Dr. Mary Claire Haver and Dr. Sarah Berry: 5 essentials for a menopause toolkit

The menopause transition can bring unexpected challenges — the symptoms and effects can significantly impact daily life and long-term health.

Dr. Mary Claire Haver is a board-certified OB-GYN and a menopause specialist. In today’s episode, she and Dr. Sarah Berry shed light on what to expect during perimenopause and menopause.

They describe practical strategies for managing symptoms, critical conversations to have with healthcare providers, and how to advocate for yourself effectively in medical settings.

Dr. Mary Claire Haver has helped thousands of women in perimenopause, menopause, and beyond to actualise their health and wellness goals by creating the online course and national bestseller The Galveston Diet.

Follow Mary Claire on Instagram.

Dr. Sarah Berry is an associate professor in the Department of Nutritional Sciences at King's College London and chief scientist at ZOE. She’s also the lead nutritional scientist on the PREDICT program. Her research focuses on precision nutrition, postprandial metabolism, food, and fat structure.

Follow Sarah on Instagram.

If you want to uncover the right foods for your body, head to zoe.com/podcast, and get 10% off your personalized nutrition program.

You can find the Mary Claire Wellness website here

Find our top 10 tips for healthier living: Download our FREE guide.

Follow ZOE on Instagram.

Is there a nutrition topic you’d like us to explore? Email us at podcast@joinzoe.com, and we’ll do our best to cover it. 

Episode transcripts are available here.


[00:00:00] Jonathan Wolf: I'm your host, Jonathan Wolf, co-founder and CEO of ZOE. Today, we discuss a condition that half the population face, but only a fraction get adequate support for. Today we're talking menopause. 

Your doctor may not know how to identify your symptoms. You may even have thought these are simply symptoms of aging. We're joined by a menopause doctor to demystify this life stage. She'll clear up questions about hot flashes and bust myths on heart health. 

Dr.  Mary Claire is a board-certified gynecologist, menopause specialist, and best-selling author. Dr.  Sarah Berry also joins us with some exciting new discoveries from ZOE's health study about nutrition during menopause. Sarah is an associate professor in nutrition at King's College London who led the ZOE PREDICT study on over a thousand people which uncovers the way women respond to food during menopause.

So whether you're approaching this stage of life, already in it, or want to support the women in your life, this episode is an eye-opening journey into understanding and thriving through menopause. 

Mary Claire, thank you so much for joining me today.

[00:01:11] Dr. Mary Claire Haver: Thanks for having me. 

[00:01:13] Jonathan Wolf: And thank you also, Sarah. 

[00:01:14] Dr. Sarah Berry: Great to be back, Jonathan. 

[00:01:15] Jonathan Wolf: So Mary Claire, we have a tradition here at ZOE, which we haven't told you about before. So we always start with a quick-fire round of questions. And they come from our listeners, and we have some very strict rules. You can say yes or no, or if you absolutely have to, a one-sentence answer.

[00:01:32] Dr. Mary Claire Haver: Okay. 

[00:01:33] Jonathan Wolf: Are you willing to give it a go? 

[00:01:34] Dr. Mary Claire Haver: Let's do it. 

[00:01:34] Jonathan Wolf: All right. Do you think that most women know what to expect from menopause? 

[00:01:39] Dr. Mary Claire Haver: No.

[00:01:40] Jonathan Wolf: You got there before I even asked the question, that's good. Do most women have symptoms? 

[00:01:45] Dr. Mary Claire Haver: Yes. 

[00:01:46] Jonathan Wolf: Do most women know that they have started to go through menopause? 

[00:01:49] Dr. Mary Claire Haver: No. 

[00:01:50] Jonathan Wolf: Can most women expect their doctor to be supportive?

[00:01:53] Dr. Mary Claire Haver: No. 

[00:01:55] Jonathan Wolf: Is it possible to prevent bone loss and osteoporosis after menopause? 

[00:02:00] Dr. Mary Claire Haver: Absolutely. 

[00:02:01] Jonathan Wolf: Sarah, can you improve your menopause symptoms with diet? 

[00:02:05] Dr. Sarah Berry: Partially. 

[00:02:07] Jonathan Wolf: Does your metabolism change during menopause? 

[00:02:10] Dr. Sarah Berry: Absolutely. 

[00:02:11] Jonathan Wolf: And then finally, Mary Claire, and you have a whole sentence, what's the biggest misconception about menopause?

[00:02:17] Dr. Mary Claire Haver: That it's just hot flashes. 

[00:02:19] Jonathan Wolf: We've talked about menopause on a number of episodes, and I believe we're going to continue to talk about it, and we're definitely seeing more about it in the media, although I know that it's different from country to country, but definitely seeing that growth everywhere.

Every time I have this conversation, and Mary Claire and Sarah and I were talking before the show, I'm always amazed by how little it has been studied. So how little science understanding there is, and also how taboo the subject was when I was growing up and how even now I don't feel like those sort of taboos are being completely smashed.

And I often talk Mary Claire about the fact that my mother went through this and I had absolutely no idea. Didn't say a single word. I only found out anything about it when I discussed it with her a couple of years ago when I first started to understand what a big deal it was because this was sort of invisible to me.

[00:03:09] Dr. Sarah Berry: And it's not just because you're male. It was the same for me growing up that I remember occasionally my mum saying, oh, I'm feeling hot and bothered. But yeah, you didn't talk about it. And I had no idea what my mom's symptoms were, what age she went through the menopause. 

And even now, I'm at that perimenopausal age, I'm 47, lots of my friends are going through the menopause. Lots of my friends still talk about it kind of in hushed tones, so even though we are talking about it more, it's still a bit something not to shout from the rooftops about. 

[00:03:46] Dr. Mary Claire Haver: Well, my own mother, it was this dark room she'd go into, you know, I just remember like my father would say leave her alone, it's menopause, you know, it was this like really scary thought process and I learned so little about it in medical school and even in my traditional OBGYN training.

[00:04:03] Jonathan Wolf: Can you just define what OBGYN means for listeners outside of the U. S.? 

[00:04:07] Dr. Mary Claire Haver: Sure, it's someone who has specific training and for, in the United States, it's four years of training in obstetrics and gynecology, otherwise known as women's health. 

When I graduated and started practicing medicine, I hated menopause. Like, hate's a strong word. I just, ugh, you know, there's nothing we can really do for these women. It's just this terrible time in their lives, etc. And really a disservice to half of the population that we are not talking about this and learning as much as we can about it. 

[00:04:42] Dr. Sarah Berry: And I think what really shocked me is something you said earlier when we were chatting before the podcast, that you had only one or two hours training in your whole medical career on menopause.

And this is something that I find also as a nutritional scientist shocking because medical students also only get one or two hours training on nutrition. And the fact that menopause and nutrition in total, they're getting about two to three hours training to a five, six, seven-year medical degree.

That's just really not on. 

[00:05:09] Jonathan Wolf: It is immensely surprising to me, and how does that tie into this thing that you've talked about a lot publicly about us not talking enough about menopause? 

[00:05:17] Dr. Mary Claire Haver: Well, I think when we look at how society views the aging woman, how society views menopause. If you go on AI right now and ask them to create a menopausal woman, it's going to be a very gray haired, frail, very, very elderly appearing woman who does not appear to be in good health.

[00:05:35] Jonathan Wolf: And is that an accurate representation? 

[00:05:38] Dr. Mary Claire Haver: Absolutely not. You know, I am a 55-year-old fully menopausal woman and I am probably as healthy as I've ever been in my life. 

