Interview with Dr. Mary Claire Haver, Menopause Expert: Symptoms and Solutions

Table of Contents

• Hormone therapy that fits the person
• Screening before problems become obvious
• Nutrition and supplements with a purpose
• Sleep and vaginal health deserve direct questions
• Five habits we want to take into midlife

Hormone therapy that fits the person

When we hear “bioidentical hormones,” what should we ask before considering them?

We need to ask a more useful question than whether a hormone is described as bioidentical: How is this product made, tested, prescribed, and monitored? A compounded hormone is still a medication. A pharmacist prepares it, and a physician should help determine whether it is appropriate. Dr. Mary Claire Haver joins Dr. Thais Aliabadi and Mary Alice Haney to discuss this and other issues. 

Compounding has a place in care, but it also leaves more room for variation. We discussed testing in which compounded products showed substantially more disagreement between their stated and measured contents than FDA-approved products. That matters when we are trying to adjust a dose carefully and understand whether a symptom is coming from the treatment.

Our preference, when there is a suitable option, is to begin with an FDA-approved product whose formulation and quality controls are established. Testosterone is one area where finding an appropriate option for women can be more difficult, so we may work with a compounding pharmacy we know and trust. “Compounded” is not automatically wrong, and “bioidentical” is not automatically safer. We still have to look at the actual product and the person using it.

Why might we choose an estradiol patch instead of an estrogen pill?

We often start with a transdermal estradiol patch because it avoids the increased blood clot risk associated with taking estrogen by mouth. If a patient has a uterus, we also have to think about protecting the uterine lining. Micronized progesterone is an option we commonly discuss for that role.

There is no magic starting dose that suits everyone. If someone is younger and having substantial symptoms, we may start at a higher patch dose than we would for someone with milder symptoms, while leaving room to adjust. Then we follow what happens: Are the hot flashes improving? Is sleep better? Are new side effects appearing?

This is where menopause care becomes both art and science. We are not trying to put every woman on the same dose. We are trying to find the lowest practical dose and combination that addresses her needs, while staying alert to her medical history and any changes after treatment begins. For a broader discussion of individualized choices, we have covered menopause hormone therapy and its formulations in more detail.

Does premature ovarian insufficiency change that approach?

Very much. Premature ovarian insufficiency, or POI, means ovarian function declines before age 40. Menopause between 40 and 45 is considered early, but POI calls for particular attention because a young woman may otherwise lose many years of estrogen exposure.

With POI, our goal is not simply to make a hot flash stop. We have to think about long-term health, including bone and cardiovascular health, and whether hormone levels are appropriate for someone who is still decades younger than the usual age of menopause. Some patients need more hormone than an older postmenopausal patient would. That is why we cannot take a standard postmenopausal dose, apply it to a 28-year-old with POI, and assume we have done enough.

We also want to investigate the circumstances around an early loss of ovarian function and maintain close follow-up. It deserves its own care plan, not a footnote in a general menopause conversation.

How do we know when an estrogen dose is not working well?

We pay attention to both relief and side effects. If hot flashes improve but breast tenderness, headaches, bloating, or other uncomfortable symptoms appear, we may need to reduce the estrogen dose. Higher doses can also be associated with more breakthrough bleeding.

That does not mean we should add extra patches because one patch helped and five might help more. More hormone can mean more side effects, not better care. Sometimes a bleeding pattern improves when we adjust progesterone rather than estrogen. The right response depends on the whole picture, which is why we make changes with a clinician instead of experimenting on our own.

When is bleeding after starting hormone therapy a reason to call?

Our rule is simple: Tell us about any bleeding, especially after menopause. Irregular bleeding can occur during the first several months of hormone therapy, and some early breakthrough bleeding settles as the body adjusts. Still, we want to know about it so we can document the pattern and decide whether anything needs to change.

If bleeding begins or continues after those initial months, we should not assume it is just the patch. Postmenopausal bleeding needs an individualized evaluation by a gynecologist. That may include imaging or a sample of the uterine lining to check for abnormal cells. We also need to know whether someone is taking progesterone consistently when it has been prescribed to protect the uterus.

We can be reassuring without being dismissive. Bleeding does not automatically mean something serious is wrong, but “probably normal” is not a reason to keep it from the care team.

When might a birth control pill make more sense than menopause hormone therapy during perimenopause?

Perimenopause does not eliminate the possibility of pregnancy. If contraception is needed, that has to be part of the decision. A birth control pill such as Loestrin may also help when periods have become irregular or heavy, once concerning causes of bleeding have been evaluated. For some patients, suppressing ovulation can help with acne or other symptoms associated with androgen changes.

Birth control pills and menopause hormone therapy were designed for different jobs. The pill was designed to prevent pregnancy by suppressing ovulation. Menopause hormone therapy was developed to treat symptoms such as hot flashes. Their doses and formulations can differ, although a low-dose birth control pill and a higher-dose menopause hormone regimen may sometimes be closer than people expect.

