The Dr Louise Newson Podcast - 064 - Early Menopause and Fertility - Jon Hughes & Dr Louise Newson

Episode Date: September 8, 2020

In this podcast, Dr Louise Newson is speaking with Jon Hughes, a gynaecologist who specialises in fertility and endometriosis. Jon and Louise discuss the various reasons why women may have reduced fertility, including women who have an early menopause or Premature Ovarian Insufficiency (POI). Jon talks about his work and details the possible ways that fertility can be improved. Jon has recently joined the team here at Newson Health and is now offering individualised advice to women with fertility problems or potential fertility issues as a result of their early perimenopause and menopause.   Jon is the lead clinician for Worcestershire Fertility, which is part of Oxford Fertility. Oxford Fertility is part of TFP, with 37 fertility clinics across the UK and Europe.  Jon Hughes' Three Take Home Tips for young women with potential fertility issues: When trying to start a family, try and live as healthy a lifestyle as possible. Try to maintain a healthy weight, stop smoking and moderate any alcohol. Talk to your mum, aunties, grandmothers, and find out if there is any history of POI or early menopause in your family. If so, it may be helpful to start thinking and talking to your GP about your fertility. Keep an eye on the symptoms! If your periods are becoming irregular and you are planning on having a family, it may be worth getting everything checked out. Find out more about Jon's clinic at Newson Health here.

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 on my podcast, I'm very delighted and pleased to have John Hughes with me, who is a fertility and endometriosis specialist. He's a consultant who works with me and works near to me, and it's been really interesting talking to him over the last few months about the sort of patients that he sees in his clinic with fertility problems. And there's a big overlap with some of the young women we see in our clinic who have problems with the perimenopause and menopause and have reduced fertility.

So welcome, John. Thanks for joining me today. Honestly, thank you for inviting me. It's such an important subject and this is a great way of, I think, raising people's awareness. You don't know where to look at for what is to you. Absolutely. No. And I'm not a fertility expert.

I'm a GP, I've got a lot of hospital medicine experience, and I'm really keen to just explore various issues. So before we get started, just tell me a bit about you and how you developed your interest in fertility and endometriosis. With the endometriosis side of things is the surgery. It's keyhole surgery. It's quite complex surgery, and I've always found that quite rewarding. The fertility side, a bit of a personal journey. Actually, my wife and I, we went through five cycles of IVF before she became pregnant twice naturally to give us our two children. Right. And so I got a lot of insight into what IVF involved.

And it was after that I realized what was good, what was bad, how I'd like to see things done. And I really developed my interests from there. And so this is why I've got the two. And quite often the endometriosis patients will have subfertility. And so there's a big crossover between the two. So it's a very rewarding area as well because it's the only treatment where you get a of tablets and do some medicines and things and nine months later you get sent a baby photo. It's great. Yeah, so very rewarding, but also very difficult emotionally, I'm sure, as well, because

it's a huge emotional journey for any woman who wants to get pregnant. And I think it's very interesting and it's very kind that you've told about your personal journey, because that does make a difference. I think as doctors, obviously, we can't experience every condition we treat, but I know myself having gone through the perimenopause and suffered for several. months without realizing even what was happening to me. And when people sit there and tell me about their brain fog and memory problems, I completely understand what it was like. And it must be the same for you because to go through any investigations or tests and treatment is very grueling for both partners, isn't it? Yeah, especially when it doesn't work. And so that was difficult

for us, but I see it's every day with the patients. And yeah, that's obviously a difficult part of the job when it doesn't work every time. No. And there are so many reasons why fertility is reduced. Obviously, there are male reasons, there are female reasons, there are a combination of reasons. But obviously, because I do so much menopause work, I really wanted to focus on those young women who have early menopause and those women under the age of 40 who have POI, premature, ovarian insufficiency, because quite often I see women who have an early menopause in the clinic and their periods have been irregular for a while. They've often have fertility treatments, sometimes successful.

