The Menopause: Symptoms, Long Term Health Risks of Low Hormones, HRT & Treatment Options

we're filming this today from my clinic in stratfor carl aven so i've got with me rebecca lewis who is a director here with me who's also a gp with a special interest in the menopause so thank you for joining us those of you who are live tonight um and we were going to record it so it will be available at other times as well so for those of you who are on our waiting list we're sorry that we can't get through you all and we've had a massive expansion in the clinic but for us it's really important that women are given the right information the right treatment by doctors and nurses and other health care professionals who really are very well trained and very frustratingly too few people are trained in the menopause so all the the healthcare professionals that are working with us have been trained to a high standard so we are recruiting more people we've got lots more doctors nurses and pharmacists actually coming to join us soon so the waiting list will improve so we wanted really just to share a bit of us with you tonight but also to just to talk through some of this you might know already some of it you might be pleased to hear again and hopefully there'll be some new information as well you'll see we we're not selling anything here we just have um different types of hrt that we will talk through later so we thought initially we would just talk about the menopause the perimenopause what it is what the symptoms can be and also the health risks as well which some of you might not be aware of then we'll talk about um treatments that are available and then finally we will talk about ways that you can help either before you come to the clinic or if you're never coming to the clinic that's fine as well but ways that you can empower yourself to get the right help support and treatment so rebecca we'll start off and i'm going to just we're going to do as a question and answer so to try and make it a bit less formal so let's just think first off what is the menopause and what is the perimenopause yeah i know it's important to get definitions right isn't it so menopause is actually a year and one day after your last period so you only know that once it's happened so it's a look back in time diagnosis isn't it and the peri-menopause is the time leading up to that to that last period and that can precede the menopause for about 10 years really so this is when the ovary begins to fail and stop producing eggs reliably we we run out of eggs which is normal and natural but when the ovary starts to fail the production of hormones is intermittent and fluctuates and can give women a lot of symptoms often quite dramatic in their perimenopause and this is the time when it can be difficult for women to understand what's going on because they're probably still having their periods or they may have changed a small amount and got a bit longer further apart or a bit closer together the period has actually got heavier or lighter and but they're beginning to develop symptoms and of course the symptoms can be quite strong on one month and then disappear uh the next so we you know it's here constantly in a clinic that people sort of normalize their symptoms so they attribute their their work life balance their stress at work difficulties with the children elderly relatives perhaps it's a it's a stretched time for women generally so this is why it could be difficult to know what's going on and and actually their symptoms are probably due to their uh fluctuating hormones rather than lifestyle because hormones are so important aren't they throughout our whole body and a lot of people think well hormones are just about our periods and when our periods stop well that's it end of and it's not as easy as that and there isn't one cell in our body that doesn't respond to the hormone estrogen then and when you think about that then it makes you realize that every single system in our body can be affected by our low hormone levels and that's what the menopause is it's a low hormone it's a hormone deficiency isn't it absolutely um and so a lot of people think you go through the menopause because symptoms might improve or stop or change but the low hormones always occur don't they and that's what happens isn't it with the menopause because our ovaries stop producing eggs this is it you're never going to get your hormones back no and a lot of people it happens naturally doesn't it our hormones just run out because our egg production reduces and our eggs stop being produced so therefore the hormones decline but yeah there are other reasons aren't there white people can be menopause yeah exactly so the average age of menopause here in the uk is about 51. but the age range is 45 to 55 earlier than 45 is called an early menopause but one in 100 people will be under the age of 40 when they reach their menopause which is not rare and one in a thousand will be under 30. reaching menopause naturally and then of course we have to think about menopause because of treatments um often cancer treatments the drugs themselves the chemotherapy can affect the the ovary and render women without without hormones or surgical they may have been removed um deliberately for a treatment process so women can be plunged into the menopause at all stages of life really it's important to know that yeah and like you say the perimenopause and that's the time around before the actual period stop the menopause can occur for a decade before so if one in 100 women are having it under the age of 40 yeah that means there's a lot of women in their 30s and 20s who are perimenopausal and don't know absolutely because there's not a blood test is there to diagnose how do we explain it it's very difficult there is no reliable blood test to diagnose this so it's a clinical diagnosis in the main you know on women's symptoms we we have a whole set of eastern deficiency symptoms um that we can go through and everyone knows about hot flushes and night sweats but actually as louise was saying earlier the importance of the hormone around our body i mean i i you know never ceases to amaze me how many symptoms lack of eastern can come and there are so many different websites out there and some of them will say there's 72 symptoms 96 there's some yeah and and there's always a discussion how many well actually i don't think there is a maximum number isn't it there because we constantly hear different symptoms yeah and even the hot flashes and sweats they're not even hot flashes sometimes some people become very cold don't they yes exactly so their temperature regulation yeah it's gone yeah so and if you work through the whole body you know our brain is really important so people get headaches dizziness they can get brain fog memory problems concentration problems yeah eyes you can get dry eyes and even dry mouth yeah