The Dr Louise Newson Podcast - 202 - What does the future hold for menopause and HRT? With menopause activist Kate Muir

Episode Date: May 2, 2023

Making a welcome return to the podcast is menopause activist, author and documentary maker Kate Muir. Kate is the author of Everything You Need to Know About the Menopause (but were too afraid to ask) and the producer behind Davina McCall’s two award-winning menopause documentaries; her third documentary, investigating the contraceptive pill, is currently in production. This week, after more than 200 episodes of the Dr Louise Newson Podcast, Kate is the one asking the questions. She asks Dr Louise about her hopes for HRT and menopause care over the next decade, and about the importance of hormones for healthy ageing and prevention of future disease. They also discuss barriers to accessing HRT, the so-called natural approach to the menopause and tackle claims the menopause is being over-medicalised. And in place of the usual top three tips, Dr Louise shares the four things in her handbag that she can’t live without. For more about Kate visit her website Follow Kate on Twitter @muirkate and Instagram @muirka Kate Muir photo credit: Suki Dhanda  

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 the podcast I've got with me somebody who has been on the podcast before and hopefully a name that you'll all know, Kate Muir, who is the most amazing now producer, didn't used to be, and she's produced the two Davina

documentaries about HRT and the menopause and now she's working on a contraceptive pill one, which I'm going to get her to come back actually and talk about once it's out later this year. But Kate and I met some of you might realize a little while ago, and she actually became a patient, and I'm not breaking confidentiality because she's shared the story before. And actually, she's a very straightforward patient. It wasn't straightforward her story, but I knew that she needed the right dose and type of hormones.

So once I did her consultation, we started talking about the injustice to women, and the sheer horror of what's happened over the last 20 years or so with women not being allowed to have the right information to make the right decision. And she has now become a very vehement campaigner for the right education, the right treatment for women and has written an incredible book, as well as read probably nearly as many references and articles and papers and scientific journals that I have, which is no mean feat. So Kate, I asked to do the podcast today, and she decided to spin it on its head a bit so she can explain more what we're going to do over the next half an hour or so. So go for it, Kate.

Well, I decided, Louise, that you've done over 200 podcasts and you're always asking the questions. And I actually have a lot of questions to ask you. And often you're sitting there agreeing with some expert. And I know you often know more than they do about something. And I just wanted to get a feel for the really big picture in menopause, because we're always looking at the kind of little niggles and the problems and debates. And I want you to come with me today and imagine the future. And almost the first thing I want to ask you is, how do you imagine menopause will be in the UK in 10 years' time? what do you think will have changed? Well, do you know what? I have so many mind games and I think a lot about what the future could look like

and what the future would look like and how much is reality and how much is in my dreams. And there's two things, as you know, are very different when you're talking about helping women because there's so much that's stopping and there's so much potential. But it's how we unlock it. Because I think once it's unlocked,

it could go very quickly. And I feel it's that whole, we take two steps forward and one back. And I think actually when it's about women, it's probably one and a half back. And what is moving this whole conversation forward is women, actually, more than healthcare professionals, more than thought leaders, more than politicians. It's actually the grassroots of women and they're the ones that are affected. So I really think a lot about how the world and the UK, obviously, would look, like if all women who wanted hormones were able to get them. I'm not only get them, but get them

in the right dose and type, because as you know, about a third of women who come to my clinic are already on HRT. So 20 years ago as a GP, I'd give someone awful, you know, horses urine HRT, because that's all I had available. And they'd come back with some symptoms. And I would say, well, it can't be on menopause because you're on HRT because I didn't know anything else. I didn't know I could change the dose. I didn't know about testosterone. But now I do. And so if women have the right dose of estrogen, the right type of progesterone, if they need progesterone, and they were offered testosterone to the majority of women, not the minority of women, then how would it look? And I really dream that it could happen. And I think with more patient choice, with more availability of HRT,

with more access to the right information and knowledge, backed by science, of course, then 10 years actually is quite a long time. And I think that's quite ambitious, but actually I know what I've achieved over the last seven years with very little money, with very little resources. I've never had external funding even for the app. So I feel that this momentum, if it carries on, we could achieve so much more where women are not fobbed off, women are able to have what they want. And then the bigger picture of women's health being better,

women being able to stay working, women be able to be promoted at work, women be able to lead households in way that they'd not be able to, women who can lead communities as well. And having the conversation, not just for British women, but for women in all cultures as well, the world would be so different and the UK would be so different. and the UK would be so different. I see all these nursing homes and residential homes being knocked up all the time.

