Professor Lesley Braun facilitates a conversation on the complex journey of perimenopause and menopause, looking at this important life stage from the four perspectives of our fx Medicine ambassadors in part one of our two-part series.
Professor Lesley Braun facilitates a conversation with our fx Medicine ambassadors Lisa Costa-Bir, Dr Adrian Lopresti, Dr Michelle Woolhouse and Emma Sutherland, in part one of our two-part series navigating the complexities of the menopausal journey.
In part one, Dr Braun and the fx Medicine ambassadors explore the hormonal changes associated with this perimenopause and menopause, the typical signs and symptoms a woman may experience when going through this transition phase, and how healthcare professionals can help their patients to navigate these changes by ensuring a thorough case history is taken, and by identifying key investigations to support the patient. In part one, we hear about the impact of the Women’s Health Study on the use of HRT in women and the repercussions of this.
Prof Braun and our ambassadors share their clinical knowledge and expertise to give listeners a well-rounded and thorough look at the impact of menopause, the clinical manifestations that can present to healthcare professionals and how we can support and empower patients to navigate this profound time in a woman's life.
COVERED IN THIS EPISODE
(00:48) Welcoming our four ambassadors
(02:00) Introduction to menopause
(08:35) Hormonal changes during menopause and Perimenopause
(12:57) Signs and symptoms of perimenopause and many menopause
(20:12) Perimenopause and menopause as a differential diagnosis
(27:25) HRT
(37:05) Looking at the research
KEY TAKEAWAYS
- The average age of menopause for women is 51 years. However, perimenopausal symptoms can start 5 to 10 years earlier.
- Menopause, by definition, is the cessation of the menstrual period for at least 12 months. And after 12 months, a woman is then said to be postmenopausal.
- Perimenopause is the transitional period from regular ovulatory cycles to a more fluctuating menstrual cycle. It can last anywhere from 5 to 10 years prior to that complete cessation of the menstrual period.
- Hormonal changes during perimenopause and menopause:
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- Estrogen starts fluctuating during the perimenopausal transition: The ovarian follicles stop communicating effectively with follicle stimulating hormone. There is no surge in luteinizing hormone. This leads to a decline in estrogen production, and no ovulation.
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- Because we're having less ovulatory cycles in perimenopause, we don't make the same amount of progesterone as we did before.
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- During perimenopause, the ovaries continue to secrete androgens. However, the disparity that comes as a result of that lowered estrogen, but normal androgen levels can cause what we call a relative androgen excess.
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- Clinical presentation in perimenopause will include signs of depletion and insufficient DHEA production from the adrenals, which impacts testosterone production and contributes to symptom severity.
- Common signs and symptoms:
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- Lower levels of estrogen have a significant impact on the hypothalamus, which controls body temperature. The hypothalamus senses that the body temperature is too hot, which triggers hot flashes, which are designed to cool down the body.
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- That declining estrogen level may compromise libido, cause vaginal dryness, and sexual discomfort.
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- 50% of postmenopausal women have symptoms including vaginal dryness or itching, burning or painful sex, and urinary symptoms. A reduction in lubrication may lead to discomfort or pain during sex.
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- Common digestive symptoms include constipation, diarrhea, bloating, and heartburn caused by hormonal fluctuations.
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- Allergies and the histamine: Estrogen receptors are located on mast cells. Hormone fluctuations experienced during perimenopause can increase histamine production by the mast cells. Common clinical presentation includes symptoms such as hives or sneezing, headaches, and sinus congestion are common during this period.
- Investigations include:
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- Thorough case history
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- DEXA scan and bone mineral density
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- Breast health check to determine risk factors for breast cancer
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- Kidney function
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- Screening for metabolic syndrome
- Common differential diagnosis:
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- Hashimotos thyroiditis
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- HPA axis dysregulation
- HPA axis dysregulation
Forms of hormone replacement therapy (HRT)
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- Estrogen or estradiol creams.
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- Prometrium: progesterone
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- SERMs; Selective estrogen receptor modulators.
