Feel Better, Live More with Dr Rangan Chatterjee - Everything You Need To Know About Menopause with Professor Annice Mukherjee #360

Episode Date: May 9, 2023

Right now, there are more than 13 million peri- or post-menopausal women in the UK. That’s around 25% of the population, you may be in that category or you will be interacting with women in that category. That’s why it’s imperative that all of us have a deeper understanding of what exactly is going on for women at this stage of life. Menopause has become one of the most talked about health topics over the past few years. And, as topics get talked about more, the variety of information available increases. But is all the information we are consuming accurate? Today’s guest is one of the UK’s most respected medical experts on women’s hormones and menopause. Professor Annice Mukherjee is a leading UK endocrinologist and author of the bestselling book: The Complete Guide To Menopause. She has over three decades of clinical experience and has supported thousands of women going through menopause to manage their symptoms and improve their wellbeing. She is an Honorary Professor at Coventry University, on the British Menopause Society Medical Advisory Council and was recently named in the Financial Times list, of ‘Women of 2022’. Our aim for this conversation was to make it a comprehensive guide for all things menopause related and we managed to cover a wide variety of topics, including: What happens in the lead up to the menopause What symptoms are commonly caused by fluctuating hormone levels Why not all women experience menopause symptoms How it IS possible for women to prepare their bodies for menopause The impact of stress and other lifestyle behaviours on symptoms Why menopause should not be thought of as a hormone deficiency state The Pros and Cons of HRT And so much more. We explore something that Annice calls the ‘menopause paradox’ – there has never been a better time in history to be a woman, with greater equality and better treatment options for symptoms, yet at the same time more women are struggling with their midlife health than ever before. Annice also speaks from personal experience - having been diagnosed with breast cancer she went through menopause herself at the age of 41. Annice passionately wants all women to know, that they have more control over their health and wellbeing, than they think. This is a wonderful conversation, it is jam-packed full of information and practical insights. I hope you enjoy listening. Support the podcast and enjoy Ad-Free episodes. Try FREE for 7 days on Apple Podcasts https://apple.co/feelbetterlivemore. For other podcast platforms go to https://fblm.supercast.com. Thanks to our sponsors: https://www.seed.com/livemore https://www.athleticgreens.com/livemore https://www.vivobarefoot.com/livemore Show notes https://drchatterjee.com/360 DISCLAIMER: The content in the podcast and on this webpage is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your doctor or qualified healthcare provider. Never disregard professional medical advice or delay in seeking it because of something you have heard on the podcast or on my website.

Women have so much more control and agency over their hormone and menopause related symptoms than they think. Things should be much better for women today, but it doesn't seem to be at all. I'm seeing more women struggling today than I saw day in, day out in my clinics when I started out, which is more than 30 years ago. So it is a real paradox. We should be so much better. There are more treatments available if you have problems. Why are we struggling so much more? Hey guys, how you doing? Hope you're having a good week so far. My name is Dr. Rangan Chatterjee, and this is my podcast, Feel Better, Live More. Before we get into this week's conversation, I really want to emphasize that

this conversation is just as much for men as it is for women. Just listen to this statistic. Right now, there are more than 13 million peri or post-menopausal women in the UK. That's around 25% of the population. So whether you are in that particular category or not, you will absolutely be interacting with women within that category on a daily basis. So I think it's imperative that all of us have a deeper understanding of what exactly is going on for women at this stage of life. Now, I would say menopause has become one of the most talked about health topics over the past few years. And as topics get talked about more, the variety of information we all get exposed to, of course, increases. But is all the information we are consuming accurate? Well, to try and address this,

I invited one of the UK's most respected medical experts on women's hormones and menopause onto my podcast. Professor Anise Mukherjee is a leading UK endocrinologist and the author of the best-selling book, The Complete Guide to Menopause. She has over three decades of clinical experience and has supported thousands of women going through menopause, manage their symptoms and improve their well-being. She is an honorary professor at Coventry University, is on the British Menopause Society Medical Advisory Council and was recently named in the Financial Times list of Women of 2022 for her work in menopause. Now our aim for this conversation was to make it a really comprehensive guide for all things menopause related and I really do think we managed to cover a wide variety

of topics including what exactly happens in the the lead up to the menopause, what symptoms are commonly caused by fluctuating hormone levels, why not all women experience symptoms at that time of life, how it is possible for women to actually prepare their bodies for menopause, the impact of stress and other lifestyle behaviors on symptoms, why menopause should not be thought of as a hormone deficiency state, the pros and cons of HRT, and so much more. Yes, Anise is a highly qualified and credentialed professional, but she also speaks from personal experience. She has previously been diagnosed with breast cancer, and following this diagnosis, she went through menopause herself at the age of 41. Anissa is someone who passionately wants all women to know that they have more control over their health and well-being than they think.

This is a wonderful conversation. It is jam-packed full of information and practical insights. I enjoyed having it. I hope you enjoy listening. And now, my conversation with Professor Anis Mukherjee. You are, I think, regarded as one of the most experienced, one of the most respected medical menopause experts in the country. Right at the start of this conversation, what is it that you would like most women to know? Well, both in relation to all aspects of women's health, but particularly menopause,

women have so much more control and agency over their wellbeing, their health, but particularly menopause, women have so much more control and agency over their well-being, their health, their hormone and menopause related symptoms than they think. It's really interesting to hear you say that because one thing I've observed in the social media space, the public conversation around female hormones, is that on one hand, it's been really good that there's more and more awareness, but I really feel there's been a lot of negativity as well, a lot of fear, a lot of confusion. Why do you think that is? Absolutely. And I agree with you that raising awareness is crucial because women's health, menopause has been shrouded in secrecy until, you know, very recently. So raising awareness is really important. But with that comes problems because misinformation can

spread, particularly on social media, not deliberate, but, you know, things can be taken out of context. And also the big issue around social media is that it tends to facilitate extremes of view and it's also sound bites and negativity bias is very prevalent. So if you've got, if you're saying bold statements, if you're, you know, talking about all the negatives and more people talk about the negatives on social media than they do positive. You don't hear people saying, I'm having a wonderful menopause experience. You know, you hear people saying, I'm really struggling. I've really struggled.

And unfortunately, that paints a very negative picture. Women who are doing well don't tend to take to social media to say, I'm doing great. So it just makes the whole picture more unbalanced. In your book, I think you say something to the effect of this. There has never been a better time in history to be a midlife woman. What do you mean by that? There's so many opportunities for women now. You know, equality is better than it's ever been. It's not perfect, but things should be much better for women today. But it doesn't seem to be at all. There are actually more women struggling with quality of life and wellbeing today

through the menopause transition, but also younger women. I see lots of younger women with different hormone health issues. And I'm seeing more women struggling today than I saw day in, day out in my clinics when I started out, which is more than 30 years ago. So it is a real paradox. We should be so much better. There are more treatments available if you have problems. More people can access treatments. Why are we struggling so much more? That's really interesting. You've been practicing for over 30 years, so you will have seen tens of thousands of patients. But you're saying women are struggling more today than they were 20, 30 years ago. Why do you think that is?

The world's changed, hugely. The world has changed for women. Women going through menopause are the fastest growing demographic in the workplace, in modern societies. There are more demands. Everyone's living longer, so more midlife women are looking after elderly parents with all sorts of health issues. They have other care roles. Many women have their kids later or they've had to have fertility treatment. There's all sorts of things going on in women's lives. They're looking after teenagers when they're going through menopause, which was less common 30 years ago. So there's lots of challenges. Teenagers, young people are having lots of health issues, mental health issues today. A lot of the burden of care and, you know,

as well as work roles are falling on women. And so midlife is an incredibly busy time of life for women. It's, you know, I call it sort of a rollercoaster total wipeout course. And of course the menopause hormone transition comes during that phase. So it can sometimes be difficult to know if you're not feeling well, you know, what symptoms that you're suffering from are due to hormone changes and what symptoms are due to, you know, the general stresses of modern life. You know, multimorbidities are more common today than they were 30 years ago in terms of, you know, health issues. There are so many different things and social media makes everything out to be simple, but people's lives and people's health are not simple. We're definitely going to get into what kind of lifestyle changes women can make to feel better at all aspects of their life, how it can help them with hormonal symptoms,

perimenopausal, postmenopausal, whatever it might be. Before we get there though, I think you really raised some fascinating points for me, societally, culturally, if we look at this. One thing you mentioned there was maybe 20, 30 years ago, women at that phase in life, let's say in their 40s, may have been through raising their kids. And obviously now with people, families, women having children later, it does shift when are you going to have those teenage children? When are you going to have those elderly parents at the same time when your body is going through all kinds of changes? But culturally as well, I really think about this. We live much more individualistic lives these days, don't we? Many of us have moved away from our family, from our tribe. And so

many of us have moved away from our family, from our tribe. And so many families, many mothers are trying to raise kids by themselves. There's a lot of pressure on everyone these days. I do agree with you. I think in many families, women take on an extra burden. And for all the kind of evolution that we've had, and of course, it's great that women have so much opportunity. I don't think everything has changed enough. So what ends up happening, and I appreciate your perspective on this, what ends up happening is that women are probably under more pressure now than ever before. I agree. I totally agree. And everything that you've said is absolutely spot on. And also, you know, if you've got elderly parents, they might not be together. They might be in different parts of the world. There's a lot more traveling going on. You're not near your elderly relatives. If you haven't got children, many of the women today have got incredibly challenging work roles as well and taking on other responsibilities. So I do think women have, midlife women in particular, have more challenges today than ever before. So I wonder if a good place to go would be

to talk about some of these terms, perimenopause, postmenopause, menopause. I wonder if we could just go back to basics right at the start. And I read a pretty alarming statistic, Anis, the other day. It was well over 50% of women, certainly in this survey that I read, said that when they first experienced their very first periods, they were petrified. They're getting scared when they're experiencing their first period. And from the women I've spoken to, presumably that's around education, whether your mother, your school, your community discussed it or not. So I wonder if you could just speak to that initially and then broaden it out as to what happens, what are these different phases, what are they called and why do we need to know about them? Yeah, I mean, it's absolutely right. Teenage girls, you know, going through adolescence