[00:05:44] Jonathan Wolf: Which is a really positive story and definitely something I want to pick up on because I think there is a lot of negativity. Now you also just said right in those quickfire questions that sort of most women are going into menopause blind.

[00:05:56] Dr. Mary Claire Haver: Exactly. 

[00:05:57] Jonathan Wolf: What do you mean by that? 

[00:05:58] Dr. Mary Claire Haver: So because we're not talking about it, we're not sharing the cross-generational stories of how the menopause affected your mother, your aunts, the women in your life. Because there's a big genetic component in how your body's going to express the estrogen withdrawal symptoms.

People are blindsided. If I would have known, if I would have known. So there are very cliche symptoms of menopause that you can't really blame on anything else. And the classic is the hot flash. 

So for years, all of the science centered around vasomotor symptoms, or hot flashes, or hot flushes. So some countries call it hot flushes, in the U.S., we call it hot flashes. Basically this eruption of heat that starts in our core and tends to go up, you know, into our chest and head and neck and then out into the extremities. It's very disrupting. 

Quite often it's preceded by a panic attack. In some patients, you get this level of anxiety, then you get really hot, then you start sweating. This could be in the middle of a boardroom presentation, in the middle of teaching children, you know, at any point of your life. These hot flashes, flushes, can cause significant sleep disruption. 

We know that when you go through the menopause transition, the loss of estrogen accelerates our bone loss. So osteoporosis starts, you know, osteopenia, and osteoporosis start to begin to manifest. 

And then there's genital urinary symptoms, which we have lots of estrogen receptors in our vagina and our bladder. And when we lose estrogen in those areas, we start having dryness. You know, loss of lubrication and recurrent urinary tract infections.

So those are kind of the ones we know. But modern science is teaching us that we have estrogen receptors, estrogen-sensitive tissues all over our body. So another woman's menopause may skip over all of those traditional symptoms easy to, oh that clearly must be menopause.

And of course her cycles, right? Cycle disruption and then they stop, period, stop. 

But there's neurological symptoms, cognitive disorders, mental health changes, GI, you know, gastrointestinal changes, as you guys know, musculoskeletal issues that pop up. 

So a lot of women don't realize that their menopause may be manifested by a frozen shoulder, or tinnitus, or vertigo that came out of nowhere suddenly in this time period clumped around her last menstrual period. 

[00:08:19] Dr. Sarah Berry: But what happens is you don't suddenly go to bed one night, a pre-menopausal woman, and wake up the next day a post-menopausal woman. There's a period of transition which is called the perimenopausal phase.

And during that perimenopausal phase is when the burdensomes, I think, can be particularly challenging for women. And this is because you're having a decline in oestrogen, but not in a nice steady way where, you know, it's slowly declining and your body's adjusting each day to this tiny little decline.

It's this state of hormonal chaos. It's like a rollercoaster. 

[00:08:52] Dr. Mary Claire Haver: That's exactly how I explain it to patients. The zone of chaos. 

[00:08:56] Dr. Sarah Berry: You know, you've got other hormonal changes happening in the background, but the most disruptive is this kind of rollercoaster of oestrogen. And it's like oscillating, so it's going up and down and up and down. 

You know, some days it might be down all day, some days it might fluctuate throughout the day. And so, ss well as each woman's symptom being different, day to day, what you experience is quite different I think as well. And I think 

[00:09:20] Jonathan Wolf: Which must be very confusing. To not have a sort of solid…

[00:09:24] Dr. Mary Claire Haver: You have no idea that this is coming. You just think your periods will stop one day and you might have a few hot flashes. 

You think you have dementia. You think you're on the path to Alzheimer's, especially if you have a family history and here you are, suddenly forgetful, suddenly struggling for words, suddenly having anxiety, suddenly having increasing depression, and no one let you know that this might happen and to be aware so that you weren't so scared and terrified when these symptoms started happening to you.

[00:09:52] Dr. Sarah Berry: And I think because there was this misconception which you said right at the beginning, was one of the biggest misconceptions that menopause is hot flushes. So many women don't have hot flushes but have these other symptoms. 

I'm one of those. I've never had a hot flush. I have terrible brain fog, as Jonathan knows quite often. I also get the palpitations particularly in the morning. And it's really scary when you first get them, and even though I've researched in menopause, it really kind of blindsided me when I started getting them in the morning. And I was scared, what's going on? 

And that's for someone that's educated in this. Waking up with those kind of really scary palpitations or the brain fog, you know, it's I think a frightening time if you don't know what is a normal symptom or a symptom that you might get. 

And going back to the point I made earlier, that everyone's symptoms are variable. This is another challenge, I think, because when you're in that perimenopausal transition, you do talk to all your friends about it, because if you're having symptoms, it's so all-consuming because you feel out of control from so many things that you felt in control of before.

But because your friend's symptoms will differ to your symptoms, it then is an added area of concern. It's like, oh, well, is this normal? Because you're having this, but I'm not. I'm having this. And actually, from our own ZOE predict data, where we've looked at the prevalence of symptoms, we actually see hot flushes ranks about 5, I think, in terms of the prevalence.

And yet, we're always talking about it as being the main symptom.  

[00:11:15] Dr. Mary Claire Haver: So there's a couple of large databases in the U.S. that have been created by the new menopause telemedicine companies. So, they collect data on their patients or people who are interested in becoming a patient. And they said the number one thing is, you know, sleep disruption, anxiety, weight gain. Hot flushes are coming in at about 5th. 

[00:11:34] Dr. Sarah Berry: Yeah, that's interesting. So, we see that over 80% of people report disturbed sleep as their main symptom. We have about nearly 80% anxiety, which is the next one, and then brain fog, and then the weight gain, and then like you say, the hot flushes is a bit further down.

[00:11:48] Dr. Mary Claire Haver: We have about 80% with musculoskeletal issues, and for 20% of them, it's their worst symptom, their most life-disrupting symptom. 

[00:11:56] Jonathan Wolf: And when you say musculoskeletal symptoms…  

[00:11:58] Dr. Mary Claire Haver: Usually joint pain or adhesive capsulitis, which is frozen shoulder the generic name is. So you get the lack of movement. It's really painful. You can't put your hand behind your back, put on your bra and it requires probably usually about a year of therapy physiotherapy And there are definitely things we know now that you can probably do to prevent that occurrence happening. 

[00:12:19] Dr. Sarah Berry: I want to know what that is, but maybe we'll come on to that later. 

[00:12:23] Jonathan Wolf: I think we've talked quite a lot about the symptoms as you're going into perimenopause, and Sarah, you mentioned something about actually, potentially the symptoms could actually be worse in perimenopause than after menopause. What does that look like, and what happens then after time after menopause?

[00:12:41] Dr. Mary Claire Haver: Great question. So, we have the best data on hot flushes. Vasomotor symptoms is the medical term because that's pretty much all that was studied in menopause for 40 years. 

We know that the duration of hot flushes begins in perimenopause. The worst of the symptoms is clustered around the last menstrual period in that year. But on average, they last about seven years. In women of color, at least in African American women, that can go up to ten years of symptomatology. But the majority of women will eventually, the thermoregulatory center will adjust after several years to the lack of estrogen and stop firing.

So, that is where the hot flushes and the hypothalamus are what controls our body temperature. It gets disrupted and those will go away. 

