The Dr Louise Newson Podcast - 038 - Research on Testosterone & Menopause - Lauren Redfern & Dr Louise Newson

Episode Date: March 10, 2020

In this week's podcast, Dr Newson is joined by Lauren Redfern, a researcher who has been exploring the experiences of women using testosterone as part of their HRT treatment. Lauren has been spending time at Newson Health Menopause and Wellbeing Centre over the past year observing many different aspects of women’s care; from the moment they make contact with the team right through to their consultation. She is interested in hearing stories from women first hand about their treatment journey and is particularly interested in the gendered aspects of hormonal care. Lauren hopes that her work will provide insight into the realities facing women negotiating menopausal care in the UK today; something that she feels is currently vastly underrepresented in both social and public health research.   If you would like to know more about Lauren’s research you can visit her website www.laurenredfernwrites.com or follow her on Instagram @laurenredfernwrites where she posts about everything from the history of hormones to updates on her research.   Lauren's Top Three Facts about Testosterone and Menopause care: Time is an underestimated benefit in healthcare. Women need longer than 10 minutes to adequately explain their symptoms to a doctor. Menopause isn't just hot flushes and something to "get through" - the symptoms can have a massive impact on a woman's life. Testosterone is not just the male hormone, it is essential for re-balancing female systems, just as it is for men.  Newson Health Research & Education

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsom, a GP and menopause specialist, and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. In this podcast today, I'm really excited to have Lauren Redfern with me, who I met a while ago and she's been working very closely with us in the clinic doing some fascinating research. So hi, hi Lauren. for coming. Hi, thanks for having me. So I can't even remember when we first connected. You emailed me, didn't you? I did. I emailed you over about a year and a half ago now, I think. And I think I was

having a conversation with you actually when you're in the car and you were picking up your kids. I hasten traffic. It's always hands free. But really constantly flying around, trying to put my children up from school and not be too late. And it's a really good time. So yes, I remember. And then actually, I was in a meeting in London and I was waiting for my train and we had a long conversation. there. Yeah. So talk or through, what were we talking about? So I got in contact with you originally, I think, to talk about use of testosterone

among menopausal women. Yes. And I think I had just come across your work. I don't think you'd even set up the start of the clinic at that time. And I wanted to get your insight, really, into using the hormone as part of menopausal treatment and your experience of working with patients. And we had quite an impassioned conversation. I seem to remember about it.

And you very kindly, when the clinic got on its feet, invited me to come in and sit on a few appointments with you. Yeah. Because you're not a medical student. You're not a medic, are you? So what's your background? No, I am a medical anthropologist. I have a bit of an interesting background.

So I did my undergraduate degree in sociology and anthropology and my master's degree in reproductive and sexual health research, where I have continued at the same university, the London School of Hygiene and Tropical Medicine, to do my PhD funded by the ESRC Council and they have very kindly allowed me to pursue my interests kind of drawing these two fields together one side being anthropology and the other being public health and sexual health.

It's very interesting, isn't it? I think, you know, when I speak to people that I've met an anthropologist who's interested in the, it's the perceptions of testosterone as well, isn't it? So when you were doing your master's and your degree, did you know anything about testosterone for women then? No, my prior research had always been focusing predominantly on young people. So my interest had always been in gender and how gender might impact our health. But I tended to focus on particularly men, masculinity and men's role within sexual health,

because it's often not necessarily picked up as much within research. And the thing that first drew my attention to testosterone was actually the way it came up in men's narratives. So often being referenced as a reason for behaviour. So my testosterone makes me X, or it must be the testosterone, or this kind of perception they had about this hormone, which made me question actually, what is this knowledge founded on? Where does it come from? Where's the science behind it?

And I just kind of couldn't shake it. Every time I was pursuing a different research project, it kept coming up in people's narratives, and it just made me really interested in how hormones feel, feature in our everyday conversation and rhetoric. Without much thought, we talk about testosterone is this, estrogen is this. We think about hormones in a very binary way. Women have estrogen, men have testosterone.