They're full of menopals or women. We wouldn't have all those. We could have, you know, different things. You know, the whole generation below could be completely different. And I would be so proud if it could happen because I think you, me, others have really played a big role in history making, actually. Yeah, and I think understanding, you know, about longevity and one of the things you mentioned to me the other day,

which was inflammation. And of course, we love ageing and we love being wise, but we do not want creaky joints and we do not want our bones turning to crunchy bars, and we do not want to be the one in two women who get osteoporosis. And I just wanted you to tell me a little bit about what the better kind of hormones,

the transdermal estrogen and the body-idential hormones are going to do to me, like think of me, I'm 59 this weekend actually. But, you know, normally between 60 and 70, that's when things get creaky in a woman. And I want you to tell me what's not going to happen to me. How is taking testosterone, estrogen and progester going to protect me for what is about to land? Yeah, and this is really interesting because when you think about aging, if we start with this first, I read a really great paper recently written in an ethical standpoint about is aging a disease or not. And for years, we've been told you can't have a disease if it affects the majority of a population

because then it's thought of as being normal. But how do you define ageing? Is it a number? Sadly, you're going to be older at the weekend than you are now. We're aging all the time, aren't we? But when aging is associated with disease, this is when it's a problem. And as you say, this whole inflammation, aging, this low-grade inflammation. that occurs. If our immune systems aren't primed and really healthy, of course we can get

infections, but also we can get other diseases, these inflammatory diseases that occur, are actually the diseases that are very common. So cardiovascular disease, diabetes, dementia, osteoporosis is even an inflammatory disease. We know a lot of mental health conditions, so clinical depression, schizophrenia, even Parkinson's disease are inflammatory diseases, obviously inflammatory bowel diseases and autoimmune diseases can be as well. And we know they're more common as people age, but we also know from some very interesting studies, once women are menopausal, they have this accelerated aging and this accelerated risk of these inflammatory conditions.

So none of us really want to age, but we are, that's fine, we can't stop that. I'm not bothered about a few wrinkles, but what I am bothered about this accelerated aging, this inflammation that can occur. And we know that there's all sorts of reasons why we get inflammation. One of the reasons is eating a rubbish diet. So if I fill my body with ultra-processed foods, then I'm going to have more inflammation in my body. If I smoke.

Yeah, that's really interesting because if you look at those brain scans of people in your worst Western diet, basically the brain scan on McDonald's and the brain scan on vegetables and fish, you actually see there are these huge, holes in the brains of people who are living on a rubbish diet and it's really frightening. It's very scary. So we know diet has a massive role to play. We know that obviously smoking, alcohol, of course, has a role to play. Not doing exercise has a role to play as well. So all these things are choices, of course. We can all decide if we want to eat processed foods and

takeaways every day or we could, you know, cook from scratch or whatever. That's our choice. The problem is with women, we don't have a choice as to when we don't have hormones in our body. For a lot of women, it's just part of aging that our ovaries stop working, as you know. For some women, that choice actually is a bit different because they have their ovaries removed. And we know from Walter Rocker's work for the Mayo Clinic that women who are under the age of 40 who have their ovaries removed, i.e. become menopausal overnight, have this accelerated aging. They have a lot of methylation of their receptors. They have a lot more aging.

and all these diseases I've mentioned and more, including kidney disease, lung disease, even psychosis and drug addiction can increase because of having this early menopause. So with ageing, we all want to be healthy. It's about how we live. It's living healthily for longer. So it's not the number that we die or the age that we are. It's that journey and it's about preventing disease and keeping as healthy as possible. So this is where hormones do have a role, like all these other lifestyle interventions,

but we know that there are receptors on our cells of inflammation in every single cell for estrogen and testosterone actually. And we know from well-established studies that if our immune system isn't prime properly, it doesn't work as well. If we have low estrogen levels, it doesn't work as well. So once we have estrogen, we know that we can change the way the immune cells work. We can increase the number. We've got more of a good thing.

Obviously, that's going to be good for our bodies. It can genetically reprogram these cells. So actually, our immune cells can be more efficient. They can produce more cytokines that are chemicals that kill things in the body. And they can just work in a lot better way. And so if you've got your hormones, which you have, you're quite open that you take HR, unless you've changed your mind over the last few days since I last saw you. So taking adequate estrogen will help reduce that inflammation.

