The Dr Louise Newson Podcast - 089 - The Benefits of HRT - Professor Isaac Manyonda & Dr Louise Newson

Episode Date: March 8, 2021

Professor Isaac Manyonda is a professor of obstetrics and gynaecology at St George's Hospital in London with a major interest in the menopause. In this very detailed discussion, Prof Isaac and Dr Newson talk about the huge benefits of oestrogen in HRT and how many ways oestrogen can improve future health and prevent disease. They discuss the misinformation and misunderstanding of HRT over the last 20 years and how this has led to so many women being inappropriately denied HRT. Prof Isaac also speaks very eloquently about the perceived risks of HRT and also how oestrogen on its own can lead to a lower future risk of developing breast cancer and also dying from breast cancer. Dr Newson says that the information discussed in this podcast is evidence based and it is essential that all women listen carefully!  Professor Isaac Manyonda's Three Take Home Tips: HRT prevents many of the health problems that women can develop after the menopause and it does so in a very simple, cheap and effective way. In terms of the menopausal symptoms that women often experience, there is no better intervention than HRT. Here is a hormone that is essentially like  'magic bullet' - it really can help improve quality of life.  

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 on this podcast, I'm very honoured and privileged to have with me, Professor Isaacs Mannyanda, who is a professor of obstetrics and gynaecology at St George's Hospital in London. And he has a particular interest in the menopause. And actually, I first met, Isaac, when I was at a British Menopause Society meeting, and I didn't know who he was, and I couldn't even see him because it was in a crowded room.

And he was just talking sense. He was answering a question, and I thought, who is this person? I need to find him. And then I couldn't find you because you left. And so you've been on my radar, and I don't know how, but I've managed to find you again. so I'm delighted. So thanks for joining me today, Isaac. Well, thank you. Thank you for the interesting. So just tell me a bit about your background, if you don't mind, because obviously you're a professor of obstetrics and gynaecology, and I'm not a gynaecologist. You know, I'm a physician.

And it's always quite interesting to me thinking traditionally the menopause has always been thought of as a gynecological specialty, hasn't it? It has. And quite rightly so, because of course, the gynecologist and obstetrician looks after women from a very early stage throughout their reproductive life, but also then looks after them in the post-reproductive phase of their life. And this nowadays is a huge part of women's lives, because of course longevity means that women are living into their late 80s, 90s and so forth, within the menopausal transition. So it is an important part of women's lives. And it is an important part of a gynaecologist's work.

But yet so many women who are menopause will never see a doctor, will never see a healthcare professional. And because for a lot of women, the menopause is a natural process, they feel that they shouldn't matter with nature and shouldn't consider any treatments. So I don't know what you think about that. Well, indeed, it is a natural process in the sense that aging is a natural process, but there are many things that we can do as we age to improve the quality of our lives. There are many preventative interventions that can be undertaken to minimize morbidity and mortality.

So remember, when we offer a lot of people's statings, for example, we are trying to prevent disease. We are trying to improve quality of life. in the same way, when we look at the menopause and we look at the changes that take place and we look at the impact of the menopause on the quality of life of women, it is clear that there are many things we could do and should do to improve that quality of life at that stage in women's lives. So I think it's a mistake to think that, yes, it's a normal physiological process and we must just accept anything and everything that happens. and wrong with it when we know there are things that we can do to make it better. I think that's so important, isn't it? And it's so much more important than it was, say, 100 years ago

when life expectancy of women was not so much. And certainly as a physician, and I'm sure as you as a doctor, it is about disease prevention. We have a very overloaded system healthcare in the UK, but also worldwide. And it's about trying to improve our health. It's not about the age that we die. it's our journey, isn't it? And so our hormones are so important to us. But often, myself included, we don't realise how important they are until they're not there. But the menopause isn't just

about symptoms, is it? Absolutely. I mean, Louis, let's remember this, that up until the menopause, women are largely protected against many diseases that men suffer. Women are protected against cardiovascular disease. They are protected against bone, brittleness, development of brittleness. They are generally speaking healthier than men. They hit the menopause and they catch up very, very quickly. And what has happened in menopause is that their hormones have changed. So in reality, it is this change.

