The Dr Louise Newson Podcast - 237 - The juggling act: how to navigate menopause and midlife

Episode Date: January 2, 2024

Menopause often happens at a time when you are juggling a career, relationships and caring responsibilities. Here Dr Nadira Awal, a GP and menopause specialist, joins Dr Louise to discuss her work in raising awareness of the menopause and the importance of partners and families understanding what their loved on is going through. Dr Nadira’s personal experience of the menopause helped drive her passion for educating and supporting other women, especially those in ethnic minority communities who may not feel able to speak openly about it. She talks about increased health risks owing to genetics, particularly with diabetes and increased blood pressure, and the challenge of treating a woman’s symptoms holistically in a ten-minute GP appointment. Follow Dr Nadira on Instagram @pauseandcohealthcare and on Facebook at Pause and Co Healthcare. Click here for more about Newson Health

Hello, I'm Dr Louise Newsom. I'm a GP and menopause specialist and I'm also the founder of the Newsom Health Menopause and wellbeing centre here in Stratford-Pon-Avon. I'm also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research,

bust myths on menopause symptoms and treatments, and often share moving and always inspirational personal stories. This podcast is brought to you by the Newsome Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. So today on the podcast, I've got a fellow GP, someone who I've met a few times in real life, unlike some of my other podcast guests,

who's very inspirational, who's doing a lot of work behind the scenes actually to really help women in many ways. So, Nadeira, thank you so much for coming on my podcast today. Thank you, Louise. Thank you for inviting me. So we've known each other for a little while. And recently we met again in Liverpool, actually. I'd gone up to the Royal College of Psychiatrist's conference, annual conference.

And you were there as well. And we were in the same group, actually. They kindly invited me to be on the panel. And you were talking about your own experience, actually, won't you? Yes, that's right, which has gone down very well on your Instagram, post, which I'm very grateful for you sharing, so thank you very much for that. Well, I felt a bit naughty because I stepped away from the panel to go in the front row so I could take a few videos, and your one was just amazing. And we've just looked just now, and it's had

nearly a quarter of a million views. It's resonated with a lot of people. And I've been told off quite a few times for talking about my own personal menopause experience in the media by other healthcare professionals. But actually, if I wasn't a menopause or woman, and if I didn't take HRT and if I hadn't struggled, I think doing my work, I could still do it, but I couldn't do it with as much energy and passion and determination as I do. So I think people like to know, this is going to sound really awful here, they like to know that healthcare professionals suffer and are human and actually sometimes struggle. We don't get it right the first time. And I had to see a specialist to get the right dose of HRT that was right for me. And I learned a lot from him,

actually. He really taught me, actually, and I've still got his clinic letter telling me to increase my dose because my level was low and I clearly wasn't absorbing it well and increased the dose and it really made such a difference. And I'm very grateful to him. But you talked about your struggles to get the right dose from your own doctor and having to see a gynecologist. And, you know, we are humans, aren't we? And we can't always access the right person first time or know everything. And it's very different when it's ourselves that are experiencing symptoms. Completely agree with you, Louise, actually. And almost as clinicians, we're probably the worst patients, aren't we?

We're completely in denial of what's happening to ourselves. And it actually makes it a little bit more fuzzy to connect the dots together. Yes. And you actually need that outside approach to sort of say, actually, these are the things that are happening to you. But yes, you're completely right. It's made me more passionate talking about the menopause, educating my patients, educating anyone who will listen really. So it's not just about the patient,

it's about their family as well, and how the menopause can affect everybody, really. So it's not just women, it's the men need to listen as well and really appreciate what's going on. Because you've got two young children. When I was experiencing symptoms, my three children were obviously a lot younger

and really were suffering but not realizing. I just presumed I was very irritable and short-tempered because having three children is difficult. having any children can be hard. And I just thought, oh, I can't cope very well. And then I sometimes think about, there was one time that I was called in by two of the partners because I'd prescribed a lady,

some morphine who had some really awful arthritis of her knees. Terrible, she was housebound. And I just gave her aurimorph. So it's not even, as you know, a control drug. And I put it on a repeat prescription because she couldn't get out to the pharmacy and her daughter lived a long way away, and it was causing a lot of work.