that's quite common actually ears can be affected company tinnitus is a common commonly yeah yeah um our hearts are affected lungs even can be affected some people have breathing problems don't they or asthma can worsen it's um and then even the bowel a lot of people have um gastritis or irritable bowels yeah i've had some people with nausea actually come to me which was you know quite a new symptom i haven't encountered that that commonly but it is quite common and then if we think about our arms then a uh muscle can be painful sore people can have joint stiffness inflammation often people find in the morning just getting out of bed a lot of women say i feel like an old lady i can't walk down the stairs yeah and this is because estrogen is an anti-inflammatory isn't it in our muscles and our joints and and then if you work further down obviously it can affect the vagina we've already said vaginal dryness is a is the symptom which is very common and i think vaginal dryness is such a wrong word it's it makes it sound a bit dry i put a bit of moisturizer it'll be fine and it's so devastating yeah and it's bright actually a lot of people don't have dry vagina they they sometimes have increased secretions they do or they have discomfort or pain yeah and yeah there's any sort of difference in cleaning really isn't it but because we've got estrogen receptors on our vaginas but also in our bladders and our urethras people can have jewelry symptoms as well yes and often investigated have cystoscopies and investigations so that perhaps they may have had recurrent urine infections which is very common isn't it and again don't think about how important estrogen is and so really everywhere can be affected and it don't people don't get all the symptoms and some people don't get any symptoms some people get some symptoms and then they change with time and so it can be very difficult and the big sort of barometer if you like is periods isn't it so if periods are changing or altered or certainly they've stopped and you have symptoms you have to think about the perimenopausal menopause but a lot of women might have had a hysterectomy removal of the womb or a lot of women also have a marina coil yeah sometimes for contraceptive purposes and then they won't have periods so then how do we diagnose that's quite hard isn't it yeah i mean i i always advocate the use of um menopause questionnaire um which lists all these symptoms we've just listed um and and you can see it a quick glance yes you've got one i've got one here i'll show you yes so there we are it looks see and there are more symptoms than that but these are a list of all the symptoms we've just discussed so this is one we use in the clinic it's modified from one that's used a lot in research and you can grade your symptoms and it can be downloaded from my website manifolds doctor dot photo dot uk and it also the free app that we've got balance you can download and that's really useful actually and i really feel that women who are really young should start i mean i wish i'd started doing one of these 10 years ago and then every um like four times a year every three months you just do it again and if you're finding your symptoms are changing think about your periods if you're having them and if they've changed too they don't always have to change um in frequency but just their nature some people say oh they've got a bit lighter or even a bit heavier yeah it could be really subtle i mean often it could be someone who had a 28 day cycle and suddenly it's then it becomes 26 and the period's a bit lighter for example yes as a subtle change in periods and so again it's important to track and monitor your periods and so even with the app balance app you can do it that way as well um because it it's it you know everyone's busy i never used to monitor my periods at all time i wish i had because i would have realized what was going on when i started to have migraines and forgetfulness and irritability so um but this is a really great way isn't it and certainly for a lot of women just making the diagnosis themselves is really important because it can be really scary actually very frightening well you mentioned the brain fog and the loss of concentration struggling at work and people have really really worried that they're getting dementia they may have it in the family it's on their mind and they and they and just me saying that to them it's not dementia it's your hormones it's a great relief i don't say anything else when they're just pleased to know that information so one of my patients recently told me she'd given up work and she worked as an administrator she went in a big company she went there for 25 years and she said in the morning she'd get to work she couldn't remember her password and we all have times what we can't remember but she said every morning she'd look at the screen and think my goodness i can't remember and she'd hear the younger girls behind her almost laughing and she just lost her confidence completely and anxiety is a really common symptom isn't it i don't know anyone who hasn't had a degree of anxiety and gone through the menopause i mean various obviously but it can be just i mean paralyzing i would say absolutely women have become housebound certainly aren't able to work yeah not driving that's a common symptom actually they really people suddenly decide you know there's so much thing they can't drive on motorways or at night and they're not at all it's really common and i hadn't realized how common it was but just because we see so many women but also people um say they don't go on public transport and this is pre-covered times yeah you know they're too scared to go on someone said the other day she stopped driving because she couldn't use the sat nav because her brain couldn't drive and follow her directions two things going on too much multitasking yeah so it's um and women don't always realize and if you don't talk to other women you don't realize other women are suffering the same either do you well no well if you don't know it's the menopause you you're probably down having having head scans and seeing a neurologist and worrying about early dementia so you you haven't got a common sort of ground to talk with your friends necessarily that it is and you might be a little bit ashamed or worried about it for some reason which is crazy but yeah it's it's so wrong um you know when we are feeling anxious that we try and hide it and we need to need to discuss this and understand why definitely and i think some people are scared of talking about it because they think it's it's aging and of course it is something that happens when we get older but actually because young women are affected as well and i'm saying to you earlier i spoke to a lady today he's 27 and was brought into the metaphors because she had scotland we had breast cancer and the treatment it