So, that's where kind of this thought process around, well, menopause is temporary, if you just chin up and hang in there, you know, these hot flushes will be, you know, gone. And just focusing on that one cliche symptom, I think is really a problem in the way a lot of studies are done. 

[00:13:47] Jonathan Wolf: Because you're missing all these symptoms during perimenopause.  

[00:13:50] Dr. Mary Claire Haver: Right. Your bones are always deteriorating. Your genital urinary system is always on the decline. You know, your cognition will likely return, but it'll never be what it was before. You'll likely get most of it back. 

[00:14:00] Jonathan Wolf: How long, on average, would a woman expect to have symptoms during this perimenopause period? Just to sort of look at that. Because you sort of got the second half, it sounds like, with previously very little focus on the first half. 

[00:14:10] Dr. Mary Claire Haver: So, let's go way back to embryology. Because I think for your listeners, if they really understand what the menopause is, they'll get a clear grasp. 

So difference, big differences between male and female. Females are born with all of their egg supply that has to last them till their menopausal. Males have the opportunity to make their germ cells, our little cells that create people eventually, you know, every day. So they're constantly of little factories creating new ones. 

We're born with all of them. They start deteriorating even in the utero. So at five months gestation, you have your max amount of eggs. You're born with about one to two million on average. So then you start ovulating. We lose about 11,000 a month through the ovulation process. And by the time you're 30, the average woman is down to 10% of her egg supply that she had at birth. And by the time she's 40, she's down to 3%. 

Menopause represents no more eggs. You're done. You have exhausted that supply and there will be no more estradiol produced in any clinically significant form from the ovaries.

[00:15:16] Jonathan Wolf: And estradiol…

[00:15:18] Dr. Mary Claire Haver: Is the main hormone, the main estrogen hormone that is produced by the ovaries and it's the most biologically active estrogen hormone in our bodies. So it is the one really responsible for keeping our inflammation levels down, supporting our reproductive function, et cetera. In perimenopause, we start to see these very dramatic ups and downs rather than this nice EKG because our levels of egg supply are dropping so low. 

[00:15:45] Jonathan Wolf: Just to make sure I got it, rather than like a nice smooth up and down curve over like roughly four weeks or whatever it is. Suddenly you're saying it's sort of jumping all over the place. 

[00:15:54] Dr. Mary Claire Haver: Our brain produces hormones. The brain is constantly checking for estrogen in the blood supply. There is like a little monitor in there. And when estrogen levels get low, the brain says, hey pituitary, let's create more stimulating hormone so that we can get an egg out this month. And that process goes really well until perimenopause. And then the egg quality and the number gets so low, the brain has to really push and push and push to get those hormone levels up.

And it gets harder and harder each month, which is where the chaos comes from. The symptomatic expression of that usually begins 7 to 10 years before the final menstrual period. 

[00:16:32] Jonathan Wolf: Which is a really long time, isn't it? Because I might have thought listening to that that you're like talking about the last 12 months or something. But like 7 to 10 years, it's a long time. 

[00:16:42] Dr. Mary Claire Haver: A long time. So if you think of average menopause in most countries is around 50, 51, maybe 52. In India, it's 46. Significantly less. But still, the normal curve, 95% of women will have their menopause, at least in the U. S., with the average of 51, between 45 and 55.

That's still considered to be normal. Back that up 7 to 10 years. It is completely reasonable for a 35-year-old woman to begin, her body is showing her something's not right. Things are changing and that could be joint pain, brain fog, weight gain, I forgot, the big, one of the biggest symptoms is she's tired all the time.

And then if they do bring it up with their healthcare provider who's not trained to be able to diagnose perimenopause or recognize this as a potential constellation of symptoms that might be related to hormone changes. Well, just get on with it. You're okay. Maybe some tests to run. Everything looks normal.

And another problem is a one-time blood test or urine or saliva is not clinically diagnostic for perimenopause because of the chaos that's going on.

[00:17:51] Dr. Sarah Berry: . Yeah, they've estimated that there's billions of pounds that are spent unnecessarily, total waste of money on doing hormone tests. Where, you know, perimenopausal women are saying, well I want my hormones tested. And so these are being done unnecessarily because it's fluctuating so much. 

Unless we can be continually sensing over a couple of weeks, waste of time, generally.

[00:18:18] Jonathan Wolf: So the point might be that you get a test, it says that your estrogen is fine, but if you tested it like eight hours later, it might have been really low.  And so just like one test is…  And so you don't use that in your, in your practice? 

[00:18:30] Dr. Mary Claire Haver: No. To diagnose perimenopause, I never do a one-time blood test. It is a diagnosis of exclusion. And I will listen to her symptoms. 

There's a green score, a very validated scoring system done in perimenopause and they don't even use the menstrual period. They use a constant, they use about 9 or 11 symptoms and her severity and it's everything from mental health, general urinary symptoms, etc. And I use that score to be able to tell her, okay, most likely it's this, but because you've gained some weight, let's check your thyroid. 

I'll do lots of blood work, actually, to rule out other conditions that might look like some of the symptoms of perimenopause. I don't want to miss an autoimmune disease or a nutritional deficiency. And so, that's where the focus of in my patients, where I do the blood work, but rarely on hormone testing. 

[00:19:18] Jonathan Wolf: So, I just want to be clear, just so that I've got it, there, because I think a lot of listeners will be really surprised, there is no sort of one-time perimenopause test, whether it's a blood test or a scan or anything that just gives the answer. 

[00:19:31] Dr. Mary Claire Haver: Not yet. 

[00:19:32] Jonathan Wolf: So you need to work with your doctor to understand this. It's like excluding a lot of other things is what gets you to the point that you're saying yes, I feel quite confident about this diagnosis.

[00:19:41] Dr. Sarah Berry: And I think Mary Claire made a really important point there that for the women that are coming to her, she will make sure actually these symptoms aren't an indicator of something more sinister. 

And so something I think we need to be mindful of is, given that we are thankfully now talking about menopause and talking about symptoms a lot more, and certainly in the U.K., it's all over social media.

We do also need to highlight that not all of these symptoms will be necessarily menopausal. And so it is worth also speaking to your healthcare provider. Just to check that there isn't something else underlying. 

[00:20:15] Jonathan Wolf:  We've talked a lot about sort of the symptoms you're experiencing through perimenopause and after menopause.

I'd love to talk a little bit about what this means for sort of long-term changes to health. And Sarah, I know this is something that's really important in your research, but I know that it isn't just about the symptoms that you're going through in this period. It's also about sort of changes in general to your health risk.

Could you tell us a little bit about that? 

[00:20:37] Dr. Sarah Berry: Yeah, and this is something we looked at in our ZOE PREDICT studies. So in our study with 1,100 individuals, we looked at people who were pre-, peri-, or postmenopausal, and we looked at lots of different things, but one thing that we really focused on was their disease risk.

So we looked at what we call intermediary risk measures. We want to look at what are the risk measures that put you at higher risk of the heart attacks, the stroke, et cetera, you know, high blood pressure, high cholesterol, worse insulin sensitivity, high levels of inflammation, visceral adiposity, which is the fat around your tummy.

And we looked at this in our PREDICT cohort and what we found was that peri- and post-menopausal women had significantly worse intermediate risk factors. They had higher blood pressure. They had worse insulin sensitivity. They had higher cholesterol. They had higher inflammation. They had higher visceral adiposity.

[00:21:33] Jonathan Wolf: Which is the weight shifting around your stomach. 

