The Dr Louise Newson Podcast - 149 - What I have learnt since falling in love with menopause care with Dr Abbie Laing

Episode Date: April 26, 2022

In this episode, Dr Louise Newson speaks to Dr Abbie Laing about why she now specialises in menopause care and what she has learnt through her research and writing on the subject. Together the experts discuss clinical hot topics where misinformation and misunderstandings are rife such as what the evidence shows about the risk of clots and breast cancer with HRT, and treating symptoms of genitourinary syndrome of menopause (GSM) with vaginal estrogen. Abbie’s 3 tips for women with symptoms of GSM: Seek help early and use vaginal estrogen; persist with treatment options if the first one doesn’t suit you. The benefits are huge, and treatment should be long term. If you have recurrent UTIs, consider vaginal estrogen treatments . For elderly, frail, or very busy women, the vaginal estrogen ring (Estring) is a very effective and safe option. Vaginal estrogen treatments are very safe and do not have any associated risks, including for people who have had cancer. To access the treatment pathways discussed in this episode, become an associate of the Newson Health Menopause Society at www.nhmenopausesociety.org For more information on any of the treatments discussed, visit the balance website at www.balance-menopause.com

Hello, I'm Dr Louise Newsome and welcome to my podcast. I'm a GP and menopause specialist and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-Bron-Avon. I'm also the founder of the Menopause charity and the menopause support app called Balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based, information and advice about both the perimenopause and the menopause. So today on my podcast, I want to welcome to you, Dr. Abbey Lang, who is one of the doctors that works very closely with me in a clinic, but she also has a brain very big and she likes writing and researching, and

she's a bit like me in the respect that a lot of her time is now thinking about the menopause and talking about it to anyone that will listen. So thanks ever so much, Abby, for joining me today. Thank you, Louise, for that kind introduction. I feel very grateful to be here speaking with you today. So tell me about you first and then we'll talk more about clearly the menopause, but why are you interested in the menopause and what was your journey from medical school to hear? So I was always interested in women's health. If I look back retrospectively, I can see that I always wanted to work in women's health and I had a natural passion towards that side. My initial career started out in obstetrics and gynecology and I did that for a few years initially in

Perth, Australia. I moved out to Perth and did a lot of obstetrics and gynecology. But as part of my rotations out there, I never went through a menopause rotation. And I know that in Perth, they were available, but unfortunately I didn't get to do one of those. My husband did do a menopause rotation in Perth. And he always talked about menopause aspects of care that I felt I didn't fully understand. I then returned to the UK and did my GP training. And I knew that I wanted to be a GP with a specialist interest in women's health. And I felt I'd equipped myself and most of the prongs of women's healthcare, but HRT still felt like a grey area. And I was finding it really quite hard to learn about HRT and access good HRT information. And it became more of a mission might be the right

word to learn about it. And I spent many hours reading journals and emailing people to try and get more information because I wanted to get really good at it. There's lots of perimenopause and the menopause or women were coming in. And I still felt I hadn't quite mastered the art of it. And it's actually, I emailed you when I was working in primary care and asked you some questions and you kindly replied to me, which I was so pleased about. And the penny started to drop with the more questions. And the the more questions I asked and the more information I read, which you had written, the penny started to fall into place. And I started to understand menopause care. The penny dropped for me. And that was when I fell in love with the subject. And I read more and more about it. And I saw

more and more perimenopausal patients and I realized how much I could help them and how much these ladies were struggling and they could have their lives turned around. And I have completely fallen in love with menopausal care and I have now jumped ship and as you know I work three days a week in your news and half menopause clinic at the moment which I absolutely love so it has become my main speciality it's amazing isn't it it's so interesting how people come from different backgrounds obviously I've not come from obstetrics and gynaecology and I've come from a background of hospital medicine and general practice but again menopause wasn't in my radar at all but once you start reading and reading the evidence as well, not just the evidence for HRT,

but also the evidence of the risks of not having our hormones replaced. It's quite outstanding. And actually, I spend a lot of my time feeling cross for lots of reasons, but I feel very cross and disappointed that no one told me the obvious years ago. I wish in the 90s and 80s when I was at medical school, someone sat me down literally on the first day almost and said, do you know, estrogen and probably testosterone in women are the most important hormones and we have to be thinking about it all the time and it would have changed the shape of so much I'd done over the last 30 years. When I look back now and I think I was given quite a lot of misinformation as part of my training, you know, I was told things like taking HRT