successfully and sometimes not successfully, but no one's really explored to them about the menopause and hormones obviously are important for our function and our future health, but they're important for fertility reasons as well. But also we have our eggs, don't we, and our ovaries, which are important, but we only have so many, don't we? We can't increase the number as women that we have. That's absolutely right. Although there are things that you can do that can reduce your reserve of eggs, which would be smoking and maybe some poor lifestyle choices in terms of diet. If someone's weight is excessive, that can reduce the quality of the eggs, but living a healthy life will improve things. The real problem that we see, though,

is there are some women unfortunate that have a low reserve of eggs at birth, and so how would you know that you're in that risk group, and that would be women who perhaps their mother or the sister has gone through the menopause before the age of 40. And if that's the case, then her risk of going through the menopause is six times higher. That does not mean she's going to go through the menopause or develop premature ovarian insufficiency before the age of 40, but it increases the risk. And so it's something that she needs to bear in mind. So it is worth, I mean, a lot of women ask me, how do I know how old I'm going to be when I go through the menopause? Is there a test? Is there a way? And there's no way, is there,

of knowing for sure. But it is worth, and it's more useful if women come from families where there are female members because if their mother, auntie, sister, cousin go through an early menopause, that like you say, they've got an increased risk, haven't they, of developing an early menopause? And there are other risks. There are medical conditions where the body's immune system can attack the ovaries or the hormones might be out of balance, although even some rare genetic conditions, which can lead to a low reserve of eggs in early POI or early menopause. There's also things that doctors can do to you. For instance, if someone's had surgery on an ovary,

for instance, from my practice, endometriosis, or other conditions such as that operating on the ovary will reduce the reserve of eggs amidst. Or if someone's had childhood cancer or cancer in young adulthood, radiation and radiotherapy or chemotherapy, that can destroy the eggs in the ovary. And so that can bring about a premature menopause. So these are all things that would either cause or massively increase the chance.

And so if there's anyone that we feel might have, we'd investigate or take a history to address those questions. And it's important, isn't it? Because some of those reasons might be permanent and some might be temporary. So, for example, some people who have having chemotherapy. they might not know whether their ovarian function is going to return or not, it depends on the type of chemotherapy and the dose. But certainly for people who are undergoing treatment that is going to affect their ovaries, then I presume you see these people in advance, do you, to discuss about...

Yes, yes, yes. So that's really important, isn't it? I mean, that's a very specific case, obviously, and if someone was in that situation, we'd be talking about it in depth, but it is possible to collect the eggs using half of the IVF cycle and effect, collect the eggs and then either freeze them or fertilise them and freeze embryos, which can then be used for future fertility treatment once or the cancer treatments behind them. That's a very specific situation now.

But it is very important because thankfully childhood cancers the prognosis, the outcome is so much better than it used to be. And obviously women are living longer, which is fantastic. But every so often I do see people in my clinic where quite rightly they've been focusing on the cancer and the treatment and the whole question of fertility hasn't been brought up because perhaps the patient was quite young or wasn't with a partner at the time. And then it's sadly become too late because they've had irreversible damage to their ovaries. So having the conversation early is really important, isn't it?

Oh, yes. Well, maybe we'll talk about what we would do in that situation if there are no eggs left. But hopefully we'll be seeing people before it gets to that stage. Yes. And it's worth, particularly if someone thinks they're a risk if family members come through mannepause early, to think about strategies for not family planning, but planning a family the other way around and think maybe I won't leave having kids to my late 30s because then you might be too late. I guess then the next question that quite often I get asked is, is there any way

of predicting if that reserve of eggs is going to run short because it is irreplaceable. Yeah. And certainly I've seen lots of tests that are of available online or you know you send your blood away do a scan do this that and the other and I'm always worried about tests like the same with menopause tests there's no good test that you can do as I'm sure you know but so is there a test that women can do to see how many eggs they've got left or what their ovarian function is so I wish it was simple there is a test you could do there's a blood test called the anti-malarian hormone or AMH. Now, you have to be very careful.

