The Dr Louise Newson Podcast - 084 - Menopause and Health - Dr Annice Mukherjee & Dr Louise Newson

Episode Date: February 1, 2021

Dr Annice Mukherjee is a U.K. hormone specialist with almost 3 decades of experience in hospital medicine. From the early days, her specialism in hormones has always focussed on optimising quality of life in hormone diseases, imbalances and deficiencies. Her knowledge helped her hugely when she went through an early menopause due to a cancer diagnosis ten years ago. Annice is the author of “The Complete Guide to the Menopause” which is hot off the press, having been published by Penguin Random House on 28th January.  In this episode, Dr Newson and Annice discuss how different hormones in the body interact with each other and the importance of using holistic approaches in managing menopause alongside HRT, as well as for those of you who do not take it. She emphasises that in the context of today’s world, lifestyle approaches are all the more important and should be adopted by every women in menopause to optimise wellbeing and long-term health.    Annice’s Three Take Home Tips: Menopause affects every system in the human body and all hormones interact with each other. Improving your overall health can help with hormone balance and your menopause experience. Understanding how to do this is key.  Stress is more prevalent and relentless in today’s world and acknowledging and addressing your stress, even with tiny lifestyle tweaks, downtime and applying selfcare can be transforming, both in terms of menopause symptoms and your overall health.  Exercise, good nutrition, good sleep habits, stress management and some complementary therapies can work as well as, or better than the many of the alternatives to HRT and don’t have any of the down sides or side effects.  You can buy Annice’s book here: https://linktr.ee/annicemd   Find Annice on Instagram:  @the.hormone.doc Facebook: @thehormonedoc

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. Today I'm really excited to have with me, Anise Mukerjee, who is a consultant endocrinologist in Manchester, the city very close to my heart. heart because it's where I trained. So welcome, Anise. Thanks for coming today. And thank you so much for having me. We've got a fantastic platform here and I'm really happy to be part of it. Oh, thank you. So we connected fairly recently because we've got some mutual friends and I'm sure we were both together in the medical school in Manchester just in different years, but we probably did cross each other at

some stage then. So we're both really interested in the menopause and hormones because I'm the GP, obviously, not an endocrinologist. And I'm very interested in all hormones, but especially estrogen and also testosterone and progesterone in women. And as you know, I run a menopause clinic and see a lot of menopause or women. But a lot of women have symptoms related to their menopause, perimenopause. And it's very hard sometimes to know whether it's related to their sex hormones or a lot of women are worried it's their thyroid or their stress or their cortisol and there's so many hormones. So before we start talking about the menopause specifically, could you just sort of simplify a bit about what an endocrinologist is and does and the different

types of hormones we have in our body, if that's okay? Yeah. So, well, yeah, I'm an endocrinologist and I actually specialised in endocrinology 25 years ago. So that was when I first started my specialty training in endocrinology after I'd graduated. It fascinated me because I just find hormones very interesting. We've got hormones circulating all over our body. So it kind of links every bit of the body together. So you've got brain hormones, thyroid hormones. The pancreas produces lots of hormones. And when they don't work, that can cause diabetes, which most people have heard of. But there's really important adrenal stress hormones. And of course, all of our reproductive hormones are hugely important throughout life, you know, from when we go into puberty,

through adult life and then in women as they go into menopause. And all the hormones interlink really, and they interlink with all the other systems in the body. So to train as an endocrinologist, you have to train in something called, you know Louise, but it's called general medicine. So I kind of always had an interest in piecing together the jigsaw of health issues rather than just looking at one bit of the body.

So as I've sort of trained and risen through the ranks, as you have, our healthcare systems have changed and we have lots and lots of specialists so we've got specialists who look after your heart, your lungs, your joints but there's a bit of a problem in that everybody wants to look at every bit of our body separately

and I think as an endocrinology because hormones affect everything it's a nice opportunity to kind of put everything together and I think that's very important to get well-being optimised actually I don't think you can just look at one bit and focus on that

and health issues And I think that's so important, isn't it? Because certainly when I was at medical school and when I'm sure you were at medical school, we were very much taught about diseases about treatments and you do a cardiology session like you say or respiratory or ophthalmology. But actually the body has so many systems that are interlinking and so much of what we do is about disease prevention as well. And there's so much that's interlinked. And I think when you realize the power of hormones, because we have. cells that respond to hormones pretty much everywhere in our body, don't we? Absolutely, absolutely everywhere. Pretty much every cell, I think. I don't know any system that doesn't get impacted by hormones. And a reduced level of one hormone can affect a level of another hormone, can't it, as well?

