The Dr Louise Newson Podcast - 278 - World Menopause Month special: common questions answered, with Dr Rebecca Lewis

Episode Date: October 15, 2024

In a special episode to mark World Menopause Month, and ahead of World Menopause Day on 18 October, Dr Louise is joined by Dr Rebecca Lewis, co-founder of Newson Health. Together they cover some of the most frequently asked questions about perimenopause, menopause and HRT, including: When should I expect symptoms to improve after starting HRT? How long can I take HRT for? Plus advice on taking a holistic approach to menopause, tracking your symptoms, and talking to your healthcare professional. Dr Rebecca also suggests three things women and healthcare professionals should consider about hormones: Know there is a difference between older synthetic hormones and body identical, natural hormones Be aware of the health benefits of HRT  The importance of shared decision making and patient-centred care. You can download the balance app here, and the Easy HRT prescribing guide mentioned in the episode here. For more information on Newson Health, click here. Dr Louise Newson’s first-ever live theatre tour, Hormones and Menopause – The Great Debate, runs until 12 November. For more information and tickets, click here.

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. 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 for World Menopause Day in World Menopause Month, Rebecca Lewis and I decided to do a joint podcast.

So Rebecca, as many of you know, is a very good friend, but she's also a work colleague, and she's a co-founder of Newsome Health, and she props me up in many ways. We both encourage each other, and also we both learn from each other as well. We have professional curiosity that keeps us open-minded, we challenge each other, and we're learning all the time.

So Rebecca's been on the podcast before. She's on it again, and I'm sure she'll be on it in the future. So welcome, Rebecca, thank you. Oh, it's lovely to be here again. Thank you, Louise. Always good to talk to you. Ah, so we're learning all the time as doctors. We learn from the evidence, and as many of you know, medicine is a science and an art, and the science is the knowledge and the art is individualising care for patients. And certainly we're very patient-centred and everything that we do. But we thought today, oh, I thought today, that we would just sort of go back a bit to basics, actually, because there's been so many questions that I get through my social media. We get from patients in the clinic. So we thought we'd just go back to basics. And a lot of of questions actually about hormones. And hormones cause a lot of confusion for a lot of people

because there are so many different types and doses and even people knowing when should I start, when should I stop, what should I do? How do I know I'm on the right dose? How do I know it's right for me? So I thought I might just ask you a few questions and you can answer them if that's okay. Sure. Yes. So when we talk about hormones and hormone replacement therapy, It's actually only three out of dozens of hormones that we have that is important in this conversation, isn't it? Yeah. I mean, hormone replacement therapy refers to estrogen, progesterone and testosterone. It's a relative hormone deficiency.

The ovary starts to fail and it fails to produce these vital hormones. But it's also really important to know when we say estrogen, what estrogen do we mean? Because in the family of estrogens of very different types with very very. different properties. And we mean the natural estrogen produced by the ovaries, which the chemical name is 17 beta eustodial. And that's available to be taken through the skin in patch or gel form or spray form. And that is the best, most effective, safest way of giving the estrogen from the eastern part of the HRT. But it's simply, really, the whole principle is the hormones lower and fluctuate in the perimenopause and then eventually settle down to a very low level from which

they will never recover in the menopause when the ovary has finally failed and stopped reducing these hormones. And all HRT is doing is replacing the level back to the physiological range we had before the ovary started to fail. So probably levels in our 20s and 30s on average. It's not giving high doses unlike the contraceptive pill, which the potency of which is about 10 times the dose of HRT. It's a different type of a synthetic eustrition, of course. So that's those sort of principle, I think, covers what hormone replacement therapy means. Yeah, and it is really just replacing what's missing.

And sometimes we give different doses to different people, but also we don't always just give it for menopause, do we? Not at all. I mean, through women's lives, there's fluctuation of hormones from our teens, as we're going through puberty, there's a lot of hormonal fluctuation as our cycle settles down. And then during our reproductive time, when we're having periods, there's a huge fluctuation within our menstrual cycle. So hormones are estrogen levels high in ovulation, then it drops. Progesterone rises after ovulation and then drops precipitously.

