The Dr Louise Newson Podcast - 154 - How pharmacists can improve menopause care in your GP practice and community with Rupa Lyall

Episode Date: May 31, 2022

Rupa Lyall is a clinical pharmacist who works in a GP practice in Buckinghamshire seeing patients with minor illnesses and prescribing medications. In this episode she tells Dr Louise Newson how she became interested in the perimenopause and menopause and how, through the training on fourteenfish.com and resources on the balance website, Rupa now supports and educates other clinicians in HRT prescribing. Their conversation covers raising awareness among professionals, working with patients from BAME communities, the importance of empowering women to improve their quality of life and the transformational effects of hormone replacement. Rupa’s 3 tips for pharmacists interested in the menopause: Go to fourteenfish.com and do the ‘Confidence in the Menopause’ course Don’t be frightened of the menopause, learn more and talk to others Speak to patients about their HRT, ask them how they’re doing, especially in the community. You will learn a lot by doing this.

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 with me in the studio, I've got Rupa, who I've never actually met before, like a lot of people I seem to podcast. I've corresponded quite a lot over the internet and now I'm delighted to meet her virtually, but at least I

can see her face and listen to her now. So hi Rufa, thanks for coming. Hi, Lee. No problem. So tell me a bit about your healthcare professional, but you're not a doctor, you're not a nurse, you're a pharmacist and pharmacists in my mind have a really, really crucial role for many reasons, but obviously all I think about is the perimenopause and menopause. And when it comes to care of women, actually pharmacists, I think, have been neglected for quite a long time about how important they are and the pivotal role that they can really have at improving the future health of women and actually avoiding them going to see their GP sometimes as well. So tell me a bit about your work and Why did you even decide to be a pharmacist in the first place?

Wow, that was 18 years ago. I made the decision for a long time. Pharmacies changed since then. We were only really looking at working in community or hospital. But now as the years have gone by, we can now be prescribers, which is what I am. And we are now able to go and work with GPs in GP practices, which is amazing. But a lot of pharmacists have bad experiences in GP practices. They use as admin work rather than really resigning our skills.

but I am fortunate that I work with an amazing practice, Dr Bupau, Dr. Bhopal, they're my mentors. I've been there for about two and a half years and any interest that I have, they've supported me in. I can knock on their door, I can do anything and ask questions about patients. They're there. That's amazing. So you're actually consulting patients as well. Yeah, I'm consulting them face-to-face as well as video and telephone calls. I specialize in minor illnesses, depression and now menopause.

ties in nicely with the depression side of things because we tend to treat women and men separately for certain conditions, but women especially for the conditions that are linked to their hormones, we're treating them separately for. And I have found that now we can treat them as a whole and really get into those symptoms that they're suffering from. And it's amazing. And I'm seeing really good results. Likewise with the GPs that I work with, they're getting into it as well. They're getting more confident with your teachings, to be honest, Louise. Great. Lovely to hear.

Your platform has really made us all confident. And I'm talking for GPs as well. And it gives that patient the empowerment to feel. You get the sigh of relief from them when they say, oh, my God, that's me. Yes. When you show them the menopause questionnaire especially, that's my tool that I use. I say to them, here, have a look. And they're just ticking all the boxes saying, that's me, that's me, that's me.

And certainly people find it really reassuring to know that. there is something that is causing their symptoms, isn't it? Because I spoke to a lady this morning and she told me she had to give up her job because she was unable to string a sentence together, let alone hold a board meeting, turn up at work. And she said it was awful actually. And it's still taking a while for the hormones to work. She's better, so much better than she was. But it's very scary. And how do you admit to people that something's happening when you don't know the reason. It's so much easier. If I had a big rash on my face, I could say, oh, if I look at this rash, this is really painful. And you'd say, oh, I'll give you some cream,

or I'd recommend you have some treatment, and it will improve. But especially when it's emotions, or something that you don't know. Another lady I spoke to today was having really bad palpitations. And she was under the cardiologist. She'd had some heart investigations. They were all normal. And she was just told, well, there's no cause. Your heart's normal. But it's probably related to her low estrogen. That's right. But she was just sent away and that was it, you know, and that's very hard, isn't it? It's very hard, yeah.

But we, you know, the women that I've treated so far, I've had good results from. With some, it does take time and a bit of tweaking with their doses, which they're aware of. We go through everything with them. But on the whole, it's serving a bigger purpose. Yes. It's working. So how did you get into the menopause then? Because did you get any training as a pharmacist on the menopause?

