're looking at the macro and micronutrients. I'm really going hard on fiber and vitamin D and magnesium and things that we tend to, as a gender, be deficient in, especially with menopause. I'm really trying to highlight those things to make sure instead of counting calories, let's see how much vitamin D you're getting every every day. See how much fiber you're getting every day.

And is there a certain ratio of foods that we should be.

Having in terms of of protein? I originally developed Galveston diet for weight loss, but if I had to write it over again, so I went really heavy on healthy fats, were lower on carbohydrates and and 20 protein. But I think doing it again, where I'm I'm my patients now is I'm going much higher on protein. What I've learned since that book was written was how important protein protein is to maintaining muscle mass. I'm also talking a lot about creatine, and there's some nice studies done in, we call it the elderly 65-year-olds and above, which I'm nine years from that right now. Now. So how creatine supplementation, just creatine supplementation on its own, well, combined with weightlifting, we're seeing bigger gains in the menopausal patient. Post-menopausal patient, yeah.

-bigger gains in.

Muscle muscle mass? Muscle mass and strength.

I was going to ask you about this whole whole muscle endpoint. Why is muscle mass so pertinent to this conversation?

What we know in menopause is that aging combined with menopause, we see a dramatic loss of muscle mass with the menopause process. And so in that first 10 years of menopause, we could lose up to 10, sometimes sometimes 15 of our muscle mass. And that muscle mass is going to determine your resistance to sugars. So your insulin resistance is really tied to your muscle muscle mass, functionality, your ability to recover from a fall. Fall. And other thing is what most people don't understand is the musculoskeletal unit acts as one. One. So we have low muscle mass, you are dramatically increasing your risk of osteoporosis. Now, right now, this might shock you, but 50% of females will have an osteoporotic fracture before they die, and this is almost completely preventable.

What is an.

Osteopthic fracture? Fracture? So is when we the density of our bones bones estrogen. So all of our life, we remodel our bones. We chew up bone and we lay down new bone. And so we reach our maximum bone density as females at about age 35, and then it slowly starts to decline through the aging process. And then when we get to menopause, dramatically, we see see massive loss of bone. So this loss of bone makes the bone weaker and much more likely to fracture when we we fall. And so you fall and break your hip in menopause, 30 % of women with surgery will die in the first year. 70 % will die without surgery. And that year is marked by horrific pain and not being able to move and just really, really miserable people. And so much of this is preventable. Going on hormone therapy, getting adequate exercise, doing the resistance training, eating the protein, adding in the creatine, making sure you're getting enough vitamin D is going to be huge at protecting my population from this happening as we age. We can prevent the majority of this. I want.

To talk specifically then about this hormone replacement therapy you mentioned there. You also referenced a study previously which scared people.

Yes, the Women's Health Initiative. Initiative.

And study suggested that there was an increase in breast cancer if someone did hormone.

Replacement therapy. Let's break it down. Originally, the study was designed to see if we knew it from observational studies, was hormone replacement therapy going to truly be protective for cardiovascular disease? That was the function of the study in women who took it versus women who did did We knew from observational studies that, yes, they had a much lower risk of death from cardiovascular disease and all-cause mortality, meaning death from any cause, as well as heart disease in itself, atherosclerotic heart disease. But that's observational. The way to prove these things is to do a randomized controlled study versus placebo. So finally, this is 1998, women were getting money. There was a new female head of the National Institutes of Health. They were funding this study. This was so exciting. Women were lining up at droves to sign up for it. But because the end game was to prove whether or not it was protective for cardiovascular disease, the average age of the patient was 63 years years old, that they could see if it was going to affect heart disease, because women tend to get that in their 60s and 70s. So they recruit, they develop two groups.

We have women with uteruses and women without women who had had hysterectomies or were born without uteruses. And so each of them had a placebo arm and then a medication arm. When you don't have a uterus, you don't absolutely have to have progesterone. When you have a uterus, it's required to give a woman progesterone as well, or a a progestin as to protect the lining of the uterus from the estrogen. Unopposed estrogen can cause endometrial cancer, but we can negate that by giving her progesterone. You following me? So we have an estrogen-only arm, and an estrogen-and-a-progesterone arm, and they each have a placebo. So off we go. Let's take our meds, let's take our placebo, and let's start measuring. What they saw in the estrogen-plus-progesterone arm after two years was a very slight increased risk of breast cancer versus placebo. Now, you have to understand there's a difference between absolute risk and relative risk. So the relative risk went from... So the absolute risk went from four out of 1,000 women per year to five out of 1,000 women per year. So one out of 1,000 women treated in estrogen and progestin or developed breast cancer over placebo.