made her have an early menopause and she was really struggling and she said the clinic they said to her well it's just a symptom it's just a side effect of treatment and they sort of trivialized it so now she's finding it really hard to sit down because she has such bad vaginal dryness but she doesn't know who to talk to about she's had urinary tract infections no one's spoken to her about that and she's really alone actually very isolating when she's got enough to contend with her diagnosis totally so all ages we need to be talking about it and break this taboo so um but as doctors obviously we worry about women and patients who have symptoms but also we really look at people's future health as well don't we because as much as we're doctors we want to keep people away from us and you know the nhs in the uk is is overwhelmed but even other health care systems in other countries um only have so much money to spend and certainly since we trained in the 80s there's been a big shift isn't there between um now people with obesity type 2 diabetes cardiovascular disease alzheimer's the rates of these diseases is really gone hasn't it yes and most people now um women will die from alzheimer's or cardiovascular disease it's the number one cause of death yes and that's partly we're living longer aren't we so if we had this conversation 100 years ago um death would be quite different because we would die in our 50s which is quite soon after most women have their natural menopause as you say yeah but actually now the average life expectancy is so much more isn't it in the uk it's 82. yes exactly so that's a good 30 years on average yes you'll be post-menopausal yes so that means a third of our lives or so without hormones and so whether women have symptoms or not there are health risks aren't they not having these hormones which um for some of you that know me know i go on a lot about them because i think it's so important that we know because it didn't matter in the victorian times about these health risks because we died quite soon after exactly but they're they're real and and they are directly related to low eastern levels aren't they so so it's just yes so i mean as you say in victorian times the average age of death was 59 so we are now knowing more about the health risk because we're living longer we can see the devastating effect of living without estrogen on our cardiovascular system um and the the risk of of heart disease increases enormously when a woman goes through the menopause and often it's undiagnosed because women can present slightly different types of symptoms compared with men so they often do worse when they do have a heart attack um osteoporosis is one in two women over 50 will suffer with osteoporosis i mean that's a shocking shocking statistic and of course that's due to lack of estrogen as well um young women especially if they have a long time without eastern it's very clear that they have a higher risk of of all of many diseases including cardiovascular disease osteoporosis dementia type 2 diabetes obesity and even other sort of illnesses like asthma and depression um so it just shows how important it is um having our hormones are for our future health yeah for the function it is and and younger women who have an early menopause it's even more important because they have longer without their hormones potentially exactly so um these risks are really real and they're there and you know when when you say to women i spoke to a woman this morning no i'm through the menopause well firstly you're never through it even if you're through the symptoms you've still got low hormone levels but you're five times more likely to have a heart attack after the metaphors yes because estrogen is a great anti-inflammatory it reduces any low-grade inflammation in the body and low grade inflammation is not good because it increases like you say the risk of heart disease obesity diabetes but also some types of cancer so for example bowel cancer is thought to be a higher risk um when we were older as well but other cancers we are more common as people age and some of this is probably related to this sort of chronic inflammation that goes on when we haven't got estrogen in our bodies and so it's quite um it's more to it than just having estrogen to um stop your symptoms really isn't it so much more yes i mean it's really for the future your future health i think is is so important to be thinking about after all we're thinking about it in our diet perhaps or looking at exercise and and what have you which is all very important but actually the lynchpin is getting your hormones balanced and right first i think so that comes under treatment doesn't it so when we um look at what we're doing with our treatment for for menopausal women we've made the diagnosis or hopefully a woman's made the diagnosis herself then what can she do about it and the most important thing is to have evidence-based treatment because if you google menopause treatment there'll be so much that will come up and there'll be a lot coming up about using natural treatments as well and we all want to be as natural as possible we all want to eat fresh food we want to look after ourselves and so what is the most natural treatment for the menopause well i would compare it to is rectifying the problem which is replacing your deficiency similarly as if you had a low thyroid i don't think anyone would bat a knife if someone came to me and they had a blood test and showed it to low fire and i offered thyroxine it's obvious it's logic um well it's the same principle as in the menopause or perimenopause when the hormones are beginning to go down we simply propose to replace that with hormone replacement therapy that's what it stands for it's just giving you back your hormones to a normal level not a high level no normal female level and actually it shouldn't be called replacement i don't think because we often start hrt during the perimenopause when i've only said hormones start to dip sometimes they can only dip at some times in the cycle so some people with pms premenstrual syndrome find that their symptoms are worse just before their periods and that's when estrogen classically drops so we can sometimes give them hrt bit of hormone but we're not replacing what's there we're just topping it up aren't we so it should be a sort of hormone top-up treatment as opposed to hormone replacement because that sounds quite harsh that sounds like we're stripping women of their normal yes and then giving them something which actually happens with a contraceptive pill doesn't it yeah so with a contraceptive pill which most of us have been on at some time of our life is is quite high doses of hormones they're all synthetic so they're very man-made sort of processed hormones and and because they're high doses they suppress normal hormone activity don't they yeah and that's why they