The Dr Louise Newson Podcast - 201 - More than skin deep: menopause, skin and HRT doses with Dr Andrew Weber

Episode Date: April 25, 2023

Dr Andrew Weber is Medical Director of the Bodyvie Medi-Clinic in London and has more than 40 years of experience as a GP and 25 years specialising in advanced medical aesthetics and cosmetic procedures.   In this episode, Dr Weber and Dr Louise Newson discuss the impact of the perimenopause and menopause on the skin and throughout the body, the importance of hormones and benefits of HRT, and why it is crucial healthcare professionals listen to their patients.   The episode also covers how HRT has advanced and the importance of individualising treatment to find the right dose – Dr Weber likens HRT to buying a bespoke, made to measure Savile Row suit, rather than an off-the-peg outfit.   For more about Dr Andrew Weber and the Bodyvie Medi-Clinic visit bodyvie.com Follow Dr Andrew Weber on Twitter at @drandrewweber

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 well-being 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 in the studio I have someone with me who I've never met face to face, like a lot of people I seem to meet now, but he's another doctor who's got actually far more experience than me

and I reached out to him actually and spoke to him, I think, on New Year's Eve over some posting that he did on our advice and guidance platform and we started to talk and now I've poiked him into the studio to talk even more. So his name's Dr. Andrew Weber and he's a GP and has lots of experience in general practice but also in menopause as well. So thanks for coming to talk to me today, Andrew. It's my pleasure. So we started a conversation about dosing actually of hormones, didn't we? But before we get onto HRT, menopause, how we can individualise treatment, do you mind just telling me a bit about your background? As you said, I'm a GP. I have now retired after 33 years as a GP principal from the NHS.

However, I had contact early on with women's services, even when I was on my VTS. So I ended up running a once-weekly, well-woman stroke family planning clinic for about five years, which I finally gave up because general practice was taking over my time. I've drifted in and out of other bits and pieces with clinical assistantship in diabetology, which led on to being an associate specialist in erectile dysfunction, which actually makes general practice much more interesting. I have an FPERT, so I still have my lock for IUT, which is coming very useful now that we've got engaged much more with menopause management.

So that's my background. Within general practice, I think retrospectively, we're actually pretty poor at managing menopause in view of what we know now. And we stack to the old PremPack and Premarin and things. Gone of those days, I think we have a much fuller understanding now. In the late 1990s, we developed an interest in medical aesthetics with IPLs, lasers, Botox, Fillers. And with a certain amount of knowledge in dermatology, we took over skincare as well. And it's really only, sadly, after the knockback of 2002 and the WHOI report, that about six, seven years ago, we took a step back and thought, well, they're treating all these women. 95, 96% of our patients are women.

Most of them are 35 to 65 years of age. And they've all got one thing in common. and it's the menopause. So we started opening discussions with women about the effects of menopause on skin and the benefits of HRT, not primarily for the skin, but for general well-being. So since then it's developed and we now have quite a large following of patients who are on HRT. And it's so interesting, isn't it? because over the years people have changed in their perceptions of HRT and the number of prescriptions have changed a lot. But actually, women still have had many symptoms, often don't realize they're

related. And skin changes are very, very common during the perimenopause and metapause. And estrogen, but also testosterone actually, very important for our skin. And I always sort of have a bit of a joke with some of my friends because they always say, I bet you can spot who's on HRT just by looking at the. and it's sometimes because these people are happier, they often feel better, but you can tell by their skin. And there now is a big narrative that HRT is taken for a lifestyle because women want to have nice skin. And I really push back on that because, you know, yes, having nice skin is important, but there's other things. But the other thing that I think we all forget as physicians, but also in the public, is that skin is a active organ.

It's a very large active organ in our body. if our skin is looking well, it means that often our circulation is good, that our collagen is good and so forth as well. But if our skin as an organ is healthy, it's more likely that our other organs are healthy as well. So it's just a reflection of what's going on. And we've sort of forgotten often how anti-inflammatory estrogen is actually on our other organs. So on our heart and our bones and our brain and so forth as well. So it's sort of, the skin is a window often, isn't it, as to what's going on inside our bodies. And we've used that as an entry into perimenopause, menopause, what the symptoms are.