[00:21:36] Dr. Mary Claire Haver: From subcutaneous to intra-abdominal. 

[00:21:38] Jonathan Wolf: Which is like from a healthy place around your hips all the way over to this unhealthy place around where I saw my fat as people have, as I've discovered in previous shows. 

[00:21:47] Dr. Sarah Berry: Oh Jonathan, you don't have any fat there.

But yeah, it's shifting it from the pear, so around your hips, and estrogen actually directs the fat, funnily enough, to your hips. You lose the estrogen and then it goes in a more male-like configuration, which is that apple around your tummy. 

But lots of people say, like Mary Claire said, well, hold on, that just happens when you age. And so what we looked at males as they age in these, risk factors, the blood pressure, the cholesterol, etc. And what you see is as you age, each year, they go up longitudinal. And you get this kind of nice straight, pretty straight line, or as straight as you can get in human biology and science.

When we looked at our females, we found all of the females for most of these risk factors, yeah, are sitting nice and low, so we're doing a lot better than our male counterparts, hit the menopause or perimenopause, and suddenly, well, that line goes off the charts, and often in most of these risk factors, even goes above.

And we've got in our paper that we published on this some really lovely figures actually that from our own real data showing that which is really interesting. 

[00:22:50] Dr. Mary Claire Haver: You know, it's not scientific, but when I posted about how shocked I was. In my patient population, looking at cholesterol levels and 80 % of my patients have hypercholesterolemia in their menopause journey.

[00:23:07] Jonathan Wolf: Meaning? 

[00:23:08] Dr. Mary Claire Haver: Elevated levels of bad cholesterol. Their HDL drops and the low density go up in a negative fashion. I think it had millions of views, comments of that no one told me. You know, they just said I needed to change my diet. Well, I haven't changed it with no changes in diet and exercise. None. 

That menopausal status, estrogen deprivation, or the loss of our estrogen, the senescence of our ovaries, is a direct risk factor to these more likely to be associated with cardiac disease.

[00:23:39] Jonathan Wolf: And Sarah, can you explain for a minute, I know this is, you know, a big area of expertise, what's going on in the way that these women are responding to food because that's really changing, isn't it? And that's what's sort of explaining why these cholesterol levels are going higher and, you know, their responses to the blood sugar is changing. Could you just explain that? 

[00:23:57] Dr. Sarah Berry: Yeah, I mean, there's loads of changes going on,  everywhere from our hunger receptors in our brain, and again, this is something that I think, you know, surprises everyone. They're like, I'm eating exactly the same food, but I feel so hungry all the time.

Estrogen even impacts the hunger receptors, it impacts the release of fullness hormones, impacts how we metabolize.  

[00:24:19] Jonathan Wolf: So it's completely transforming the way that you engage with food and how you feel. 

[00:24:21] Dr. Sarah Berry: Yeah, so first it's impacting your, people are hungrier. Because it's mucking up your hunger and your fullness signals, the release of those hormones.

When you're eating those foods, it's also changing how you're processing those foods. And this was some really interesting findings from the ZOE PREDICT research and quite novel findings. And what we did is we looked at how people were processing the fat that they were eating from the meal and how they were processing the carbohydrates that they were eating.

And we can measure this by measuring in the blood circulating blood glucose, or we also call blood sugar levels, which typically after a meal would rise reaching 15 minutes, return to baseline about two hours. 

We can also measure how we respond and metabolize the fat in the meal by measuring something called triglycerides in the blood. And that's a slower, you know, reaches a peak about four hours, returns to baseline around eight hours. 

And what we found is when we gave our 1,100 participants standardized meals that contained exactly the same amount of fat, exactly the same amount of carbohydrate, the peri- and postmenopausal women had what we would call unfavorable postmeal responses in this circulating fat, in this circulating blood sugar. 

So what was happening was that the post and perimenopausal women had significantly higher increase in circulating blood sugar, which we know if it's excessive, repeated over long periods of time, increases our risk of chronic diseases, type 2 diabetes, cardiovascular disease, obesity.

[00:25:47] Jonathan Wolf: So that means basically you could be eating exactly the same food as you were eating five years before and your body was just fine with it. And now suddenly every time you're doing this each day, it's just this little bit of damage. So it really is true. You are doing the same thing as before and now you sort of can't cope with it in the way that you could before.

[00:26:05] Dr. Mary Claire Haver: The conventional thinking around this is that the patient is not being truthful, that's impossible. When you don't take into consideration the gut microbiome, metabolism changes associated with the menopause transition.

I've seen it in the literature when I was researching for the new menopause, this kind of paternalistic, well, women do tend to somaticize their symptoms. Women do tend to stop moving quite as much and there may be some truth to that and they are hungrier. We know that. 

Just believe the patient. She's telling you, I have not changed my diet and exercise, and all of these cardiometabolic risk factors have worsened for me. What's going on? 

[00:26:48] Jonathan Wolf: And you know what, Mary Claire, I'd love to actually, to take that opportunity to now imagine this woman who is saying, it sounds like possibly quite a long time from start getting the symptoms, like, hang on a minute. There's something real here. 

You said, and again, coming back to these quickfire questions, you shouldn't necessarily expect your doctor to be supportive, which is like it's quite a strong thing to say. I mean, could you maybe start with that? Why is that? And then I’d love to talk through, so how could you help a listener to be able to talk well to their doctor to get the right focus and treatment?

[00:27:25] Dr. Mary Claire Haver: It's really. You know, of course, for some people, it's a personality thing. They just have a checklist and if you don't fit the checklist, you know, but if you're not trained and educated as to this basic biologic process, you don't know how to associate it with what's going on. 

So I think we have a huge problem across the world and how we train and educate our healthcare providers in as far as the far reaching aspects of the menopause and the menopause transition. And so I think that's the first problem.

So, I arm my patients with lots of tools. I arm my followers with lots of tools to try to advocate for themselves. I'm like, there's no guarantee, but I give them research studies to print out and, you know, these are big meta-analyses. These are big, big things, not little, and so that they can… 

The American Heart Association wrote a beautiful study on the menopause transition and the risk of cardiovascular disease. I hand them that. You know, I give them things from the Menopause Society in the U.S. or the British Menopause Society in the U.K., you know, with tools to advocate for themselves. 

Often, they are educating their providers. I teach them the words to say to go in and ask for certain treatment options that might be available to them that the physician may not have realized could help them. 

[00:28:50] Dr. Sarah Berry: I think the next generation of doctors, I hope, are going to be more aware and.. 

[00:28:52] Dr. Mary Claire Haver: I think my daughter's in medical school. I think her generation forward we’re great. But it's going to be our generation to kind of retire the ones who are out who aren't learning, don't have the time or inclination to. care really to pick up this new information. The menopause, the societies are not on board yet with menopause, so it really has to come from above.

We just have so much, this is a big shift to course correct. 

[00:29:18] Jonathan Wolf: I do find it a bit surprising because one of the striking things is how many doctors are women today, right? So that's definitely a shift from when I was a small child. 

[00:29:27] Dr. Mary Claire Haver: You know, we were trained in male medicine, male-centered medicine, that any female experience, whatever it was, was abnormal, and, you know, different than the standard. The male patient was standard, and we have so much work to do around that as well.

[00:29:40] Dr. Sarah Berry:  It's the same in research. Most scientific, nutrition, biological research is undertaken on males, because males are easier to study. You don't have to think of their menstrual cycle, you don't have to think of whether they're pre-, peri- or post-.

