The Dr Louise Newson Podcast - 027 - Menopause and the Skin - Dr Sajjad Rajpar and Dr Louise Newson

Episode Date: December 10, 2019

In this week's podcast, Dr Louise Newson is talking to leading consultant dermatologist Dr Sajjad Rajpar. Together, they discuss all about the skin and how it can change during the perimenopause and menopause. The low hormone levels that occur during the perimenopause and menopause often have a negative effect on the collagen in the skin, which can lead to changes in appearance and elasticity. As well as this, skin concerns such as dryness and acne are a common occurrence during this time of our lives. Dr Newson and Dr Rajpar also discuss HRT and the effectiveness of giving oestrogen through the skin as a patch or gel. More information about Dr Rajpar, including his serum, is available here: https://belgraviadermatology.co.uk/  Dr Rajpar's Three Take Home Tips for Healthy Skin: Avoid soap and use gentle cleanser, moisturise twice daily. Be sensible with the sun - wear factor 50. Stop smoking! Nicotine can have a very negative effect on your skin.

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsome, a GP and menopause specialist, and I run the Newston Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. Today I'm really excited and delighted to have with me a colleague who works locally and also in London. I've got Sajad Rajpah with me, who works in Belgravia Dermatology and also the Westbourne Centre. in Birmingham. So I wanted to talk today about skin because, as many of you know, when our

estrogen levels reduced during the perimenopause and menopause, it can affect everywhere, but it also can affect our skin. So I just wanted to tap his amazing knowledge and try and get as much information as possible in the next half an hour. So thank you for coming. It's a pleasure, Louise. Thanks very much for the invitation to do this podcast. That's okay. So tell me about skin. So before we talk about skin and menopause, skin is a really important organ, isn't it? Yeah, absolutely. Skin is the largest organ in the body and, you know, the average skin would contribute to 15 kilograms of your body weight. See, it's amazing, isn't it? Because when you look at organs, you think about your heart, lungs, liver, spleen, but you don't,

you think of the skin as just, it's a protective thing that covers us. But it's more than that, isn't it? Absolutely. We often forget that the skin has a lot of functions in in the immune system, in fighting off infection, in protecting the skin, in also forming vitamin D as well. So there are all sorts of different functions of the skin. So that's a sunlight vitamin. Yeah, that's absolutely it, the reaction from ultraviolet light to the skin. And we see a lot of changes with the menopause because of course the reduction in estrogen in the body causes changes to several layers. of the skin. And I think the most common thing I would see in regular practice is ladies complaining that their skin's becoming dry and itchy. I don't know whether you see that as well.

Very common. Lots of people have, especially itchiness. And some of them even get formication, that feeling of spiders crawling over their skin, often can wake them up at night. And a lot of them have actually seen dermatologists or they've seen the doctor. And because they haven't thought it to be associated with the hormones and people maybe haven't asked about their periods, they haven't realised that it's a symptom of low estrogen. So why does that happen? What does estrogen do in our skin then? Yeah, I think there is a lack of awareness that estrogen is quite important. And in the context of itchy and dry skin, estrogen stimulates sebaceous secretions, which are greasy secretions from the sebaceous glands. So that keeps our skin lubricated and

moisturised. And estrogen also produces a substance called hyaluronic acid. Oh, okay. That's in quite a lot of, you know, moisturises and treatments now, isn't it? It's become really trendy in topical cosmetic creams and anti-aging solutions. But estrogen actually stimulates the production of this hyaluronic acid within the dermis layer of the skin, so below the skin surface. So it's not something you can just replenish. by putting on top of your skin because it would not get absorbed. So when we talk about working from within on the skin, this is something, so if a woman was menopausal and wanted to use that as an external product,

it wouldn't have the same effect as having estrogen within the skin? Definitely not, because the hyaluronic acid in creams would just sit on the skin surface and would be quite temporary, whereas the high aleronic acid that the estrogen stimulates will actually sit within the substance of the skin, draw water to it. And that's a sort of natural hydrating agent in the skin. And it sort of brings back the fullness to the skin and reduces perhaps fine lines and just aids the general elasticity as well. And the third reason we see dry and itchy skin conditions is because estrogen produces something called seramides. And you might have started seeing these in moisturising creams as well. And seramides

