The No.1 Menopause Doctor: They’re Lying To You About Menopause! Mary Claire Haver

Mary Claire Haver 0:00 In 2023, 85% of women are complaining of menopausal symptoms, 10.5% are receiving treatment or therapy. I mean, it would be as if your testicles shriveled up and died at 51. That's the equivalent.

Steven Bartlett 0:10 Let's get started.

Mary Claire Haver 0:11 Dr. Marie Claire Haver. Renowned menopause expert.

Steven Bartlett 0:15 With more than two million followers. Helping countless women through their menopause experiences.

Mary Claire Haver 0:20 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 were 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, risks for cardiovascular disease and diabetes increases, recurrent 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, you know, 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. What about your diet? I developed a program for my patients, and it's not rocket science, it's...

Steven Bartlett 1:30 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 mum 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. And for everybody new to this channel, can you do me a favor? If you like what we do here, you like the guests we have on, and you like the show that we bring to you, can

Steven Bartlett 2:56 you hit the subscribe button? It is the single thing and the only thing I'll ever ask of you. I would love you to join us on this journey. And if you do, I will repay you and that is a promise. Do we have a deal? Thank you. Dr. Marie Claire Haver, why do you do what you do?

Mary Claire Haver 3:21 You know, 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 OBGYN. 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 gonna be my calling. And so I did the traditional four-year residency and loved it, and really did well, and went into private practice. Um, 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, you know, doing Pap smears and babies and birth control and all the things a traditional OBGYN 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." You know, we tend to move less, we tend to... 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, you know, in medicine in the US, we have very little background in nutrition. We learn 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, 'cause 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 in 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 in my... 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? And...So I took everything I learned and I developed a little program for my patients, um, 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 muscular skeletal issues, mental health, brain fog, you know, 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 multi-organ system, you know, 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... and my- it's really my kids, who, I have two daughters. One's 23. She's in medical school right now and she's, um, she's actually here with us.

Steven Bartlett 7:01 Yeah.

Mary Claire Haver 7:02 And then, um, the other is 20 and they were like,

Mary Claire Haver 7:05 "Mom, you've- you've got this social media presence. You really need to use it for good." And that's kind of where that conversation exploded for me on social media and where I realized by reading the comments what a much bigger pic- you know, what was really happening in the menopause world and how we need to bring it to the forefront.

Steven Bartlett 7:25 For people that don't understand menopause-

Mary Claire Haver 7:27 Mm-hmm.

Steven Bartlett 7:27 ... um, they might think it's, that it's a s- a small issue affecting a small group of people, but how many women are affected currently by perimenopause, menopause, and post-menopause?

Mary Claire Haver 7:38 Sure. So right now about a third of the female population of the world is in peri, full, or post-menopause. Um, 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 s- of syndrome, where it used to just be thought it was a few hot flashes and some night sweats, maybe your sleep's disrupted, your genital urinary system is gonna take a hit, um, your bones are gonna get weaker, but what we know now is how much it's affecting our mental health, our capabilities, our skin, our bones, our kidneys, you know, vertigo, tinnitus, frozen shoulder. Any time I post about those on social media, the internet explodes and women by the thousands are like, "Oh my God, I had no idea." You know, and just the validation piece-

Steven Bartlett 8:37 Mm-hmm.

Mary Claire Haver 8:37 ... was so huge for them to make, because they've been dismissed for so long and told it's all in their head.

Steven Bartlett 8:43 And if we think about from sort of peri to post-menopause, what is that sort of typical, and I know that's a tricky word to use-

Mary Claire Haver 8:49 Mm-hmm.

Steven Bartlett 8:49 ... but what is the ab- sort of average typical age range? And then also, what is the sort of more, um, possible age range? So it could-

Mary Claire Haver 8:58 Sure.

Steven Bartlett 8:58 ... start between this age and this age.

Mary Claire Haver 8:59 So i- 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 recognizing, recognizes there's some declining estrogen

Mary Claire Haver 9:13 levels and you're beginning to be symptomatic, can start seven to ten years before that. So normal menopause is still 45 to 55.

Steven Bartlett 9:21 Mm-hmm.

Mary Claire Haver 9:22 And so if you do the math and back that up seven to ten years, it is completely reasonable for a 35-year-old woman to begin to experience some of the symptoms of perimenopause.

Steven Bartlett 9:33 So let's start with, what is it? Um, and I would love you to explain this-

Mary Claire Haver 9:37 Yeah.

Steven Bartlett 9:37 ... to me like I'm a 10-year-old.

Mary Claire Haver 9:38 Okay.

Steven Bartlett 9:39 (laughs) Because I'm sure-

Mary Claire Haver 9:39 So-

Steven Bartlett 9:39 ... there's a lot of people that are, both men-

Mary Claire Haver 9:42 So-

Steven Bartlett 9:42 ... and women that aren't fully-

Mary Claire Haver 9:42 So we're gonna talk about gonads, right?

Steven Bartlett 9:44 What's gonads?

Mary Claire Haver 9:45 So gonads are, um, where our... So in men it's the testes.

Steven Bartlett 9:50 Okay.

Mary Claire Haver 9:50 And where you're making your genetic material.

Steven Bartlett 9:53 Okay.

Mary Claire Haver 9:53 So, you know, where you're making sperm, right?

Steven Bartlett 9:56 Mm-hmm.

Mary Claire Haver 9:56 And in a female, it's going to be ovaries.

Steven Bartlett 9:59 Mm-hmm.

Mary Claire Haver 9:59 Her ovaries. So the difference, 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, we're- she's five months pregnant with us, we have our maximum eggs that we're ever gonna 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, you know, 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, um, 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 so... 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, arthralgias, generalized aches and pains, and most physicians aren't aware of this. You know, 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.

Steven Bartlett 11:56 And what's happening at these sort of three stages? So we have the perimenopausal-

Mary Claire Haver 12:00 Mm-hmm.

Steven Bartlett 12:00 ... stage, which is, from what I've understood there, when estrogen levels start to drop.

Mary Claire Haver 12:04 Right. So we start seeing disruptions in the force. So 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, like, you know, hemorrhagic almost. Um, and again, individual, um, the way the body reacts to this is very individualized from patient to patient. Doctors love something that follows a list, a checklist, right? You know, 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, the, 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. You know? 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. You know, there's some, some really good studies showing how testosterone also affects our mental health and our cognition as well.

Steven Bartlett 13:23 Why does this happen? From the s- a sort of like an evolutionary or...

Mary Claire Haver 13:27 So the anthropologists have looked at this heavily, and there's, we're on, there's only a couple of species in the world that go through menopause. Humans are one. There's a specie- couple of species of whales, and I think they've now discovered one of the giraffes, (laughs) species of giraffes can do it. But the, by and large, most mammals will die while they're still ovulating. You know, like they're not gonna go through a menopause. Um, and so there's something called the grandmother hypothesis where there was an evolutionary advantage for a woman 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 healthspan because of modern medicine. So probably when we evolved, we weren't living this long. You know, a woman my age was pretty rare. I'm 55.