And I know I've often told you this, Jonathan, but Mary Claire, before I started working with ZOE, I had conducted about 30 randomized controlled trials looking at the impact of diet on cardiometabolic disease. And I had never recruited females into my trials because it meant it would triple the cost of running the study because I'd have to recruit more individuals to take into account all of the factors that I just said. And you can't get that funding. 

And so, unfortunately, as a female, only up until five, six years ago, I was only including males in my studies. Fortunately, at ZOE we're really kind of pioneers in terms of, we're over-indexing on females in our research, which is fabulous, which is why we can produce all of these great, great findings.

[00:30:37] Jonathan Wolf: So coming back to this woman who's going in to see her doctor, so hopefully she sees a doctor who is completely informed, that's great, but let's say they're worried that maybe their daughter isn't going to be completely up to date. What can they do? Walk into that doctor's office with or how can they approach this to try and make sure that they do get the best outcome for them.

[00:31:01] Dr. Mary Claire Haver: I'd say for her to educate herself as much as possible because at this point She knows her body better than anyone to be very clear like write down her symptoms Make sure she has her family history ready 

In the U.S. we have something called the well-woman exam. That is not the time to talk about menopause symptoms. You have a 10-minute visit, half of that's in stirrups, getting your breast cancer screening and your cervical cancer screening. 

Schedule a special visit, a problem visit, you know, just to discuss the menopause. Call ahead and see if they are willing to discuss this, do they feel comfortable, would they have an open conversation with you? Because a lot of physicians, rightly so, know that they have a lack of education. They're very, very busy discussing this, you know, doing surgery and delivering babies. 

I mean it's really sad in the U.S. that this all gets dumped in the lap of the poor, busy OBGYN. And this really should be internal medicine and family medicine or GPs.

And so, taking the time, do your homework, go in prepared with questions, go in prepared with your history, go in with all your previous blood work and lab tests that you've had done, so that you can create a clear picture for your physician to be able to help you. 

One of the starkest examples of where the focus and priority in women's health, there's two. If you go into PubMed, which is Google for doctors, Google for medical scientists, and you type in the word pregnancy, 1.1 million articles come up. Then if you just type in the word menopause, we have 94,000 articles. And when you think of the money, the brain power, the lab space. 

Is the last third of our lives not worth us in, you know, once our reproduction ends, are we no longer, are we only worth 10% of the research funding and dollars?

[00:32:49] Jonathan Wolf: So you're basically saying there's 10 times as many sort of medical trials and studies and papers on pregnancy than on menopause. 

[00:32:54] Dr. Mary Claire Haver: Yes.

[00:32:55] Dr. Sarah Berry: Well, in that PubMed search, if you then put nutrition and menopause, you get in the hundreds. And yet, if you were to put nutrition…

[00:33:04] Jonathan Wolf:  Quite a lot of those are yours. 

[00:33:06] Dr. Sarah Berry: If you were to put nutrition and, I don't know, cholesterol, you'd get in the hundreds of thousands. And so it's crazy. 

[00:33:15] Jonathan Wolf: That is crazy. Well, look, I think that's really fantastic advice. I'd love now to talk about what's the advice that, you know, you can give today to our listeners, whether it's for themselves or for you know, for loved ones. 

And I know in your book, Mary Claire, you talk about sort of a toolkit of strategies. There's not like just one answer. 

We should probably start with medicine and talk about hormone replacement therapy, but I definitely want to make sure that we have time to talk about a lot of the other things because, of course, that's a conversation with your doctor. And then I think for many of these other things are things that you can implement at home.

[00:33:54] Dr. Mary Claire Haver: So hormone replacement therapy is something I discuss with all of my patients. We talk about the risks and the benefits. We direct those risks as to what may apply to her. And we talk about the benefits for everyone. 

We talk about the cardiovascular benefits, the neuroprotective benefits, the osteoporosis prevention benefits, the general urinary preservation benefits.

We talk about, yes, it will help you with your hot flashes. It will probably help with your brain fog. 

[00:34:22] Jonathan Wolf: Could you talk for a minute just about those? benefits around long-term health because again, I think it's often been presented as something that's very much around symptoms, but it's interesting that all those things you just started with were about sort of the long-term risks that Sarah was talking about earlier.

[00:34:37] Dr. Mary Claire Haver: So one of the meta-analyses that stopped me in my tracks, it really changed my practice of medicine was in 2020 when the American Heart Association published a treatise on the menopause transition and cardiovascular risk changes. And they really were very, very clear that a woman's cholesterol dramatically moves towards an unfavorable profile through the menopause transition very, very quickly.

Usually it's a slow process over time like Sarah talked about, and then all of a sudden it just, boom, accelerates beginning in perimenopause. And they talked about looking back at the Women's Health Initiative study, if you started hormone therapy very early in your transition state, within the first 10 years or before the age of 60, there is a cardiovascular benefit to being on hormone therapy.

[00:35:31] Jonathan Wolf: So you're less likely to have a heart attack or a stroke.. 

[00:35:33] Dr. Mary Claire Haver: Less likely to have a heart attack, not a stroke. Less likely to have death from a heart attack. And less all-cause mortality. 

[00:35:41] Jonathan Wolf: Which is just death. 

[00:35:42] Dr. Mary Claire Haver: Death from anything. But 50% reduction of cardiovascular disease. 

[00:35:49] Dr. Sarah Berry: We see in our own data from ZOE PREDICT studies some suggestions of why this is. And so when we looked at individuals who were taking HRT we found that those individuals taking HRT had significantly lower blood pressure. They had significantly lower heart rate. cholesterol, particularly the bad cholesterol, they had significantly better insulin sensitivity, significantly lower visceral, so that the tummy, the tummy fat, and significantly lower inflammation.

And it's this inflammation that's actually, I think, really interesting as well, post menopausally, that we know chronic inflammation underpins many long, you know, chronic diseases like your type 2 diabetes, cardiovascular disease, etc., even some cancers. And the fact that HRT was reducing the increase that you see post menopausally in inflammation was interesting.

But I think the problem with HRT, there's been so much confusion and you mentioned about the Women's Health Initiative and this is a landmark study that came out in the early 2000s, 2002, that had this big headline saying, you know… 

[00:36:53] Dr. Mary Claire Haver: They called a press conference to stop the study and share this incredible finding that not only was estrogen not cardioprotective, it was increasing your risk of breast cancer.

[00:37:04] Dr. Sarah Berry: And this is before they had actually completed all of the statistical analysis. I mean, you know, Jonathan, having just gone through the process of the papers we've done, and we've just finished Mary Claire, a randomized controlled trial, that everyone's blinded who's doing the analysis to actually the analysis that we're doing.

We wouldn't even consider talking about it until it's undergone lots of review processes. So, the whole way that these results were presented, was not appropriate. Plus, the type of HRT that was given to these individuals was oral HRT, so that was in the form of a tablet. 

[00:37:42] Dr. Mary Claire Haver: Premarin and Prempro. 

[00:37:42] Dr. Sarah Berry: In the U.K., I know it's a little bit different in the U.S., but in the U.K. we only prescribe transdermal HRT, so these are the patches or the gel. How you process the oral, the tablets, versus, The transdermal HRT is different. 

But also the evidence, and you know, you mentioned this, didn't you, that the timing of taking it versus the risk is really important. And so in the Women's Health Initiative, women were being prescribed it later in their 60s. 