No, zero. zero there's no training at all i actually came across your 14 fish training material which i joined and then i just started listening and looking at your videos and i thought god this makes sense this is and as hard as i thought it was and then i started talking to other gPs and who are using your material as well and have gone through your training programs and it just started jelling especially with the depressed ladies that i see and now i'm targeting people in the beaum community yes Because I speak Punjabi so I can explain to women who are the Punjabi speaking. And how are you finding that? Because I find just in my experience that certain groups of women,

it's so much harder to talk about it openly as well. And certainly in BAME communities, there's a lot of stigma and shame almost associated with menopausal. There is, yeah. And a lot of them don't actually, because I see a lot of women from Pakistan And a lot of them aren't even aware of it to be on. They don't know. And sometimes explaining it in Punjabi can be difficult. But I try to do the best I can or they bring other family members like their daughters or, you know, sisters or whatever it is. And it's working.

But it's just them being compliant on it as well. And how do they feel about taking HRT some of these women? So far it hasn't been a problem. But there is a bit of skepticism around it. They're not sure or they want to, you know, investigate it more. but I would like to target those women a bit more now. And that's important because, again, we're treating them for separate things and it's not working. Yeah, and certainly certain groups of BAME community, but other women as well have an increased risk of heart disease and diabetes, don't they?

And so I really worry because there are so many women who were on statins for their raised cholesterol, they're on blood pressure treatment, they're often on pain killers because they've got pains in their joints and muscles. and as you say, antidepressants as well. So that's for at least medications that they might actually not need, isn't it? Yeah, that's right. And likewise, working in community as well. So community pharmacists now, I think we really need to be upbeat about this. Because, you know, over the counter we see women coming with prescriptions for HRT more and more now.

The pattern, the gels and the progesterine capsules and all of this kind of thing going on. And we should be counselling them. We should be asking them how they're getting on with it. what benefits are they seeing? What benefits aren't they seeing? Are they consulting their doctor? So I do a lot of coaching with patients over the counter to make sure that they're getting the right advice and treatment ongoing from their doctors as well. And they appreciate it because now they can come back to you and say, right, okay. Yeah. And I think that's really important because certainly for those of you listen before, HRT is not a one-size-fits-all. And I spoke to a lady this morning who was really

frustrated. She'd started HRT three months ago and she said, I'm reading about all these women that feel great and I'm not. And she said, some of my symptoms have improved, but a lot haven't. Well, you know, firstly, three months is a short period of time. Secondly, she was on quite a low dose of estrogen, which needed probably increasing. She'd only recently started testosterone, which can sometimes take several months to have an effect. But just to know that it can take time and also to know that women are allowed to increase the dose if they're still getting symptoms. That's right. It's fine because the hormones are so safe. And I think it's absolutely right to empower women. So they can make decisions with some support, but they don't have to have consultations with their GP every single

step of the way, do they? That's right. That's exactly right. And the resources that they can go to as well, like the Balance app, balance website, the fact sheets and information booklets that you've got on your use and health, I tend to direct patients to that and they get a wealth of information and confidence as well because a lot of their patients are answered in those resources. Yeah, which is important because there's a lot to take on board, isn't it? Yeah. And certainly if you're like me, when I had low hormones, I couldn't remember anything anyway. So you could have a consultation and think, great, I've done a good job there, but then the woman goes out of the room and what did that lady say? I've got no idea. Yeah, yes, right, yeah. Yeah. Yeah.

Yeah, so, you know, this is something that I feel very passionate about, and pharmacists now need to be confident to take on this topic. You know, it's not difficult, and it would make them feel good, actually, because they're going to be having such a great impact on so many lives. Yeah, absolutely right. And I think in the past, people have thought it's complicated. And I was at a meeting yesterday, and people were saying it's become very complicated, prescribing all these hormones separately. We shouldn't be doing this. And I think it's very straightforward. if you do do the hormones separately because women can then be in control, they can work out which

bits are working for them or if they're getting side effects, which bit that might be. And actually, I think to take the mystery out of the menopause is really important because when you're not taught about something, you sort of avoid thinking about it almost, don't you? In my mind, it's always been thought of as something that causes some hot flushes. It's just something, an inconvenience really, that women will experience part of a natural process. Whereas when you think actually what it means with the hormone deficiency, with the myriad of symptoms that can occur, someone was saying to me yesterday, well, a lot of the symptoms, of course, are just natural ageing. Yeah.