will increase your risk of blood clot. I remember that being a teaching session. And actually, that is factually wrong. We know that there's different types of HRT. It's much more complicated than that. And if you have estrogen through the skin with micronized progesterone, it doesn't increase your risk of clot. And I think I've become very passionate, as you know, about trying to improve access to educational resources

because it feels very, very confusing when you are working in primary care, for example, or as a clinician. And there is misinformation. and you think, well, who do I trust? What's right? Who's saying the right things and who's saying the wrong things? And it was only after I read endless papers, endless papers by BMS, IMS, North American Menopause Society, for example,

that I've managed to do my own research and realize what's right and wrong going forward. And I think that needs to be corrected so that clinicians have good access to educational resources that are evidence-based, because there's so much confusion out there for people at the moment. And it's very difficult, isn't it? When you're a busy general practitioner or busy clinician,

it's very hard to go back and unpick the evidence. And, you know, you just read what's on face value, really. And a lot of it is based on information that's associated with drug prescribing. So it's from the MHRA, the Medicines Health Regulatory Authority, which unfortunately their information is wrong. So it will say about clot risk, for example, or breast cancer risk. and although we've been trying to change it, it hasn't happened yet. So you can understand why people are confused.

And having evidence-based information is absolutely crucial because when we get the right treatment for women, obviously we can improve their symptoms, but more fundamentally we can improve their future health. And this is something that I think we haven't been taught enough about how health can improve with HRT, have we? Absolutely. It's a huge part of it. There's risks to not giving HRT. And I think that's not talked about enough. There's risks for your cardiovascular system, a women's cardiovascular system, her bone have, her brain have, her mental, have, emotional well-being. It is not without risk to not give HRT. And I think that needs to be thought about more. And I think it's really hard to be a GP at the moment out there. It's really hard to be a generalist because the menopause care,

is one aspect of primary care. And it's very, very hard to be good at everything. It's probably impossible to be good at everything. And it's for that reason that GPs and clinicians in general need really good educational resources that they can access quickly and easily and is readily available and is trustworthy because GPs have a very short period of time with a patient. Often It's 10 minutes. They often have complex comorbidities. It's a really challenging job. So I would like to try and make that 10 minute consultation easier for GPs because I think it's really tough out there for them. So already, it's not that you've just seen patients, you've been working really hard on some very big projects. And so one of the first things you did

is develop treatment pathways, which we have put through at the News and Health Menopause Society that we've opened through my not-for-profit, which is really helping with getting some great feedback from clinicians. So just talk me through what they are and how they help people. So I've made about 10 treatment pathways that are a concise overview of common consultation types in menopause and primary care. For example, there is the initial consultation and common problem solving aspects focusing in that. There's a three-month review and looking at what happens if there's side effects, common side effects, what to do if there's no symptom improvement. There's one on POI, which is premature ovarian insufficiency. There's one on testosterone,

and there's one on GSM. And there's others as well, which provide a concise evidence-based overview of those topics. Which is so helpful because, again, for busy doctors and clinicians, prescribing clinicians, they're just really useful to be able to help to just look at and know what to prescribe and how to prescribe safely. Because as we know, the more we see menopoles or women, the more we learn from our clinics, the more we can share with other people, it just makes it easier. So, you know, we did some research not that long ago through my not-for-profit, and we found that 7% of women took at least 10 GP consultations just to get some advice, let's alone any treatment. And many women are waiting several years, actually, to get treatment,

which, you know, it shouldn't be. And that's partly, I understand if the doctor doesn't know, then the patient might go off and then come back again, and then, and see someone else. And it's just not fair because also it's draining the NHS resources, isn't it? If we can get on and help and treat in the first or second consultation, that would be so much better. And it's really powerful to use the menopause symptom questionnaire or to use the balance app for this. And I know that we use the menopause symptom questionnaire for all our patients in the private sector. But you can use it in primary care as well as a way of looking at symptoms, which are often very insiduous.

and can take a long time to tease out in the consultation, but can very quickly be identified using the questionnaire. It's also very powerful for women as well, because it's a reminder. As they look at the symptoms, they think, actually, no, I do have palpitations, or, yes, I do have this symptom. And it's a very, very powerful tool to use both clinicians

and the patient involved to identify menopause symptoms, and it can help to reduce 10 consultations. and the effect of that, which is a burden on NHS. Yeah, absolutely. So it's about being empowered as a patient and also being educated as a healthcare professional. And my dream is that balance will do the educating for patients and the Menopause Society and the educational work we were doing