So she just had one bottle every month. And I said to all love, I'm leaving the practice soon. So if I put it on a repeat, it would be very easy for you to get it. And I used to inject her knee every three or four months or so, if it was a lot more painful. And she'd tried so many other pain killers. And this was the only one that worked for her.

She'd just take a spoon in the morning and a spoon in the evening. Anyway, they'd called me in to say, how dare you do this? This is absolutely outrageous. And you shouldn't do this because people could overdose on morphine. And I said, well, she's 91. She probably would have overdosed if she was going to. And I will take full responsibility because I've signed the prescription. and I'm an independent prescriber.

And then I walked away into my room and I burst into tears. And Helen, who now actually works with me, came into my room to cheer me up because she'd never seen me cry at work before. And looking back, I know it was related to my hormones. And I knew I was going to get too cross to sort of retort to these two male doctors who were telling me off in their room. So I withdrew and then just thought, well, maybe I am really dangerous. Maybe I shouldn't be doing this.

maybe I shouldn't be looking at what's best for my patient and catastrophizing really and then had no self-confident, feeling of low self-worth and being very tearful. And those are all classic perimenopausal symptoms, aren't they? Absolutely, yes. There's so many women and myself included that you do feel like you're questioning what you're doing on a daily basis. And, you know, we always describe it, you always hear about it in social media that we're the sandwich generation. We've been looking after our elderly parents and we've got young children. As you know, in that podcast, I talked about, you know, I was renovating my house and I had my young children as well dealing with builders on a daily basis. And it was really difficult. So you think,

oh gosh, you know, there's all the stress that's coming with it. You know, we lead busier lives. I mean, think about it 100 years ago. Women weren't working. They, you know, we're looking after the children, but not really. We had potentially, we had maids or we had people who were helping looking after our children. There was a lot of family network as well. And so where we were us now, we're busy. you know, we've got full-time jobs. We're trying to hold down a job. We're trying to hold down a relationship. We're trying to look after our children. There's a lot of social media sort of presence as well and saying that actually we should be better at things. We're always negating ourselves, aren't we? And I think it's important to actually be really empowered and say,

we're doing a great job. You know, we're working really well. We're looking after our kids. They're happier. You know, if you think about it, we were talking about this the other day, that actually our parents' generation only took us to the zoo. You know? We didn't have things like soft play. We didn't have iPads and we didn't have mobile phones. We went out on our bikes and we just came home at desk, didn't we? So, you know, whereas now we have to entertain our own children.

And it's hard work. It is. It's very different. Yeah. We used to just play in the street and sometimes remember to come home for a meal. And so it's very different. But also I was talking to somebody in America yesterday, actually. It was Sunday.

And I was trying to arrange all week to speak to this person. The only time I could find was on Sunday. I've just got back from being with my husband in the late district. My mother-in-law wanted to come for supper, which is great, lovely. But then I had to cook supper. So as I was talking to this woman, I said, well, look, I'm really sorry. You're going to hear the oven door open and close, and I'm chopping some vegetables because I'm cooking at the same time. And she said, I love the fact that you're multitasking.

And I said, but do you know what? I sometimes joke with my children and say, goodness, I could do so much more if I didn't have children. but actually I also laugh about it because I'm a lot more productive because I've got three children because if I have five minutes between, I don't know, picking one of them up or taking one of them somewhere or doing something, I will do that work in five minutes. Whereas before or without children, I'd probably be thinking, right, I've got all day. I could just have a little cup of tea and I'll just listen to the radio and then I'll sit down and my nice tidy desk whereas I'm literally just doing something on my phone while the kettle's boiling

and then I'm going to the next thing. But on the other hand, you've got women who've not had children and they're busy with their life, aren't they? And they're busy doing all their extra-curricular activities or holding down their job as well, and busy. Yeah, but I think it's also the way that women's brains are wired. And it is a gender difference. So it's not just about children. Of course it's not. But I think women are used to multitasking.