And the more I learned about menopausal health and hormone replacement therapy, the more I realised, actually, it's a really strong balance of all of these different hormones that we have put different perceptions onto. Which is so interesting, isn't it? And certainly my children at school, learn about estrogen in women and testosterone in men. And at medical school, as many of you know, I didn't really get much formal menopause teaching, but we always learn about estrogen and progesterone for the reproductive cycle, how important estrogen is for our bones, for our heart,

for our future health, as well as our mental state often. And we do learn a little bit about testosterone, a deficiency in men, but there's nothing about it in women. And it was only a few years ago when I started to become more actively interested in the menopause that I started reading about testosterone in women. And I didn't realize that we produce as women more testosterone than estrogen before the menopause, yet it's not spoken about. And then when I sat in one of the first menopause clinics down in London that I had a privilege of sitting in,

and they were giving testosterone to women. And I was saying, what on earth are you doing? I've never, ever seen this before in my life. And fast forward a few years, I prescribe and I'm quite open, I take testosterone, I replace my deficiency in my body. And we know what an important hormone it is. Yet there's this big stigma. And the stigma isn't just for women.

It's a lot of healthcare professionals are scared about testosterone for women. And as many of you know, it's not licensed for women in the UK, which I actually feel is quite outrageous when it's a natural hormone that we're denying women replacing. So talk us through your research. Since you've been involved, it's been wonderful because you've come up from London a lot. And you've not just sat in my clinic, you've sat in other clinics with other doctors here, but you've also been in reception and answering phones and doing the letters and really getting into this whole clinic setting that's evolving. So talk us through your research.

As anthropologists, I mean, the loose term I'd probably term my research is ethnography. And that means kind of coming into a setting and scenario and really embody. everything that happens. So not just looking at the way doctors interact with patients, but the way patients experience the service from the minute they walk into a clinic. And I really surprised myself actually with the findings that I've taken from my time here at the clinic, mainly around how many women had similar stories and narratives. So every person has an individual journey, healthcare journey that they've taken. But the big thing that seemed to be reoccurring in phone calls, in letters, in, you know, the moment they walk through the door,

in the patient interactions, was this sort of sense of desperation of feeling they'd lost a part of their identity. And I think what's really fascinating about that is menopause is often overlooked, both in public health research, but also in social research. And I think that that speaks volumes of the way that period of a woman's life is mirrored in her own experiences, which are a sense of invisibility, a diminishing sense of identity, you know, a feeling of becoming less and less significant. And I think the thing that I actually observed the most was, yes, an excellent quality of care is provided at the clinic. But I think the thing that perhaps more importantly, these women receive is time, time to talk from the minute they make contact. So maybe

that's on the phone or with the reception staff or when they have their bloods taken, but also in a consultation, you know, they get a longer proportion of time to be able to talk through what's going on for them. It wasn't really until I started observing, listening, and hearing women's experiences of menopause, how much I appreciated what I'll term brain fog actually impacts your ability to communicate what it is you want to say. I was just talking about it this morning actually and saying, I don't know what it is over the last few months. I've just, I haven't been able to find the words for certain things. And I reminded myself of the amount of times I've heard women say this.

I can't find the words. I can't find what it is I'm trying to say. And actually what I've observed is through time, through having a longer interaction, they're able to find those words and communicate what it is they want to say. And I think what gets fed back is it's not necessarily that they feel they've received a terrible quality of care via their GP or that they even are. necessarily unsatisfied, but just that they haven't had time to fully explain what it is they need to say and the complexity of their conditions as well. Yeah, and I think it is really interesting.

So certainly as a GP, I would just see the patients who clearly were registered with me. And they often didn't have symptoms for very long because I would try to help them, clearly. But in the clinic, people self-refer. And so a lot of women had suffered for longer. And when you talk about this invisibility, and I think women do become, quite invisible during the menopause. And often they don't realize either because they'll think it's due to life events or just because they're getting a bit older and they're being pulled in other directions. And the power of hormones and the importance of hormones on our brains is huge that we don't realize because we're not prepared for it until they've gone.