work because that's what it works to stop you so but hrt is different isn't it yeah and that's i think because everyone bundles hormones together and and hormone replacement is topping up your hormones so you're at a steady level really a female the female level um and not super high like the pill has to be much higher ten times at least the dose um to suppress um uh ovulation and and releasing the experts the whole point of it it's good you know for that point but it's completely different um concept really yeah um and it's it's topping up hormones or replacing hormones that have been lost and we and we always think in the most natural way using the regulated body identical in hrt um and it's derived from the yam root vegetable it's a nice derivation source you know it's really natural yeah you can't eat enough yarns to get the right levels so so yes and and it's very safe but it's regulated so we know exactly it's very important that the type of hrt you have it should be regulated body identical is the best and the safest and the less side effects and it means it's exactly the same chemical structure as the estrogen progesterone our ovaries produce um so the body likes it because it itself if you like it's not alien or foreign it works much better as well because it latches on to the receptor perfectly and then induces a the function in that cell that is attached to and it penetrates the blood-brain barrier very well to help our symptoms in the brain of anxiety depression concentration problems word-finding difficulties libido that sort of thing so that's why we all prefer this regulated body identical and that's different from unregulated bio-identicals yes and that is available in some private clinics and usually it's very expensive so if anyone's paying a lot of money for their actual hrt then it's just check what the source is and if it is a compounded bioidentical hormone then you should really question it because it's not regulated there's no evidence to support the use of these hormones and so the hormones and our little display here and are all hormones that we commonly prescribe in the clinic so the oestrogen we give through the skin and some of you might have read the reason that we do that is because it goes straight into the bloodstream we're just using the skin as a vehicle to get into the blood now it's different to a moisturizer for example when we put scented moisturizers on they're made in a different way so they can't penetrate through the skin and this is made so it does penetrate through the skin goes into our bloodstream so it's very different than if you're taking a tablet because if you have a tablet or something you have to digest it and then metabolize it so it gets broken down into something different and your liver has got chemicals and enzymes if you like that breaks it down it doesn't have to do that when it's through the skin does it just go straight into the bloodstream and the reason it's important that you know that is that the liver produces what's called our clotting factors so if we have a cut obviously we want to clot and stop the bleeding which is very good but if you have a tablet of estrogen these clotting factors can become activated and there's a small risk of clot now i'm not saying that everyone on tablet estrogen should stop taking it the risk is still small isn't yes it's a double risk which sounds really high but a woman's risk of clot is quite low so doubling a low risk is still a low risk um but because we've got alternatives that have no risk isn't it better to have that yes exactly why do um so we have choices which is great um so we have the gel we have patches or we have a spray so for some of you that haven't seen um this is a placebo but this is what the gel looks like obviously this is uk so in other countries it might be slightly different but the gel is just a clear gel like this so it's you can see it's very light it's very easy to apply now it's licensed for the outside of the arms and the inside of the thighs there's actually not much difference between the outside of my arm and the inside of my arm and so i wouldn't worry too much and you just literally rub it on like you would rub on a moisturizer and you know put it down some people um if they need two or three pumps would actually put two pumps in their arms and then rub it down together some people put two pumps on one arm it all depends on the skin type and you might see that this has rubbed in fairly quickly into my skin once it's rubbed in completely like a moisturizer and the skin is dry then you can carry on with your daily activities just wash your hands obviously so then you're not touching anyone with estrogen and after about an hour you can put on sunblock if you're going out in the sun you can go in the shower you can go swimming because it's already gone into your system you can't take it out again once it's there it only lasts the time that you use it um so the half-life of it is about 18 hours so it will only last today if i'm using it today tomorrow it will have gone so it doesn't build up in your system but it's a very efficient way to get in some people find that it doesn't rub very well don't they some people say it just drips off them if you have that skin type and you shouldn't be using it because it means that it's not being absorbed and so we then would look at something else there is a different type of gel that we sometimes use which is in a sachet like this and it's more concentrated so there's less volume which can be quite good for some people so it's quite nice having an option um and then there is a spray that's um been out in europe for a while but more recently in the uk and this is only red here because it's the placebo the real one is white um and this can be sprayed on the forearm and if you just literally spray it you might not even see on the camera it's a very fine mist that comes out and then you can just rub over the excess and then it goes under the skin and it's a sort of slow release into the body now this is designed that you can do three sprays on one arm and it's difficult to know roughly compared to the gel how much it is but one spray is similar to one or maybe one and a half pumps of the gel it all depends how the body absorbs it but you can see if you were needing to use say three pumps of gel twice a day you're going to run out of skin because the way you rub it in whereas this you can quickly do it and then you're good to go as soon as it's gone and your skin's dry then you can carry on with everything else and then there's the patches on there so she wants to just show you these are the sort of main patches that we use just because they stick on well really yes there's several types aren't there and i think some people have a problem with one but they change the type and they're fine so sometimes it you do have to sort of see which one suits