Begin Again with Davina McCall - GP & Women's Health Expert: How Menopause Affects The Whole Body. Why Women Are Ignored In Medicine! Dr Nighat Arif.

Episode Date: October 24, 2024

This week on Begin Again, Davina welcomes the incredibly inspiring Women’s Health Expert and GP, Dr. Nighat Arif. In this episode, Dr. Nighat joins Davina to talk about her career dedicated to breaking the taboos surrounding reproductive health. Born in Pakistan and having moved to the UK aged nine, Dr. Nighat shares how her personal journey and cultural background have driven her passion for advocating for women’s health, from menstruation to menopause. She reflects on her ongoing mission to empower women of all ages to approach their health with confidence, understanding, and without stigma. Find Dr Nighat's book "The Knowledge: Your guide to female health – from menstruation to the menopause" here: https://amzn.to/4fcOXh6 Follow me here: www.instagram.com/beginagain https://www.tiktok.com/@beginagainpod  (00:00) Intro (01:24) What Is Nighat's Mission For Women's Health? (04:48) Growing Up In Pakistan: Nighat's Story (08:29) How Nighat's Father Inspired Her Family's Success (12:23) Nighat's Journey: Identifying The Need To Support Women's Health (13:53) Misogyny In Medicine (15:53) Uncovering Racism In The Healthcare System (20:13) The Menopause Explained: What Every Woman Needs To Know (23:44) The Stigma Of Women's Health In South Asian Communities (25:31) How To Find Help For Menopause: Nighat's Advice (27:49) YouTube Health: A Platform For Women's Health Awareness (29:15) Adobe Ad (30:24) Spotify Ad (31:23) Hormone Replacement Therapy (HRT): What You Need To Know (33:01) Breast Cancer And HRT: Understanding The Risks And Benefits (34:57) The Health Benefits Of Hormone Replacement Therapy (36:48) Vaginal Oestrogen And Breast Cancer: Separating The Myths From Facts (41:57) Why Women Have Been Misled About Their Health (43:28) Is Age A Limiting Factor For Oestrogen Therapy? (45:41) Are We Over-Medicalising Women's Health? (50:35) The "Tough It Out" Mentality: Why Women Deserve Better Healthcare (53:13) Nighat's New Book: A Must-Read For Women’s Health Sponsored by: Adobe - https://www.adobe.com/uk/express/ Shopify - Shopify.co.uk/DAVINA SetArtwork provided by Kimi Zoet. Enquiries: [e-mail] https://g2ul0.app.link/oQMAPbdSGNb Learn more about your ad choices. Visit megaphone.fm/adchoices

This episode is brought to you by Tellus Online Security. Oh, tax season is the worst. You mean hack season? Sorry, what? Yeah, cybercriminals love tax forms. But I've got Tellus Online Security. It helps protect against identity theft and financial fraud so I can stress less during tax season or any season.

Plan started just $12 a month. Learn more at tellus.com slash online security. No one can prevent all cybercrime or identity theft. Conditions apply. If you want to find a toxic workplace that's misogynistic, and I hate saying this because it's my own community. It is medicine. Still now.

I became a doctor and I was like, I never want to do women's health. But 3 o'clock in the morning, I had a patient who came in, who now I know was perimenopausal. The doctor said to me, it's flipping nothing, just get her out. And I was just like, sorry. It's really sad that women put up with that. It was then for me the penny dropped that. I am dealing with women's health issues which are going in and out of A&E,

and this could be prevented at the door. Women need to understand what's happening. My grandmother went through this, my mother went through this, I'm going through it, and I'll be damned if my daughter goes through this. If nothing changes, nothing changes. And that's so sad and we're stood still. You have to think of menopause as being a head-to-to-to-to-to disease, physical symptoms and then psychological symptoms.

The best way I can say it is I just don't feel myself anymore. It's very lonely when you're in that space by yourself. and you're thinking, I'm the only one going through this. There's one person saying, absolutely don't do that. And there's another person saying, do do that. Where do people go to find the truth? Menopal sells. And I'm afraid snake oil always sells. We have so much work to do.

But anybody listening to this podcast and talking, I would say three things to you. Please, if you do anything. Nigat, I'm so happy to have you sat opposite me today because, well, firstly, I want to say we've been friends for a very long time now, haven't we? And I really, really admire you. And I think the work that you've done around women's health for so many different communities and for so many different people, the difference that you've made to their lives going forward.

I mean, even personally speaking, my daughter, realizing that she had adenomyosis. And it was thanks to you. He spoke about that. I had somewhere to go. So thank you. So it's an honour to have you on here today. I wanted to start by asking you kind of what is your mission in life. In terms of work, who do you want to reach?

Where do you want to go? I think firstly, my imposter syndrome just won't let me hear all the nice stuff that we just said. So that's my first mission to flippin, get over that. I just be like, I struggle with compliments. But thank you so much. And I think my main mission is just to have accessible women's health. because I fundamentally believe that if the woman is well within any household, any workspace and she's happy in her skin, she's happy physically, she's not in pain,

she's able to carry on and look after her babies and look after her family, look after herself, you know, even if she doesn't have extended family or those around her, and she's just comfortable with herself, then she thrives. But not only that, society thrives, community thrives. economy thrives. And so if you put women and girls at the heart of any of your work plan, I always think that when we were building a house, you put foundations in. And in your foundations, you're thinking about women and women and girls.

Then whatever structure you put on top, it's going to be flipping so strong. And we haven't done that for decades and decades. Look at the research. Look at everything. We always sort of think of women as an afterthought, and they are secondary to men. They are secondary to men's achievements. They are secondary to what is capable of as a society, of even when it comes to basic things like respect or accountability

and making sure that women are looked after well. And we're not little men. We're not little men. We're not little men. And so my mission really is to change the narrative or change the dial in the most smallest way possible. but in the biggest way where it's not just then, when it comes to women and girls, it's not just for the majority you're always seen.

