The Dr Louise Newson Podcast - 074 - HRT Prescriptions in England - Dr Sarah Hillman & Dr Louise Newson

Episode Date: November 17, 2020

In this episode of the Newson Health podcast series, Dr Louise Newson is joined by Dr Sarah Hillman, a GP and clinical lecturer in Primary Care at the University of Warwick. Sarah talks about a piece of research she has recently published that looks at HRT prescriptions in England. The research shows that women in deprived areas are less likely to be prescribed HRT and Sarah talks to Dr Newson about why this matters.  Sarah and Dr Newson also discuss a menopause event at Warwick University and how important engagement is within women’s workplaces.  Dr Sarah Hillman's Three Take Home Tips: Speak to your GP about your menopause, and ask which GP has an interest in women’s health. Have a look online for evidence-based research. including the new Balance app. Make time to think about your body and how to get help through the menopause, it’s hard to always find time, but you need to be well in order to look after others and function at work.   

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsome, a GP and menopause specialist, and I'm also the founder of the Menopause charity. In addition, I run the Newsome Health Menopause and Well-Being Clinic here in Stratford-upon-Avon. So today I have with me, Dr Sarah Hillman, who is a clinical lecturer in primary care at the University of Warwick, And I was introduced to her a few years ago now by Rebecca Lewis, who's one of the doctors, as many of you know, who works with me. And Sarah's got an interesting background. She's interested in women's health and primary care, which essentially means general practice. So I wanted to interview her today to talk about her job, about research, but also about some really interesting research that's just been published.

So welcome, Sarah. Thanks for coming today. Thank you, Louise. So tell me a bit about your background because actually it's very interesting. A lot of people think doctors are people that see patients and make patients better, which hopefully we do. But there's a lot more that goes on in the background. And you didn't start off doing research, did you?

So just tell me how you got your way you're going. Sure. In fact, I didn't even start out in primary care, Louise. I started out because I wanted to be an obstetrician. So I started training in obstetrics and gynaecology. And I did that for quite a long time and I did some quite a lot of research and I was very quickly becoming an academic obstetrician but I realised that that wasn't really where my heart was and that actually surgery wasn't what I really enjoyed.

What I enjoyed most was talking to people and being with people and so I spoke to a few people about retraining as a GP and it seemed to be that the work, the clinical work would suit me but that actually my gynecological background would be something that would be quite useful in primary care, as well as my past experience of research. So I retrained as a GP in the local area, local to you actually, Louise, in Coventry and Warwickshire. And now I'm a salaried GP in Warwickshire, but I also work at the unit of academic primary care at Warwick University. So I have an interest in women's health. So I've done work around PCOS and the doing some work at the moment to do with pelvic injury following birth. But one of the other things

that really interests me is the menopause and HRT. When I was training both as an undergraduate, and interestingly enough, even when I was training in obstetrics and gynecology, very little time was ever paid to the menopause. And so I didn't get too much training at all. And then I turned up in general practice and suddenly it became known that I had a gynecological background. And I ended up with lists and lists of women that wanted to talk to me. And they were women that all had something in common. They were between the ages of about 40 and 55 to 60. They often were working, often in jobs that were, you know, becoming more stressful.

They had children often that were becoming adolescents and they had parents that they were starting to have to look after. But on top of all this, they started to really struggle and they couldn't really work out why they were struggling so much. And it all boils down to the fact that actually they were in the time of their life of the perimenopause and men of menopause. And that they really needed help and they really needed somebody to listen and to see what they could do to help. So that's sort of clinically where my interest lay. In terms of the research, I have a colleague, Sarin Shanti Kumar, who works in public health at the university alongside me.

and he does a lot of work looking at the primary care prescribing data. So I said to him, it'd be really interesting to look at HRT prescriptions because my opinion is that there are women that are coming in and they're asking for this medication, but there's an awful lot of women out there who aren't. And maybe we should look at this. And Saran, who's a whiz with numbers and stats, said, well, you know, actually what we could do is we could look at all the prescribing data in England and we could then look at it by the practice deprivation level. Right. And we could work out if people who are in more deprived areas are not getting HRT prescriptions and those in affluent areas are.

So that's what we did. And as I'm sure you won't be surprised to know, and I wasn't surprised to know either, that actually, the difference is quite stark. So what is the difference? What did you find? What we found was that overall, the prescribing rates of HRT in the practices that are the most deprived are 29% lower than those in the most affluent practices.

That's a huge difference, isn't it? 29% lower. Yeah, it is. And we don't know whether that's because the doctors are prescribing less or the women are less insistent. Absolutely. So I suspect that there is both patient and clinician factors here. There's lots of problems with access to care in deprived areas.