And we actually start that as part of our discussion about skin management, sun protection, vitamin C, vitamin A, retinoles. And also talk about what's happening as women are getting older. They're losing, let's say, 1% of their collagen every year, postmenopause, it becomes 6%. So it opens up that particular conversation about HRT. A lot of the time, we will give them a list of potential symptoms, not 90, but 34 symptoms, the main ones. And I've had women in their late 30 sitting there going, yes, yes, yes, kicking off all the symptoms that they have, they're still in there below 40. But then we know that one in a hundred

women has menopause below the age of 40. So there they are. They're actually diagnosing themselves. Some of them come back to us for the management. A lot of the other ones go to their GP. And they say, look, I've got all these symptoms. And this is because they've come in for an aesthetic treatment. So we're using our position where we have a lot of women who will are going to go through the menopause. And we can open that discussion and have a word with them about it and what can be done and what the benefits are. And that's what we sell it on. It's the long-term benefits. It's one, the control of symptoms and two, the longer-term benefits as well.

Yes, which is so important. And I think often, even today on my Instagram actually, quite a few people have posted that they've diagnosed themselves. They're in their 30s and 40s, yet they've been told they're too young to be menopausal. And I feel very sad actually because no one's too young to be menopausal or perimenopausal, are they? No. And also the women who've had a hysterectomy, which again can interfere with the blood supply to the ovaries and they can develop premature symptoms as well. Absolutely. And often, actually, we know from some studies that women who have an earlier menopause,

their symptoms can be more atypical, so not as classical. And a lot of younger women tend not to have as many hot flushes and sweats. And it might be that they have more mood changes or they have more joint stiffness or, like you say, skin changes. There's all sorts of symptoms. And I think the most important thing is that women aren't listened to and thought about hormones as an option. And I'm sure you're the same as me. I often say to women, I have no idea how many of your children.

your symptoms are related to your hormones. But what I do know is some of your symptoms might be related. And I do know that for most women, HLT is safe so we can try it and see. And if it doesn't work, we can stop. And we do that a lot in medicine, actually. We often try, you know, if someone's got raised blood pressure, we'll try one treatment. And if that doesn't work, we'll give them something else. And I think in general practice, we're quite good at adapting and changing, aren't we?

We are. I think we are. But as you say, I mean, I've had patients in who've been referred to cardio, because of palpitations. And it may be the sole symptom they've got, so they may have other ones as well. But we've tried them on HRT and it seems to have controlled everything. I mean, they went to see the cardiologist or this particular one, went to see the cardiologist. Everything was normal.

They couldn't find a single problem and she was better on HRT. So that was her sole sort of perimenopausal symptom. My wife's cousin, her only symptom was joint pain. She was, let's say, coming up to 60, late 50s. She was referred to the rheumatologist who couldn't find anything. She was put on anti-inflammatories and painkillers. Eventually ended up on HRT and she felt her proper age again. The pains have gone.

Yeah. And we see that a lot. And I know personally sometimes, if I forget the days, the week and I haven't changed my patches. The first thing I notice is stiff knees and stiff joints in my hands and it's really unusual. Well, it's not unusual. It's not even uncommon, but I'd never have thought about that before I started to do as much menopause were as I do because when I did a rheumatology job as a training as a general physician, no one taught me about the role of hormones in our joints and they're very good. They work as an anti-inflammatory, don't they in our muscles and our

joints? Yes, they do. Yeah. So I'm not meaning to be. rude about your age, Andrew, but you were around practicing, and indeed I was too, so it's fine, I can be rude about my own age. Before the WHOI came out, this big study that came out 20 years ago, the Women's Health Initiative study, which was the real nail in the coffin for HRT. It was. And before that time, we would give HRT a lot, wouldn't we? It would be quite a standard voice-line treatment for the menopause. But it was one-dimensional. Here's your tablet. You're You're on HRT. That's it.