That is a 25 % relative risk increase. And that is the statistic that set the world on fire. Fire. So researchers held a huge press conference at the Watergate Hotel in DC. Every major news out there, this was before the internet, and announced that estrogen causes breast cancer. Now, remember, these women were on estrogen plus the progestin, which is called Provera. The estrogen-only arm continued for a few more years because the women on estrogen only not only did they not see an increased risk of breast cancer, they had a, I think it was a a 20 decreased risk of breast cancer. Cancer. Yeah, relative risk. And the relative mortality went down down 40 %. So think it's because estrogen feeds a breast cancer cell, but it doesn't cause breast cancer. Our highest levels of estrogen are in pregnancy, and it's so rare to ever be diagnosed with breast cancer. And a healthy breast cell has estrogen receptors. And all that estrogen receptor positive means is that that breast cancer cell went from healthy to cancer through a mutation, but retained its estrogen receptors. And so we can use those receptors against the cancer cell to treat the breast cancer.

So that study has been walked back. Multiple studies have been done, but the whole mindset has not changed. Myself, as an an was still the lowest dose for the shortest amount of time, and only in women where absolutely nothing else is helping her, hot flashes. Menopause was defined by the vasomotor symptoms. That's it. Vaginal Vaginal estrogen, is just putting estrogen locally in the the vagina. So of the biggest things we see in a huge amount of patients, like well over over 50 is something we call genital urinary syndrome of menopause. Menopause. And is the bladder, the vagina, and all of the tissue in between all has a lot of estrogen receptors. When we take the estrogen away, that tissue becomes very thin. We lose elasticity. We see recurrent urinary tract infections. The most likely treatment to help a woman in menopause with recurrent urinary tract infections, which is a major cause of death for women, is vaginal estrogen. And it's safe for everyone, even with breast cancer. And so even that option is taken off the table for so many women who are suffering needlessly with horrible painful intercourse, dryness, recurrent recurrent UTIs, it's just such a simple thing to help a woman and fix, and they're not being offered that treatment.

Is vaginal estrogen the only form of administering administering estrogen?

When we look at hormone replacement therapy, or any medication, we have... Steroids is a good way to think of it. Say you have a rash and you go to your pharmacy and you pick up a cortisol cream, that's local therapy. Vaginal estrogen, cream, there's pills, there's different ways to put it in the vagina, but that's considered local therapy. It's not absorbed systemically. We're just treating it at the moment. Systemic therapy is when it's treating everything, our brains, our bones, our general from the inside out. You can ingest it. There's creams, there's patches, there's rings, there's pellets that are now available. There's multiple ways to get this medication into your body.

What's the most popular form of administering hormone replacement therapy?

It depends on the country. In the UK, it tends to be a gel or a cream, which is where most GPs, if you can get one that will follow the guidelines and prescribe it, I think it's the most easiest easiest option to get in the UK. In the US, it tends to be the patch for the non-oral form. We also have pills available as well. There's a caveat with estrogen pills. There's something whenever we ingest anything, food, medication, goes into our stomach, into the intestines, and then it gets picked up by the portal hepatic circulation, the liver. And so the portal vein goes straight to the liver for processing. And when that bump of estrogen or testosterone typically hits the liver, we see some problems with... For testosterone, it's it's liver toxicity. For estrogen, we see bumps in our clotting factor. Factor. And so see a lot of women who are terrified of hormone therapy because of this potential risk of blood clots. They either have a genetic risk of blood clots or a a or they've had a clot in the past. But if they avoid oral estrogen and go with a non-oral form like the patch or the ring or even a pellet, then we bypass the liver and we don't have the increased risk of clotting.

Are there any other side effects? In life, there's no such thing as a free lunch.