often still don't really know what's going on. And it can be frightening the changes that are occurring to their body if they don't know if no one's talking about it. And it's similar during the menopause transition. And that's why it's really important for us to raise awareness. Because if a woman notices changes in her symptoms, well-being, her periods, and she knows what's going on. She's ahead of the game. She can start to think about things that are causing her symptoms. She knows what's happening. She can work out strategies that might help with symptoms. She'll know when to seek help. So the raising awareness bit is really important, as long as it just doesn't focus totally on the negatives, which is what we mentioned before. So, I mean, in terms of the terminology, if you want to talk about the terminology. So puberty, I think most people know that puberty in boys and girls is when they go from very low hormones, a little bit like in postmenopause, through to secondary sexual characteristics and fertility. So pre-pubertal children are not fertile. They go through puberty, they develop longitudinal growth,

secondary sexual characteristics, and then they become fertile. So then you've got all your pre-menopausal years, which are your fertile years. So we call that pre-menopause. years, which are your fertile years. So we call that pre-menopause. And that in women is depicted by usually a regular cyclical cycle of periods. So we usually say monthly periods, but every woman will have a slightly different timing of their menstrual cycle. And we call that the infradian rhythm. It's a body clock. So every woman's body clock will be different. Interestingly, women who are fertile, who live together, align their body clocks, which is fascinating. We don't

understand why that happens, but they tend to align. And it's all related to a field of medicine that's growing actually called chronobiology, because there's a number of body clocks. Most people know about circadian rhythms, which is the day-night rhythm, but the infradian rhythm is the female cycle body clock. And so that happens obviously through younger adult life. And then at some stage, the eggs start to run out. And essentially menopause occurs when a woman's finite resource of eggs,

which she's actually born with in her ovaries, runs out. But it's not a sudden, it's not an on-off switch. As she has less eggs in her ovaries, the periods can start to become less regular because the changes in hormones, which occur every single day of the month through a woman's monthly cycle are related to changes in oestrogen, progesterone, testosterone through that month. And it's all based around release of the egg. So it's quite a big deal. The energy required to produce a monthly cycle is like a little miracle every month for women. Okay. So a woman at birth is born with all the eggs that she's going to have. So the woman's got all of

that potential within her already. What is it that happens at puberty? What's the stimulus to the female body to start changing and developing and start having a period basically? Well, that is quite complex and that's been studied quite a lot recently. It all comes from the hypothalamus and pituitary within the brain, so the master hormone glands of the brain. And we recently discovered a sort of a neurochemical, neurohormone called kispeptin, which is brand new and all the incredible neuroscientists and neuroendocrinologists talking about this at the moment because we didn't really understand why that occurred why at the end of puberty did the egg release start to happen and so it's complicated and you know I'd love to make it all simple but it isn't but we now

understand that much better and that's actually helping a lot of current really state-of-the-art research looking into infertility because you know it is precarious you know not everybody it doesn't work nice and smoothly and synchronously for every single woman. So there's a message from the brain essentially of some sort that sends a signal to the body okay time now for puberty time now for things to start changing. Yes. A friend I spoke to literally this weekend said she can still remember having her first period at school in the toilet. She was literally petrified. She didn't know what was happening. She thought she was going to die. And she actually told me that actually one of her friends at school was the one who told her, no, no, I've been through this. This is okay.

And she said she went home and spoke to her mum and her mum still didn't say anything. She just pointed her to the bathroom where the sanitary towels were sort of there on the shelf, but no one had ever spoken about them. So if there is, you know, a mum or a dad who wanted to talk to their children about this, what's important for them to know? Well, it is important to talk about it and to talk to their daughters. You know, it's very, very important. It's actually taught in schools now. So at school, girls and boys will be taught about this. And there'll often be communications with parents about, you know, talking about that they're going to be talking about the topic and it would be good to expand on that at home. So this is a good thing in your view? To raise awareness, absolutely. To raise awareness of all aspects of women's health

is really important. It has not been talked about enough and it is starting to be talked about. And, you know, I think working in my field, I think everybody knows now, but they don't, they really don't. And the story that you described was really, really common 20, 30 years ago. I'd like to think it wasn't common nowadays because actually girls get a lot of information from social media as they're getting older and they get information from school. And I hope parents are talking more openly to their daughters and sons. You've seen so many patients over 30 years. to their daughters and sons. You've seen so many patients over 30 years.

And have you noticed between different ethnicities or cultures, have you noticed a difference in the tendency or the desire to talk about these things? Because of course, every culture is different. And in some cultures, it's pretty open to talk about female hormones and periods and things like that but in other cultures it's probably a bit more taboo what's your experience been of that well I think 30 years ago it was taboo in pretty much all cultures I mean even in western cultures which are tend to be more vocal in talking about things all women's health aspects were very little talked about. So if I saw a patient in clinic, they'd be surprised that I'd be talking openly about the topic, because that's what we do as endocrinologists. But nowadays, there's quite a discrepancy. So

white women in the West tend to be more open about talking about hormones. North America, UK, to some extent Europe, but it does vary even when you're talking about Western culture quite a lot. Caribbean Health Network recently. And it was really interesting preparing the talk for them about menopause for International Women's Day. And it's very interesting that black women suffer probably more severe symptoms of menopause, but they don't talk about it. And they may suffer symptoms longer, but it's still much less talked about than it's talked about in white women. Most of the research on menopause and lots of aspects of women's health are in white Caucasian women. Yeah. I mean, it's so, so interesting. Before we get into some of these lifestyle changes that people can make, the other thing I was thinking about, in particular, in relation to this, In particular, in relation to this, I think, very negative view that menopause has a lot of the time on social media. I came across some research, I don't know what your

view on this is, Anise, something called Dr. Mary Jane Minkin, professor in obstetrics and gynae and reproductive health at Yale Medical School. She did some research where she concluded in societies where age is more revered and the older woman is the wiser and better woman, menopausal symptoms are significantly less bothersome. Where older is not better, i.e. Western culture, many women equate menopause with old age and symptoms can be much more devastating. So I guess my broader question is, how much does our view of what it means to be old, of what the menopause actually is, how much of that view influences, do you think, our experience of it? Very significantly. Really? Very significantly,

yes. And it's absolutely true that that is an observation that's been, you know, seen and some Asian cultures are more revering of menopause. In Japan, I think menopause is, I don't think it has a name. And certainly there was no name for hot flushes or the vasomotor symptoms, but it's a sort of a respected state. And I think at the moment in general society and through social media, we have this sort of anti-aging culture. Anything that could be related to aging is, you know, negative. And there is a fight back because, and myself included, we, you know, I think we should be talking about pro-aging and healthy aging, not anti-aging. None of us can stop the aging process, although social media would make you think you could.

And I think it's associated, it's a very loaded statement, anti-aging. And I think it does make women feel that menopause is symbolic to aging, which in a negative way, which it shouldn't be negative. It should be, we've got so much life experience, knowledge, you know, it's actually your fertile years. I mentioned, you know, you're going through regular monthly cycles. It's exhausting for the body. I see so many younger women with hormone imbalances. They have to have bleeding every month. The hormone fluctuations can cause lots of symptoms. Postmenopause, you don't have to have a regular bleed. Actually, you're not deficient in hormones. The postmenopausal ovaries and the adrenal glands produce oestrogen and testosterone postmenopause,

but not enough to create fertility, not enough to create a menstrual cycle. So it's not a state necessarily of hormone deficiency as you write in your book? Yes, it's not a state of hormone deficiency. It's a state of lower stable levels of hormones. And there are exceptions, Rangan, because if you have both your ovaries removed, or if you have both your adrenal glands removed, or you don't have adrenal function, that can have a significant impact on hormone production. But most women who go through menopause haven't had both their ovaries removed and haven't had their adrenal glands removed. That idea, and you really emphasize

this in your book, that menopause is not a deficiency state. I think it's so important because as a medical doctor who has seen tens of thousands of women throughout my career as patients, this is very, very important to me, how we think about these things, how we frame these things. I think your final chapter in the book is my favourite. There's so much practical information in the book, but it's really an empowering, uplifting, inspiring end. This is what you write, I would love to make menopause into a positive word, something for younger women to aspire to and men to respect. Now, I thought that was really key because it's easy to think that what we're going to talk about throughout this conversation is only

relevant for women. But it's not. It's just as relevant for men as well. And in the intro to your book, you say that 13 million, one three, 13 million people in the UK are peri to post-menopausal. I think the latest statistics higher than that now, actually. But yeah, it's going up. So first of all, just remind us what peri to post-menopausal means, what it encompasses. And then if it is high, even that is pretty much a quarter of the population, right? Yeah. So that quarter are, of course, interacting with the rest of the population. So I think we

all want you to know about this. Definitely. So perimenopause is a hormone imbalance phase as the ovaries are starting to sort of, I describe it as misbehave. They're not able to produce the nice harmonious monthly cycles as a woman would be able to produce in her younger years because the eggs are running out and actually the egg release every month is integral to the hormone changes during every monthly cycle so perimenopause you know it can be very short from a few months to several years and it can be depicted by symptoms that are similar to menopause symptoms, which we can talk about, but particularly also period irregularity. And that can be more frequent, less frequent, more painful, less painful periods. So the periods can change in perimenopause,

but you can be perimenopausal and still be having regular periods. And in perimenopause, the hormones can be extremely high or extremely low. They can change very rapidly. And I often describe it as a bit of a hormone roller coaster. And then menopause is essentially the time when your periods stop. But because, you know, your periods can stop for six months in perimenopause and then restart, we time menopause as, well, it's when you had no more periods. So we define that as a year later, because when you've had no periods for a year, we know that a year ago you went through menopause. So it's a retrospective

diagnosis. So you only know after the events that I have now been through the menopause. Yes. pause. Yes. If we perhaps go through different ages, maybe that will be a nice way for people to get their heads around what happens, what are common symptoms, how can they be treated, for example. So do you think that's a good way to look at this topic? It is, it is. So younger women are also subjected to different hormone problems and imbalances so there are a number of different conditions premenstrual disorders premenstrual syndrome or premenstrual tension more severe premenstrual dysphoric disorder which is where you can get quite severe symptoms as the hormones change through the month polycystic ovarian syndrome is a metabolic condition that can result in women having often less frequent periods.