So we have actually quite no hormone levels of estrogen and progesterone just before our period. and this can give rise to many symptoms for some people, like premenstrual syndrome and even worse, premenstrual dysphoric disorder, PNDD, which for some women can be devastating. PMS is quite common in a mild level. Most women experience the drop in hormones as it's shown as low mood, perhaps irritability, breast tenderness, a bit of anxiety, perhaps poor sleep. often, you know, the week before, a few days before their period, and as soon as the period starts, the hormones recover and get back to a decent level and their symptoms disappear.

And if it's worse than that, PMDD, perhaps in 5% of the population, which still, when you think how a larger population of women is in the UK, that's a large number of women affected quite deeply by their hormone problems within the time just before their period, which is called a routine phase. and very serious symptoms can arise from some people who are very vulnerable sort of fluctuation, very low rude, depressed, intrusive thoughts of self-harm, exhaustion, fatigue, almost a Jekyll and Hyde sort of character

women describe themselves, but don't recognise themselves at all. Often their partners can really see and they know exactly when their period is due because there's a sudden change It's like night and day for some poor people. And this is the power of hormones and the effect it has on our brain and should never be underestimated.

And there are treatments really with replacing these hormones with exactly the same or body identical hormones can resolve these symptoms. Yes, because it's also always, you know, caused by hormone changes. So the symptoms of PMDD are similar and the same really as symptoms related to perimenopause and menopause. So, and it depends on when we give it. So if we're only giving it for when people have symptoms,

often in women with PMDD. But dose change, and a lot of things people ask, and I saw a patient the other day, and she said, but how do you know what dose to start? What do you do? Can you do a blood test and can you work out all the time my dose? And it's not quite as easy as that, is it? Often we start on a dose that we think is going to be right.

And then we review people and monitor their symptoms. and we often do do a blood test to check that the hormones are being absorbed into the body and the blood test is a guide and symptoms are a guide and we put things together and see. And often doses do need to change, especially if we start in the perimenopause when women are still having hormones, we might find when their own hormones deplete their dose needs to be changed and often increased when to match their hormone depletion, if you like. Yeah, absolutely. When you start off on HRT started in the perimenopause, when perhaps, let's say, for simplicity of explaining it, the ovarian function has gone from 100% down to 80% and symptoms start to appear.

Then HRT really just tops up the existing basal level of hormones by 20% to get you back to the physiological level. But of course, that ovary is going to only decline over the years to come. and that's very variable for each individual. It might be over the next three years. It might be over the next seven years. It might be over the next six months. But educating women about what to look for of symptoms of hormone deficiency so that they can be alerted that actually, hang on,

I feel much better on HRT. Perhaps that happens when they're topped up. But in six months, they feel they're falling off a cliff again. Then their dose needs to be reviewed because probably their own endogenous, meaning the internal supply of the hormones has deteriorated a little more, and their ovarian functions gone from 80% down to 60%. And we need to bridge that gap by a corresponding change in their dose of HRT. So it's very critical.

It's a real art, actually, to understand what's happening with the physiology and get the right dose for that individual. And so many people ask, how long does it take for hormones, to start working once they've started HRT? Yeah, it's a good question, isn't it? I mean, women always ask that. When am I going to feel better? Does I'm desperate to feel better one?