Of course, we're talking about people maybe not even getting as far as the GP's door. But I also suspect that when they get there, there is other things that mean that they don't end up with that HRT prescription and they're not walking out the door with it. And it's interesting, isn't it? So, you know, you've come from a gynecological bar. background. I've come from a hospital medicine background and then I went into general practice. And neither of us had any menopause training. And certainly even in my general practice, I didn't have any menopause training. And now my whole life is taken up with the menopause. But I think back and reflect and I must have missed the diagnosis of the menopause in hundreds, if not

thousands of women. Because when women have come to me with low mood, with anxiety, with joint pains, muscle aches with migraines. I never once thought about their hormones. I never once asked them about their periods. And a lot of these women, like you say, are the women in their 40s, 50s and sometimes younger, because no one told me that it was associated. I didn't realize migraines got worse

during the perimenopause and menopause. I didn't know that people with fibromyalgia actually probably is related to their hormones and certainly the psychological impact. Yeah. So you can see quite easily, can you, why it's being missed. Because the women are coming, are they, and saying, I'm menopausal or I'm perimenopausal,

they're coming with real symptoms and real issues that are affecting their lives. This is it. And actually, when I first started training, I was doing all sorts of inflammatory blood tests on these people. And of course, the other thing is, I had no idea quite how much this time impacted on mental health. Yes. You know, it's really common for women to sit in front of me and just say, look, everything's just falling apart. My relationship's falling apart. My life's falling apart.

And actually, I don't know what's happening. Maybe I'm depressed. Do you think I am, doctor? Yes. And it's very hard because I'm sure you were the same. I had a lot of education as an undergraduate and also a postgraduate about psychiatry and mental health, which is vitally important.

So actually I pride myself. I'm very good at diagnosing clinical depression. But somehow a lot of these women, it doesn't quite fit because they sit there and say, do you know what, doctor, I know I'm not depressed, but I have waking in the night. I have low mood, low energy, not interested in things. So they tick all the boxes for clinical depression.

But I look at these women and I think they're motivated. They've got eye contact. They want to get better. They've got insight. All these things that a lot of people with clinical depression don't have. But I couldn't, for many years, put them in the right box almost. And medicine, we try and fit people in a box to make a diagnosis almost. And once you realize how important the hormones, estrogen,

and also testosterone often and women's brains are. It makes so much sense, but no one really has told us. And so no one really tells the women either, do they? No, no. And I think that the other thing is that there's a big problem with doctors being scared to prescribe sometimes. And of course we know that that comes around because of the big trials that were done in the early millennia. But one of the things we tried to do to try and see, well, a couple of things we tried to do with the data that we had. And the first was that we tried to factor in cardiovascular risk to see if that was changing

the prescriptions, as we know, if women are within 10 years and the menopause are under the age of 60, actually, the HRT doesn't increase their cardiovascular risk. And in fact, if it's estrogen alone, it can actually improve their cardiovascular risk. But we thought we'd factor it in just to see if it made a difference. And that reduced the impact. So people in the more deprived areas were 18% less likely than those in affluent when you start to factor in cardiovascular risk. But the other thing we did that we thought was important was we looked at the different types of HRT. So we looked at oral estrogens compared with transdermal. So that's over the skin. And the reason we thought that was important was that actually because when you prescribe

HRT over the skin, it eliminates the increased risk of having a clot on your leg or your lung. and that actually if some of these women in more deprived areas were at more risk of these things, then actually they should be prescribed therefore more HRT through the skin. But in fact, we found the opposite, that if you were in a more deprived practice, you were more likely to have the oral HRT, the type that you take through the mouth. So I don't quite know why there is that difference either, but we need to find out. Yeah, and I think traditionally people have usually prescribed oral. oal estrogen because that was all we had for a long time and people think about tablet HLT that

they do with tablet contraceptive but then things have moved on and certainly like you say the big study the WHI study from 2002 was using tablet estrogen and using synthetic progestogens and now things have moved on so the estrogen through the skin and the natural progesterone doesn't have the same risks and has a lot more benefits so certainly in my practice I never give oral estrogen unless there's reason. So very few women. And I'm sure that would probably be down to the education for the doctors because women don't always know, but certainly I try and do a lot of work giving free resources through my website. So actually now a lot of people come to my clinic and they say, oh, I've been thinking about HRT and I've read about or I've listened to you're talking about

the patch and gel, but I think I'd prefer the gel or I think I'd prefer. So they've already got it, But actually getting the information out to women is really difficult. And certainly the charity that we've set up, the menopause charity, is really hopefully going to help disadvantaged women as well. Because it's getting information out to them. So they can come and say to their doctor, I've got these symptoms, but I think they're related to my hormones.

