The Dr Louise Newson Podcast - 239 - Challenging NICE's draft menopause guidance

Episode Date: January 18, 2024

On this week’s podcast, Dr Louise is joined by Dr Peter Greenhouse, a menopause specialist with 40 years’ experience in women’s sexual healthcare who is actively involved in postgraduate lecturing. He has recently spoken out about NICE’s draft menopause guideline update, and tells Dr Louise it contains inappropriate and inaccurate statements, particularly concerning HRT and breast cancer safety, and ignores the cardioprotective effect of HRT when it’s started within 10 years of the menopausal transition. Dr Peter challenges NICE’s stance on HRT for primary prevention and proposes a pre-emptive approach that could help reduce the amount of other medications GPs are prescribing menopausal women. Finally, he shares his belief that women should be able to take as much HRT for as long as they need to. You can read about Newson Health’s response to the NICE draft guideline consultation here. Follow Dr Peter Greenhouse on X @GreenhousePeter You can read Roger Lobo's paper, Back to the Future, which is referred to in the podcast, here. Click here for more on 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. Today on the podcast I'm very excited to introduce to you Peter Greenhouse, who I've known for a few years actually, first met up a menopause society meeting

and we're very inspired by his enthusiasm and determination to educate people in similar ways to me, really. We have very similar ways of thinking. So welcome, Peter. Thanks for coming today. Hi. It's a delight to be here. I hope we can get the relevant amount of information across in plain English.

Yeah. And see what feedback we get. So you're similar but different to me. You're similar in that you're interested in hormones. But we've got different backgrounds, actually, in different training, haven't we? Oh, very different. Yeah. Well, I train in both what one of my core veneriology,

and gynaecology. I did the gap between the two, and I was the first person to do integrated sexual health care in the UK. And I saw the need for it as a medical student nearly 50 years ago, but I finally got round to doing it when I got my consultant post because I'd trained between the two subjects. But at that time, it's interesting at that time, certainly as a gyne registrar, the first thing about menopause, and I'd always struggle a bit understanding contraception and how to do it. Because as a bloke, you don't feel any of the, you don't get any of the hormonal changes. I mean, a man has a stable testosterone in all his life, has no excuse for being moody, whereas, you know, women are totally different. And, you know, the main reason that I

learned about menopause was because I married one of the world's top teachers on it. Annie Evans, and we had a great time, and I taught her everything she knows about PowerPoint and STI, and she taught me everything I know about menopause. I've also learned, of course, subsequently, from going to loads of lectures, but most importantly, listening to very large numbers of women telling me their stories. And that's, I think, probably where the most learning goes on, where you just listen and you use the accumulated knowledge and the accumulated anecdotes that you've got from all the different women that you speak to, and it all adds up to your clinical approach. And it's got to be a humane and humorous

approach that is tailored to the woman's needs. And that's basically where I'm coming from. I'm a clinician. I'm not an academic researcher. I don't think I could do that. I haven't got OCD. I've actually got ADHD. So it's a very different way of approaching it. But anyway, there we go. So that's my background. Yeah. And it's very interesting, isn't it, when you think about clinical experience, because I think recently things have swung the other way where we're always wanting evidence, scientific evidence, and sometimes we don't have it. And actually, when you have a patient in front of you, it's about what's relevant for that individual. I visited a friend this morning who needs to have some chemotherapy

for breast cancer. But no one told her the risks of having this chemotherapy and the absolute numbers for benefit. She just presumed everyone who had chemotherapy would benefit, but actually only about 2% of women who take the chemotherapy will benefit. There's a very individualised choice. Just for complete clarification here, when I'm talking about the 2% benefit with chemotherapy, this is for this individual person. Any treatment, especially after breast cancer, is very individualised, looking at the overall benefits and risks for each individual treatment. And we often use the predictable when looking at overall outcomes for individual treatments. So I hope that's cleared any confusion from my sentence. Thank you. It's almost as if we're doing practice-based evidence,