Estrogen, so we have to look at each. So when we look at hormone replacement therapy, we have our estrogens, we have our androgens, which would be testosterone, DHEA, and and then we have our progesterone, which is the bio-identical form progesterone. There are synthetic progestins available, but I tend to just prescribe the progesterone. And so each of them has issues that might happen. So with estrogen, you can see headaches. So that's a red flag for for us, worry. You can see migraines getting worse. Those are patients you have to be really careful with going low dose. You can see unexplained. So So 40 of patients on menopausal hormone therapy will have vaginal bleeding. It doesn't mean it's a period. We have not woken your ovaries up. They're gone. We are just stimulating that tissue in the lining of the uterus, and it's bleeding a little bit. It's usually self-limited. It can go away on its own. If it persists past several months, we'll get ultrasounds to make sure we're not missing a polyp or something there. But it's one one of things things I'm my patients about. About. So I worry about, headaches, some women, depending on the formulation.

Formulation. So the patch, it has an adhesive to stick to your skin. There's probably 10 % of women will have some an allergic reaction to the the adhesive. We have to look for alternative forms. Thankfully, there are multiple forms on the the market, and patients, we have to do some trial and error to find out not only which formulation is going to work best for her, but also what dosing is going to work best for her.

If I was a a menopausal and I came to you and I said, I need help, you must get thousands of messages like that. Thousands of messages a week probably. And I walked into your practice. Where would you start with me?

I start by letting you tell your story.

I tell my story, and it's a typical story that you hear. Right, yeah.

What happens next? Symptoms. I will get blood work. Sometimes I'm getting hormones to see if I'm not clear where she is in her journey, I may get blood work to help me define if she's she's peri or especially if she's had a hysterectomy. I'll get a lot of blood work around checking her thyroid. A lot of things look like like menopause, So fatigue and night sweats, that might be hypothyroidism, weight gain, hypothyroidism, autoimmune disease, all this rheumatoid rheumatoid I want to make sure I'm not missing something else that looks a lot like peri-menopause. So I'm doing blood work around that nutrition deficiencies, vitamin D, her basic labs for her blood count and her electrolytes. I'm doing this full panel- Okay. But then I'm beginning to treat immediately. And so we have a discussion around her sexual wellness. Is she struggling with desire? Then we'll have a discussion around testosterone.

I'm struggling. My desire is gone.

Okay, and it's very common. Common. So we talk about female sexual function, there's five buckets why a woman would be suffering or not happy. One is a relationship disorder, and no amount of medication really helps with that. That. So want to make sure she's in a good place with her relationship, supportive partner, all that. We have a discussion about that. Then there's an arousal disorder, where that's what most men are treated for when they talk about libido issues. It's really nothing's wrong here. They're struggling to maintain an erection. And so we use Viagra and those types of medications for that. So if a woman has an arousal disorder, vaginal Viagra can be helpful for that. So we talk about that. We talk about orgasmic disorders. Some women have about 10 % of women will never have an orgasm in their life. Imagine if that was 10 % of men, I think it would be a national emergency. I think we would divert military funding in the US to get this fixed, and it's just something we don't talk about or offer much help. And so then that leaves desire. So most women who are in secure secure love their partner, miss that part of the intimacy that they used to have, that desire to initiate, that that Yes, that seems like a good good idea, goes away with menopause a lot.

And so for those women, testosterone might be helpful, or there's a couple of FDA-approved medications as as well, and and Vylce. And so have talked about costs and how to get it prescribed and testosterone. There's no FDA-approved option for women. So quite often I will have to compound that medication for them at a local compounding pharmacy versus going to to Reed or a CVS or Walgreens to pick it up using their insurance. I know that you're coming from the UK, our health systems are a little bit different. But because my reach is so large now, I try to include all the different health systems when I'm talking about your options.

Give me a case study of a patient that walked into your door and- Gosh.

I had a patient who came came and her name is Michael, and she won't mind me saying it because we're really good friends. And she came in and typical, overweight, not sleeping, some brain fog issues, some joints, aching, aches and pains, all the things. And sweetest woman, absolutely adored her husband, but was struggling with desire as well. So we started her. I developed a nutrition plan for her. She hired a personal trainer. She got to the gym. She got serious about about She started on hormone therapy. And she is my biggest cheerleader on social because she's constantly... She's lost probably about 60 pounds of body fat because we get to to measure So in my clinic, I have an in-body scanner where I can measure muscle mass and visceral fat. So it's not just the number on the the I'm able to tell them. So she's probably gained maybe 10 pounds of muscle, lost a tremendous amount of fat. She feels amazing. She has this beautiful... She's back to her intimacy level that she desired so much before. She is absolutely thriving on all aspects, and she's constantly sharing her stories, her story online so that other women can learn that they don't have to suffer as well.