And it is a difficult one to say for sure with the individual, because again, it's very individual. We have some people who really feel better in two weeks, and that's not uncommon. Others may take really six months or something, three months to feel better, and then to build on that, to get the dose right for them. It takes several visits.

sometimes to get the right dose and build. Perhaps they're not absorbing it very well through the skin. So it looks like they're giving themselves a reasonable dose, but nothing, hardly anything's getting into the blood system. So their body's not getting the right level of hormone at all. So we have to work that out gently and see the response because it's difficult to, there's not a blood test that's stable and accurate to say you've reached the target level because hormone blood tests fluctuates so much

that it's actually quite difficult to sort of say, like a thyroid test, you can test your thyroid function, say yes, you're back to the normal range now. With in the perimenopause, in particular, hormones fluctuate so much. So it's a mixture. They can be very helpful if they're low. That does suggest that the absorption's poor, plus looking at the person clinically

and how many symptoms are they still having? are they still suffering? So it's a clinical diagnosis based on symptoms first, backed up perhaps by low levels in the blood test. All these sort of things, I explained to patients, it's all a piece of the jigsaw to give us the overall picture. And it's about the experience of a practitioner and understanding, seeing patterns from there, they've seen in other patients as well. Yeah. And it can take a while because there are so many changes that occur in the body with hormones. So I'm not very patient, as you know, but patience is a virtue when you start taking hormones. But sometimes I see people in the clinic, and I'm sure you do too, who have been absolutely fine on their hormones, they feel a lot better.

And then suddenly they come back and say, you know, I'm getting more symptoms. Like it's not working. What can I do? So what do we do then? Because it's not a one-size-fits-all treatment, is it? No. So if they had a good response, that's a good sign that the hormones are working for them. They haven't got side effects from them or intolerances.

So they were working and now they're not. We need to really say, how are they absorbing it? Are they on the right combination, number one, the right type of hormones? Are they make sure they're on the natural body identical hormones? Very, very different from the old-fashioned synthetic hormones, of course. You know, have they got estrogen, progesterone, testosterone? Are they also on that? We know that that improves libido, but also we have testosterone receptors all over the

brain all over the body, like the Eastern receptor, which is on every single cell in the body, including our immune cells, you know, are the testosterone? Is there enough testosterone in the blood system as well to improve symptoms? So we've got to look at all of these sort of things to optimise, what we call optimising the dose of the individual, which would be very different from anyone else from their friends' dose, because it's so particular and individualised how one absorbs through the skin based on the pH of the skin, the hydration, the depth of the skin, the number of capillaries in the skin, etc. It is very, very individualised, actually how much gets into the blood system. So all these sort of things, one we need to be thinking about,

to get the dose optimized. Yeah, and that's why we certainly review people regularly to make sure that they are on the right dose. There's always confusion, isn't there, about how long do I take HRT for, do I have to stop it? Every so often I read articles on various websites to say that we need to reduce or stop after a certain length of time, but this has all been based on this unfounded fear about breast cancer risk and HR2, which actually isn't there with the natural body identical hormones that we usually prescribe. So do we have to come off it at a certain time or a certain age, Rebecca? No, very much. Again, you know, we hear constantly, you must or you mustn't, you should or you shouldn't, you're not allowed, you are allowed.

That's absolute rubbish. You know, woman, there's no time limit. And nice guidance say that, to quote nice guidance, there's no time limit for how long you have to take HRT. HRT has so many benefits, not only on the quality of life, restoring women's function back to normal, allowing women to reach their potential. I mean, that's good enough. But also, certainly the evidence is very clear if we start it within 10 years

woman's last period or under the age of 60, we can hold their risk of heart disease. I mean, that is a phenomenal thing. We can treat their osteoporosis, bearing in mind one and two women will develop osteoporosis over the age of 15. We want two women. That's a huge amount. You know, it reduces the risk of bowel cancer. It reduces the risk of type 2 diabetes.

It reduces the risk of osteoporotic fracture by 30%. It reduces the risk of obesity. of major depressive illness and really encouraging evidence now to show that it may well be a really strong factor for reducing the risk of dementia as well. I mean, you know, so many benefits that why should women stop having those benefits after five years is a nonsense. There's no evidence for that at all. So a woman should always have an annual review if she's on medication and then the potential benefits discussed with her and whether she wants to continue and if they're reviewed to make sure there are no risks,

which they usually are none or very few, unless there's been a change in her health circumstances or anything like that. So, you know, there's no time limit. I think one common question, you probably have that too, haven't you, Louise? A lot of women think, if I stop it, I've got to go back like snakes and lullers. I've got to go back to the beginning and go through it all again. And so that's a really good myth to bust now, actually. It doesn't mean you have to go past the beginning again.