So several months of missed periods or irregular periods. So there are quite a lot of different hormone problems and imbalances that can affect younger women during those fertile years. Obviously, different fertility problems. There are gynecological problems like endometriosis, which can affect women's health through those fertile years of life. Now, in terms of sort of diagnosing menopause and numbers and rates, it varies between ethnic groups. We tend to say about 1% of women will go through menopause under the age of 40 years. So that's quite young. And usually there'll be some other medical problem that's led to that. Sometimes it's just, it's a family history of early menopause, but usually those are the causes. And if it's before 40, we call it premature

ovarian insufficiency. And about one in a thousand women will go through menopause under the age of 30. So that's pretty young. And it's not on anybody's radar. When I see younger women going through an early menopause, unless it's after a cancer diagnosis when it's more predictable, it's diagnosed very late. Because if a woman says, you know, she's in her 20s and she's not having regular periods, the first thought process is not by whatever doctor or healthcare professional she sees. The first thought process is not, by whatever doctor or healthcare professional she sees, the first thought process is not, this could be menopause. So that's often diagnosed very late. And why is it that a woman may go through it in their 20s?

Is this normal physiological? It just happens to some women or is it secondary to something else? It's obviously very rare. One in a thousand. It can be either. So it can be due to an autoimmune condition. So like most people have heard of things like autoimmune thyroid problems, arthritis-type problems can be autoimmune.

You can get an autoimmune disease that stops the ovaries from working pathologically early. It can be related to other treatments. So women who've had chemotherapy. So we're seeing a huge increase in long-term survival after cancer treatments now, thankfully. You know, many younger people who have various different solid organ cancers and blood cancers and lymphomas are treated with very toxic chemotherapy. And that can cause an early menopause. So that's more predictable because the doctors caring for that woman will be aware that, and they'll make her aware that she might go into an early menopause. So menopause typically happens at what age are you saying?

So the average age in Caucasian women is 51, but it's quite variable. So in black women, it's around 49. In Indian Asian women, it's around 46. In the Far East, it's more like 48. So it actually varies. And we don't actually know why there is such a variation in average age of menopause between different ethnic groups. Okay. So a woman's in their fertile years and at some point they start to get symptoms. Let's go through what are the common symptoms that women will experience and then how are they meant to know if this is related to their hormones and them being perimenopausal or whether it's completely unrelated. Just taking a quick break to give a shout out to AG1, one of the sponsors of today's show. Now, if you're looking for something at this time of year to kickstart your health,

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So the most common ones would be a woman experiencing symptoms prior to her menstrual bleed. That's always when a woman will feel a little bit more vulnerable as her oestrogen is dropping at the end of the month, whether she's 18 or 45. And can we call that a normal thing? It's very difficult. There's not hard lines between these things. I mean, I have to emphasise that other things that are going on in your life can impact the severity of hormone symptoms. So if you're under a lot of stress, stress hormones suppress healthy hormones. It's just a fact, you know, cortisol, if it's dysregulated, will suppress female hormones. So if you're very stressed, you might have a month

where your symptoms are much worse. And then another month when you're, you know, you've had less stress, you might not have as severe symptoms. But if a woman's having symptoms with every menstrual cycle, that is a suggestion that she's got a degree of hormone imbalance. And there is a little bit of a gray area between what might be a premenstrual disorder and what might be something progressing into perimenopause. And in perimenopause, you know, the symptoms can be relatively similar to the symptoms that a younger woman would be experiencing as a premenstrual disorder. So it really, I will say to my patients, if they feel that they're losing wellbeing at certain times and they're not sure what it is, and they might have impacts on sleep, on mood, they might be getting a bit hot

and sweaty. I ask them to keep a diary of symptoms because that can sometimes help them understand, is this really related to my menstrual cycle or actually is it actually related to other things? Yeah, keeping a diary is really interesting. I've had several patients throughout my career who, for various religious reasons, are keen not to use contraception. And so these women would be very, very particular about taking temperatures and diarising what's going on so they know when they are likely to be fertile and when they're unlikely to be fertile. And one of the things that they would often say is that they started to become more in touch with various parts of the cycle. They would start to identify patterns. I mean, if we talk about something else like food diaries, for example,

when people start documenting things and seeing, oh, wow, when I have that food, I have tummy cramping and bloating. It just starts to help build that own self-awareness. So it's really about empowerment, isn't it? It absolutely is. And I'm not saying everyone should be over-focusing on every symptom they get because hypervigilance can be a problem with health, but it can really be helpful if you're running into difficulties. And it can be empowering because you can look back, you can see patterns, and it's insightful because you can think, oh, actually I was stressed. So maybe I can do something about that stress. Maybe I was over committed, you know, something else was happening and it helps you paint a picture for yourself.

And it also, the key point there is that every single woman is different at every stage in her hormone lifespan during the perimenopause. It's not the same for everybody. So I think that also feeds into if you see scary stories in social media about somebody having a terrible problem or even scary stories, somebody has a terrible problem and then they found a miracle cure. It doesn't mean that's going to work for everyone because actually the treatments for the various different hormone problems that I see, it will vary even with the same condition as to the individual needs of that woman. Stress can worsen symptoms. So let's talk about some of the symptoms that I guess people commonly associate with perimenopause and menopause, night sweats, mood disturbances, fatigue, you know, weight gain, hot flushes. If we look at

those symptoms through the lens of stress, in your experience, can stress management potentially help with a lot of those symptoms? The short answer is absolutely yes, it can. The narrative answer is more complicated. So there are some symptoms that are very tightly linked with the menopause hormone changes or the perimenopause transition or whatever you want to call it. The vasomotor symptoms, which are the hot flushes, flashes, night sweats, are very tightly linked to the drop in estrogen. And the severity of those symptoms is very variable. So about 80% of women going through the menopause transition will experience those symptoms. But that doesn't mean that they're going to be, you know, severe. That doesn't mean it's going to be impacting on everything to do with their lives. But there are a number of women, and we don't understand why,

that suffer really severely with those vasomotor symptoms. Now, those symptoms are tightly linked with hormone changes. And if you're having drenching night sweats every night so that you're having to change your bedclothes three times a night, which I've seen that happening, and then you're not sleeping because you're so disrupted at night, you will have brain fog the next day. You will be exhausted. You know, you've had no sleep. You'll be hungrier during the day because you're not sleeping. That all links very tightly into the menopause symptoms. And if you're stuck in a rut, it can be quite difficult to manage, you know, to use stress management to get out of that cycle. But that is not the majority of women.

The majority of women will say to me, yeah, I notice hot sweats and flushes. They're not really bothering me, but doesn't that mean I'm going through the menopause and that bothers me? But actually the symptoms, the heat symptoms aren't severe for most women, although most women will experience them. So then we can look at other symptoms. So the irregular periods. So in the menopause transition, if a woman's having absolute flooding and severe pain, which is erratic or unpredictable, and it's causing anemia because she's bleeding so much, she might be bleeding chronically, she might be bleeding, you know, for multiple days in a month. That's exhausting. And we need to address the cause of that, which is very linked with the hormone transition. cause of that, which is very linked with the hormone transition. So the vasomotor symptoms and heavy painful periods can be really difficult to then just manage with lifestyle because they

can really affect everything that's going on in that woman's lives. However, there are a lot of symptoms in today's world across society that are being attributed to menopause in midlife women, but actually may not be as tightly linked with the menopause transition. So things like overwhelm, anxiety, sleep problems, there are other causes of those symptoms across society. You know, it's not just hormone changes that are affecting sleep problems across society. You know that sleep problems in the pandemic were exponentially society. You know that sleep problems in the pandemic were exponentially rose. You know, there are many modern world factors that disrupt sleep, you know, blue light on devices that, you know, suppress melatonin and delay melatonin

release. There's many other factors. It's like a matrix trying to work out what your symptoms are caused by. Yeah. so whilst the growing awareness of menopausal symptoms on social media across society is a good thing, one of the downsides can be that we doctors, women, are maybe putting things down to their hormones and the menopause when it's possibly completely unrelated. I think that's a really, really important point. At least, why is it? If we take a 30,000 foot view on this and go, okay, by definition, all women, when they transition from being fertile to being post-menopausal, when they are no longer fertile, my understanding is that every single

woman will have a change in their hormones. But not every single woman will have menopausal symptoms. So when we look at that, and of course the human body is very, very complex, one might go, okay, everyone's hormones are changing, but not everyone's getting symptoms. So is it just the hormones or, of course, there's individual variation, but at the same time, are there other factors going on in their life? Let's say the stress load they are under, which we've obviously spoken to how much stress there is on women. What I have seen in general practice, more often than not, when a woman was suffering with severe menopausal symptoms, not in every case, but in a lot of cases, there was also a lot of stress.

Now, could it be that the menopausal symptoms were making them feel bad and increasing the stress in their lives? Or could it have been the other way around? I'm sure it was a bit of both, whereby chronic stress was potentially exacerbating their symptoms. Quite a little bit there. I wonder if you could unpick some of that and share some of your thoughts. Yeah. So as we've already discussed, modern lifestyles are much more adverse than they were 20, 30 years ago. There's been a paradigm shift in women's lives, actually in all of our lives throughout, you know, men and women of all ages. So the stress factor and the adverse lifestyle factor is definitely a new factor in terms of the symptoms women are having to

experience during the menopause transition. And the human body is complicated. And we know that even from studies done 20 years ago, about 25% of women will have severe menopausal symptoms. We haven't had a study that can tell us if that's increased or not in today's world. But I would probably say symptoms during the menopause transition are worse. But is something changed about menopause itself or is it from the outside? Are there things going on? And I think it's more likely that there are other things going on in women's lives that are making their menopause experience more difficult to navigate. lives that are making their menopause experience more difficult to navigate. And, you know, we can, I mean, we can talk about this later. But, you know, if you look then at the treatment that we recommend for menopause symptoms, the first line treatment, if we're going down a medication route

would be hormone replacement therapy or menopause hormone therapy. And what I know, and what's evident from research, because there was a very nice report done last year by the Fawcett Society, 4,000 women were surveyed who were on hormone replacement therapy. 54% said that the HRT had resolved their symptoms. And that was probably women who'd gone on HRT for the hormone for menopause symptoms. 46% said it hadn't. So it's not helping every single woman, even if you're targeting the actual cause, which is the low oestrogen. For a woman who thinks that they may be perimenopausal or menopausal, right? And is getting symptoms and is seeing things online and they're thinking,

wow, I think this is, I think that's me, right? What that lady is describing or what that doctor is describing, that's me, that's my life. How are they to know if this is the menopause or not? Are there blood tests, for example, which can help or can they be misleading? or not, are there blood tests, for example, which can help or can they be misleading? Well, while a woman is still having periods, as I mentioned, the perimenopause is a hormone rollercoaster. So blood tests are not really very helpful because you might do a blood test and it looks normal, but you might repeat it a week later or a month later and it's very abnormal. So we tend to say actually perimenopause, it should be a clinical diagnosis. You should be excluding other potential causes for symptoms. A it should be a clinical diagnosis you should be excluding other

potential causes for symptoms a clinician should be looking for red flags in their patient but if if there's nothing else for people who don't know can you explain what a red flag is so so um in a clinical consultation you know if if a woman is saying i've got hot flushes night sweats brain fog anxiety it's all new i've got got sleep problems, then they're pretty typical. There's no red flags there. If a woman comes and says, you know, I've lost two stone in weight, I'm not sleeping, I'm having night sweats, but I'm also feeling absolutely exhausted, I haven't been able to work three months, it's a more extreme paradigm. And things like weight loss is something that we don't expect, a significant weight loss.