We can use menopause hormone therapy during perimenopause too. In someone who is still having periods, we may discuss cycling progesterone rather than taking it continuously. Other options, including an IUD, may also belong in the conversation. We do not need to force every patient across the same bridge. We choose the route that fits her symptoms, bleeding pattern, contraception needs, and preferences.

Screening before problems become obvious

Should we ask about a DEXA bone scan before age 65?

We think it is worth discussing, particularly after menopause or when there is a family history or another reason to worry about bone loss. Insurance coverage and screening guidelines do not always answer the question we are asking in the exam room: Would an earlier baseline help us make better decisions for this person?

A DEXA scan measures bone density. Some centers also offer body composition estimates, such as muscle mass and visceral fat, although those measurements are a separate reason someone might seek a scan. In our conversation, we shared our own experiences with earlier testing. One of us found osteopenia at 50 and has a family history of osteoporosis. Finding low bone density before a fracture gives us an opportunity to address it.

We would bring personal risk factors to the appointment and ask whether earlier testing makes sense, rather than assume that waiting until 65 is right for everyone. We can also learn more about osteopenia and osteoporosis during menopause before that discussion.

What role does a coronary calcium scan play?

We want to understand cardiovascular risk, especially if cholesterol or other markers raise concerns before starting estrogen. A coronary calcium scan is a CT-based test that looks for calcified plaque in the coronary arteries. It can add useful information to a broader risk assessment, but it is not a substitute for a medical history, laboratory work, or a conversation with a cardiologist.

We tend to be proactive about establishing a baseline when it is appropriate. In our practices, elevated cholesterol or markers such as ApoB or lipoprotein(a) may prompt a discussion about coronary calcium scoring. Whether to order it, and at what age, should depend on the individual rather than become a universal instruction for every woman turning 45 or 50.

The principle is to know what we are treating. When we have a clearer picture of existing risk, we can make more thoughtful decisions about hormones and long-term prevention.

Nutrition and supplements with a purpose

Which supplements come up most often in our menopause visits?

We start with what someone needs, not with a shopping basket full of bottles. Vitamin D is one nutrient we check frequently because we see substantial deficiencies. If a level is very low, a clinician may prescribe a higher-strength course and then recheck it before deciding on maintenance. The amounts discussed in our practices are not a reason for everyone to take the same dose without testing and guidance.

Vitamin D can be difficult to get consistently through food. Fatty fish and mushrooms contribute some, but intake varies. We also protect our skin from sun exposure, as we should, and skin pigmentation affects how readily sunlight supports vitamin D production. That is one reason we pay close attention to deficiency rather than assuming everyone’s level is fine.

Fiber is the other big one. Many women get far less than the roughly 25 grams a day we discussed as a useful minimum. We would rather build intake with food when possible, then use a supplement to fill a gap if food alone is difficult because of appetite, preferences, or intolerances.

We may also discuss collagen with someone who has osteopenia; one specific collagen product came up in relation to a long-term bone-density study. It is not a replacement for an overall bone-health plan. And when symptoms point toward a possible deficiency, we look further, including iron studies and other nutritional markers. We do not need to order a stack of hormone levels to prove a patient’s symptoms are real.

What can we do about hair loss?

Hair loss is complicated, so we begin by asking what kind of loss is happening. Diffuse thinning is not the same as a patch of missing hair, and a pattern that suggests androgen involvement may call for a different approach. We review nutrition and may check a blood count, vitamin D, and iron studies, including measures that help us understand iron stores. If the clinical picture calls for it, we look more broadly at health and inflammation.

Then we talk treatment. Minoxidil is often an early option. Topical minoxidil works for some people, but keeping up with applications alongside washing and coloring hair can become an entire scheduling exercise. Low-dose oral minoxidil may be easier for an appropriate patient, though it still requires a prescription and a discussion of risks. We do not choose a dose by copying a friend’s regimen.

Red light devices and platelet-rich plasma, or PRP, injections are other approaches we discussed. They can involve considerable cost, so we want realistic expectations before investing in them. If hair loss is patchy, persistent, or resistant to initial treatment, we want a dermatologist involved. Patchy loss in particular deserves evaluation because the cause may not be a routine hormonal change.

We also review any hormone products already being used. If someone has received a testosterone pellet and is experiencing high androgen levels, that information matters. We cannot solve every case of hair loss by adding another supplement. First, we need to understand the cause.

For gut health, should we focus on prebiotics or probiotics?

We focus on fiber first. Soluble fiber acts as a prebiotic, providing food for microbes in the gut. A capsule containing a tiny amount of prebiotic fiber cannot make up for a diet that is consistently low in fiber. We look for practical ways to eat more fiber-rich foods, such as legumes, nuts, seeds, whole grains, and leafy greens, according to what each person tolerates.

Probiotics are different: they contain microbes. Foods such as yogurt, kimchi, and miso can be part of that conversation. If someone is struggling to include them, a probiotic supplement may be useful. We look for third-party testing because supplement quality varies, and we consider products containing multiple species rather than assuming one strain addresses every need.