RESOURCES DISCUSSED AND FURTHER READING
RESOURCES
| Podcast: Let's Talk HRT |
RESEARCH AND STUDIES CONDUCTED
TRANSCRIPT
Lesley: Hello and welcome to fx Medicine, where we bring you the latest in evidence based, integrative, functional and complementary medicine. I'm Dr. Lesley Braun, Director of Blackmores Institute and editor in chief of fx Medicine. I begin today by acknowledging the traditional custodians of the land on which we gather and pay my respects to their elders, past, present and emerging.
I extend that respect to Aboriginal and Torres Strait Islander peoples here today, and wherever you are listening from. Today, we're talking all things menopause and the menopause journey with our four fx Medicine ambassadors, Dr Adrian Lopresti, who will share his thoughts as a psychologist as well as being a renowned herbal medicine researcher, Emma Sutherland, who brings an important naturopathic understanding of the menopause journey and of course, will draw on her many years of experience in clinic, Lisa Costa-Bir who's going to add her naturopathic views on the role of hormones and beyond. And finally, Dr Michelle Woolhouse, who brings her perspective as an integrative GP.
Lesley: Hi, everybody, and thanks for coming together today.
All: Hi Lesley.
Lesley: Historically, perimenopause and menopause have been somewhat of a taboo topic with very little public discourse. Unfortunately for some women, this has led to a period of being misinformed or having to grin and bear symptoms without even recognising what they are and how they could be managed. Even women themselves don't often talk about this amongst their own friends, which can make it a pretty lonely and confusing journey. But thankfully today there is greater awareness and a lot more openness to discuss menopause than ever before amongst individuals and even more broadly in the public domain. Before we jump into specifics, I'm going to take you through some background on why this is such an important topic.
The average age of menopause for women is 51 years. However, symptoms can start many years beforehand as the perimenopausal period can start 5 to 10 years earlier. It's important to recognise that every woman's experience of menopause is unique and personal, and for some, the menopause journey is a seamless transition into a new phase of life, requiring minimal to no interventions and can be quite positive. But for a lot of other people, the journey can bring with it a plethora of changes and symptoms that need to be better understood and would greatly benefit from some extra support to improve their everyday quality of life. When you take a minute to think about it, 51% of people on the planet are women. That means half the population will be going through menopause, so it's actually a widespread phenomenon and in no way is it a niche experience.
So for this reason we need to be talking more openly about it. What I find particularly interesting is how children around the ages of 9 or 10 get a lot of education about puberty. But there's next to nothing around to educate old women about what to expect during the period menopausal and menopause of periods, so they too, can be better prepared. Today, we're going to open the conversation on the menopause journey. Looking at it from four unique perspectives.
Lesley: And so, Michelle, I'm going to start with you. Can you tell us how the medical profession defines and understands perimenopause and menopause? And is there a consensus around this?
Michelle: Well, as you said, Lesley, menopause is going to happen eventually to all menstruating people. So menopause, by definition, is the cessation of periods for at least 12 months. And after 12 months, a woman is then said to be post-menopausal. So that's the complicating kind of factor. So there is no strict definition of what menopause is. You kind of go from perimenopause, which is the time leading up to menopause, and then you go into being post menopause.
So perimenopause is the transitional period from regular of ovulatory cycles to a more fluctuating period of time. And as you mentioned, it can last anywhere from 5 to 10 years prior to that strict cessation of menstrual period. But often for women, they don't know when their last period is going to be. So some people might have a period and then they might have another one five months later and then seven months later. And so that time can be very, very fluctuating and very unique for every individual. As you mentioned, it can be an asymptomatic experience or one littered by a whole raft of different symptoms and issues. So then the medical profession will also kind of create a new category, which is what they call medical and/or surgical menopause. And that's characterised by either a chemical or a drug related intervention or a surgical procedure that involves the removal of the ovaries and medical menopause.