Equally, you know, if a woman says I've got severe palpitations, it can be due to menopause changes, but that would need to be looked at separately. And, you know, if a woman says she's absolutely exhausted, she's, you know, was completely fine. And over the last few months, she's exhausted. Blood tests are going to be needed to see if there's a thyroid problem, if there's anemia, if there's something else going on with the liver or kidneys. So a doctor should be able to identify if there are concerning features in that history quite easily. So the key then is if a woman is experiencing symptoms, she and her health professional think that perimenopause or the menopause transition is causing or contributing to those symptoms, then she should be offered a trial of treatment as long as she has no risk factors, contraindications to that treatment, which would usually be hormone therapy.

And hormone therapy works pretty quickly. It's sort of somewhere, I mean, as early as two weeks for treating the vasomotor symptoms, which are impacting sleep, energy, mood. It can take up to three months. So I would normally say, try treatment for three months. If after three months of taking treatment, a woman says, well, her hot flushes, night sweats have gone, but she's still feeling exhausted. She's still gaining weight. She's still getting migraines or she's still got brain fog, overwhelm, anxiety. We need to be looking at other causes for those symptoms. And that goes back to modern lives, stress.

symptoms. And that goes back to modern lives, stress. Many women I see in my clinics come to me and they say, I've tried six different hormone therapies and my symptoms are more severe or exactly the same as they were. Or in fact, my symptoms are the same and I've now got side effects from the treatment. And then I look into their lives and they've got the most unbelievable challenges. And I think women almost are a victim of their own success because they just think they can take on everything and do everything for everyone. And our bodies are not invincible. And that stress on the body, even if it's not psychological, if it's physically stressful to do what that woman is trying to do, it doesn't matter how much hormones we give, it's not going to cure the underlying cause.

So powerful. And it really makes me think about one of the other ideas that you write about, and I've heard you speak about, that a woman can actually prepare for perimenopause and menopause. You really make the case that actually that time can often simply exacerbate underlying issues. So the issues were already there. Maybe women were pushing too hard, they were taking too much on, they were chronically stressed. And then the perimenopause happens, there starts to be fluctuating hormone levels. And yes, of course, it can be down to the hormones, which might require HRT in the right patient. But it can also be a reflection that this is almost like a warning sign to say, hey, listen, if you can start making some changes, not only can your perimenopausal sensors get better, but also you can probably learn things

about yourself and your life that are going to help you, yes, now, but also for the next few decades. Would you agree with that? Absolutely. Absolutely. So, you know, I sometimes say to my patients, you know, you've really been building up some of these, you know, over-commitments, challenges, adverse lifestyle. We're all guilty of it, you know. And the perimenopause, you can look at it one way, it's like the straw that breaks the camel's back. You know, you can't do this any longer. Your body's telling you no. But equally, it is an opportunity if you start to get symptoms and they're not severe, but you start to think, oh gosh, it's an opportunity to take back control or maintain control to stop the symptoms from progressing. And I'm not at all

saying that if a woman is experiencing symptoms, she shouldn't use treatments that are going to be helpful, such as hormone therapy, if she can take it. Because, you know, it will help the hormone changes. But if you take hormone therapy and your symptoms don't improve, you need to be looking more widely and reflecting more widely at why that is. And if they do improve, it's still helpful to apply self-care

and lifestyle approaches that are going to help with your long-term health, even if your symptoms do resolve with hormone therapy. How common is it for a woman to come and see you and they're really struggling, they've got a lot of symptoms and they think HRT is the answer. Do some people these days see it as a quick fix magic bullet so that I don't want to make changes, my life is busy, I've got a lot going on and I'm sympathetic, I understand that. If I could just get the HRT, my life would be okay, I could continue doing what I'm doing.

Is that something you're seeing? It is. And I never, I will never say, here you go, here's a prescription for HRT, you're perimenopausal. I start off by, tell me about your life. What is going on? Tell me about your health. How overcommitted are you? You know, tell me about your diet. Are you smoking? Smoking makes menopause symptoms worse. Are you drinking alcohol? Alcohol makes, too much alcohol makes menopause symptoms worse. You know, it's a medical history. But I think, again, the social media algorithm with menopause is a catastrophe and hormone therapy is a quick fix, does make women think, maybe I will, as long as I just take the hormones, everything will be fine. And HRT, hormone therapy, will help the

symptoms that are specifically linked with menopause, but it won't cure all those other things. Well, let's talk about HRT. I don't think we've ever covered HRT in detail on this podcast. So I'd love to go through the basics for everyone, including how has the narrative changed over time? You know, there was all kinds of talk about risks, cancer risks, and the narrative changed over time? You know, there was all kinds of talk about risks, cancer risks, and the narrative on that, the prevailing view has started to change. As things stand now in 2023, what is the current view? The current view in 2023 is that the most effective treatment to treat menopause symptoms is hormone replacement therapy. And for the majority of women experiencing symptoms that are affecting her in her life, and she's seeking treatment during the time she's got symptoms, which are for most women time limited, hormone therapy has much more greater

benefits than harms. It's really effective and safe during the menopause transition to treat menopause symptoms. Okay. And do you know when HRT started? So HRT started to become really popular in the early 1960s. They worked out that you could give oestrogen to treat menopause symptoms. They didn't realise that at that time in the 1960s that you could give oestrogen to treat menopause symptoms. They didn't realise that at that time in the 1960s that you needed to give progesterone to protect the womb. So HRT's had so many rises and falls. So it was really popular because it helped with the aches and pains and the vasomotor symptoms and sleep. And then there was this huge rise in endometrial cancers because HRT didn't include progesterone at that point.

The sort of logic that we need to protect the womb in women who have a womb with progesterone because estrogen thickens the womb lining. That's the sort of side effect of estrogen with all the benefits it has on general well-being through the menopause transition. It thickens the womb lining. So then they worked out that you have to give progesterone to women who have a womb. You don't need progesterone if you've had a hysterectomy, if you've had your womb removed. It's just to protect the womb. And then, you know, different regimens were tried, different dosing was tried. And it was worked out that if you have, if you're in perimenopause so you're still having some bleeding we give progesterone for part of the month but oestrogen continuously and we're

we're not really replicating a natural menstrual cycle but we're trying to give you the oestrogen all of the time and protect your womb lining that's important. So HRT is not there to replicate the natural cycle. It's there to help with symptoms. It's there to help with symptoms by giving you oestrogen, but we have to give progesterone to protect the womb lining in women who've got a womb. So we give a higher dose of oestrogen for part of the month in women who are perimenopause, that's called cyclical HRT. But if you're post-menopause and you haven't had a natural bleed for a year, there's a different regimen. We just give a low dose oestrogen progesterone all of the time

because the endometrium doesn't need as much progesterone to be protected post-menopause. So you mentioned that we know HRT now is very good for menopause or symptoms. Does that mean that you think most women should be taking HRT? I would take every single woman individually. We think from data we've got, 25% of women experience severe menopause symptoms, but that's pretty established data. And in today's world, life is different and it may be that more women need it. Do I think every woman needs it? that more women need it. Do I think every woman needs it? Absolutely 100% no. In fact, all the data we have suggests that most women either don't need it or only need it for the time they're experiencing symptoms. And symptoms average is about seven years, range two to 10 years.

But many women won't need it for symptoms. They'll say, I've got a few hot flushes, but it doesn't bother me. I think the narrative at the moment is everyone should be on it. It might be controversial to say it's almost because of social media, a little bit fashionable, you know, I'm menopausal, I should be on HRT. But it's not as straightforward as that because many women will then go on HRT and they'll say, oh, but I've gained weight or I feel bloated or I've got migraines or bleeding problems. So it's not as straightforward as just going on HRT because a lot of women struggle with HRT regimens. Yeah. So you're saying 25% of women experience severe menopausal symptoms. And so if the prevailing view now is that HRT can help with menopausal

symptoms, it seems reasonable that a good few of that 25% may well benefit. But of course, that means that 75% of women are not experiencing severe menopausal symptoms. So is that fair to say based on what you just said? So what we know 80% of women will experience menopause symptoms. How many of those are going to feel they need treatment and how many of those are actually going to benefit from the treatment? Isn't that clear? This is complex, isn't it? It's really complex.