[00:38:09] Dr. Mary Claire Haver: Yeah, so they were in their 50s to 79 was the catch ages. And so the average age was 62. Much older than the traditional patient would have been started on hormone therapy, but the outcome they were measuring was cardiovascular disease.

So, I get that they start, you know, they wanted an older population because it takes a while to develop, you know, to get your outcome. And the longer you run a study, as you know, the more expensive it is. So, it turns out that estrogen is better at prevention than cure. And when you put estrogen on top of disease, sometimes it can make it worse.

Whether it's oral or transdermal, estrogen can make platelets stickier, and if you have issues in your cerebral blood vessels, you have an increased risk of clot. No increased risk in the first seven years of therapy in the WHI, but they did see a very slight increased risk. And what the data scientists think is that was probably they had pre-existing disease, and then you added estrogen on top of it for the older patients.

But clearly the data is clear when you start estrogen or you continue someone's estrogen, you know, who has no cardio, no clots, no plaques in her arteries, she's going to be fine. 

[00:39:20] Jonathan Wolf: And so that means, I guess if I understand that right, It's not for everybody, but Mary Claire, it sounds like if someone is coming into your clinic, quite a lot of those women end up taking hormone replacement. Is that…? 

[00:39:32] Dr. Mary Claire Haver: Yes. After we discuss the risks and benefits for her, most of them will decide to. 

[00:39:38] Dr. Sarah Berry: Because there are some cases where there is increased risk, and it's important we mention that. If you've had breast cancer, etc. So, there will be some people that it isn't appropriate for.

[00:39:50] Jonathan Wolf: This is an individualized conversation with your doctor, but that's a big shift, isn't it? From saying it's sort of dangerous almost, no one should take it to actually or saying probably the majority of women who end up coming to see you at this point in their lives much earlier are…

[00:40:04] Dr. Mary Claire Haver: You know, clearly we know that when we lose our estrogen, we're less healthy on multiple ways to measure human health. And it's now looking very clear that the longer your body is exposed to estrogen, that was published in the BMJ, the British Medical Journal, looking at cognition. They looked at risk of dementia and instead of saying, was she on HRT or not on HRT or is she menopausal and what stage is she in? They simply looked at lifetime exposure to estrogen in any form. Whether it was from the time you stop your periods, from the time you start, however many years that was, plus hormone therapy in the form of estrogen, and the more years you had estrogen on board, the lower your risk of cognitive deficits.

[00:40:49] Jonathan Wolf: Amazing. I would love to switch to some of the other things that people can actually do for themselves. There'll be a lot of listeners who, like me, to be honest, sort of, five years ago, thought, well, you know, can really nutrition have any impact on this sort of catalog of really serious symptoms?

That sort of sounds crazy. So, you know, what does the data say? 

[00:41:13] Dr. Sarah Berry: So the data shows that nutrition can have an impact on symptoms and what we certainly know is that it can have a huge impact on all the kind of disease risk factors that Mary Claire and I have been talking about. So nutrition can help with the two problems of menopause, one the symptoms but one the increased disease risk.

Now it might work better for some people than other people and it's really important that we say that. 

What we've found in our data is that when we look at people's overall diet quality, those people that have a higher overall diet quality have a significant reduction in symptom prevalence. So they have lower levels of sleep disturbances, they have lower levels of hot flushes, lower levels of anxiety, palpitations, etc. And for some of these, this is like 30, 40, 50% lower depending on the symptoms.

[00:42:00] Jonathan Wolf: 30 to 50 % lower. And is this one of these nutrition studies on 20 people, Sarah?

[00:42:07] Dr. Sarah Berry: Of course, not Jonathan. It's our ZOE studies. So, this data actually comes from the ZOE Health Studies Research Platform.

So, this is actually in hundreds of thousands of individuals, which is fantastic. Because that gives us the power to delve even deeper, which we haven't done yet. So, we need to do another podcast in about a year when we're next in New York with you to divulge these kind of details. 

But what we've started by looking at was just overall diet quality. What we're going to be doing next is looking at individual components of diet and looking, how does it differ depending on clusters of symptoms or depending on, you know, other characteristics such as, you know, the age at which you might have started that kind of perimenopause transition.

[00:42:49] Dr. Mary Claire Haver: And a lot of women will say, okay, at least on my social media following, you know, I'm choosing not to take it or I have an absolute contraindication. What can I do? And then I say, we have to double down on all the other aspects of the toolkit, especially nutrition. 

[00:43:08] Jonathan Wolf: And Mary Claire, if you are taking hormones, does that mean you can just forget about all the rest of this?

[00:43:12] Dr. Mary Claire Haver: Absolutely not. If you don't maximize your nutrition, hormone therapy is really only going to help your hot flashes, you know. 

[00:43:19] Dr. Sarah Berry: Yeah, nothing offsets a bad diet, Jonathan, and this is where the whole kind of, the supplements, all of these other kind of silver bullets that people take, nothing offsets a bad diet.

We need to make sure we are having that healthy, balanced diet. And I think for me the icing on the cake in terms of the evidence for symptoms and diet is from some what we call longitudinal analysis and science.

[00:43:42] Jonathan Wolf:  So this is brand new and it's not yet been peer-reviewed, right? 

[00:43:47] Dr. Sarah Berry: This is hot off the press, it's some results we only got last week, so it's even quite new for you. So we followed the people who were on the ZOE program. So this is where we're encouraging people to have the healthiest diet possible for them and we took baseline measures prior to them starting the ZOE program, where we looked at menopause symptoms and we looked at their diet.

And then after 18 weeks, we collected added information about their menopause symptoms; had they changed, what symptoms did they now have, severity, etc. And I must say I was really surprised by this. We found a huge reduction in the prevalence. So how many symptoms people were having and how many people had each symptom. So we were having up to about 70% reduction in some of the symptoms. 

[00:44:31] Jonathan Wolf: And this was after about four months, you're saying? 

[00:44:36] Dr. Sarah Berry: This is after about four months of following, yes. And, you know, we checked for, had you started HRT in this time. So we adjusted according, according to that as well.

[00:44:43] Jonathan Wolf: Are there lots of studies showing a particular diet intervention and its impact on menopause? 

[00:44:50] Dr. Sarah Berry: There are some studies out there, so there are some cross-sectional studies. So the studies at one point of time look at what's your diet? And what's your symptom prevalence?

Those studies show that generally, if you're following a Mediterranean style diet, which is a very kind of healthy, plant-rich diet, that you have less symptoms than those not following that kind of diet. Those following a Western style, as we call it, in nutrition research diet with heavily processed foods have more symptoms.

There's a couple of randomized controlled trials, but not many looking at whole dietary patterns. So these are trials where they'll randomly allocate one group of people to follow a Mediterranean style diet and another group of people to follow the typical U.S. or U.K. diet. They also see improvements in symptoms if you're following that Mediterranean diet.

Then there's hundreds of studies. And I think this is where we need to be a little bit careful that there's a lot of inconsistencies. Now that's partly because there haven't been enough good studies on each individual nutrient, etc. But I think that this idea that you can have a silver bullet where you just take, I mean, I can't remember…

[00:46:02] Dr. Mary Claire Haver: A probiotic or turmeric. Yeah. 

[00:46:04] Dr. Sarah Berry: Yeah. Where it's like a single component. And you know, you see some of the claims that are made. I don't know if you have this term here, we call it menowashing. 

So you stick meno- in front of it, you charge up to 10 times because you put menopause in front of it. And hey you're like. rubbing your hands together and off on your yacht in the Mediterranean retiring early. 