It's very controversial. AMH is a hormone that's made by the tiny little eggs in the ovary that are lining up waiting to be released over the coming few months. And the more eggs there are, the higher the AMH will be. And so it can give you a clue as to how many eggs there are there. But what it does not tell you, it doesn't tell you if someone's likely to get pregnant. Right. And so you can do an AMH and find maybe it's slightly low

and they might have no problem at all getting pregnant. And so knowing what to do with the result is difficult. The time it is useful, I mean in this context, in terms of trying to predict those at risk of early menopause, if you did one and then you did another one and you found there was a dramatic drop over a year, then you might start thinking maybe we've got a problem. But being on the pill can make AMH go down.

And so it's not easy. There's not a straightforward answer. You could also do scans to look at the number of eggs, again, these early ones that are lining up, waiting to be released. But there's not a, unfortunately, it's not a simple one, no matter what you might be told. And then, of course, there is the option of freezing the eggs, which again is an enormously controversial area and very complex in order to preserve the fertility for the future, which is what we do for the chemotherapy patients. but whether someone who's at risk of premature menopause does that or not, that's quite a long conversation that we normally have. Certainly that came to the press, and it a few months ago,

about delaying the menopause, they were saying, about freezing some of our ovarian tissue and then putting it back in after, which I don't know as a menopause of women, I really would like that. I'd much prefer to take identical hormones and know what I'm taking rather than having some of my own tissue put back in. But also it's not really just the number of eggs, it's the quality of the eggs that's really important. For me, with the fertility side, absolutely, and this is something everyone will be aware

of the age effect when it comes to getting pregnant. But I guess we're talking about premature, hervarian insufficiency, so the women will tend to be younger, but there's no doubt that over the age of, when you get into the late 30s and certainly the early 40s, that the quality of the eggs that remains, even if women's got more eggs than she needs, the quality of those eggs will be reduced just by her age alone. She says she might have perfectly fine hormones and might be releasing eggs absolutely fine. But that's a separate thing really. And so just to reiterate, you were saying about smoking can affect the quality, if you like, of the eggs and diet. So which diet is best? Is it sort of processed foods

or certain types you've also said about obesity as well, didn't you? Well, certainly with obesity there's evidence that when the BMI, which is the measure of the weight versus the height, goes over 30, then the quality of the eggs that we see is lower. And it makes it harder to become pregnant. So it's important to try and keep the BMI down below 30 if possible. And certainly for our fertility treatments, we need the BMI down less than 35 in order to be able to proceed with anything. again because the quality of the eggs that we receive

but that doesn't tend to drive people into premature menopause it just reduces the quality of the eggs that we get and if we've already got a low reserve we want the best we can get please if we're going ahead of IVF treatments which is something else to discuss I think yeah so I mean there are a lot of treatments available to women but not all of them are available on the NHS

and certainly I see in my clinic people that come from all over the country so it does seem a bit of a postcode lottery for women, doesn't it? Fertility treatments. It's very sad. It's something that we do campaign about. The availability of fertility treatments is variable across the country and I don't think there's anywhere that provides as much as we would like but particularly these days there's increasing pressure on resources and so I don't think that that provision is going increase unfortunately. And so a lot of the fertility treatments that we might talk about are very, very expensive and we'd obviously try and get treated on the NHS what we could, but it isn't

necessarily possible. So we're talking obviously about women who have premature ovarian insufficiency POI and a lot of women think that they are infertile and a lot of doctors think that these women are infertile but actually it depends on the underlying cause of the early menopause and women who have this so-called idiopathic as in we don't know the underlying cause. We know that there are around probably 10, 15% of women who will still be fertile. So firstly, really to say is that women should still, if they don't want to get pregnant, they should use contraception because even if they're on HRT, HRT is not usually, depending on the type, but it's not usually a contraception. But also it means that if a woman has a family history of early menopause and her periods are changing,

it doesn't mean that she's necessarily infertile. And so it's very important. that women receive individualised help, wouldn't you say, John, from a specialist. Absolutely. And people can be panicked as well by this AMH blood test. Because even if it does come back low and then you do other tests. And as you mentioned, the vast majority, we don't find a reason for the low reserve of X. If we do find that, then they do still have a reasonable chance of getting pregnant. Okay, it's only one in ten, maybe slightly quiet. But it's still a chance, isn't it? Yes.