And we've seen, as you know, that clear. This is complex, isn't it? It's really complex. And we've seen, as you know, a really high rise in HRT usage in the last two to three years. But are some women having it or being prescribed it when they don't need it? From my perspective, I want my patients to feel well, be empowered and achieve long-term health, to be able to apply lifestyle approaches, to keep them fit and well until they're in old age. The problem is women are going on HRT and it's not a miracle cure. So now we're seeing women going, I'm on HRT, but I don't feel well. I'm not on enough. I need more, or maybe it's not being absorbed. And there's mass confusion. We know that the doses of HRT we have licensed

are effective in treating menopause symptoms and this goes back to if a woman goes on to hormone therapy and after three to six months she's got some ongoing symptoms we need to be looking at what those symptoms are are they tightly linked with menopause or do does this go back to what we talked about in terms of women's complicated lives today, the commitments they have, the stress they're under, the lifestyle factors that are relevant? We need to be looking at what residual symptoms are on treatment. If that treatment works for a woman and it's a safe, licensed treatment, then she can carry

on that treatment. And that's brilliant. She should be given it and there is no HRT is not time limited some women say to me I'm never coming off I can't I do not ever want to stop treatment that is the minority of women. Let's talk about cancer risk because you've touched on this already a little bit, but I think it would be really good to get real clarity for people because a lot of women don't want to take HRT. Now, they'll have different reasons for that. Some of the time, the reason is because of what they read

when there were real concerns over the long-term risks of HRT. I know you've touched on it a little bit, but to ask you a direct question then, is there an increased risk of cancer if a woman goes on to HRT? I'm going to have to give you a narrative answer there. So I'll go back to the womb cancer rates that happened in the 1960s, 70s. And then we worked out regimens of HRT that would prevent womb cancer. And that was fine. And then the Women's Health Initiative study was set up in the 1990s and early publication in the early 2000s. It was actually 2002.

And that study looked at women being commenced on, it was a randomized double-blind placebo-controlled trial, and it looked at women being commenced on HRT between the ages of, I think, around 50 to 76. And that study showed an increased risk of new breast cancers in the hormone replacement treatment arm. The treatments that were used in that study were, it's fair to say, older-fashioned hormone regimens that included conjugated equine estrogens, which is a synthetic estrogen, and medroxyprogesterone acetate, which is a synthetic progestogen. And the overall results suggested an increased risk of breast cancer.

And there were also increased risks of cardiovascular and cerebrovascular events in the women in the active treatment arm. So that means the women who were taking HRT. But the majority of treatment was oral HRT. The majority of treatment was synthetic hormones. And actually, you know, the main subsequent analysis suggested that the risks were generally in older women who'd started the HRT much later. So there was this study called the Women's Health Initiative study where they had, you know, I'm really trying to simplify it, two groups, one group were taking HRT, one group were not taking HRT. And initially there were concerns that in the group taking HRT there was an increased risk of

breast cancer, strokes and some heart events. Cardiovascular events, yeah. So at that time there was some negativity saying, well we need to be really careful here because yes on one hand we're helping women with symptoms but on the other hand we might be increasing their long-term risk. Now you're saying with a subsequent reanalysis of that data, it's more nuanced than that, isn't it? It's very much more nuanced. So first of all, we know oral oestrogen, the tablet forms, was used in the Women's Health Initiative study. So if you're taking HRT as tablets, it can increase the risk of blood clots and strokes. can increase the risk of blood clots and strokes.

And oral oestrogen, the risk is going to go up. The risk of blood clots is higher in older people anyway. So if you're treating women in their 60s and 70s with oral oestrogen, they're at a higher risk of blood clot type events. So we do know and we still know and everybody agrees that oral forms of HRT in the wrong women can put them at increased risk of blood clots, whether that be deep veins thrombosis or strokes. But for younger women, that risk is very low. You know, if you're in your 40s and you're healthy, you've got a healthy lifestyle, the risk of a blood clot is low anyway, unless you've got a family history or you're a smoker, you know, there's other risk factors. But the risks in women in their 60s and 70s is going to be higher. And then if you give oral oestrogen, that's risky. So actually that meant that over the last 20 years, the HRT that

has been utilised, we've moved more towards transdermal oestrogen. So that's skin patch, spray, gel oestrogen, because when oestrogen is given through the skin it does not increase the risk of blood clots at all so we've immediately taken away one of the big risk factors that was found in the women's health initiative study were any of the women given transdermal some were but most were on. So when they've re-looked at that, they think, oh, actually the women with transdermal hormone replacement therapy, as opposed to tablets, they seem to be okay. Yeah. And there's been many other studies done demonstrating that transdermal estrogen doesn't. It's to do with metabolism in the liver. Yeah. Well, that's

brilliant. I think that's really helpful for people. What about those other risks then of increased breast cancer? So there's been multiple analyses. There's been many different big sort of meta-analyses looking at what's the story with breast cancer and HRT. And again, it took probably almost 20 years to kind of tease it all out. The increased risk of breast cancer with HRT seems to be more with oestrogen-progesterone combinations. So actually, we know up to 20 years of data, oest estrogen-only HRT, and I mentioned if you've had a hysterectomy, you don't need progesterone. Estrogen-only HRT amazingly doesn't seem over 20 years to increase breast cancer risk at all.

But estrogen with progesterone does increase breast cancer risk, but it's a cumulative increased risk. So it doesn't happen overnight. You don't start taking HRT and then three months later it's caused breast cancer. That doesn't happen. But certainly as time goes on, the longer a woman is on HRT, the background increased risk of breast cancer goes up and it's not a huge risk um a study that was published around 2019 suggested probably somewhere between one in 50 and one in 70 women treated for more than five years might end up with a breast cancer that they wouldn't have got otherwise

and so then we have to look at you you know, the benefits of the HRT. Because if an individual woman knows that she might have a slight increased risk of breast cancer, but if she's in the moment and her life is not worth living because she's got severe menopausal symptoms, she needs to take a view

on balancing that risk and benefit. And that has to be an informed decision. She has to understand her own risks. Now, those are kind of data that are just looking at, you know, all the data we have. But then we also need to think about modern lifestyles and breast cancer risk, because carrying excess weight, smoking, excess alcohol, not doing enough physical activity, all increase your risk of breast cancer. One in eight women get breast cancer. Yeah, this speaks to the importance of women seeing educated healthcare professionals to have this sort of nuanced conversation. If someone comes to see you in your clinic, then you're going to be having

these nuanced discussions with them and say, look, on one hand, yes, this may increase your risk here, but your lifestyle is fantastic. You've got no family history of breast cancer. Your symptoms are really bad at the moment. Let's say your night sweats are making your life miserable. Actually, maybe a few months, maybe one year of this might really help your quality of life, which in turn is going to help you stay focused on your lifestyle changes, which also are going to reduce your risk. So it's, you know, this nuance is something that's very much missing in all these conversations, particularly in one minute Instagram reels. It's very hard to get this nuance across, isn't it? And then, you know, you take it for a year and then you re-evaluate.

And I would say it's not about going on treatment and then just staying on it and that's it. Because actually the treatment, HRT isn't one thing. Your treatment requirements might change over time. You might find it's really effective at one point in your life and then later you're getting more side effects than benefits. And most women, for most women, menopause symptoms are time limited. And so most women do not need hormone replacement therapy for many, many years or decades to treat their menopause symptoms. So actually, if it's used correctly, it's really, really important. And again, to put it in context, we know there's a strong association, don't we, between alcohol intake for women and breast

cancer. I say that not to make anyone feel bad, but we have to be honest about what the data is showing, right? It's higher with excess alcohol than it is with HRT. Yeah. Are you able to speak to the relationship between alcohol and breast cancer? Well, I mean, it's a complicated one. But we know with everything, even with women who've had breast cancer, alcohol increases recurrence risk in women who've had breast cancer. It's probably somehow affecting oestrogen levels. Well, 80% of breast cancers are oestrogen driven. And alcohol has an impact on oestrogen levels. Well, 80% of breast cancers are oestrogen driven, and alcohol has an impact on oestrogen levels. Women still have oestrogen postmenopause. And so

in women who've had breast cancer, even if they're postmenopausal, we give them adjuvant therapy, aromatase inhibitors to block any oestrogen that they have around in their system. That is a real hormone deficiency state when we give aromatase inhibitors. And alcohol is probably somehow impacting on oestrogen. If somebody has had breast cancer, breast cancer rates are very common. So, you know, there's many people who are listening or watching this who will either currently have breast cancer or have experienced it. Given the potential risks from HRT, is a previous history of breast cancer a contraindication for HRT? Or are there certain instances where on balance, it's like, yeah, okay, well, we need to give you this for your symptoms? Yeah, and that's really important because as you say,

breast cancer survivors are a significant proportion of midlife women. Treatments for breast cancer often induce menopause symptoms, like chemotherapy, for example. And I also did want, as we were talking about HRT, to include those women who can't take HRT, who take it and it doesn't work, who take it, who get side effects from it and can't, or women who choose not to take it. international menopause governing bodies recommend that HRT is a contraindication after a breast cancer diagnosis. For people who don't understand contraindication... It should not be used after breast cancer. And that's not just estrogen receptor positive breast cancer, because that is 80% of breast cancers. But even in women who have triple negative breast

cancer, which isn't hormone driven, if they get a recurrence of breast cancer, secondary breast cancer, or if they get a second primary breast cancer, those secondary or second primary cancers in women who've had triple negative cancer can be oestrogen positive. So we recommend that HRT is not used, systemic HRT is not used in anyone after breast cancer. Systemic. So you mean these transdermal patches? Yeah. So when I say systemic, I often get comments, if I mention HRT is contraindicated from women who say, well, I've been told that I can have vaginal oestrogen, which is used to treat the genitourinary symptoms associated with menopause. Vaginal symptoms can occur pretty much at any time, peri to postmenopause. They're very varied. It might be itching, soreness,

burning, pain, recurrent water infections. There's lots of different symptoms that can occur, recurrent water infections. There's lots of different symptoms that can occur, most of which are actually relieved by vaginal oestrogen. And vaginal oestrogen is, it's often described as HRT, but those of us who are sort of, you know, working in the menopause field don't really consider vaginal oestrogen as HRT. We think of HRT as systemic, going through your whole body. Whereas vaginal oestrogen is just treating local symptoms, which can be really severe, really problematic for women. And again, it's an area now that's still not talked about enough. So even women who've had breast cancer, the majority, with possibly the exception of the aromatase inhibitor medication that I mentioned, most of the studies that we've had, and we've got a lot of numbers now

looking at women after breast cancer, vaginal oestrogen, if it's needed, it's not that everyone should have it, but if it's needed, it appears to be safe. I should add a caveat that any woman who's considering hormone treatment after a cancer diagnosis of any type, they should run that by their cancer team.