Steven Bartlett 14:18 Mm-hmm.

Mary Claire Haver 14:18 And so, you know, it, it's hard to say. I think we have outlived w- how w- we were genetically built. And so we're living longer and being forced to, like, deal with the consequences of that.

Steven Bartlett 14:29 So s- so then the next stage is menopause.

Mary Claire Haver 14:32 Mm-hmm.

Steven Bartlett 14:32 Um...

Mary Claire Haver 14:34 So 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 gonna ovulate again. I'm done." And so if a woman's over the age of 45 and she hasn't had a period for a year, that's the definition. Okay? 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 where we start doing blood work

Mary Claire Haver 15:00 to see, you know, where she is in her menopause journey. And then post-menopause is the rest of your life. You know, the hot flashes might go away, night sweats might go away, brain fog might get better, but pretty much everything else is gonna continue to progress in a very linear fashion until you die, without estrogen replacement.

Steven Bartlett 15:20 To put it lightly, you seem somewhat dissatisfied with the current set of answers that, um, the medical field, but just society at, at large are-

Mary Claire Haver 15:29 Mm-hmm.

Steven Bartlett 15:29 ... offering for women in this sort of peri and post and menopausal phase of their life. And 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.

Mary Claire Haver 15:46 Mm-hmm.

Steven Bartlett 15:46 Um, I was sat here a, two days ago with, um, a very, very successful woman who, you know, has all the resources in the world. And she basically c- and, and 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 s- you, you had that same energy. Like, you feel like women have been, dare I say, let down by a system.

Mary Claire Haver 16:16 I think the medical system is letting them down. I think society is letting them down. Our, our value and our worth. In medicine, you know, 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 mean, I'm gonna tell you a story, and this is, this is true and it's embarrassing, but I think it needs to be said 'cause I think it really highlights how women are treated in medicine. Um, when I was in training, we had these upper level residents. So we have a hierarchy where you have different years of training. So I was in the early years, maybe my first year, and we had these clinics that we would run, um, to take care of patients. And so we have obstetrics and we have gynecology as, like, 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 in midlife and they had multiple complaints. They didn't feel good, they weren't sleeping, they were gaining some weight, they were, you know, aching. They, you know, 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 WW 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 kind of a handed down and the lore of training. And a WW 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're, they're, they were frustrated because they, 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, um, and it was stopped in 2002. That was the end of my training program was 2002. So I'm, I come from one of the last groups of physicians in the US that were ever trained in hormone replacement therapy, and then it, the rug was pulled out from under us. So the WHI, there were mistakes, there was misinformation in the reporting, and there was, uh, 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, um, if she chooses to take it. But that option has been taken off

Mary Claire Haver 19:03 the table for the vast majority of women. Recently, I just saw the numbers, s- 85% of women will come in wo- complaining of what we know now, this was in 2023, FDA looked at the numbers, 85% of women are complaining of menopausal symptoms, 10.5% are receiving the- treatment or therapy today.

Steven Bartlett 19:24 Is there something in you that feels somewhat... (sighs) Even though you're a doctor, somewhat let down by the medical system, um, or skeptical about the medical system for personal reasons?

Mary Claire Haver 19:35 I... Yeah. I, I'm one of those women, you know? I thought I'd be one of those girlies who would just breeze through menopause because I was thin, and I was, you know, thin but healthy. I still, you know, s- that mentality was alive and well when I trained and through most of my practice. I w- I, I came through a very fat phobic, you know, uh, training, and medicine as a l- as a whole is very, um, biased against wei- people's weight. And 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, you know, women who were gaining weight with menopause, you know, 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,

Mary Claire Haver 20:40 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 your hormones back, and she would feel amazing and be able to, you know, age the way she should.

Steven Bartlett 20:58 When we talk about the potential, um, health implications of women that are going through menopause, it's not just WW.

Mary Claire Haver 21:07 Right. (laughs)

Steven Bartlett 21:08 It's much more, um-

Mary Claire Haver 21:11 That's how she feels though.

Steven Bartlett 21:13 Y- y- and that's how she's-

Mary Claire Haver 21:13 Most of them.

Steven Bartlett 21:13 ...categorized probably by people around her. But the, there's real health consequences-

Mary Claire Haver 21:19 Yeah.

Steven Bartlett 21:19 ...and life altering health consequences.

Mary Claire Haver 21:21 Yeah.

Steven Bartlett 21:21 Lifespan reducing health consequences.

Mary Claire Haver 21:23 Yes.

Steven Bartlett 21:24 What are those?

Mary Claire Haver 21:25 So (sighs) we know that a woman's risk and, and the studies have been done. It's not just aging. Of course aging plays into this, but when you add in menopause is an independent risk factor, her risk for cardiovascular disease increases, her risk of diabetes increases, her insulin resistance starts going haywire immediately. Your, your listeners and your, you know, people who watch on YouTube will be shocked, I'm gonna say, how many of their cholesterol levels shot up in their 30s and 40s with no changes in diet and exercise. You know, we see cholesterol levels changing, skin, hair, teeth, the dental changes, the inner ear changes. The vertigo is incredible. The frozen shoulder is legion. Um-

Steven Bartlett 22:11 What's fr- frozen shoulder?

Mary Claire Haver 22:12 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 adhesed and stuck, and so you have to get in there and break it up and do lots of training. So like a woman wouldn't be able to reach behind her back to do her bra. She, 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, one of the studies that I, you know, present and a lot of the stuff I do on social, I'll present the studies because I like to, I like to have data. And, you know, 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-

Steven Bartlett 23:12 Mm-hmm.

Mary Claire Haver 23:12 ... (laughs) but at least they know this is something that it's not your fault. You didn't do anything, your just, estrogen levels dropped, which led to d- increasing inflammation in those joints.

Steven Bartlett 23:22 And is, have they seen that there's a re- a reduction in lifespan in women that go through menopause that aren't treated in the same way?

Mary Claire Haver 23:29 So we know that, um, women on HRT have a lower all cause mortality.

Steven Bartlett 23:35 What's HRT?

Mary Claire Haver 23:36 Hormone replacement therapy or menopause hormone therapy. So in the studies that have been done, the observational studies and in the WHI, women who were on hormones, um, especially beginning early in their menopause, okay, so estrogen, there is a window of opportunity for reduction of some of this burden of disease and it is very, and 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, my medical school daughter was like, "Mom, I'm never gonna be without estrogen. I'm gonna start in perimenopause. Like, I am not gonna be one of those women who is ever off estrogen." Of course, she's my daughter and listens to me (laughs) on social media all day-

Steven Bartlett 24:31 (laughs)

Mary Claire Haver 24:31 ... so she's a little biased. But she says, "Why, why can't we get to that point where we have no gaps in our estrogen supply? We just support a- starting in perimenopause, you know, offer it to all women?" Not all women will choose it, and I support that. But, you know, we're not having the conversation, and they're not being given the choice.