of hormones, that if we can get on top of, we'll go a long way towards changing the quality, not just about symptoms, not just about what flashes and night sweats and so forth, but also, but what actually happens to their bones, to their hearts, to their general well-being, to their risk of diseases such as infections and so forth. And that's so important, isn't it, because I think there's a lot of women out there who feel that they need to just get through their menopause, they need to be brave, be battle through their symptoms, because maybe their symptoms aren't as bad as their mothers were

or their neighbours are or their friends are. And my discussion is always it's not even about symptoms. Whether a woman has symptoms or not, having low hormones is associated with risk of disease, where so many people haven't thought about that, have they? Absolutely. And let me just pick you up on one thing you've just said. You said, many women think, well, let's just battle through the menopause, let's get over it,

which is a complete misconception from the point of view of women, because of course, the menopause doesn't mean just the symptoms of hot flashes and sweats, and the impact is not just to the point where these symptoms appear to subside or women have learned to live with them. the impact of the loss of hormones continues for the rest of their lives. So I'm in complete agreement with you when you say it's not just about these symptoms. It's not just about giving some hormone on a short-term basis to control the immediate symptoms. It's about saying what is the long-term impact of the lack of these hormones on their lives and on disease processes? Yes. And I think that's so true because

In the past, and certainly I've actually had stand-up rounds with some of the doctors I've worked with because they've been taking off HRT from people. They've been saying you can only have it for five years and then you have to come off it. And I've been putting women back on and we've had some quite heated discussions. This is before the nice guidance came out. And my argument also is that if you were diabetic, you wouldn't only take insulin for five years or if you had an underactive thyroid, you wouldn't take thyroxin for five years. So it doesn't make sense, does it, to just take hormones for a few years?

I couldn't agree more. And it's very difficult to understand what the rationale is when people say, oh, only five years. Because even when you look at some of the evidence that people have used for this five year period, it really does not stack up. It does not add up. There's a lot of new and very clear evidence that this business of wanting to stop after five years has no basis in science.

There is a fear of hormone, which is completely unjustified. And can you imagine you have something that you feel very well on. And then at the end of the five years, somebody says, oh, no, you've got to stop. And you say, well, what am I stopping? And they say, well, actually, the risks from carrying on the treatment are very high. You ask them, what are these risks?

And I'm sure in the conversations that you've had and in stand-up arguments and debates you've had, you have not been given any solid evidence to support this concept of stopping at five years. No, you're absolutely right. And there's a couple of things, really. One of the things that I heard recently was that people were saying, well, HLT is very addictive, women really like it. And actually they should stop and they have to wing themselves off. And I thought, how awful it's not a drug.

It's a natural hormone we're being replaced. And actually, that's just like saying, I really like my arm because I can write. And without it, I'd be really quite upset. And I find that shows the misunderstanding, actually, because HRT is not a drug. It's just a replacement. Or it's not even a replacement when it's not. started in the perimenopause, of course, it's just topping up the hormones. It's not replacing anything. Absolutely. And then the other issue is about sort of what are the risks? Because we know

and you know that for the last nearly 20 years, women have been turned away and they're turned away all the time from HRT. We know the minority of women take HRT in the UK but also worldwide, whereas the evidence supports that the majority of women would benefit for their future health from taking HRT. So this means there are millions of women missing out on a natural hormone replacement. So let's just talk through these risks, because this is what scares everyone, isn't it? The risks of breast cancer with HRT. Yeah, let's hit this head on because the biggest risk that women fear or their healthcare professionals sphere is breast cancer. And of course, it's true to say that breast cancer is the commonest cancer

among women in the Western world. That is true. Accounts for about 30% of all cancers. But, you know, the difficulty is we do not look at the risk in its proper perspective. We do not look at the risk as it relates to a woman being allowed or being advised to, take HRT. Now, if you allow me, I'm just going to use a number of figures to try and get my point across, and I hope that I don't confuse anyone listening. But if we take a thousand women aged between 50 and 60 and follow them up over a five-year period. So 1,000 women, five-year period, age 50 to 60, they are otherwise healthy, they're not taking HRT, 23 of those women will develop breast cancer.

