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The
Understudies of Women Health: MenopauseThe
health of women who are beyond or approaching the end of their reproductive
years—such as those in perimenopause, menopause, and postmenopause—has been
neglected.
Dr. Mary Claire Haver:
How to Navigate Menopause & Perimenopause for Maximum Health & Vitality，Huberman
Lab, June 3, 2024.Haver, M. C. (2024).
The new menopause: Navigating your path through hormonal change with purpose,
power, and facts. Rodale Books.https://www.hubermanlab.com/episode/dr-mary-claire-haver-how-to-navigate-menopause-perimenopause-for-maximum-health-vitalityhttps://www.penguinrandomhouse.com/books/738539/the-new-menopause-by-mary-claire-haver-md/https://www.mckinsey.com/industries/life-sciences/our-insights/closing-the-data-gaps-in-womens-healthRecently, I listened
to Andrew Huberman’s podcast featuring an interview with OB-GYN Dr. Mary Claire
Haver titled "How to Navigate Menopause & Perimenopause for Maximum
Health & Vitality." It was incredibly insightful, packed with new
knowledge and practical advice. I listened to it multiple times, took notes,
and read Dr. Haver’s recently published book, "The New Menopause:
Navigating Your Path Through Hormonal Change with Purpose, Power, and Facts."
Given the general lack of knowledge about menopause and women's health (myself
included), I decided to write this post.Dr. Haver not only
explained the essence and definition of menopause and perimenopause and their
symptoms, but also delved into the endocrine principles behind them. She
introduced cutting-edge treatments and lifestyle adjustments, and highlighted
the systemic neglect of women's health—especially non-reproductive health—by
academia, the medical community, and society. This includes insufficient
research funding and studies for women’s health, particularly post-reproductive
health, and inadequate training for doctors. As a result, the health issues of
women during at least a third of their lives are often overlooked. Despite
women living longer than men globally—73.8 years for women versus 68.4 years
for men in 2021—20-25% of women’s lives are spent in poor health (illness or
disability).As Dr. Haver aptly
stated, women are not just "little men with breasts and uteruses."
The symptoms of the same disease can manifest differently in women compared to
men; women’s responses to the same medication differ from men’s; and women’s
disease burdens are distinct from men’s. However, these differences have not
been sufficiently studied, which hampers improvements in women’s health.The data gap in
women's health researchIn her 2019 book
"Invisible Women: Exposing Data Bias in a World Designed for Men,"
British author Caroline Criado Perez compellingly argues with extensive data
that there has been a significant data gap in women's health (For more details,
see City Reads | Invisible Women: When the Big Data Is Missing Half of the
Population). In medical research and education, the male body is often used as
the standard for humanity. Female animals, female cells, and female subjects
are either excluded or minimally included in various medical studies. There are
insufficient gender-specific findings, and research findings lacking female
data further result in the absence of women's health education in medical
textbooks and education. This leads to common issues such as women's diseases
being ignored, misdiagnosed, or diagnosed late.Additionally, the
understanding of women's health has been overly narrow. Historically, women's
health has primarily been defined as "reproductive health." However,
women's health extends far beyond reproductive health. It is only recently that
academia and the medical community have begun to recognize the significant
impact of gender on the occurrence and progression of many diseases.For diseases
affecting both men and women, symptoms in women can differ. For example, in
cardiovascular diseases, women typically do not exhibit chest and left arm pain
like men but may experience stomach pain, difficulty breathing, nausea, and
fatigue. Consequently, women are 50% more likely than men to be misdiagnosed
after a myocardial infarction. Some diseases have higher incidence rates in
women. Women are three times more likely to develop autoimmune diseases than
men, nearly twice as likely to have irritable bowel syndrome, and three times
more likely to suffer from migraines. Additionally, women often do not receive the
same treatment as men for certain conditions, such as pain, where women are
less likely to be prescribed pain medication compared to men.Certain diseases or
health conditions exclusively affect women, such as some contraceptive methods
(oral contraceptives and intrauterine devices) and assisted reproductive
technologies (egg retrieval, egg freezing). Women's health issues also include
pregnancy and childbirth, menopause, gynecological diseases, gynecological
infections, and gynecological cancers.When it comes to
women's health, reproductive health receives most of the attention, while he health of women
who are beyond or approaching the end of their reproductive years—such as those
in perimenopause, menopause, and postmenopause—has been neglected. This neglect is evident in the allocation
of research funds and the proportion of published papers.Dr. Haver points out
that in studies funded by the National Institutes of Health (NIH), only 0.03%
of the funds support menopause research. If you visit the PubMed website and
search for "pregnancy," there are 1.15 million results. For
"menopause," there are only 97,000 results, and for
"perimenopause," only 6,363 results.A recent McKinsey
report, Closing the data gaps in women's health, noted that in women's health,
the gender data gap and the lack of data accurately documenting the nature and
extent of women's conditions has led to lower rates of clinical development of
women's health-focused drugs: Excluding oncology, only 1% of biopharmaceutical
funding and 2% of medtech new drug approvals address women's health. When
oncology is included, the rates only increase to 5% and 4%.A 2016 study
analyzed 112 internal medicine residency programs, and about 25 percent of them
did not include menopause in their core curriculum. Even among programs
dedicated to women's health, there's an education gap: a survey of U.S.