Steven Bartlett 24:48 So what age, with your daughter, would you advise her to start, uh, hormone replacement therapy, if she so chooses?

Mary Claire Haver 24:55 So I would say, um, we start checking levels and we start looking probably in late 30s. Certainly if she starts having any symptoms out of the normal. You know, she's living her best life, you know, 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, you know, 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, something in me had changed, and I wasn't responding to things the same way." You know, their mental health had changed or, you know, the way... their gut had changed, their gut health. You know, just, just, there's barely an organ system that's not affected by this.

Steven Bartlett 25:36 I sometimes wonder, 'cause, uh, you know, 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-

Mary Claire Haver 25:49 Mm-hmm.

Steven Bartlett 25:49 ... what's going on with that person. So they'll, they might do the old WW thing, that's a w- you know, or they might label them something else. They might misdiagnose it as another mental health predicament. I remember a woman in my life who went... 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."

Mary Claire Haver 26:13 Right. I mean, it, it, it's probably contributing to divorce rates, maybe in a good way. You know, at this time, I, I... 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... You know, as a society, we tend to take on everyone's burden, and, um, you know, 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 know, "You need to pick up," d- whichever relationship they're in, "You need to pick up your, your end of the bargain here."

Mary Claire Haver 27:00 You know, "I can't do all of the organizational labor, the emotional labor." And I've, I have a patient who's a divorce attorney, and she said, "I really think a significant percentage is... 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." And...

Steven Bartlett 27:21 How can we give them the support that they need?

Mary Claire Haver 27:23 So 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. Like, 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, non-hormones, cognitive behavioral therapy. You know, 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, right? 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, you know, focused on being thin and small. It's time to be strong. You know, this muscle mass that you have is going to determine your longevity and your functionality as you age. And menopause is, you know, that loss of estrogen and testosterone is tearing our muscle units apart, which is leading to osteoporosis as well.

Steven Bartlett 28:37 I wanna go through that whole to- toolkit.

Mary Claire Haver 28:39 Mm-hmm.

Steven Bartlett 28:39 Um, but I also wanna just, before we move there, understand why women don't sometimes communicate that they're going through perimenopause or menopause. What is the... Is there a stigma associated with talking about it?

Mary Claire Haver 28:53 I, yeah, I think there's shame and stigma associated with aging, with females aging. And then, you're, 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, like, I think it's 55 billion in the National Institutes of Health in the US, you know, 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, you know, and fertility issues. Menopause gets, I think, 15 million.

Steven Bartlett 29:31 Jesus Christ.

Mary Claire Haver 29:32 Yeah. It's like 0.03%, if I did the math correctly, of all f- you know, are we not as important as we were when we were fertile? Does... Do our lives not matter? It's ridiculous to me.

Steven Bartlett 29:48 And how-

Mary Claire Haver 29:48 When we can intervene and help, and ha- give these women a longer life and a better quality of life.

Steven Bartlett 29:54 And how many women is that? I know we said, uh, it as a fraction earlier on, or a percentage, but that's like... I think in your book, I read it's 1.2 billion women by the end of this year.

Mary Claire Haver 30:03 Yeah.

Steven Bartlett 30:04 And there's, what, 47 million new entrants into the sort of perimenopausal/post-menopausal-

Mary Claire Haver 30:11 Right.

Steven Bartlett 30:11 ... category every year? 1.2 billion.

Mary Claire Haver 30:14 Billion, right. And h- and so many of them...... have no education at their fingertips, have nowhere to turn, are- you know, 85% are going into their healthcare provider's office complaining, "Help me," and being turned away, um, leaving with more questions than 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 gonna get cancer. And that- that study's been completely dismantled and walked back. We have good information that came out of that study, but, you know, the- the pr- the- the thought that estrogen causes breast cancer is the worst thing that came out of that study, because it's not true.

Steven Bartlett 30:57 The mental health implications as well, I really wanna get into the- the-

Mary Claire Haver 30:59 Mm-hmm.

Steven Bartlett 31:00 ... hormone replacement therapy and all that stuff. But the mental health, um, implications for women, do we see an increase in depression and those- and the consequences of depression, I guess?

Mary Claire Haver 31:09 Depression, anxiety, bipolar, um, the entire spectrum, ADHD. So we see either a new onset or worsening of disease. So 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 an- a very 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

Mary Claire Haver 31:54 of new onset depression in their menopause.

Steven Bartlett 31:56 Suicidality?

Mary Claire Haver 31:59 So I've looked at these numbers and, uh, COVID's kind of skewing things 'cause we did see increased suicide rates. But we definitely see an uptick, uh, especially in Caucasian women, not so much in women of color, uh, in the US, in the perimenopause and menopause timeframe.

Steven Bartlett 32:15 Inflammation.

Mary Claire Haver 32:16 Mm-hmm.

Steven Bartlett 32:16 What is- what is inflammation?

Mary Claire Haver 32:18 Sure. So inflammation, um, there's- there's- it's- 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, uh, chemical messengers are spread from the injured tissue which basically tells our immune system, "Send blood that way, send the- the, you know, white cells and the red cells and, you know, all the cells that are gonna fight and heal this. You're gonna swell, you're gonna have pain that's gonna keep you off of that joint so that it can heal," right? So acute inflammation also happens when we get viruses and other illnesses. Chronic inflammation is this low grade, kind of under the radar inflammation that's happening in the background. So autoimmune disease is a lot of chronic inflammation. But we also see aging itself, you know? We can't change the fact we're aging, but menopause dramatically (laughs) increases the amount of chronic inflammation that a female will go through just based on the lack of estrogen and testosterone in her body.

Steven Bartlett 33:25 I'm trying to figure out why the lack of estrogen, um, and the drop in estrogen causes inflammation.

Mary Claire Haver 33:31 So it turns out estrogen is a really powerful anti-inflammatory hormone-

Steven Bartlett 33:34 Oh.

Mary Claire Haver 33:34 ... so we're just, like, removing that protective blanket. And now you're- you're just aging faster because of it.

Steven Bartlett 33:41 Ah, okay. So we need to make sure that we reduce inflammation by any means necessary. And that was the- sort of the- one of- it was the second component of the Galveston Diet-

Mary Claire Haver 33:50 Mm-hmm.

Steven Bartlett 33:50 ... 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- or avoid or- or choose in a supermarket?

Mary Claire Haver 33:59 Sure. So I try to teach the principles in the form of let's add things in rather than restrict, because then we get into eating disorders. And so what- 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 gut's 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.

Steven Bartlett 34:51 And does vitamin D reduce inflammation?

Mary Claire Haver 34:53 Yes.

Steven Bartlett 34:53 Okay.