which is also based on evidence-based practice, but there's the practice that you get from talking to the individuals. Of course, another big problem about most of the research is that there are no two women who respond to hormones in exactly the same way, because each individual woman's response is genetically predetermined. So you have pharmacogenetics going on in the background. And so, although you can have a broad brush approach, quite a lot of the randomized trials, it's sometimes difficult to show an effect or you get a countertudentive effect. And of course, even worse, if you design a trial with the wrong women, like WHO, you know, too old, too ill, too fat, wrong drug. And then, of course, you get the administrative team to publish the results in

the New York Times rather than any of the primary investigators. So, all that misinformation was probably the most damaging thing that's happened to women's health ever. Absolutely. Possibly. I mean, if you think of the number of women who've probably died from not getting HRT, actually, well, let's leave the mortality loan because there's a calculation that's been done in the states of about in the first 10 years for women who'd had hysterectomy of around

the 50,000 mark of women who died from the fact that they didn't get HRT, didn't get estrogen-only therapy, which is cardioprotective. And that's one of the things we come straight into Nice about is that Nice seems to deny the fact that if you take HRT, start HRT under the age of 60, then your risk of heart disease is very dramatically reduced and your overall mortality is reduced by a third. And, you know, if you think of quite apart from the quality of life issues, which I'm sure we can talk about, and in fact you have talked about at length in all of your podcasts, we don't even really need to go into those because most people take that as read. But if you consider the difference between the huge improvement in quality of life, you take 1,000 women, you know, 900 of them will be far better off on HRT. A few of them won't be able to take it. Some of them will get difficulties with it.

Some of them are progesterone, hypersensitive. Some of them don't respond to estrogen, interestingly, very small amount. Don't do that. But about 900 will be very, very much better off in terms of vasomotor symptoms and terms of vulvovaginal atrophy in terms of mood, you know, lack of depression, and better cognition, all these sort of things are going on in the vast majority of women. And the actual risk, the relative risk and absolute risk to cardiac disease and breast cancer are actually minuscule in comparison if you take that.

And, you know, the academics are fighting over tiny numbers. Whereas if you stand back from it and take the broad brush approach, the vast majority of women will be far better off. And once again, if you start HRT under the age of 60, you have a one-third reduced. or caused mortality. Now, hang on a minute. In what other branch of medicine? Would you ignore a one-third improvement in overall mortality? I mean, I don't know.

I don't think you would, but I don't think there is anything else in medicine that is cheap. That is safe. Now, we need to be clear about the safety issues is if you use the right stuff and if you use it in the right women. And realistically, the problem with nice is that it actually has some. misleading comments. It also has some incorrect comments, and it also has some rather disingenuous comments that are technically correct, but don't give you the right idea. So I don't know which ones we want to start with, but I was just thinking of, I tell you what, let's just take a quote here from Nice. Combide HRT does not increase the risk coronary heart disease. Okay. Now,

that is technically correct. Interesting, that's the most recent update from the 17th of November, But in the previous one, it said it did increase the risk of heart disease. And that's because it was so completely wedded to the Women's Health Initiative results that it wasn't looking at the actual people that you use HRT in or you start HRT in. And so although it's technically true to say that combined HRT doesn't increase the risk of chronic heart disease and also the next statement combined HRTs does not increase mortality from cardiac disease, it very substantially reduces it. So, although their statement is technically correct, it's utterly disingenuous, utterly misleading.

And it then goes on to say, do not offer combined or estrogen-only HRT for primary or secondary prevention of cardiovascular disease? Well, once again, you have something like a 30% reduction in cardiac mortality. And it's interesting as well, if you think of some of the data that's come out of Finland, one of the best studies, it almost halves your mortality if you start under the age of 60. Interestingly, they did, because they've got really good data for Finland. You know, everybody is completely stamped, signed, sealed and delivered and studied in great detail. They know all the drugs that they've taken and everything.