will educate healthcare professionals and then we can close the clinic and get on with doing something else. So the other piece of work that we've just recently done together actually, which has been really joyous to do together, is writing an article which is soon to be published in the Cancer Journal. We're hoping all goes well. And just can you explain what that's about? Yes, so we've written a paper,

and it's about the benefits of using vagina leisdium and whether or not there's any association or risks, particularly in view of cancer development. Because it's always a hot topic that's one that can cause stress to females and to clinicians who aren't sure. as well. So hopefully this will concisely present the evidence in one place for people to read. Yes. So let's just go through. So vagina or estrogen, for those listening who aren't sure is not HRT actually. So when we talk about HRT or in other countries, it's MHT, Menopausal or Hormonal

treatment, that's systemic hormone. So that's given as a tablet or a patch gel or spray. So it goes into the body and that helps with all the systemic symptoms such as the flushes and sweats and memory problems and so forth. But it also helps reduce the future risk of diseases that we talked about. So this increased risk of disease with low hormones, those low hormones are improved by having HRT. But we know that the majority of menopaus or women, some studies say as many as 80% of menopausal women, have the effects of the low hormones in their vagina and the surrounding tissues, so the vagina, the vulva, the bladder, the pelvic floor, the urethra, the tube that we wee out of. And low estrogen can cause quite debilitating symptoms.

And one of the treatments, as well as HRT, or people can have it without HRT, actually, is vaginal estrogen and that will seep into the vagina, but all those surrounding tissues, including the bladder as well. And so it's very safe. not many people actually use it, do they? What are the percentages of women who actually use vaginal leisrogen? Only 7% of women use vagina leotrogen and as you've just mentioned, 80% of women have symptoms down below in the genital urinary system and they can be really distressing and women don't talk about it enough and it's really important to discuss it with somebody

because treatments are really effective and treatments are really safe. And the simplest way to describe it is you give estrogen into the vagina. And there is more than one type of estrogen you can use. So there is estradiol, which is the estrogen that is produced in most women premenopausally. And that's found in things like Vagifem, Vajorux, which many of you have probably heard of. But there's also Eustriol, which is another body identical estrogen that's weaker. And that means that if you don't get on with one type of vagina leotrogen, you may well get on with the nether. So if you have tried one and not had a great experience, for example, with irritation,

it is worth trying a nether because the benefits are so huge for women. And it's also available in different formulations. For example, you can have it in a ring. And a lot of people don't know about the vaginal ring. And the ring sits in the vagina for three months and then is replaced after three months. And it's a long-acting way of giving issue back to the vaginal health. And that can be really, really powerful, for example, in elderly individuals, in care homes, who can't remember to take treatments daily or who have recurrent urinary infections because of low estrogen and it sits there and it can help to prevent recurrent urinary infections. It's also really helpful for ladies who are busy and actually don't want to be thinking about inserting daily or twice-weekly regimes into the vagina.

So it's a brilliant one to think about. It's really, really small. It's really, really light and really flexible. And once it's put in, you can't feel it. So it's underused, in my opinion, the vagina ring. Other ways of having it includes a pessary, which is a small tablet. And traditionally, that's given daily for two weeks as a loading dose. And then there is a maintenance dose where you use it twice weekly.

But if you're still having symptoms twice weekly, you can increase it more than that. So it doesn't have to be twice week. It's about finding the right dose to prevent symptoms long term. So that's another way of using it. You can also use creams. And creams are really good for targeted areas.

So particularly sore areas on the labia or down below, putting creams on can be really helpful for that. So there's lots of different types and there's two types of estrogen and there's different ways of giving it as well. So there's lots of options. There's also a newer pesery, which contains something called DHEA. And this gets converted to both estrogen and androgens, which is the testosterone.

And that can be even more effective for some women because it has the estrogen and the testosterone working separately. And there is some evidence that testosterone is effective for genitone and we have independently to estrogen. So it is another one to consider. And that plessery is used daily. So there are lots of options. And I have met some ladies who've tried one and perhaps not felt any benefits or had a little bit of irritation. And I think if that happens, it's really worth trying another one because the benefits can be so life-changing for women. Yeah, you're so right.