And this just illustrates how common this condition is. Now, if we take another thousand women, same age, same time period, and give them HRT in the form of estrogen and progester, strong. Then, instead of having 23 women getting breast cancer, the number does increase to 27. In other words, four additional women as a result of taking estrogen and progesterine. Now, you could say four more women is a huge risk. Another person might say four in a thousand, well, that's a drop in an ocean. I think women should understand these figures so that they can make up their own minds.

Yeah. Now let's go and let's take another thousand women. We have had a hysterectomy. In other words, they don't have a womb. If these women need HRT, we don't need to give them progester. We only need to give them estrogen. So if you follow these women up over five years, then for fewer women get breast cancer. In other words, estrogen, which is the main hormone that we use to treat symptoms and also to prevent things like little bones and so forth, if they are taking just estrogen, they do not have an increase in their risk of breast cancer.

If anything, they have a reduced risk. four fewer women, otherwise 19, not 23 women will get breast cancer over a five-year period. And this finding has been backed up by the 20-year follow-up study from the Women's Health Initiative in the United States, where they have shown that women who are taking estrogen-only hormone replacement therapy have a reduced risk of developing breast cancer. But not only that, they have a reduced risk of dying from breast cancer. In other words, I want to emphasize this, that estrogen does not increase your risk of breast cancer. It may actually reduce it.

Now, if you then try and say, well, okay, you've said four more women if women have combined this region and progestergen, four less women if they have only got it. estrogen alone, what about other risk factors for breast cancer? How do they compare to HRT? And I'll say this, that it's very clear that if a woman is very overweight, she actually has a much bigger risk of developing breast cancer than from taking HRT. If a woman smokes, she has a bigger risk of developing breast cancer than from HRT.

If a woman drinks two units of alcohol per day, four or five more women will develop breast cancer. So alcohol is a bigger risk, I'm sorry to say, but alcohol is a bigger risk than HRT in terms of breast cancer risk. So if you look at the risks in that perspective, you realize that actually the risks that women are so frightened of is really in itself very small, but put into context of other lifestyles, then you realize that it is nowhere near the risks that we think about and the benefits, which I hope we will talk about later on, far outweigh that small risk I've talked. Am I making sense, Lerick?

You make absolute sense, and it's a lot of information maybe for people to take on board, but I think to just hear you say, which is so important, that estrogen on its own is associated with a lower risk of women getting breast cancer, but also a lower risk of dying from breast cancer. And even this maybe, it's still debatable, the increased risk with combination HRT, there's never been a study to show that women are more likely to die if they take, combine HRT, more likely to die from breast cancer

because that has never been shown in any study. And a lot of women die with breast cancer, not from breast cancer. cancer and the commonest cause of death from women who have had breast cancer is heart disease, actually. And thankfully, the prognosis after breast cancer is so much better than it used to be. And women often don't die from their breast cancer. They die from other conditions. So it's been sensationalised out of proportion. And when this study came out that was leaked to the press and everyone was talking about breast cancer, HRT almost equals breast cancer, we've seen that increased incidence of heart disease, especially in America, but even in the UK. But we've also

seen, and I'm sure you have, I certainly see in my clinic women who have really struggled because they haven't had HRT, so they've been drinking more alcohol because their symptoms are so bad, they want to numb their symptoms, they've been putting on weight because the metabolic changes that occur without estrogen, but some of them have been comfort eating because they just feel bad. and they also are not exercising as much because they don't feel like it. Their joints are stiff and sore, their energy is low,

they've got no motivation. So they come and see me and they say, I've always really fit and well until my menopause. And then suddenly I've put on weight. I'm drinking, what, I'm eating more, I'm just not who I.