Yes. Today's approach is different. It's titration versus control of symptoms. So I think, you know, we've come an awfully long way from just here's your prem-paxi, whatever it was. And you're on it. That's it. It's very interesting, isn't it? Yeah, because we've come, I think we've come a long way in one way, but then we've become

the wrong way as well because there's two things that has happened. There's a group of people that. have become very scared about HRT, both women and healthcare professionals, because of the WHOHI study, which a lot of you who are listening will know already that it was a big study that said to the world that HART caused breast cancer. Yet we know that it's unfounded and most types of HART are not associated with this risk and any risk they showed was not statistically significant anyway. But then, like you say, it was this pregnant horse's urine HRT with a single dose and also a synthetic progestogen single dose. And so there's a lot of people I used to give HRT to in that type.

They still come back with feeling, you know, a bit tired, joint pains, reduced libido. And I'll say, well, it can't be your menopause because I'm giving you HRT. And now, 20 years later, like you say, we spend a lot of time personalising HRT and making it very individual. And I tend to prescribe the hormones separately because then you have better control of the estrogen, the progesterone, the testosterone, and it's all this body identical hormones, so it's derived from yam plants, there's no horses involved at all, and you can really tailor it. And so I often say to women, I'm going to get the most beneficial effect from your hormones, and then let's see what's left. And we often try and achieve a physiological dose, so really

replacing what the body was producing before. And we can do that in a tailored way, which we couldn't do 20 years plus ago, could we? Absolutely. My analogy is, you know, HRT these days, it's not like going to M&S and buying an off-the-peg suit. This is a Savile row made to measure. And you can have 100 women.

They'll each need a different balance of hormones, a different amount. They'll all have different blood levels, and they'll have different control. And we've got to, it's like a plane. The hard work is actually taking off and landing. Once you're up there, you're on autopilot. And just keep an eye on it every now and then. But otherwise, once you've achieved that control and it's working, you're

probably okay for years to come. Yeah. And it's so true. And we often say to patients, it's a bit like chasing a moving target initially, especially when you start in the perimenopause, because your own hormones are changing, you're giving hormones, and it's very hard to even monitor with blood test because you might do a blood test at three in the afternoon when you're feeling fine. And at three in the morning when you're having a night sweat, obviously your hormone levels are going to be different. So blood levels can be a guide for some people on HRT. But we often give different doses. And I know personally when I started HRT, I was really hoping to be feeling amazing. And I'd been on it for about two months. And I felt no, I felt a little bit better. I wasn't

getting as much night sweats, but I still felt miserable and my joints were bad, my migraines were worse. I couldn't think my memory was terrible. So my consultant, I was under actually, did a blood test and said, oh, Louise, your blood test is low. Let's give you two patches. And I was very scared, actually, because I'd never prescribed a double dose of HRT. And I said, oh, I'm not sure I should do that. And he said, well, why? You're getting symptoms and your levels low. So I put on an extra patch and felt so much better within Lizard. literally a few days. And it made so much sense to me that we need to replace what's missing like we do if we're giving a patient with diabetes, insulin or a patient with an underactive

thyroid gland, they often need different doses of thyroxin. So my clinical practice now is tailoring it to their individual needs. And actually some women don't absorb through the skin very well. My patches crinkle a bit. So I know I'm not absorbing them very well, but it's just convenient to put a couple of patches on rather than putting gel on. Some women use the gel and it slides off their skin. It's like their skin is such a good barrier. They can't absorb it through. So the dose that we use externally often isn't the dose that's going in through the body either, is it? That's right. But the advantage of the gel, of course, is much easier to titrate. So if you're titrating up, they can just add in an extra pump or off a sachet or something. And they can do that

themselves with the patches, cutting them in half, and then they go and have a bath. I don't know how much water gets in there and what effect it has on the absorption. Well, it can really vary, can't it? And in fact, I know even the heat can vary, the absorption of the patches. I had one lady who's very young and she's got endometriosis, so the balance of her hormones was always quite cautious. And she said every time she sat in her car, it had heated car seats and her endometriosis pain got worse on long journeys. And I think it was just the heat. And it was just the of being in it and the warmth made it absorb better. But, and I think you're absolutely right.