Testosterone hasn't been researched in the same way on our immune cells, but we do know it's anti-inflammatory. And anybody that's had muscle and joint pains that have improved on testosterone will tell you how inflammation improves. We know that men are a lot less likely to have autoimmune diseases and less likely to have diseases such as multiple sclerosis. We know that testosterone can build a myelin sheath. It can help the way that our nerve system works. And so it is very likely that testosterone has a role in protecting from diseases such as MS and some of the other autoimmune diseases. And I think

probably has a really important role in protecting from dementia as well. So the body identical hormones that you're having, so the estrogen through the skin, is just, you're just, you're just the same hormone as what you were producing 20 or so years ago. It's just the natural estrogen. The progesterone is a natural progesterone and the testosterone is natural testosterone. Testosterone is the most annoying name I think you could ever think about because it's not derived from the testes. We don't have testes. So testosterone is always thought of as a male hormone because it's produced from the testes, testosterone, we sometimes refer to them as androgens,

but that, again, is a male connotation. But it's from our ovaries, isn't it? Yeah, absolutely. So it's coming from our ovaries and our eugenal glands and probably elsewhere. But actually, it's just another biologically active hormone, but it's the most biologically active hormone that we have in our bodies, testosterone. And we produce a lot more testosterone than we do estrogen. And actually, we've been.

produce more progesterone than estrogen when we're younger as well. So estrogen is probably the least significant hormone. So, you know, you having all these hormones, hopefully it's going to help improve your longevity and the whole journey to older age is going to be a lot better for you. You know symptomatically you're so much better. When I first met you, you were, well, you still do describe how awful it was that you couldn't remember words. And, your temper was quite vile at times and you didn't have the energy that you had. And, you know, I was looking at somebody today. I won't tell you her name, but she's quite well known, but she's one of my patients. And visually, she's changed so much over the last six months. And I know it's

because she's got hormones on board. And yes, that's great. Her skin looks different. She looks younger. She looks more vibrant. She looks happier. But her skin has this glow. But actually, that's me thinking what's happening to her heart what's happening to her lungs what's happening internally to her liver everything else i know she looks like she's lost a lot of weight as well and that's great i know she's been exercising and eating better but actually we know that the visceral fat the fat around our internal organs reduces with hormones so this skin appearance is just a window to all our other organs and that's what's happening obviously to you to me to people that take HRT. And that's really, really important when we think about disease prevention. Now, we also

know that none of the societies, the menopause societies, guidance recommend HRT for disease prevention and in the UK. Why is that? Why? Because we are looking into the future and they are looking into the past. What's happening? Yeah. So I think there's a few things. So when I go to quite high-level meetings, there's always this talk, there isn't enough evidence. And that's a jerk reaction because that's what the guidelines say. Can I say I've read so many papers and they may not be fast, randomised control trials, but there are tons and tons of trials, say, talking about cardiovascular disease and the effect of having your estrogen back or keeping your estrogen. Absolutely. There's massive evidence. And again, I was talking the night about what would a 12 year

think if you presented them with the evidence. And a 12 year old would think, it looks to me like estrogen's really helping with stopping people having heart attacks. And why is there this incredible negativity to hormones? Well, I think I've sort of been thinking about this a lot actually, because as you know, I've got a pathology degree and I do enjoy science and basic science as well. Because in medicine, if you don't understand something, one of the things I do and a lot of other clients, clinicians do is go back to basics. Just have a look at the basics. So if you knew nothing about HART, you look at the diseases associated with no hormones. And we've talked about that at length before. So it does make sense, common sense, that actually if you've got an increased risk of

dementia, the longer you are without hormones, then isn't the most obvious thing to put the hormones back to reduce your risk of dementia. The same with cardiovascular disease, osteoporosis, everything else as well. But if you look in the USA, they've grouped lots of societies together, and they've all stated there isn't enough evidence. In the journal Jammer recently, they actually did this big paper, why there wasn't enough evidence for HRT as a disease preventative agent. And a group of us actually wrote a letter to say, there is enough research actually to support this. And we weren't the only group that wrote a letter. So there are other people who are more learned academics than me who agree with this. So when I look about why is this happening, I can tell you, I think,

this is me being a bit cynical, but I'm sure you'd agree, Kate. One of the reasons is that HRT is really cheap. So pharma are not interested in it. But also, there's a lot of us. There's 1.2 billion menopausal women, 14 million in the UK. It's dirt cheap, but something dirt cheap times by 14 million. It's still quite a lot of money that they've got to shout out to us. So there's this, don't really want to do that because it's short-term pain for a longer-term gain. But then also, if you think about America who are dictating a lot more that we shouldn't be using HRT for disease prevention, Barmer is massive in America, a lot bigger than in the UK. So if women take HRT, we already know, we know it from our patients, we've got thousands of them, that women on