Mary Claire Haver 34:54 So vitamin D is a- it's ac- it's a vitamin but it's also a hormone and it has multiple functions in the body. And so vitamin D deficiencies

Mary Claire Haver 35:01 are linked to lots of chronic diseases. You're more likely to have hypertension, diabetes, stroke, you know, all of the top seven of 10 causes of death in women. And so keeping those low, it's also mental health, you know, lots of vitamin D receptors in the brain. And so, you know, first thing I do is check a vitamin D level on my patients when they come in.

Steven Bartlett 35:21 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, like, six months. You know, people, uh, historically speak a lot about protein and all these kinds of things-

Mary Claire Haver 35:33 Mm-hmm.

Steven Bartlett 35:33 ... but for some reason everyone seems to be talking about fiber all of a sudden.

Mary Claire Haver 35:37 So fiber does lots of things for us. It slows down, uh, the absorption of glucose into the bloodstream.

Steven Bartlett 35:44 Ah.

Mary Claire Haver 35:44 So that keeps our insulin levels lower over time. It feeds our gut microbiome. Soluble fiber, so there's two types of fiber, there's soluble and insoluble. So insoluble is what kind of when you mix up a fiber supplement and you see the stuff precipitate down to the bottom, that's the insoluble fiber. That's what pulls water into the gut and kind of 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. Like, that kind of 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. Um, our- our gut microbes make these things called oxybutyrates which are then absorbed into the bloodstream and- and people who have high levels of oxybutyrates are actually healthier and have less coronary artery disease, less dementia, less- less everything. So it 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. Like, it doesn't matter how many hormones you take if you're not covering your s- your nutritional basis the way you should.

Steven Bartlett 36:57 And what are some sort of fiber-dense, f- fiber-rich foods that are in, you know, every supermarket?

Mary Claire Haver 37:02 Avocado, chia seeds, nuts, berries, your cruciferous vegetables, things that are crunchy, that's fiber. That's making the crunch. Apples,

Mary Claire Haver 37:12 you know. Um, there's so many. Don't find much fiber in, uh, lean meats, uh, or any, so it's gonna be your fruits and veggies-

Steven Bartlett 37:20 What about-

Mary Claire Haver 37:20 ... and seeds and nuts.

Steven Bartlett 37:21 ... asparagus, tomato, spinach-

Mary Claire Haver 37:23 Mm-hmm.

Steven Bartlett 37:23 ... c- celery?

Mary Claire Haver 37:24 Uh, asparagus, celery, yes. Tomato, not so much. Just think of things that, you know, the crunch is f- usually from the fiber.

Steven Bartlett 37:31 Hmm. Okay. Fasting?

Mary Claire Haver 37:33 Mm-hmm. 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 and your eating window if you're not careful. And so, um, the- 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.

Steven Bartlett 38:06 There's so many different types of fasting people talk about.

Mary Claire Haver 38:08 Mm-hmm. So when I'm teaching fasting to my students or to my patients, I recommend the 16:8. So that's where Mark Mattson's data, so that's 16 hours of fasting in a row followed by about an eight-hour eating window. Now, for other, you know, again, it's individualized. Some people do great with a 14-hour fast, you know, a 15-hour fast. 16 is just kind of something to shoot for, and if someone's gonna consider incorporating fasting into their life, give yourself about a six-week trial, you know. 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 exercised, so I pushed that window to 6:15, and I did that for, you know, 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." You know, like, so I had just slowly, slowly let my body adapt and adjust, and then I've been fasting, gosh, since 2015 probably, 2014. And, um, and it's just a normal, natural part of my life. I don't even think about it anymore.

Steven Bartlett 39:28 Have you noticed any effects of that?

Mary Claire Haver 39:30 You know, I do so many things. (laughs)

Steven Bartlett 39:32 Yes, it's hard to tell.

Mary Claire Haver 39:33 And so it's hard to tell, but i- initially, I do find when I'm fasting, the clarity of my thought is much better. I get much more work done. I just, when I do my best research, it's when I do my best communicating with my followers is in the morning. You'll often, if you follow me on social, I'm always in my pajamas with a cup of coffee-

Steven Bartlett 39:49 Mm-hmm.

Mary Claire Haver 39:49 ... um, bef- while I'm getting ready for work 'cause I just get so excited about something I learn and I wanna share it with everyone. And so, I do find that once I break my fast, the synapses tend to not work as quickly for me.

Steven Bartlett 40:00 I was thinking about this through, like, an evolutionary lens, why fasting makes sense and why this sort of narrative that we're meant to have breakfast, lunch, and dinner, you know, maybe breakfast at, at most 7:00.

Mary Claire Haver 40:10 That's a social construct. There's really-

Steven Bartlett 40:12 Yeah.

Mary Claire Haver 40:12 ... not great science. Now, there are humans that will do better by eating more, meals more frequently, and that's why I say fasting's not for everyone, especially if it triggers an eating disorder, if you have diabetes or you have, you know, 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.

Steven Bartlett 40:31 I was wondering if, uh, c- I was trying to think through f- like, an evolutionary f- framework, and I was thinking about how in our hunter-gatherer past-

Mary Claire Haver 40:38 Mm-hmm.

Steven Bartlett 40:39 ... we would have needed-

Mary Claire Haver 40:40 Meals were not available 24/7. (laughs)

Steven Bartlett 40:42 Yeah. And we would've needed, like, a really focused brain to go out on the hunt, so this explains why when we're, like, hungry, our brain's working better-

Mary Claire Haver 40:49 Mm-hmm.

Steven Bartlett 40:49 ... it almost seems like there's more, I don't know, oxygen or nutrients in the brain.

Mary Claire Haver 40:54 The, the brain tends to work better using the ketones for fuel than, uh, glucose, though, though glucose is the preferred fuel in the body, you know. And, um, but, but when they did studies, they were animal studies, so take this with a grain of salt, but, you know, when they did their mazes, you know, the 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. (laughs)

Steven Bartlett 41:17 Ketones, you can also use ketones as an energy source if you use the keto diet.

Mary Claire Haver 41:21 You can. You can. Um, but I think, you know, when Matson and, and that, those researchers were doing their work, their research in Alzheimer's and dementia, you know, there was no keto diet, they were just knowing that people were utilizing ketones for fuel, which is a normal, natural process.

Mary Claire Haver 41:38 We sleep, and so we burn through the glucose in our bloodstream, then we burn up what's in our liver in the, you know, gluconeogenesis, and then it s- switches to fat to burn for fuel. And so, um, now there's people who like to take exogenous ketones. I've, I've never experimented with that. I don't, you know, that's, I don't have any literature in menopause to support that use.

Steven Bartlett 41:58 And the third component of the Galveston Diet is this idea of fuel refocus.

Mary Claire Haver 42:03 Right. So that's looking at, you know, food, uh, we're looking at the macro and micronutrients, so 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. So 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 day, let's see how much fiber you're getting every day.