And if that's what they would like, then that's great. Now, if they've been trying for three or four years already, and it's not working, and the question is what to do next, and it very much depends on how many eggs they have available. I'm not sure what people are aware of, but if we were to do a treatment like IVF, the way that works is we give medication to make women make a lot of eggs, instead of just one a month they make we aim for 10 or 15 and then the more eggs we get we fertilise

as many as we can and then we put back the best embryo and it's good to have a good choice of eggs and if we don't get many eggs through the IVF then that makes the IVF success rate lower and as a rough rule of thumb the AMH will be equivalent to the number of eggs we get so if we've got an AMH at 15 we're roughly 15 eggs, you know, it's very approximate. And so if we've got an AMH that's gone down less than 10, then the IVF success rate would start dropping. And so there isn't necessarily a big role for IVF using a woman's own eggs because her success rate using her own eggs may be less than 10%.

And so in that situation, it's a lot of money to be spending for something that's got a low chance of success. And so that's something that we'd have to spend a lot. long time, you know, looking into seeing what her, individualising it for her to decide what her chance of success is. And if after counselling and going through it or she decided there is a medication that we can add, they can increase the sensitivity of the ovaries, it can increase the success rate slightly. But ultimately, the background problem with the lack of eggs is what we're dealing with. And that's not something that's easily resolvable. Some women in my clinic have had a donor

egg and being successful. So there are choices, aren't there? It's really important that I think women get seen. And sometimes I've had some women in my clinic who don't want to become pregnant at the time, but they want to know what the options are available to them. And certainly at these times, it could be very useful to speak to a facility expert just to know that there are choices available rather than scrambling around almost in the dark when it might be sort of too late or the time is upon them to make difficult decisions quickly. Absolutely right. So it's very rare that I'll tell someone that she cannot have children,

that she cannot become pregnant and have a family. It may be that unfortunately she doesn't have enough eggs of her own for the IVF to be likely to be successful, but that doesn't mean she can't try for donor egg treatment. So it's using eggs from a young woman and potentially using her partner's own sperm. They can then proceed with the treatment and they get a very high chance of success

can be in the region of 40% or higher. And so if we talk to the women about that, we go for it. Obviously it's a big, long conversation, and they go for all the details, then by all means, so you can have the family she desires. And that, I think, is an important thing,

is not to give up hope. It is still her child. It's their family, and that's something we've spent a lot of time talking about. A lot of women who, are struggling with fertility and the NHS services are limited, it can be very difficult to know where to go because there are so many clinics and you obviously can't say which are the ones that are perhaps better than others. But I think now with the advent of the internet, there's so much

advertising and I think it's really important, isn't it, that women do their research to find out, I mean, I know you work with a very big group, don't you, based in Oxford? Yeah. So although I do work as part of Oxford, fertility, I always tell the patients to look around and make sure that they're happy with us as a match for them. There's the HFEA, the human fertilization and cryology authority. They have a website which lists all the fertility clinics in the country. And so I recommend people to always look at that and choose where they want to be treated. I mean, we personally, we're very pleased with our success rate. We think we provide an excellent service. And we do also work with foreign clinics

that can provide some advantages in terms of speed of treatment. And so that avoids some of the difficulties that people have are just going on Google and going off to unvetted clinics in foreign lands. And so, yes, we're pleased with the service we offer on all fronts. Well, suddenly, so Oxford Fertility have a network of doctors, don't they, which is really important. I'm not working on isolation and have been well established, which again is really important. So we're talking obviously about the menopause. So it lends me to obviously talk about HRT.