And it's very scary sometimes when women are experiencing perimenopausal and menopausal symptoms and even I had symptoms for a while and I really thought my brain had gone and I couldn't focus, I couldn't remember, my concentration was gone and when I'm in a consulting room and I forget the name of a drug that I've prescribed the last 20 years, that's really scary. And I see people who are, you know, barristers who stand up in court and they can't remember things. I see people who are secretaries and they can't remember the name of their boss. You know, it's really awful. So you're right. think having the time here is a great luxury, but just time to explain to women that it's related

to their hormones before giving them any treatment or talking about treatment choices, actually knowing what's going on in their bodies is really important. Yeah, I think I remember as well, it was one of the first days I sat in with you actually observing patients. And I think you can read about menopause and you can read about symptoms, but you don't necessarily piece it together until you see it in a consulting space. And I remember saying to you, oh, but couldn't you say that maybe it's a mental health issue that this person is talking about?

Couldn't you say X, Y, Z, and you very kind of sweetly said, yes. And that's often what happens in these circumstances. And actually, one of the things I found interesting is menopause isn't one symptom. It's not hot flushes. It's not brain fog. It can come in multiple forms. And I think we, in the office one day,

I decided to make a list of all of the different symptoms everybody had heard. And I think I had something like over 62 different symptoms. And some of them are more common and some of them aren't. But one of the things I started to think about was if this is the case and you are a GP consulting in the NHS, you don't have the luxury of being able to go through, just say even if a general estimate is 15 symptoms. You look at what is presenting as the most problematic to that patient at that time. And I think the stress and pressure is, enormous for GPs to have a very, very wide remit of understanding for many, many conditions that patients might be suffering with. And we don't always necessarily jump to menopause,

particularly if the emphasis in the last few years has been on mental health or prioritising that. Absolutely. And I think in general practice, it's often one problem, one consultation, 10 minutes. And people feel embarrassed talking about the menopause. They think it's a failure if they have to give in to the symptoms sometimes. And a lot of people, people do think it's just about hot flushes and sweats. And a journalist the other day said to me, exactly how many numbers of symptoms are there? I've read one article that says 32 and 1 says 36, how many? And I said, well, there isn't a number because, you know, there are so many different symptoms. And it's not often until people have the right hormones that they then start to feel

better and then say, gosh, I didn't realize my memory problems, my headaches, my urinary symptoms were related. And in fact, the day before yesterday, I was with a lady who I'd met three months ago, and she's married to an orthopedic surgeon. And when I first saw her, she really struggled walking up the stairs here because she had a lot of hip pain. And her husband had been very perplexed because she'd had lots of scans, everything was normal. And when I saw her two days ago, she just flew up the stairs and she said, my hip pain's gone. And her husband said, this is incredible because estrogen's an anti-inflammatory in the joints. And he said, I'm now asking all my patients routinely, who are in their 40s and 50s, if they are experiencing menopausal symptoms.

And he said, my goodness, most of them are saying yes, but they would never have told me if I hadn't asked. And so we're going to do hopefully some research, looking at the prevalence of pain, especially hip pain, in menopoles or women and how it can improve with HRT for the right women. But women don't volunteer symptoms because they sometimes don't piece it together. but then I think there is this whole connotation about menopause or women have this sort of figure of being annoying. Like you're saying about hormone or, you know, my teenage children and if they're in a bad mood, it's very easy to watch your hormones. Probably isn't their hormones. They're just cross.

We're allowed to be cross. And, you know, a lot of women have PMS and it really can affect their mood. And so we've grown up talking about these hormones. And I love the way that you're talking about the men, their testosterone, because it makes it very powerful. powerful and strong, but actually why can't women be powerful and strong? So one of the things I'm doing as part of my research is actually looking at the relevant historic context surrounding the synthesisation of hormones and particularly testosterone. And one of the things we like to do in anthropology is, there's quite a great term. It says I wouldn't have seen it unless I believed it.