Because there's so many cycles going on in our bodies. And I'm sure there's some that we don't even understand fully. A lot we don't understand still, I think. Yes, I think we always think we know loads about everything at any one point in time. and then a few years later we find, oh, that theory was wrong or that hypothesis was wrong. So I'm very overwhelmed, actually. And I learn a lot from my patients. My patients tell me about their symptoms.

And sometimes, you know, there isn't a simple quick fix answer, but it's, you know, trying to unravel everything and work out what the cause of the symptoms are. And I have an interest in, a particular interest in fatigue, which I've had for many years alongside my endocrinology. And fatigue symptoms do tend to come from every system in the body as well. But, yeah, really important. And I think the other issue about menopause and learning about it in medical school is that, you know, it's perceived as something that's completely normal. And I think there is still that sort of dogma that, oh, well, menopause is normal. But actually, we're meant to have it. You know, all women go through it if they reach the age where their ovaries are not going to work properly. But today, menopause is different. It's not the same as it was even 50 years ago because we're living so much longer. So health after menopause is really important. And, you know, there are so many different factors today

that women have to deal with going through menopause. They're busier than ever. They're working. Whereas 50 years ago, few women worked. So I think there's so many, you know, important factors that menopause is impacting on for women that are being taken into consideration yet in modern healthcare. I think it's really important, isn't it? Because menopause isn't a disease.

it's a bit like obesity isn't a disease, but it can lead to diseases if it's not managed properly. And with the menopause, as a lot of you know, it's related to having low hormone levels, often because the ovaries have stopped working or sometimes they've been removed in an operation or damaged by certain drugs. And a lot of women are perimenopausal or before the menopause, so when hormones start to reduce. And once they've gone, we can't replace them. but it's looking at what systems they're affecting us and how we can improve, because even if we're not getting symptoms, we've still got the effects of these low hormones in our body. And like you say, we're living for a lot longer during our menopause.

So it's not just about symptoms, is it, that we need to address when we're thinking about how to best manage our menopause? No, and, you know, there are themes in terms of well-being and long-term health in menopause. because there are things like tiredness, weight gain, that tend to link with menopause, less physical activity, that sort of links with weight gain and fatigue, and all those factors can negatively impact on your wellbeing and your long-term health as well. So you get one bit, and then that leads to it.

And I think it's really important for symptoms to be managed. It is really important, you know, and people do get very different symptom experiences. We are all different. But also, you know, you can have treatment. Yeah, and symptoms can change even within a person, can't they? So sometimes people start having hot flushes and sweats and then later on they might find they have sleep disturbance or anxiety

and then they might have urinary symptoms or vaginal dryness. So it's often a spectrum of symptoms that affects all of us in different way. in different severity as well. So some people don't really have many symptoms at all. Others have very extreme symptoms. And some people have symptoms that they don't even acknowledge or realize they're related to their changing hormone levels. So it can be quite confusing, I think, for women.

And often if the average age, as you know, the menopause is 51 in the UK. And that's often a time when thyroid can start becoming underactive as well. So I see a lot of women in my clinic who have been told they've got borderline underactive thyroid and they've been putting all their symptoms related to their thyroid and actually some of it will be related to their perimenopause as well. Yes, obviously as an endocrinologist and I have an interest in thyroid disease, I see a lot of women who come into my clinics who have both. And my observation, and it's an observation over a long period of time, is that actually you can