are another type of grease that the top layer of the skin produces. And we know that as soon as there's a reduction in estrogen in the body, we lose seramide levels, we lose hyaluronic acid levels, and we lose sebum levels. And they're all three natural, hydrating, moisturising agents. So, surprise, surprise, we get dry and itchy skin. Is that so interesting, isn't it? Because I never knew any of this when I was sort of growing up through medical school. I don't know. Did you get much training about the menopause? No, I don't think I got any training about the menopause. And actually, I kind of, put two and two together because of the patients that were coming to see me, the age range that they were in and the types of complaints that they were bringing. And of course, there might

be medications in the picture that could also be contributing to dry and itchy skin. Now, a common one is statins. Oh, okay. So it's used for high cholesterol. Yeah, it's used for high cholesterol to reduce cholesterol, but cholesterol is also used to form some of those greases in the skin. Yes. If you're reducing that, it's inevitably. that you may get some dry skin as well. So often there's a combination of things going on. But yeah, it's not the type of thing that you're taught in medical school or even actually in dermatology training.

No, I mean, as many of you who are listening, know that I do a lot with education for GPs, but also nurses, pharmacists, but I really feel that every specialty should know something. Don't you about menopause? Because, you know, there are some people that say, well, I don't treat diabetes. I don't know much about diabetes, but I'll refer people on. Whereas actually, as you know, the menopause affects all women. So any doctor that comes in contact with a woman needs to know about the menopause, don't they? I think that's absolutely essential because you cannot otherwise put two and two together

if you don't have enough awareness of the possible range of symptoms that could occur, that could be linked to your own area of specialty. And I have to congratulate you on your book. Oh, that's very kind. I actually think that could be a really good tool for medical students and doctors because it's really, really easy to read. It's got all the key facts laid out in a simple way. And, you know, it kind of brings in, you know, all the systems that could be affected. Well, I think that's one of the reasons, obviously, Haynes were great at publishing it because I wanted to say that it was easy.

And actually, a lot of people on my Instagram say, I've bought two copies, one for my GP or one for the completed room, which is great. But I think, you know, we don't, you know, a lot of gynecologists have traditionally managed the menopause because hormones, sex hormones, it's related to periods. But actually we, and I didn't really sit back and think about it until a few years ago, that these hormones get everywhere. And because they get everywhere, they affect. And as you've said to us quite right at the beginning, the skin is the largest organ. So it's going to affect the skin, isn't it?

Oh, absolutely. Well, most of the main cells in the skin, skin have estrogen receptors. So, you know, there's a large volume of receptors that are going to suck up that estrogen and act upon it. So absolutely. Because certainly when you look at the benefits of HRT, and there are, as you know, a lot of benefits, but one of them, which isn't a reason that you would take HRT, is that it is anti-aging because of it helping build collagen, reducing moisture loss, wrinkles can reduce. And it's interesting, isn't it? A lot of the time, I I can certainly spot. If there were 20 women in a room and 10 were taking HRT, you can spot.

And it's not just because they seem to be happier because they haven't got symptoms, but the skin looks different, doesn't it? Oh, absolutely. And I think we're understanding more and more the biochemistry of what's going on in the skin when somebody is devoid of estrogen and then when estrogen is replaced. And in terms of the collagen levels, there are a number of studies that have shown that the collagen levels reduce by up to as much as 30% in the first five years. In the first five years? In the first five years?

So it just talks to what collagen is. Yeah. So collagen is a protein that gives structure and support to the skin. And it gives the strength to the skin as well. And, you know, inevitably as we age, our collagen levels will go down and the quality of collagen that we produce is less good. Yeah. Other things that damage the collagen are smoking and sun exposure.

Yes. And then we get this massive dip with the menopause. Yeah. So 30% within 5%. That's a third. That's quite a bit, don't you think? That's a heck of a lot, isn't it? When we're also conscious of covering up, not being in the sun, quite rightly,

you can often tell smokers because they often have fine lines, don't they, around their mouths as well, but just because they're collagen. but that's a huge. And I also specialize in aesthetic treatments and aesthetic dermatology treatments. And one of the other big revelations, I think, in the last six months to me was a published paper that showed the changes in the face between men and women as we get older. And we both age at the same pace in terms of facial aging up to the menopause.