They're used to, you know, if they're working, sitting in meetings, thinking, right, what am I going to have for supper or what am I going to do at the weekend? Whereas men, and this is a generalisation, of course, but in general, men are a lot more focus. So I think it's good and bad, actually. Women probably need to focus maybe sometimes a bit more. But actually that ability, which is often lost in the perimenopause, because our hormones work very well on our brains, don't they? And for many years, we've just learned about flashes or vaginal dryness. And the menopause just being a natural process.

But actually, for a lot of us, it can really affect the way our brains work and think and function, can't they, without hormones? Absolutely. And I actually use the analogy, and I've used this in interviews actually, as well, where women spin lots of different plates and they're spinning, yeah, the work plate, the kids plate, you know, kind of life at home plate, the relationship plate. And sometimes it's okay to drop your plate. And what you don't do is you don't try and pick up that plate, piece it back together again. How about you just drop all your plates, smash them, make something new? And that's kind of what I described the menopause as well.

You know, this is a new stage of your life. Don't try and be what you were in your 20s. Let's try and embrace it, actually. You know, don't think I can do everything I did in my 20s and I can do it now. Make it new. Make it exciting. And that's what I've done. I really like that.

I think that's a really good analogy actually because we are different. Our life experiences are different, aren't they? And I feel, you know, it's a bit like if you've got, the privilege of being able to plan maybe when you want to have a baby, you want to make sure if you can that you're healthy, that you're not smoking, that you're not drinking alcohol, that you're taking folic acid, that you're fit and hopefully not too overweight or whatever. So you can make sure that, you know, you're giving everything the best chance for those next nine months. Obviously, for some people it doesn't work like that. But it's still something that we always

advise as medical practitioners, if people can, this sort of preconception counseling, really, isn't it? Whereas I think with menopause, it's even more important because for most women, it's decades, not nine months. And so actually to have some time before your brain goes that you can't read a book or listen to a podcast or think about everything, almost think about, right, how is my hormonal health, how is my perimenopals and menopause going to be as healthy as possible? And you're right, you know, what we ate when we were 20, we probably can't get away with it in our 40s or 50. No. And we digest things differently, don't we? As we enter the perimenopause, because the eastern declines. And so the gut becomes more inflamed. And so when it's inflamed,

you don't absorb the good bacteria. And, you know, the gut microbe makes a big part of the menopause, doesn't it? So if the gut's inflamed, you know, obviously you're not absorbing all the right nutrients, therefore you might get that gut changes as well, the diarrhea or the constipation. And therefore, you might get joint aches as well. So, you know, which we've both experienced, I think. Absolutely. I mean, it's this anti-inflammatory properties of our hormones throughout our body really, really important and misunderstood. And you're right, actually, the sort of bowel symptoms, very, very common. I mean, for many years, I've seen so many women with irritable bowel syndrome. I didn't think about the hormones at all. And even heartburn and, like you say, diarrhea, can be related to hormones. So there's all these symptoms that affect people in different ways, different stages, different types of women, but often they're not recognised. And I know a lot of the work I do, but also the work you do is trying to educate and allow women to understand what's going on. And traditionally, if you Google menopause, it will be a white middle class woman who is usually got a fan or just has a glass of water with a hand on her brow.

And that's not most women. And I did a presentation recently at an international conference about ethnic disparities with menopause. and we were asking women what their views of the menopals were. And some people from ethnic minority groups said things like, it's a dirty secret, it's a shame, it's an embarrassment, it's something I want to hide a guy, it's something that we just have to endure and suffer. And all these words, I feel are really sad

because it shouldn't be something that you have to just battle through. And there are certain groups of populations is that I think it's harder to reach as well, isn't it, culturally? Absolutely. I mean, if you can think about it, my parents' generation, so my mother never ever talked about sex, ever. You know, my mother never talked about it. My sister, who's 10 years older than I am, didn't talk about sex.

