The Dr Louise Newson Podcast - 168 - The facts and fiction about menopausal skin with Dr Sajjad Rajpar

Episode Date: September 6, 2022

Dermatologist, Dr Sajjad Rajpar makes his third visit to the podcast this week to separate the facts from the fiction about skin changes in perimenopause and menopause and debunk some of the messaging around recent skin products marketed for menopause. Dr Rajpar explains the importance of estrogen for skin and how HRT can prevent and heal damage to skin tissue such as leg ulcers, for example. The experts discuss the negative impact of skin product marketing on initially younger women and now menopausal women, and unpick some perceptions about what a ‘menopausal’ face cream will and won’t do for your skin. Dr Rajpar’s three tips for problematic skin: For dry and irritable skin, avoid foaming and detergent based cleansers and use very gentle cleansing products or even a moisturising lotion to wash with. They may not lather or bubble but they do adequately remove dirt from your skin. Use a good moisturiser once or twice a day, consider a lotion in the day as it is lighter and use a cream at night. There are creams containing active ingredients that don’t have to rob the bank. Look for ingredients like retinol, vitamin C, and sunscreen. You can visit Dr Rajpar’s website here www.midlandskin.co.uk and follow him on social media @dr.rajpar_dermatologist on Instagram.

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. Today on this week's podcast, I'm really delighted to reintroduce to you, Dr. Saj Rajpar, who is a very well-recognised and highly esteemed dermatologist who I work very closely with and always enjoy

talking to him and his podcasts and events that we do together always have phenomenal feedback. So I hope you're going to enjoy this one as well. So welcome, Saj. Thank you very much. Louise, it's great to be back on. So we were recently talking. We did a balanced live event together with a lady who'd noticed some skin changes when she was going through her menopause. So I wanted to bring you on today to talk about skin changes because they are so common and what we can do about it.

And we also want to talk about some of the marketing of some products that are sort of coming out thick and fast, actually, which really scare us. And just before we start, I really want to sort of. declare our conflicts which we don't have. We do no paid work with any pharmaceutical company and we certainly don't endorse any products that are related to the menopause, do we? No, no, absolutely not. So we have no hidden agenda here is what I'm trying to say. All we're trying to do is educate and empower as many people as possible. Absolutely. And share our points of view. Yeah. So skin is interesting because a lot of people just see it as a covering for the body,

which of course it is. If we didn't have skin, we would look quite horrendous because all our muscles would be exposed and our blood supply and everything else. It's very important, but it's actually a very biologically active organ, isn't it? So can you explain what skin is and what it does for us, Saj? Yeah, absolutely. It is a very biologically active organ. It's the biggest organ in the body and probably accounts for 15% of our body weight. Wow. And the skin has many, many important functions and as you mentioned it keeps the outside out and protects our muscles and our soft tissues but it also has several other functions it helps us regulate our temperature it allows us to have the sensations of pressure touch cold heat pain and all those things actually protect our body

it keeps environmental toxins and microbiological organisms out and it has a very active immune system. So the skin is comprised of many, many different types of cells. Some cells produce collagen to give us structure and protection. Other cells are involved in the immune system. And then we've got a lot of nerve endings that give us those sensations that we just mentioned of touch and pressure and heat and pain and allow us to function on a day-to-day basis. So really important. And it's really important that it's as healthy as possible because once we, we're we start to have changes in our skin, it can obviously cosmetically affect how we look, but it can be very disabling, actually. I've seen a lot of women who have such dry, itchy skin

that they can't sleep, they can't work, they can't concentrate, they can get a lot of soreness. And it's really difficult, actually, to explain. But if anyone's had generalised itching, it's different if it's just on one area, but if it's over the body, it can be really disabling, can't it? Oh, absolutely. Itching and itchy skin conditions can really strongly impact an individual's quality of life. It stops people from sleeping properly. It stops people from being able to concentrate and work properly. They can be extremely embarrassed about the problem as well. And there's a lot of stigma attached to itchy skin conditions. And sometimes itch can lead to more itching and you can be trapped in this very vicious cycle that you can't get out of. Yeah, and it can be extremely

disabling for people. So it is really important to try and get on top of skin complaints as quickly as possible because of that. Yeah. And so during the menopause, as we know, a perimenopause when hormones start to decline and the menopause hormone levels are low and stay low forever, we know that estrogen, estrogen is a very biologically active hormone, as is testosterone and progesterone, But we know there's some really beneficial effects of eustodial in the skin, aren't we? So when levels reduce, what happens to our skin? I think we are starting to understand that estrogen is quite important for the structure and function of the skin. And it's really important that we think about the skin as something that produces benefit to us and functions and needs to function well.