And I see a lot of women who have quite deep-seated urinary symptoms. so people who have chronic interstitial cystitis or really bad recurrent urinary tract infections. And we give local estrogen and like you say, sometimes it cancels irritation initially. And it's not usually to the hormone, it will be due to the formulation. So just changing from a cream to a pezzary or from a pezzary to using the gel or the ring can be really useful. But a lot of these women I've found it can take months to improve. So the vaginal dryness symptoms and the irritation can take weak. sometimes, usually weeks to improve. But some of the urinary symptoms I found can sometimes take six,

nine months to improve. And I recently saw a young lady in my clinic who's only 38. And so she's got early menopause. And her only symptom actually has been vaginal and urinary symptoms. But they were so bad that she actually considered taking her life. She worked as a primary school teacher. And they were just so awful, especially the urinary symptoms. You know, to have cystitis. A lot of women have had an episode of cystitis, but it was all the time and the pain and the burning and she wasn't sleeping. And she was contacting the clinic three, four times a week in her absolute crisis. And she's had some localised treatment, as you explain, and she's also had systemic hormones. And when I saw in the clinic, I actually had to look at her name twice because she came in, just breathed into the clinic, sat down, was smiling.

and I said, gosh, what's happened? She said, well, it's all just working. I haven't felt like this for years. And she said, whenever I read about GSM, so genital urinary syndrome with the menopause or vaginal dryness, it's always about older people. And she said, even some of the medical papers I've read that it's the last symptom that comes,

she said, but that's all I've had, and no one believed me. And she had been seeing different gynaecologists and different urologists. And, you know, the distress that she had in her voice when I first met her was really haunting. But it has taken quite a few months and we do see that a lot. So it's really important to persevere.

So when you wrote this amazing article, you've gone through, I think probably every paper that's ever been written about this. But also we were writing it with respect to giving these localised hormones to women who've had breast cancer, especially estrogen receptor, positive breast cancer, because I've got a podcast that some of you might listen to with Avron Blooming talking about HRT, so systemic HRT for women who have breast cancer. But we see a lot of women who are told they can't even have vaginal hormones because they've had a history of breast cancer.

And my practice has always been to listen to patients, to share any uncertainty, and to give the best treatment to improve their symptoms. And a lot of women who find it so hard to sit down or when, underclothes, actually their breast cancer is the least of their worries, actually. Their worries they can't function. So it's been an easy decision almost to give them the right treatment. But actually the paper that we've written together is even more reassuring, isn't it, for these people? So can you explain how safe? So that all of the evidence does not show an increased risk of breast cancer occurrence among women who are using normal licensed doses of vaginal estrogen, even if they've had estrogen receptor positive cancer. And there is not a huge

amount of data. We could always have more, but the data we do have is reassuring. And several organizations, including the American College of Obstetrics and Gynaecology, have endorsed the use of using vagina and estrogen in women who've had estrogen receptor positive disease. So certainly, it can be considered for women. It can offer. feel very daunting because many treatment strategies for women who have had estrogen receptive positive cancer have focused on lowering estrogen. So it can feel a little bit daunting to then have a treatment that gives estrogen back. But the absorption is minimal with this. And no study has ever shown an increased risk of breast cancer with transvaginal estrogen.

Non-hormonal treatments are still given first line, but it can be considered if symptoms are not and it should be considered. It's worth mentioning the tomoxifen and aromatase inhibitors, which are the two treatments that women are often on. So tamoxifen binds with a very high affinity to the estrogen receptor and there is no concern using local estrogen that it will compromise its effect. It is much more likely that tamoxifen will compromise the effect of vaginalestrogen and not the other way around. Aromatase inhibitors, these work slightly differently. They prevent production of eustrogen. And the use of vaginal estrogen in this setting of women, as you know, Louise, has been more controversial. And for some, it can feel counterintuitive

to prescribe eustrogen. And it might be possible to switch in aromotase inhibited to tamoxifen, which could be an appropriate decision for some women. But it is worth noting that the profound depletion caused by aromatase inhibitors of estrogen can cause such distress that it actually triggers discontinuation of the aromatase inhibitors and that could be avoidable so using vaginal estrogen

in women with aromotase inhibitors should not be an absolute contraindication in my opinion and that's very reassuring and it's not just your opinion it's looking at the evidence as well isn't it? And also sometimes and I've said this before on the podcast looking at common sense medicine as well