And she just can't believe... The thing that makes her angry is that she didn't come sooner and that she suffered for so long without looking for help, and she couldn't find it. She came from San Antonio, which is about a three and a half hour drive to come and see me. So here's the scary thing for me, it's honorable. I have patients. So I have this menopause clinic I started two years ago, and I have a waiting list that's longer than this wall. And women are flying in regularly to come and see me, which is such such an and I'm so grateful that they trust me. But it's ridiculous that they can't find menopause care in their backyard, that they have to get on a plane to come and see me because they cannot find care wherever they are. So I've started a list of providers on my website that my followers recommend where they found good menopause care. They write a a and we just compile compile and we just look online to make sure it's a real doctor and they have a phone number that works. And then the North America Menopause Society now calledCAMS, now called the Menopause Society they rebranded, has a list of certified providers on their website as well.

I got an email sent to me after listening to one of the episodes on this podcast from what appears to be a very helpless husband. It was a very, very, very long email. They'd said that one of the conversations we'd had on this podcast about menopause at one point had really helped them. But the.

Key question that.

Remained for that person was.

When does.

A supporting partner know how and at what point to help? Because no male partner wants to turn around to their wife and go, I think you've got menopause, and starts diagnosing them. But they also don't want to just sit back and be quiet.

I think it usually begins with something you can't quite put your finger on. She's reacting differently. She's not as resilient as she used to be. She's not managing situations the same way. And I think once we start taking the shame and the stigma out, him suggesting that perhaps this is menopause will not cause her to fly off the the I think normalizing this conversation, removing the stigma, it might make everyone go, Oh, I didn't realize it in myself. I thought it was was grief And I was like, Wait, when was my last period? When was my last period? Oh, I think I'm in menopause. And then I was like, Oh, God, menopause. Even for myself, it was such a negative connotation. I had that that in the City episode in my head when Samantha thought she was in in and how horrible it was for her. And then it turns out she wasn't and everything was better again. And I'm like, Gosh, is this... First of all, I applaud him for wanting to try to do something because so many... You think women don't understand what's going on. One, bravo for wanting to be helpful.

Two, say it with love. Say it gently. Let's, and then find a provider or find a healthcare provider to go in and start the conversation. And one of my best visits with my patients are when their partners partners and that the conversation is held together. And it really opens their minds to what's going on in her body and helps understand what we can do therapeutically, what needs to be done at home. This is a special time for her. She's going to need extra help. We're going to get through this. It doesn't have to destroy your sexual life or your relationship or whatever. It definitely can take a toll if left untreated. But bless him for doing it. We talked about it a little bit earlier. There's probably a fair amount of dissolutions of relationships because no one's talking about this process and what it could do to someone.

This might be a a stupid stupid question, but I don't I'd ask a lot of stupid questions. Do men go through anything like this?

There's a lot of debate about menopause. The short answer is not really. We see men's testosterone levels peak at about age 19, no shocker there, and then this very slow down tick until they they at about age 35 to 40, and then they stay stable for the rest of their lives. But there's a difference between... There's a big variation from man to man, where the shape of the curve looks the same. But as far as normal men's range is from 236 to about 1,000. So there's a big man to man variation. And there is a lot of men who are supplementing when they come in on the low end, and they're feeling a lot better. Now, this is not my area of expertise. I just read a lot of this research on on and men are included in it. It. And so are finding that they are having better cognition, feeling better, having more energy, et cetera. But there is no manopause. Manopause. There testicles don't stop working. I mean, it would be as if your testicles truveled up and died at 51. That's the equivalent. Gosh.

I do have to to say, the start of this conversation, when you said if that was happening to men, the reaction would be different. I have to say, I think I agree. I think that because it's one side of the population, I think it's been overlooked over the last 10, 20, 30 years. But if it was men or both genders, I think it would be a different response.

