The Dr Louise Newson Podcast - 112 - ‘Menopause is a public health issue’ with Nick Panay

Episode Date: August 17, 2021

World renowned Consultant Gynaecologist, Nick Panay, of Hormone Health, shares his past and current interests in hormone related issues such as menopause, pre-menstrual syndrome, progesterone intolerance and Premature Ovarian Insufficiency. He describes ongoing areas within women’s hormone health where there continues to be huge unmet need and how, through training, he is seeking to overcome this, not just in the UK but globally through his work with the International Menopause Society. Together, the experts discuss the importance of their roles in empowering women and supporting them to make their own choice about treatments and both agree that as a public health issue, the menopause requires a national approach that focusses on preventative rather than reactive medicine. Nick’s 3 aims for global menopause care: Women have ease of access to information about the menopause Recommendations on hormone therapy and menopause care need to be updated and made applicable, globally, to all healthcare professionals Receive funding for a definitive study on the best way to treat the menopause for all the benefits and no side effects or risks – that is the holy grail.   Find Nick on social media at: Twitter - @HormoneHealth92 Facebook - @HormoneHealthClinics Instagram - @hormonehealthuk LinkedIn - Nick Panay Website - https://hormonehealth.co.uk/

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 very excited and honoured, actually, to have with me someone called Nick Panay, who many of you might hopefully have heard of. and I always think of him as the king of the menopause. So welcome Nick to my podcast today. Thanks for joining me. Thanks for having me, Louise. It's a great pleasure and honour for me to be with you tonight. Oh, so some of you might know I haven't always done menopause as a full-time career. I started off doing hospital medicine and then went into general practice. And in 2015, when the Nice and National Institute of Health and Care Excellence guidelines came out in the menopause, it really sparked an interest with me because it sort of helped confirm how safe HRT was and I went to various conferences, went on various lectures, did lots of

self-directed learning, but I really wanted to get some hands-on experience. So as a crazy menopausal woman myself, I wrote to Nick as an email and said, can I sit in your clinic? And I was absolutely gobsmap when he said yes. So I went one summer, I think probably in 2016, and sat in his clinic and I know that I pestered him and asked lots of questions and I could see his inbox getting busier and fuller. And all he wanted to do was try and answer some of his emails in between patients. And all I wanted to do was pick his brains. And since that time, Nick's been a really good mentor to me and has always helps, I think, sort of protect me and looked after me a bit in various difficult times that I've had. So I'm really grateful that you allowed me that day of

sitting in your clinic. So thank you. So tell me about your background, because your background and my background are very different. We're different in lots of ways. Firstly, obviously people know that I'm female in your male. I've been called an honorary female. Well, yeah. Like Claudine Domini. So I'll take that as a compliment. But your background is not a hospital, you weren't as a hospital physician and you weren't to a GP, were you? So talk through your background to how you became a menopause specialist. Well, I trained as a gynecologist, obstetrician and gynecologist. And what really spiked my interest, in women's health, menopause, and also premenstrual syndrome was when I did research with

Professor John Studd at the Chelsea and Westminster Hospital. And John, as you know, has been a pioneer in both those conditions and set up, you know, one of the first menopause clinics in the world in Birmingham. And yeah, I did some research into, I know it's a topic that you're particularly interested in intolerance to the effects of progesterone, which still challenge a lot of our women using hormone therapy, and found ways in which we could minimize progesterone intolerance by using lower doses, shorter courses, by using intrautriand systems, so like Marina, for instance, where the progestogen is delivered locally, and also looking at more natural types of progesterone like micronized progesterone and digestrone, which mimic more closely women's natural

hormones. And so I've applied those principles over the years, and I think it stood me in good stead in terms of managing my women with menopause-related problems and difficulties in finding sort of HRT that suits them. And I know that you've applied a lot of those principles as well in your practice. And then after doing research with John, did subspecialty training in reproductive medicine because in those days it was very difficult and it still is actually to get a job in menopause as a consultant. So I trained at Barts and the Royal London in doing fertility as well as menopause and other aspects of hormones, if you like, gynecological endocrinology. And then in 2001 I was appointed at Queen Charlott's and