have a thyroid problem on its own and, you know, it's managed and then it settles. and you can have menopause on its own, and some women can be, you know, not too bad in terms of symptoms. If you put the two together, that I find causes much, much worse symptoms than you would expect. I mean, a lot of endocrinologists would just say, well, the thyroid borderline, let's leave it alone. But actually, if the thyroid is not working properly, that really can worsen menopause symptoms. And so I would tend to treat thyroid problems earlier in somebody who's, going through menopause than somebody who maybe has no symptoms and is well and it's been

picked up accidentally. Which is very interesting, isn't it? And do you tend to monitor T4 and T3 levels when you're looking at hypothyroidism or thyroid disorders in women? Good question. Well, that is a difficult issue. The reason it's difficult is because our guidance in the UK from our national bodies is quite different from Europe and the United States. So in the UK, it's not recommended, you know, as a standard practice to check T3 in people who have sort of a straightforward underactive thyroid that's being treated. But there are situations when it's helpful to, you know, understand what the T3 level is. And generally the situations, well, there's a couple of situations. One is when somebody's treated with thyroxin, levo-thyroxin, which is the standard replacement

therapy and they have got a lot of ongoing symptoms of their health consistent with thyroid, in which case we wonder whether they're converting their hormones properly because T3's a more potent hormone. So if you've got the Leibothoroxin in your system, you should be able to convert that to T3, but some people don't convert very well. So it's a bit of a complicated one, but in that situation it's helpful. And then in certain other situations where you've got odd results like one of the hormones is abnormal, the other looks normal, then it's helpful to have the T3. Because there are, I mean, there certainly are a minority, I'm sure, of women who respond well to T3 and not to T4, and I have some patients who buy it privately because they can't get it.

And so it's less common, but it still can be a problem, can't it, for some women. So if we think about the menopause, obviously for a lot of women replacing hormones with taking the right dose and type of HRT can be very preferable and the majority of women the benefits that way the risks. But there are still some women who choose not to take HRT or who can't take it for medical reasons. So there are alternatives to HRT which I'd like to talk about, but also even those of us that take HRT, it's not just about hormones that is going to make us have a healthy menopause. There's no point me taking HRT and smoking 20 a day, drinking two bottles of wine and eating chips from our supper. So let's talk first, if it's okay with you, about some of the alternatives to

HRT, and then we'll talk a bit about what else we should be doing, whether we take HRT or not for our house. Yeah. So there is some, usually it's women who have had a hormone sensitive cancer, often breast cancer in the past, who certainly wouldn't take HRT as first line. And there are some prescribable medications, aren't there? What would you recommend for people to consider? There are prescribed of medications, and I think the problem with just sort of listing them is that, as I said before, every single one of us is different. So the circumstances are different. And I think we all talk about the fact that, you know, menopause is not depression. And of course, we've just gone through a cancer diagnosis. You can feel really low. You can feel really anxious, especially if you've been put into menopause by the treatment. And so there are some treatments that are actually antidepressants that are used to help with hot flushes. sleep and mood that have got some research evidence for women going through, say, for example, a cancer diagnosis. And I think it's important to say that they're options. They're not the only option. And we're not giving it just because they're depressed, because it's not about

depression. It's about having an overwhelming set of health issues and problems and that you need to get short term some quick solutions to help you get through that. But I'm very holistic and I'm not actually a big prescriber in general. I'll always try and use holistic approaches if at all possible. So there's lots, and you talked about lifestyle measures, lifestyle measures can be really important, longer term. But when you're sort of in the midst of perhaps a cancer diagnosis, or if you've had a sudden menopause and you can't have HRT,

and there are very few situations when you can't have HRT, but there are situations when it's advised not to have it. I think there are a number of medical, I have to say that venal vaccine is one that I do sometimes prescribe, which is an antidepressant. To be honest, I don't tend to use any or many of the other antidepressants. And I will then tailor the treatment to the individuals. So with regard to vaginal symptoms, obviously there are a lot of vaginal treatments that we can use.