It doesn't put off the evil day. When you stop it, it just reveals where you would naturally be with your menopause symptoms anyway. So if a woman was to have symptoms predestined to last seven years, and she took HRT for five years and stopped it, she'd have another two years of symptoms and then they may abate. We don't know how long symptoms are going to last, really. I mean, it's commonly quoted seven to ten years, but I think the study's done

have been poorly conducted. It's not really strong evidence. We all know that many women have symptoms for decades. Even if they don't have symptoms or they have abated, the hormone levels, once you stop HRT will be low. So as soon as you stop HRT, the bone density that you've built up over the years will start to diminish then and the benefits will start to wane. So there's no time specific.

It's a very individualised discussion. Yeah, and for most of us we take it forever because of the health benefits that it affords us. And, you know, that's really important, actually. I think a lot of people think incorrectly, actually, that hormones build up in the body. Or you get sort of immune or used to them or you have to keep changing and increasing the dose, which isn't right at all, actually. And now, because they're so safe, we don't have risk. data, if you like, because we've prescribed these natural hormones. And so most women elect

and decide to continue forever. Because even if, for example, I stop my HRT, I might or might not have symptoms, depending on how my body reacts to not having hormones, but whether we have symptoms or not, we've still got this risk of diseases. And so I've said this before, but one of the reasons I take HRT is I'm very worried about osteoporosis because it, like you say, it's so common, and it's not just having a fracture of your hip or your wrist, it's a fracture of the spine that really worries me, actually. And so I know that while I take hormones, my bones will be stronger, my bone density, I've had a dexas scan is good and I wanted to stay good. But that's an individual choice. Some people less now, actually, than used to say, I'm just going to take it to help me get through my symptoms.

and then they come off. But I don't see many women, I don't see any women actually who want to come off their hormones because they're understanding more and more the health benefits. And comparing it to other natural hormones like thyroxin or insulin, there's not logical sense to stop taking it at a certain age or time, is there? No, it doesn't make sense if it's suiting the individual, they're feeling much better, it's controlling symptoms, the benefits of future health, should be, you know, appreciated. And, you know, as soon as you stop it, those benefits will start

to go. And so I want to be as fit as possible. I mean, longevity is an interesting thing, isn't it? We all want to live as long as possible. But actually, the key thing, and us as GP's seeing this over and over again, is to live as well as possible so that we can be in our 80s and 90s running around playing tennis if we wanted to or, you know, doing the things and being as active as we can. And I think HRT is really an important part of that solution, as well as, of course, nutrition, eating well, building up bone strength from weight-bearing exercises, etc. But it's looking at everything in a holistic way, having everything thought of and, you know,

balanced really. Yeah. So one of the things that people often think is that there's so much talk about horse, hormones, that everyone's on them, because we know the guidelines are clear, like we say, there are so many benefits. But actually, it's now 2024. And compared to 22 years ago when the WHOI, the Women's Health Initiative study came out, HRT prescribing has halved in the UK. So there's about 14%, maybe 15% of menopausal women taking HRT in the UK currently. 22 years ago, it was about 30% and in the US as you know it was great it was 40% and now it's probably some figures have

shown it was only 1.8% of menopals or women which is nothing I absolutely nothing and so I find like when many women and all the women we see in the clinic have come because they haven't been served or underserved by the NHS they're coming because they want some specialist advice they want time, they want some real attention and they want to be listened to, but also they want treatment that they know, as we've already said, will improve symptoms, improve their quality of life and reduce their risk of diseases. But one of the things that I hear time and time again, and I know you do too, Rebecca, is that I've gone to my doctor and they said, no, I can't have it because I'm too young, I'm too old, I'm too fat, I'm too thin, I haven't got worse symptoms,

I haven't got flushes. I've had a history of a clot. Lots of things. A lot of people just say, I'm not allowed to have it. And there's nothing black and white in medicine, but most of these women don't have risk factors for natural hormones. They don't have contraindications, whether they're absolute or relative. They are actually quite healthy women who are often really struggling and have been medicalized for their symptoms in the wrong way.