Chelsea Westminster Hospital and I got a combined post doing both obstetrics and gynecology. And whilst I enjoyed the obstetrics, there was an awful lot of after-hours work, more babies being born at night than during the day, of course. So it was fun but tiring. And so in 2007, I then went over to just doing gynecology and really started then to focus on menopause research projects

and also training, and both at Queen Charlotte's and my subsequent appointment at Chelsea and Westminster. at Imperial College London, we've been training people, as you have, at all levels, medical students, GPs, postgraduates in gynaecology, consultants from the UK and the broad, and also pharmacists as well. We have a pharmacist working with us, and until recently we had a psychologist working as an integral part of our multi-disciplinary team. So what do I do with myself now? I teach a lot, as you do. I've got an active research.

program. I've got a fantastic team of doctors, including gynaecologist, GPs, nurses who help me and support me in the work that I do. And as you know, COVID's been a real challenge and a steep learning curve to go online and keep delivering the educational programs that were given to both healthcare professionals and also to women in general. But as you are, I'm driven and passionate about this field. I feel that there's a huge unmet needs still. And I think the most frustrating thing is fitting in two pints into a pint pot. How do you find enough hours in the day to give the due care and attention that this specialty needs? So that forever is challenging me. But as you have, I think the way to do it is to train people short of cloning oneself. And hopefully they will

continue your legacy, both clinically, educationally and also from the research perspective. And it's so important, isn't it? And I have a bit of a thing to confess here, actually, because when I sat in your clinic, I remember saying to you, how do you know when to start HRT? It's all very well if someone's had their ovaries removed. Obviously, it's very obvious. They've gone into menopause as soon as they've had the operation. Or if someone comes and they tell you their last period was more than a year ago, then it's quite obvious. But what about these perimenopausal women, these women who are having periods that start to get menopausal symptoms. And I remember saying to you, how do you really know? Because in general

practice, because I had not had, you know, much training, no one talked to us about the perimenopause. And I remember you saying it's still quite obvious, Louise, often the women know. And I thought, oh, okay, you didn't really think much more of it. And then about three months later, I started to develop some symptoms. And I thought it was because I was working too hard, developing websites, I was setting up clinic, various things, and I found it really difficult to remember, really difficult to function. I was getting back-to-back migraines, muscle joint pains, just no sleep, waking up in all hours. And I was getting night sweats.

So you would have thought that I would have cotton on them, but I actually thought I had a lymphoma, a type of cancer, because as a doctor, you always think something awful is happening to you. And it took me about five months, actually, to then realise what was going on, which now it just seems ridiculous. But then actually I couldn't get HRT from my GP, and my GP refused to prescribe it, it only give me antidepressants.

So I wanted to come and see you because I knew you would be up to help me. And I don't know, if you know, I phoned your secretary who said, well, he's got an appointment, but it's not for another five months. And I was really rude to your secretary. I have since apologised, but I said, do you know who I am? I sat in his clinic a few months ago. And she said, well, he has lots of people sitting in his clinics. I said, no, but I'm really struggling.

I'm going to have to give up my job. he has to help me. I really don't know what else I can do. And I said, forget it. I'm going to email him and I slam the phone down, which isn't that so rude? And then you very, very graciously said Louise, I'll talk to you. It's fine. So we had an appointment a couple of weeks later and you made it at 9 o'clock on a Wednesday morning. And I was with my daughter. And at 10 to 9, I said to her, Jessica, in 10 minutes' time, I've got to make this really important phone call. So you'll just have to sort yourself out or whatever. She's yeah, yeah, that's fine, fine. at five past nine you phone me. I don't know if you remember you phone me on my phone

and said Louise you were going to phone me and I had completely forgotten and that's how bad my brain was I just could not remember and I was horrified firstly because it's so rude that I was late for you but secondly it made me really realise that I was really really struggling with the way my brain was working and I hadn't realised quite how bad it was and I know you've heard similar stories from women in your clinic. But the power of hormones in females' brains is huge, isn't it? And I think sometimes unrecognised and sometimes missed actually, not just in women, but in other healthcare professionals as well. Oh, totally. And as you know, the majority of women, their symptoms start before their periods have stopped. And so it's frustrating that if you

were prescribing to licence with HRT, you couldn't prescribe for at least six months after the periods. stop. I have no qualms about prescribing to women who have regular periods if I think they'll benefit, not just if they're menopause symptoms, but if their cycle-related symptoms. And what really the body is responding to is the cyclic changes in hormone levels, which are impacting, particularly in terms of the emotional and cognitive problems on the neurotransmitters in the brain. So as Eastern levels drop, that leads to fall in serotonin levels, in women who are progesterone intolerant as progesterone levels rise, the increase in stimulation of agaba receptors in the brain can lead to depressive symptoms. And these symptoms can occur independently of hot flushes and sweats,