It's very difficult to be off the grid in Finland, apparently. But anyway, there we go. They actually showed that even women who start HRT between 60 and 70 have a significant reduction in cardiac mortality. Now, remember, of course, they're mostly there taking estrogen, eustodial rather than the American stuff, the conjugated equine estrogen. And almost nobody in Europe, and I don't know many people in Europe who use the American treatments. But that taken orally, that has a slight benefit for younger women, but, you know, manifestly

doesn't for older women. And when they produce their statements, it's almost as if they're cherry-picking some of the material in the background. I mean, some of the Cochrane reports, for instance, if you drill down into the Cochrane reports, they'll show reduction in cardiac mortality, reduction. in cardiac disease. There's no doubt about that. All the studies show that for younger women starting at the right sort of time, starting indeed in perimenopause as well if you need to. But then their final statement in Cochrane is often that overall there's no benefit. And that's

because they've got this awful WHO trial in there, which much of it is irrelevant to UK, European, non-American practice. Absolutely. Hang on. The people in the WHO study, the women in the study got free Medicare, didn't they? That's a really good incentive, you know, in the States. I mean, so there's a huge bias in that. Anyway, I'm going to shut up now. You could ask me another question. I don't know if I'm going the right direction. You absolutely are. And just to be clear, these are the draft menopause guidance that have come out. So they're still under consultation. But it's very disappointing because we've moved on over the last eight years since the last ones came out, the only nice menopause guidance. But when you look at a study or a group,

group of studies that show a benefit. I do know about you, but I always then think about basic science. You think, well, how can I explain what's happened? Now, with reduction risk of cardiovascular disease, there is a very clear explanation because we know eustodial is very anti-inflammatory, especially in the endothelium, which is the lining of the blood vessels. So it makes sense as well, doesn't it? It's not just a sort of spurious result. Well, it's important. It's biologically plausible. Yes. So you're much less likely to get clots building up in. in the cardiac vessels. But it's not just that.

It also improves neurovascular transmission in the heart muscle itself. So it beefs up the heart muscle. It stops the heart blood vessels clotting off. And also the nerve conduction within the heart is improved. So it works on three different things.

Ah, that's really interesting. One of quite common symptoms is palpitations, which is not just down to anxiety and waking up in the middle of the night and having a panic attack and all that sort of thing, but actual palpitations that women feel. And that's often, often, one of the very first things to get better when you start taking HRT, even at low dose. Because quite a lot of people, I'm not one of those, but quite a lot of people will start HRT at the lowest possible dose and then increase it until you finally get on top of the mood side effects or the cognition issues or the insomnia or whatever it happens to be.

I tend to go in with a mid dose and then go up and down from there, but that's by the by. but when you start at the lowest dose, the first thing to get better is palpitations. And that's nothing to do with not having clots there or whatever or preventing the clots. It's down to a direct effect on the heart muscle. But that also is the same thing that affects the brain as well. So they've got another statement almost beneath that. I'm just going to have a look and see if I can find it. It says when talking about hormone replacement therapy as a treatment or option for troublesome menopausal symptoms with somebody,

explain that overall taking estrogen-only or combined HRT is unlikely to increase or decrease life expectancy. Now that is complete rubbish. I mean, where on earth they've got the evidence for that, I do not know. But if the evidence is a conglomerate of much older women in the WHOHI, rather than just the women for whom HRT is most useful, in other words, the under-60s, Actually, I'm going to be a bit ADHD and go off paced a little bit here. And just to say, of course, that in the over 60s, it doesn't actually increase risk. And if you give it in the appropriate dose in the appropriate route and start low and slow,

you can make a huge difference to women in 60, even 70 or so. And actually in the cardiac data, even in women starting in their 70s, there seems to be a benefit from the Finnish national study. I can't explain that. And it seems counterintuitive. but it seems to work. Well, it's no surprise, really, because it's the same hormone, and especially when given to people who are healthier,

so who don't have established cardiovascular disease. The other thing, though, we know, and we've known, and even nice actually do say top level, that HLT has more benefits than risks. Now, if you count up the number of times the word benefit is mentioned, compared to the number of time risks is mentioned. Risks is actually mentioned 256 times, and benefits is only mentioned about 146.

three times. That's a ridiculous bias because actually if you use the appropriate HRT, and I'll define that in the moment, in appropriate women, there aren't any risks. There really aren't any risks. In fact, no, actually, it's much more important to look at the risks of not taking HRT. Yes. Because quite apart from the probably excess risk of dementia, cardiac disease, etc., etc., If you don't take HRT, then interestingly, of course, if you're unlucky enough to get breast cancer, you're more likely to die of it. Now, this is something that I find absolutely unforgivable about Nice and everything.