Steven Bartlett 42:29 And is there a certain sort of ratio of foods that we should be having in terms of, like, fats, proteins-

Mary Claire Haver 42:34 So I originally developed Galveston Diet for weight loss, you know, um, but if I had to write it over again, so I went really heavy on fats, you know, healthy fats, l- lower on carbohydrates and 20% protein.

Steven Bartlett 42:47 Mm-hmm.

Mary Claire Haver 42:47 Um, but I think if, you know, doing it again to where I'm counseling my patients now is I'm going much higher on protein. What I've learned since that book was written was......how important protein intake is to maintaining muscle mass. Um, also talking a lot about creatine, um,

Mary Claire Haver 43:05 and- and there's some nice studies done in- in the, we call it the elderly, 65 year olds and ab and above which I'm nine years from that right now. (laughs)

Steven Bartlett 43:14 Mm-hmm.

Mary Claire Haver 43:14 So, and now creatine supplementation, just creatine supplementation on its own, well, combined with weight lifting, we're seeing bigger gains in the menopausal patient, post-menopausal patient, yeah.

Steven Bartlett 43:25 Bigger gains in muscle mass?

Mary Claire Haver 43:26 Bigger muscle mass and strength.

Steven Bartlett 43:28 Yeah. I was gonna ask you about this whole muscle mass, um, point. Why is muscle mass so sort of pertinent to this conversation?

Mary Claire Haver 43:32 So what we're lo- well, what we know in menopause is that, you know, 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 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 mass.

Steven Bartlett 43:57 Right.

Mary Claire Haver 43:57 Your functionality, your ability to recover from a fall, um, and the other thing is what most people don't understand is the musculoskeletal unit acts as one. So when 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.

Steven Bartlett 44:25 What is an osteopathic fracture?

Mary Claire Haver 44:26 So osteoporosis is when we lose the density of our bones through, so estrogen... So all of our life, we remodel our bones, right? We chew a 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, it dramatically, we see just, whoo, massive loss of bone. So this loss of bone makes the bone weaker and much more likely to fracture when it, when we fall. And so, if 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

Mary Claire Haver 45:23 people. And so, 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 th- our- my population from this happening as we age. We can prevent the majority of this.

Steven Bartlett 45:43 I wanna talk specifically then about this hormone replacement therapy you mentioned there.

Mary Claire Haver 45:46 Mm-hmm.

Steven Bartlett 45:46 There's... You- you also referenced a study previously which sort of scared people.

Mary Claire Haver 45:51 Yes, the Women's Health Initiative. Yeah.

Steven Bartlett 45:54 And that study suggested that there was an increase in breast cancer if someone did hormone replacement therapy.

Mary Claire Haver 46:00 So let's break it down. Um, 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 not. We knew from observational studies that, yes, they had a much lower risk of death from cardiovascular disease and- and all cause mortality as meaning death from any cause, as well as, um, heart disease in itself, okay, atherosclerotic heart disease. So, but that's observational. The way to prove these things is to do a randomized controlled study versus placebo. So finally, finally, this is 1998, women were getting money. Like, 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 in droves to sign up for it. But because the end game was to prove whether or not it was protective for- for cardiovascular disease, the average age of the patient was 63 years old so that they could see if it was gonna affect heart disease because women tend to get that in their 60s and 70s, right? So they recruit. They devile- 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 progestin as well 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?

Steven Bartlett 47:39 Mm-hmm.

Mary Claire Haver 47:39 So we have an estrogen only arm-

Steven Bartlett 47:41 Mm-hmm.

Mary Claire Haver 47:42 ...and an estrogen and 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 4 out of 1,000 women per year to 5 out of 1,000 women per year. So 1 out of 1,000 women treated in the estrogen and progestin arm developed breast cancer where- m- over placebo. That is a 25% relative risk increase.

Steven Bartlett 48:24 Mm-hmm.

Mary Claire Haver 48:25 And that is the, that is the statistic that set the world on fire. So the researchers held a huge press conference at the Watergate Hotel in DC. Every major news outlet with- this was before the internet- and, 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 20% decreased risk of breast cancer.

Steven Bartlett 48:59 Relative.

Mary Claire Haver 49:00 Re- of, yeah, relative risk.

Steven Bartlett 49:02 Yeah.

Mary Claire Haver 49:02 And the relative mortality went down 40%.So, we think it's because estrogen feeds a breast cancer cell, but it doesn't cause breast cancer. We, 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 mu- 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 like, the, the whole mindset has not changed. Myself, as an OB GYN, 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. You know, vaginal estrogen, which is just putting estrogen locally in the vagina, so one of the biggest things we see in a huge amount of patients, like well over 50%, is something we call genital urinary syndrome of menopause. And it 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 u- 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, you know, recurrent UTIs, and it's just such a simple thing to help a woman and fix, and they're not being offered that treatment.

Steven Bartlett 50:55 Is vaginal estrogen the only form of administering estrogen?

Mary Claire Haver 51:00 So, we have... No. So when we look at hormone replacement therapy, we have, um, or any medication, we have like... Steroids is a good way to think of it.

Steven Bartlett 51:08 Yeah.

Mary Claire Haver 51:08 So say you have a rash, and you go to your pharmacy and you pick up a, you know, cortisone cream. That's, that's local therapy, right? So vaginal estrogen cream, there's pills, there's, 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 kind of at the moment. Systemic therapy is when it's treating everything, our brains, our bones, our general urinary sy- you know, from the inside out. And so 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.

Steven Bartlett 51:43 And what's the most popular form of administering, administering, uh, ho- hormone replacement therapy?

Mary Claire Haver 51:48 So it depends on the country.

Steven Bartlett 51:49 Okay.

Mary Claire Haver 51:49 So 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 (laughs) and prescribe it, I think it's the most easiest pharmacologic 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 in the liver. And so the, 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... And for, for testosterone, it's liver toxicity. And for estrogen, we see bumps in our clotting factor.

Mary Claire Haver 52:33 And so you'll 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 gene, 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, or even a pellet, then we bypass the liver and we don't have the increased risk of clotting.

Steven Bartlett 52:53 Are there any other side effects? You know, in life, there's no such thing as a-

Mary Claire Haver 52:55 Of course.

Steven Bartlett 52:56 ... free lunch, so.

Mary Claire Haver 52:57 Yes. (laughs) And so, um, it, 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-

Steven Bartlett 53:09 Mm.

Mary Claire Haver 53:09 ... um, DHEA, and androstenedione, and then we have our progesterone, which is, uh, the bioidentical 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 kind of a red flag for us. We worry. You can see migraines getting worse, so those are patients you have to be really careful with, going low dose. Um, you can see unexplained... So 40% of patients on menopausal hormone therapy will have vaginal bleeding. Doesn't mean it's a period. We have not woken your ovaries up. They're gone. We are just stimulating that tissue, um, 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, um, it's, it's one of the things I warn my patients about. So things I worry about, you know, headaches. Some women, depending on the formulation, so for the patch, it has an adhesive, right, to get it to stick to your skin. And there's a, hm, probably 10% of women will have some kind of an allergic reaction to the adhesive, so then we have to look for alternative forms.