And I think it's quite true how often our perceptions, our beliefs, really inform what we choose to see and what we choose to follow and what we choose to research. And when you actually strip away, you know, a lot of the texts around the time when the synthesization of testosterone is taking place, there are lots of themes of masculinity that are associated with the turn of the 20th century of modernity, of second world war, of masculinity that are really embedded into the science that's happening at the time. So these metaphors that we come to know of, when you actually look at their roots, you can see that they're deeply, deeply, deeply embedded. into historic and social context that come to feed our knowledge and understanding.

A really nice example, separate example, is anthropologist Emily Martin has done some amazing work in the 90s actually, but on the process of conception. And looking at how in medical textbooks, often conception is explained in a very gendered way. You have the passive, docile egg gently bobbing along and then the ferocious, aggressive sperm fighting its way towards and, you know, penetrating the egg. Whereas actually, when you look at the process, what they're now seeing is it's a much more collaborative process where egg and sperm work together for conception to occur. But because of our gendered perceptions and understandings, we often look at science, technology and biology in this manner. Which is so interesting, isn't it?

And I think I'm not really a feminist, but I do sometimes think if the menopause affected men, if we said to all, men, when you get to the age of 51, you're going to be castrated. So you won't have that same testosterone in your body. Your brain will go. Your memory will go. You probably won't be able to have sex. And if you do, it will be painful because obviously a lot of women have vaginal dryness, which is very sore and painful. We've got a treatment for you, but we probably won't give it to your get antidepressants instead. It just wouldn't work, would it? It wouldn't happen. Well, it's the same sort of argument that you could put around contraceptives that technically we've had the science and technology to create a form of contraceptive similar to the female pill for men for decades,

but we're not necessarily willing to take that risk with male sexuality. And similarly, I think the important thing to emphasise here is that the purpose of my research is not to prove that, you know, testosterone isn't the male hormone. Men produce far greater amounts of testosterone than women do. But I think what I am trying to shine light on is the impact that these perceptions can have on women, or other patients using this hormone as part of their treatment and the way they may come to view it as a consequence. And I think undoing those ideals or just questioning them a bit can allow us to see actually, you know, science and technology is rarely value-free. And I think we often don't question that. We often don't even query it. It's just taking this given.

Patients we don't. And as health care professionals, we don't either. And it's not until you take a step back and really think about what we're doing and how we can individualise care, then we think about the bigger picture and the different hormones involved. So I know you've met and spoken to a lot of women who are taking testosterone, haven't you? And what's been your sort of taking from talking to these people? I mean, I think it's different for every person, but I think the take home I've had from it is that there isn't necessarily, you know, one generalizable effect for every single person. Obviously, you have the benefits that we know,

which are increased libido. I've heard a lot of people talk about improved cognitive function and ability. And that I have to say I found interesting because this has been negated by quite a few professionals saying, oh, there's no evidence to demonstrate that what I have found interesting. A lot.

Because this isn't something that I feel is necessarily being influenced. No. I think you're right. And it's very interesting. So when you look at the nice guidelines, you know, the National Institute of Health and Care Excellence guidelines, menopals guidelines we work out of. They say that if a woman is taking HRT and has

reduced sexual desire, we can consider testosterone. And as you know, we do the green clemecteric score, this questionnaire that's available on my website on all women. And we've analyzed over 350 of these on women taking testosterone and we've found that their psychological symptoms have improved significantly as well as their libido. So it's often women find that their vasimotis symptoms improve, so their flushes, sweats, improve with estrogen. Sometimes their energy, their joint pain, headaches can improve. But it's usually, like you say, the cognitive problems, such as low mood, low energy, memory problems, concentration problems, and reduce libido. It's usually those symptoms that once women have estrogen, we then add testosterone and those really do improve,

which has been confirmed by our research. But certainly globally, there is very little research done on the psychological impacts, which we know. There's testosterone receptors in our brains, aren't there? So it makes sense that it helps. I think as well, I mean, it's something that, you know, you're consistently struggling with as a qualitative researcher. We can't produce clinical trials to the same extent as other public health studies. We can't interview thousands of women in very great detail.