obstetricians and gynecologists found that fewer than 20 percent had formal
training in menopausal medicine.Menopause not only
has health and economic costs for individual women, but also significant
socioeconomic costs. About 80% of women report that menopause interferes with
their lives, and about one-third of them suffer from depression. Menopause
places a heavy economic burden on the global economy, with an estimated $810
billion in healthcare spending and lost productivity.Mainstream medicine
defines menopause as the day when one year has passed since the last menstrual
period.Dr. Haver disagrees
with this definition because, first, not all women menstruate, and those who
have had a hysterectomy, use an IUD, or do not have menstruation as a result of
some kind of treatment (surgery or medication) do not fit this definition. Second,
the mainstream definition defines menopause as the day when one year has
elapsed since the last menstrual period, representing the failure of ovarian
function. But the impact and significance of menopause extends far beyond a
specific day.Dr. Haver offers a
definition of menopause from an endocrinological perspective. When a woman is
born, she has 1-2 million eggs; thereafter, the number of eggs in her body
continues to decrease. Upon entering puberty, women begin to ovulate, creating
menstruation. Each menstrual cycle, although only one egg is ovulated, about
11,000 eggs are lost in the process as these 11,000 eggs compete with each
other and only one egg is eventually successfully released. By the time a woman
is 30 years old, only 10 percent of her egg count, about 120,000, is left; by
the time she is 40 years old, only 3 percent of her egg count is left. Egg
quality is also declining. Menopause is when the eggs are depleted and the
amount of sex hormones produced by the ovaries drops dramatically, with
estrogen levels at less than 1% of what they were at childbearing age.
Progesterone levels also drop dramatically. Testosterone levels are declining,
although since the adrenal glands can also produce testosterone, testosterone
levels drop to 50% or slightly lower of the pre-menopausal levels.The average age of
menopause for women in the U.S. is 51-52 years old, with menopause between
45-55 years old being normal (a year and a half earlier for blacks, the latest
for Asians, and in the middle for whites.) Menopause between the ages of 40-45
years old is classified as early menopause; menopause before the age of 40
years old is classified as premature ovarian failure.Dr. Xu Bing in her
new book "Her Thorns: From Dysmenorrhea to Endometriosis" quotes the
data released by the Menopause Group of the Obstetrics and Gynecology Section
of the Chinese Medical Association, which shows that the average age of Chinese
women's first menstruation is 12 years old, and the average age of menopause is
50 years old, and based on this data, it is estimated that a woman will have
her period about 450 times in her life.A woman who has
never given birth and has normal menstruation (ovulation) means that she may
run out of eggs sooner and go through menopause relatively early; a woman who
has her uterus removed and her ovaries preserved will lose about four years of
ovarian life; if she has had a unilateral oophorectomy, her ovarian life span
will be shortened by a year and a half; the ovarian life span of a person with
endometriosis is also shortened; and inflammation of the abdominal cavity,
intestinal stress, surgery, and chemotherapy will all shorten ovarian life.
Suppression of ovulation, on the other hand, slightly extends the ovarian life
span and delays menopause for up to about nine months.Dr. Haver divides
menopause into three stages: perimenopause, menopause & post-menopause.Perimenopause is a
longer transitional phase that occurs before menopause, averaging 4 years but
possibly spanning 2-10 years, so the age of entry into perimenopause may be as
early as about 35 years. Perimenopause is triggered by fluctuations in the
levels of hormones such as estrogen and progesterone. Fluctuations in hormones
such as estrogen, follicle-stimulating hormone, and luteinizing hormone are
more dramatic and unpredictable during perimenopause because the aging ovaries
gradually fail to produce the hormones, and so the pituitary gland is
continually prompted to send signals to produce the hormones. Perimenopause may
be characterized by a variety of menstrual irregularities, including shorter
cycles, longer cycles, or even skipping a particular period. There is an
overall decline in estrogen during perimenopause.![]()
Postmenopause: After
menopause, i.e., one year after the last menstrual period, one enters
postmenopause, which encompasses the rest of one's life after menopause, and
common menopausal symptoms such as hot flashes, palpitations, and night sweats
tend to occur during this phase, which may last from 4.5 to 9.5 years.Estrogen and
androgens are both human hormonesIn the dominant
narrative about gender, estrogen is usually associated with women and androgens
(represented by testosterone) with men. But in reality, this is nothing more
than a socially constructed fact. The physiological fact is that estrogen and
androgens are both human hormones, and both males and females secrete estrogen
and androgens. And women may not necessarily have higher levels of estrogen
than men.First, in terms of
absolute levels, testosterone levels in women are higher than estrogen levels.Second, estrogen