And so much of what women were going through in menopause were dismissed as psychological. I've really had multiple times in their life. It's all in her head. We never said it's all in his head. That's not a thing on the words. It's all in her head was very much alive and well in my training and a lot of my practice. I find myself now even having to pull myself back a little bit just because that was ingrained so much to always look for the psychological reason. I mean, a woman right right in in is more likely to be prescribed an antidepressant for her menopause than hormone therapy. Multiple reasons for that. The way we were trained, the way we were taught to approach a woman's medical issues, and also the fear, unfounded fear, around the Women's Health Initiative and what it did to physicians feeling confident about prescribing hormone therapy.

Is there anything else that you do on a day-to-day basis in your life that we haven't talked about yet? Is there any.

Apps or tools? Yeah. I really like Headspace. I I know some good meditation apps. I really thought meditation was woo woo and not anything that I would just sit there and my brain would be bouncing all over the place. But once I went through menopause and suffered so horribly from the mental side effects and all this happening at once, to me with my brother's death, aging parents, teenage girls in the house, and realized something's got to give. And so I I a counselor, I went to therapy. And she recommended getting an app to help guide me through meditation, and that has really turned the needle for me. Really? Yeah. How? Carving out out it's just five or 10 minutes in the morning to think of what I'm grateful for, focus on that gratitude. And I love teaching that to patients and to my followers of really putting yourself first, the thought of you have to put your own oxygen mask on first before you can go take care of your family and all the other things on your plate. And just giving my brain that time to just relax and let it flow and just let the thoughts and just focus on me for that, that's really made a huge difference for me.

What role does sleep play in all of this?

So sleep disruption is massive, massive, massive in perimenopause and menopause. And when we don't sleep, we see everything. I tell patients, that's the thing we need to work on first. We need to get you sleeping because nothing's going to work until your body is able to restore itself. That's when we build muscle. That's when when brain resets. That's when our whole body... And if you're having disrupted disrupted and you're waking up at 3:00 in the morning and your brain is racing, everything is worse. Your cortisol cortisol spike, your insulin resistance goes up, everything gets worse. And so when my patients come in, we focus on sleep first and nutrition pretty much.

Easier said.

Than done though, right? If their sleep disruption is due to hormones, then it's such an easy fix. I just give them back the water they were drinking and they sleep again. Where the struggle is if someone's never been a good sleeper, then that's probably out of my area of expertise. I'm going to send them to a sleep medicine specialist. One of the things that we now see is a sleep apnea, even in the thin patient and menopause in women. We're seeing a big bump in the sleep apnea rates in women who are... They don't even have to have a weight problem.

And what is sleep apnea?

That's when people- Sleep apnea is when you stop breathing or you snore quite a bit. You see the the relaxes and you're not getting as much oxygen into the body and into the brain. It's a big health risk.

And what is your personal exercise regime?

What are you doing? I came from the long long years of just just I was exercising to be smaller, and now I'm moving to be stronger. And so now I'm doing resistance training. So I have a treadmill that I set up on an incline, and I do a lot of Zoom calls there. I do lots of meetings there. There. So I'm working from home and working on The Galveston Diet or the new book, I'm doing on my treadmill, but at an incline. So I'm really working on my legs. I will wear a weighted vest so that I'm getting the upper body. So I'm doing this for bone density. I'm doing a lot more lifting than than ever, ever, ever did in my my life I have a body scanner in my my I have sarcopenia. I have a genetic low, I'm very thin individual, and was not blessed with a lot of muscle mass. And the fact that I focused on being thin for so long, and that was my social currency, is I was thin, I was healthy, probably I lost that window of opportunity to gain more muscle easily in my 20s and 30s.

So what I would tell my 35-year-old self, what I preach to my daughters is focus on being strong, not small. It's all about muscle, strength over skinny. And so the muscle mass that you develop now is going to serve you so much more than the lack of fat or this perceived lack of fat that you think you need. Don't worry about the curves that you have. That's natural. That's the way you're built. Let's get some muscle.

And what about your diet?

So what my personal?

Yeah, eating window, I think you talked about.