And actually, there are some hormone-related vaginal treatments that can be safe in women who are going through breast cancer. other than that, I'm not a big prescriber. I'll often recommend natural treatments because there's lots of natural treatments that many women gain benefit from, actually. I think that's important for people to know because certainly in the nice guidelines,

they do list prescribable treatments, but a lot of them have side effects. And a lot of people find the side effects are worse than the symptoms they're trying to treat. And so if a healthcare professional is talking about prescribing a non-hormonal treatment, then I think we need to be questioning what they're being taken for and to be monitored closely because I see a lot of women who have been given higher and higher strengths of a medication,

sometimes two, three different medications, and they're really flawed with the side effects, but they weren't warned or they weren't, no one explained to them the reasons for taking them. So like you say quite rightly, the antidepressants can sometimes help with hot flushes, but they can also sometimes cause night sweats. They can cause weight gain. And because everyone's an individual, it's very important that women are monitored closely if they're on any sort of prescribable medication, especially for this indication. So what about the things? Because there's a plethora of different supplements that can be bought. The menopause shelf in the chemist seems to get bigger and bigger by the day. And certainly on

the internet, there's so much. So where would people look or what would you suggest for them to do? Well, there are loads and loads of different supplements. I mean, I tend to to suggest as a simple first option would be a plant-based phytoestrogen like red clover, which is a safe option to try in somebody who doesn't want to take HRT or who doesn't feel in a position to take it. There are loads and loads of others, but, you know, some of them, like, for example, St. John's Wart, can be quite dangerous in that it can interact with other proportions. And I think the key is to make sure that you read the label, that you make sure that there are no contraindications, sort of reasons why you shouldn't take that. And they all have,

there's lots and lots of different supplements, and they all sort of say they've got different benefits. Some are good at helping with hot flushes, some with mood, various different symptoms. So I think if you find a supplement you like the look of, the key is to make sure it's safe. And then if you try it and it works for you, then that's fine. We don't know how most of these things, we don't know how they work. What's about people that have had breast cancer? Would you say that they would be safe to have red clover or something with a phytoeastergen in it? I think if the symptoms and the quality of life of that woman is poor, I think it's reasonable to try red clover in the first instance because it doesn't affect

blood-eastern levels. So, you know, it's an option to try. It's not actually recommended as a treatment, you know, if somebody's managing well with lifestyle measures. But as you and I know, some women with breast cancer are really struggling with menopausal symptoms. And so it's the safest option that helps to manage those symptoms. So yes, I would sometimes recommend red clover and breast cancer, as we will sometimes give estrogen replacement in women who've had breast cancer. And we try and use the safest possible option that balances quality of life with risks. But if quality of life is severely affected, that's a fine balance. And as you No, Louise, decisions should be made by specialists in menopause, not outside of that setting.

Yeah, absolutely. And it's certainly, this is where individualisation of care is really important and discussing any potential risks with any potential benefits with each patient. But there are some lifestyle measures that can make a big difference, aren't there? So even simple things like avoiding spicy foods or caffeine or alcohol can improve the vasomotor symptoms, as well as sleep and energy and everything else as well, can't they? Absolutely. Just things like wearing, you know, non-synthetic clothing in layers and don't wear the turtlenecks so that, you know, if you start to feel your overheating, you can cool down quickly. In office, as we know, many women are working and going through menopause.

So, I mean, obviously, if you've got an office that has climate control, great. But if not, desk fans, being able to have your exit route to have your flush easily accessible, little things like that can make a difference because if you suddenly get very, very hot and you've got the sweat dripping down your forehead moment, it increases your stress levels. You've lost control, you feel awful. So trying to prevent those. And yes, as you say, avoiding hot drinks, spicy food are all quite important. Last minute deadlines, because if you're stressed and flustered, you tend to be more susceptible to flushing.

There are lots of small measures, and they can actually make a big difference. And those sorts of measures in the workplace can be helpful. Yeah. And certainly one of the big things that people complain to me about and notice even as early as in the perimenopause is poor sleep. And we know that women and men who don't sleep well have an increased risk of heart disease, diabetes, depression, even some cancers it's been shown. So it's really important to get our sleep right, isn't it?

