Menopause Masterclass: My Menopause Toolkit – HRT and more

Haver explains that she was on the highest-dose patch and felt great, but her serum estradiol levels were below the bone-protective threshold. She considered adding a second patch but faced insurance issues. She opted for low-dose oral estradiol at night, which not only boosted her estradiol levels but also normalized her cholesterol. She emphasizes that this is an individualized solution based on her labs and goals, not a standard recommendation. She also notes that oral estrogen's effect on SHBG can be problematic for libido, so monitoring is important.

Haver emphasizes that progesterone is mandatory for uterine protection but also a powerful sleep aid. She describes how she never misses her dose because of the sleep benefit. She notes that some women cannot tolerate it orally and can use the same capsules vaginally, which still protects the uterus but bypasses the first-pass metabolism that produces allopregnanolone, potentially reducing the sleep benefit. She also mentions alternatives like the Duavee (conjugated estrogens/bazedoxifene) for those with progesterone intolerance or high breast cancer risk.

Haver explains that she started testosterone off-label not for libido but because she read that women in the highest quartile of testosterone had better bone and muscle strength. She hoped it would help her maintain muscle with her workouts. She later noticed an uptick in desire. She stresses that testosterone is for women who miss their previous libido, not for those content without it. She details the application method (pea-sized amount on hairless inner wrist, rubbed between wrists) and the importance of baseline and 3-month follow-up labs. She also warns against pellets due to supraphysiologic levels and irreversibility.

Haver passionately advocates for vaginal estrogen as a life-saving intervention, noting that severe GSM affects up to 84% of postmenopausal women and remains undertreated. She explains that the tissues become thin, dry, fragile, and prone to infection. She uses the cream because it's cheap (~$15/tube) and accessible. She describes the application technique in detail and mentions alternatives like Vagifem tablets, Imvexxy suppositories, and the Femring. She also discusses DHEA (Intrarosa) as another option but prefers her OTC DHEA cream for the vulva.

Haver explains that she uses a specific OTC product from Dr. Kelly Casperson (Julva) that contains DHEA and vitamin D in an oil-based moisturizer. She prefers it over the prescription Intrarosa due to cost and texture. She notes that even with vaginal estrogen, some women need additional androgen support for the vestibule. She applies it externally, not as a suppository.

Haver notes that one can use vaginal estrogen cream on the face, but the alcohol base can be drying. She prefers a dedicated estriol cream (likely Alloy M4) in a moisturizing base. She applies it every morning and finds it easy to incorporate. She emphasizes this is not a recommendation for everyone but part of her personal routine.

Haver explains that in her clinic, over 80% of menopausal women have low vitamin D. She checks levels and often gives a prescription loading dose first, then maintains with this supplement. She combined omega-3 and vitamin D for convenience, adding vitamin K for synergy. She emphasizes that vitamin D deficiency is linked to weight gain, diabetes, dementia, poor sleep, and cardiovascular disease.

Haver notes that she checks homocysteine levels in patients and finds many have high levels due to poor B vitamin utilization. She designed this product to address that with methylated forms. She also included CoQ10 for heart health and genistein for its studied benefits in menopausal women. She emphasizes that this is a targeted multi, not a generic one-a-day.

Haver explains that she was excited by the Fortibone studies in menopausal women not on any other bone interventions, showing benefit over 5 years. She combined it with Verisol for skin benefits. She adds it to her morning shake along with Greek yogurt, whey protein, creatine, and fiber.

Haver references research by Dr. Abby Smith-Ryan on creatine in women, noting that aging reduces endogenous creatine synthesis. She adds creatine to her water with electrolytes for taste and hydration. She emphasizes that most women should consider creatine supplementation.

Haver notes that she consistently gets 25–30 g from food (avocados, seeds, nuts, legumes) but uses the supplement to exceed 35 g for cardiovascular protection. She emphasizes that fiber is a key tool for reducing diabetes and heart disease risk.

Haver explains that she takes this form specifically for its brain penetration. She references a study where it helped SSRI-resistant depression. She takes it during the day to get magnesium into her brain, while using magnesium glycinate at night for sleep.

Haver explains that after reading data from the Louise Newson Clinic and other publications on transdermal absorption variability, she began checking levels in her own practice. She found that even on the highest-dose patch, her own levels did not reach the bone-protective threshold (around 70 pg/mL). This led her to add a low-dose oral estradiol at night. She now recommends a high-sensitivity serum estradiol level at month three for all patients, especially those with osteopenia, osteoporosis, or family history, to ensure adequate absorption. She acknowledges that guidelines are likely a decade away from changing but believes this is the latest evidence patients deserve to know.

Haver explains that after realizing her patch alone wasn't getting her estradiol high enough for bone protection, she considered adding a second patch but faced insurance hurdles. Instead, she added a very low dose of oral estradiol at night. She notes that oral estrogen improved her cholesterol more than the patch alone, bringing it into the normal range. She emphasizes this is not a blanket recommendation but an individualized solution based on her labs and goals. She also cautions that oral estrogen can increase SHBG, potentially worsening libido or genitourinary syndrome, so monitoring is key.

Haver explains that one can use vaginal estrogen cream on the face, but the alcohol base can be drying. She prefers a dedicated estriol cream (0.3%) in a moisturizing base, which she applies every morning under makeup. She emphasizes that this is purely cosmetic and not something she recommends to every patient due to cost, but she includes it for transparency.

Haver explains that she uses a lower-dose DHEA cream from her friend Dr. Kelly Casperson (brand Julva) on the vulva, in addition to vaginal estrogen. DHEA converts locally to estradiol and testosterone, addressing both estrogen and androgen receptors. She notes that the FDA-approved vaginal DHEA suppository (Intrarosa) is expensive and not generic, so she prefers this OTC option. She likes the texture and the added vitamin D in the product.

Haver explains that fezolinetant (Veozah) and a newer competitor from Bayer are neurokinin 3 receptor antagonists that stabilize the thermoregulatory center without systemic estrogen. They are particularly useful for active breast cancer patients or those with contraindications to estrogen. She notes that paroxetine (Brisdelle) is FDA-approved for hot flashes but is contraindicated with tamoxifen because it inhibits the enzyme that converts tamoxifen to its active metabolite. Fezolinetant does not have this interaction, making it a valuable option. Cost is currently high, and generics are years away.

Haver describes her experience with perimenopausal hair loss, which she likened to postpartum shedding. After working with dermatologists and ruling out other causes (low iron, etc.), she used topical 5% minoxidil for years but found it messy and incompatible with hair coloring. She switched to oral minoxidil 2.5 mg (half of a 5 mg tablet) at a cost of about $5 for a three-month supply. She explains that minoxidil prolongs the anagen (growth) phase of the hair cycle and dilates blood vessels to the follicle. The dose for hair is far lower than the 10–40 mg used for blood pressure. She emphasizes that anyone with hair loss should first check vitamin D, ferritin, and see a dermatologist.