And so all my consultations, I very much put the patient in the centre because I feel very strongly as a patient myself that I want to be in control of my body rather than someone else controlling me and telling me what to do. But I also feel the menopause should be a time where we are as healthy as possible. We reduce disease. And individually, we're the best version of ourselves. And for a lot of us, that is optimising. our hormones and we are all different and so as we've already said we absorb hormones differently

but we also metabolise them differently and need different amounts don't we? We do. That's right. And we know actually from evidence that I mean the problem is with the evidence regarding menopause is quite scanty because no one's done really good studies over the last 20 years and women's health is neglected for evidence and research but menopause especially so but we know that women with POI, premature ovarian insufficiency, so women under the age of 40, often do need higher doses than older women to achieve a physiological response. And there is some evidence that people with severe psychological symptoms, so low mood, anxiety, depression, actually need higher levels to affect the brain in a positive way. So we know that anyway,

don't we? We do. And some people actually need to have higher than the licensed dose as well. And it's very confusing when we talk about licensing of doses, isn't it? I think we use so many other medications off licence that it shouldn't be that confusing. Just because a pharmaceutical company has done the studies on such and such a dose, doesn't mean to say that somebody else doesn't need a higher one. And we are responsive as well to the patient's needs. And we are happy to go the same way we do with metformin and spirolactone, for other unlicensed conditions, we're happy to go beyond the license.

We do believe in blood testing. Yes, it may vary, but it gives you a ballpark that they are in. So we can keep an eye on it. But the most important thing is we are responding to the patient's needs, which are paramount. Yes, absolutely. And I think it's so important because certainly with other drugs, we often give different doses. and there isn't, well, it's very interesting, a maximum licence dose for thyroxin, for example. And I have, and I'm sure you have seen some women that need 200 micrograms of levo thyroxin and others are fine on 25 microns.

That's right. And I've never worried about that at all as a GP giving different doses. I've just given what they need. But there seems to be this sort of big worry. And we have a lot of GPs actually and gynaecologists who write to us in the clinic to say, you've prescribed a high dose of estrogen, we refuse to prescribe, and they're concerned. But when I speak to them and say, what are you concerned about? They just say, well, it's above licence.

But there is no evidence that a high dose causes any harm that I'm aware of. No, I'm not either. And it takes us back to the first thing you're taught in medical school is, listen to the patient. Yes. 99% of diagnoses are based on what the patient tells you. And here they are, they're saying, I'm no better. So it's logical that we actually increase the dose because we want to get a response. And then they'll say, oh, I'm much better now.

And then they tweak it a bit themselves. And they say, perfect. And they've worked it out for themselves. And also the balance between the progesterone and the estrogen. We have patients who've played and jiggled around with how they take it to minimize any side effects, maximize the benefits, and they come back and tell us what they're doing because they've worked it out for themselves. Yes. And I think women are quite intuitive, especially when it comes to hormones. And I've had a few patients who've had a hysterectomy in the past, but they were on HRT before their hysterectomy.

And they come back and they say, oh, Dr. News and I've actually started taking my progesterone. again, and I feel so much better. I'm calmer. My sleep is better. And again, I've had people right to me to say, how dare they take progesterone when they don't need it because they've had a hysterectomy? And I've said, well, there are actual benefits of progesterone. Some people, it's quite marmite, I find progesterone. Some people really like it and other people find that they're intolerant. But that's why we're all different. But you're absolutely right. I think if women have the knowledge, then they are allowed to try the dose a little, bit and I've done it before. I have a threshold where if I'm too low in my estrogen, it will

trigger migraines. And sometimes I thought, oh, if I increase my dose, it might trigger a migraine as well. But you almost have to get through that threshold. And then you come out the other side, it's a bit like your plane analogy. Once you're high up and you're cruising, you just wish you'd done it before. And it's really quite difficult. You're on autopilot up there. The difficult things are taking off and landing. But once you've taken off, It should be plain sailing for years to come. Yes. With a little bit of maybe sort of just slight adjustment.