There isn't enough evidence yet for that. There's some interesting evidence coming out around soy isoflavones. Isoflavones are a particular chemical that mimics estrogen and there's some really interesting interaction with the microbiome related to this. And that's a fascinating area. And I really think watch this space on that. Where there is, I think, you know, enough evidence to say may for many people supplementing with isoflavones may have an impact. 

All of these studies, even these hundreds of individual food item studies, their outcome is hot flushes. It's the easiest thing to measure. 

[00:47:04] Jonathan Wolf: So basically your study is much the first one ever to actually look at this full set of symptoms. 

[00:47:07] Dr. Sarah Berry: I've never thought about that until, I mean, I've always been looking at the literature thinking, well, what about this and this symptom? But because of that misconception… 

[00:47:14] Dr. Mary Claire Haver: Anything to do with menopause, if it's not measuring a hot flash, it doesn't exist. You know? 

[00:47:20] Jonathan Wolf: I'd love to talk about other actionable advice Mary Claire. So we talked about, so sort of the hormones in the diet, if you were gonna say to somebody here are the three other things that you could really do that could make a difference potentially on top of those others, what would they be?

[00:47:38] Dr. Mary Claire Haver: So again, you have to let go of the notion that menopause is hot flush. Right? So, my big three are usually make sure you're getting a minimum of 25 grams of fiber in your diet per day. Most women on the Western diet are getting 12. 

And that's going to hit so many points in what you're dealing with. It's going to help with cholesterol. It's going to help with your blood glucose. It's going to help with your insulin levels. It's going to help with your gut motility. It's going to help with your microbiome. 

And that should come from food. You need to get this from food because those foods are also packed with micronutrients, minerals, vitamins, you know, of healthy fats, other things that will keep you healthy as part of a profile.

Nutrition is a profile. It's not one thing. 

[00:48:25] Jonathan Wolf: So one is fiber. 

[00:48:26] Dr. Mary Claire Haver: The other is watching the amount of added sugars that you have. So not fruits and vegetables or dairy, but sugars added in cooking and processing and in alcohol. You need to limit those to less than 25 grams per day. Women who do that consistently have less visceral fat. Less hot flashes. We have pretty decent data to show that you're healthier when you do that. 

And the keto movement really, so many of my patients who've done keto for years are really anxious when they see sugar levels. And I try to talk to them about the difference between an added sugar and a sugar that's naturally found. Because a sugar molecule is a sugar molecule, of course. But those naturally occurring sugars are wrapped in a package, usually with fiber and vitamins and minerals and nutrients, and have a very different impact on your health than a simple sugar that's through processing. 

And then to add in consistent resistance training, muscle training. Most women are doing cardio and they didn't want to gain weight, they didn't want to be bulky. And they didn't understand the impact of weight training and keeping strong muscles and bones. 

When I talk to my patients, when I talk to my followers, I did this questionnaire and said, What scares you the most about getting older? It shocked me because for me, it's cancer. I've lost two brothers to cancer, multiple aunts and uncles. It's just my genetics and it's okay. 

But you kind of come from your place of what you know and it was overwhelmingly to not be able to think and to not be able to move. Basically, not be able to care for myself and be a burden on my family as I age. They want to limit that time as much as possible.

And so what causes people to go into a long-term care facility or not be able to care for themselves is loss of being able to walk, move, and break a hip, you know, whatever, or dementia, you know, whichever form of dementia. 

So if we just look at frailty What can we do to decrease that risk in muscle mass and bone strength? And that begins now in our 30s, 40s, 50s, you know.  

[00:50:33] Jonathan Wolf: And they're not the same thing, are they, the bone strength and the muscle mass? 

[00:50:35] Dr. Mary Claire Haver: Well the musculoskeletal unit works as a unit. So stronger muscles means stronger bones. You're sending that signal that's going to slow down the rate of bone resorption that we see accelerate when we have our estrogen loss.

And so, you know, that remodeling process slows down so that we can hang on to strong bones. 

[00:50:54] Jonathan Wolf: And so what are you advising your patients to do? 

[00:50:57] Dr. Mary Claire Haver: At least two days a week of resistance training with probably weights. I tell them there's YouTube videos now, there's lots of free resources. Start investing. 

And my favorite hack is get a weighted vest. There's some beautiful studies, small, but they're there, done on women in their 70s and 80s wearing weighted vests. They were in long-term care facilities and looking at their improvements in their bone, in their bone density and muscle strength.

Now, this was combined, some with creatine, some with, they're all doing muscle training, but just wearing that weighted vest and also the vibration, the vibratory… which not everyone has access to, but wearing a weighted vest to clean the house or walk on the treadmill, or when you walk your dog. Adding in that little bit of extra stress will send that chemical signal to the bones and muscles to be more resilient and to be stronger.

[00:51:46] Jonathan Wolf: So literally wear the weighted vest while either just walking around the house or something like that. And that's going to sort of do all this extra pounding on your bones and sort of muscle work. That will make a difference. 

[00:51:58] Dr. Mary Claire Haver: Just start at 10% of your body weight. That's a very safe place to start. 

[00:51:58] Dr. Sarah Berry: So, we often talk about exercise snacking. Because I think if people haven't been used to either doing weights or any exercise, it's really daunting to suddenly go into a gym. And so, something we really advocate is do an exercise snack, and by this, it could mean do 10 squats, do a wall push up, you know.

You can do this when you're on the move. You use your own body weight as your weight. You only need 30 seconds. It can actually build up to doing quite a lot over the day if you're snacking on exercise in that way. And I think that's a really great way to start. 

[00:52:33] Jonathan Wolf: I did want to pick up on one thing that you'd mentioned earlier. You talked about a frozen shoulder being quite common, and I at least hadn't heard about this before. 

I'm imagining now that there'll be a set of listeners who are suddenly going to be thinking, Well, I've got that, I suspect. Some of them will not have associated this with menopause and may just be basically grinning and bearing this. Is there anything you can do if this is something that you are living with? 

[00:53:01] Dr. Mary Claire Haver: So what it is, is adhesive capsulitis, the capsule around the shoulder joint becomes adhesed and freezes. And so you start losing… the beginning stages you have pain and loss of movement. You can't put your hand over your head. You can't put your bra on, you know, you can't reach behind your back and it's very, very, very painful. 

And in the advanced stages, it could take a year or more of physiotherapy to get  that physical therapy to break down and regain your movement. And quite often they'll have it on one side and they'll go to the other.

So when I talked about it, so many people asked me on social media about frozen shoulder. Instead of saying, no, I've never heard of it, I'm curious. So I start digging in the literature. I find a recent study coming out of Duke University where the head of the orthopedic surgery department, who was a woman, and the head of OBGYN, who was a woman, got together and said, there's too many patients who are having this and they're all menopausal. You know, is, is there a connection? 

And what they found in reviewing the literature is that we know the age at which you get it, and it's definitely perimenopause and menopause, early menopause, and early menopause. If you're on hormone therapy, the risk is significantly less that you will develop frozen shoulder. But say it's too late, you're not on hormone therapy so it's preventative, what can you do? 

Know early this might happen to you. When you start noticing, I can't quite reach, this is hurting or just feel stuck, immediately go to orthopedic surgery. Go get a referral for physical therapy. Go online and look at the exercises that you can do.

Dr.  Vonda Wright is an orthopedic surgeon and she does a lot of menopause care. She talks about this extensively. You know, things that you can do in the early stages to prevent having the severe adhesive capsulitis and then ending up needing surgery. 