HRT are less likely to take statins, they're less likely to take blood pressure, lowing medication, they're less likely to take antidepressants, they're less likely to take painkillers, they're less likely to take sleeping tablets, and oh my goodness, they're less likely to take some of these expenses, osteoporosis medication and dementia medication, because they won't get these diseases. So what will happen with pharma if every woman who needed her hormones had them back? And actually, let's think about men. If every man had testosterone replacement when they needed it, about a third of men at least, we wouldn't need all these other medications.

So pharma will be a lot reduced. And I can't think of any other explanation because the science is there to support it. We've got more evidence that HRT is beneficial at reducing cardiovascular disease and statins. Yet as GPs, when I was working as a GP, I was encouraged to prescribe statins because it helps with a quoth,

it helps with a quality framework to help the way GPs. should we talk about the quaffes because people don't know what quaffes are but when you tell them they're really shocked so they're the quality outcomes framework framework yeah that's right so basically and you can explain it in more detail but basically your GP surgery gets paid an extra 50 or 80 quid if they diagnose someone with depression if they diagnose someone with diabetes if they diagnose someone with using tobacco and they get all this extra money for ticking these boxes and for a while they got money for just mentioning the coil at one point mentioning larks and just mentioning it at all they were

given an extra and then lots and lots more people took up the coil because the doctor had mentioned it now if we had a quaff which really wouldn't cost very much or we could swap one of the other quaffs over that was just saying please mention menopause and hormone replacement therapy and what the possibilities are to the appropriate women. That would make this extraordinary change in the costs of the NHS. But why aren't we going to do that? Well, I mean, I was always a salary GP. So my salary was the same, whether I saw one patient or 100 patients a day,

or whether I contributed to cough or not. My salary was the same. But you're absolutely right for GP partners, for practices. they have this way of being paid. And the quaffs do change quite a lot. But there are certain targets. So if I saw you, for example, you were my patient in general practice and you had a raised cholesterol,

if I gave you a statin and reduced your cholesterol, then the practice would get paid if there were a percentage of people. And I can't remember the percentages and they change all the time, but it doesn't really matter. You get paid more for a higher percentage of people whose cholesterol have reduced. Now, you as a very educated woman would probably say to me, Louise, I'm not diabetic, I haven't had a heart attack, I'm really fit and well, I exercise regularly, I'm not overweight, I don't smoke and I don't drink. So actually, my cholesterol isn't going to be the thing that's going to cause my heart disease. And I don't want to take statin because there are risks. And actually, when I've read the evidence, there isn't good evidence that statins for primary prevention of heart disease in women is really that good. So I'm going to refuse. So I'm going to refuse. I could then mark you as an exemption so you wouldn't be in part of these figures. That's absolutely fine.

But if you came to me and said, I don't want to staten for all these reasons, but actually I would like to take HRT because I know it reduces my risk of a heart disease, but it also reduces my risk of osteoporosis diabetes, clinical depression and probably dementia as well, I could give you that, but I wouldn't get, or not me personally, but the practice wouldn't get paid. It wouldn't be part of the quaff. Now, one of the problems is introducing something. thing. Introducing anything in the NHS means a lot of work, a lot of effort. And they will do it if

farmer are behind it or if there's a real reason that it's going to reduce disease and make a big sort of impact for a public health reason. Now, they won't do that for the menopause until they understand what the menopause is because every time I say the menopause should be categorized as a disease, I get shot down on social media. But let's think about disease. actually and causing harm. And we've already said all these diseases that are associated. Now, obesity for many years has not been thought of as a disease. But actually now it is thought of as a disease because it has so many risk factors associated with it. And as you know, it's overtaken smoking as a commonest contributing cause for cancer, risk factor for cancer.