Yes. And I think the years to come is also very interesting actually because I've posted a couple of videos on my Instagram recently about how long to take HRT for. And it's had hundreds of thousands of views. And there's still this confusion and concern that we need to stop HRT after a certain time or after it been on it for a certain length of time.

There's no reason for that, is there? No, no. I think our oldest patient is 86. Her GP took her off. She was miserable. We put her back on. She's now got a toy boy of 60-something and enjoying life again. Yes.

Yeah. Well, my mother-in-law, she went on me saying, she's 86. And she started HRT when she was 38 because she had a hysterectomy when she was 36 and had just over a year of feeling absolutely awful. She said it was a cloud. was over her and she managed to get hold of some estrogen. It was a long time ago now. And there's no way on earth anyone's going to take it off her. And it's absolutely fine. You know, she's fit and she's well. She's independent. She lives on her own. It's wonderful to see. And of course I don't

know whether she'd be like that if she wasn't on HRT, but there's no reason for her to stop. And it suits very well. So the whole point, I think, is allowing women to have a choice and us as doctors to enabling them to be safe, but have the right dose and type of HRT and other medication if they need it that's suitable for them, isn't it? It is. And it takes us back to the point I made, listen to the patient. They will tell you what their needs are. And it's for us to then respond to that. Yes. It's not, you know, you're on this, that should be working. Well, if it obviously isn't, listen to the patient. Yes. And you're right. I mean, you know, when I trained and same for you, it wasn't so easy to get scans. Even MRI scans weren't really around when I first

qualified. I did a neurology job and, and it was very hard. We had to listen and examine the patient really, really carefully, a lot more than now because we didn't have the beauty of tests. But Menopause actually doesn't have the beauty of tests, like you say, blood tests can sometimes help, but 99% is in the history. And I think we've lost this art sometimes. And I think the more I read about women's health in history, but also recently as well, that women are not being believed, they're not being listened to. It's almost like we make up these symptoms.

They're in our heads. And I think we have to change this narrative and really listen and believe women and try and help them actually, rather than being barriers and blocking and saying, how dare you ask for your hormones back? How dare you ask for HRT? How dare you think your joint pains could be due to your hormones? Let's try and learn from our patients, because I learn every day from my patients.

And they will tell you what their needs are. We give them a carte blanche. Here it is. Here's your gel. If after sort of four weeks, there's very little improvement, up it. And then we'll see you, you know, two, three months later. and we'll find out where you are and what's working, what isn't, and take it from there. Yeah, which is great advice, and I'm just pleased that we sing from the same hymn book as it were.

And it's lovely that, you know, I think it's the most transformational medicine that I've ever practiced. It's very rewarding as a doctor to be able to help so many people in my clinic, but it's also very frustrating listening to the people that are suffering. So there's lots more that needs to be done. But before we finish, Andrew, I'm going to put you on the spot because I always ask for three take-home tips. So I'm just going to ask you, if you don't mind, for three things a woman could do if she was on HRT already, but feeling that her dose wasn't quite right or that she was still getting some hormonal symptoms, what would you suggest that she could do to help?

Be flexible. I mean, control your medication because I've already said that. You're going to know what works for you, what balance, what amount. That's really the first one. In terms of pump priming, we start discussions in the 30s because we're talking about skin. And we make patients aware of what potential symptoms might be what to just keep an eye out for, that they may be hormonal. So at least, you know, they can come to us. And the third one, I was a GP in Chiswick for 33 years and I had a local pharmacy and there have been shortages of HRT.

Now, he's twigged onto the fact that I prescribe a lot. He has everything in. So he's actually found a little niche. We tell our patients, look, he's got everything. He'll update me on what he's got, what he has. hasn't got. So test him's out, he's got it. You name it, he will have. And then, you know, once a month he'll phone up and say, look, I've got it back in. So we're aware and we can actually send our patients not so much to him, but to contact him because he's happy to receive the

prescription and then post out. So yes, that would be number three. Have a friendly pharmacy that has everything in stock. Very good advice. And the most important thing is, If you're not getting help from the first person, there are always other people that you can see. So people shouldn't be suffering alone. Yes. So thank you ever so much for your time. It's been great. Thank you. Thank you. 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.