Because their cancer team has their specific statistics. And you might ask me, is there ever an exception? And there are always exceptions to a rule. But any exceptions should really be with full informed consent. But we put this on all the copy on YouTube and on my podcast that these conversations, these are for information only. People should not take this as medical advice. If they want to talk about this stuff and they want to make these changes, they need to talk to someone about them. These are really quite complex issues. I just want to highlight that.

to talk to someone about them. These are really quite complex issues. I just want to highlight that. But just to summarize what I feel you said there, Anis, if you have had breast cancer in the past, no matter what type it is, HRT, systemic HRT, oral or a transdermal patch should not be taken. It's a contraindication. But if you are having specific local vaginal symptoms like itchiness, dryness, pain, whatever it might be, it seems as though the prevailing view is you can take it once you've had a proper conversation with your healthcare professionals. Is that an accurate summary? It is. But again, and I'm conscious that there may be people listening who say that they're not fitting into one of those categories. And so if systemic HRT is ever going to be given to somebody who's had breast cancer, it needs to be an informed decision. It is likely to be associated with increased risk, but this has to be taken in the context of that woman's life and also her individual circumstances.

And there are situations and they're rare situations. So, for example, a woman who's got the BRCA gene, who is diagnosed with a very high risk of breast cancer in her 20s or 30s. She has a double mastectomy. She's found to have an early primary breast cancer. She's got a full hysterectomy with her ovaries removed. She's young. She might go five years. She's clear from the early cancer that was a low-risk cancer. There may be situations where, particularly in younger women, the cancer team will say, actually, you can now take HRT safely. But it's so nuanced. cancer team will say, actually, you can now take HRT safely. But it's so nuanced. Equally,

there will be women who desperately want to have HRT, who may have a high risk of breast cancer recurrence, who've had oestrogen receptor positive disease. And they need to have a really detailed, nuanced discussion with their health professional about, are they happy then to get a recurrence 10, about are they happy then to get a recurrence 10, 15, 20 years later? Because breast cancers are notorious cancer for coming back many years later. Most cancers, if you survive five years, you're cured. With oestrogen positive breast cancer, you're not. And it often comes back later. So a woman needs to be able to make a decision, being aware that, you know, she might feel great on the HRT now and she might be fine in five years, you know, she might feel great on the HRT now and she might be fine in five years, but something, she might increase her risk. Yeah. And there's a whole section in your book on breast cancer, I think, which will help people.

One of the concerns I've seen in the media recently is that some women are being prescribed very high doses of HRT. Are you also seeing some women who are on really high doses of HRT? And what are the potential implications of that? Before we get back to this week's episode, I just wanted to let you know that I am doing my very first national UK theatre tour. I am planning a really special evening where I share how you can break free from the habits that are holding you back and make meaningful changes in your life that truly last. It is called the Thrive Tour. Be the architect of your health and happiness. It is called The Thrive Tour.

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and I can't wait to see you there. This episode is also brought to you by the Three Question Journal, the journal that I designed and created in partnership with Intelligent Change. Now journaling is something that I've been recommending to my patients for years. It can help improve sleep, lead to better decision making and reduce symptoms of anxiety and depression. It's also been shown to decrease emotional stress, make it easier to turn new behaviours into long-term habits and improve our relationships. There are, of course, many different ways to journal. And as with most things, it's important that you find the method that works best for you. One method that you may want to consider is the one that I outline in the three-question journal.

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yeah a lot of patients are coming to me who have experienced difficult menopause symptoms that haven't been relieved by HRT and they're coming to me on sometimes alarmingly high doses of HRT and when I say alarmingly high I don't mean just high licensed dose I'm talking about significantly higher than what we know is licensed. And when we talk about licensing, all the efficacy and safety data on all medications that we prescribe are based on, you know, clinical trials that demonstrate the doses that are needed and the doses that are safe. safe. So actually, I don't very often use the highest dose of HRT. There are situations when I will prescribe a woman slightly higher than the licensed dose. And I think that is recognized that for some reason, and particularly younger women with premature ovarian insufficiency may need higher doses. But the rate at which women

are going on higher doses at the moment is exponential. It's definitely linked with social media. But the biggest concern I have is that the women who are coming to see me on high doses, really high, excessive dosing, two, three, four plus times higher than what is licensed, which you really wouldn't generally see with any other, you know, medication. I wouldn't give three, four plus times higher than what is licensed, which you really wouldn't generally see with any other, you know, medication. I wouldn't give three, four, five times the dose of thyroxine for somebody with hypothyroidism because their symptoms continued. I would be saying, what are your ongoing symptoms? Let me just see, are there other causes for those symptoms? And I can tell you that in every woman I see who's on really high

doses, who comes to see me, there are loads of other causes for those symptoms that are being ignored. Because I think that woman is being led to believe that if she takes enough oestrogen, it will work. If her symptoms aren't resolved, it's because she's not on enough oestrogen. And it's kind of the elephant in the room that we have complicated bodies. and it's kind of the elephant in the room that we have complicated bodies. So Anissa, I remember maybe 10 years ago or so trying to find someone local who was holistic minded to help certain female patients of mine. And I remember referring quite a few patients to you. You've always been, and your book I think really reflects this. You're very pro-empowerment. You're pro-helping women make small lifestyle changes. Whether they go on HRT or not, you still want to empower them

to make changes. So I wonder if we could just shift the focus slightly now to what are those lifestyle changes that you commonly recommend to your patients? I understand, and it's my approach as well, that no one size fits all. Every woman is going to need a slightly different, I guess, lifestyle prescription, if you will. But I wonder if you could just talk us through what are some of the common things that people can do that are going to help them with their hormonal symptoms? And just to give you a background, this goes back to the fact that I worked very much in a tertiary referral menopause service. Women who, over the last 20 odd years, who had the most severe problems, symptoms related to particularly menopause, would get referred to specialist clinics. And I worked at Christie Hospital, which was a cancer hospital.

And I looked after many women who'd had an early menopause from cancer treatment, many women who'd gone through breast cancer and developed menopause. So I was there being asked, how do we treat these symptoms? You know, how do we how do we treat the symptoms in someone who can't safely take HRT? And how do we treat the symptoms? And this was very much my later experience from when I went to Salford in about 2005, was women were coming to me on HRT already and still suffering from symptoms. So then I think, well, look, I've got to find out if they're already on treatment, how do I make them better? If they can't have that treatment, how do I help these patients get better? And so my clinical experience then went to my general medical experience and looking at a patient holistically, looking at any other medical problems that might be contributing. And that's important because, you know, I might say women in perimenopause might be anemic. If you treat that, you're reducing the burden of symptoms. Hypothyroidism is actually, although we can diagnose it much easier now because of thyroid function tests, hypothyroidism

is 10 times more common in women than men. It's really common in the demographic 40 to 60 years. Other medical problems should be treated. So, you know, I address that. There are other non-hormone medications, which we haven't talked about, which I'd like to cover for those women who are told you can't have HRT and they feel like they're missing out because we're talking about HRT all the time. But then, you know, I would talk to my patients and they, you know, we try a few things and we'd optimize the anemia or the thyroid or, you know, try some non-hormone medications. And they go, yeah, but I'm, you know, I'm still feeling exhausted. I've still got aches and pains. So then, you know, and this is clinical experience, this really, is that I then go, right, just tell me a little bit about your lifestyle. And it would invariably themes come up of overcommitment of women expecting too much

of their bodies, not having enough downtime, not having good sleep patterns, not having good nutrition, often too much alcohol, too much smoking. This is not rocket science. This is easy, but it's not something that we tend to do in conventional medicine. We have too short consultations. And so I started to look into this and actually, funnily enough, when you, when you get good at it, it doesn't take that long to get over it. And the other thing is major life events, because again, talking about that midlife rollercoaster, as we get older, major life events hit us more and more, you know, men and women as you get older. Historic trauma is a big factor in the experience of symptoms with other medical conditions. So there's lots of themes. And I will ask patients about different, you know, lifestyle, historic traumas.

And then it's about, there are themes as to what people can do, but it's not the same for everybody. And as you say, there's not a one size fits all, not with medication, not with lifestyle. Because if you're absolutely exhausted, you're sitting at your desk and then you're sitting on your sofa, you don't see daylight, you haven't got energy to go and cook fresh food, so you're eating ready meals,

maybe smoking and drinking too much. As coping strategies, and again, alcohol is an unhelpful coping strategy. It can, over a number of adult years, as your life gets busier or more stressful, you know, it can all sort of hit you. You then got hormone symptoms and we're expecting a miracle cure with hormone treatment, but actually we need to be sitting back. So the first thing I would say in terms of lifestyle to every woman I see regarding menopause is how much are you moving? And I'm not saying go and do a marathon.

I'm not saying go and, you know, be an expert at yoga or do HIIT classes because there's no one size fits all. And actually, if you try and do too much too quick, you're back to square one, it's snakes and ladders. It's about starting where you are and making small changes. I sometimes describe them as micro dosing your lifestyle and just tiny moments. If you're exhausted, don't expect yourself to go for a 30 minute walk. But if you do, if you don't do any exercise, you could start off by just going around the block and getting some daylight for five minutes in the morning and then building very, very slowly. There is an amazing woman who I follow on social media called Joan MacDonald. Her Instagram is trainwithjoan. Oh, is she sort of 70, 80?

She just turned 77. Joan at 46 didn't really do much exercise. And then she decided with her daughter to start doing some exercise. She didn't think, I'm going to be at 77. I'm going to be like, you know, an internet sensation, which she is actually. She didn't think that. She just, she just said, I just went one day at a time and I built up slowly. She never had, she didn't put pressure on herself. She didn't have over expectations. Joan is like a miracle. I mean, she's amazing. She's absolutely amazing. She's really strong, isn't she? She's incredibly strong. She's built up gradually. And she's not saying, you know, I'm in a deficiency state and I'm a mess. If you look at Joan, she is the picture of, I think,

what pretty much most women would think they want to be like when they're 77. It's, if not every single woman on the planet, she's amazing. She's so healthy and she's done it all through lifestyle. The key to that is make small changes because Rome wasn't built in a day and we all want quick fixes. We all want to do a miracle diet, a clever hack, a boot camp for six weeks and suddenly drop, you know, the, you know, four stone in weight that we've gained over three decades, you know, or suddenly be fit when we haven't done any exercise for 20 years. And that isn't realistic. So it's about starting where you are and building up. So that exercise, nutrition, I mean, as you're aware, nutrition is a real trigger topic. Loads of people have different views.