Mary Claire Haver 54:16 So thankfully, there are multiple forms on the market. And for patients, we have to do some trial and error to find out not only which formulation is gonna work best for her, but also what dosing is gonna work best for her.

Steven Bartlett 54:28 So if I was a menopausal woman and I came to you and I said, "I need help," you get, I mean, you must get thousands of messages like this.

Mary Claire Haver 54:34 Thousands.

Steven Bartlett 54:34 Thousands of messages a week probably. And, you know, I walked into your practice. Where would you start with me?

Mary Claire Haver 54:41 So I start by letting you tell your story.

Steven Bartlett 54:45 I tell my story, and it's a typical story that you hear.

Mary Claire Haver 54:47 Right. Yeah.

Steven Bartlett 54:48 What happens next?

Mary Claire Haver 54:49 Symptoms. So I will, we'll get blood work. Sometimes I'm getting hormones to see if, if I'm not clear where she is in her journey, I may get blood work to help me define if she's peri or post-menopausal, especially if she's had a hysterectomy. Um, I'll get a lot of blood work around checking her thyroid. A lot of things look like menopause, right? So, you know, fatigue and night sweats, that might be hypothyroidism. Weight gain, hypothyroidism. Autoimmune disease, all this, uh, rheumatoid arthritis. I wanna make sure I'm not missing something else that looks a lot like perimenopause.

Mary Claire Haver 55:21 So I'm doing blood work around that. Nutrition deficiencies, vitamin D, um, her basic labs for her blood count and her electrolytes. I'm, 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. Um-

Steven Bartlett 55:41 So I'm struggling. I've got my... Desire's gone.

Mary Claire Haver 55:43 Okay. So it's very common. So when we talk about female sexual function, there's kind of five buckets why a woman would be suffering or not happy, okay? One is a relationship disorder and no amount of medication really helps with that. So we wanna make sure she's in a good place with her relationships, supportive partner, all that. So we, 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 is really, nothing's wrong here, they're struggling to maintain an erection. And so we use Viagra and those type of medications for that. For, so if a woman has an arousal disorder, vaginal Viagra can be helpful for that. So we, we talk about that. We talk about orgasmic disorders. Some women have ne- 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 there would be, you know, we would divert military funding in the US to get this fixed and it's just something (laughs) we don't talk about or offer much help. And so then that leaves desire. So most women who are in secure relationships love their partner, miss that part of the intimacy that they used to have, that desire to initiate, that desire, "Yes, this seems like a good idea," that 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 well, Addyi and Vyleesi. And so we have talked about costs and, you know, how to get it prescribed and, you know, with testosterone, there's no FDA approved option for women. So quite often I will have to compound that medication for

Mary Claire Haver 57:12 them at a local compounding pharmacy versus going to, uh, Duane Reade or a CVS or Walgreens-

Steven Bartlett 57:18 Oh, okay.

Mary Claire Haver 57:18 ...to pick it up using their insurance. So I know the U- that you're coming from the UK, our health systems, you know, are a little bit different.

Steven Bartlett 57:25 Yeah.

Mary Claire Haver 57:25 But because my reach is so large now, I try to include-

Steven Bartlett 57:28 That's good.

Mary Claire Haver 57:28 ...you know, all the different health systems when I'm talking about your options.

Steven Bartlett 57:32 Give me a case study of a patient that walked into your door-

Mary Claire Haver 57:34 Oof.

Steven Bartlett 57:35 ...and...

Mary Claire Haver 57:36 Gosh. You know, I ha- okay, I had a, a patient who came in and, uh, her name is Michael and she d- won't mind me saying it 'cause we're really good friends and she came in and typical, overweight, not sleeping, some brain fog issues, some a- joi- joints aching, aches and pains, all the things. And, um, sweetest woman. Absolutely adored her husband, you know, like, um, but was struggling with desire as well. So we started her, you know, I developed a nutrition plan for her, she hired a personal trainer, she got to the gym, she got serious about, you know, mu- lifting. Um, she started on hormone therapy and she is my biggest cheerleader, you know, on social because she's constantly... She's lost probably about 60 pounds of body fat 'cause we get to measure her. So in my clinic I have a InBody scanner where I can measure muscle mass and visceral fat. So it's not just the number on the scale, I'm able to tell them. So she's probably g- gained maybe 10 pounds of muscle, lost a tremendous amount of fat. She feels amazing. She has this beautiful, you know, 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 studies, her, 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 or 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 an honor and I'm so grateful that they trust me. But it's ridiculous that they can't find menopause care in their backyard, you know, 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,

Mary Claire Haver 59:45 uh, a list of providers on my website that my followers recommend where they found good menopause care. They write a testimonial and we just compile them and we just look online and make sure it's a real doctor and they have a phone number that works. You know? Um, and then the, the North American Menopause Society, now called NAMS, um, i- now called The Menopause Society, they rebranded, has a list of certified providers on their website as well.

Steven Bartlett 1:00:06 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 and 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 really at what point to help? Because, you know, no p- male partner wants to turn around to their wife and go, "I think you've got menopause-"

Mary Claire Haver 1:00:37 Yeah. (laughs)

Steven Bartlett 1:00:37 ...and starts diagnosing them. But they also don't wanna just sit back and be quiet.

Mary Claire Haver 1:00:42 I think you, it's, 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 s- start taking this shame and this stigma out, him suggesting that perhaps this is menopause will not cause her to (laughs) fly off the handle. I think, you know, normalizing this conversation, removing the stigma, it might make everyone go, "Oh, I mean, I didn't realize it in myself." You know, "I thought it was grief related and, and I was like, 'Wait, when was my last peri- when was my last period?'"Oh, I think I'm in menopa- I mean, I was- and then I was like, "Oh God, menopau-" you know, even for myself, it was such a negative connotation. I had that Sex in the City episode in my head when Samantha thought she was in menopause 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..." You know, 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. And so 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 I- one of my be- my best visits with my patients are when their partners come and that the conversation is held together and it really opens their minds, you know, to what's going on in her body and helps understand, like what we can do therapeutically, what needs to be done at home. This is a special time for her. She's gonna need extra help. We're gonna get through this. You know, it doesn't

Mary Claire Haver 1:02:38 have to destroy your sexual life or your relationship or whatever. It definitely can take a toll if left untreated. But you know, bless him for doing it. Like we talked about a little bit earlier, you know, 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.

Steven Bartlett 1:02:58 This might be a really stupid question, um, but I'm no-

Mary Claire Haver 1:03:02 (laughs)

Steven Bartlett 1:03:03 ... I'm no, uh, I ask a lot of stupid questions. Do men go through anything like this?