although there's some really interesting work at the moment looking at the genetics of the genesis of PMS, PMDD symptoms and menopause symptoms showing that the genes that code for these symptoms are co-located. And we know that women who suffer with more premenstrual syndrome and postnatal depression also suffer more with menopause-related symptoms as well. So I suppose the principle of what we're doing when we're using hormone therapy before the periods have stopped completely is that we're stabilising hormone levels rather than replacing hormones that are absent. And I suppose that's the key difference, isn't it? Yeah, and it shouldn't really be called H.R.T. Hormone replacement therapy, should it? So for a lot of women who start, when they're still got their

own hormones, it's just topping up as opposed to replacing, isn't it? Yes, I call it hormonal balancing rather than replacement. And in fact, the International Menopause Society has coined the term menopause hormone therapy, which, you know, doesn't have the word replacement in it. True replacement of hormones actually only really occurs for women who have premature menopause or premature ovarian insufficiency, as we call it, or early menopause, where you're putting back hormones that would have naturally been there, at least until the average age of the menopause, which is 51. And as you know, premature ovane insufficiency is a condition I feel particularly passionate about

because we talk about natural menopause being poorly diagnosed and poorly managed. This is a condition, POI, that's even worse in terms of its diagnosis and management and resource. but it's very encouraging that we have been given a grant recently collaborative group in the UK to study the pill versus hormone therapy in women with premature vane insufficiency. And that's headed up by Melanie Davis at University College London and a number of us collaborating with that study. So we should get some answers in terms of the impact on quality of life and also protecting, as you know, heart, bones, brain, etc., all of these things

which are even more severely effective in women. with POI. Absolutely. And about one in a hundred women in the UK under the age of 40 have P.O.I, don't they? And certainly when I was in general practice, there was no way we had that number diagnosed. And that wasn't because it was an unusual area where I worked. It was because people weren't picking it up. And, you know, when I was at medical school, I was taught if a woman has a period of time without her periods, just make sure she's not pregnant. If she's not pregnant, don't worry about it. And that's completely wrong. Absolutely wrong. because, like you say, it's the health risks of not having these hormones is so huge.

So the IMS, the International Menopause Society that you mentioned, you've got a big involvement in that and it's soon to be even more involvement. So tell me a bit about that, Nick. Well, my relationship with the IMS goes back to the mid-90s when I took over the co-editorship in chief of Climacteric, which is the International Menopause Society Journal with Anna Fenton. So for a decade, we were co-editors-in-chief of this journal, which I think, again, fantastic outreach to the four corners of the globe and really helped to promote the evidence-based practice of the diagnosis and management of menopause. I then joined the board of IMS, and I was promoted to general secretary and now I'm president-elect of the International Menopause Society.

and the vision that I have and the mission that IMS has is to provide education for women and healthcare professionals around the world in order to empower women to be able to seek the help that they need and deserve for menopause that troubles them, but also to empower healthcare professionals and educate healthcare professionals to treat women and not be scared of hormone therapy. and also to be able to counsel women not just about hormone therapy, but all aspects of menopause management, lifestyle, diet, exercise, supplementary therapies, etc., etc., so that we can truly individualize management for every woman. And also to make it more, if you like, region-specific. So, you know, we've been educating in Latin America, in India, in Russia, we've produced, as well as the webinars that you've been involved with, and thank you very much. Yours on COVID was fantastic.

We've also produced a slide set where many thousands of healthcare providers have signed up to learn about menopause called the Impart Program. So really, it's about getting that information out there, and an IMS has a responsibility for doing that globally. So it's another area of passion of mine that I hope to be able to influence, particularly when I'm president. So a lot of healthcare professionals are scared of HRT, aren't they? And I think it's not their fault, actually. It's just because all their training, all their mentors or their peers have scared them away from HRT for often the wrong reasons, haven't they? Yes, as you know, it's the minority of women who are using hormone therapy. Many women find it very difficult to access,

not just hormone therapy, but sensible advice about menopause. And I know that you've been trained and the programs that you've instituted, your menopause charity, the app, etc., you're providing all of that support and education. And my work through the international and also the British Menopause Society as chair and now as a trainer, menopause trainer for GPs, we're trying to put it educationally on the map and also working with the Department of Health to try and get it properly a resource. We've just submitted evidence to the Department of Health for their women's health strategy, which hopefully will make a difference