I've already said that HRT isn't a contraception, but actually a lot of women with fertility problems don't want to use contraception because clearly they're keen to try and become pregnant. And quite a few women I speak to either directly in my clinic or indirectly through social media tell me that they have been waiting maybe to see a fertility specialist. They're having menopausal symptoms because they're perimenopausal, yet they've been advised not to go on HRT because it might reduce their fertility or be dangerous if they got pregnant. So there are different types of HRT and there are different doses,

but certainly, as many of you listening know, we use body identical HRT, so the estrogen through the skin, natural progesterone, and if they need testosterone, the natural testosterone as well. So it is just replacing. hormones, isn't it, John? So if a woman was to become pregnant taking the natural type of HRT, the body identical HRT, it's not going to harm the developing baby, is it? No. And in fact, if I do see someone who's entering POI, early menopause, then we will tend to recommend HRT to protect the uterus. Because if you do not, then as well as all the other health things,

that's why it's great working with you, that you address, the uterus will get smaller. And then if we do eventually want to proceed with donor egg fertility treatment or if she gets pregnant naturally, then the uterus will be too small and that can in itself reduce the chance of success. And so by having someone on HRT, it protects the uterine volume, which is important. Which is so interesting. And I think that hopefully will be really reassuring. And as John says, there are lots of health benefits of taking HRT because women who have an early menopause have an increased risk of heart disease, osteoporosis, even dementia and diabetes. but it's here and now.

We want women to feel that they're as healthy as possible if they're going to become pregnant. And we've already mentioned about diet and not smoking and keeping your BMI, your body mass index, reduced. But also keeping your womb is something, obviously if you're going to use it, then it's important that it has the right hormones,

so it has the right blood supply and the right function as well, which is something else. So hopefully people can be reassured that it is safe to take HIV. and certainly if there's a long weight, HRT will improve symptoms and a lot of women I see are very anxious, understandably because of their perimenopause and also anxious because of their possible reduced fertility. So if we can reduce the anxiety by replacing the hormones or reduce

some of the anxiety, then that also can be very beneficial as well, can't it? Yes, certainly for her mental health, if nothing else. Absolutely, the HRT will be essential in that situation, particularly if she's gone past the early stages and she's starting to get that perimenopausal state, then I don't think there's any choice really. I would always recommend, refer on to a menopause specialist in that situation to make sure that things are ideal. Yes. And then we would then alter the hormone balance during the fertility treatment, during the weight to keep her healthy, and it's vital. She's for the right things. So it's very important that women know that there is plenty of help and support,

but sometimes it's just accessing it is really important. And certainly we're trying to do some work to increase awareness for women, but also for healthcare professionals. So women who have reduced fertility, the healthcare professional can discuss and talk about hormones and ways of improving hormones. And a lot of women, quite rightly, don't want to take the contraceptive pill if they're planning a pregnancy. but they think that's the only treatment when they're young. And the hormones in the contraceptive pill are very different, aren't they,

to the hormones in HRT? Particularly different versions of estrogen that you get in the HRT, which have got different effects. They're not as ideal and greater risk, some rare side effects as well. And so the HRT is undoubtedly a better choice. It's just a matter of getting onto the right one, which quite often means seeing the right person, doesn't I?

Yeah, absolutely. And, you know, some women who have an early menopause or POI prefer to go on the contraceptive pill, certainly if they need contraception. And if they do, then it's very important that they run the packets together so they don't have a week break because then they're only having any hormone replacement for three out of four weeks. So if anyone is listening and has been recommended to take the contraceptive pill, or once contraception and find that it's the most suitable method, that they can use it, but it's better to take all the time.