Mary Claire Haver 1:03:09 So there's a lot of debate about menopause. Um, 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 kind of downtick until they stabilize at about age 35 to 40, and then they stay stable for the rest of their lives. But there's a difference between in- there's a big variation from man to man where the cur- 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, you know, 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. This is not, you know, I just read a lot of this research, you know, on testosterone and men are included in it, and so they are finding that they are having better cognition, feeling better, having more energy, et cetera. But there is no menopause. Their testicles don't stop working. I mean, it would be as if your testicles shriveled up and died at 51. That's the equivalent.

Steven Bartlett 1:04:23 Gosh. I do have to say at 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 kind of been overlooked over the last 10, 20, 30 years.

Mary Claire Haver 1:04:45 Mm-hmm.

Steven Bartlett 1:04:46 Um, but if it was-

Mary Claire Haver 1:04:48 And-

Steven Bartlett 1:04:48 ... men or both genders, I think it would be a different response.

Mary Claire Haver 1:04:50 And so much of what women were going through in menopause were dismissed as psychological.

Steven Bartlett 1:04:57 Hmm.

Mary Claire Haver 1:04:59 And really a m- multiple times in their life. You know, "It's all in her head." We never said, "It's all in his head." That's not a thing on the wards. You know, "It's all in her head" was very much alive and well in my training and along a lot of my practice. I c- 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, women- a woman right now in 2023 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, to approach a woman's medical issues, and also the fear, u- unfounded fear around the Women's Health Initiative and what it did to, you know, physicians feeling confident about prescribing hormone therapy.

Steven Bartlett 1:05:47 Is there anything else that you do on a day-to-day basis in your life that, um, we haven't talked about yet? Is there any sort of apps or-

Mary Claire Haver 1:05:56 Yeah.

Steven Bartlett 1:05:56 ... tools, or-

Mary Claire Haver 1:05:57 So I really like Headspace. I know there's some good meditation apps. I really thought meditation was woo-woo and not anything that, you know, I, I would just sit there and, 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 the de- you know, all of this happening at once, uh, to me with my brother's death, aging parents, teenage girls in the house, you know, and realized something's gotta give, and so I hired like a counselor, you know, I went to therapy. And she recommended, um, getting an app to help guide me through meditation, and that has really turned the needle for me.

Steven Bartlett 1:06:40 Really?

Mary Claire Haver 1:06:41 Yeah.

Steven Bartlett 1:06:41 How?

Mary Claire Haver 1:06:42 I, you know, carving out that it's just five or 10 minutes in the morning to think of what I'm grateful for, focus on that gratitude, you know? And I love teaching that to patients and to my followers of, of really putting yourself first.

Mary Claire Haver 1:06:58 You know, the thought of you have to put your own oxygen mask on first-

Steven Bartlett 1:07:00 Mm-hmm.

Mary Claire Haver 1:07:00 ... before you can go take care of your family and of 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, you know, and just focus on, on me for that. That's really made a huge difference for me.

Steven Bartlett 1:07:18 What role does sleep play in all of this?

Mary Claire Haver 1:07:20 So sleep disruption is massive, massive, massive in perimenopause and menopause, and when we don't sleep, we see everything. I, I tell patients if you're not... that's the thing we need to work on first. We need to get you sleeping because nothing's gonna work until your body is able to restore itself. That's when we, that's when we build muscle. That's when, you know, our, our brain resets. That's when our, our whole body, you know, and if you're having disrupted sleep......and you're waking up at 3:00 in the morning and your brain is racing, I mean, everything is worse. Your cortisol levels spike, your insulin resistance goes up, your, you know, everything gets worse. And so when my patients come in, we focus on sleep first and nutrition pretty much. And if the-

Steven Bartlett 1:08:07 Easier said than done though, right, with sleep?

Mary Claire Haver 1:08:09 Yes, if the est- if their sleep disruption is due to hormones, then it's such an easy fix. I just give them back, (laughs) the, 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 gonna send them to a sleep medicine specialist. One of the things that we now see a correlation is a sleep apnea, even in a thin patient and menopause

Mary Claire Haver 1:08:33 in women. We're seeing a big bump in the sleep apnea rates in women who are, um, they don't even have to have a weight problem.

Steven Bartlett 1:08:41 And what is sleep apnea? That's when people-

Mary Claire Haver 1:08:42 So sleep apnea is when you stop breathing, um, a- or you snore quite a bit as you see the palate relaxes, and you're not getting as much oxygen, you know, into the body and into the brain. It's a big health risk.

Steven Bartlett 1:08:53 And what is your personal sort of exercise regime? What are you doing?

Mary Claire Haver 1:08:56 So, you know, I came from the long, (laughs) the 20 years of just trying, I was exercising to be smaller.

Steven Bartlett 1:09:02 Mm-hmm.

Mary Claire Haver 1:09:03 And now I'm, 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. Um, and I do a lot of Zoom calls there, I do lots of meetings there. So when I'm working from home and, and working on the Galveston Diet or the new book, I'm doing it 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. Um, I'm doing a lot more lifting than I ever, ever, ever did in my life because I have a body scanner in my office. 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, you know, I was thin, I was healthy, probably I've lo- you know, I lost that, that window of opportunity to gain more muscle easily in my 20s and 30s. So what I, what I would tell my 35-year-old self, what I preach to my daughters is, "Focus on being strong,

Mary Claire Haver 1:09:58 not small." You know, muscles, 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. Um, don't worry about the curves that you have, that's, that's natural, that's, that's the way you're built. Let's get some muscle.

Steven Bartlett 1:10:18 And what about your diet?

Mary Claire Haver 1:10:21 So what, my personal?

Steven Bartlett 1:10:22 Yeah, yeah, yeah.

Mary Claire Haver 1:10:23 Um-

Steven Bartlett 1:10:23 Eating, eating window. I think we talked about that.

Mary Claire Haver 1:10:24 Yeah, so I tend to, um, I break my fast at around noon-ish typically. If I'm hungry before, if I'm traveling or, you know, on a plane, I, I don't do well on a plane without food. And so, but on a normal day when I'm, like, going to clinic, um, the night before is when my diet starts. I will pack up my meals and snacks that I'm gonna take to the office with me when I see patients. And so I know what I've got. I'm doing, uh, you know, I'm loading up on protein. I'm doing something green, some kind of a green veggie. I'm doing lots of fruit. I've got nuts and seeds. I eat nuts and seeds all day long, um, for the anti-inflammatory benefits and for the healthy fats and for the fiber. And so I've got all that. So I 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. Um, 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, um, to help with that. And then in the evening, now we're empty nesting, so it's just my husband and I. And so he, you know, we'll kind of discuss what do we have in the freezer. We'll pull out some salmon or, you know, we'll, we'll make some, um, I don't know, uh, burgers or something. And, um, you know, we try to be protein centric, and then we're adding in, like, a beautiful salad with lots of avocado and chickpeas, um, on the side. So I think I covered it all. Yeah. So I'm typically done eating by 8:00 PM.

Steven Bartlett 1:11:52 Mm-hmm.