So women like me are seen, South Asian women, black and Asian communities, marginalized communities, whatever you identify, you come and bring your full self and not hide who you are. So I'm really proud to say, I'm a Pakistani, British, Muslim woman who wears a hijab. And I'm really comfortable. and it's taken a journey to get to this point, whether it's my journey with the hijab. But I am the most comfortable I've ever been,

but it's taken me to my 40s to really understand that. I want to talk to you a little bit about growing up in Pakistan. I know you left when you were nine. But what was life like for you before that as a young woman? I have really clear memories of being in Pakistan. So we as a family, there are two families, and we grew up in a village and it's named 38, so 38 Fatei in Bahawalpur, Bahawal Nagar.

And it's on the river Indus, so in Punjab, and we're in the thick of it because we were subsidy farmers. So we grew up on a farm. And I remember having very vivid memories about sort of the age of four or five going to the cotton fields with my mum to pick cotton. And I was expected to pick cotton. And it wasn't a bad memory because I was always with my cousins,

but it was just survival. remembering, you know, if the monsoon rains didn't come, there was famine and remembering the fact that my first drowning experience happened when I was about seven because there would be makeshift little canals of river to try and get all the water into the fields. And I thought I could swim. So that put me off swimming for a very long time. But fast forward now, I'm now a really good swimmer. So I go swimming regularly.

And then the first experience of being held back because of my gender, the nearest closest school was about a mile away, which was a walk in really blistering heat. And only my male cousins were sent. I wasn't sent because it was really difficult for the family to ever send girls so far away and especially really, really little. I remember talking to my grandmother when I was about 23

and I was getting married and, you know, God rest of soul, she's not with us anymore. And I spoke to her and I said, you never sent me to school and she laughed and she said to me it did you no harm but had I sent you to school your father was in the UK being the Imam he's a priest and she goes that if you'd got kidnapped then I wouldn't have been able to look your father in the eye and so very little I was I grew up as a tomboy my head was completely shaved me and my cousin who was also a girl and we would just brought up like little boys up until the time came when it was sort of safe.

And it's because it was... So you mean you were kind of treated like boys so that somebody wouldn't kidnap you? Yeah, I wouldn't wear a little... I remember not having dresses. I think the first dress I wore was when we came to the UK and my mum put me in a little pink dress. And there's a photo of me in a small pink dress. Because my father had convinced my mother we're going to a lush green country

where it's absolutely beautiful. So I think she thought we were coming to the Caribbean because he was like, we're going to an island, which is right, because we are an island. Not quite the same. Not quite the same. So we landed in April on Heathrow, walking down the stairs. And it was raining and it was nine.

And I wore a pink dress, which my mother had sewn because my mother's a seamstress, and absolutely in flip-flops and suddenly landing in this alien country in rain. And I just remember going, oh my God, what is this place? I'm fascinated by this new journey because it's me, my two other brothers

and my mum and my dad. And the decision was made to come over because my father, who's the Imam, had been here for a long time. And my uncle, my father's older brother, had said to him, you know, the kids are getting older, and it gets now older.

She really is fighting to go to school because I would fight. I would argue so much with my other family members going, I don't want to do household chores. I don't want to learn this. I don't want to be doing domestic chores around the house. I want to go to school.

Your dad was something of a legend, right? He's the longest serving Imam. Yes. So my father has been the longest serving Imam in one area in Cheshim. He got an MBE from the Queen, from the late Queen herself just before she passed. And so it was a real moment for us because he's been recognised as someone to further the Muslim faith. And I suppose the significance of that is, is there's so many misinterpretations in mainstream media

of what Muslims are like, that we're very aggressive, suppressed women, depressed, and don't integrate with the community. And that's really unfair, because I would definitely say, I'm not a unicorn. I'm not hidden. I'm everywhere, thankfully.

But I'm also very much integrated in society and community with my family. And my father was at the forefront of that. He had to really battle the congregation to try and get me into university, but behind him was my mother, who's a proper Punjabi woman who's so strong. What do you mean by he had to battle

with the congregation to get you into university? So when I started doing GCSEs and A levels, I said to my dad, I want to be a doctor, and he just sort of looked at me and just thought, A, that's an impossible dream. I'd come so late into the country. And so I was catching up. up so much. And then secondly, it was always like, so we have a phrase which I think translates

to every culture, but in Punjabi's log gear kha hangi, what will people say? And so the fact that I would leave home to go to university and be out of the house and living independently by myself. And so I genuinely had women from the community, women, I have to say, more than men, maybe they did come to our house, because our house is next door to the mosque in Cheshim, who would say to my father, your daughter's going to go off, you know, she'll never come home. And also, as the leader of our community,

how dare you send your daughter off, unmarried, single, she will get a boyfriend, she'll smoke, she'll run away. And I think that for my father was quite difficult. And then were congregation members who at that time, I'm not even talking long ago, when did I go to medical school? 2002.

So I'm not even talking about this is like Victorian time. But there were people in the congregation who really fundamentally believed that a girl shouldn't be educated. And my father was like, I will treat all of my five children equally. And all of my children will equally go to university and school as far as they want to. So I became a doctor. My brother is a barrister. Wow. My other brother is a chartered accountant.

My sister is a dentist. My younger brother is a pediatric nurse. And we all fully work with the mosque. We've started a football group, computer classes, through the mosque. And so we talk to the local rabbi. We go to various events at the local church, the Methodist church. We're very close with the Quaker community in Cheshem. So we really, I think if there's a blueprint to show how it can be done properly,

then that is one way of doing it. through the mosque, using that congregation, and building that trust between communities, so prejudices and, you know, the phobias of each other's faiths or the fear that builds around. And I think that fundamental fear is so much because you just don't know, and you start learning about someone

and actually you realize, oh my God, we are exactly the same. Yes. We believe exactly the same. And regardless of coming back to that conversation about labels, at the core of it, if you are just flipping human, I will respect and love you. And that's it. When did you see that there was a need to help women with their health?