So if it's thought of as a disease, you automatically get more funding. You get more attention to it. So the problem is if you ask people what menopause is, they'll say it's an inconvenience, it's a few symptoms, it's something that women just have to endure, and it can't be a disease because it affects 51% of the population. But actually, I can't think of anything else that has such negative effects on future health and such risks of other diseases. It's a little strong bag of diseases. It's a little collection, and you're likely to get one of them. and, you know, in terms of women, one in two is going to get osteoporosis, so you really don't want that in your shopping bag if you don't have to have it. And, I mean, that's what I find sort of extraordinary and sort of so irritating. But another thing I want to ask you about, Louise, is digital menopause world,

and you've made this huge leap into it. I think almost much to your own surprise in a way that you are, you know, doing the Steve jobs of menopause, you've got this. app, the balance app, it's great. It's really easy to use. I recommend it to everybody as the best source because it's really up to date. And you've got almost a million downloads and you're up there on the app charts with it. I mean, there's a huge demand for good information, isn't there? Yeah, absolutely. I mean, as you know, I developed the balance app with a great team of people to try and improve awareness and diagnosis thinking, I wish I'd had it.

when I was perimenopausal instead of, you know, thinking all the things that I did without thinking about hormones. So what it does highlight more than anything else is this huge thirst and appetite for more information and knowledge from the users, from women. It's only allowed to be used by women. And it shows how important women are at being involved in this conversation. And it's highlighted not that it's the most amazing app in the world, not that people go because they like the colours and the logo, they're going out of sheer desperation. And that's, you know,

really sad we've had over three million comments on the community section of the app. And I actually can't bear to look at them because I know I could help every single woman on there, but I don't sleep enough anyway, but I can't, I wouldn't ever get any rest if I was trying to help three million people on my own. But actually, there's a lot more that we can do with technology. And this is one way. I mean, I also developed it

because I knew that I would never be able to help all the women I want to help. Even in the UK, I would be so naive if I thought I could really help through my clinic, 14 million women. But actually, I don't want to. I'm very uncomfortable charging a lot of money for people to come and see. But the good thing is, some of the profits we use can fund balance and funds a lot of the other, you know, work I do. So there is some benefit, but actually we're working really hard behind the scenes to even look how we can use technology in different ways. And hopefully I can explain more over the next even few months, I think, because what we're doing is going to really challenge the way that we undertake consultations, the way that we can be more patient-led with what we do

and use technology, because technology is the only way we can reach people at scale. I can download a new article on balance, press a button and that's it, it's gone to a million homes. I can't do that with anything else, you know. So we've got some really exciting things up our sleeve that I think when they're switched on, we can really make a difference to as many people as possible and as many different types of populations as possible. I was thinking about that because the problem is that as we realize, and you know, smart women and smart 12-year-olds are realizing that if they can take hormones, it's a brilliant plan. And, you know, once you get your HLT levels sorted out, you are not going

to suffer and you're not going to risk getting these diseases and you're less likely to get to bees and you're less likely to forget everything and you're less likely to lose your job. And that's exactly what an elite of women have worked out. And I was very interested looking at LinkedIn the other day, all the people on LinkedIn who had responded a thousand women to a menopause survey, and 63% of them were on HRT. And it was like, yeah, so those people are on HRT. The people in boardrooms are quietly on HRT.

But what happens in Glasgow, where I come from, what about economically deprived communities? What about the people struggling on drugs or just got off drugs? What about the racial weathering on women who have suffered from racism, all their lives and have earlier menopause. All those things, you know, by ignoring the future here, you know, the NHS and the government and whoever are making this divide and we've already got an economic divide and we've already got a health divide, but it's growing and growing and growing.

Absolutely. And it horrifies me. And I spend, as you know, a lot of time thinking about how do I reach women who I'll never see, I never come to the clinic. And actually, we've just given a free book, one of my books, to every prison. because, yeah, I know. And we're working with women who've had FGM, female genital mutilation, because you can't imagine what their perinear must be like when they've been cut.

When they're menopausal, obviously the tissues become very thin, they get urinary symptoms, they get a lot of pain, discomfort. So it's how do we educate them? Me as a white English middle-class woman is going to be very hard going into those communities and try and explain, in my very posh English voice, what it all means. But we can educate, we're working with some charities and we can educate the leaders of those charities who can then use their own language and terms and in a safe environment. But technology obviously has a role with that with the different languages and everything else as well.

And learning about different cultures is so important. And I think this is where trying to get into lower generations before they suffer. So they can not only educate themselves, but they can educate their elders. is going to make such a difference too. Now, here I want to ask you 10 years' time, will there still be a shortage of the only body identical progesterone that seems to be around for most of us? Utruegastin.