you but they're very very nice to use um they come in a pack like this i'll open the pack um and the beauty of these is that they um release the hormone through the day um just gently every hour they release the almond so the hormone so it's a nice steady absorption and there we are i could see that that that patch it's very small it's discrete it's opaque really um and you put that patch on below the waist the upper thigh or the buttock under underneath the pants so no one can see if you're sunbathing or swimming or anything you can wear these swimming um you can go chat you know just do your normal activities um and and that's and that's fine um and they stay on you change them twice a week so one patch would stay on for three days and another patch will stay on for four days but they've got enough to last for four days anyway um and the hormones released slowly um every hour and as absorbed into the skin and it's exactly the same hormone as all the other gels we've just sprayed it's called 17 beta easter dial body identical estrogen and so it's just a different way of giving it and some people prefer patches to the gel or they might not get on with the patches so they use the gel and vice versa but generally they stick on very well now yeah they do and some people find if you shouldn't be having to put a sticking plaster on top some people on social media say to me oh i'm putting a plaster on top and it's sliding well then you're not going to absorb these student problems so you should use a different manufacturer because they all use different materials that's right so sometimes if you have a trouble with one that keeps slipping off you can find one that's more sticky and it stays on nicely but then some people have a reaction to to the glue very rarely but it might get a bit red or inflamed it depends if sometimes people take it off and there's some slight redness of the skin well you always put a new patch in a slightly different area and it comes down but if you have a very angry irritative area on the skin then um you can probably should talk about changing the type because it's just usually not a reaction to the hormone but a reaction to the gluten yeah exactly and these are very good for people with migraines often we use a that yeah level that people get and if they come in different doses so we can start off with a smaller dose and then gradually increase if need be and they can be cut as well if someone's feeling that they're on too much maybe initially and their body's getting used to it they can be cut as well it's half licensed but it's quite safe to do this as well so that's that's the oestrogen now um estrogen is needed by all women if they're perimenopausal or menopausal some people will write about estrogen dominance and say well i don't need estrogen and what happens in the perimenopause is you get these big swings so sometimes the estrogen will be very high and other times it will be very low and then when we're menopause and it's always low um when people um have these swings it can cause all sorts of symptoms yeah but sometimes actually having a bit of hormone estrogen like this um flattens out these spikes as well so it doesn't mean you can't have it um but estrogen is the good bit like rebecca said it helps all these cells that respond to estrogen people need different doses so it's not like the amount that i use will be different to the amount that rebecca uses that other people use because we are all different so we often start off with one dose and then we monitor how symptoms are don't we and then we sometimes do a blood test to see how much is being absorbed as well but younger women are designed to have more hormones than older women so if a woman is in her twenties or thirties she'll probably need a lot more estrogen than a woman in her sixties that's right and some people will have to wear two patches because they haven't got a we haven't got one that's high enough strength or some people have a patch and then sometimes have symptoms and then they might use the gel on those days when symptoms change so this and some people find that they're absolutely fine maybe for a few months or sometimes a few years and then they come back and say oh the hrt is not working that's right and it is working but it's just that's right i mean i say to ladies in the clinic that actually it's chasing a moving target when you're perimenopausal because your ovary is working we're not 100 and you may come to see me and it's sort of 80 functioning um and as louis is saying you top up to make it the right level and you carry on but then that ovary is only going to deteriorate sadly and that's natural that's normal it's going to decline in its function so as the ovary declines we need to top up more so that's why it's really important women know about their symptoms and if their flushes or sweats or their sleep which had been good deteriorates again they could think ah i think i need some more estrogen to top that up yeah and it says fluctuating because literally if you draw a graph the estrogen goes up and down up and down in the perimenopause it's a chaotic and that's really how women can feel one minute they're okay next minute they're on their knees and it's really important just to say a little bit about the the mental psycho psychological changes of the menopause because that's what brings women to their knees um the low mood um the loss of joy i describe it as really a lot of women have this loss of joy in in things that they used to find exciting interesting their schwa de vivre everything is is overwhelming and an effort isn't it and the anxiety and and this is to do with the fluctuating hormones in our brain so if we can add in estrogen when they're fluctuating we find that the um levels just steady out and that's very good for our brains and our sleep and our mood so estrogen is the really good bit and actually it's really safe so if we get the dose right it can improve the symptoms that are related to estrogen deficiency which is great but also we know from really good studies that estrogen reduces the risk of all these diseases that we've spoken about so it reduces the risk of heart disease by about 50 it reduces the risk of death from heart disease by about 70 so that's a lot but it also lowers risk of osteoporosis of type 2 diabetes and also dementia too we also know that it can um help with weight so actually estrogen through the skin can help reduce weight because our bodies put on weight during the menopause often because fat cells contain a very weak oestrogen and our body needs estrogen as we've said and how can it create it we can't create it in other ways we can't restart our ovaries so fat cells produce this very weak estrogen which is a bit pathetic really but it's all it's got and so when you're giving yourself estrogen um the fat cells don't need to work in the same way so people