And one of the functions is the skin barrier, which is what protects the skin. And that's comprised of cells and oils. And they're arranged almost in a sort of brick wall type pattern. So you've got the bricks and the mortar. And they're glued together and they protect the skin. And we find that with skin where estrogen is lacking, the skin barrier function is not as good. And that may be because we're not producing as many greases

that are the mortar, if you like, between the bricks. And so the skin has a tendency to dry out. And so dryness is often the most common complaint that we find that patients get. And when the skin dries out, it might start not shedding properly. And that's when we start seeing scaling and roughness. So the skin may feel dry as well. And that's part and parcel of the function that's lost in the skin. There's one other thing that it was very interesting to hear in the Balance Live the week before that we did our Balance Live with Shelley,

which was that you had a very young lady. I think her name was Ellie, and she mentioned, and she had a premature chemotherapy-induced estrogen deficiency. And one of the things that resonated with me was she mentioned this sensation of, I think she said ants. I think she said it was like as if there was ants all over my skin. And many people will actually describe that. And the skin can reflect, you know, when something else is wrong.

So it doesn't necessarily mean that there's. there's a problem in the skin at that point of time. It can be actually a reflection that there's some other imbalance somewhere else. And in her situation, I did wonder, was the estrogen actually, you know, causing a problem in the function of the nerves in the skin? Yes. And we do know that nerves have got estrogen receptors. We know that the skin has got a rich number of nerves as well.

So there can actually be that sort of those sensations, those phantom sensations, Tartile sensations that aren't there that make people think that there's a sensation on the skin, but actually it's the nerves tricking the brain because they're not functioning properly. Yeah, and that's very interesting because we know that estrogen and testosterone actually help with the physical nerves. And a lot of people get pins and needles, some people get tinnitus, and this sort of formication, this spider ants crawling under the skin is probably a combination of reasons, but we know low estrogen is a really common cause of that. because it improves when we replace estrogen.

So our nerves are really important running through our skin, but also our blood supply is really important as well, isn't it? Because our blood, as many of you know, leaves the lungs full of oxygen and goes all around the body and gives us oxygen that all our cells need, but also nutrients, because every single cell has its own individual mechanisms, really, and it all needs glucose. It needs good chemicals to function,

but it also as byproducts produces toxins as well, all these processes that are amazingly going on in our body, produce toxins which the veins have to then take back through the liver, which is a lovely great big sieve to get rid of all the yuck that's going in our body and then back to the lungs to be oxygenated again. But if we don't have good blood supply, then that's going to affect our organs. And we know that as we go through the menopause,

our blood cell, or the lining, of the blood cells, the endothelium become more inflamed, they've become thicker, there's more risk of heart disease, we know that, but also if the blood going into the skin is not as freely able to because the blood vessels are narrowed and diseased, what happens to the skin then, Saj? Yeah, absolutely. The skin needs its blood supply and it's very important, especially when there's a wound, that there is an adequate amount of blood going into the skin so that the wound can heal And we know very interestingly that a study that was actually done in the United Kingdom and published in a very reputable journal called The Lancet showed that women on HRT had a one third less chance of getting leg ulcers or pressure ulcers on their skin than women who were not on HRT. And it may be that one of the mechanisms that tissue and wounds heal better is because there is,

is an increased blood supply. And we also know that in clinical studies where an injury is made to the skin in older people, both men and women, if you apply estrogen on that wound, the wound heals faster. And one of the things that is noted is that there is better new blood formation. So there's new blood vessels into the area of injury for much quicker in the presence of estrogen. And there's also less inflammation. And it may be that the lining of the blood vessels, as you mentioned, have less inflammation as well. And so wounds are seen to contract and heal at a faster pace in the presence of estrogen. So this is where the function of the skin seems to be improved when the hormones are replenished. And that's really important actually. So we talk