Yeah. So I tend to... I break my fast at around around noon-ish typically. I'm hungry before if I'm I'm or on a plane, I don't do well on a plane without food. But on a normal day when I'm going to clinic, and the night before is when my diet starts, I will pack up my meals and snacks that I'm going to take to the office with me when I see patients. And so I know what I've got. I'm loading up on protein. I'm doing something green, some green veggies. I'm doing lots of fruit. I've got nuts and seeds. I eat nuts and seeds all day long for the anti-inflammatory benefits and for the healthy fats and for the fiber. And so I've got all that. So I'll break my fast at about noon. And then between patients, I'm constantly snacking. I'm really focusing on protein for myself. I don't have a weight problem. And so I'm trying to get stronger. And so my protein needs have really increased. And so I'm sometimes doing a protein bar or a shake middle of the day to help with that. And then in the evening, now we're empty nesting, so it's just my husband and I.

And so we're we'll discuss what do we have in the freezer? We'll pull out some salmon or we'll make some burgers or something. And we try to be protein centric. And then we're adding in a beautiful salad with lots of avocado and chickpeas on the side. So I think I covered it all. Yeah. So I'm typically done eating by 8:00 PM. If it's an office day, I'll either exercise when I get back. I'm struggling to get up. I do a lot lot of work in the morning, so it's hard for me to get to the gym and the the office, I'll save my workout for when I get.

Home from work. If you had a megaphone and you could speak to every woman right now, the 1.2 billion that we talked about earlier that are in that that or the the menopause phase or post-menopausal, and you had to communicate one message to them. I'm actually going to bring in everybody else as well, because although it's just those women I've mentioned, everyone around them in their life probably needs to hear somewhat similar message message they can play supporting roles in that individual struggle. What would you say down that menopause to those women and their loved ones?

My mantra is menopause is inevitable, suffering is not. But you're going to have to advocate for yourself because society has failed us. Our medical system is built to fail the menopausal woman, and there is good help out there. You're going to have to do the the leg I've got tons of resources on my website to help you. List of articles to print out and hand to your doctor. Symptomatic sheets that you can keep track, journals that you can hand to your your physician way that I can help you advocate for yourself because I can't be everyone's doctor. But that this is real. You're not crazy. This is happening. And there are lots of things that we can do, even nonhormonal. Don't feel like if you're not a candidate for hormone therapy that you're stuck. Exercise, nutrition, other pharmacology, stress reduction, sleep. It's time to to take of yourself first so that you can have the best end of your life that you deserve.

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As with all private and equity investments, all of the investment capital is at risk. This communication is for information purposes only and should not be taken as investment advice or a financial promotion. As you guys know, I'm a big fan of of I'm an investor in the company and they sponsor this podcast. What I've done for you, I've put together what I call the the Stephen Bundle, which is is a of my favorite products from from including the Black Edition, Salted caramel flavor, which is super high in protein and has 17 servings per container. My favorite favorite bottle here, which comes with my bundle. And also the brand new and very exciting Heal complete nutrition bars. This is Chocolate Chocolate You can see from the empty box in front of me that I've eaten most of them. Me and my team team here, you leave these on the counter for five seconds, they'll go. I'm going to say something I've never said. When When first made their bar many, many years ago, I tried it and I didn't like it, so I've never talked about it on this podcast. They've spent roughly the last 2-3 years making a brand new bar, which I absolutely love.

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Your family have a history of health complications and illnesses, right? Yeah. What is that history? But also has that played into your overarching perspective about nutrition, the healthcare system, how it treats people?

I'm one of eight children. I have six brothers. My oldest brother, brother, died when I was nine years old from acute lymphocytic leukemia, one of the most common forms of childhood leukemia. Now the cure rate is 95 %. But at the time, he was put into remission, and then he came out of remission in his late teens and died a year and a half later. So my childhood was that year and a half was all about trying to save him. Everything my family did of taking him to Memphis, which was so far from Louisiana, where I grew up to St. Jude's Hospital, the last ditch effort to try to find another chemotherapy regimen, which he failed. And that drove me. But it was leukemia. It was childhood. It was one of those things. Fast forward to 20... He died in 2015. So in 2010, my my I I knew, HIV and had also contracted hepatitis. And he was doing great on his HIV meds. His counts were good. He was healthy, functional. He'd been with the same partner for over 30 30 years. Then his liver was getting worse and worse and worse. He also struggled with alcoholism.