I knew that straight away from a really young age. I was the first person that spoke English. So I was translating periods, miscarriages, fibroids, anemia, not really knowing what I'm translating because I was taken in as the 12. 12-13-year-old to translate. Right, okay. For the community and for my family.

Even before I became a GP. So Rachel and I, you know, Dr. Firth and I, many years on now when I'm a doctor and she saw me on BBC breakfast, we had a coffee and we were laughing about it. She goes, I remember that 13-year-old girl who used to come in and translate UTIs and try and find the words. And I could never find the direct translation of words. So I'd have to use English words and try and explain to the auntie.

because not my biological auntie, but just so from the community, what those words are. Is that because there isn't a word? Yeah, because there isn't a word. And then I did women's health, and I was never, I was like, I never want to do women's health.

I became a doctor, I became a GP, and I was like, I can't swear on this, can I? Yeah, you can do whatever you like. No, because I think swearing was, I was like, I'm never, I'm never going to do like women's health. I can't stand periods. I used to think it was a sign of weakness

because my gender was always held against me. Right. And it was always like women in medicine, if you want to find a toxic workplace that's misogynistic to the nth degree, and I hate saying this because it's my own community, but I know this will be resonated by so many, it is the NHS.

It is that, that, that, medical fraternity, that academic fraternity, because unfortunately, at the core of it, it is still very misogynistic. And then I think it's changed a lot because we've got incredible campaigners who've come out about sexual harassment. You know, Liz Arridden, who's been our dear friend and colleague who's spoken about the sexual harassment as a surgeon, Rashina, who's, you know, documented quite a lot about her experience.

And I think women are now calling it out and men are calling it out. We've now got allies and support and men going, actually, this is so unacceptable. But when I first went into medicine, it was, it was almost seen as the achievements of what a woman was doing was never on par. And you don't have to look far. The current euros that we've just had, the male team going right to the sort of semifinals and not winning, it was almost like, oh, the hurt goes on for another 59 years. It's like, hang on, the lioness has brought it home. Like, what are you talking about? But the women bringing home the European cut was not on a part.

Didn't count. And that doesn't just cut people like me as a medic, but it cuts all the little girls. And all women, I think. All women. But it means that those little girls playing in the field with football and battling with the boys still are going to be like, well, do you know, it doesn't really count because what does it mean at the end of it?

And so I think for me, in medicine, that was the thing. I felt like I was always the sort of second degree doctor. And so I just thought I don't want to do women's health because that will just immerse me in the weaker sex. And I feel awful for saying that. There were two conversations that I had and they were in Wexam Park Hospital. That's where I did a lot of my training.

And I would see a lot of the Punjabi South Asian communities. One was three o'clock in the morning. I had a patient who came in who now, I know, was perimenopausal, 46, holding on to the bed bars like this. And she was sweating, profusely sweating. It's three o'clock in the morning. And she's going, Minot al-a-hi-hund-the-air, I can't sleep. So Dalekhi is, I've got palpitations.

So she said all of this, even though she spoke good English, she said all of this in Punjabi to me. I can't stop sweating. I can't remember anything. I cannot talk to my husband anymore. My husband doesn't listen to me. My kids, I need to arrange their marriage and I can't sort out their wedding, etc. And the community talks about me all the time.

And I just cannot keep the household. And I've always been a housewife. And now I'm losing my mind. And as much as she was Sikh, so she was, as much as I go to the temple, the Godwara, and I'm praying. God isn't listening to me. And so I'm praying harder and harder. That makes me really sad. I know.

And I just looked at her and I just, I didn't know. So we did her bloods. We did all her functions. she came back with a little bit of vitamin D deficiency. So the doctor said to me, who was actually a South Asian doctor who I respect very much, she was just like, oh, for goodness sake, another South Asian woman. You know what this is?

This is a B.B. Begham syndrome. They come in at 3 o'clock in the morning, taking up our time and resources, and it's flipping nothing, just get her out. And I was just like, so that was me encountering the first bit of, as a junior doctor, internalised racism within the healthcare sector.

And I was like, because my mum, her surname is actually Beebe, so she's Manira Beebe. And it's the term that we give for a lot of women. And it's the term that came over when a lot of communities from India and Pakistan under the British rule, because all women were given that term. So the colonial aspect of it runs deep. The partition runs very deeply. There's a lot of trauma that I think we still need to deal with.

as a community. But to have another South Asian doctor reflect that back to me was just that icing on the cake of this is what colonial impact that we still have, that we still think ourselves as second-class citizens to our white British rulers that were there at one point. So, and then she goes to me, and also I would really rethink about how you wear hijab. I used to wear my hijab slightly differently, but she goes, you'll never get far in your career wearing a hijab because people won't take you seriously at all and they'll always see you first and think that you can't speak English and have those assumptions about you. So you'll get further in

your career negat. And I think she thought she was being really helpful. She's trying to be helpful. Really helpful to me. But I took away from that going, oh my God, like I'm in this, in the medical field and I cannot help my own. And my own, who I think are helping me, actually can't see the wood for the trees from themselves. So it has to fundamentally change because if we don't help women, women need to support women. But women need to understand what's happening. So fast forward,

I went into Wexham Park, out of Wexham Park, into my GP surgery. That same patient that I'd seen three months prior, she'd accidentally booked in to see me. So she came in to see me and I realized then, because my trainer then did women's health. And she was just like, this is all perimenopals are related. And it was then for me, as a junior doctor when like the penny dropped, that I am dealing with women's health issues, which are going in and out of A&E.

And this could be prevented at the door. And we would save resources, respect for women, but also their livelihoods and the way that they function and their families because the poor husband was like beside himself going, I don't know how to have. Her faith was being tested. Her faith was being tested. This idea that God isn't listening. Exactly.