And then when the menopause, sets in, women have an accelerated loss of bone from the jawline and the chin as compared to men. Do they? Yes. And that connects completely with one of the major treatments I do for post or perimenopausal women, which is augmentation or filler injections around the jawline and the chin because the chin's receding. Oh, isn't that interesting?

And then that causes a heaviness and gowling to the cheek area. And the skin is thinner as well. So it's more like to do it. SAC. And we're all familiar with osteoporosis of the hip and other areas, but actually it's happening on the face and that's actually accelerating the aging process. And it's a bit like saying, you know, the table's getting smaller, but the tablecloth doesn't change, you know, with the bone shrinking year on year. And I think that's one of the other reasons why you'll be able to pick out the women in a room. Yes, because of their facial structure changing. Because

the bone's been protected from having estrogen. Yeah, no, and it's very important because people worry a lot, as you know, about HRT, and I don't know if any doctors spoke to you, but certainly when it was mentioned, certainly my GP training, people would say, oh, no, it's too dangerous. Just ignore it, just don't give HRT because it's going to give women breast cancer. And as we know, most women on HRT do not develop breast cancer. And certainly young women, there's no risk. Women who've had a hysterectomy, there's no risk. And women who take progesterone over the age of 51, the risk is very low. It's a lot higher if a woman's overweight or obese. So it's looking at the risk factors, but then it's looking at the benefits. Absolutely. One of the benefits, certainly one of the reasons I personally take HRT is I'm very scared of getting osteoporosis. And I'm sure you have too seen a lot of women who have had osteoporosis of their spine, this awful curvature, they recurrent chest infections, they're on morphine, they're not independent. And as you alluded to, bone loss is very rapid around the perimenopause and menopause. And it's very hard to replace it once it's

lost, isn't it? Absolutely. And this is why prevention and active planning is so much more important than trying to reverse things because that is just doesn't work. It's not a satisfactory. It's so much harder, isn't it? And I think once the osteoclast, the building cells for our bones are out of sync with the ones that are breaking it down, then it's hard. And we know that estrogen can help restore that, which is important. And like you say, the earlier, the better. And I think the skin is in a similar position, which is that if you can protect the collagen before there is a decline, you're much more likely to preserve the skin quality than if you allow the collagen levels to decline and then try to then boost it up with estrogen, for example. So I've read some places, not your clinic,

I hasten to add, do topical, so cream with hormones in it to put on and they talk about how they're bioidentical creams, but for the face to improve. Would you, I can see you smiling there. Okay, yeah, that's a bit of a smirk. Because, yeah, I don't think that that would be a evidence-based or reasonable way of trying to improve the skin. We have got, you know, Eastern receptors in all the skin, not just the skin of the face. Yeah. So we've got to treat the skin as a whole.

So I think locally treating certain areas that perhaps look like they've aged with topical hormone treatments does not seem to me. the reasonable thing to do. And like you're saying, it might not next unless it gets through to the dermis. Yeah, absolutely. And, you know, the stimulation of collagen can be done. You know, there are creams that can be explored that you can either get over the counter without a prescription or by seeing a doctor who specialises in anti-aging. And the common things that help boost your collagen level are vitamin A-derived products

known as retinoles or retinoids. and there's a huge body. There's so many, aren't there? There is so many. And, you know, they're probably all work in a similar way, and it's trying to find the product that suits your skin, that doesn't cause too much irritation. But there is a huge body of evidence for retinoids,

topical retinoids, and retinol lotions. And then there's other products that contain vitamin C and antioxidants and things like that. So I think if we're looking at topical treatments, then that would be the line that I would have suggested. Container creams. And I think if you're thinking about hormones, I don't think they ought to be topical.

Because you need to do a serum, don't you? You produce a serum, which has got, what's it got in it? Yeah, so, I mean, I sort of shortlisted all the ingredients that have a base of evidence that also I get very good feedback from patients and try to just make it very simple for my patients to use, really, because it just gets so confusing when you, you know, go out there and try and get some skincare advice. It's scary because I don't really, I don't have much time to go shopping, but I don't really like it, really. When I go into a department store and there's so many brands and they're all trying to sell you different things, they all tell you, oh, there's evidence behind this, that and the other and you think, really, what sort of evidence is there? And then I think, well, I'll go online and there's all these wonderful online shops where you can get all the different makes.