My mantra regarding nutrition is clean, whole food. Keep your plate full of real food. Not processed, ultra processed, not packets, jars, you know, ready meals, but actually just real food, you know, fresh fruit, veg, nuts, seeds, lentils, pulses. We eat a lot of processed foods. I think I say to my patients, do you eat processed food? They go, no. And I said, oh, do you have any bread, pasta cakes, biscuits, pizza, pastry or noodles? And they're going, oh yeah, I have those. And I'm like, well, that is processed, right? So, and I'm not saying exclude it, but that shouldn't be your staple diet. I keep it simple. And then having a social network, having laughter is really, really important.

And all of those things will help your weight management because, you know, increasing weight, you know, having an excess weight as you get older is not good for long-term health risks. So everything ties in when it comes to lifestyle. Yeah. I mean, first of all, I really appreciate you sharing, Joan, sharing the advice that you give your patients. Tying it back to hormonal symptoms, are you finding that when you can help women to make these small, sustainable changes to their lifestyle, then of course different women will choose different things and go at different rates. Are you finding that often the symptoms that they came to see you with are also getting

better? Yes. So building up movement and exercise is a stress reliever. So you're reducing the impact, that stress burden on your body. Eating whole foods, you're going to have more nourishment, proper nourishment um too much alcohol and smoking worse than hot flushes vasomotor symptoms alcohol is very disruptive to good quality sleep if you the other thing about food is if you're eating a lot of ultra processed foods people talk about sugar crashes which and you know sugar surges and crashes which is not really a medical term but people do get reactive hypoglycemia, which is essentially a sugar crash if they eat a lot of processed foods. And that kind of perpetuates a craving for high sugar carbs. And so, you know, all of these things,

there's actually more science behind lifestyle than there is with any medication. The thing that I would add to that is if a woman who's going through severe symptoms is listening to, you know, us talking about how important lifestyle is, she'll go, I can't, I can't do it. No, I get that. So what I would say there is that, okay, there are medications that can help to try and lessen your symptoms to give you that opportunity then to use lifestyle. But medication is never a substitute. It won't make you achieve improvement in your long-term health and wellbeing, but it can give you a platform from which to start what you need to do. One thing that's often talked about is that we're living longer now. So you've probably got more, for the average woman, more adult life after menopause than you have

before it. So then somebody arguing the opposite point would say, no, no, no, but you must have hormones for longer because we're living longer. But I will stick with what I say is that during that hormone transition, we need support to get our lifestyle optimized because living longer should be about quality of life and being well, like Joan Macdonald, right? At 77, who's stronger than she was, you know, probably when she was in her younger adult life. You don't get that through any medication. You will only get that through empowerment and making sure that your body is working well. Yeah, I appreciate you clarifying those points.

And I guess what I'm really trying to emphasize is I do think in medicine, we can over-medicalize things sometimes. I think it's quite a big problem, taking it beyond female health, just into all kinds of things now. They become medical things that needs a medical diagnosis and treatment.

And I also completely agree with what you said. Sometimes hormones or, I don't know, let's use a non-female health example, migraines, for example, right? If someone comes in and I diagnose them with a migraine, what I tend to say is, look, I think this is a migraine. There are a number of options here, okay? There are some medications that are likely to help you reduce the pain. There's also some things in your lifestyle that I feel I can help you with that may also help. What approach would you like to take? I always respect what a patient's going to say. A patient may go, look, I don't really want to take

medication. Yeah, sure. Help me. Let's see if we can tackle this another way. Well, I would say the majority, a lot of people will say, well, look, I'm interested. Can I have the pill just at the moment to help me get through? And that's why I feel it can be really useful. It's like, okay, it's going to help you with the pain. It might help you get back to work. It might help you have more energy so you can go to the gym, so you can cook yourself a fresh meal. And then over time, the medication actually allowed you to make those changes. And I think we're saying the same thing can sometimes happen with HRT. It can help you feel so much better that you can then put in those other changes that are going to help you now, but also beyond.

Yeah, definitely. And the other non-hormone options that women can have. So let's get into those because there will be women who say, yeah, I can't have hormones. What else can I do? There are a number of different medication options that we've had available for many years that can work to help for menopause symptoms, but it depends on the specific symptoms. So there's a number of medications. The longest used one is clonidine, which is an old fashioned central antihypertensive medication. What does that mean, central antihypertensive? So it's a blood pressure-lowering medication,

and it works through mechanisms within the brain, lowers blood pressure, but it also reduces hot sweats and flushes, and the heat sensitivity symptoms associated with menopause transition. So it's been used for a long time. It does tend to have side effects in that it can make you a bit dizzy, it can make you a little bit drowsy. So in high doses, and it can obviously lower the blood pressure. So if you've got low blood pressure, you may not tolerate it. But for a woman I see who can't have HRT, who may have

high blood pressure or other medical problems, clonidine can be a good fit if her main symptom, it also can help with sleep and migraines. So it depends on the particular symptoms that a woman has. There are other medications, a lot of antidepressant medications, which are given a really bad rap today in relation to menopause because people go, well, you know, it's hormonal depression, it's not depression. depression but actually some of the antidepressants in very low doses so not even antidepressant doses can reduce vasomotor symptoms so hot sweats flashes flushes they can help with mood and they can help with sleep so let's say a woman for whatever reason cannot take hrt and you're saying now that some medications that are typically colloquially called antidepressants, you're saying that in small doses potentially they can positively

help some of those symptoms that you would have normally got HRT for. Does the same principle apply just for a short period of time until you no longer need it? Definitely, yes. If I start something and I'm seeing them, I would review it and I would only use it for as long as it's needed. But it's individual because, for example, many of the women who end up going on to those treatments can't have HRT because of an oestrogen receptor positive cancer. So they've also gone through a major life event, which has an impact on your mood. And so it depends on what happens to that woman later

down the line. And there are other medications. There is one brand new medication, which is going to be licensed this year, we think. It was due to be licensed by the FDA in America in February, but it has been delayed. And it's called Fezolinatant. And this is a group of, well, it's a neurocanin-3 receptor antagonist, which works centrally in the brain, in the hypothalamus, directly targeting the menopause hot sweat mechanism, which was only found a few years ago. It's an amazing new treatment. It looks as if it's pretty much as effective as HRT for the vasomotor symptoms, sleep, fatigue, and even, you know, some of the studies suggest it might help with weight management as well. So it's really exciting to have. It's the first time in my

career that we've had a new alternative to HRT that actually has a correct mechanism of action for women who can't take HRT because it doesn't work through oestrogen. So the studies are underway for a similar drug in women with breast cancer at the moment. So that's really exciting for women who feel left out by the HRT conversation. Weight gain in midlife for women is something that commonly comes up. If we just go really specifically around the issue of weight gain in perimenopause, does that time in a woman's life cause stroke contribute to weight gain in men and women weight goes up in midlife metabolism goes down slightly probably a little bit more in the menopause transition but it's it's it's a few calories worth it's not you know it's not the

three stone that you've gained in the last 20 years that you suddenly gain another half a stone because there's other things going on in your life. You're busy midlife. It goes back to that whole, you're busy in midlife. You're drinking too much. You're not able to focus on enough exercise or a good nutrition. And the weight is going up for other reasons. And we cannot blame weight gain on menopause hormone change throughout society because the whole of society is gaining weight from small children because of our lifestyles. You know, HRT, I see patients who say they go on HRT and they gain weight. I see some women who say, oh, I've lost some weight since I started HRT because it's helped them be motivated to do more exercise.

Overall, the impact is pretty small. But the other thing that I would say about weight is that, you know, obesity stigma is a real problem for progress. Okay. And there are many people because of the way the food industry is regulated and all sorts of other reasons that we haven't got time to go into. We have got an obesity epidemic and having severe obesity is a problem for health longer term. It's associated with a number of other multi-morbidities and there's a whole field of healthcare, medical and surgical weight management to help people who have problems with their weight. Because when you've gained a certain amount of weight and your body mass index might be 35 40 45 or 50 these are you know very high bmis and bmi isn't a great way to describe you know whether you're overweight but it's it's probably the the easiest crudest

measure that we have but it's very difficult to lose all of that weight and get into a normal body mass index when you're at that level, because you get more insulin resistance, which is basically going against your metabolism. So we shouldn't be saying obesity is bad. We should be saying we need to be helping people who need to lose weight. And we also have some amazing, again, the first time in my career, new medications to help people who have gained weight through their adult life, perhaps even since childhood, who really, it's going to be very difficult for them to just go on a diet and lose that weight. So we need to be looking at things differently. But if you're a

little bit overweight when you're hitting menopause, you know, there are ways that you can, you know, in terms of exercise, movement, adjusting your nutrition, managing your stress, managing your sleep, that help with weight management. We mentioned a lot about symptoms. There's also potential long-term health consequences after a woman has gone through the menopause because of changing hormonal levels, bone loss being one of them. And there's a really nice section in your book, including a quite worrying graph, but an informative graph of what happens to bone density throughout our lives, both for men and women. And we see how stark it is for women compared to men, how the bone mass, the bone density starts to decline in midlife.

So maybe we talk about bone loss for a minute. Do you get symptoms with that or is it more a long-term risk and what can women do to prevent it? So osteopenia, thinning of the bones, osteoporosis is silent. It causes no symptoms until an event occurs such as a fall where the bone is brittle and can fracture much easier. So a lot of people say, oh, I've got aches and pains. Maybe I've got osteoporosis. And actually, osteoporosis causes no symptoms until you've fractured something. Osteoarthritis is a different condition that causes aches and pains. So men and women's bones increase from puberty quite dramatically. And when you finish linear growth, when you reach your adult height, your bones still continue to grow and mature outward strength wise, not longitudinal growth, until you're in your sort of mid to late 20s.