I really hope you're enjoying this episode. And if you can, give us a follow. Now, you were just talking about the woman that came into A&E and who you then were able to help in your clinic and you talked through some of the symptoms. And I just thought it would be interesting to just chat about a few of the symptoms or not even chat about them, but just mention them quickly. Can you just tell us a few of them?

I always say you have to think of menopause as being a head-to-to-toe disease. So it's all-encompassing. So you start from the head. And we always, in medicine we go, they're vaser motor. So they're the ones that are going to cause physical symptoms and then psychological symptoms. They are very much part of the reduction in estrogen that happens. So if you think of about head, so hair thinning, scalp issues, you might get skin changes as well, brain fog, memory issues, lack of confidence, lack of self-esteem, tearfulness for neuroprone, for no apparent reason.

Rage. Lack or concentration. Yeah, rage. Absolute anger that can happen without any rhyme or reason. And normally you're quite a placid person. Changes in your hearing, so tinnitus, changes in your taste.

Yeah, I've started to, now I'm perimenopausal. I started getting this sort of a metallic taste, which was very significant when I was pregnant. And also gum health. Gum health. I mean, the number of dentists that I've told, watch out for this. This is perimenopause.

And again, it's because of that reduction of estrogen, You might notice then around your hearts of palpitations, as my patient was saying to earlier. You might notice that actually your allergies that you never had before are suddenly flaring up again. Gut. Remember, a third of your immune system, which uses estrogen as an immune modulator, sits in your gut. So bloatedness, weight gain around the middle that can happen through your adipose fat tissue as well. Foods that don't suit you so well. So alcohol, you could tolerate it before. now you just cannot tolerate alcohol anymore.

Yes, we talked about that. Pins and needles in your legs or feeling like spiders are crawling down your legs on achy feet, achy joints. So there's a lot of symptoms within the South Asian community that they complain of, the sarahosh dohde, sirtoleke, perotach. So it's translated as everything hurts from my head right down to my toe. And now we know it's arthralgia, it's your joints and your aching hands and your feet, etc. fatigue, extreme tideness. Japanese women complain of sort of shoulder aches more so.

And then the fundamental one, which is always given as number one, is hot flushes, night sweats or cold flushes. And then the most taboo symptoms that we never talk about, a vaginal atrophy or genitone or urinary syndrome of the menopause. So that's soreness, splitting of the skin, irritation around the vulva and the vagina, recurrent urinary tract infection, which cause a lot of misery.

for so many patients, uterine prolapse, increased urination. So you're feeling that you need to go for a wee all the time. We're not able to hold your wee as well. And then just sex is so difficult or going for a smear is so difficult. So the whole body is taken over. And it's a transition. It starts around the age of 40 and they don't all come at once, as you know. They come as hodgepatch.

And I think we need to start thinking of ourselves as these transitional, cyclical beings. So now I'm 40. I'm really comfortable in saying the fact that I'm a perimenopausal woman and everybody's like, but you're 40. But as South Asian women or Black and Asian women, we start between two to five years earlier than our white counterparts. And a lot of Black and South Asian women don't know that. No, they don't. Because in their own communities, you don't, it's been a shameful thing or an embarrassing or a weak thing to talk about before. Because in Punjabi, the word for periods is Kapri Khatamogu, which is you are off the rag.

Now, what woman is going to openly say that when it's so entrenched in patriarchy and misogyny? And then in Urdu, it's translated directly as baron, banji. So you're banji, you're baron. And they're like, well, no, that's not really the case at all.

In Arabic, the literal translation is the age of despair. So these conversations, it's terrible. And my granny, my granny, used to call it the curse. Oh, the change. Yeah, oh, well, the menopause is the change.

Yeah, the change has happened, because you don't want to use the anatomical words. And so, you know, Canongi is the word in Japanese, and it's like, it means rebirth or, you know, second spring. And you're just like, these are lovely words that they have a completely different spin on it. And we understand that women are born, we go through puberty, then we go through our fertility years, and then we go through perimenopause, menopause, which is defined as one year without a period,

and postmenopause, which is one year and one day without a period, and you're postmenopausal. But because we're seen as little men, men go through born, puberty, and then that's it. So we have never seen women, and I always say as women, we are these incredible circles made to fit into squares constantly, wherever we are. And so that's why nothing is set up for us. And that's why I go back to where we started, we were never at the thought when the foundations were put in.

You know, the other thing that I feel that a lot of women get hit with, but like you said, it's an emotional symptom rather than a physical one. And this was the one that I hear so many women are unable to kind of describe, but the best way they can say it is I just don't feel myself anymore. And that one always really breaks my heart because I can really remember that. And from being a uber, I mean, I think you and I are so similar in personality,

very confident, kind of, happy to talk to anybody, extrovert, enjoy company. And suddenly I lost the ability to be myself. and when I say to somebody, are you able to feel joy? Often they say, oh, I've forgotten what joy feels like. I'm sort of flatlining, and that's exactly how I felt. Where do people go to find the truth? I mean, I find it all the time with health issues, any health issue. You look, and there's one person saying absolutely don't do that,

and there's another person saying, do do that. Where do you go? What we're trying to do, so I know you're part of it as well, but we're working with YouTube Health. I think YouTube health and platforms have got a huge role to play here. And the WHO, so the World Health Organization. So I am a member of the WHO FIDES program and the YouTube Health Program because we're trying to get content creators like me who look at data, who look at evidence,

who are giving a sort of down the middle view. Unfortunately, what we're sales on socials is clickbait. So you've got to be either the extremes of the two. and then where do you get the misinformation dealt with? Well, you've got to look at verified, you know, doctors. And then I think within that, if I'm a bit selfish in saying that, doctors who actually clinically practice. Yes.