And it's a cultural thing. It's something to be feeling almost ashamed about all. It's about being hidden. You can't really openly discuss about it. My cousins and I, you know, there's five of us and there's six months between all of us. And I remember about 10 years ago, And I've already been married 18 years. So 10 years ago, we were talking about sex.

And I've been married eight years by that time. So you can imagine it's something that it's just not culturally talked about and not open about it as well. So my focus is about talking in the ethnic minorities. It's about being open with them and saying it's okay to talk about it. So yes, I don't, you know, we're trying to change the mindset of the older generation. but the newer generation who have social media, they can see that actually they're getting their education through that, which is great, you know.

But change doesn't happen instantly, unfortunately. It comes about slowly. And so people are becoming educated through social media, through your podcasts, for example, as well. And, you know, Instagram and Facebook, it's great. TikTok, but change needs to come. And it is rolling and it is getting better. And I think it's really important to be educated.

So I go into mosques. and I've very openly talked to women about the menopause. And there's lots of giggles. We do it very, very, very informal. And it's so important. And I use questionnaires as well. I think it's important. So anonymous questionnaires.

And I have people, you know, saying, do you find sex is important? Do you find that sex hurts? And it's anonymous. So they don't feel ashamed of it, which is great. And I think we need to talk about it more openly, will it, Louise? And I bet you hear stories that are sad. I know I'm overwhelmed with sadness actually listening to so many stories from women from all over the world, but I'm sure when you go to the mosque, some people know it's safe to talk about.

I have to say the most interesting one is I worked in a quite socially deprived area quite locally to where I am. And actually, I had a lady come to me and she went, my vagina is so dry. I just can't have sex. But my husband really wants to have sex. So I just have to lie there and just basically take it. I hate it. And I said, well, do you say no? And she said, no, because it's part of my role. As a wife, I need to have sex with my husband. And I went, you can say no, it's almost like rape. And she went, no, it's not rape. It's my husband. I went, if you say no, it is rape. And it was

really quite distressing, actually. And I said, look, let's give you some vaginal estrogen and let's talk about HRT as well. And actually, she came back to me and she went, actually, sex is so much better with some vaginal estrogen. Yeah, and it's, I've had so many stories that are similar, first lady who spoke to it was many, many years ago. And I suppose the beauty of the clinic that I have, I have longer to talk to women in general practice having eight, ten minutes. It's quite hard to ask intimate questions.

But because on the questionnaire, it talks about libido. I will usually, if it's appropriate, ask women about sex and if it's uncomfortable because vaginal dryness means nothing to a lot of people. people and it's one of those horrible terms. It's really difficult, isn't it? Because then you talk about vulvo vaginal atrophy. And if you look up the word atrophy, it means withering or wasting away. Well, I don't want to think any part of my anatomy is withering or wasting away. So, and it's not just about penetrative sex sometimes. It's actually externally can be very painful. So a lot of women don't want to be touched or explored or anything happening in that area. And one lady said to me many years

ago she said she had no libido she loved her husband and really you know their relationship was good but she had no interest she said I would prefer to drink toilet water than have sex with my husband but he needs to have sex and we do sometimes and I said what is it painful she said oh gosh yes it's like having a red hot poker shoved inside me and I said well do you tell him she said no because I know it won't last very long so I just lie there and just wait for it to finish and I said but don't you tell him she said no but I can't because I know how much you want sex. And there's so many layers to that conversation, aren't there? And I feel really sad to think that people are in relationships that they can't even talk,

but also more sad that there is a treatment that's available that women are not able to access in an easy way. Yes, completely agree with you, Louise. The impact on relationships can be quite horrific, actually, can't it? And you can actually see that some people actually have marital problems as well, and you see people separate so sometimes, unfortunately. Yeah, I mean, divorce rates really do increase in the perimenopause and menopause. And often, like you said earlier, you know, partners need to understand, really need to understand as well. And we see a lot of people in the same-sex relationships.