You know, qualitative studies do exist, but it's usually survey-based or questionnaire-based. You don't get that time to really talk. with your participants about how they feel their experiences. And for some reason, those that are can sometimes be seen as not as valid. But actually what I found interesting is that whilst we have on the one hand people negating these claims, you also have the narratives of multiple women coming and saying, actually, well, my experience is that this did improve. This did, I did notice a difference.

And I think that's so important to listen. You know, we're always taught as physicians, the patients will give you. the answers and we've got to listen to women and I was talking to someone the other day and he was trying to tell me how good a placebo HRT is and we know there's a placebo effects and everything we give but women are almost hoping that their libido improves because they've read about testosterone and libido but they're not expecting their memory to improve and a lot of people find because it's very good for muscle strength and stamina that their ability to exercise improves and their muscle strength improves as well and they weren't expecting those improvements so i'm really loaves to believe it is

just a placebo effect and i think it's important as you say to learn from the people on the front line often we by that i mean the women going through it yeah because often we defer to experts which is important but i always wonder you know have they lived through that do they know how it feels so you know i find it interesting when people comment or talk about i think attitudes have changed towards menopause. But I feel like there has been a perception for some time that it's something that you just need to get through. And the thing that I am noticing more and more

is that, you know, there are multiple women that come through that are at the height of their career and then step back and take a break because they can't cognitively function on the level that they need to. And whether placebo or not, again, like I say, I'm not necessarily trying to prove a definitive link. But what I am seeing is that for them, their experiences, my cognitive function,

improved, I was able to go back to work, I was able to function at the level I'm used to or return to the person I feel I am. And I think considering that women, you know, women 50 years ago weren't necessarily expected to stay in the workplace after menopause or even be in the workplace. And now we are. So it's different. It is. I totally agree. And I think, you know, years ago, our role as a women in society was very different. You know, I remember my grandmother, as long as my grandfather had a meal on the table and they weren't expected even to drive. There were lots of people that didn't drive. And I hear time and time again about women who have stopped driving because of their crippling anxiety because of the menopause.

So I do often think I wonder it did suit them almost because they didn't have to drive, they didn't have to go out, they didn't have to socialise, they could hide a bit. Whereas women now don't want to. And I think having personal experiences makes a huge difference. And one of the reasons I'm driven so much to help women is I know if I wasn't taking the right dose and type of HRT for me, I wouldn't be allowed to work because I wouldn't be. So my brain really did go. But also my body was going and I was really struggling with yoga. I was struggling to think about eating healthily because everything was an effort. I couldn't be bothered. My sleep was bad. We know poor sleep. Has lots of problems associated with it as well as disease risk. And without hormones, my stomach. A lot of women's sleep is affected. So I've learned so much about myself, how I've responded to hormones, and maybe some of it is placebo.

But actually, as long as I'm not doing harm, it doesn't matter so much. And I think that's one of the other really interesting factors that's come up through this research is the conceptualisation of risk. I found it really interesting to spend time in the clinic, I guess, during a period of time in which there has been concern and worry again, reignited around these narratives we have linking HRT to breast cancer. And one of the things I found interesting and have observed in some of the consultations the clinicians who will do here is also, I guess, make reference to that in saying we take

risks every day, even by drinking a glass of wine or, you know, having a high BMI. That's a risk factor. But for some reason, this risk factor is seen as far more problematic. And I'm curious about that. I'm very curious as well actually because I read recently that there's a type of medication that we use for heart disease and blood pressure called a calcium antagonist. And they're associated with a double risk of breast cancer. Yeah. Yeah, that's never in the press.