Because I think that makes a huge difference. And a medical doctor. Yeah. Because there are lots of people that call themselves doctors that aren't actually medical. Yeah, it's a bit of the Wild West at the moment, unfortunately, because you could do now a three-week sort of online course and say, I'm a menopause expert. So it's, and, you know, what sells? Menopal cells. And I'm afraid snake oil always sells. And that is where we are.

This YouTube health channel, is that up and running yet? It's up and running. So the program's been running for about a year. Alison Lomax, who's the first woman to head YouTube, UK and Ireland, is really on it at the moment. And we've got Vishal who is heading all the doctors. So there's a lot of us doctors who are practicing. clinicians. The reason that it came about was actually the brainchild from the pandemic, because in the pandemic, if you remember back, the horrific time that we had as clinicians, but we learned from other clinicians around the world what was working well and trying to educate our communities around the virus, which we didn't really understand in the early days. And so

we realised that actually public health messaging only works if you trust someone. And so making content in different languages, which is what I do on YouTube. in Punjabi, etc. It means that people are more likely to download that and share it with their friends. And so what we have sort of guidelines that we need to follow as YouTube health content creators. And we're hoping to build on a lot of that.

But at least you feel like there's something to trust. There is. There is. There is. And then obviously, you know, we would say the NHS websites. I always say go back to the NHS websites. But you and I know,

and it comes to menopause, we still have a lot of work to do on that. And we recently didn't have a whole page for adenomyosis until now. I've been thinking about the power of community lately, thanks to our favourite creative tool and sponsor Adobe Express. You might know it as the quick and easy create anything app from Adobe, but it's also a really buzzing creative network. So the other day, I couldn't get our Begin Again logo to look how I wanted in a doc.

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That's Shopify.com.uk slash divina and join the gang that's working smarter, not harder. I do want to touch on hormone replacement therapy because just like you were saying, the pill was a revolution for women and it was a freedom for women. if you have quite bad symptoms during the menopause and, you know, maybe 75, 80% of women struggle with symptoms, some of them very badly, there is something that can help that has got such a bad reputation still, even today. And it doesn't just help, it has some health benefits, maybe not all the ones that lots of people say, but it does have some health benefits to it as well. could you just quickly talk through HRT because it is such a hotbed of controversy?

Yeah, three words, H.R.T. Hormone replacement therapy. We are literally just replacing the hormones which gradually start to decrease. And they decrease because you're genetically programmed to do that. But your brain is so amazing because when you're genetically decreasing in hormones, it produces it elsewhere. So we now know your brain produces estrogen. It also produces your cortisol. So that's your stress hormone, your melatonin, your sleep hormone, your dopamine, which is your get up and go hormone, your adrenaline, your adrenaline, your noreadrenaline. And what the brain does so cleverly is it talks to your fat cells.

So in your fat cells, you also produce sex hormones as well. So your estrogen, progesterone and testosterone. Now, we do know that some women actually don't respond well because it's not the right level that you need at that time. And those dips and troughs means that actually your symptoms will flare up. So the vasor motor symptoms of hot flashes. So what we now know, because HRTs moved on so much from the synthetic version, which the WHOI studies were done. So they were the ones that the synthetics were associated with breast cancer increase,

cot increase. We now have what's known as body identical HRT. So they go through your skin, their patches, gels and sprays, and then a capsule version of the progesterone as well. The data from that shows that actually the risks of breast cancer are only of a, either not increased from your background risk. So what do I mean by that? You and I are sitting in this room. We both have boobs. Well, I definitely, I know you do. That's the way. And if I, in this room, there were seven of me, so seven Dr. Nogat's, unfortunately, one Dr. Nagat in her lifetime would get

breast cancer. And that's not because I'm on HRT. That's because my own natural estrogen is working on my boob cells. And in my boob cells, there are receptors which are receptive to estrogen, because I'm genetically programmed as a woman, so I will produce that estrogen. And that causes inflammation. And that is so key, we've realized that inflammation is a huge instigator for so many problems, cardiovascular problems, clots, but also cancers as well. So we now have started to understand that cancer is far more complex than to say, okay, taking estrogen will definitely give you breast cancer. Actually, that's not true at all. For women who've had their womb removed and their over, is removed, and that's known as surgical menopause, they only need estrogen on its own.

And estrogen alone actually could be protective for breast cancer. And that's like incredible that we now have this data. We've got to beyond. I think that will blow some women's minds because I constantly get back, but it gives you breast cancer. Yeah. So do I. And, you know, when you say that, without a womb or ovaries, it could actually protect you.

Yeah, it can do. And also, not just that, there is no preliminary studies that coming that actually has cardiovascular benefits. So reduce high blood pressure. And because it offloads your fat cells, your adipose brown fat cells from producing estrogen, actually it's showing that women won't be putting on weight with it. So that's the other myth I hear. If I go on HRD, I'll put on weight. I hear that all the time. Oh, I didn't know that. The data never shows that because what it, so I say, in my clinics, I say to my patients, look, by you putting on HRD, I put on weight, I hear that. I hear that all the time. I hear that. Actually, I hear that's not. I'm not. I'm not. I'm. I'm. But, but. But by you. But, by you. But by you. But by you. I. But, by you. Actually, by on this gel on your skin, it goes through the skin and talks to the fat cells and says, mate, I'm here. I am going to give you a bit of estrogen because it's literally replacement. So we are just replacing what you need. And that's where the tweaking comes in and that tailor-made sort of advice. But it's only one bit of the toolkit and it's not one size fits all. By knowing from sort of individuals who have gone through that transition, and we've had this conversation, I'm trying to be better with my nutrition. Because even as a doctor, I never get taught about nutrition.

So I'm now learning about nutrition. I'm learning about sort of exercise and weight-bearing exercises. I'm doing lots of holistic. I took up swimming two years ago. And Professor Joyce Harper's data from UCLA shows that swimming reduces hot flushes. And really, it does it? It does. I forgot the data.