And nearly all the recommendations that come out of people who support Nice is that it was known from before WHOHI that if you happen to be on HRT, when you were unlucky enough to get a breast cancer, your survival was much better. 10-year survival was 80% versus 64%. and that was back in 1999 or thereabouts. I think that was a Danish study, but the fact is it's not very different from in other centres. And although people said that's a healthy user effect

because they're healthy enough to go to the doctor, they're on HRT, and maybe the HRT reveals a breast cancer that was there and wouldn't have been seen, et cetera, et cetera, on mammography beforehand. But whatever, taking HRT is associated with better breast cancer survival. But in the Finnish data, once again, we come back to Finland because they probably have the best figures for their entire country. We're talking about, you know, half a million women being studied over many years.

It actually shows that women between 50 and 60 have two-thirds reduction in breast cancer death. And overall, it's 50% reduction. So you're half as likely to die of breast cancer if you take HRT at whatever age. And nowhere does that appear in any of the information. And, you know, that's the opposite of what your GP might tell you or what your GP might think. And it's also the opposite what members of the general public would think. So it's inappropriate that these negative messages you would get out when you could actually give a positive message. The other thing I wanted to say, I was trying to get to, was that the biggest risk of not taking HRT is ending up in the hands of your GP with random polypharmacy.

Because if you've got a pot-poury of peri of perimenopausal or menopausal transition symptoms and you go there with your, if you don't happen to have hot flushes, because a lot of GPs will say, are you got all these other symptoms? Your insomnia and your low mood and depression, your brain fog and all that sort of stuff. But you haven't got hot flushes. You can't have perimenopause or metapause. Absolute rubbish, of course. So if you've got the classic symptoms, the worst symptom, I know you've done studies, but I personally think it's insomnia and brain fog are the two big ones. And certainly those are the things that affect me.

And, you know, blokes get the same sort of symptoms if they're on call for a long weekend. You know, anybody who's sleep deprived will get brain fog, although actually they're there's a direct effect on neurotransmission, as you know, and you're much better at explaining it than I am. There are so many different effects that the estrogen works together. And, of course, the hot flushes are a neurological phenomenon, actually, neurovascular phenomenon. So if you put all that lot together, it's so much better to be taking HRT than

taking hypnotics or sedatives to make you sleep. You get addicted to them. What next? Oh, antidepressants, the worst possible thing you could take. You need a hormonal solution for a hormonal. problem. Why would you want to take an antidepressant? And actually, you came up with this lovely description that some of your women describe, your Birmingham women describe, and I don't know whether we can use an expletive.

I think you know what I'm going to say now, but they call it the effort pills. Because, you know, crash the car, oh, sod it. In other words, it blunts your emotions and it inures you to some of your problems, which sometimes can help you get through if you're not going to take the HRT. But the way I try to describe it is that SSRIs are a bit like pouring oil, on troubled waters. It can smooth some of the ripples, may very slightly reduce the amplitude, but has absolutely no effect whatsoever on the wave motion underneath. So it doesn't affect the hormones. And it might be detrimental. We know there are some long-term risks of the

SSRIs, including osteoporosis, actually. So nothing with it is without risk. I got a minute. I would have said there's a multifactorial thing in there. I would have said that one of the main, if SSRIs are associated with osteoporosis, that's because the women aren't taking HRT. Well, it's a combination. So men have an increased risk of osteoporosis too. Ah, right. Okay.