and hopefully it will have teeth and money behind it. But I think the important thing is getting the dialogue going so that women can have access to appropriately resource menopause care. Yeah, and I think it's a real problem actually because I was reading some articles last night from the British Medical Journal, just talking about burnout actually with COVID in primary care and about how many doctors now want to take early retirement,

they want to leave or they want to go part-time and not just doctors, nurses as well and other healthcare professionals. And then when you suddenly say to them, right, we want you to treat menopause as well, a lot of them are really pushing back and saying we can't do it. But actually, and I'm sure you'll agree, if women who are menopause will get the right treatment, they actually don't go to their doctors as much because for a start, they don't have symptoms or they're less likely to have symptoms. So symptoms like palpitations, which are leading to card. appointments or migraines leading to neurology appointments, that will really reduce. So actually to invest in a bit of time in that first perimenopause or menopausal consultation

is not just investing in their woman's future health, but it's actually saving money and time in the healthcare, isn't it? Absolutely. It's a public health issue, Louise. I keep saying, you spend a little money now, you save a lot of money in the future. because as you say, you then reduce the number of unnecessary appointments. You reduce the huge expenditure required for dealing with osteoporosis-related fractures with cardiovascular disease, with dementia-related issues.

And it is frustrating that, you know, what we need is a good preventive strategy rather than a responsive strategy. But I think we're still too reactive rather than proactive. in how we managed these situations. We were speaking earlier that in 2010-2011 in response to the government's white paper, we proposed then that there should be a menopause check, a menopause chat, where every woman has the opportunity to go to the GP to talk about lifestyle diet, exercise, hormonal options and alternatives.

And of course, the concern then, as it is now, is, well, how are stress, tired, GPs, who not only have to be a jack of all trades and now have COVID to deal with as well, how are they going to be able to implement this? And the only way this can be implemented is through appropriate resourcing through the Department of Health, where money is spent on training more doctors, training doctors in menopause specifically and having it as a key part of the curriculum, both undergraduate and postgraduate, and also in research, because we know that HRT is treated as one preparation with one class effect. And we know that there are many different types of hormone therapy.

And if you use the right type of hormone therapy and the right woman, you get a much better outcome than you do using the wrong therapy and the wrong woman for the wrong indication, which is what's happened in some of the previous studies that have been done. Absolutely. And I actually remember listening to a presentation you gave at a conference for a GP journal actually called Pulse. It was probably, I don't know, 10 years ago, so a long time before Nice came out

and you started talking about body identical hormones and the natural micronised progesterone and ways of changing if someone's progesterone intolerance. And I remember just sitting bolt upright and thinking, goodness, this makes so much sense, actually. This man is really talking sense. And, you know, they are completely different drugs. They work very differently.

me, and then you start thinking about all the contraceptives containing the synthetic progestergens that have been given to women quite rightly for contraceptive purposes. And, you know, lots of us have children that have tried one or two or three or maybe four different combined oral contraceptives. And often it is a progestogen having this effect. And it's, you know, these poor teenagers are blamed for being moody and don't get me wrong, they can be. But often the hormones are affecting then, aren't they?

Yes. And then, as you quite rightly said, you know, PMS is really under-resourced, isn't it? And it's so much more. I remember sitting in, before I started in your clinic, I also had a privilege of sitting in Professor John Studglin. And I remember he gave someone some estrogen gel, a lady who was in her 20s who had really bad PMS. And for one week out of four, she couldn't go out, she couldn't work, she was really struggling. And he gave her the gel. And when she left, I said, oh gosh, I've never done that in my practice.

and he said, well, Louise, it's just topping up the hormone she's missing. And I said, but we've always been taught in general practice. You should give these people antidepressants, even just for short, you know, one or two weeks a month. And he said, but that's just sticking a plaster on it. I don't see the sense. And ever since then, I've done exactly the same because I think, well, there's no harm. And these women come back. And not all of them, obviously, but a lot of them do, don't they?

Because you're just giving them what they're missing. I think it's about the life course approach. And I think it's great that finally menopause is on the educational curriculum in schools. We need to have menstrual disorders there in PMS. And with PMS, we know that these problems start in school children. I see numerous teenage children who come to our clinics who have been misdiagnosed with bipolar disorder or psychosis and actually have cycle-related symptoms. And as soon as as you've balanced their hormones, miraculously, they start doing much better in school and achieving and not being a handful for their families, etc. And then it's about using the right types of hormones. We know that if you use the wrong type of pill, as it is with the wrong type of HRT, that the progesterogens can give them PMS-type progestergenic side effects. We also know that in somebody with cycle-related symptoms, if they have a seven-day interval with their pill, that will allow regeneration of their PMS symptoms. And so these women should be treated with back-to-back pill regimens as much as possible.