do tend to lose a bit of weight as well don't they um so but people worried about hrt and they're worried about the breast cancer risk which we'll talk about in a minute but everyone thinks that it's the oestrogen that causes breast cancer doesn't it and that's not true is it no it's not not eastern at all in fact women who've had a hysterectomy they have their hormones back just with estrogen um and they have been followed up for 18 years and they have actually found to be have a slightly lower risk of breast cancer for women who are on estrogen-only hrt now we think why isn't everyone on eastern only hmit if you do have a womb then you have to have a progesterone it's advised to have a progesterone because the estrogen would cause thickening of the lining of the womb and if it was left and left it's a risk factor for further problems of hypoplasia and even endometrial cancer so it's important to obviously to prevent that and progesterone will prevent that so if you have a womb you must take estrogen for your symptoms and progesterone to protect the lining of the womb and that's really important to know so most um women and also most healthcare professionals who've done some surveys which have confirmed it think that estrogen is the bad bit of hrt because if a woman has breast cancer it's always categorized is it estrogen receptor positive or negative just because it's got an estrogen receptor on it doesn't mean the estrogen has caused the breast cancer the same way that rebecca said we have estrogen receptors on cells in our body this is another cell but it doesn't mean estrogen has caused it and it's very reassuring from this study that shows over 18 years women have a 25 lower risk of breast cancer and also a lower risk of death from breast cancer if they have estrogen on its own so really there's very few reasons why women wouldn't have oestrogen the biggest reason really why women wouldn't have it in their first line is if they've had an estrogen receptor positive cancer often breast cancer um and but we haven't got good data to say that it's actually harmful for these women but those women should be seen by a specialist menopause um doctor or nurse um to discuss through their options that you can never say never to anyone about anything and this includes women who've had breast cancer whether it's oestrogen receptor positive they still sometimes can have um estrogen but that's a very individualized choice so we can't really talk about specifics um so then where is this breast cancer risk come from because we've said how safe estrogen is so we think it's the progesterone possibly that increases the risk of breast cancer but when you look at all types of hrt and we're talking about the old-fashioned hrt they used to make from mayor's urine and looking at all the different types of progesterones there may be a small increased risk but it's very small and four extra cases per thousand women after five years of taking combined hrt what does that mean so it's a funny thing to sort of visualize that actually is less than drinking two units of alcohol every night so that's a large glass of wine and that's the reason because that's the risk that's the respect for breast cancer isn't it yeah two glasses of wine a night yes is the same risk as the older types of progesterone and progesterone yes and but if you look at a bottle of wine it doesn't say risk of breast cancer you know stopped straight away but actually if you look at the insert even for the oestrogen and it will say in here risk of breast cancer now it doesn't have a risk of breast cancer and even in the progestogens and the progesterone it will save risk but actually the risk is so low that it doesn't even need to be reported we haven't got a really good study that shows that there is definitely a risk with breast cancer because the way the big study that was designed that came out in 2002 it wasn't looking at breast cancer as an endpoint it was looking at um are there health benefits of taking hrt in women who started when they're a bit older in their 60s and they gave very high doses of tablet estrogen and which i've already said has a clot risk and an older type of progestogen which also has a clot risk actually and a risk of heart disease and possibly this risk of breast cancer but it was so small they couldn't say for sure and they don't think it was statistically significant but the media were told the results before they had been analysed properly and it went crazy in america came over here and everyone just said my goodness me it's going to cause so much breast cancer we need to stop hrt now that was 18 years ago in 2002 but actually the incidence of breast cancer hasn't reduced its increase hasn't it since that time so if hrt which lots of women were taking far more frequently than they do now if breast cancer had been caused by hrt it would make sense that the level that the incidence of breast cancer would have fallen off and reduced it hasn't and that's partly because of lifestyle factors such as obesity drinking alcohol not exercising are risk factors for breast cancer and breast cancer is actually more common in women who have gone through the menopause and what is it about women have gone through the menopause let's think well they don't have estrogen in their bodies no so why are they getting breast cancer well because estrogen isn't the cause of breast cancer so you need to take a step back and think logically and we've all been whipped into this frenzy haven't we about that and we're the same we've grown up being told this wrong information as proud care professionals as women we've been fed wrong information so the work that we're trying to do from the clinic and some of the education we're doing is really difficult because we're trying to make people think very differently but actually what we're trying to do is give people the evidence you know and the evidence is very clear so the oestrogen is what's needed we've already said so progesterone is this natural progesterone that people can take as a tablet and in the uk it's this which is called eutrogestan and it comes as a capsule so it's an oral capsule that is very sort of soft it's a gel filled jelly filled capsule and this is the same as a record of this body identical progesterone so it's the same structure as we produce ourselves and it can be taken in two different ways so if a woman starting hrt who hasn't had a period for around a year she can take one of these every night we say take it at night because it can be a natural sedative which is quite nice for some women actually you just take it at night um orally one every night and going forwards periods shouldn't occur if a woman is still having periods so she's perimenopausal we change the way it's taken so people usually take two of these at night for two weeks and then have a two week break but continue with the estrogen