Well, I'm not going to go down there because I don't know enough about men. But it's a fascinating thing because we're almost going down my mental list of all the things that go wrong, your risks of not taking HRT. So we've done SSRI. Oh, yes. What we haven't done with SSRIs is that women should be told that they've got approximately a 70% risk of anal orgasmia. if they take SSRIs. Now, that's been brilliantly hidden in the small print by the drug companies,

but it's actually true. And of course, virtually all women will get some diminution in their libido when they take SSRIs. We know this, of course, because we do know an effect in men. Of course, we use these drugs for premature ejaculators in men, stops them getting to orgasm. So, of course, it has the same effect in women. Why would you want to take a drug that stops you getting to orgasm? I mean, I'm sorry, I haven't got an answer to that one at all. Where did informed consent and side effects go in the advice that people are supposed to give? I'm sorry, I'm a bit lost on that one. Anyway, you see where we're going with this.

Another thing, of course, is that if we get and get cardiovascular protection with HRT and you don't take the HRT, then you're going to be doing the statins, the ACE inhibitors and all the other drugs, all the other stuff that people get. And, of course, that stuff needs monitoring. It needs dose adjustment. It needs loads of, I mean, the bottom line with the whole thing is you've got loads of visits to the GP for a poorer overall result and poorer quality of life. And a lack of jaw.

That was it. I came up with this little phrase in my lecture about lack of JDV, which actually is enormously important because you know, we've talked about this before that quite a lot of women will describe this lack of joy, not just on taking SSRIs or just from perimenopause and menopausal symptoms. And you can get quite a bit of that back. with estrogen. Of course, quite a few people will need testosterone as well, but we can talk about that separately if necessary. I don't know whether we wanted to get onto any of the other things

that NICE has said, because I've got a few other odds and sods here. Well, as good and say, there's two areas that I think are also disappointing and nice. One is when they talk about dementia risk because they don't actually talk about benefit with HRT and they seem to have forgotten. They just talk about risk in women who start HRT over the age of 60. So it's very skewed the results that they've looked at. But dementia is very important because if you actually start early enough, there are loads of different studies on dementia, but most of the recent randomised trials going forward are never going to be long enough to show an effect in a large enough population. And the only really good study that we've got is actually retrospective study from

Roberta Brinton's group, where they use the Humana Insurance database. They've got 400,000 women. And of course, the great thing about the insurers is they know exactly who's been taking the drugs because they've damn well had to pay for them. They also know who got Alzheimer's and who got this, that and the rest because they've had to pay for them to go to hospital. So it's actually pretty robust, albeit retrospective data, and what it shows is that if you take transdermal's HRT, it reduces your risk of neurodegenergogenic disease by 80%.

And even if you take oral and conjugated equine estrogen, it reduces it by 6060%. And also the confidence limits are very, very tight. it's an enormously significant reduction. And actually even WHA came up with a, in the women on conjugated equineasestrogen only H.R.T, they had approximately a 15% reduction in mortality from Alzheimer's disease. Now, even WHA using stuff that we would never use still gives you a benefit. And of course, remember that when they actually looked into, when Roberta Brinson's group looked into their study,

They showed that it needed to be, remember it need to be MHT, menopausal hormone treatment, at those HRT started the right time, started early enough, either before menopause or just after, or within a few years off. So if provided it was started early enough, the effects were manifest by about the age of 65. So you've got to continue it at least until 65,

and the longer you stay on it, the greater the magnitude of the effect. And then finally, you know, the idea is basically, for God's sake, don't stop it. Now, why does it work? Why are we coming up with this when Nysus telling you not to do it? Well, it's biologically plausible. We've already said in the long term that estrogen protects against

microvascular atheroma, which is one of the causes of the dimension contributes to all the neurovascular, the neurodegenerative diseases. But not only that, it improves initial cognition anyway, which helps a lot. But it's not just from dementia. We know that, for instance, if you control hypertension, then you also reduce dementia. If you control diabetes, you also reduce dementia. And once again, it's the same mechanism. It's this estrogen giving protection against microclotting mythraoma in the,

not just the arteries, in the tiny little arterials that supply all the tissues of your brain and all the heart muscle, all the rest of the body. So there's a huge biological plausibility for HRT reducing your risk of dementia. Quite apart from improving your joy, your quality of life, your sex life, the whole bloody lot, and also protecting your bones as the best thing. So what the hell are they going on about not to give it for primary protection? I suppose, I mean, actually that's one of the things that none of the menopause organisations have actually put a marker down for, although some of the top people in the