So they've been given antidepressants or they've been given mood stabilising drugs or they might have been given painkillers or whatever depending on their symptoms. So I just wanted to hear from you what tips would you give to women who might be listening and saying, yes, I know I want hormones. I've read all this information. I've downloaded the free balance app. I've gone on to your website. I've listened to your podcasts. But I can't get it. Like what would you say to these women?

What's a good tactic? Because none of us want to upset our doctors. We want to work with them. We want to feel empowered and we want to feel central to our any decision-making processes. But what would you say to women? I mean, I think everything you've said to empower yourself with knowledge and the balance app and download the health report, because that does get conversations off to a good start. Because the health report immediately, you can see if you're still having periods or you're not,

or they've become irregular or heavier or lighter. and there's a symptom score, menopause symptom score checker there as well. So it helps conversations focus on hormones because you can politely go to your duplean to say, listen, I've got muscle pains, my sleep is poor, I'm more anxious, I've got terrible bladder infections since last year I've had three or four courses of antibiotics and my periods have become irregular. Do you think it could be hormones because I've done some reading and this is my health report? And I know now that the modern body identical, natural hormones that we use really can be given to most people.

Can we talk about hormones? So that does get the conversation off. And I think a lot of people have success like that. But if they've done that and still had a no, you know, this is more dangerous, really, because denying people these benefits is risky. You know, if a younger person comes in, we've missed the diagnosis of a burning menopause and not give an adequate hormones, when they have an osteoporotic fracture, you know, in their 50s.

So you really have to think about the risks of not having hormones in certain cases as well. And I think pointing that out and saying, look, I don't want to have hormones. If you're getting a negative, I would ask for a referral within the NHS to a medical specialist to get their opinion. But it can be really frustrating, can't it, Louise? Yeah, I think you're absolutely right. I think going with lots of information and knowledge is really important. Downloading balance and doing the health reports, so looking at the symptoms,

and going to a doctor and saying, look, these are my symptoms, because so often people say one problem, one consultation, and they don't know whether to go with their palpitations, their joint pain, their headaches, their urinary tract symptoms or whatever. So having all the symptoms together and going with your hormonal symptoms, as opposed to an individual symptom, I think it's really useful. And actually, before you book the appointment, it's worth asking the receptionist, does this doctor or nurse or pharmacist,

whoever's a healthcare professional you're seeing, does this person have experience in hormones? Because if they say no, then actually you'll probably waste your time and their time as well. So in making sure that they are confident in prescribing the natural body identical hormones. And we've got an easy HART prescribing guide, which is available, which is referenced. And actually a lot of women download that and share it with their healthcare provider, which can be really useful and empowering as well.

And we've got good guidelines telling us how safe hormones are and how effective they are. So GPs, nurses, doctors, in hospitals, pharmacists should have more education and training. And that is happening. But because we're talking about treatment that it can improve our future house, treatment that many of us will take for decades, it's not just like taking a paracetamol because you've cut your finger and it will be repaired by itself in a couple of days. This is long-term treatment.

We're investing in our future health. So we have to have the right decision-making process with the right healthcare professional. So the other thing is that it's quite all right. to see two or three different doctors. And sometimes it might be that the doctor or healthcare professional doesn't have the knowledge or you feel uncomfortable and don't feel confident in them. It's absolutely fine. None of this mind if you go and see someone else and have another opinion or if you change your mind.

It's absolutely fine. And I think that's really important to not give up at the first hurdle. And then also a lot of people come to our clinic and we see them and we give them hormones that are the same as the ones prescribed in the NHS. And then actually we do find increasingly, don't we, that doctors then say, oh, that's good. I know what to prescribe. I can see that you're better. I'm going to carry on prescribing XYZ hormones to you. And that's happening more and more.