And so those women, actually, because of their lifestyle, are increasing their risk of breast cancer without realizing it, more than if I even gave them combination HLT, And when they take HRT, often they feel better, so they lose some weight, they don't drink as much alcohol, they're eating better. So their lifestyle modification means that even this slight increase that may or may not be there is offset, isn't it, by their lifestyle?

Absolutely, absolutely. Couldn't agree more. Good, I'm pleased that you agree because I think it's so important for women. And I'm here as a healthcare professional, but I'm also here as a woman who takes HRT. actually my GP wouldn't give me HRT because he thought it was too risky. So I had to go and seek it elsewhere. But actually, I was really struggling with my brain and I thought I was just going to have to give up my work because I couldn't remember doses of anything. I was really struggling. And physically I was struggling I couldn't do yoga. My joints were really stiff. I started to put on weight in the midline, which I'd never done before. And I was thinking what's happening to me?

This is awful. I'm only 45. Didn't even think it was my horse. hormones, but when I did finally realise, I still struggled because this risk, whisk, whisk, and actually, even if I stopped taking HRT, I've been on it now for nearly five years, if I stopped taking it, I might not have any symptoms, but my bones would start to suffer, and I really worry about osteoporosis, more than heart disease, actually. I worry about my bones and I worry about my brain, I worry about dementia. So I have chosen to take it because I want to keep healthy. But it's sad that a lot of women don't have that choice, which isn't right, is it?

Well, Louise, if you think about it this way, you as a physician, as a doctor, had difficulty getting resched you from your GP. Can you imagine how the ordinary woman in the street must fare? and, you know, it's so difficult, so difficult to even contemplate how, because they'll just be dismissed by their healthcare profession. I totally agree. And this is what I see and I hear. And I did make a comment at one, a lecture I gave the Royal College of GPs a while ago to say actually it would be easier sometimes to get methadone or heroin

than it would to get HRT. And everyone sort of laughs in the audience, but I think it's true. You like that. Right. I can see the logic. Yeah. We also know from studies that, you know, women from low socioeconomic classes are less likely to get HRT.

Women from ethnic minorities are less likely to get HRT. There's a language barrier with a lot of people. There's a cultural barrier. There's also a country barrier. I've got some patients from the Middle East. They can't even get it in their country. It's not allowed. It just seems wrong in so many levels.

I have links, a lot of links research work with India, for example. I have a lot of colleagues that I work with out there. And when you imagine the population of India, and for some reason, I think their menopause is a little bit earlier than the 51 years we talk about in here. But virtually hardly do you get women taking a charity. They simply are expected to accept their lot. And what actually often happens in India is that women will have their children quite early.

And once they have a problem, their uterus is up. India has one of the highest rates of hysterectomy in the world. And of course, there is some evidence that if you have your hystectomy, then your menopause could come a bit earlier than if you had your uterus in place. So there is a huge population of women who probably just suffer in silence. Yes. But Louise, we've talked about the risk of breast cancer. That's one risk. What other risks do you come across as being, as people using to dissuade women's living? Well, there's also people will think about clot risk. They think about, even if you Google HLT, it will talk about heart disease risk. But actually, as you know, we use estrogen through the skin and the natural progesterone, and neither of those have a clot risk. So that's easy.

the heart disease risk, when women started, certainly within 10 years of their menopause, the risk of a heart attack reduces. So actually, I don't see there are any risks with HRT for most women. No, I just wanted to tease it out of you because you were saying, let's talk about the risks. And I was going to say, well, look, if most of these risks can be eliminated. And in fact, if you allow me to go back to the breast cancer and combined estrogen progestogen risk, then I'll say actually you can reduce the risk from the estrogen progestogen combination if you give the progestergen in a different way.

The risk I've talked about relates to the progestogen being given by mouth. Yes. But if you give the progestrogen either as the myrina coil or as the bioidentical preparations, you actually do not increase the risk in the same way. Yeah, so this is a body identical progesterone in the UK. It's called eutogestan and it can be used orally or sometimes we recommend it vaginally if people can't tolerate it orally or the marina coil, which contains a synthetic progestogen, but it's such a low dose, isn't it? And it's very local.

