Ask the Expert: Dr. Mary Claire Haver on Why Menopause Care Must Be Personalized

You are a unique person with your own set of symptoms, medical history, and concerns, so it’s important that your care be unique to you as well. To dig deeper into the idea of personalization in menopause care, Alloy’s community manager, Rachel Hughes, talked to Dr. Mary Claire Haver.

Dr. Haver is a board-certified OB-GYN who graduated from Louisiana State University Medical Center and completed her residency at the University of Texas Medical Branch (UTMB). She is also a Certified Culinary Medicine Specialist and a Menopause Society Certified Menopause Practitioner (CMP). Her 2024 book, The New Menopause (a New York Times #1 bestseller!), is a guide to navigating symptoms, mediating health risks associated with your body’s drop in estrogen, navigating doctor visits, and shares the latest research on Menopausal Hormone Therapy. 

To see the whole discussion, please watch the webinar on our YouTube. 

The following interview has been edited for brevity and clarity. As always, this content is for educational purposes only and should not be used as medical advice.

Rachel Hughes: I’d love to get feedback on this career you’ve built helping women navigate menopause, and try to understand your deeper “why.” Was there a personal experience or defining moment that led you to focus on this field?

Dr. Mary Claire Haver: I feel like I’m living proof of happy accidents. If you had told me 10 years ago that I would be where I am today, doing what I’m doing, I would have said you were absolutely nuts. My husband worked overseas and I was a single mom six months a year. I was mothering full time and a full-time academic OB-GYN, and I would have told you I was a great menopause provider, but I can look back now and tell you I was terrible. I knew about hot flashes and how the withdrawal from estrogen takes a hit on your bone density, and maybe about some of the genitourinary symptoms, but outside of that, there was no teaching. I didn’t really understand perimenopause, even when I was going through it myself. And I was terrified of hormone therapy because of the WHI study. For me, it started with weight gain. I was frustrated with what was really cosmetic weight gain. I wasn’t unhealthy, but I was frustrated. So I did a deeper dive into nutrition and lowering inflammation through nutrition, and I learned about how estrogen loss leads to increasing inflammation, and my whole world exploded. This was way bigger than some uncomfortable waistband on my pants. I went to my first menopause conference and heard Dr. Avrum Bluming, Dr. Carol Tavris, and Dr. Sharon Malone speak, and I was crying in the audience because no one had ever put that information in front of me. No one had ever told me that actually hormone therapy is safe for the vast majority of patients. I was reluctantly prescribing hormone therapy with so much fear that I was going to hurt the patients. And it’s just been a revolution in my head. I got one hour of menopause training in medical school and then maybe six hours in my OB-GYN training. And 10 years ago I would have said I’m a great menopause provider. I passed my tests, I blew the top off my boards, I recertify every year, I know what I need to know. The truth was I hadn’t even scratched the surface. And it took me being self-taught, seeking out the right experts, and joining the Menopause Society for me to realize we’re not doing this right. So I started talking about it on social media on a whim, just to see what would happen.

Rachel Hughes: Today's focus is really about personalized approaches to care. When it comes to menopause, there's no one-size-fits-all solution. How do you approach personalizing treatment for each woman? 

Dr. Mary Claire Haver: irst we look at all of the things that Menopausal Hormone Therapy (MHT) is approved for. It’s approved by the FDA for the treatment of severe vasomotor symptoms (hot flashes, night sweats, and palpitations), the prevention and treatment of osteoporosis, and for premature ovarian insufficiency. Then we look at what it might do for you. And then we’ll look at age. We know that women who start hormone therapy close to their menopause (within the first 10 years), or before the age of 60, could have a cardiovascular benefit. And there are other benefits as well. Then, we’ll look at family history, potential risks and benefits, and we’ll have a discussion about starting MHT. 

In my clinic, we start with estradiol. It’s the most studied and we know that there are many benefits. Then we’ll add in a topical or local estrogen if she has genitourinary symptoms. And, if she has low libido, we do a very aggressive sexual function screening, and talk about what might be helpful for that. I also have a body scanner, where we can look at visceral fat and muscle mass. I can then provide meal plans–I have a background in nutrition, so I’m able to do that for them. And we’ll talk about exercising. I try to meet them where they are. We’ll start with walking, and then we can talk about resistance training. I encourage them to download a nutrition tracker, and we’ll look at fiber intake, vitamin D, magnesium, protein. 

When I talk about personalization, we are doing the whole toolkit, and I do extensive screening. Rachel Hughes: I love that, in the truest sense of the word, this is a holistic approach to women’s health. And I also encourage people to speak to a menopause practitioner like we have at Alloy. We have a deep bench of physicians who have gotten that extra training, and who can speak to you about the immediate benefits of MHT as well as the long-term benefits and who can talk you through whatever you have going on.

I’m seeing a lot of questions about fiber and weight gain, especially around the midsection.

Dr. Mary Claire Haver: Let's do a little dive into that. So, everybody knows the term “belly fat.” In medicine, we refer to belly fat as visceral or intra-abdominal fat. Viscera is Latin for organs. So, it’s the fat inside of our abdomen wrapping around our organs–around the liver, stomach, and intestines. And that fat is different from subcutaneous fat. Subcutaneous fat responds to calories. Visceral fat is different. It’s typically driven by inflammation, higher insulin levels, and diabetes. You can be thin and have a tremendous amount of visceral fat, and you have just as much cardiometabolic risk as what you consider to be obese. When you have intra-abdominal fat, regardless of your weight or size, you are at risk for hypertension, diabetes, and stroke. 