And then I get really scared, and I've got no idea. Yeah. And then you left even more confused. Oh, yeah. So you end up buying loads and then you don't know which order to put things on, or you end up just, because. sticking with your basics. And I've got, as you know, teenage children, they have so many products, but they seem to understand. So your serum was great because it's so easy. Yeah, yeah, I know. It was designed to just be that one product that could be used twice a day.

And the layering up of products and the combining of products on the skin just doesn't make sense to me. Because we don't really know whether one product may interact with another and, you know, will the absorption be affected and what have you. So I think with skincare, we've got to keep it simple. And one thing that actually, you know, I find that helps those ladies who are suffering with just going back to our first point with the dry and itchy skin is just simple things like avoiding soap. Because soap is real irritant, isn't it? Yeah, absolutely. It's actually pretty bad for your skin.

So unless there's a really good reason, unless your hands are very soiled, you know, you don't want to be using a soap-based product. Just think of what happens when you wash the dishes. You've got grease on the dishes. is you put soap and you've just stripped off all the grease. And then you're going to go and do that to your hands 20 times a day and then to your body twice a day. So what do you recommend people washing with? There's a load of gentle cleansers out there,

a cetacephil cleanser, for example. And any moisturising lotion that's light enough can also be used as a soap. So those products don't lather, they don't bubble, but they will cleanse your skin. Yeah. And they will, you know, keep your skin feeling nice and hydrated after. a shower. So there are any that you would recommend? I very much like the

the Cetafil range and the Cerevay range. They, you know, available commonly and, you know, they're not ridiculous the expensive, are they? No, gosh, no, they're about a tenor each, I would have thought, and, you know, easily available in super drug and boots and places like that. Yeah. And, you know, you can keep the, both products in the bathroom and just allow your skin to replenish that moisture every time you're having a shower. Yeah, which is really important, isn't it? Because I think people think if they wash and scrub, especially if they it's going to be better. And that's just the worst thing, isn't it? Yeah, that's absolutely the thing that will probably drive the itch even more because you're stripping the greases. And as you

sort of rub and some people want to use a lufa brush or something really quite aggressive, you're stimulating histamine release in the skin. And that's going to actually cause you to it to it even more. And then you're going to be in this cycle of just not being comfortable with your skin. So you want to not do that? Yeah, you want to not do that. that and just really look after your skin, hydrate it, moisturise it, and that's always a good start. And then we, as you know, use a lot of, especially estrogen, because it's the safest way of having it through the skin, as a patch or a gel. And so the gel is very easy because we can change the dose according to our symptoms, especially if people are perimenopausal, because

their hormone changes every day often. And so when I explain to women, all you just put a pump or two, you rub it onto your arms or your legs. And often people say, well, gosh, how does that work? Because we rub moisturizers in and does that get through our skin? So what would be the different? How does it work? That's a really good question. Okay. So this comes to the term of transcutaneous absorption of medicines. Okay. All that means is that some medicines, if the molecule is small enough and they're in a base that's greasy, Yes. Those molecules will actually work into the greases of the skin and dissolve in the greases of the skin and get into

the dermis. Right. And we've got loads of blood vessels in the dermis. Remember, we've got this 15 kilogram of skin and all these little blood vessels will just absorb that estrogen molecule, which is a fatty-based molecule, and that will go directly into the bloodstream. So it's safe because it's going straight into the bloodstream. It's not going through the liver or anything like that.

So things like drugs that are fatty-based will get absorbed. Yes. Things that are not do not get absorbed. So moisturizers are not designed to be absorbed. Moisterizers are designed to form a very thin layer on the surface of the skin that prevents evaporation of your natural water and just so that you can hang on to that water. Right. So they won't get into the bloodstream?