And so that combination was really hard to watch and love him through his choices. And he ultimately died in 2015. He had a a stroke, then I was able to to go do his care. And the first book I wrote, I talk about him in the book because in my rush to deliver his care, I forgot my own. And that's when I realized I was was was through my grief process. I thought I was was I gaslit myself. Like, no, you're not sleeping. You're waking up all night. You're upset, and your mental health and your brain fog is all because you're just grieving his death. And then my next brother, Jude, was diagnosed with stage stage four cancer. Shortly, he was diagnosed when Bob died, and then he survived a few years. So Bob died at at and Jude died at 57, and I'm I'm at And I know a lot of it was lifestyle, but I still have those genetics. And I'm about to to survive of my six brothers outlive. And I know that these choices that I make with my nutrition, my exercise, my sleep, my stress reduction, what I call the Menopause Toolkit and my choices for HRT are are I want to see my grandkids one one day I'm lucky enough to have have I want to watch these women I've raised grow up and be the women they're meant to be.

And that choice might get taken away from me if I'm not careful. So a lot of what I do and why I do it is because I have to. I may not get the choice.

What an incredibly important mission you're on and what incredible work you're doing, because there are, as we've talked about, there's been a group of people in society that have been, I guess, disillusioned, but they've also must have felt incredibly isolated in their experience and what they were going through. It seems that there's been a real shift in recent times towards the conversation around menopause. Hopefully, these conversations, if anything at all, will dismantle the stigma, which is often the first wall that needs to fall for people to be able to take action and have those conversations. And just speaking from my own experience, I didn't really understand what any of this stuff meant until I started doing this podcast. I had the first couple of guests on, and then someone said the word menopause to me, and then we started having a conversation about it. I go, Oh, my gosh. Maybe when I was in school, someone should have told me about this phase of life. We talk about how to get a job, but it seems to fall fall The education system seems to stop caring caring we've had had almost.

That's what we're experiencing here as well.

It's really crazy. And the work you're doing is so unbelievably necessary. And what I love about the way that you write and how you educate people is it's so science-based, but it's so accessible at the same time.

That's always been my superpower, I think. And I realized that very quickly in my career was that I had this knack of being able to take something really complicated and break it down into terms that people could understand that most people would be able to grasp and walk away from.

And you have nuance and empathy, which is the necessary ingredients when you're talking about subject matter like this, where everyone's symptoms are typically quite different from one one and they will have different circumstances. We talked about other conditions and contraindications that might be complicating things, and you seem to have a really wonderful empathetic view on all of those things. I put an appreciation that everyone's circumstances are entirely different. I'm excited and I'm really looking looking forward to more conversations like this and learning more. Because although I am a 30-year-old man, I have a partner that I love. I have a mother that I love. I have an older sister that I love. My partner is 30 as well. My sister is 36. My mom is 60 now, nearly 60 now.

I challenge you to have this conversation with her and ask her about her experience.

I really applaud all all the, I don't know whether I should say this or not, but I really applaud all the men that got to this far in this conversation and chose to listen and have an appreciation that the betterment of 50% of our population who are going to go through something is the betterment of all of us. Exactly. And that they also have a role that they can play in being a support and encouraging and having the conversations that will bring down the stigma and the suffering of what is currently about 1.2 billion people, but will be 50% of people in our population. I highly recommend everybody goes out and checks out both this book, which is The Galveston Diet, but also can we preorder the.

Upcoming book now? Yes, it's available for preorder wherever you buy books.

You'll think it will be out in 2024 in-.

For sure. The latest May.

The latest May, okay. That's called The New Menopause. You can preorder that now wherever you get your books. That's the culmination of many decades of very, very hard work. I'm very, very excited to read through that myself. The Galveston Galveston book is out now as well. It's been out for a while. We have a closing tradition on this podcast where the last guest... And also your website is an incredible resource for all of the things you talk about, your social channels, et cetera. We have a closing tradition on this podcast where the last guest leaves a question for the next guest not knowing who they're leaving it for. The question here is you get one last conversation with somebody you love, a child, maybe your husband, maybe someone else. What do you say to them in that conversation that maybe they haven't already already.

I love you. There's nothing more than love. I have had done it three times. With my dad too. Bob and Jude were five years apart. My dad was shortly after Jude. Jude. My my parents three kids was a lot. Just love.

Thank you. You're welcome. Thank you so much. Quick one.

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Podcast to listen to next? We've discovered that people who liked this episode also tend to absolutely love another episode we've done, so I've linked that episode in the description below.

I know you'll enjoy it.