Why is it just with one manufacturer and what can we do? Well, I mean, it's crazy. I mean, you don't put all your eggs in one basket, do you? And this is what's happened with utergestin and besin's. I wanted four months to get mine in my local pharmacy. I think, you know, when I started, Menopause work seven years ago. I wrote an article about the effects, the beneficial effects, especially with respect to cardiovascular disease, for body identical hormones. And I got a letter

of complaint, and as you know, I get lots of letters of complaint from all sorts of clinicians. And this doctor wrote and complained for two reasons. Firstly, how dare I say that HRT reduces risk of cardiovascular disease, because he was taught it increased. And I did say, well, actually, if you read the article, there's a little number above the end of the sentence, and that number is related to the reference and the reference is an article by Boardman et al from the Cochrane database so perhaps he could go back and not shoot the messenger but read the original reference so he was quiet then and then he said I've also always respected things you've written in the past dr Newsom but you've mentioned a drug I've never heard of called uta Jastan why mention a drug that

you're only prescribing in your posh private patency clinic and I said no look in the BNF it's been there for years and I thought ah people aren't realising about it so obviously Now people are. And actually I phoned the drug company and said, who's your women's health specialist? What education are you doing? So we don't have one because no one really prescribes you to Justin. It's not there.

So to be fair to Bezance, they've gone from hardly any prescriptions to now millions of prescriptions, literally overnight. And I did speak to the managing director tonight. And they're building a factory. They've got nine acres of land for a factory. And they're really cranking it up.

There's going to be a lull, because there always will be, but they actually, our CEO went and spoke to them last year to tell them about the plans and the projections are going to increase for prescribing. And he said then, think big. And he said, Louise, our motto at the moment is think big because of what you've said to us. So we are being bolder. And it's a big financial commitment for a company, especially when some people are saying, we're prescribing too much HRT and we have to slow this down. And so there is a bit of, But that's not what women are going to do. It's not at all.

It's very clearly. And also, just like myself and you, when you pass through the door and you put on the menopause glasses, but we are not, because you are a patient too and you have changed. The hormones, you know, have changed our lives overnight or within a couple of days. Yeah. And I think we're different in a way from many doctors in that you are physicians who have cured thyself kind of thing. And so many of the great doctors are women of a certain age in the menopause movement.

And I think that's really important that you understand it from the inside and you understand that you couldn't remember the name of a prescription years ago before you went on HRT. And I think that changes the way we think. Of course it does. I think it's incredibly important to understand this from the inside as well as the outside and reading the science. But a lot of it is about emotion in midlife. We're all struggling with all sorts of other things.

And to understand that additional burden on women who are holding up so much, particularly if they're working and they've got a family, we understand that. We are those people that we're talking to. We're not coming from above. In fact, we've come from right below and dug our way out. And I think people should remember that about you too, and that you're not coming in, you know, all dressed in white like an angel.

You've actually struggled from the bottom to do this. And I think that's really important. Here's another mad thing I want to talk about before we go, is you know how people are always saying to you, we need to go the natural route? Isn't it marvelous that orcas, killer whales, have the same menopause as women. They're the only other species that have it.

There's one other kind of whale as well. But these big whales, big killer whales. And I thought, right, I'm really interested in that. I thought, I'll look up this, because I'm geek now too, but I'll look up the testosterone level in the blubber. of orcas male and female. So I'm wondering how, you know, the orca, age 40, has her menopause and can go on to live about 90 and lead the pod and lead them to salmon.

And, you know, pods that are led by these grandmother orcas do really well and the young thrive better in their wise pods. So that's really, really interesting. And of course, it's like, this is totally natural. there's now looked at the testosterone levels and obviously they didn't necessarily know what stage each female world was at but basically they have half the testosterone that male whales have so that's a huge amount isn't it that is a lot of what men have and i'm thinking so what is that female orca doing with all that testosterone in later life you know and why is she leading the pod and

you know there is that thing that you think there are those women in life like one of my heroes is Ruth Bader Ginsburg, the great American jurist on the Supreme Court who died a few years ago. And, you know, I always thought she must have a lot of testosterone and doing that in the 80s. And so everything everybody tells you, you know, this is the natural way. Look at the blubber samples and see what hormones are in them. It's fascinating, isn't it? I think when you look at nature, what do you mean by natural? You know, I go into my garden, it's beautiful, it's spring at the minute. So the flowers are out, the blossoms are, you know, we only need to look around us and nature is wonderful. But I wouldn't want to go and eat my garden.