They're not due to menopausal symptoms. But actually, we know that when you replace hormones, they improve. And you could say that other conditions are due to natural aging, such as raised blood, pressure or arthritis, but we still treat them, don't we? I don't see why we have to ignore the menopause or some of the symptoms associated. Yeah, and all the risks involved. I think people have already made their minds up some of them. Oh, you know, I don't want to because, you know, breast cancer and all sorts. But now, especially with your material, we can reassure them that, you know, don't be scared. We can do this. Yes. And I think it's very hard, isn't it? Because

we've always been fed about risks, risks, risks, risks. And there are risks, as you know, more than me being a pharmacist of any medication, isn't there? There's always a potential problem. But actually we have to then think about the benefits and the evidence is so clear about the many health benefits of taking HRT. And a lot of women have never heard of any health benefits, have they? No, they haven't, no. But yeah, I think, you know, the ongoing work that I certainly plan to do this for a while. great but it's also very i mean i find the work frustrating because so many women are suffering but actually day to day when i see patients it's absolutely transformational medicine isn't it i can't think of any other area of medicine where i can pretty much guarantee that in three to six

months my patients will start to feel better and their future health will be better as well that's right And giving them the additional lifestyle advice, you know, diet, which you provide on your website. I mean, I have some of the courses that I do for my GP work, tutors that I have, they're coming to me for advice. Great. Just for information. And they're like, oh, this is great. But it's because I talk about it so free, positively, but also give them that the one size doesn't fit all scenario as well. Just be sure of that.

But it doesn't matter because we're raising that awareness. We're telling them how they look into it. And then they can make their decisions as well that they need to. Yeah, which is so important, isn't it? And are you involved in any training of pharmacists at all? The GP practice, where I am, they do do training for junior doctors and pharmacist prescribers are on the course. So sometimes they sit in with me as well, which is nice. They can see what I'm doing and we work together on a lot of things as always.

So, yeah, I am involved in a little bit of it, but not, you know, to a major extent. but yeah, I'd like to. Yes, and it's having this ripple effect, as you say, that I think I feel for every one person I tell, there's probably 10 or 20 people that benefit because they all talk, whether it's patients talking together or whether it's healthcare professionals talking together. And it is about confidence, I think, is really important

because I know that I learnt the most from sitting in consultations. And for some of you that know the 14 fish calls, we've got some videos of consultations where we can see how it works actually and in fact we're videoing some more today to add some more different cases on and we're also using those consultations in the balance app the balance plus area people can watch those consultations and they can just try and hopefully learn what the conversation should be like and also allowing women to be really involved in their consultations I think is really important. important, isn't it?

100%. Definitely. Yeah. So, yeah, we just need to keep going and raising the awareness. I think pharmacists as well can do a lot in terms of outside of pharmacy, like going into workplaces as well. I think that's quite important how we can support women there. Yes, because there's a huge amount in the workplace.

And I feel actually quite sorry for some of the workplaces because they're almost being forced to doing their policies, increasing awareness, but they don't quite know how to do it. and then there's all this narrative of, well, perhaps women could sue you if you didn't treat them properly or listen to them. But actually, what women really want is a treatment. So then they can not just carry on in the workplace, but they can hopefully get promoted or they can increase their hours or they can change their job role. And so many women have said to me, well, of course, now I'm menopausal. I've taken a different job. I've reduced my hours.

I couldn't expect to have the same high-powered job. And I feel really sad about that because we're losing. losing a lot of really good workforce. And, you know, when we think 40% of the NHS workforce are menopause or women. And we hear about midwives, nurses, GPs, people leaving all the time. Of course it's not all going to be menopause, but I can 1,000% say that some of it will be. I had a lady who used to use the same route to work driving on the motorway, 20-odd years also. And suddenly she just became anxious about using that route. You know, it's just the smallest things, but it has such a massive impact. Absolutely. There's a huge number of women that stopped

driving, or like you say, stop driving on a motorway. One lady I's which recently said she used to forget how to fill her car up with petrol. She used to have to phone her husband and say, taught me through what I do, how do I fill it up and where do I go to pay? And she said, it was very, very scary. But as soon as she started taking HRT, that came back. It was just a natural process, but she really thought she had dementia. She was going to stop work. I mean, how can you work? If you can't even fill your car up with petrol, it's very scary, isn't it?

It's scary. And if we can share stories like this as well, I think that's important, you know, the good and the bad ones, you know. Yes. I think that would be another empowering aspect of us raising the awareness. So, yeah. Yeah, I think it's really important that women know that they're not alone. And actually, if women are still experiencing symptoms on HRT, then they should still get help.

Because there are a lot of women who say, well, my night sweats have gone, my headaches have gone, but I'm still finding my memory or my mood affected. And of course, we don't know whether it's related to their hormones, but I feel that women should have their hormones optimized and then they can see what's left almost. Yes, definitely. You know, it's definitely, you know, it's definitely something that I am finding that women are interested in and want to know more about. I'm on a GP pathway course at the moment. It's an 18th month course that I'm coming to the end of. And I was on a tutorial session. And I just mentioned you and what I'm doing and everything.