So, what do we know? Studies have told us that menopausal women who start MHT early have less visceral fat than women who do not. And, it’s not FDA-approved for the prevention of cardiometabolic disease at this point. My hope is someday it will be. But, nutrition is your friend here. Fiber is so important. Fiber-rich foods reduce your risk of chronic disease. The average woman is getting about 10 grams of fiber in her diet per day, but women should aim to get 25 grams or more (the cognitive benefits seem to max out around 32-35 grams per day). And we should be aiming to get that from food rather than supplements. Fiber-rich foods include beans, legumes, berries, seeds, nuts, and vegetables that crunch.

Next, let’s talk about sugar. We need to watch out for added sugar. Yes, sugar is sugar, however, sugars added in cooking and processing are not your friend. If a food is rich in natural sugar, like an apple, or dates, they don’t raise your blood sugar very much, because they’re also rich in fiber. Fiber slows down the absorption of sugar, so your insulin levels don’t spike. Added sugar is what we should aim to be eating much, much less of.

And then there’s exercise. I’m sick of seeing all these exercise physiologists battling it out about HIIT, or this, or that. I’m not here to get an athlete 1% healthier. That is not my job. My job is to meet women where they are. If she’s on the couch, we have to get her walking. If she’s walking, she should put on a weighted vest. If she’s there, we need to add in some weight training. And on and on. We need to meet people where they are.

Rachel Hughes: 

Thank you. Can you talk a little bit about the differences between the birth control pill and MHT? Dr. Mary Claire Haver:

So, the only thing the birth control pill is FDA-approved for is contraception. But we use it all the time off-label for acne, PCOS, cramps, dysmenorrhea… It does so many things for patients, but it’s all off-label. Going off-label should not be demonized. Basically, the way birth control works is, you stop ovulation. You give your body enough estrogen to tell the hypothalamus, to tell the brain, we have enough. Menopausal Hormone Therapy was developed to stop a hot flash. That’s it.

The dose needed to stop ovulation is three to four times higher than the dose needed to stop hot flashes for most women. So, dose is the biggest difference. The dose in birth control is much higher as far as estrogen goes. The other difference is in formulation. The estrogen in most birth control pills is synthetic. Bioidentical estradiol is what most people use for MHT. Bioidentical means it’s giving patients back what the ovaries made as closely as possible. 

Now, if a perimenopausal patient comes in and she needs contraception as well as treatment of her perimenopause, we may offer her a very low-dose birth control pill, because she needs things outside of just treatment of perimenopause.

Rachel Hughes: Yes. Thank you for saying that. You can still get pregnant in perimenopause. If you are getting a period, and you have not gone one full year without a period, you are considered perimenopausal and therefore able to get pregnant. 

Moving on: What are three lifestyle changes women can make right now to improve their menopause transition?

Dr. Mary Claire Haver: Make sure you're getting enough fiber in your diet. I think that’s critical. And fight to make that fiber from food. Limit your processed foods. I think limiting your alcohol intake as much as possible would really probably go a long way for your cognition, for your sleep, for so many things.

The more we're learning about alcohol, the worse it's getting. And so drinking less, focusing on drinking less, focusing on eating more, eating more protein, eating more fiber, is such a better mindset than restriction, right? 

Nutrition over calories, strong over skinny. You want to start building a body that is going to support you in your old age. And it starts now. Since the Galveston diet started in 2016, we've completely changed our song about weight loss. It's more about health gain and eating more, not less, strength over skinny.

Rachel Hughes: I saw a question about testing. Can you clarify this? Should we get tested in perimenopause?

Dr. Mary Claire Haver: Remember, perimenopause is the zone of chaos. I wish that we had this kick-ass test to be like, yep, you are in stage one of perimenopause. But because it is that zone of chaos, and it is completely unpredictable, blood, urine, and saliva tests are not clinically relevant. So we make a diagnosis of perimenopause by listening to a patient, believing her, and ruling out a whole bunch of other stuff. 

Rachel Hughes: I am seeing questions where people are talking about side effects from estradiol or progesterone. It’s a two-pronged question: First, how do you address them? And second, how can she best communicate with her practitioner?

Dr Mary Claire Haver: On our website, we have the Menopause Empowerment Guide. You go to the link in my bio on TikTok or Instagram and it's there, it's a free PDF to download. We have tons of links like how to talk to your doctor about something difficult, things to look for, questions to ask, lab tests to ask for, so that you can go in as empowered as possible. But when I have a patient who's not doing well on her HRT, maybe her hot flashes went away, but she's having recurrent vaginal bleeding, or another side effect. That’s why we have different formulations. So we can try decreasing her dose or her formulation. If that doesn’t work, there are other medications to try.  Because one size fits all is not how it works.

Rachel Hughes: Right. Menopause care is nuanced. And that’s so important.

Thank you so much for coming today. We loved having you.

Dr. Mary Claire Haver:

Thank you!

For much more of their great conversation, please watch the full webinar on YouTube. To learn about future webinars and events, follow us everywhere @myalloy!