I wouldn't want to eat half the stuff that's growing there or growing wild. So when people say I want a natural treatment, what does natural mean, of course? And a lot of these supplements are for symptoms, but we've already said that menopause is far more than symptoms. And then we think about our conversation earlier about aging and inflammation aging, and inflammation aging, You know, were we really designed to live for so long and get dementia? You know, dementia is the cruelest condition. I don't need to tell you because you've got first-hand experience. But it's a horrible, horrible condition.

We're not designed to have dementia. We're not designed to keep living. And so medicine has advanced so much, you know, cancer treatment is so much better. When I was younger, as a junior doctor, I always saw so many people with strokes, so many people with heart attacks, that's better because management of hypertension has improved. We're now going the other way because of obesity. Obviously, there's far more other conditions, but we're really not designed to have all this time without hormones. And if people really, really push back, okay, well, that's fine.

If you're over 50 and you decide you don't want hormones, that's fine. As long as you know the risks, that's absolutely fine. And of course, if you optimize your diet, if you optimize your exercise, you will mitigate some of these increased risk of diseases. But then let's look at those people who are under the age of 51 or even under the age of 40 who have premature ovarian insufficiency POI. We've always been taught one in 100 women under the age of 40, but a recent study in Clementeeric shows that it's probably more like 3%.

And I think it's probably even more than that who have early menopause. Well, there's nothing natural about not having your hormones in your 20s or 30s. So 3% of half of the population is still a lot of people and there's a lot of disease associated with it. But then if you think, well, if you're 100% want to treat people when they're young, what happens to them between their 50th and their 51st birthday? Do they really change? Do their bodies really change?

Of course they don't. So why do we then need to stop something? So we've got to think about sort of this meddling with nature or not. And then the other thing to add to that is, as you know, I get a lot of pushback because people say that now I'm over-medicalizing the menopause and it's natural. Well, the average number of medications that women I see in my menopause clinic are on when they're not on HRT is about three or four. You know, and so they are being medicalized with other drugs, usually antidepressants, as you know, but there are other drugs that people are giving to try and help with their symptoms, such as gabapentin, which is a horrible. drug, really horrible drug. Some people are given antidepressants for their vasemotor symptoms, their flushes. People will put all sorts of things in their vaginas, which actually

aren't made for their vaginas to try and help some of the burning, the irritation, the discomfort. The antibiotics that are used for urine retract infections, which are often associated with low hormones, they're not very natural. So we've just got to take a step back before we get into this boxing match about natural or medicalisation. I think. think we need to just look. And hormones, like you say, they're plant-based, they're just not even medication. They are just hormones that we're using here. And what nobody seems to understand. I mean, the idea that one patch suits all women is absolutely hilarious because we know all our hormones are completely different, never mind every day, but from all our friends.

And that that's really difficult. But, you know, the very simple thing of saying, are you over-prescribing estrogen? Are you not? I mean, very simply, If I have two pumps of estergell a day and I get mine from the NHS from my local doctor, I get hot flushes. If I use three pumps, I do not get hot flushes. Now, it's absolutely clear to me that's exactly the level I should be at because my body has agreed that that is good for me. And I've done that over time and it just makes complete sense.

And I've been doing studies for my pill documentary. And we've been talking to people sequencing sort of the genome around, hormones and there are sequencing the levels of estrogen and whether women with certain genes absorb estrogen or progesterone or whatever more or less or react badly. And by looking at women who've had terrible symptoms on the pill, they can see that their particular pattern is different. And then they can look at another woman and say, you're going to be fine taking the pill because you don't have this weird selection in your genome. And we know that we can sequence it,

we can see it just like we can see our ancestry, you know. And the idea that we are one cookie-cutter human being and that you can stick the same patch of me because I'm just a woman and I'm old and I'm complaining is so utterly wrong and kind of really misogynist and really uncomprehending, I think. So I'm very interested in doctors being taught that HLT is incredibly complicated and, you know, it is not literally a sticking plaster on your arm. Absolutely. And I think a lot of it, again, the common sense has gone out of the menopause. And so even when I was first prescribed my HRT by someone who's a very eminent menopause specialist who's very high up in the International Menopause Society, I was given a 100 microgram patch with some progesterone and went off to.

see if I felt any better. And three months later, I contacted him and said, I feel a bit better, but I still feel rubbish, actually. I'm still getting bats back migraines. I'm still getting night sweats. I'm still getting joint pain and I feel as miserable as sin. So he did my Eustradile level and it was low. And he said, well, just use two patches. And I said, oh no, I can't do that because that seems really high. He said, don't be ridiculous. You're not absorbing it properly. I said, yeah, you're right. Actually, my patches do slide a bit. They often end up in my jeans. I don't think they stick that well at all. So I used two patches. And then after a couple of days, my night sweatsweets improved.