No. But if a moisturiser had a small enough, fat-based chemical like estrogen in it, then the estrogen could get into the bloodstream. Right. So it's very interesting, isn't it? Because we've been using these patches, for example, with a morphine equivalent for pain killers. They can be really useful, can't they? Absolutely, yeah. And, you know, a few years ago before I knew, as much as I do now about menopause, I didn't really use much of the estrogen through the skin as gel or patches. Because traditionally, the contraceptive pill is a tablet, as you know. So you think, oh, well, hormone replacement therapy

another tablet. But then now we know there's no risk of clot or stroke with having through the skin. And it's more reliable absorption. You don't have to, a lot of women have digestive problems during the menopause. I didn't know that. So that's really good to... Yeah, because as you say, it goes straight into the bloodstream. So it bypasses the liver. Right. So, and as you know, the liver produces our clotting factors. So it makes sense. Yeah, it does make sense. Like a lot of things in medicine, when you sit back and think, or if you're taught, it makes sense. And there are the other problem, as you might know, is because hormones are grouped together, when a doctor tries to prescribe, even the estrogen gel, it will still say risk of clot. When a patient, a woman

opens the products and looks at the SPC, the product characteristics, it will say risk of clot because they're all grouped together. And I've been trying to do some work with the MHRA to try and remove this because we know they're very different. Yeah. But as you know, it's very hard to make change. Yes, yes. But that's really important, isn't it? Because that information, yeah, that's actually incorrect, would put somebody off. Yes, it puts, it puts women off, but it also puts doctors and nurses off from prescribing it as well. And we see a lot of women here who've maybe had a clot after a long flight or they've got a family history of clot, and they've been incorrectly, sadly told they could never have HRT. And yes, they couldn't have

the oral estrogen, but they can have it through the skin. So do you think, Louise, when you're prescribing estrogen through the skin as a gel, that you're able to control the dose or change the dose a lot more, you know, easily because, you know, it's hard to, you know, you have to go in units of tablets, don't you? Well, that's the thing. And it's very easy. So a lot of women, for example, people who have PMS, premenstrual syndrome, often traditionally have a dip of their symptoms before their periods,

which is often when their estrogen levels drop. And when they become perimenopausal, it's not just a day or two before their periods. It's sometimes a week or two weeks. before and they really, really struggle. And so often we will say to them at those days, use three or four pumps and other days just use one or two. And I strongly feel, I know you do too, is that our patients need to be in control. They need to be feeling it's their bodies.

They need to be in control of what they're doing. And so this is a really good way of them to be able to adapt, really, to their symptoms. And also, they're very reassured to know that it doesn't build up in their bodies because everyone's still scared of hormones. And I keep saying, there's a reason that you're using it once or twice a day is because it wears out. Yes. Yes. And that's reassuring, isn't it? Yeah. And it's the same, I'm sure, with some of the treatments and creams that you give. Yeah. Yeah. You know, they have to be applied. And I know with skin, I just wanted to talk briefly if it's okay about acne, actually, because we see, oh, I see a lot of women who have had troubles to

matinee when they were teenagers and then they're in there mid late 40s and they're how these spots have come back or you know why is that yes yes um that is a important problem and i think that's again because we might have a imbalance in the ratio yes between testosterone and estrogen and even if there is a slight imbalance with that the skin can react and the skin has got a lot of Androgen or testosterone receptors. Yes. So if the skin sees relatively more testosterone than estrogen, then the sebaceous secretions in some areas, especially around the mouth on the chin and the jawline, can increase and

then we can start getting acne spots. Yeah. And, you know, it is a difficult time because several changes are occurring and the last thing somebody would want is a spotty face. Yeah. But, you know, the good thing is that there are a lot. of topical treatments that can help with that form of acne. There are things that contain benzol peroxide, which can be purchased over the counter, and the retinoles, which are also used for anti-aging,

also help acne at that stage. Now, there will be some ladies who will find that their sort of tendency for spots is more to do with another condition called rosacea. Yes. And that can give little pimples as well. Often that involves the nose and the central forehead as well. And they can be sort of flushing. And sometimes there's a crossover between the flushing from menopause with the flushing of rosacea. And sometimes you can have both conditions. So sometimes if you know you're not winning with the simple treatments that either you've purchased from the pharmacy or had from the GP, it might be worth just discussing those with a dermatologist. Because it's very easy to get it wrong with dermatology, isn't it, I think?