But also, if a woman is on the contraceptive pill, then it can be sometimes very difficult to know what her underlying fertility is like. And a lot of women are sometimes quite surprised when they're on the pill. They've been taking it three out of four weeks, been having withdrawal bleeds, which they think are their periods, and then they might stop taking the pill and find that their periods are absent or very scanty. That's quite a common thing I see. in my clinic is they've been having regular periods, no problem at all on the pill.

And it's not that being on the pill has caused them to run out of eggs. It's just they've run out of eggs naturally. And then when they stop, where are my periods? And it's then that we identify as the problem. And, you know, what do you do about that? It's tricky, isn't it? I don't think we're at the point of saying everyone should have this AMH blood test to make sure that they've got lots of eggs because, again, what do you do with the results?

Do you have to repeat it, however often? And it's certainly not anything that there's any science there in what we should be doing. No, and I think it's important that people know that as well, but also that a lot of women almost regret going on the contraceptive pill because they think the pill has caused them to have reduced fertility. And that's not the case, is it? No, no, no. It's just getting them healthy and it's given them a regular bleed.

And it's just hidden the signs rather than caused it. Yes, absolutely. So that's really important. to know. And I think one of the big messages from talking you to today is for women to try and think ahead really. You know, we very much live for the moment. But when thinking about family and many of us, myself included, left it quite late. I was actually 40 when I had my last child. But actually, we should be thinking about ways of preserving, maintaining, improving our fertility if we can. And just having a conversation. And I think seeing the patients that I've seen over the years

it's never too early to have a conversation with someone who has a special interest in fertility and you certainly would never be wasting anyone's time if it was something that you weren't even thinking about at the moment but perhaps you've got a family history of early menopause. I certainly think it's worth exploring the options sooner rather than later even if you're not going to use them. Wouldn't you agree? Absolutely. I have a detailed and honest conversation with someone who's going to give you some straight answers. It's a difficult subject because you don't always meet the right person to try for kids at the right age but I think increasingly women are starting to realize that fertility drops off in the 30s

and that they need to focus on that and I am seeing people come through for fertility checks in their 20s to make sure they haven't got anything to worry about. That is something that we do do but it's like I mentioned a tricky topic because there's no perfect test that we're will tell you, yes, you've got a problem. No, you haven't got a problem, but there are things that can give us a hint in the history and blood tests and examination, etc. So all really useful information, and I just want to add, actually, that older women can get pregnant too. I saw someone in my clinic last week who was 49 when she had her first baby. So there you go. That was quite a surprise and a delight for her at the same time. And then she was plunged into

the menopause when she was breastfeeding her little boy when he was six months. old. So we just need to think about contraception when we're older as well. Tired and brain fog with sleep deprived. So that's been really useful, John. Thank you ever so much for your time today. So just before we finish, could you just give three take-home tips for women who might not have perhaps thought about their fertility before, but are concerned that it might be something that they need to address going forwards? Well, obviously, when you're planning a baby, you're Try and get your health as good as you can.

So a healthy weight. Certainly, try and aim for a BMI of 30 or less is proven to be helpful. Don't go crazy, just a sensible weight. Stop smoking, moderate any alcohol and eat a healthy diet. And those are the first things. I think secondly, particularly on the subject we're talking about today, just think about maybe if you've not talked to your mother about it, is there a family history of premature menopause?

Are you at an increased risk? And if there is, then think about talking initially to your GP and potentially get referred in and we can investigate if it's indicated because you don't want to leave it too late. And keep an eye on symptoms, I think. If you find that your periods are becoming irregular and scanty the likelihood is that it's not premature ovarian sufficiency. But if you're still planning to have a family

and your periods are starting to become erratic, then I think it's worth getting checked. It would be what I'd say. Excellent. Really good advice. So thank you ever so much for your time today and look forward to seeing you again soon. Thanks, John.

Thank you. And thank you again for a vitamin Emanuel. For more information about the menopause, please visit our website www.menopausedoctor.com.uk