And the other thing is, is that when women have quite severe symptoms, the lining of the vagina can be very, very thin, because without estrogen, you get thinning of the tissues, there's less blood supply, there's less collagen. And so anything that is inserted in the vagina is more likely to get absorbed into the body because the lining is so thin. Eustrogen works very quickly when used locally to thicken these tissues, to improve the blood supply, so all the good nutrients, go there, but also collagen deposition and everything else. So that's why after a few weeks

symptoms of vaginaldrinis can improve, but the tissues can reverse quite quickly actually. But as you can imagine, if the wall of the vagina is thicker because the treatment's worked, then anything that's going to be absorbed is less easy to be absorbed, if you see what I mean, isn't it? That's why it's really important not to stop and start the treatment, because if you do that, you're going to have that initial peak in blood level happening over and over again, whereas if you stay on the same dose consistently, then the vaginal skin will thicken and absorption at that peak will not occur. So it's important to stay on it and not stop and start it. Yes, and that's for anyone to carry on with it because we know that some symptoms such as hot flushes

might last a few months, they might last a few years, they might last decades, but a lot of people with find that some symptoms do improve. But symptoms related to vaginal dryness actually worsen with time, don't they? So there's no need to stop using this treatment. And I've certainly spoken to a lot of women who have been advised, like you say, to stop the treatment, see how they feel, and only rest out if they have symptoms. And that doesn't make any sense to do that, does it? It's progressive. It should be placed on the repeat prescription. It should be used long term. If you stop it, symptoms will reoccur and they will become progressive with time. And unfortunately, that's why we see so many little old ladies with recurrent UTIs and discomfort

down below because they haven't had vagina leisdine long term and structures have progressed to that point. And actually, it's really important to mention recurrent UTIs. I think I touched on it earlier. But you see this a lot where people are placed on recurrent antibiotics to the point where they get placed on prephylaxia antibiotics, which means they take them daily to prevent infection. And this is often because estrogen has gone down and affected the bladder half and the ureth and the pelvic floor. And actually, by giving antibiotics, you're not treating the underlying cause. You need to give back estrogen replacement. And there is a fairly prompt reversal then, as long as it started earlier and it's not progressed too much. There is a

prompt reversal in the genital urine we have, and that should prevent recurrent urine infections for most women. So if you know somebody or you have a patient who has had recurrent urine infections, it is really important to consider estrogen as the underlying reason here, and it gets missed commonly, and it can lead to perennial antibiotic use, which is not without its own risks in itself. Yeah, absolutely. And it's so important. And I I feel that actually we've already said 80% of women experience symptoms, so that means 80% of women should be receiving treatment. And so we've got a long way to go. But certainly when the article comes out, that's really going to reassure people who've had breast cancer. And I think it's essential that anyone who's had certainly more than one course of antibiotics for urine infection should be thinking, why am I not using vagina and estrogen?

And even women who take HRT, about 20% of women who take HRT still need to use. of vaginal preparation. Often actually women who have had a hysterectomy find that they can, might be fine before on HRT after a hysterectomy, they often find that they need vaginal estrogen as well. So really important that any symptoms are discussed with a healthcare professional who understands the importance of having the right treatment. There's been a very good study on vaginalisturgeon called the Women's Health Initiative Observation Study undertaken in 2018.

And this included 45,000 women. So this was a prospective cohort. And the outcome and the summary was that using vagina leastrogen, there was no increased risk of coronary heart disease, no increased risk of stroke, no increased risk of blood clot, no increased risk of colorectal cancer, no increased risk of endometrial cancer, and no increased risk of breast cancer.

That is how safe this treatment is, and it's extremely effective and restores quality of life for women. And we know that the emotional and physical well-being of the symptoms of genital urinary syndrome of the menopause cannot be underestimated. It can hugely affect women every day in many, many ways. Yeah, I mean, that's a really reassuring way to end, actually.

So thank you ever so much for highlighting that and reassuring us all and how safe these treatments are. So just to finish, Abby, are you able to give three tips to women who have, maybe have been listening to this and think, yes, I might have some of these symptoms? And certainly I've had the urinary tract infection or not even an infection, just some cystitis. What would be your three tips for those women to seek help? I would seek help early and use vagina leisrogen. And if you haven't got on with the first one, assist and try a different one. because the benefits are huge for ladies.

And there are many different options, and they should be used regularly, and they should be placed on your repeat and not stopped, because that is the safest way to use it. If you have recurrent urinary infections, it is always important to think about estrogen as being the underlying cause and low estrogen causing these infections. And for frail ladies and elderly ladies,

and elderly ladies in care home, or for very busy women who are on night shifts or busy rotors, the S-string ring is a really powerful and underused vagina and estrogen. And these treatments are safe. They've not been shown to increase the risk of any disease, and that's been in a huge study that's been proven. And they can be considered in women who've had estrogen receptor positive cancers. Excellent. So great advice, and thank you ever so much for your time.

and look forward to all the other work you're going to do for us going forward as well. So thank you. Thank you, Louise. Thank you for your time. For more information about the perimenopause and menopause, please visit my website, balance, balance, or you can download the free balance app, which is available to download from the app store or from Google Play.