cosmetically about skin, how it feels, how it looks, whether it's dry. But leg ulcers are actually really common and very disabling and certainly when I did general practice for many years I'd often go and do visits on people that started off having a little knock on the table on their shin and the skin over the shin as you know is very thin if there isn't much fat behind it there's not much cushion so it's just straight next to the shin bone once there's a little wound if it's not getting good blood supply it's not able to heal well then it can break down and break down and then ulcers can often develop and They're often venous ulcers. So they're not excruciatingly painful, but they're very prone to infections.

They're prone to just this low-grade inflammation, but they can really affect mobility, and they're more common in women. But also they cost a lot of money to the NHS because these ulcers often take a long, long time to heal. So there's multiple visits, usually by district nurses, often very expensive dressings. Often people need antibiotics because they can get more inflamed. and infected quite commonly. People find that their mobility reduces, so then they're more prone to chest infections, urinary tract infections,

more prone to be going into a nursing home or residential home, so less likely to be independent. So they are a real problem. And I know you worked out the cost, didn't you? How much do the leg ulcers cost, the NHS? Absolutely. I'm just bringing that note up. And actually, I've got it down here, that Nice, the National Institute of Clinical Excellence,

has estimated that it takes two billion pounds per year to treat Legos. And I believe that data is four or five years old now. So at least two billion pounds a year. Absolutely. And Legosers are approximately twice as more common in women as they are in men. And, you know, a third reduction would have a massive impact in the quality of lives of those people just for the reasons that you mentioned and, you know, how a trivial not can actually turn into sepsis and chronic wounds and also the cost of healthcare in the UK. Now, we don't know the exact

mechanism, we should say, you know, we don't know the exact mechanism as to how this data could be a claim as to why there is a third reduction. It could be that women on HRT are more active, and it's through that mechanism. It could be through the direct tissue effect on the skin. But, you know, there is enough there to suggest there is a hugely beneficial effect and that, you know, this needs to be taken into account in health policy planning. Absolutely. And I think the problem is when people have been very scared, as we know, about estrogen and HRT for the last 20 years, and even now, every day I'm told reasons why we shouldn't be prescribing HRT. But actually, if you look back in the biology, in the physiology,

the pathophysiology of how eustodial works and how low esterdial can be associated with disease, it actually is just common sense medicine a lot of the time. It's not rocket science. I'm not promoting anything that's new or fancy or even expensive. It's dirt cheap. And so we have to look at the basic reason and look about why is it that women have estrogen. You know, it's not there just for fun.

It's there because it's a really important hormone biologically in our bodies. And so a lot of people think now that there's this demand for HRT because women want to look well. They want to have this. divina effect. But actually, I'm really worried about my bones, actually, more than anything else. I really don't want osteoporosis. And I quite like not to have heart disease, diabetes, dementia, and I want my mood to be good. So there's lots of reasons why I take HRT. But when we think about the skin, a lot of people just think it's about a face. And yes, certainly when I was

perimenopausal, my skin would often be quite sort of lifeless, really, very very dark. My complexion wasn't glowing or bright. Even when I wasn't tired, it just didn't look the same. And my skin was drier on my face, but on my body as well. But somehow for women, it's all about our faces, isn't it? I think people forget that we have skin elsewhere. Yeah. So now there's a lot of products talking about skin, but not about the body.

It's just about female faces, isn't it? And, you know, that scares me because, you know, I'd like to think I'm more. than just my face. Obviously, it's nice to have, you know, it's glowing skin when I'm not tired and it's great we can put loads of makeup on and cover up our blemishes and our bags. But actually, I want people to admire me for my brain, not my skin. But there's this massive marketing. It's gone on for a long time. In fact, my 17-year-old wrote a great article recently about the gender inequality of advertising and how it's still there, the 60s. It was, you know, looking great for your husband coming home from work.