And we're getting some great feedback from many of our patients saying, actually I don't need another appointment with you because I'm getting the treatment I need from my NHS GP. And that's really lovely because we work very closely with the NHS, don't we? Yes, indeed. Yes, I've seen that more and more. People are understanding more about menopause. And it's quite often it's not the GP's fault. It's not the doctors and secondary care for, really.

They've never been taught about menopause properly in medical school or postgraduate. They haven't been taught. So, you know, it's something that we're working on with our confidence and menopause course that's available for all healthcare professionals. And I think, you know, people have found that incredibly useful. It's so practical. And it's changed their prescribing and it's changed their outlook completely on menopause. Because if you don't get taught about it, you can't understand it or see it properly. So you're absolutely right. This is we're in that stage where we need to do more education.

throughout the healthcare professions, but actually empowering yourself and taking someone along to these consultations is quite helpful as well so that they can advocate for you because when you're feeling dreadful, tearful, you can't get the right words because your brain's not working properly.

It's very difficult to sort of put your case forward as to why you think this is hormones and why you believe you may well benefit or at least have a trial with HRT. Yes, absolutely. So all good advice. Lots of knowledge. There's lots more that we could talk about, but we do need to come to the end. Just before we finish, though, three tips. So three just facts about hormones that I'm going to put it on the spot here and ask you that you wish you knew as a doctor 25 years ago, that you feel that every healthcare professional and every woman should know.

Just three things about these hormones. Well, the modern type of natural hormones is so different from the previous older type of synthetic hormones we used to use, you know, from pregnant horses urine. I mean, they're as different as, you know, a pear-flavored sweet as a pear, the real thing. They're more effective, the real thing. It's more really very little risk at all for the majority of people compared with the old-fashioned synthetic. type of HRT, which had some risks. They've still fairly safe, but they still had more risks that needed to be discussed. So people have attributed those risks that they had, perhaps the increased risk of blood clot, stroke, etc. cardiovascular risk from the synthetic hormones. They've

put that onto the modern, you know, body identical, natural hormones. And it's wrong. It's completely wrong. It literally is a pear-flavored sweet on one side and the actual pair that we have now. revolutionized treatment. It's so much more effective. Of course it is. It's replacing light with light. I mean, you know, I love physiology, Louise. So for me, as a doctor, it's perfect. It's replacing exactly the same hormones and the response is so much better. So understand the difference and why people are saying you can't have it is probably related to the old-fashioned type of HRT. So that's number one. Number two, I think be aware of the health benefits of HRT. You know, this is so much more powerful than the statin, for example, for primary prevention

for women. It halves the risk of heart disease. I'd like to have some of that, please. You know, why shouldn't women have that benefit, that opportunity to benefit their heart, their bones, their mental health, risk of diabetes, etc., etc. So know about long-term benefits of health. Know that you're in charge, actually, things about hormones. You are the centre of, everything. You as a patient, there's no can or cannot ever in medicine. You may be advised sometimes to do one thing rather than other, but that is advice that actually the person who can accept the advice is the individual in front of us, the patient. They know how bad their symptoms are or aren't. They then need to be balanced and make the decision for themselves. And that's really important.

It's not as didactic. You know, this paternalism in medicine. has to stop. It's a two-way conversation. They're two experts in that room, the patient and the doctor talk about HRT or menopause. And actually between the two of you, you'll come to a conclusion. And that is the key, I think. It's patient-centered, the shared decision-making. That is the most important thing. So please know that you are the most important person in that room when you consult. Absolutely. So great. advice based on a huge amount of clinical experience in knowledge. So I'm very grateful for your time tonight, Rebecca. And look forward to seeing you back in the podcast soon. So thank you.

Thank you, Louise. You can find out more about Newsome Health Group by visiting www.newson com.uk. And you can download the free balance app on the app store or Google Play.