And it is about tailormaking. I find it really frustrating that we keep doing these retrospective data trolls because they're easier, they're cheaper than doing long-term perspective, randomized trials of new hormonal options that we know from your considerable. or observational data that we have appeared to behave much better in terms of metabolically, from the breast perspective, from the psychological perspective, et cetera, et cetera. And yet we keep doing these data trolls and surprise, surprise, we're finding problems.

We've moved on. We're not using the hormones that we used to use 20 or 30 years ago. Now, let's do some studies looking at that and not just keep looking at breast cancer. Let's look at the woman as a whole. And yes, look at. breast cancer as an outcome. But let's look at her quality of life aspects in more detail. Let's look at bones, heart, brain, the immune system, which is so fascinating in terms of, particularly now with COVID as well, understanding that. We know that the estrogen can have a

beneficial effect from that perspective. So we need more research, looking at how we can bolster the immune system to try and mitigate the effects of future pandemics. It's so important, but it's so frustrating, isn't this? And I think the other thing is when this podcast released, they will have done the nice guidance in shared decision making. And for me, as a woman who had been refused HRT, actually I feel very strongly it's about my choice. The whole risk of breast cancer, people can argue till they're blue in the face,

but it's still not high, even when you look at the highest figures. But it is offset for loss of women by the benefits. And like you say, you know, my risk of osteoporosis without taking hormones is far greater than my risk of breast cancer. And actually the prognosis following a osteoprotic hip fracture is far worse for a lot of women in the first year. Then the prognosis following a diagnosis of breast cancer. But it's an individual choice. So I think what you're saying is absolutely right. And it's also about holistic approach.

And I recently did a survey of 5,000 women and found that only 24% had been given any information about lifestyle. And, you know, it's so important that we're looking at ways of helping our heart, our brain, our bones, in what we eat, the way we sleep, the way we exercise, everything else as well. And so I think having this reach where we can reach as many women as possible to educate them for themselves, because I really feel women need to be empowered. But it has to be matched up with their healthcare professionals education as well, doesn't it? So then the women can actually receive what they want. And, you know, I'm sure you agree. Neither of us are here to be didactic and say every woman has to do this, have this, make this choice, because we're all different. And that's really important as physicians and healthcare professionals. We recognise and acknowledge that. But I think we should take in a woman's choice and respect her wishes, whether we agree with them or not.

It's the same in all walks of medicine, isn't it? Oh, totally. I mean, it's about giving women the correct information to empower them to make the choice that's right. for them. That's what I believe passionately. You know, we, you and I are busy training GPs and, you know, we've got our new course, which is principles and practice of menopause care through the British Menopause Society. But it takes time and, you know, we're training hundreds. We need to train thousands. And that's where, you know, we need to appeal to the Royal College of GPs, to the Royal College of obstetricians and gynecologists to expand their curriculum in menopause training. And that way we will start to make a difference and give women the information that they need

to make these choices. Absolutely. So there's a huge amount of work to do. And I think we can all only do it by working together. And the more people that have the knowledge, the better future health for women will be, which will be amazing. Absolutely. Thank you so much for your time, Nick. Before I end, I always do three take-home tips,

which I didn't warn you about before, I'm sorry. But if you would mind, just giving me three key things that you would like to achieve when you're president of the IMS. I would, first of all, like to ensure that women globally have ease of access to information on menopause. Secondly, we do need to update our recommendations on hormone therapy and menopause care and make it applicable globally to all healthcare professionals. And thirdly, and this is my big mission, Resondetra, if you like, is to try and get funding for that definitive study that I still think we need to do. And we may need to go cap in hand to the WHO.

show, obviously now is probably not the best time, but as, you know, we come out of this pandemic, to look at the best way to treat menopause with the best preparations, which will have all the benefits and no side effects and risks. And that is the holy grail. Absolutely. Well, there's no harm trying. Absolutely. Yeah, it would be brilliant. So thank you ever so much for your time. I really appreciate it, Nick. And I look forward to seeing what the future the IMS has for us women at here, so thank you. Thank you, Louise. It's been a great pleasure. 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.