Yeah, that's right. So there are certainly ways around. But I think we need to just talk again about the benefits of HRT because this is what a lot of people, even a lot of my colleagues, who are GPs think that HLT is a bit of a lifestyle drug. It's about having nice skin and hair and having a bit more energy or libido, and it's a bit frivolous almost. But it's not. Just remind us of the huge benefits of taking HLT to our health.

Well, I mean, even those things that you mention, things like libido, things like skin, things like air, well, those are part of quality of life. And if you can improve a person's quality of life, that has to be an important intervention. But actually, let's look at the real benefits that you have. Let's look at bones, bone health. The prevention of osteoporosis has to be a massive plus, plus, plus. Because, of course, fractures from osteoporosis are a major drain on the NHS

resources, quite apart from the fact that they kill women. Within a year of having had a fracture from osteoporosis, a third of women are gone. Osteoporosis is a big killer in that way. But it also has a huge impact on the quality of life of women. When you've had a fracture, the recovery from that, even if you have the best surgeon to repair your fracture, the quality of life is very, very compromised. So the positive benefits from bone health are huge. If we look at the issue of dementia, there is very solid accumulating evidence that

HRT can prevent or reduce the risk of Alzheimer's disease. And without confusing people by going into too much detail, Let me just say that the place in the brain where the pathology takes place, the hippocampus, is full of estrogen receptors. And after the menopause, when estrogen goes away, these receptors die a death. Now, you can, by starting estrogen at the right time, maintain the estrogen receptors, maintain the health. of the hippocampus. And there's a lot of research, both in the laboratory and in the clinic, that's beginning to support the idea that you might prevent or reduce the risk of dementia.

And of course, dementia, people will not be aware of this, but dementia is now the communist killer of women in the UK. And it's important to remember this. We look at other benefits now. I have already said that when women hit the menopause, they quickly catch up with men in their risk of cardiovascular disease. And now the evidence is very good that HRT will reduce their risk of cardiovascular disease, provided you take it at the right time, provided you take it early rather than late when the pathology has set in. So really, if we are thinking of being proactive,

we should be thinking that as women approach or enter the menopause, that's the time they should be considering HRT, not 10 years down the line. The horse is bolted by them. That's why it's important. And, you know, there are the general issues about risks of infection. Now, I know that there would be some controversy about whether HRT protects women against infection. but if you look at all of the pandemics of recent years,

there is a well-recognized gender difference in favor of women. In other words, women have a better immune system because of the effects of the hormone estrogen. There is no doubt that the fact that they are protected or appear, look at COVID. Let's look at just what we are in the middle of right now, that the proportion of women who are dying from COVID, the proportion of women who have to go to ICU because of COVID,

is much lower compared to men. And really the only convincing explanation is based to a large extent on the gender differences in terms of hormones. Yes, of course, lifestyle differences may also be important, but there's no doubt that the immune system, based on the differences in their hormones, plays a huge role. Then, of course, more benefits.

There isn't a treatment for menopausal symptoms that is better than giving the hormones themselves. And if we have time, I would like to say, it's not just estrogen, is it? We need also to talk about testosterone. Because at the moment, people think of testosterone, male, estrogen, female. But actually, that's a complete misunderstanding. But let me leave you talk to you to comment. Well, we have talked about this on another podcast, but I am going to invite you back to talk about that again.