But it's also marrying up the education for the healthcare profession, isn't it? So that doctor can quite readily say, have your periods change or have they stopped? Oh, I see you've had a hysterectomy. It's probably your hormones. Let's try HRT first because it don't think you're depressed. And also, women from low socioeconomic classes actually often have a higher cardiovascular risk, don't they? So they've got more to benefit from taking HRT. And they've got a higher risk of type 2 diabetes and sometimes obesity as well. Yeah, and osteoporosis. So the benefits from them receiving HRT, are actually higher than women from higher socioeconomic groups who are more likely to get HRT. So that doesn't seem right, does it?

No, doesn't. And I think a lot of doctors, nurses, healthcare professionals, and also women think that HRT is about just helping with symptoms. And a lot of women think, well, I just need to battle through. I'll just get out on the other side and I'll just muddle through my symptoms. But actually it's not about that, is it? it's about this hormone deficiency that occurs. And unless people understand that they've got benefits to their health with taking

HRT, then they're less likely to ask for it, I think. Yeah, no, I'm sure you're right. It's really good the work you're doing, Louise. Oh, thank you. There's a lot more to be done. Did you look at ethnic minorities at all in your research? We couldn't, unfortunately, Louise. This wasn't individual patient data, so we were just looking at trends.

Yeah, but that's exactly what needs to be done as well, isn't it? We need to look what's happening here. And I think that there again, I'm sure we'd find some big differences, not just in women accessing HRT, but also how they present to their doctor. So I think there's quite a bit of evidence out there about women from different ethnic minority backgrounds. And the fact that they probably won't go and sit in front of a doctor and say, actually, I'm getting hot sweats. Yes.

And therefore, they're less likely to be diagnosed as having problems with the menopause if they start complaining that they've got pain in all their joints. Yes, definitely. And I did a podcast a while ago now about ethnic minorities. And a lot of Asian women actually just talk about down there. And they don't even talk about, so it could be a period problem, or it could be a discharge problem, or it could be some dryness or soreness, but it's just down there.

They wouldn't even have a word for it. And then a lot of them will talk about having total body pain. and then they're misdiagnosed because no one puts the pieces together. And then, you know, they don't have any information. We had some of my videos translated by a fantastic GP into Punjabi. And people really engaged and listened. And it's great listening to them being done. But actually, every so often she'll say a word such as ovary or hysterexomy or menopause in English.

And I said to Ritika, after, well, do you not, no, we don't have words for them. So if you don't even have a word, how are you going to know what it is? It's really difficult, isn't it? And I think wherever you look, women are neglected. And I did a lot of work. You're probably know West Midlands Police. And we did some research, and we found that 78% of women had experienced symptoms of the menopause, but they didn't know they were related to the menopause until they were given information.

So these were symptoms mainly such as anxiety, mood problems, fatigue. they had no idea. And a lot of these women, as you know, give up work or have time off work because of their menopause, but they don't realise. So they're often being signed off for depression or anxiety when they haven't got it at all. So when I read about your research, I made me think about these women in the police because I think this is happening a lot. But if you don't understand what's happening to your own body, how are you going to access the right advice and the right treatment? Yeah, absolutely. So you would think of the women in the most deprived areas of this country, they are probably caring for lots of

different people in their family, they're often working one, maybe two jobs. And if they can't function, then suddenly we've got a really big problem on our hands as a society, haven't we? Absolutely. Absolutely. And it has, you know, it has such an effect, not just on the individual, like you say, it's all their surrounding people with them. And, you know, I had symptoms for a few months and I hated my husband. My children were just an annoyance. Everything was awful and overwhelming and I couldn't concentrate. I couldn't work well.

I would have given up my job if I hadn't got the right help. And I often think back, gosh, if I was a single mom with five children, if I had other issues, or like you say, I was a carer for someone, how would I work? I don't know how I would do it. And one of my patients actually works for the Samaritans, and she said, over the last 10 years I've worked for the Samaritans, and it's only now I've realized how many of these women are menopausal, because I didn't think, didn't know. And so these women aren't getting the right help. And there's been so much poor publicity, hasn't there, about HRT.