[00:54:47] Jonathan Wolf: I'd literally never heard of it and I imagine there will be some people listening to this who are suddenly going to go out and speak to a doctor who didn't otherwise thank you.

I would love to try and summarize what we've covered. We've covered a lot of things and I know the two of you will correct me where I've got this wrong. 

So, we actually started by talking about the fact that the symptoms of menopause are actually quite different from the way that many people understand them, including women going through it, including doctors and scientists. That amazingly, these hot flashes or hot flushes are only the fifth most common symptom, even though they're the only one that people have historically used to decide whether or not someone's going through menopause.

I think you said, for example, both bad sleep and anxiety, 80% of women are having, and then there was this very long list of other symptoms you can have. Both things like bone loss at a long-term. joint pain, this frozen shoulder I've never heard of, forgetfulness, anxiety, it's an amazing and very complex catalogue of things. And this is part of the reason why often it's been hard to diagnose. 

You explained a bit about what's going on and the fact that we've historically thought about menopause as very much it's at the point when you stop having eggs, but that actually we now understand that there's this long period, seven to ten years, I think you were saying, before the point of your last egg, where there are suddenly not that many eggs left, and so instead of having this sort of constant amount of estradiol, did I get that right? Which is this form of estrogen being produced. 

We have this hormonal chaos, I think you said, Sarah, so it's all over the place and so actually sometimes the symptoms could be worse because it's not like it's just stopped, it's sort of up one day and down the other. 

But that also means the total period that you're experiencing this is a lot longer than people have previously said because you might have seven to ten years before menopause, maybe seven years afterwards, you said maybe ten years if you're African American. So this really long period that could even start when you're 35 and might go on until you're 60, so this is a very long period.

And, you know, a big period of a woman's life. And it's made harder still because there is no test. Mary Claire, I cannot just go into your clinic and get a single test that tells me you have perimenopause. 

[00:56:53] Dr. Mary Claire Haver: We're great at postmenopause. 

[00:56:54] Jonathan Wolf: Postmenopause is, I understand quite straightforward. But for perimenopause, you don't know what's going on. 

And if we said the first thing actually is just if you understand what's going on and that you are maybe going through perimenopause, that already might help with your stress reduction because suddenly at least you understand what's going on in this area.

I think you shared some great examples of where even when you're as educated about this as you are through your work, as an individual experiencing it, it can still be a shock because it's not so obvious to just this one symptom. 

You then said, not only are there all these symptoms, but actually it really is having a big impact on your long term health. And that this is something that has not been well understood, but that suddenly a woman's risks of many long-term diseases, and we talked a lot about sort of cardiovascular, so sort of heart-related diseases, but that just in general, the risks to your bones, all these sorts of things start to shoot up.

And I think you explained that this is because there are these little receptors for this estrogen everywhere in your body. And so sort of every part of your body is changing and I actually have for the first time that we now know you get hungrier, for example. But that also the way you process the food that you were always eating no longer works the same way.

So suddenly you're eating the same food that you were eating five years ago. Before you were fine with it and now actually it's starting to cause you this harm and so you're seeing the raised cholesterol and all these other things, more inflammation, weight moving towards your stomach, which is more dangerous, so suddenly you need to change things around your diet as well as everything else that before you were okay with.

And then we talked about, okay, so what can you do about it. We talked about hormone replacement and that there's really been a big shift in understanding the benefits, and the risks. That the way that you get this now is different from in the past. So that's a conversation with your doctor, but in general, you are now prescribing this to a lot of the patients who are coming to you versus a situation where it might've been viewed as you know, for 5%.

[00:58:49] Dr. Mary Claire Haver: Right. I think in the past, we were overemphasizing the risks unnecessarily and we were dramatically underemphasizing the benefits and we're really understanding the benefits a lot more now. 

[00:58:59] Jonathan Wolf: So I think that's really interesting. Then we talked about nutrition, Sarah, you just said some sort of amazing new data, some of which has not even yet been released. And that's very hard, by the way. So I'm quite pleased that Sarah must be very convinced about it, to be able to share it before it's peer-reviewed. 

That not only do you see that diet is correlated with big differences in symptoms, and I know that's already been published, but also this new data about members of ZOE who are following their individual guidance getting this retest and actually seeing amazing results.

I think you said 70 % of people saw their symptoms decrease in just four months, so in a very short period of time and across this whole cluster of symptoms, which I know Sarah is very excited about and I'm sure we'll be talking a lot more about that soon. 

Mary Claire, you gave some great, really practical tips about what you could do. So first was like fiber within food, double it, so this is like all those healthy plants that support you in many ways, and you see that as really important. 

Watching the amount of added sugar you have, so not worrying about the fruit, but worrying about all the things that are in there, drinks and the cakes, and all these sorts of things.

And then you talked about how important consistent resistance training. You were saying you're trying to advise your patients at least two days a week to be working with weights. And that might well not be what they've been thinking about before, but now because of all these risks to do with bone loss, but also the strength that's going to allow you to continue to stay in your home, that's really important to ensure they can do what they almost all want to do, right, which is to stay at home for as long as possible. Not break a hip, but also not get dementia. 

And you have this brilliant tip that I hadn't heard before, get a weighted vest. You can start at just 10% of your body weight, and you can just wear that while you're doing some activities around the house, and that alone could really make a difference. Which I love because I think we have a lot of listeners talk to us about the idea of going to the gym is really scary and so I think we often talk about what are ways to sort of start to make those changes.

Finally, I mustn't forget this frozen shoulder thing. So there will be a bunch of people listening to this. Either listening to themselves or thinking about their wife who's been sort of complaining about this for some time but doesn't want to make a fuss, is really busy. And so if you have got sort of part of this frozen shoulder, you should go and get that checked out because that is now sort of being identified as a real menopause symptom and it sounds like it gets very serious if you aren't taking it seriously. So it's something you should go and have checked out. 

[01:01:27] Dr. Sarah Berry: We need to add that to our list of symptoms that we ask in the ZOE app. 

[01:01:32] Jonathan Wolf: I feel like we'll be coming back next year and there'll be even more symptoms on this. 

[01:01:35] Dr. Mary Claire Haver: I've got, I think, 70 listed in the new book. 

[01:01:39] Jonathan Wolf: That's amazing. Mary Claire, thank you so much for coming and joining us today.

[01:01:41] Dr. Mary Claire Haver: Thanks for having me. 

[01:01:42] Jonathan Wolf: I thought that was fantastic. 

I hope you learned something today. If you listen to the show regularly, you probably already believe that you can transform your health by changing what you eat. But there's only so much you can learn from general advice on a weekly podcast. If you want to feel much better and live many more healthy years, you need something more.

And that's why, each day, more than a hundred thousand members trust ZOE to help them make the smartest food choices so they could feel better now and enjoy many more healthy years. Combining our world-leading science with your ZOE test results, ZOE is your guide and coach to sustainable improvements to your health.

So how does it work? ZOE membership starts with at-home testing to understand your unique body. Then ZOE's app is your health coach, using weekly check-ins and daily guidance. To help you shift your food choices to steadily improve your health. I rely on ZOE's advice every day and, truly, it has transformed how I feel.

So, to take the first step towards the possibility of more energy, less hunger, more healthy years, take our quiz to help identify changes to your food choices that you could make right now. Simply go to zoe.com/podcast, where as a podcast listener, you can also get 10% off.