And now it's about just looking great so you can have more sex or what have you. And it's quite awful. It's very disparaging for women. I find it very insulting because men's products are increasing, but they don't have the same advertising. They don't have the same sort of pull. So we've been looking around at the menopause market. And there are a lot of menopause products that have been around for many years.

There's a lot of menopause branded supplements. all sorts of things. And most weeks I get asked to be a face behind, a name behind something, and I'll just say a blanket, no, I don't even accept any of these products to even look at. But Menopause face creams have been intriguing because we've both been behind the scenes for, I don't know, a couple of years now looking at some of these products. And also, we've been really trying hard to do research in this area. We have got some great links with some amazing people at Bradford University that we're hoping to do.

some proper research looking at the effects of eustodial and testosterone in the skin, which I think is going to be really exciting actually once we start with that. But in the meantime, other groups have been doing some work. Not some really high-brow research either, but what they have done is marketed it very well. So tell us about what's going on at them, Saj. Yeah, I think all of that Louise was extremely well put. And to your comment on the gender inequality on advertising, it is so real and it is having such a negative impact on so many young women, especially those who are on social media, but now the target audience has now become the perimenopausal and menopausal woman. And it is very disturbing. And, you know, the facial skin accounts for 3% of your skin

surface area. Hang on, 3%. So that's very low, isn't it? It's very low. So we've got to not forget the other 97%. And, you know, when I give talks, I constantly get asked. And this can be from medical and from non-medical people, I should add. And they will say to me, well, why don't I just put the estrogen gel on my face? And my answer to that is, if we're just talking about the skin now, what about the other 97% of your skin surface area?

does that not matter? And, you know, it's the leg ulcer in 20 years time that I'd much rather hear that you prevent it than, you know, a fine line that might have improved for a few years on the face. And, you know, that's what I'll say? And then I'll say, well, what about all the other benefits to your bones, your heart, your brain, your metabolism, all the other, you know, issues, how are you going to obtain those benefits by trying to target your facial skin? And marketing, it has become, very much like that something suddenly will happen at the menopause and that you've got to suddenly take some corrective action and that this is going to come in the format of a facial cream. And that's simply not true. The change of in the skin of the menopause and, you know,

what is the menopause? Is it where would you draw that point in time? And, you know, if you started HRT and the perimenopause, did you have a menopause? Are you menopausal then? You know, what is the definition? It's the first thing. Right, Saj. So, for example, I started taking HRT when I was perimenopausal. I was getting irregular periods, lots of menopausal symptoms, finally realized what was going on in my own body, started taking HART, which I've been on for several years now. But actually, the only way of me knowing whether I'm menopausal or not is stopping HART, waiting for a year to see if I have a period. Well, actually, in the meantime, since I've been perimenopause and I've had a hysterectomy,

so that's never going to happen that I'll have a period. But I stopped. have my ovaries in me. So are they still working or not? I have no idea, but does it matter? Of course it doesn't. And that's where HRT is weird because we call it replacement. I'm not replacing hormones. I am just giving myself back hormones. So some countries call it MHT, menopausal hormonal therapy. And I think that's actually a better term for it because it is just hormones that I'm having. But whether I'm perimenopausal or menopausal, it doesn't matter because my hormones are low, just because I'm older. So these creams, I think, number one is they're marketed wrong because they should be perimenopausal and menopausal, but that's too long, obviously, to put on a label. So, you know, like you say, there's no test for menopause. We can't do a blood test, a saliva test, a urine test. So, I mean, by default, most women in their 50s will be menopausal. But actually, one in 100 women under the age of 40 will be menopausal. Are they going to market these creams on 20-year-olds, 30-year-olds, or a teenager like Ellie, who, you know, who, you. you said she became menopause or when she was 14.

So they haven't quite worked out their market audience first. And, I mean, if I had a new product, the first thing I would do is do market research to work out who is my target audience. But these creams seem to be aimed at middle-aged women who often have a bit more money, have got a bit more time maybe, if they haven't got the children running around so much or their children have gone to university or whatever. They're certainly targeted at, you know, these sort of older women, sort of women that you, when you Google menopause, it's still that grey-haired woman with a fan.