My mood, my energy, my concentration didn't, but that was testosterone deficiency rather than estrogen. But I did feel better. And that makes complete sense. So what I'm being prescribed is not actually what is going into my body because my patches do not stick very well. But if I use the gel, it just slides and slips and it doesn't really get absorbed very well in my skin.

So there's all this narrative that we're prescribing too much, but actually we're all different. So the amount that's absorbed through the skin can really vary. But actually, the amount of hormone that I need is probably different to what you need. It's probably very different to my 22-year-old patient who I saw yesterday needs, because her body requires a higher dose. And we see this in other hormones. I've prescribed 25 micrograms levothyroxin for people with hypothyroidism. And I've also prescribed 225 micrograms to very similar looking women with very similar symptoms, but their requirements have been very different. When I

ran a diabetic clinic. I'd see women and men with type 1 diabetes and they'd all need different requirements of insulin. So why is estrogen so different? Why is it we so worried about our own hormone? I'm not aware of any data showing that there are risks or benefits with high dose antidepressants or lithium or quitoopane or the drugs that have no biochemical measurement that we see a lot of menopause or women on. So we're almost singling out a hormone trying to prove that it's dangerous for women when we're not looking at all the other drugs that people are given a sort of ad nauseum almost.

So it doesn't all add up. No, none of this adds up, but when things are really difficult and you find sort of, you know, an establishment saying, oh, that can't possibly do that and this isn't good for women. You know, I just think that women know what they're doing. And having sort of made these two in this third documentary,

and I'm very aware on the pill, that there's going to be this huge push of women saying we've been gaslighted about our side effects for years. We genuinely do have these, even though you haven't done a randomised control child of a million people, we happen to know that, you know, we're coming off the pill because we're depressed and we feel much better the month after. And that women's truth is not being heard in both departments of hormones, both down at the pill end in your early life.

And we happily give women the pill for 30 years. oh my God and we hand it out free and it only costs a pound a month. But yet HRT is some other weird stuff, even though it's much safer and the formulation is much safer than the pill. What are we doing there? What is the game? The game is that men are involved in benefiting from the pill. Men are not necessarily involved in benefiting from HRD,

although I have to say that in my life, men do benefit from the HRT. Because they do. They get more sex, right? They get more sex. It is absolutely clear that it's okay for 70% of women to try the pill, but HRT is over there. And it is a deep, deep-seated medical misogyny,

which I am very glad you are fighting. Thank you, Kate. So before we end, you have to ask me three take-home tips, because I always ask. Oh, God. So I don't know what you're going to ask me. I want to know what's in your handbag. What do you carry around?

So the three things that are. I can't survive that in my handbag. It's obviously number one, my mobile phone because I'm addicted. Obviously, I have so much going on all the time. Number two is my glasses because without my glasses, I can't read my mobile phone because I'm old and I need glasses. And number three, I'm always, well, I could have maybe three and four. The two things that are really important to me are having herbal tea bags because I don't

have caffeine. And the other one is summer trips in which is a migraine tablet. I have to have that on me all time because as you know, I'm often get migraines and triggered by all sorts of things. So those are the things in my handbag that I have to have. The other things, my notebook and my pen, really important because I'm a bit old-fashioned with writing down lists. I have lists all the time of things that I think of, people I need to contact,

things I need to do. So yes, I don't have a big handbag because that's enough for me. Well, that was good information. You can go. Well, thank you very much. It feels very weird being the other side of my podcast. And I know we've gone a bit over time, but I hope you've all enjoyed it. And I am going to ask Kate to come back to talk about the documentary

because although the contraceptive pill might be thought of as not for menopause, actually a lot of perimenopause or women are on it. And a lot of women who have hormonal changes. And my interest is not just about the perimenopause and menopause. It's about health, longevity and hormonal health for men and women. in actually for all ages. So I'm looking forward to our conversation next. So thanks ever so much for your time today, Kate. It's been great. Thank you. 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.