I think it was something like 60% of women that reduced hot flushes. But not only that, it's a life skill. But I've started swimming. and it's been a joy because I'm preparing for my next transition to when I come to my menopausal years. And I'm fully already using HRT or a version of it. I use topical vaginal estrogen already. So it's so important to think about transitioning before it even happens. Viginal estrogen.

I mean, I had a bit of vaginal atrophy when I went into perimenopause. But actually when I started taking hormone replacement therapy, it got slightly better. And then when I went into full menopause, so my periods had stopped, and it was quite interesting because I didn't know when my period stopped because I have the Morena coil for my progesterone.

So I wasn't sure if my periods had stopped or not, but my vagina told me. That's so good, because I have exactly the same story. And I was like, oh, I need some vagina and estrogen. Now, what was interesting with that is that, is that not only did it reopen my shop, so sex wasn't painful anymore, I wasn't feeling uncomfortable down there.

But really amazingly, I started sleeping through the night, and it was because my urinary kind of, I don't know what I'd call it, but me going to the blue, got sorted out that I could go longer in between weeing, and that meant that I could sleep through the night, which has completely changed my life. And I had no idea that vaginal estrogen could do all of those amazing things.

And again, I have constantly women asking me, can I take it and be on HRT? I'll let you answer that because you're the doctor. Yes, you can, definitely. And that if you're on it, it doesn't mean you're going to overdose on it. No, you're not going to overdose on it. And if you've had breast cancer and you've been treated for estrogen receptive breast cancer,

So can you take vaginal estrogen? Definitely you can take it. And we're doing a lot of educational work around that. And if you've had an astrosol, so that's one of the medications that you have after your breast cancer, there's a derivative of a type of vaginal estrogen that we can give you. And it's called intrarosa. So even that is now becoming safe. I would say topical vaginal estrogen is the most kept secret from women.

And it blows my mind how not enough women of all. age groups know about this and how it's not incorporated into the clinical pathways that we have. So I've now started, I would almost say the advocacy bit where I started becoming so vocal and it starts by breaking down the taboo. So it's really sweet when you said to me, you know, my vagina told me because I posted about vaginal atrophy because that was my first symptom. I was 39 years old. As crazy as this sounds, I was in a women's health conference where I was a keynote speaker in

Sweden and this was my third UTI. And as a doctor, I was just like, okay, this is not real. But I wasn't getting dryness. I'm not getting painful sex and smears haven't been painful with me, but it was my third duty. And then I thought, maybe I didn't drink. You, you gaslight yourself, thank you. Oh my God, you gaslight yourself. And as women, we're like pros at that. We should get like a gold medal. We're gaslighting ourselves because even as a doctor, I started doing that. And I was in Sweden and I was in a pharmacy. And that's when the penny for me dropped that actually I think it's vaginal estrogen that I need. But you can buy it over the counter.

And you can buy it over the counter in the UK. And that's also important to say. Because of the menopause mandate and we're part of that and we worked really hard. So we looked at the MRI guideline. So you can. It's called Gina. It's exactly the same as say vagu-femal vagu-vagy rucks. Can I just say something?

That did really make me laugh because I just thought, what a funny name. Firstly, don't call a vaginal estrogen a lady's name. Exactly. I know genus. This is not okay. And secondly, vagina. Yeah. Oh my gosh.

I know. Okay. And so I brought some topical estrogen and then of antibiotics and I got better. And I came home and I had a conversation on the phone with a very sweet locum doctor. And he was just like, you're 39 years old. I don't think it's vaginal estrogen that you need. I think it could just be a UTI. And I went.

I wrote a book. It's the first time I ever sort of like a mic drop moment. And he just went, okay. And I wrote, it's called The Knowledge. And I wrote a whole chapter on vagina atrophy and what it does. And I think this is it. So then we did like an educational piece. So, and then he was just like, okay, Dr. Arro.

And I love him. And he learned something. He learned. He learned something. And I think that's it. And it's been a game changer. Oh, my God, it's been a game changer. I've not had UTIs.

in October 2023, when the NHS England guidelines came out for UTIs, they've documented that we get over 64-year-old women or post-menopause of women have the highest rates of UTIs. Over 100,000 women admitted into A&E with UTIs and chronic UTIs and nowhere in the clinical pathway did they mention top of vaginal estrogen. Because fundamentally, we still do have, I believe, this misogynistic view that this is how, because it's men's medicine, part of the process. We have lied to women over two things.

And actually, you say I don't get angry, but these are the two things I get angry about. One is, is that we've lied to women about their pelvic floors and said to them, just do pelvic floor exercises. And if you leak after having a baby or you have an oops moment, don't worry, it's okay, here's a pad and you can treat yourself. Actually, no, there are two times in our lives when we reduce estrogen. One is when we've had a baby, and that's when we are lactating. So we are breastfeeding our baby and our pelvic floor is for love no money.

You can do as much pelvic floor exercises, and I'm not discounting pelvic floor exercises. You know, I do them and I encourage people to keep doing it. But that's only 50% of the argument. Eestrogen is the other bit that you need to give women. So if you get a woman in your surgery who says, I'm breastfeeding, and I'm totally getting irritation and soreness, and I'm getting an itch, Please don't treat her for thrush because that's the other mistake that we make. You need to give a topical vaginal estrogen.

And it's known as genitory urinary syndrome of lactation. So there's a lot of doctors who are sort of talking about this, but still very quietly in the women's health sphere. And it works wonders. So now my midwife colleagues, I'm teaching them in their NCT classes going, please talk about vaginal estrogen. The safety data is phenomenally good. So it's so local, so it's localized.