And most of us are not that when we're menopausal. So I have an issue with that from the start. And then let's look at the ingredients. What's magical about these creams? I know you've been looking into what they contain, Judge. Absolutely, Louise. And I absolutely share that view as to when does somebody define the onset of the menopause. And I looked at six products that are available or are going to imminently be available on the UK markets,

five of them are available at the current time, and these are marketed as menopause facial creams. They all claim to put back what the skin is missing because of the menopause, and we know the only thing that can actually restore that is restoring estrogen, which is the reason why these changes may well have occurred. And I looked at the active ingredients in these products, and I established that a couple of them had four active ingredients, some had six, one had eight, and another had nine.

And when I looked at what kind of ingredients they were, some had antioxidants, and these are chemicals that reduce free radical damage, and we know about these in dermatology. We've known about these for years, and they're used in anti-aging products anyway. Some contained botanical products, and it wasn't clear what those botanical products would do,

and some contain peptides, and we've known about peptides for a number of years as well, which are collagen stimulating chemicals, and all of them had a moisturising effect. So they were all effectively moisturise it. When I looked at the active ingredients and I said, well, is there anything unique about these active ingredients that would make them special for the menopause?

Then in six out of six products, I said, no, there was nothing unique about the menopause. in those products. And the next question I asked, well, would this product work as a moisturiser for a premenopausal woman or a man? And I concluded that all six products would work equally well in a premenopausal woman or a man as a moisturiser and hydrating agent and an antioxidant if that was their primary mechanism of action. So my conclusion was there was absolutely, nothing unique about these products as being anything specific for the menopause. There was nothing in the active ingredients that would suggest that this would be the case.

I think it is just a marketing ploy and we've got a group of very potentially vulnerable women who may feel that they're starting to see some changes. And of course, we look at our facial skin more than we look at any other skin. So we're going to recognize those changes on the face and then be allured into obtaining products that probably do not outperform an equivalent moisturiser or another anti-aging product that isn't marketed for the menopause. And one of the other things I just want to draw attention to is the price point. And this is really important. And the moisturiser that I would recommend for, you know, any person, young or old, and of course we deliver skin care based on

the skins need. So if you're 20 and you've got very dry skin, you need a heavy moisturiser in the same way as if you're 65 and you've got very dry skin. And a good over-the-counter moisturiser is £3.17 per 100 mil. And these facial moisturising menopausal products started at £31 per 100 mils. That was the cheapest one. The next one up was £54 per 100 mils. The next one was £64 £100 mil, then £66 £100mills, and then the final one was a whopping £154 per 100 mill. So you can see that you're talking about price points

that are 10 to 50 times more expensive than a potentially equivalent acting product on the skin. That's all really, I mean, it's really interesting, but it's also really scary. I mean, that's more expensive than champagne, isn't it? Yeah, yeah. It's just the marketing thing. It's really scary because for most of us, if we don't have time, we don't have the knowledge,

we don't have the experience that you have, SaG. So how can we know? We look at the marketing and the branding and their well-known brands that are reliable brands, you think great. And I was reading a review of one of these products, someone who was tested it, and she said that her skin felt noticeably softer and plumper in the morning. But that's no surprise, is it, from what they contain. And when we look at one of the products ranges, they've been tested on quite a small number of women, although they say on their

label that they've been, you know, produced with men and palsal women, the market research has been low. But even the medical publications, one of them you looked at, it's very low numbers of people that they've looked at. Yeah, absolutely. Sometimes the data will include only a handful of patients. And I think the issue now goes down to what other criteria required to legally advertise a product. And the actual threshold is very low for cosmetic products compared to pharmaceutical products. Okay. So anyone can make claims based on patient's perception. So if somebody perceives their skin to feel plumpher and they are menopausal and then it is possible to make a claim therefore to say that, you know, menopausal women felt their skin felt plumber.

However, you know, we know as you say, that probably anyone's skin would have felt plumber with those products because there's nothing unique in them that is special for estrogen depleted skin. And of course, that is no longer required if that woman had access to advice on HRT. So it's only those small number of women who, you know, even if there was a product, So let's just turn this around and say, look, there is a product out there that is so special for, you know, so unique for menopausal skin. Then that only becomes an option when a woman has had the opportunity to have the information presented to her about how to replenish estrogen for the body, the risks and benefits. And she's made a decision not to proceed.