every day and that often leads to periods and some women who have heavy periods find they're pretty much lighter when the hormones are balanced that's great yes so this is the best type of hrt and the progesterone to have because there's less side effects because it's a natural body identical progesterone and it can be good for blood pressure so anyone who has blood pressure can have the estrogen through the skin and this whereas they wouldn't have the contraceptive pill within their example so um and also it doesn't affect the risk of heart disease or clot so so this is the safe one some people use the marina coil as rebecca said which contains a synthetic progestogen but um it helps to keep the lining of the womb thin and also works as a contraceptive so that can be very useful as well and there are a couple of patches we've got here um this one's called everal conti and overall sequi and these contain a combination of estrogen and a synthetic progestogen that go through the skin this is the only way that you can have progesterone through the skin and in a regulated way and some people find these are useful they contain quite a low dose of estrogen so sometimes people use the gel or a different patch as as well at the same time um but there are progesterone creams available but they're not regulated are they um so you can buy them on the internet sometimes can't you but well we don't know anything about them no you know i would really worry about that because how much is getting into the bloodstream after all the reason we're taking progesterone to protect the um so and some of these bio-identical clinics we mentioned do do uh creams of progesterone and so you really shouldn't be taking them to protect the lining of the womb yeah so that's so it's quite straightforward the estrogen the progesterone and then some people um use testosterone as well because testosterone is another hormone that we produce in higher volumes actually than estrogen before the menopause it's another hormone from our ovaries and a lot of people think well estrogens for women testosterone is for men and so many things people think that it's so vital for women it is isn't it and we produce more testosterone yeah than instruments and it affects lots of cells probably all ourselves um but it it we know we work out of all the guidelines here we've got very good guidelines and we're working with from the evidence but the guidelines say that if a woman has reduced sexual desire she can consider testosterone once she's on hrt so for those of you that are scrambling after testosterone you have to have estrogen first for a good three months really yeah because if you don't the testosterone just gets converted to estrogen doesn't work does it exactly so you have estrogen first and then if you still have symptoms but it's not just libido is it no it really helps so many other other factors again in the brain so vital our cognitive function you know problems with word-finding difficulties multi-tasking it can really help that our memory just thinking clearer and sharper so getting back to work is easier functioning at work and that that sort of thing so our memory concentration and fatigue is a really big big symptom and it really can help that sort of that as well so it really helps improve stamina but also some of the muscle and joint pain yes it does as well and athletes often notice straight away that they're without their hormones they're much weaker and even when eastern is replaced properly they're still not back to their usual uh standard but then add in some testosterone and their muscle function becomes much better and you we sometimes do a blood test but blood tests are usually lower aren't they testosterone levels a woman is perimenopausal or menopause it's very likely because testosterone declines with age whether it's really related to the menopause or just getting older we don't really know but then what we do is replace the missing testosterone and monitor blood tests to make sure it's within the normal female range and we don't have a licensed preparation for testosterone in the uk which is absolutely outrageous shocking it's awful um obviously there's male testosterone because of course men need their testosterone if they have a deficiency so you can through the nhs and have male testosterone and very low doses prescribed or some of you might have seen this which is um called androphyll which is a female testosterone cream made in western australia and actually it's just been licensed in australia testosterone for women which is a great move for women and hopefully it will be licensed in the uk before too long and this is just a cream that you just use it's um just a pea size of white cream that you rub onto to your leg and it comes with a syringe actually so you can draw up the exact amount and rub it on it can take several months to have an effect so we often say to use it for six months and then decide whether it helps or not and a lot of people find it really helps with a lot of symptoms and there's some evidence that it reduces risk of cardiovascular disease and maybe dementia as well so there's benefits for it too um and then the other selection of things we have here is is actually vaginal symptom treatment so you know we've talked about vaginal dryness actually it's now being changed and the term is now called genitoury syndrome of the menopause gsm because it's quite a mouthful because of the urinary symptoms that occur a lot of people um are ignored maybe if they're not sexually active a doctor might not think about talking to them or asking if they've had any symptoms but if a woman has recurrent urine infections or going to the toilet more frequently then we really need to think about what's going on locally and this is regardless of hrt or not so around a fifth of women twenty percent of women taking hrt will still develop some vagina that's right i often need treatment for the vagina in a local way as well as this is what we call systemic hrt which is is the the gels and the progesterone that's right and women who don't take hrt studies have shown about 80 so 8 out of 10 women will have some symptoms at some time and symptoms such as flushes sweats can improve with time it can take several years for some people but they often do subside whereas vaginal dryness symptoms will carry on often worse than won't they so if you are experiencing symptoms now then you're likely to always have them unless you have treatment and the most obvious way of treating is by replacing the estrogen locally in those tissues but we know only about eight percent of women have symptoms so there's a lot of women out there really struggling so these are treatments that can be given um locally we've got a choice which is great we've got pessimise a vaginal tablet we've got cream and most of them just contain estrogen but it's a very low dose