It doesn't get taken up in the bloodstream. Therefore, doesn't increase your risk of breast cancer and does not increase your risk of clots. Does that also mean that a woman, say, in her 60s, late 60s, 70s, could she start taking vagina estrogen? Because I know it's maybe not so good for somebody to take HRT more than 10 years after you've had your last period. Systemic HRT, so something that goes throughout your whole body,

there are conversations and guidelines. But I never say no. I always talk to individual women on that. Topical vaginal estrogen, lifelong. At any point, you could start. So I've started women in their 80s, and it's been a game changer for them. Honestly, it's like they come in.

I had a woman who saw me, who was 73, who'd had horrific vaginal atrophy. We'd changed it, and we got it all better again. And she came to see me, and she goes to me, I've had sex with my husband, and it was the best sex that I'd had. in over two decades. Oh my God.

And those conversations... But you know, like, what's sad. Sorry. But you know what... Sorry. That's okay. I get like that in the consultations as well. It's really sad that women put up with that.

Like you're denied pleasure. Even on your own or like anything, it's like... And you just think, I can't talk about it. That's what makes me so sad. Sorry. We're receptacles, right? Yeah. So you have your periods.

And then you're... or a womb for a very long time. You do your babies, your boobs are sore. Then everything else is just like, well, you know, have an air and a spare. And this is what I see in my culture a lot. So when I shared my vagina atrophy story for the first time,

oh my God, the vitriol. Really? Sister, please don't share this. Oh, really? This is against Islam. This is haram. Don't share this. Why are you sharing things, you know,

about your vulva and vagina? My poor husband then was just like, you know, this is really against our cultural norm. But I would be so upset like this if I wasn't able to, as a clinician, have the information that I have and go, well, I'm going to keep this knowledge to myself because of log kiakahinghe, what will people say? I've thought that all my life.

And now is not the time to start. The other thing I really wanted to touch on, because we've heard now about the benefits and in all the ways that, vaginal estrogen hormone replacement therapy can help you on your journey if that is the choice that you would like to make. What is this thing with the medical profession or sometimes the British Menopause Society talking about over-medicalisation? Not that many people take hormone replacement therapy. So are we over-medicalising? What is that? It comes back to the transition. we try not to over-medicalize lots of the bits.

So for example, puberty, I mean, that's emotionally all the physical symptoms and the psychological symptoms. But we don't have treatments for that and we don't have medicalization treatments for that. Pregnancy, you could say we do. We have a whole field of pregnancy, obstetrics. But if you look at it, it's mostly because we want the baby to survive. And also because mortality of mothers dying is not a good thing to have. And so then we come into this bit of life.

and women are pushing back and going, I've done my dues, I've done my pressures, now give me the functionality and please don't use my biology to make me walk out of our workplace. One in ten women leave the workplace. Promotions aren't given to women. So the glass ceiling, I would say, is still there. So there's that sort of battle because actually biologically,

we are programmed to survive the menopause. But I think the conversation has shifted where women don't want to survive, they want to thrive. Yes. And that is the bit in medicine. We're expected to. You know, we've got to work till we're 65. Like, what?

And we are living longer. Yeah. And so why not as well? I mean, if we're living longer, we want to thrive and we want to be happier. But the medical bit is why we don't want to medicalise this. And I think that also comes back to how these colleges are usually run, I would say, come back to that whole conversation piece we had earlier about misogyny in medicine. And I think still it's seen as well, that's not the most important bit in medicine to focus on

because the funding and the research needs to go on cardiothoracic surgery. Because cardiothoracic surgery is a proper man's job or neurosurgery. I remember being a medical student, and I'll just really quickly tell you a quick story. We went on a ward, and it was in the old days where the consultant will take all his medical students, so I must have been about a fourth-year medical student on a neuro-carthagoracic ward round.

And the professor of cardiac, I won't name him, cardiothoracic surgery, the patient said to them, will I be okay from the surgery? Like I, like, well, I don't want anything awful to happen. Will I even pull through? And he just went, there are two people who can save you from, you know, your medical condition. God and me, frankly, God's not here. And I just was like, we were just, I was just looking at him. And I was like, that level of cockiness you would never get in women's health or obstetrics.

or gynecology, but there is that sort of, and so when you've got individuals like that who are just so like we, this is a field, so raw, so important. So unfortunately, the research isn't there. And because the funding, and this is where I really think is awful, the funding for, say, testosterone therapy in women beyond libido, is it great for our cognitive function and our muscle?

The research for HRT, beyond the fact that it's just for hot flushing, but is it safe for women who've had breast cancer being treated it for it? Could they 10 years down the line think about body identical? It's easier to say we're over-medicalizing it. Don't give it too much because there are going to be more things that will come out of that. So greater risks of endometrial hyperplasia. So womb cancers or women bleeding on HRT, where are we going? Because there's no real, I mean the guidelines have been updated, but what are we going to look at that?

And then also, what about the risk of breast cancer in relation to the fact that we're getting fatter and fatter as a nation as we're getting older? So how does the NHS cope with that? And I think, you know, if I'm cynical, and I hate being cynical in women's health, if I'm cynical, it is that whole, well, let's control women a bit more. And if you look at the data, marginalized communities, so black and Asian communities, actually there's only about 10% uptake in HRT. There's very little.

And overall, it's only about 25% of women who even consider HRT. Which is tiny, really. It's not over-medicalising, that's for sure. In my NHS surgery, I would say, it's really, I would have less patients on HRT. But if you think about it, historically, we were dishing out antidepressants like smarties. It was crazy. And that's not seen as over-medicalisation. That's what's so strange.

The other thing I think is interesting is, you know, that leads us to just suck it up. Yeah. Well, then just suck it up. You know, rather than medicalising yourself. Well, you did it in your pregnancy. And you did it in your period. Exactly. So why are you sucking it up now?