And people are scared, don't they, from taking it? Yeah, absolutely. And I think also, as you were saying, doctors are scared to prescribe. it because we sadly, as we've already said, not been given information, but more recently we have been given information from the MHRA, which has been based on one study, which was a review of old studies, which wasn't even looking at the newer types of HRT and the benefits. It was all about the breast cancer risk, which isn't there for many types of HRT, and if it is there, it's very low and it's offset by benefits. So again, this hasn't helped, I think, has it?

doctors are genuinely, and I completely understand, scared, and they don't know about all the benefits and how safe it is, like you say, even just giving the gel, a gel, or patch. So at the Warrant University, you very kindly invited me, you did an event, didn't you, last week, about talking about menopause. So tell me a bit about that, because that, again, was some great work that you did. Yeah, so the medical school is part of an Athenae-Swan initiative, and that's looking at women's careers and advancement of women's careers. And as part of that, we have a menopause task force. Because as you've described, Louise, so many women's careers can falter at the time of the

menopause. So it's really important to acknowledge that it's a problem. So as part of the menopause task force, we put on an event last week. And of course, it was meant to be face-to-face, but because of COVID, it was remote. But I was really pleased. We had over 100 people that came online to listen to you and another, a couple of speakers as well, and it was so well received. But what I was so pleased about afterwards was how many people got in touch, not just to say thank you, but that story resonates with me.

I think maybe HRT would be something that I should go and ask my GP for. And it wasn't just the sort of professors of the medical school getting in touch. It was the estate staff. It was the cleaners, you know? And that's where we need to make the impact. So that was an event. that we did and then we'll continue to do work through the task force. My next job is to try and roll some of this work out to the NHS because I know you've spoken about the police force, but there's a big piece of work done by the BMA actually. It did a huge survey of doctors and asked them about how they were getting on during the time of the menopause and the results were just striking, weren't they? I mean, we're losing a huge amount of our workforce during this time and we can't

afford to. You know, if doctors themselves aren't diagnosing the menopause, aren't getting treatment for the menopause, then we are in trouble. And I certainly speak to a lot of women that work in the NHS, a lot of nurses, midwives, allied health professionals that really struggle during this time. And actually, we need them to keep going. Absolutely. Yeah, totally right. And I mean, in this study, 90% of the doctors, there were 2000 in the study, about there, 90% had had symptoms affecting them at work. But it was something like 38, or it was around a third of the GPs had considered giving up or changing their working pattern, but didn't actually know how to. And actually, you know, if women receive the right help, they shouldn't have to

reduce their working hours. You know, I already said I would have been very close to giving up my work, but actually, I've never worked as hard as I do now, and I can only do it because I take HRT. And it's completely wrong that people should just think, well, I just need to reduce my hours. I just need to not work. And I read the other day that a third of the nursing staff are going to leave in the next five years in the NHS. And we need nurses. We need healthcare assistance. We need people working the NHS.

The NHS is a huge employer. And a couple of years ago, I was at a task force meeting with Dame Sally Davis, who was then the chief medical officer. And she said it's a real priority. We have to help women in the NHS. but sadly nothing's really been addressed. And I just hope some of these conversations will allow people to really think

because we're losing really good stuff, but also there's billions of pounds a year spent on osteoprotic hip fractures, on cardiovascular disease, on mental health, on migraine management, on all this that's related to the menopause, which can be reduced quite easily by HRT, which is dirt cheap.

So we need to, just change, but it's a massive task, isn't it? It's a huge thing. Someone said to me, who is quite high up in the NHS I'm doing some work with, said to me, Louise, what you're trying to do is change people that don't know they need to be changed. And I think, oh, that's so true. Because actually, I've always been interested in the menopause, but a few years ago, I didn't understand what a big problem it was. I really was concentrating on more of the flushes and sweats. But because I've learned so much and I've seen so many women, women and heard so many awful stories, I think, gosh, the more it's spoken about, and like you say,

even from the event last week, people are coming up and saying, gosh, that's me. And that happens a lot. Yeah. But once people realise that, that's the time they need to get help, isn't it? Yeah, yeah. I suppose it's one event at a time, one podcast at a time, you know. Yes, and I think, you know, women are great at helping each other, aren't they? Absolutely. And certainly the work I'm doing, there's some amazing people that are behind what I'm doing, which is fantastic. And it's also, I'm not a feminist, but it's very important that women have a voice. And for those you that haven't heard it, Sarah, you've done the most amazing TED talk, haven't you, about women in medicine?

And it was very inspirational. I don't know if you want to just for a couple of minutes, just mention that. Oh, thank you, Louise. Yeah, so actually, well, the title was, I am a medical feminist. And I, like you, Louise, never used to describe myself as a feminist, but I couldn't find another word that actually fit what I wanted to say. So, yeah, I did a TED talk, and it was talking about women in the NHS, and it was talking about women as doctors and their history, really.