And the session just turned out to be available. And everyone was taking note, what's the website? That's great. That's why I have tutors calling me and asking, have I got some time just to discuss a few things? But why not? You know? Well, I think so.

And I think it's crucially important that everyone knows, because it's every woman. You know, you're talking about people who were depressed earlier. Of course that is very important, but not 50% of the population will be depressed. But I've been looking at some of the antidepressant prescribing, certainly in England, and twice as many women than men receive antidepressants. And obviously there are other reasons, but I'm sure hormones are related. And I really, really strongly feel that any woman taking an antidepressant should have

the question asked, could your hormones be associated with your low mood? And some women need both, don't they? Antidepressants and HRT. But there's still a lot of inappropriate antidepressant prescribing when we should be considering HRT first line. Definitely. And a lot of women do feel better when they get the feedback from their husband or their partner. And it's made a difference. I can see a difference in you. So that's what women tell me after the three-month review that I have with them that my partner or my husband's notice that I'm in a better place. So that's another sort of tool that they're used for their monitoring, I suppose. Well, I think it's very important.

It's like anything isn't to any illness or certainly any chronic disease. When you're living with yourself all the time, you don't notice the difference. And you really need other people to monitor. And sometimes when I see patients in their first follow-up, they'll say to me, oh, I don't feel any better. Yeah. We get them to fill out a symptom questionnaire. and you can see that their ticks have moved to the left. And I said, well, actually, you do seem better and your symptoms are less.

And then I read out the notes that I've made in their first consultation. And they go, oh, yeah, I forgot I was that bad. I forgot I was shouting all the time and had no sleep. And, you know, getting out of bed was so uncomfortable. And so because it's a gradual change. But I think it's great because these women are getting better. But then in the same way, there's a gradual deterioration. often during the perimenopause and menopause. And you sort of accept that you've maybe put on a bit of

weight and that you're a bit more irritable and life's a bit more difficult. And I mean, I was getting the stage where loading some washing was just more of an effort and I would just delay it by a day because I can't be bothered to unload the washing machine. It's going to hurt my joints. I just want to sit down. And you just accommodate and change in a very negative way really. And it's only when your husband comes home and says, why are there no clean whatever, anything like because I haven't done washing. I mean, that sounds very sex. He does use the washing machine.

But you know what I mean? There are things that fall apart a little bit that no one probably would notice other than those who are nearest and dearest to you or someone in the workplace. You know, I know it when I was working, I just found everything overwhelming. I'd look at the visit book and think, oh my goodness, how am I going to get all those visits done, getting in my car? how am I going to find out where to go? And I couldn't tell anyone because I felt that I was just failing.

But if someone had said, oh, Louise, you look a bit worried, are you okay? And then start that conversation. And had you thought maybe some of it could be your hormones? I wish someone had said that to me. And it's those just open conversations, isn't it? Definitely. And for the women that are, you know, in their early 40s, it's important that they're aware of it. They're not started on anything yet.

that, you know, the long-term benefits are going to be very important here as well. Just think about it as well. And there's a lot of women, I don't know if you see them, but we certainly do, who have missed out on HRT. You know, they're sort of now in their 60s, 70s. That's very right. There's a lady that worked with at Boots. She's in her 60s and she never went on HRT and I always said, I wish you could have done

because she's suffering from so many of the symptoms, especially joint aches and pains. She's crippled by it as well. And she's on all sorts of medication now for it. And I just always say to it, I wish, you know, wish you had been on HRT before. Well, it's never too late, is it? Yeah, that's what I would. Yeah, I've advised us to go back to a doctor now and, you know, discuss it fully. But I hope she won't get brushed off.

Well, I hope not. And there is a leaflet on the balance hyphen menopause website about starting HRT many years after your menopause. And for a lot of women now, as you know, because it's the body identical hormones, the estrogen through the skin without a risk of clot, you can usually safely see. start HRT and older women. Even I've had some patients in their 80s or even 90s that I've started HRT. Because, you know, we don't know if their symptoms are related, but we know that even small doses of estrogen can increase bone density and osteoporosis is so common.

A lot of women who are older have vaginal dryness, urinary symptoms, don't they? So even if they didn't want to try systemic HRT, they could still. safely use vaginal estrogen preparations. And certainly pharmacists who are selling cystitis relief type preparations should really be thinking about that, shouldn't they? Exactly. We're missing the bigger picture. You know, when we do, like I said before, treat the individual symptoms.