And I know you share some very simple tips, don't you, with your patients about sleep. I do. I do. And yes, unfortunately, the menopause sleep link is a very problematic one for many women. And the problem again, well, part of the problem is our modern world because we have so many influences like, you know, blue light on devices that we look at night and stress, which many of us have far more than stress was around 50 years ago, chronic stress. So many different factors that affect our thought. And we live a 24-7 lifestyles. So we don't tend to have nice simple sleep routines. Light is always there and we socialise more in the evenings. I think there's lots of changes. So actually addressing some of those factors, even if you're addressing them some of the time,

not all of this, because nobody's perfect. We can't all go to bed at nine o'clock and switch our devices off at six o'clock. It's just more realistic. So it's about sort of splicing and adding helpful measures into your life as well as you can. It's a bit like diet and moderating alcohol. Nobody's perfect, but you can make small changes. And if you make a number of them, that can make a really big difference. And the other thing about sleep, you know, because I'm very passionate about sleep, I'm an insomnia at myself, is that when you make all the right changes, you don't feel better straight away. You know, you can do everything right. And then two weeks later, you're thinking, I am still waking up. And it's easy then to stop all those health.

things thinking they didn't work, when actually you have to persevere with those measures. So, yeah, little tips you're going to ask me, I think, what tips do I suggest? So whatever time you get with your device, the earlier the better, even if it's 15 minutes earlier than you would normally, you know, have a relaxing environment as you go to bed if you can. So I was compare it with the spa. If any of us go to a spa and have a spa treatment, you feel really relaxed. There's background music, the lights are dimmed. It's very relaxing and sometimes, you know, nice smells from candles or aromatherapy oils.

And those are very relaxing and that helps with our adrenal stress. So recreating that spa environment can be really helpful. If you can, obviously if you've got teenage kids screaming in the background, it's not easy. You know, doing those sorts of things can be really helpful. Having a warm shower can help because then you cool down after it and that can help with sleep. and trying to have a regular routine, trying not to go to bed at wildly different times each night, it's helpful because it helps with our biarrhythms, our circadian rhythms to do that. There's lots of different tips that can help.

And there's obviously different tips in relation to night sweats as well, having cotton bed sheets that you can throw off, keeping cold, yeah, things like that. There's some essential oils. I mean, I always use a lavender spray on my pillow before I go to sleep. And whether it is a placebo effect or not, I don't mind. because without it, I know I can't sleep. But it's safe and it's easy, isn't it? A lot of complementary treatments work via relaxation,

and that is affecting your adrenal stress response. It's calming your adrenals down. It's a different way from exercising and it completely... It's like having a massage. You'll easily fall asleep. Well, I will easily fall asleep. And it's not placebo. It's because we're allowing our adrenals to get properly rested in preparation.

Which is so important. And there's quite a few supplements out there called adrenal support. or their varying types, which a lot of women buy, but I'm not aware, I don't know if you are of any evidence that these actually make any difference. And some of them I don't even know what they contain. So I presume you wouldn't recommend any of those to try and relax our adrenals.

No, I don't tend to recommend them because the thing is that some of them actually at worst contain steroids and that's not going to be for weight management, for cancer risk, for vascular risk, and have had patients who've gone on them. and then when they've tried to stop, they've got very ill because their adrenals have stopped working. So that's really important, isn't it? And you don't know what you're getting because they're not well-labeled.

So most won't be that bad, but it's like a lottery or Russian roulette, you don't know. I think some of them help people because they have certain ingredients. So there's a lot of B vitamins that are helpful for adrenal health. And from my own experience, I tend to recommend vitamin and mineral supplements in menopause just because of things like fatigue, energy, sleep, well-being, hair, nails, skin, you name it. If you're deficient in a whole number of different vitamins and minerals, you're more likely to have problems in those areas.

And if you take a bog standard general vitamin and mineral supplement, that can help with all of those things, and it will help some of those B vitamins in particular help with the adrenals. I tend to recommend that. The other one, which I still on the fence about, is something called Ashwaganda, which is an ancient IEVADIC treatment that it is in a lot of the adrenal support type supplements. So it's been used for a long time to support adrenal health. And I don't think it's really well understood how it works.