And if two of them are perimenopause or menopause are at the same time, it can be a double whammy, of course. But it's not just the immediate partner. It's the wider community, as you were saying. And certainly a lot of the work that you're doing with ethnic minorities, communities are there, more than for a lot of us Caucasians, actually, but they don't know how to help because they can't understand. And I think that's really important. And I was talking to someone recently who's based in India. And I really worry because menopause age is often younger. You know, the average age is probably in the early 40s, as opposed to early 50s. And

there's an increased risk of diabetes, heart disease and these women. And we know that in the is an increased risk of heart disease and diabetes. And so it's a double whammy that really needs to be discussed more, doesn't it? Absolutely. Unfortunately, sort of our genetics makeup is that we are increased risk of heart disease. We are increased risk of diabetes. Often our parents and grandparents have had these health conditions. And yes, we can change it through lifestyle.

But actually, we can't change genetics. And you can appreciate actually, you know, our diet is often made up of a lot of carbohydrates. and so we're increasing our risk even further as well. So it seems really, really important. Yes, we maintain a healthy lifestyle and have a look at our gut, having a look at kind of our exercise. And we are getting better, definitely. But if you can appreciate when you see that lady who comes in from an ethnic minority

background, we're having to deal with her diabetes that might be poorly controlled, we're having to deal with her blood pressure that's maybe poorly controlled. As GPs, we're having to do that in 10 minutes. And yes, you know, there's a lot of, information out there that says, no, this is menopause related. Not everything is the menopause. It's not the panacea. You know, giving someone HRT, it's not the panacea. It's about the holistic approach to that woman as well. I totally agree. And I think it's a shame, actually, because there's got so much conversation that's trying to be negative about HRT. We know that in the UK,

about 14% of menopause or women take HRT. Worldwide, it's as low as 6%. So it is low, but it's a bit like treating blood pressure. I never as a GP, and I'm sure you hopefully agree, I would never just put someone on a blood pressure lowering treatment. It would just wouldn't be doing my job properly. I would talk about lifestyle, I would talk about the different types of drugs and the different side effects they might get and how we might need to change the dose or maybe add in another drug because often two lower doses of drugs is better than just increasing one. And I would review when things would change. And often their treatment actually. if you get it right and their life's unapproves, you can lower the days as well.

Correct. But it's the same with menopause. It's not just, oh, here you go have some HRT. That would just not be doing our jobs properly. It's about what it means because I've done, and I'm sure you have done many home visits where you open the kitchen cupboard and literally packets of medication for now that you think you've been prescribing really happily for years.

And women, one man, have said, oh, no, doctor. I read the insert. There's no way I was going to take that medication. And I'm thinking, well, no, wonder your blood pressure hadn't gone down because you've never taken this medication. So if we want to improve concordance, compliance, if we want to really work in a partnership with our patients, they have to have a full understanding, but they also need help to change and improve their lifestyle, to look at their mental health and other things that are going on. You know, how you said before this sandwich generation, well, you know, HRT is not going to improve the fact that they're looking after

their mother in a care home who's 100 miles down the road and they've got children and whatever else. And certainly often as a GP, a lot of my role was sort of also listening and understanding and saying to women and men when they were having difficult times, I can't change your life, but I can help you improve the way you deal with it. And that makes quite a difference, doesn't it? Absolutely. I always use the analogy with my patients. I'm like you're sat now. I can help guide you and tell you which way to turn. But really it's up to you to make the decision making. Yes.

And whichever way we go, the ultimate destination is going to be the same. And that ultimate destination is death, I'm afraid. You know, where we get it or how we get there. It's, you know, we can either have a great journey together or we don't have a great journey together. Yeah. That's so important, isn't it? And I learned so much in my training year as a GP actually with Dr. John Sanders,

who was my trainer in Manchester. about looking together with your patient and everyone's different and everyone's expectations of what they want. You know, I could be expecting all my patients to do a regular yoga practice and do a headstand three times a week because that's what I do.