isn't it very low dose and very safe to use i was just going to show this one as a popular one vagifem and that's body identical 17 beta estradiol and that's given um the little uh applicator with a small white tablet of estrogen in there in the top and it's simply inserted into the vagina um every night for two weeks and then um we reduce the dose according to the symptoms really you can then reduce the dose to twice a week but some women we find need more than twice a week and so we we may say go up to four times a week the dose of vagifem this is what it's called is 10 micrograms in these little tablets they used to make um vagifem 25 micrograms so we used to be able to get two and a half times the dose but they don't make it anymore and that was useful for women's whose symptoms hadn't settled just using the 10 micrograms twice a week so you can go higher than that and the reason you can go higher as well is because hardly anything gets into the bloodstream so i think if you use pessary twice a week for a whole year that is the equivalent in blood level terms of one hrt tablet of estrogen so you can see it's very safe it works really well locally in the vagina on the walls to increa increase blood flow to increase the layer of lubrication which we should all have in the vagina to strengthen the pelvic floor muscles to help bladder muscles so that urgency and frequency is is helped by estrogen to help the lining of the urethra that the tube the urine comes down because that can get very dry and red and angry without estrogen and if we put the eastern into the vagina because the bladder sits just in front of the vagina it gets absorbed into the bladder as well so it can really help what we call those local symptoms of vaginal pain soreness you don't have to be sexually active to have these symptoms just even sitting down the leak can be horrendously uncomfortable women stop wearing jeans or underwear it's so uncomfortable so it's a very simple very safe way of delivering estrogen into the vagina and and these are not hlt actually no so although it's a hormone and it isn't same as hrt so despite what the insert says which again is out of date and wrong all women really can use vaginal estrogen so even women who've had an estrogen receptor positive breast cancer can safely use vaginal estrogen because the amount that's absorbed is the same as a placebo as in it isn't absorbed into the rest of the body so women who have been stripped of their estrogen because of their treatment can still safely have estrogen locally and that's very important actually a lot of women don't realize that a lot of healthcare professionals so oncologists breast cancer specialists don't realize how safe it is and it really is so most experts are in agreement that you can and so there's really very few women who can't and so if you've been refused it you should really be saying what what's the reason so just for the last few minutes i really wanted to just maybe help empower you with information it's all very well for us as medical specialists to sit here and say this is what you need but i completely understand how hard it is for so many women to get hrt actually we know a lot of women are incorrectly prescribed antidepressants some women are told it's just a natural process you've just got to go through it and other women are telling well really don't worry you don't need hrt because it's going to give you breast cancer well i hope you've realized now how safe hrt is it's not just about hrt we have to look after ourselves as well but hrt really makes a difference because it's that hormone so there's lots of information and on my website menopause doctor dot co dot uk um rebecca's got some booklets and and fact sheets that we have printed here in the clinic um but they're very easy under the resources section we've got a lot of these that you can download print off um and also there's lots of videos as well that you can show and then for some of you might have seen um my book that i uh came that came out last year it's a haines menopause manual um which is full of evidence-based information i've got another book by penguin coming out in 2021 and then also there's our app called balance which is a free app available to anyone to download worldwide just go to the app store or google play and search balance and this has got a lot of information in it but there's also a community section where you can share your experiences with others and others can comment you can also have the questionnaire of your symptoms and you can track how your symptoms hopefully improve with treatment and you can see how other people's treatment has hopefully helped them or not help them as well and there are some experiments that you can join in with to try and really help improve your lifestyle and we've got a lot more plans for the app going forward so there's a whole armor really of ways that you can really help um but i understand it can still be difficult when your doctor who's very qualified and knowledgeable sits there and says no you can't have hrt you know we shouldn't be here in a private clinic we should be working in the nhs but neither of us can get a job in the nhs because menopause care isn't a priority it will do and it will change if your doctor or healthcare professional is refusing to give you hrt then i think you should really just say look i've read this information i know it's backed by evidence and please could i see someone else in the practice or could you really tell me the reason why i'm being denied it and if they say it's a breast cancer risk you can explain that you know the risk is very low and it's about your choice as individual patients we are allowed to have our own choice whether there are risks or benefits whichever way they are even if the risks outweigh the benefits we can choose but we know that for the majority of women the benefits of taking hrt outweigh any risks so we are at liberty to ask aren't we for treatment and i know that's really hard to say but for those of you who are waiting for treatment or those of you who are denying treatment and you think it's wrong then you really need to have some confidence to go back to your doctor and to challenge which i know is really difficult but i hope this last hour has given you some information some food for thoughts and ammunition as well but more importantly some encouragement that there is help all of us should receive the right help care advice support and treatment because the menopause needs to be really positive experience for us so i hope this some way will help you so thanks ever so much for listening today and good luck with everything is all we can say already so thank you thank you you

Channel: balance Menopause

Views: 266,263

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Id: 2EKE59OwMx0

Length: 57min 13sec (3433 seconds)

Published: Tue Dec 22 2020