It's not prescribable. It's you just buy it. But it seems to be safe. And some people seem to go and benefit. Others don't. So there are a few things that are reasonable to try. But the evidence, as you know, is not really there for most. Yeah.

And I think you have to be really careful. Lots of people think because it's, It's sold as a food supplement and it's maybe sometimes plant-based, therefore it's natural and it's safe. And that's not always the case. So you have to be really careful. And I think if any of you are not sure, then you should check with your doctor or your pharmacist to see whether you should be taking these. And I think when you look at, like you say, complementary treatments, then there is a lot that can be done in a very simple way. So sometimes just having time out for a massage or just a cup of tea. can be really helpful, you know, sit in a quieted room.

I, as some of you know, do yoga and I usually meditate at the end of my practice. And for me, that's a really good way of emptying my brain and trying to just get ready from the next stage of whatever craziness I'm doing in my life because it's so easy to just go from one thing to an X to an X and our stress levels, like you say, just escalate. And we all need to reset our bodies. And this is really important, not just for day-to-day living, but for future as well, because as you know, with stress,

there can be this low-grade inflammation that carries on, increased risk of all sorts of diseases. So a lot of what we're trying to do with managing the minimumables properly is by preventing disease, isn't it? And there's so many different ways of disease prevention. Absolutely. Prevention is better than cure, I would say. Absolutely.

And I do believe, again, our modern world has an awful lot more chronic stress than 50 years ago. So it is really, really important. And actually, things like meditation and yoga are amazing, but not everybody is able to do that. You can do sort of what's coined as everyday mindfulness very easily just by sitting down and stopping what you're doing and noticing things that are around you in real time. And then the other thing is exercise, which is, I always say, it's going out for a walk is like, almost like a meditative practice because you're you're going to automatically notice what's going on around you.

So that brings me on to exercises of really important aspect of management of menopause as well, for many reasons. But yet simple walking for 10, 15 minutes can make a big difference in the stress levels. Yeah, which is really important. And I think with any exercise, it's finding an exercise that works for you as an individual that you can do regularly as well. There's nothing worse than forcing people to do a type of exercise that doesn't suit them. And then they feel more of a failure.

And I think to be menopausal, you can often have all these baneing thoughts anyway. So you don't want anything that's going to make you feel bad about yourself. The more that we do that makes us feel better about ourselves has got to be good for the long term and also reduce our stress too. So we've covered a lot, which is really useful. And I'm hoping for a lot of people, it will make them think about some of the supplements they're taking, maybe to empty some of their cupboards with things that they're not taking or shouldn't be taking. to really take a stock about your lifestyle, how important that is, whether you choose to take HRT or not, it's everything else that's really important as well.

So we can really think about giving ourselves the best holistic care in an individualized way for our perimenopause and menopause. So thank you so much for your time. But before we finish, do you mind just giving three simple take-home tips for women who want to think about how to optimize their menopausal health going forwards. Yep, okay. So the first one would be managing stress and not beating yourself up about, as you say, having low self-esteem because you feel like you can't do things.

Do not beat yourself up. Self-care is really important. So managing stress, if you can, don't think, if I can't do something, I'm not good enough. Think I need to look after myself for, my stress and then, you know, I will be better. And that's for everyone around me. The second thing is sleep because there's lots of evidence to show that poor quality of sleep and inadequate sleep causes chronic disease and preventable disease. So focusing on getting decent quality sleep,

there's lots of things you can do and that's really important. And then the other, and it's another lifestyle, I'm afraid it's not to do with drugs, is what you put into your body and what you put out. So try and avoid processed foods, which we've not talked about very much today, and keep your diet as clean as possible with natural foods. And that has to be dovetailed with some movement, however much is more than you're normally doing. It doesn't have to be loads. But even if it's five to ten minutes extra, that would be amazing. And those make a huge difference. Yeah, really important. Very simple, achievable tips as well. So thank you ever so much. Thank you for your time today. Thank you.

My pleasure. Thank you for having me. For more information about the perimenopause and menopause, you can go to my website, menopausedoctor.com.uk. Or you can download our free app called Balance, available through the App Store and Google Play.