We are interested in research on probiotics and metabolic health during menopause, but we do not treat a capsule as a substitute for a varied diet. Food provides fiber and other nutrients together. That is usually where we want to begin.

Where does metformin fit if blood sugar is becoming a concern?

We do not prescribe metformin just because it has a reputation as a preventive or longevity drug. If someone has prediabetes or evidence of insulin resistance, the conversation becomes more specific. One measure we may use is HOMA-IR, which draws on fasting glucose and fasting insulin to help assess insulin resistance.

We start by addressing nutrition and reviewing the broader metabolic picture. If those efforts are not enough, metformin may be worth discussing with a clinician who knows the patient’s health history. It has potential downsides as well as possible benefits. We also want to be careful about applying results from studies in young men directly to women in midlife. We deserve decisions informed by evidence that is relevant to us.

The same care applies when cholesterol rises around menopause. A single number should prompt a fuller cardiovascular risk conversation, not automatically settle every question about treatment. Family history, other risk markers, and existing disease all matter.

Sleep and vaginal health deserve direct questions

If progesterone is not an option, how do we approach disrupted sleep?

First, we ask what is waking someone up. Is it a night sweat? Anxiety? A need to urinate? A room that is too warm? “I cannot sleep” is an important symptom, but the answer changes when we understand what is interrupting sleep.

We start with the environment and routine: a cooler bedroom, less stimulation before bed, a consistent sleep schedule, and putting the phone away. A fan or a cooling pad can help when heat is the problem. If nighttime urination is driving repeated awakenings, we may look at fluid timing and whether urinary symptoms need treatment. If anxiety is the issue, behavioral therapy may belong in the plan.

These steps are not meant to dismiss how miserable broken sleep can be. They help us target the reason it is broken, particularly when hormone treatment is unavailable or unwanted. We can also review common causes of menopausal sleep problems before deciding what to raise at an appointment.

What about magnesium, melatonin, or prescription sleep medications?

We discussed magnesium threonate as an option we sometimes favor when someone is looking for a calming supplement. Different forms of magnesium behave differently, so we would check the exact product and dose rather than treat every bottle labeled “magnesium” as interchangeable.

Melatonin may be more useful as a short-term tool than an indefinite nightly solution. Products also come in widely varying doses, and more is not necessarily better. With prescription or over-the-counter sleep aids, we want to ask about next-day grogginess, tolerance, and whether the medicine is masking a treatable cause of waking.

We are particularly cautious about routine, long-term reliance on sedating medicines. Even a common over-the-counter product used at night can leave someone feeling hung over the next morning. If a medication is needed during an unusually difficult period, that is a different conversation from taking it indefinitely without reassessing sleep.

What is our step-by-step approach to vaginal dryness?

We ask about it directly because many women will not volunteer the symptom unless someone opens the conversation. A lubricant is a practical starting point, especially when dryness or friction is affecting comfort during sex. We do not need to wait for symptoms to become severe before discussing one.

When dryness is an ongoing complaint, we discuss vaginal estrogen. If someone does not want estrogen or feels uneasy about it, we talk through the concern and consider other options. Intravaginal DHEA is one treatment we discussed because it may help support vaginal, vulvar, and nearby urinary tissues. An oral option exists too, although side effects can make it less appealing for some patients.

We also discussed vaginal CO2 laser treatment used in one of our practices, particularly when someone is reluctant to use estrogen. It is an option to discuss with a clinician, not a reason to assume every patient needs a procedure.

A history of breast cancer can make any estrogen conversation feel frightening. We do not want women to rule out relief without speaking with their own care team. We can review the available options and make a decision that reflects both the symptom burden and the individual cancer history. Vaginal dryness is common, but suffering in silence should not be the default.

Five habits we want to take into midlife

If we had to choose five priorities for perimenopause and menopause, what would they be?

We would choose actions that help us understand our risks and support our health beyond any single symptom:

1. Train for strength. We want meaningful resistance training with progressive challenge, not only movement that leaves our muscles doing the same work forever. Maintaining muscle becomes increasingly important with age.
2. Know our family history and find a healthcare partner. A family pattern of osteoporosis or cardiovascular disease can change the questions we ask. We need a clinician willing to have an informed conversation and work with us on a plan.
3. Learn what menopause can affect, then talk about it. This transition is not limited to hot flashes. Understanding potential changes across the body helps us recognize symptoms and seek care. Sharing experiences with friends and family also makes menopause less isolating.
4. Eat enough fiber. Most of us can do better here. Rather than obsess over a perfect supplement routine, we can keep returning to fiber-rich foods and notice whether our daily intake comes close to our goal.
5. Take an honest look at alcohol. We may find that drinks affect sleep and how we feel more than they once did. Limiting alcohol can be a practical choice, especially when rest is already fragile.

We do not have to navigate menopause by guessing which symptom is “normal” or by copying someone else’s prescription. We can bring our symptoms, risks, and questions into the same conversation. That is how we move from putting up with changes to making an informed plan for our own health.

This discussion is educational and does not replace medical advice. We should review symptoms, tests, supplements, and treatments with a healthcare professional who knows our history.