world, Roger Lover, John Stevenson, Howard Hoddes and Company wrote about seven years ago about back to the future, HRT as primary prevention. Yeah, which is a great paper. Brilliant, absolutely brilliant paper. I think, in fact, instead of reading the current nice guidelines, I would advise anybody's go and read Roger Lobo's paper. I'm sure you can add a reference to the bottom of it. It's beautiful. Well, you absolutely can because it's a really lovely paper and it talks about science and it talks about evidence. One of the reasons that HRT, certainly in America, isn't recommended for primary prevention is because of insurance.

Because if they said it was, it would have to be covered by insurance and no one wants to pay for insurance that affects 51% of the population. So it's more of a political thing. But why would the insurers want to pay for all the early day, you know, the cardiac disease and all the other stuff? Who knows? That's just madness, isn't it? How many times do you need to go to see your GP for your sedatives and for all the other things? And also the long-term nursing care of people with cognitive difficulties. I mean, Nice is supposed to take an overview of the whole economic model.

And I don't think that the economic model is very good if it's going to cause more GP. visits for poorer mortality. Yes. It's very much looked in the short term and yet again it's been focusing on symptoms, especially vasic motor symptoms, which we've already said are not the most common and hasn't paid regard to the longer term health risks, which is really important. So hopefully this consultation document will not get through without significant red pen going through it and alteration. If we can shout loud. Not shout loud enough. argue calmly enough with the right evidence-based.

Baring in mind, of course, our own practice-based evidence as well from what we see from the individual women in front of us, because most of the epidemiologists will have never seen, you know, we'll never actually have practiced clinically. And I think it makes a big difference. I mean, actually, that's one of the lovely things about doing menopause work, is that, I mean, I'm now retired from the NHS, but I keep going because, of course, luckily everybody can Zoom or whatever it is nowadays.

And it's the fact that you can make such a huge difference to the quality of a woman's life in a one hour or half hour consultation. And, you know, one of the reasons one does medicine is to help people. And you get so much, by and large, excellent feedback. And there are very few women that you can't make a huge difference to their quality of life. And then, of course, you're not going to see it X years later. You will have probably made a contribution to their quantity of life. And that's not a bad thing at all. Absolutely.

No, it's very powerful and very transformational medicine. So before we finish, Peter, there's lots more we could talk about, but we do have time constraints. When I spoke to you probably about three or four years ago now, we were talking about, instead of HRT, just calling it natural hormones, because that's what it is. Oh, yeah. We have this debate about this medicine, but it is just natural hormones. So what I'd like you to do is just, I always ask for three take-home tips. So three reasons why people should consider their natural hormones. Well, because if you take away the natural hormones, then you're going to get difficulties and issues.

And if you lost any other natural hormone in your body, such as insulin, you'd get insulin replacement up for diabetes. If you're hypothyroid, you'd get a thyroid hormone. And so why not get estrogen and testosterone plus or minus progesterone if you need it? So I think it's really just a question of replacing what you've lost to keep you going in much better shape. That's the first point, I would say. Other things to think of is also, of course, if you do stick it out and stay on it for life, you know, why on earth would you want to stop treatments that are going to keep you in better shape? So there's really no very good reason to stop. And in fact, if you use transdermal estrogen and a natural human progesterone, if you use human estrogen and human progesterone, natural hormones, basically, then there is

never going to be a point at which any very, very small theoretical risks might in any way outweigh the enormous benefits that you're going to take it. So I suppose the final punchline then is in terms of how much what you need is as much as you need for as long as you live, because why would you want to stop? Yes. Very good advice. As much as you need for as long as you live is just sums it up really. So thank you ever so much for your time and keep flying the flag for us men and pals or women. So thanks very much. Thank you, Louise. It's great. Cheers. Bye. You can find out more about Newsome Health Group by visiting www.newsonhealth.com. And you can download the free balance app on the App Store or Google Play.