Well, of course, some women are very happy just sitting on the sofa watching telly and actually who am I to judge? They probably have a far better time than me who's constantly working and fitting in yoga in between a hectic schedule. but actually it's working out what they want. And this is the same with HRT.

If a patient or a woman really doesn't want it, that's fine. But they have to understand the risks of not taking medication as well as the risks of taking it. The same as the risks of eating McDonald's or smoking. I would never judge a patient and treat them differently because they decided to carry on smoking. But I do feel it's my role to tell them that smoking is not the best thing for their health.

But I think being a job, GP actually gives you some great skills where we're not judging, we're not preaching. And that helps with all the education work that I do and you do as well, because we're used to dealing with different people and speaking to people in different ways and giving them the information in the way that they want it as well. Because, you know, what I might give a professor of neuroscience who's a patient might be very different to someone in a city who doesn't speak English as their first language. They both are entitled to as much inflammation as possible, but they might want it in different ways and different stages by different people as well.

Absolutely. And I think it's really important. As you say, it's a professor of neuroscience or neurosurgery, for example. Even though they're a doctor, they probably know nothing about the menopause, actually. And actually, it's really important to explain it in layman terms as best as possible. And actually, I often find that my patients actually have more education than I do. And it's great. I love it. I love hearing from my patients. actually what the latest research they found and I will embrace it because you have to embrace it. Yes, I love it. I mean, when I first started the GP, the internet had only really started going.

And it used to be the front page of the Daily Mail saying, I'd like this treatment. And then you look at it and it's been a study of four people have found that something. And you're like, but now actually they learn from their communities as well. And there's a lot of pushback about social media. But actually it can be very useful if it's done in the right way. it can also allow people just a bit of space to think and they can communicate with others that they might not meet in a mosque or the supermarket or a church or with their local communities. And it allows them probably to ask things in different ways because they are more anonymous as well,

which I think is really important. So the huge amount that we need to do, there's a huge amount we need to carry on educating women, men, families, but also healthcare professionals as well. And all the work you're doing is helping with that. And you, Louise and you. Well, it's great to connect, and I hope we can carry on doing things together. So before we finish, so, Adira, I'd really like to ask you three tips, actually. So three tips of how women and healthcare professionals and anybody,

so professional or non-professional people can just become more educated, more empowered to help more people. I think the key thing is, as a GP, I would really appreciate if somebody, if they were concerned about the menopause itself, I think my top tip is download the questionnaire, have a look at it, fill it out beforehand, tell me your symptoms within that first two to three minutes. So we're both singing on the same hymn sheet just so that we know we're tackling with the menopause. Please don't be alarmed if I'm going to be ordering blood tests, looking at vitamin D deficiency, looking at iron levels, looking at your thyroid function, I won't be prescribing HRT on the first consultation. I have 10 minutes. as a GP. I need more information from you. And the menopause isn't the fan. You know, it's not the only diagnosis out there. You know, it's really tough as a GP. We need to rule out more sinister causes. So I think that's my top, top tip. Two other tips. I'd say be wary that actually women of ethnic minority, we often need higher doses, actually compared to our Caucasian counterparts.

Everybody absorbs their Eastern differently. And that's my third tip. So, please, if you're going to the maximum doses, check eustodial levels. You know, we've got a lab for a reason. You know, so just everybody is individualised. Everybody has a different story. So please tailor it to your patient. Very good. Very good.

Everything we do in medicine should be tailored to our patient. Absolutely. So important. So I'm very grateful for your time and keep doing the work you're doing. And thank you again. Yeah, thank you, Louise. Thank you. You can find out more about Newsom Health Group

by visiting www.newsonhealth.co.uk. And you can download the free balance app on the App Store or Google Play.