Thu 20 Oct 2022

Me.No.Pause Me.No.Pause


For centuries women have coped with symptoms of menopause and the world has labelled it as “normal”. The inevitable that will happen to every woman. Women heading into middle age wondering how bad it will be for them. Hoping it will be fast. Hoping it will be pain free. 51% of the world population is female, but this thing called menopause affects us all. Newson Health Research and Education found that 99% of women felt that the perimenopause had affected their work. One in five women had passed on the chance to go for a promotion they would have otherwise considered, 19% reduced their hours and 12% resigned. Brain fog, tiredness, poor memory and concentration are cited as reasons. This has a massive impact on the remaining work force and leaves women feeling disempowered, unhappy and isolated. The good news is, that there seems to be a movement towards realising that this is treatable and that women don’t need to suffer in silence. Finally it feels like the world is ready to think about menopause properly. 


HRT was first prescribed in the 1940s but became more widely used in the 1960s and they revolutionised the treatment of the menopause.The Vagina Monolgues in the 90s brought a new era of empowered, youthful women who no longer needed to give up on their sex life and resign themselves to a life of anxiety and fatigue. Then came the Women’s Health Initiative (US) and the Million Women Study (UK) which were published in 2002 and 2003. The studies that it now seems ruined the lives of millions of women. The studies that blamed breast cancer on HRT. The studies that caused panic amongst doctors and meant women made the decision to “go through it naturally” with the prescription of HRT dropping by 66%. Only the problem (which we are now more aware of) was that the numbers were misrepresented. The tiny percentage of people adversely affected by HRT expanded through misinterpretation of data. In fact the Women's Health Initiative long term randomised controlled trials published in 2020 showed a significant reduction in breast cancer diagnosis and mortality in women using oestrogen only HRT.


What we know now is that women under 51 need oestrogen and it is important that it is replaced appropriately because without it they are at risk of osteoporosis, dementia and heart disease later in life. 1 in 7 of us as women will get breast cancer whether or not we take HRT. We know that our risks of breast cancer increase as we get older, if we smoke, drink alcohol or don’t exercise. We know there are a small number of women with a genetic tendency towards breast cancer at a young age and this group needs to take specialist advice when it comes to taking HRT.  We know that the highest rate of suicide in women is in women aged 45 to 49 and yes we know that suicide is complex and can not all be blamed on hormones, often this stage of life is also peppered by home and work stress, but if we layer perimenopausal symptoms on top of that stress, it is another thing that can lead women to feeling like life is not worth living. 


So what do we know helps? 


Lifestyle medicine can be life changing for a lot of women. Taking regular exercise and in particular moving to more resistance and mobility rather than cardio exercise can be really beneficial at avoiding the muscle wasting and joint problems common at this stage in life. Stopping alcohol can reduce a lot of the symptoms and is also better for our physical and mental health generally. Thinking about our nutrition and focusing on whole foods, increasing protein and “good” fat intake and reducing sugar and saturated fats intake, again can improve symptoms but also help our general health. Making time to reduce stress by being in nature, slowing down, focusing on our breath and being mindful, makes us more efficient and productive. Keeping up social connections will protect us psychologically and working to improve our sleep will also help with the fatigue that is associated with this time of life. 


But it is also important to consider the benefits of HRT. There are certain people who should always be offered HRT including those who develop perimenopausal symptoms and who have had hysterectomies and oophorectomies under the age of 50. For these women it has always been clear that the benefits far outweigh any risk. But research is finding more and more that for the average women hitting menopause around the age of 51 that the benefits also outweigh the risks. 


The bigger story here are the benefits that we have as women by sustaining our oestrogen levels. The big benefits we have are on our bone health with HRT associated with a 30% significant reduction in vertebral and non vertebral fractures, and also our cardiac health. HRT has been shown on a meta analysis of RCTs if started below 60 years of age or within 10 years of onset of menopause to give a significant reduction (>30%) of MI or cardiac deaths. The benefit on our cognitive functioning has been shown by the prevalence of Altzheimers being less on HRT and the use of oestrogen reduces the risk of AD by 5% annually. In fact even just 12 weeks of Oestrogen has been shown to increase verbal memory in healthy post menopausal women. Oestrogen is also a serotonin agonist and several RCTs have shown it to improve anxiety and depressive symptoms in up to 80% of post menopausal women.


Seems so simple but yet social media is full of discussion around why some doctors don’t feel happy prescribing. Why women have to go to private doctors for help. Why women are mistreated with antidepressants and still scared off by the misinterpretation of the risk of breast cancer. I’ve been a doctor for over 20 years and have been a GP for 16 years and a Psychiatrist for 18 years. As a woman at the age of 46, as a GP trainer and medical student teacher I have seen education around HRT and menopause develop and change. It is there. There seems to be a myth that it is not. Advice and research has changed and there are many GPs out there who still feel uncomfortable prescribing HRT as it is out of their knowledge area. There is a postcode lottery of how easy it is to access a specialist service if your own GP is not knowledgeable and women are suffering as a consequence. My advice is to ask who in your practice leads on women's health and ask to see them. If there isn’t someone then change practices or ask for a referral to a women’s health service. Check out the great information available on social media. For lifestyle measures I recommend @lesleywaldronhealthcoach or @nicolaostler_fitness_coach and @ekhowellbeing. For advice around HRT I recommend Dr Naomi Potts @drmenopausecare . I am also happy to review you through my private practice at Cambridge Private Doctors. The biggest lesson here is that you are not alone and that help is available. Please don’t suffer alone. 


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