And then it stays fairly stable. And then in midlife, from the five to seven years across the menopause transition, there's quite a steep drop in bone density for women. And there's a drop for men and women through later life that's associated with aging. But there's a lot of variation. It's not like everybody's bones get thin and it's not like nobody's bones get thin. There's a variation. The graph in my book is a smoothed off average. I think that if we can communicate the message properly, it's like, okay, what can we do and what do we need to do? What do women need to do in your view to sort of mitigate against this bone loss? Well, I've got a scarier graph actually that I could show you, which I

didn't put in my book, which is from, it was from 2016. It's the World Obesity Forum, I think, who produced a consensus statement about lifestyle factors in, and I'm sorry to go back to lifestyle again, but lifestyle factors in... You're in the right podcast for this. In accrual of peak bone mass and through life. And the graph is quite frightening because if you have poor lifestyle from, you know, becoming an adult, so you smoke because smoking is really bad for bones. You drink too much alcohol, alcohol causes bone loss excess alcohol causes bone loss if you have some chronic stress allostatic load chronic stress causes bone loss you know lack of weight bearing exercise and movement is profound for for bone loss and then the other factors which are calcium and vitamin d i mean there are more but these are the main factors

that i talk about. Vitamin D is very important because it helps our gut absorb the calcium from our diet. And that helps the calcium get into the bones. And vitamin D we get mainly from sunlight. We don't get a lot from our diet. And modern lifestyles, we're indoors all the time. We don't see daylight. When we do go into daylight, we don't want to get burnt, which is is quite right we don't want to get skin cancers so we put sunscreen on and

unfortunately that combination means that certainly in the uk the majority of people are vitamin d deficient most of the time and there are guidance about taking vitamin d in winter what about strength training it's hugely important yeah and know, there's got to be a big factor in, you know, frailty and ageing because people move much less as they become elderly. It's hard not to make the case that strength training becomes more and more important as we age. Yet, as a society, we associate it with teenagers and young men and women in their 20s trying to look buff and trying to look good, right, going to the gym. But, you know, I'm not saying it's not important then, fantastic to do it then, but it's more and more important as we get older, as we lose muscle mass, as our bone density starts

to go down, because we don't want to be weak in old age. We don't want to be frail. We don't want to not be able to stop ourselves falling or fall and then not be able to recover from that fall, which is really, really common, isn't it? And that's the problem with aging and frailty. And having worked on acute medical wards for 25 years and looking after people coming in with all sorts of different health issues and complications of illness, as people get older, if you're weak and you're sitting and you're not moving and you're not using your brain and you're not eating very well, it's sort of just an ongoing decline. And I will not accept that for myself. And I will not accept that for any of my patients, any of my

patients who say, no, I'm just going to sit on the sofa now. I don't want to do any exercise. I can't do any exercise. That will not take anyone anywhere good with their health, no matter what medication they're given, no matter what. If you sit on the sofa and you are not using your body, you're not using your mind, you know, that affects your gut. It's not good for strength. It's not good for anything, sleep, anything. And so then if you go, oh, no, I'm not going to, but I'll take medication that will beat disease.

It won't work. One of the other long-term risks that people worry about post-menopausally is dementia. Now, there's, of course, many different factors that can increase our dementia risk. But I'm talking specifically about oestrogen going down after the menopause. I had Lisa Mosconi on the podcast maybe a year and a half, two years ago. She's a brain researcher in New York. And she was talking a little bit about estrogen deficiency and potential risk of Alzheimer's. Again, in 2023 now, based upon your experience and expertise, what can we say about that? So the big interest in dementia and the possible impact of oestrogen deficiency is really based on the fact that rates of Alzheimer's disease, which is the

commonest dementia, is sort of double the rate in women compared to men. So women, there's something about women that is increasing the risk of dementia. And that is the commonest time to manifest symptoms for the first time, maybe in the menopause transition, and then symptoms tend to become more evident later on. So it's logical to want to do that research to see, is it something to do with menopause specifically, hormone changes, and particularly, gosh, wouldn't it be amazing if we could give HRT and that would prevent dementia. And there's so much existing data actually on this, that there's data that suggests that actually younger women, changes in the brain

improve if women with premature ovarian insufficiency take HRT up to menopause. And if they don't take it, they tend to have problems with brain changes that can predispose to dementia later. There have been a lot of observational studies. It's quite a difficult thing to study. Observational studies are, you know, can be fraught with things like selection bias. So it's difficult to make really robust conclusions from observational studies. There was a big review of all the data in 2021, which was published in the BMJ that looked at studies of women on different formulations of HRT, and it basically showed a null effect. So at the moment where we are is women get more dementia than men. But the data we have do not suggest if we look at all peer reviewed data, I'm not talking about one study that might have shown a benefit, because for every one study that might have shown a benefit, there are also studies that might suggest

that HRT probably made things worse. So actually, it's really conflicting, that data. And there appears to be a null effect, but there are some interesting studies looking at particular subgroups of people who may be more at risk of dementia, like the APOE4 gene and people with family history. Now, I'm not an expert in dementia, but

there was a study published in Norfolk either earlier this year or the end of 22, which was an observational study. It was a very small study, but it was promising that suggested there might be some potential benefits in women, particularly with this gene. So they are quite rightly not making any bold statements. They are saying this justifies a randomized control study, which will be definitive. Observational studies often show dramatic results. When we do the randomized control trial, it's shown to be non-effective.

So I think we all want a miracle cure and social media wants to say, well, look, there was this one study that suggested HRT cures dementia, end of story, everybody should go on it. But it's not as straightforward as that. If you look at all comers. The other thing I want to say, because I do talk about this, is that in the Western world, in North America and Europe over the last 30 years, there's been a 13% reduction in dementia. One three. One three per decade. Each consecutive decade over the last 30 years, there's been a 13% reduction in dementia. And that's in the Western world where rates are quite high. And overall, if you take the whole world, it's 15% reduction in 30 years. But in North America and Europe, rates of dementia are falling at this moment.

That, we don't know why. The researchers think it may be due to something to do with our lifestyles. It may be reducing smoking because smoking is awful for dementia risk. It may be something else in lifestyles. It may be that we're more stimulated because stimulation is a protective effect. But dementia rates are falling by 13% every 10 years in Europe and America. No one talks about that. It doesn't hit the news because it's a positive story. Yeah. And that's quite a nice, uplifting thought to sort of bring our conversation to a close, really. I appreciate what you said there about where we're currently at with hormone replacement, postmenopausally, and dementia risk.

And it may be that in certain groups who are deemed to be at higher risk for whatever reason, potentially genetics, potentially something else, there may be an indication. And that's currently being studied. Again, I need you to talk about nuance. That's not how we roll in 2023. It needs to be black and white, right? You're talking about nuance and context. The other thing to say there is that, you know, we're talking about lifestyle a lot. Well, chronic unmanaged stress damages and kills nerve cells in the hippocampus and increases your risk of dementia and cognitive decline, right? So of course, your book is a very, very readable, a very practical guide. It's very clear that you have been practicing for over three decades now,

because it's going to really help people understand what they can practically do what are some of your kind of um go-to tips i guess stress management my favorite stress management recommendation because anyone can do it is just everyday mindfulness which is walking outside in the fresh air without headphones without a phone because it's it's it's an everyday mindfulness tool. Some people struggle to meditate or do more, you know, specific sort of stress management strategies. But everyone can go outside in the fresh air and listen to the birds and look at the sky and be in the present that way. So I think that's a really great stress management tool that anyone can do

immediately. There's obviously much more detailed things that people can do. But I think if you're really struggling with symptoms, it's quite difficult to then start doing something that's quite, you know, detailed in terms of managing stress. I love that recommendation. Anissa, it's been a real joy speaking to you. Is there anything you feel that's important in this area that we've not covered yet? Well, I think we've covered everything, but I think what's really important,

we talked at the very beginning about empowering women. And correct facts are empowering, but misinformation is very disempowering. It makes women feel they need something that's going to fix everything. And women have so much more control than they think. And that's what we've talked about today. And, you know, after menopause, you don't have to have periods anymore. I used to suffer terrible migraines before menopause. I don't get migraines anymore, you know.

Actually, at some point, you get an empty nest. Some people get upset about that I've got an empty nest at the moment but the kids come back all the time and actually it makes doing things for yourself easier you've got so many more opportunities to build your own social networks because you tend to have more time your career is often in a great situation we haven't covered employment but I think everything that we've talked about is going to help women know that we have to have female leaders in our workplaces. And, you know, it is a, menopause is a great opportunity for women today. It's, it's, we're in a situation where it is the best time ever to be a woman, but it's just so complicated

for women, but it is such an opportunity. And I am pretty determined, no matter what happens over the next few years, that I will still keep talking about women regaining control or, you know, maintaining control would be the best option if they're proactive. No, I love that. I mean, you mentioned empty nest there. And you say that and I'm like,

I can't imagine my kids leaving. I don't want them to leave home. I love hanging out with my kids. It's such a crazy thought for me to think, what the kids won't be at home. Like I can't imagine it. Well, you know, given the age my kids are at the moment, it feels like it's going to be a million, an eternity away, but I'm sure it isn't. Anissa's podcast is called Feel Better, Live More. When we feel better in ourselves, we get more out of our lives. There's so much we've covered today, but just to finally finish off, for that woman who's listening, who is currently struggling,

what would you say to that woman? she's suffering from there are solutions the solutions are not the same for everyone and sometimes when you're in the most difficult phase of symptoms of life it's the hardest time to find solutions so making small changes doesn't feel like it's going to make any difference. It's like that first step of a mountain. But if you just keep that focus of the things that are within your control, a little bit prescriptively, not like a medication, but like a prescription of something that you know will help eventually, you will get there. And there are better times ahead. Elise, that's coming on the show. My pleasure. Really hope you enjoyed that conversation. As always, do think about one thing that you can take away and start applying into your own life. Now, before you go, just wanted to let you know about Friday Five. It's my free weekly email containing five simple ideas to improve your health and happiness. In that email, I share

exclusive insights that I do not share anywhere else, including health advice, how to manage your time better, interesting articles or videos that I've been consuming, and quotes that have caused me to stop and reflect. And I have to say in a world of endless emails, it really is delightful that many of you tell me it is one of the only weekly emails that you actively look forward to receiving. So if that sounds like something you would like to receive each and every Friday,

you can sign up for free at drchatagy.com forward slash Friday Five. Now, if you are new to my podcast, you may be interested to know that I have written five books that have been bestsellers all over the world, covering all kinds of different topics, happiness, food, stress, sleep, behavior change, movement, weight loss, and so much more. So please do take a moment to check them out.

They are all available as paperbacks, eBooks, and as audio books, which I am narrating. If you enjoyed today's episode, it is always appreciated if you can take a moment to share the podcast with your friends and family or leave a review on Apple Podcasts. Thank you so much for listening. Have a wonderful week. And always remember, you are the architect of your own health. Making lifestyle changes always worth it. Because when you feel better, you live more.