There are some great papers I know you're working on, and when they're published, it would be good to talk about those again. But I think, you know, testosterone is very important, absolutely. But my issue is that even estrogen is hard for people to get hold of, and testosterone is even harder because it's not licensed, which is scandalous in my mind. But before we finish, I also wanted to bring up, because you're a gynaecologist, obviously you spend time removing ovaries as well as

wombs from women. And I see hundreds, if not thousands of women in my clinic who have had their ovaries removed and their consultant, not you, I hasten to add, says to them, let's just see how you get on, come back if you get any symptoms. And these are women in their 30s, 40s, sometimes they're 20s who have had their ovaries removed for cysts or other conditions. And they're not given any estrogen replacement and taking their ovaries will take them straight into the menopause. And why does this happen? It doesn't make sense to me. Well, again, you know, it's very difficult, I guess, from my perspective to give an explanation that would make sense. Because I never take off ovaries without a good reason. And if I do,

the impact of removing the ovaries is something that is really top, top, top. of the list in my discussions and considerations with the post-operative care of the woman. Basically, for any woman who is premenopausal, who has her ovaries removed, unless there is, and I can't think of one immediately, unless there is a pressing, pressing, pressing, reason, really she should be given hormone replacement. At least until her anticipated natural menopause for those who are not happy with giving, giving long-term HRT. But by and large, I do not think that removing a woman's ovaries

and not considering the issue of human replacement is acceptable in my book. Well, and it's exactly right, because in the nice guidance, it's very clear that women should. And on my website, we've written a booklet for women about surgical menopause because it's a very harsh, very unnatural menopause. And, you know, again, you wouldn't take out a thyroid gland and not the... give someone replacement thyroxin. So anyone who is listening, who might be having have their ovaries removed or have had them removed, it is always worth questioning why they weren't given.

And sometimes it can be the surgeon didn't realise and the junior doctor didn't write the lady up and then the GP didn't see. But certainly we see a lot of women in my clinic who have had 10 years of being diagnosed with chronic fatigue, fibromyalgia, depression, the current migraines, they've been back and forth to various specialists. And no one realizes that it's all because of their missing hormones. So it's so important, but there's a lot of work that needs to be done. Yeah, absolutely.

This is the thing, isn't it? It's about how much misinformation and or misunderstanding there is out there, even among people that you wouldn't think would have that misunderstanding or that misinformation. That's very sad. And I hope that we will have a chance at another stage to discuss. two issues that immediately come to mind, which to my way we have not had a chance to discuss today. One is the testosterone story. I think that's a first-in-story story that... Absolutely. We'll definitely do that.

And the other issue is the women who have had a triple warming of breast cancer. Yes. And there, Louise, is a huge unmet need. Because a lot of these women suffer hugely for menopausal symptoms. and they are told by their cancer specialist, be grateful that you are alive. But what quality of life do they have? And yet you see, again, there is emerging evidence

that they need not suffer in the way that they do. They are very safe ways of replacing their hormones and still protecting them from a recurrence of their disease. But maybe when we have time. Absolutely. Yes. So for those of you that are listening, I have done a podcast about this with Avram Blooming and also Tony Branson, who's an oncologist in Newcastle, but I am going to invite you back not once but twice. So we can talk about it again because the more it's spoken about, the better, because so many people will comment and say to me, well, it's all very well for those women that can't take HRT, but what about those women that can't? And it's often women who have had breast cancer who have been almost forbidden to take HRT. So I would like to re-explore it because I think the more we talk about it, the more women know those options for them. So before we finish, and I'm very, very grateful for your time, I would

really like you just to give three take-home tips, so three reasons why women should take HRT for their future health. First of all, HRT prevents many of the health problems that women develop after the menopause. And it does so in a very simple, very cheap, and very effective way. In terms of symptoms that women commonly experience, then there is no better intervention than HRT. And the third reason is that really here is a hormone that is almost like, a magic bullet in terms of quality of life and so forth. Now, I know I haven't sort of dissected

down to three reasons as you asked for, but I think they are all covered within. I think that's absolutely perfect and it's real food for thought and there's plenty more information on my Menopause doctor website and on the balance app to really get your teeth into because we've just talked at quite a high level. There's a lot of information in this podcast but it's all just fantastic and what is really important is that all the information and the discussion is based on good quality evidence so thank you so much for your time i really really appreciate it so thank you my pleasure my pleasure for more information about the perimenopause and menopause you can go to my website menopause doctor dot co.uk or you can download our free app called balance

available through the App Store and Google Play.