I've got a few patients at the surgery that I treat for recurrent UTIs. I've now put them on the vagifem and let's see how they get on because it's bound to be associated with that. Yes. Especially when they talk about what's causing it and, you know, what triggers it off. Yeah, absolutely. So it is really important the whole awareness. And I think lots of people think it's a GP problem, the menopause.

And it's not just for GPs to be educated and informed. And certainly, I look at the data of the 14 fish course. It's a free course called Confidence in the Menopause that anyone can access. We've found that there's a good proportion. of pharmacists that are doing the course, which is great, actually. Yeah. You know, I'm hoping that more and more pharmacists now will find the confidence and the interest, really, to really talk about this and develop themselves further on it. That's important. Yes, and a lot more pharmacists now can prescribe, can't they?

Yep, it's growing. And when you do the prescribing course, you're always asked for an area of specialty. If I had known about it, I did it about four years ago. I would have done the menopause, for sure. But now, you know, hopefully they'll be selecting that as their area of specialty. So yes. Not then you keep developing yourself further. Yes. And I think it certainly is an area that covers so many other areas as well. So even if someone was interested in diabetes, well, obviously, menopause is, you know, a risk factor for diabetes.

If they're interested in heart disease, we know there's an increased risk, you know, mental health. It sort of ticks all the boxes. But the other thing I think pharmacists are really important for. is trying to reduce medication. So we have this whole thing called polypharmacy, which basically means lots of drugs. And it's very easy as a clinician to add on more and more medication without removing medication.

And we do this even with blood pressure. We know about probably a third or so of people who take anti-hypertensive probably could reduce them with time. And I always used to, and the annual review of blood pressure was normal, and it would be normal for a little while, I'd try and reduce medication. Because most medications do cause some side effects and people can feel better. And, you know, I've done it lots before with people who type 2 diabetes.

They've changed their lifestyle. They've reduced weight, but they're still on nose of diabetes medication. You think, well, they don't need to. They come off and they suddenly feel even better. And so with menopause, especially when people have been menopausal for many years, they are often on layers and layers of drugs to treat their individual symptoms, aren't they? And so I'm sure you do it and I certainly do it, is once a woman is more stable on HRT, we then start to think about medication that she can reduce.

That's right, yes. And I think it's great that this pharmacists and GPs can work closely now as well, especially with this topic. I certainly do and it's a great discussion that we have as well. So, you know, the GPs and the pharmacist in the area of menopause are probably at the same. level, if you could say, of developing themselves. Yeah, and I think that's so key. I mean, all the work I do is multidisciplinary and involving all members of the team. And I don't think anyone is more or less important than anyone else. And I think if we can learn from others,

it's only going to excel our knowledge, but also it will be transferable to our patients, which are the most important part of this conversation. And having time is actually really important, but also I think some patients find it less threatening, actually, talking to pharmacists or nurses than they do to doctors. And it shouldn't be like that, but I think they often open up a bit more, don't they? And I'm, like I said, I'm privileged. I'm blessed, actually, to be working in this practice because we're all the clinicians, you know, there's no hierarchy. That's why I've been able to develop myself further, because I've come from a complete retail background. And when you're in a retail background, you lose all your clinical skill. And I found that

daunting to go and, you know, think, open up a BNF. I haven't done it for years, to be honest. Yeah. Because I've had that support from the doctors, that's why I've been able to really expand myself and help so many people. And I think everyone needs to be in a practice like this. And if not, then encourage the GPs to work with pharmacists, you know. Yeah, absolutely. And it's so brilliant and so liberating hearing the work that you're doing. And so just keep it up. And thank you very much for your time today. So just before we finish, can you give three tips? And I'd really like, if they, I'm sure there will be some pharmacists listening. So three tips for people who are pharmacists who are thinking, how can I do more in the menopause? So what are the three

things that you would recommend for them to do? First of all, go onto the 14th Bush website. Get yourself signed up to it and listen to Louise's videos and watch her role plays because that's what gave me the confidence. Secondly, don't be frightened of this topic. Go for it. Just learn more about it. Talk to others about it. And thirdly, the walls your oyster, just speak to patients about their HRT prescriptions, especially if you're working in community, I think that's the key. When you see women coming in, just ask them how they're doing. You don't need to, you know, start a whole discussion about it, but in terms of just ask them how they're getting on, you'll get a of information from them to help you develop as well.

Lovely. Great advice and really empowering and just keep up the good work. Thanks ever so much, Rupa, for coming today. No, it's a pleasure. Thank you, Louise. For more information about the perimenopause and menopause, please visit my website, balance, hyphen menopause.com, or you can download the free balance app, which is available to download from the app store or from Google Play.