Yeah, yeah, because a lot of things can look similar. Yes. And there are only subtle clues. Yeah, and I think especially now, you can look at so much on Instagram or online more than when, you know, we were students. And so it's very easy to think, but actually dermatology, although it's very visual, you have to see the real flesh, don't you? Yeah, it's really, really difficult to look at a picture and say, that's this. And it's not just looking at the flesh, it's getting an understanding. from the history, you know, what's happening. So, for example, if somebody does come with facial

spots, I'd like to know, you know, did they have them as a teenager? Do members of their family have them? Are they using comidogenic skin products? What's their sun exposure like? What's the hormonal situation? And those are things that you can only really dig out during a consultation. And I think it's really important. I know we did speak before. We started recording about, there's a big plethora of skin clinics now because everyone wants perfect skin. we all want that Instagram look. But actually to have, as a dermatologist, you are a trained doctor. Right.

But it's really important because I think a lot of people that they don't know necessarily who they're seeing because there's so much treatment, like you said, there's so much choice out there and you can be taken in. But actually, with the skin, a lot of it is from within as well. So like you was talking about the statins having an effect, drugs having an effect. Absolutely. It's very important if you have a skin condition. that you see a trained doctor who can be very holistic about it.

I think that is so, so important. And I think that that's the case with every, you know, specialty, but especially with skin because there are so many on the high street who may not be medically trained and have access to a lot of products and devices, perhaps. So, yeah, I think the training for dermatology is completing medical school, then doing training in internal medicine. So you have a, you know, a good. good awareness of all the systems of the body and how drugs interact with the body.

Yes. And then a four-year training in dermatology. And then some dermatologists like myself may do further training and procedures. And then that's when the real learning begins is when you actually start seeing patients on your own and really developing patterns and seeing patterns and understanding, you know, what works and what doesn't work. Yeah. Yeah.

I mean, it's a journey, isn't it? I constantly learn from my patients. And it's a great privilege, isn't it? a doctor, we really, very grateful to our patients because we share. And sometimes we don't always know the answers. No, no. It's sharing uncertainty and being able to try in a very stepwise way, things that help. Yeah, I think we're very similar in our practice in that we would discuss what is known.

You know, it's not a black and white specialty, not the skin isn't, the menopause isn't. No. And provide the information that our patients require to make their own informed choice. and I think that's what we've always done in our practice and I understand that from your practice and knowing you over the years. Yeah. And I think, you know, at least with dermatology,

there's a set training program. I think with the menopause, was there any training? No, not at all. No, I mean, there is some training, the British Menopause Society do a specialist training program, which I've done. I'm an advanced specialist, but it's very hard because there's very few trainers.

So we're actually, as you know, creating a menopause or developing an education program I'm really for primary care. So that would be GPs. So for GPs, nurses, pharmacists. But also, there's no reason why, you know, dermatologists couldn't come. Absolutely. So I know you're talking at our next event, which is great,

because it's so enriching once you've got some understanding and knowledge about it as well. Yeah, it is actually because you kind of then can explain symptoms, both biologically and in simple terms. And then that paves the way to actually improving those symptoms. Absolutely. So thank you so much. We've sadly run out of time. I'm going to call you to come back another time because I really want to talk about hair changes. We've talked about skin. But hair changes is something that we know we see a lot during the perimenopause and menopause. So before we finish, could I just ask for three take home messages that for people who are listening and maybe thinking, yeah, my skin is not great. What could they do? What would you recommend? Okay. Tip number one would be avoiding soaps and using a soap substitute. to cleanse the face and the body and moisturising at least a couple of times a day, especially if you're prone towards dry skin.

Step two would be to be very sensible with the sun. Yes. So wear a hat, wear a good factor 50 product. It doesn't have to be expensive. Just make sure you put it on five or ten minutes before you go out and every couple of hours that you're out and about. Yeah. And then step three would be to, if you are a smoker, stop smoking.

Because the decline in collagen from smoking is equivalent to sitting in the sun every day. So if you do all those three things, you'll keep your skin as healthy as you can with very simple measures. Yeah. Moving forwards. That's brilliant. Oh, thank you ever so much. Well, we'll put some links to the products that you mentioned, including your serum on our podcast notes. So thank you ever so much for coming.

Thank you for giving up your time. Pleasure. thanks so much for the invite. For more information about the menopause, please visit our website www. www.menopausedoctor.com.uk.