Taking most types of HRT is less than a double risk of breast cancer. Yes, it's in the media time and time again. And then women are made to feel really bad that they're taking this risk. And when we talk to women, especially young women, women who have had a history. misderectomy don't have an increased risk actually of breast cancer with their type of HRT. And even older women, like you say, the risk if they were obese is about 10 times more than taking HRT. Yet they're made to feel bad for taking something with this risk. But actually, when women understand what risk means and the magnitude of risk, they still say, well, actually,

I want my life back. And even if I have this increased risk, I still prepare to take it. Because There's never been a study that shows there's an increased risk of death from breast cancer. And we know a lot of women have breast cancer, but most women who have had breast cancer still die from heart disease, which are taking HRT diseases. So it's educating so people have the choice. And I think for a lot of women, the choice has been taken away from them, not necessarily for the right reason, which is dreadfully sad, isn't it?

I think also it demonstrates actually how sparse our knowledge in hormones and the way they work are, you know, as I said, I'm not an endocrinologist, but I kind of learned through experience in the last couple of years, which is I sometimes surprised myself at going, oh, I do understand a bit more about that than I thought. But when I think about endocrinology, on some level, it is a relatively new science. We're discovering things all the time around hormones. And I always think something is only true until it's not.

You know, we're very, very keen to get behind this being a definitive link or association. but actually, as you've talked about before, there isn't necessarily a strong causal pathway or link here to be seen. And I do worry about the way these messages get filtered into the experiences of women so that when they are using HRT or testosterone or estrogen, that there's a sense of guilt that comes up around it,

that I have to feel guilty for making this decision and choice. And I think that's totally true. And it's so wrong really. Some of the work I'm trying to do is to change the perception. So we're not thinking of the menopause as a natural process that causes symptoms, but we can think about it as a female hormone deficiency. And when you talk about deficiency, then you think about replacement. So if you're iron deficient, you know you need to take an iron. So if we've got a hormone deficiency, then we're replacing that deficiency.

We're not thinking about the symptoms. And then I think women will then feel more justified to be able to. to take a replacement hormone. Yeah. And I think that's what's actually kind of interesting about testosterone or the pushback you have around using testosterone among female patients. Because actually, as far as I'm aware,

and perhaps I haven't found the research yet, but there hasn't been any contraindications that I've seen. Obviously, I think people are concerned around gender identity and that it's going to cause changes, which it won't in the amount that you use. And as you know, we monitor women. Absolutely. Their blood tests are in their female range,

the risk of side effects. is not there at all. And I think this is curious as then why it is that there is maybe this concern around women using testosterone as part of their HRT treatment. And yeah, the stories around that for women saying, actually, I was quite aware that this might be helpful for me, but I really struggled when talking to my GP. Not only that that treatment wouldn't be considered, but even the blood tests or levels being tested wouldn't be considered.

I mean, I think a lot of that is down to education. I said I didn't have any education about it. And as some of you might know, we're developing a menopause education program, which will be rolled out with a company called 14 fish. And that will have a lot of information about testosterone in it. So it's been brilliant talking. There's more and more that we need to talk. And I'd like to have you back in a few months' time to talk more about your research,

which would be brilliant. So normally at the end of the podcast, I will ask for three take-home tips for women. But because Lauren's research is so fascinating. What I'd like to ask you, Lauren, is three most important things that you've learned since being part of your research and working with us. Yeah, definitely. I think the first one would have to be what I've already spoken about, but that time is often an underestimated benefit for healthcare or a form of treatment in itself. That menopause or symptoms for many women is simply not just hot flashes or something that they need to get through, but has a massive impact on their well. being in their life and that testosterone is not just the male hormone but essential for as you've

mentioned rebalancing our systems in the same way it is for men oh and can i add like a tiny one that i actually didn't know until i started this which is exactly what you said earlier which is um that we produce more testosterone as opposed to estrogen but that's just a fun one for me yeah no thank you that's brilliant and there is plenty of information about testosterone for women and also for healthcare professionals on my menopause doctor website so thank you so much for sharing your time to do. Really good. Thanks, Lauren. Thanks so much. For more information about the menopause, please visit our website www.com.com.com.ukesdoctor.com. UK.