But then went on to talk about the medical inequalities that we have, because historically, of course, a lot of research from a cellular level up to a human level has all been focused on the average Caucasian man. And therefore, there's an awful lot that we don't know about the rest of the population. So we make mistakes because we carry on practicing medicine the way that we always did, the way we always have. And I suppose it's looking also at areas such as the menopause that are sort of Cinderella services, if you like, the places where the work hasn't been done because nobody was really that interested.

And one of the reasons that nobody was really that interested is women never used to, none of us used to live that long. Absolutely. And none of us used to work that long. And therefore, actually, suddenly it's become a real problem because over the age of 50 women are working and living for a significant amount of their lives. So I suppose it was just about rethinking medicine and making sure that we address our own. sometimes unconscious, sometimes conscious biases, and that every time we prescribe something or, you know, think about a piece of research, ask ourselves, are we doing the best for the people we're trying to help here? And do we know enough about the thing we're prescribing or what we're

trying to research and making sure that women are sort of equally addressed in all those things, really? And it's so important. And it's certainly when I was at medical school, it was always a 70-kilogram man. That was always a standard. And actually, most men have weighed far more than 70 kilograms, but actually there was nothing about women. And we know women present with different diseases. We have a lot more autoimmune diseases, such as thyroid disorders, diabetes, than men. But none of the research is done. And the way our immune system works, for example, especially when we think about COVID, is very different for women than men. But there's seven times more studies done in men than women looking at COVID.

And when I was talking to some of the researchers, I'm doing some work with it, Liverpool University, they were really horrified with seven times. And I was actually said to them, I thought it would be more like 70 times. I think that's not bad. And they said, but this is awful. I said, but this happens. And women's health has been a Cinderella specialty for a long time. And menopause has just been, people have been neglected.

And I think a lot of people portray the men. menopause is an older person's condition that's not an illness, it's not a disease, so why do we need to bother? It's a natural process. But as you know, there's lots of young women who have menopause and many of my patients have had cancer. So they've been forced into the menopause as a result of their chemotherapy or radiotherapy or surgery, and they're not being addressed either. So it's a huge problem, but it's not going away because women are here. We're here to stay. So it needs addressing and and I think you know the study that you've got in it's in the British Journal of General Practice isn't it yeah I really hope people will just look at it and think

what can we do to help address this inequality because it shouldn't be there at all should it no no it should in fact it should probably be like we said the people in the poorest areas have got the most to gain it should probably be the opposite absolutely so wouldn't it be great if you had we did another podcast in a few years time and it had changed but bringing it out to the agenda and letting people know that this research is there, that we can't argue with research, you know, it's amazing that you've done this work and it's brilliant. So thank you for sharing it today. Oh, thank you very much for asking me, Louise. That's okay. Before we go, I always do three take-home tips. And I'm just thinking about women who have listened to this,

whatever socioeconomic background they're from, and think actually that might be me. They've had that moment, like some of these people you say, who listen to, our talks last week and their GP's offering them antidepressants or not talking about the menopause. What three tips would you say for these women to try and receive the right help for them? So I suppose my first tip would be go to your GP if they don't listen, ask who's got an interest in women's health. So there'll normally be somebody in the practice who does more women's health than others. I think to explore the menopause online to try and look at some of the the wildly available, educational things that are available.

And of course, there's your app out. Isn't there, Louise, the balance app? So have a little look at that. Yeah. And then what would my third tip be? I think it would be that actually a lot of women in this time find themselves very sandwiched. And that actually they don't give themselves the time or the space to realize what's going on. You've got to give yourself the time and the space to realize, address the problem.

so that you can stay well. Because if you don't stay well, then actually there's a whole lot to lose. So actually, you must give yourself the opportunity to address how you're feeling and find someone who can help. That's brilliant advice. And I certainly know as I've got older, no one else really looks after ourselves.

It has to be us as individuals. And we've got to seek the right help, the right advice, the right treatment. And if we don't get it in the first place, we keep trying. and there are people out there help. There's lots of really, really good, motivated, educated healthcare professionals. And if they don't know the answer, they should be able to signpost you to the right person. So no one should be suffering alone.

And watch this space. Let's see what happens. But thanks ever so much, Sarah, for joining me. Thank you, Louise. For more information about the perimenopause and menopause, you can go to my website, menopausedoctor.com. or you can download our free app called Balance available through the App Store and Google Play.