But I mean, the amount that we suffer, it's like can't we just not suffer for a bit, you know? Yeah. Yeah. So I think that's an interesting conversation. And I think that's where the people like clinicians like myself, we have to put our head above the parapet, but then we're really easy targets. because then I'm seen as a radical GP or a radical clinician. Why can't I just sit in my surgery, put my head down and see patient after patient treat them as a number, as a number as a number. And there comes a point where you think, hang on, I'm working in the system.

I am an NHS trained doctor and this is happening to me. And there's a great sort of quote that says, you know, my mother went through this. Sorry, my grandmother went through this. my mother went through this, I'm going through it. And I'll be damned if my daughter goes through this. And there came a point in my journey where I just had to lift my head up and go, I'll be damned if the next generation of Ngaats, who have to translate the same thing when they're 40,

if nothing changes, nothing changes. And that's so sad and we're stood still. So where do individuals go when they're still stuck in this hole? And like you say, it took a lot. Like, you weren't the first person to talk about the rena, of course. But yet it became the Davina effect. And it then became, well, now doctors are just joining Davina. And I was like, no, it wasn't just joining, you know, we're not just joining Devenile.

We've been there because it's a collaboration. And we've got to start making this collaboration and get out of our surgeries and really pay attention to what's going on. Because it's going to happen to me. In my, I do a private clinic. In my private clinic, I would. say half of my clinic now are clinicians. And I'm not happy about that. It breaks my heart when I get a surgeon, a fellow GP who trained me, somebody else along the line, nurses, physiotherapists, I get dietitians, theatre surgeons and theatre nurses who are now coming to see me

because they just want their menopause dealt with or their vagina atrophy dealt with. And they don't know how or what's happening. Exactly. And that's a travesty, right? And that's a travesty because we're not keeping these women in the workplace. I want to talk about this amazing encyclopedia. Now, what I loved about this book, because I actually would like to say that I read it absolutely ages ago, is, well, there's a lot of things. Firstly, it represents.

Yeah. Talk me through that. And you're thinking behind that and how you did that. When I was at Barts, and I was in the most sort of cosmopolitan, a huge Bengali patient list, you know, area, there's a lot of us brown people around in Whitechapel and Stepney Green, and that's where I did all my medical training. When I opened up a medical textbook, I just never saw me. And it was always pale skin.

And then I'll try and work out what it looked like on, say, a Bangladeshi child that came in with Exma. or a woman that had come in with vulval lichen sclerosis, and I never saw that. But just me, my own self, if I look at myself, as a woman of colour. And so when I got older, I had the opportunity to put down all my 10 years of knowledge. So this is a book that is for the whole family, the mother, the daughter and the grandmother with men,

with women of colour. And that page took a lot of conversations, actually. you wouldn't think of it in, you know, in 2023, 2024, because the pigmentation taken or the colour puts the cost of the book up. So it's a table of coffee book. Can we just have a kind of neutral, like a black and white or line drawing? Or line drawing. And I said, no, because I need women to see themselves in this

because this is my clinical stuff. So this is bare bones of what I do and I have been doing for the last 10 years. So if you read it, it's a bit like me sitting down and having a coffee with you. So I take out all the jargon. I'm dyslexic. So I need to... It's your superpower. It's my superpower.

No, but, negat, I'm not joking. Yeah. Because this book is so palatable and easy to digest because you're dyslexic. So it's written with me as if I'm talking. And it really is like I know lots of people say their books are labours of love, but it really is my labour of love because this is, what I did was put myself out there as a doctor. So I was really scared. So that throwing yourself into the fear.

Yeah. scared because this is literally a window into my clinical room. So how I see patients, what I look at, what conditions I look at, how I treat them, what I see. So it's got the first picture of what Volvo lichen sclerosis looks like on black skin, which isn't anywhere else. It's so important. It's got a woman of colour who's from an ethnic community doing a breast examination. And when I did my first breast examination, although it was on clothes on BBC breakfast and then later on this morning, oh my God, it was like the most horrific thing. A woman with a hijab, examining her boob.

This is like, guys, this is normal. It's going to save a life. It's going to save a life. If a woman just examines herself there and then and fix up a lump, you are literally going to save a life. And the other thing I love is that it just explains everything. So it goes from first period all the way through to death, basically. But even things like hormone replacement therapy, which is, a minefield and you can never, we can't even get it, you know, in enough detail in our talk today.

It's all listed. It's all named. It's all what it does. Is it body identical? Is it synthetic? You know, can you take it? It's like the best chart ever, all of it. Exactly.

Because that means that you can go in and say, and it's the same for contraception. So it's the name. So you can go in and go, okay, this is the type of HRT I've read about. Can we have a conversation? Yeah, about would it be suitable for me? And actually the biggest people who've championed my book are clinicians. Like Professor Dame Leslie Regan, who is the ambassador. All hail.

She endorsed my book and came on my book launch. And I got a fellowship from the Royal College of Obstectors and Gynaecology off the back of the work that I'm doing. And it is a real honour to have, I think, clinicians, because that imposter syndrome, that little nine-year-old. There's got to be going now, hasn't it? It's getting worse, mate. Are you serious? Yeah, it's getting worse and probably more ugly. I just want to say that this conversation has made me love you even more.

I didn't even think that was possible, but it's been lovely getting to know you a bit, and thanks for sharing. You're just wealth of knowledge but also acceptance and love for the world and need to share your knowledge with other women and clinicians, which is so important. So thank you from the... bottom of my heart, womankind, on behalf of womankind. We have so much work to do.

We do. But I would say anybody listening to this podcast and talking, I would say three things to you, please, if you do anything, whatever knowledge you have about whatever aspect you think will save your community, share it and sprinkle it like confetti and bucket loads. Throw yourself into the fear. Put your head above the parapet. I promise you, we will find you, your tribe will find you, and they will lift you along the way. And I think that that is very lonely when you're in that space by yourself,

whatever irks you and you're thinking, I'm the only one going through this. And then at the end of the fear, on the other side of fear, is a whole wealth of goodness. And I promise you, you will find that goodness.