drops off a cliff in menopausal women to only 1% of pre-menopausal levels. In
fact, estrogen levels in menopausal women are even lower than estrogen levels
in men.Therefore, the use
of estrogen to differentiate between women and men is not based on
physiological facts.Symptoms of
menopause and its impacts on women's healthDue to the absence
of sex hormones (especially estrogen) and the loss of estrogen protection
during menopause, women's health is negatively affected and shows various
symptoms.First, body
composition changes (even if weight remains the same): visceral fat increases
and muscle decreases. Pre-menopausal women have 8% visceral fat, and after
menopause, visceral fat increases to 23%, even when diet and exercise remain
the same. 80% of women experience abnormal cholesterol levels during the
menopausal transition (even if their levels were normal before menopause).It is not impossible
for menopausal women to avoid gaining visceral fat, but it does require a great
deal of effort, including exercise, diet, and, if necessary, menopausal hormone
therapy (MHT), which is known in mainstream medicine as hormone replacement
therapy (HRT). Dr. Haver prefers to use MHT to refer to hormone replacement
therapy from perimenopause to post-menopause.Other common symptoms
of menopause include fatigue, bone and joint pain, bone loss, weight gain,
heart palpitations, hot flashes, sleep disruption, ringing in the ears, vertigo,
dry and itchy skin, hair loss, mood swings, loss of libido, genitourinary syndromes
(which include thinning of the tissues, loss of elasticity, decreased
production of mucus and deterioration of urethral health, urinary tract
infections, etc.), gastrointestinal problems and more.The
impacts of menopause are not limited to the aforementioned uncomfortable
symptoms. More profoundly, menopause increases the risk of major diseases in
women, including osteoporosis, cardiovascular diseases, insulin resistance and
prediabetes, neuroinflammation, increased visceral fat, and sarcopenia.Fifty
percent of women will experience osteoporotic fractures before they die, and
cardiovascular disease is the leading cause of death in women.Treatments and improvements for menopausal symptomsMenopausal
Hormone Therapy (MHT) or Hormone Replacement Therapy (HRT): Dr. Haver believes
that for most menopausal women, the benefits of hormone replacement therapy
outweigh the risks. The preventive effects of hormones are greater than their
therapeutic effects, and it is important to start early. Beginning hormone
therapy between the ages of 50 and 59 reduces the risk of cardiovascular
disease, cardiovascular-related deaths, and all-cause mortality by 50%.HRT
estrogen supplementation can be administered in oral and non-oral forms.
Non-oral methods are preferred, such as estrogen patches, sprays, or vaginal
rings (the only drawback of vaginal rings is their high cost). Oral estrogen
carries the risk of blood clots due to liver metabolism, whereas transdermal
estrogen patches do not have this risk. Estrogen patches can be used
indefinitely if there is no reason to stop. Dr. Haver jokingly said, " I
will probably die with my estradiol patch on."Hormone
supplementation in menopausal women significantly improves various symptoms and
conditions. For example, administering estrogen to perimenopausal and
menopausal women with depression is more effective than antidepressants.The
best treatment for recurrent urinary tract infections in postmenopausal women
is vaginal estrogen, not antibiotics. Estriol cream is the most effective
method to prevent urinary infections and urosepsis, and every menopausal woman
should use it.Applying
estrogen (Estriol) cream to the face of menopausal women can slow collagen
loss.Oral
progesterone is effective in treating insomnia during menopause.Lifestyle changes to improve menopausal symptoms and quality
of lifeNutrition:
It is important to focus on fiber intake, aiming for 30-32 grams per day, and
ensure adequate protein intake, especially animal protein, as most women do not
consume enough.Exercise:
Engage in strength (resistance) training 3-4 times a week. Wearing a weighted
vest can enhance the effectiveness of the training.1.“Representation
of the world, like the world itself, is the work of men; they describe it from
their own point of view, which they confuse with the absolute truth.” — Simone
de Beauvoir, The Second Sex2.“Historically
it’s been assumed that there wasn’t anything fundamentally different between
male and female bodies other than size and reproductive function, and so for
years medical education has been focused on a male ‘norm’, with everything that
falls outside that designated ‘atypical’ or even ‘abnormal’.
...
This
male-default bias goes back at least to the ancient Greeks, who kicked off the
trend of seeing the female body as a ‘mutilated male’ body (thanks, Aristotle).
The female was the male ‘turned outside in’. Ovaries were female testicles
(they were not given their own name until the seventeenth century) and the
uterus was the female scrotum. The reason they were inside the body rather than
dropped out (as in typical humans) is because of a female deficiency in ‘vital
heat’. The male body was an ideal women failed to live up to.Modern
doctors of course no longer refer to women as mutilated males, but the
representation of the male body as the human body persists." — Caroline
Criado Perez, Invisible women: data bias in a world designed for men![]()
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