Mary Claire Haver 1:11:53 Um, if it's an office day, I'll either exercise when I get back. I'm struggling to get up. I do a lot of great work in the morning, so it's hard for me to get to the gym and the office. So I'll save my workout for when I get home from work.

Steven Bartlett 1:12:05 If, if you had a, a megaphone and you could speak to every woman right now, the 1.2 billion that we talked about earlier that are in that perimenopausal or the menopausal phase or post-menopausal, and you had to communicate one message to them... And I'm actually gonna 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 a som- somewhat similar message so they can play supporting roles in that individual's struggle. What would you say down that menopause to those women and their, their loved ones?

Mary Claire Haver 1:12:36 So 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 s- system is, is built to fail the menopausal woman. And there is good help out there. You're gonna have to do the legwork. I've got tons of resources on my website to help you. You know, lists of articles to print out and hand to your doctor. System, you know, um, uh, symptomatic sheets that you can, like, keep track, journals that you can hand to your physician. Um, a- any way that I can help you advocate for yourself 'cause I can't be everyone's doctor, but that this is real. You're not crazy. This is happening. And there

Mary Claire Haver 1:13:17 are lots of things that we can do, even non-hormonal. Don't feel like if you're not a candidate for hormone therapy that you're stuck. You know, exercise, nutrition, other pharmacology, stress reduction, sleep. It's time to take care of yourself first so that you can have the best end of your life that you deserve.

Steven Bartlett 1:13:36 In 2023, I launched my very own private equity fund called Flight Fund, and since then, we've invested in some of the most promising companies in the world. My objective is to make this the best performing fund in Europe with a focus on high-grath companies that I believe will be the next European unicorns. The current investors in the fund, who have joined me on this journey, are some of Europe's most successful and innovative entrepreneurs, and I'm excited to announce that today, as a founder of a company, you can pitch your company to us. Or if you are an investor, you can also now apply to invest with us. Head to flightfund.com to gain an understanding of the fund's mission, the remarkable companies we proudly support, and to get in touch with me and my team. Legal disclaimer, Flight Fund is regulated by the FCA, so please remember that investing in the fund is for sophisticated investors only. Don't invest unless you're prepared to lose all of the money you invest. This is a high-risk investment, and you are unlikely to be protected if something goes wrong. There is no guarantee that the investment objectives will be achieved, and as with all private 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 Huel. I'm an investor in the company and they sponsor this podcast. And what I've done for you, I've put together what I call the Huel Stephen Bundle, which is a selection of my favorite products from Huel, including the black edition salted caramel flavor, which is super high in protein and has 17 servings per container, my favorite Huel bottle here, which comes with my bundle, and also the brand new and very exciting Huel complete nutrition bars. This is ch- chocolate caramel. You can see from the empty box in front of me that I've eaten most of them, right? Me and my team here, if you leave these on the counter for five seconds, they'll go. I'm gonna say something I've never said. When Huel first made their bar many, many years ago, I tried it and I didn't like it,

Steven Bartlett 1:15:30 so I've never talked about it on this podcast. They've spent roughly the last two to three years making a brand new bar, which I absolutely love and that's why I now talk about it, because it's a product that I eat. If you wanna order them yourself and get started on your Huel journey, the link is in the description below. In this podcast episode, wherever you're listening to it, there'll be a Stephen's bundle link and check it out. Back to the episode. Your family have a history of health co- complications and illnesses, right?

Mary Claire Haver 1:15:55 Mm-hmm. Yeah.

Steven Bartlett 1:15:55 What is that history, but also has that played into your overarching perspective about nutrition-

Mary Claire Haver 1:16:01 Yeah.

Steven Bartlett 1:16:01 ... the healthcare system, how it treats people?

Mary Claire Haver 1:16:03 (inhales deeply) So my- I'm one of eight children. I have six brothers and, um, my oldest brother, Jep, 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% and... but at the time, he was put into remission, and then he came out of remission in his late teens and died like a year and a half later. So my childhood was... but that year and a half was all about trying to save him. And 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, you know, find another chemotherapy regimen, which he failed, and that kind of- kind of drove me, but, you know, it was- it was leukemia, it was childhood, it was one of those things. Fast forward to 20... he died in 2015, so 2010, my brother, I knew, had HIV and, um, had also contracted hepatitis, and he was doing great on his HIV meds. Um, his counts were good, he was healthy, functional, he'd been with the same partner for over 30 years, but then his- his liver was getting worse and worse and worse. He also struggled with alcoholism, and so that kind of combination was really hard to watch and love him through his choices, you know? And, uh, he ultimately died in 2015. He had a stroke, and then I was able to go do his end of life care, and the first book I wrote, um, 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 menopausal, was through my grief process. I thought I was grieving. I gaslit myself. Like, "No, no, you're not sleeping. You're- you're waking up all night. You're, you know, upset and your mental health and your brain fog is all because you're just grieving his death." And then, um, my next brother, Jude, uh, was diagnosed with stage four esophageal cancer. Um, shortly, uh... he was diagnosed when Bob died, and then he survived a few years, um, so Bob died at 56 and Jude died at 57 and I'm 55. And I don't... you know, I know a lot of it was lifestyle, but I still have those genetics and I'm about to survive three of my six brothers, and, um, outs- 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, you know, and my choice for HRT, are all... I wanna see my grandkids one day, if- if I'm lucky enough to have any. I wanna watch

Mary Claire Haver 1:18:43 these women I've raised grow up and, you know, be the women they're meant to be, and that choice might get taken away from me if I'm not careful. So, you know, a lot of what I do and why I do it is because I have to. I may not get the choice.

Steven Bartlett 1:19:02 What an incredibly important mission you're on and what incredible work you're doing, um... Because there are, as we've talked about, there's been a- a group of people in society that haven't... have kind of been, I guess, disillusioned, but they also must have felt incredibly isolated in their experience and what they were going through.

Mary Claire Haver 1:19:19 Mm-hmm.

Steven Bartlett 1:19:20 And it seems that there's been a real shift in recent times towards the conversation around menopause, and hopefully these conversations, if anything at all, will dismantle the stigma, which is-

Mary Claire Haver 1:19:29 Yes.

Steven Bartlett 1:19:29 ... often the first sort of wall that needs to fall for people to be able to take action and have those conversations. And I- just speaking from my own experience, I didn't really understand what any of this stuff meant until I started doing this podcast, and 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, and I go, "Oh my gosh." Like, you know, 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 off. You know, the education system seems to stop caring once we've had kids, almost.

Mary Claire Haver 1:20:01 That's what we're experiencing here as well.

Steven Bartlett 1:20:04 It's really, really crazy. And the work you're doing is so unbelievably necessary. And what I love about the way that you, you write and how you educate people is it's so science-based but it's so accessible at the same time.

Mary Claire Haver 1:20:15 That's always been my superpower, I think, is... And I, I realized that very quickly in my