And then I think that would only leave a very small number of women out there who then might say, actually, yes, I want a product that is potentially unique and does something unique for the menomies. And then you've got to say, well, how am I going to apply this to, you know, 100% of my body surface area? Because it's the skin of your whole body. You know, the surface area of the skin, just to put it into context, is the size of a very large bath towel. So you've got to apply something on there normally twice a day to get the physiological benefits of estrogen. So when I'm looking at a product and, you know, feel free to contact manufacturers. I think that, you know, the public will do this extremely well and say, well, look, Is there anything unique in this that is specific for menopausal skin?

And is there anything that would mean this wouldn't work in a man or a premenopausal women? I would actually challenge the manufacturers to answer those questions. It's so important that we know. And I think the other thing that really worries me as well is about the research side of things because, as you say, it's very different if it's a supplement. So all supplements come under as just food supplements. So that means they're not regulated or licensed like prescribed.

medications are, but that's the same with beauty products as well. And so finding new science in menopause is very difficult. There's very little funding for proper menopause research. Even within our patients, we're looking at symptom improvement with estrogen, but also with testosterone. We did it a few years ago and we had just short of 200 women and we found that their symptoms significantly improved. It was statistically significantly improved of their mood symptoms. their physical symptoms and their basimotor symptoms. Yet we were told it can't be published because it's probably a placebo effect. So we've now got thousands of women that we're looking at their data. You know, we're obstructed all the time because there's so much resistance to

women's health research as well as menopause research. Yet I could do a stupid study with six people in it and say there's maybe some changes and then I can produce the most rubbish face cream and fleecing women. And it's a time. when we were in a financial crisis. You know, if I was spending all that money on a face cream, which meant that I couldn't buy my children's uniform or I couldn't put a good meal on the table, you know, these are real decisions, aren't they, that people are making.

But women I know, because I speak to enough of them, are desperate to feel better and also desperate to look better. So the marketing side of this is, and we've only seen the beginning, So we'll have to come back and talk about the hair products that are starting to happen. That's a whole other conversation. But, you know, this is just the beginning of a conversation. And I think what we have highlighted today is about how skin is a window to the rest of our body. If our skin is changing, our internal organs are changing as well.

So we have to be looking from within. And we know that eating well, exercising, sleeping, all these things help our skin from within, but they'll also help our organs and our future health as well. So the sort of take home really is that slapping anything on your skin is not going to improve your general health. And for both of us as physicians, we're very keen to improve people's future health in a very holistic but evidence-based way. So I'm very grateful for your time today, Sadd, and I know you will be coming back, I'm afraid, to the podcast to talk more. But before we finish, so three take-home tips. So if people are having problems with their skin, so it's dry, it's itchy, it just is changed in appearance.

And they do want to look better, not just with their face, but their skin in general. What three basic tips can they do to just improve their skin that's not going to rub the bank? Yeah, absolutely. So if they've got dry, irritable skin, basic tip number one is avoid foaming and detergent-based cleansers and use very gentle cleansing products or even a moisturizing lotion to wash with. And this is a completely novel concept for many people, but it is a standard of care in dermatology for anyone with sensitive skin. And while these moisturizing creams don't lava or bubble,

they will adequately remove dirt from the skin and help your skin feel less dry after cleansing. Number two, use a good moisturizer that you can put at least one, or twice a day. And I often recommend to patients that they use a lotion in the daytime. Lotions are lighter and a cream at nighttime. Cremes are heavier. But if you find creams too heavy, just stick to using a lotion. And number three is that there are active ingredients out there in skincare that work and that have been tried and tested and have been present for a number of years and they don't need to rob the bank. And what I'll do is I'll put a list that we can share on our social media,

but look for ingredients like retinol, vitamin C, ferulic, and sunscreen. And sunscreen is one of the most important anti-aging products out there that will help protect the skin and reduce deterioration in collagen. So those are very simple things that everybody can get on with very easily straight away. Brilliant. Thank you. And as ever, thank you so much for your time today and sharing some of your knowledge and experience. So thanks, Saj. You're welcome. 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.