And surgical menopause, it definitely impacts the ovarian function quite dramatically and so often result in a sudden onset of menopausal symptoms. And for many, that can be very severe and very dramatic. And some examples of that is like the drug Tamoxifen, which is an anti estrogen. And there's a raft of other medications that can cause this as well. And then there's a subsection, which is quite uncommon, but it does happen called primary ovarian insufficiency. And we also call that premature menopause. So this is a secondary failure of the ovaries. It means that the ovaries stop working prematurely. And to categorise that, that is before the age of 45. And there tends to be a genetic risk for this. But it is by no means set in stone and is often quite a shock for the women experiencing that.
The significance of this is that the protective aspects of the menopausal cycle finishes early and that women can be more at risk of things like cardiovascular disease, bone loss and other issues.
Lesley: So, Michelle, is that why you sometimes hear of women who've gone through premature ovarian insufficiency who might be, I don't know, say, on HRT for quite a few decades? Is that the reason why?
Michelle: Yeah, that's right. So, I mean, we want to try and make sure that particularly for the bone loss, because we generally tend to drop our bone density around the perimenopause menopausal phase. And so if you if you think about it, if a woman's going in ten, 15, even 20 years prior to what an average woman goes through, she's going to have 20 extra years of bone loss. And that's significant for the risk of osteoporosis. And so we want to use that hormone replacement to protect the bones. And there's burgeoning research that that will also positively impact things like metabolic syndrome and cardiovascular disease risk, among other issues.
Lesley: Yeah, look, that makes sense because they're missing all those extra years where estrogen can actually be quite protective. Yeah, no, I understand. Look, thank you for explaining that. But moving forward in this discussion, what we'll do just to make it simpler for everyone listening is when we refer to menopause, we're going to be talking about natural menopause or the time in which menstruation stops permanently without the involvement of surgical or medical intervention. I just think that that'll be the easiest way forward so that there's no other factors that come into play.
Lesley: But I want to talk to Lisa for a minute about this. As I mentioned earlier, a lot of people liken menopause in some ways to puberty. I mean, only in terms of the fact that there's a huge hormonal shift that happens at this time, obviously, in really different directions. Can you tell us a bit about those hormonal changes that happened during this time? Because I imagine that might be the reason why it varies so much for so many women. You know, change is happening at different times as well.
Lisa: Absolutely. So there is a profound shift in a woman's hormone profile. And let's start with estrogen, since it's probably the most well studied. So prior to perimenopause, most women have a fairly predictable pattern when it comes to estrogen. We know it peaks to its highest a couple of days before ovulation drops and then rises again in the luteal phase. But during the perimenopausal transition, we don't see this usual pattern with estrogen. Instead, we're seeing these really big ups and downs that are unpredictable, kind of like what happens when you're on a rollercoaster. And so these huge dramatic surges and then withdrawal of estrogen drive a lot of the symptoms that women experience.
But then at a certain point, the ovarian follicles stop communicating effectively with follicle stimulating hormone. There is no surge in luteinizing hormone. This leads to a decline in estrogen production, no ovulation. And then that cessation of menstruation, which is the menopause.
Now, if we think about progesterone because we're having less ovulatory cycles in perimenopause, we don't make the same amount of progesterone as we did before, because we all know that we need to ovulate to make those large amounts of progesterone. And for many women, this can cause an estrogen dominant picture, even though they're not necessarily producing large amounts of estrogen. And then if we consider the androgens, I’m going to put them all in together. During perimenopause, the ovaries continue to secrete androgens. However, the disparity that comes as a result of that lowered estrogen, but normal androgen levels can cause what we call a relative androgen excess. And this can also happen because those high levels of luteinizing hormone increase, androgen secretion from the ovaries. So the result of this is increased sebaceous gland activity. So we see more perimenopausal acne, more oily skin, and some of those pesky chin hairs that randomly occur. And then as we head into more of that menopause picture, we see that the androgens definitely do decline as more of that aging process.
And so I would say that a lot of the women I see in the actual menopause, they have lower in DHEA and testosterone. And for me, this is really representative of more of that depletion picture that we might see. And they often have that low sex drive, issues with their body composition, low energy and that sort of picture.
Lesley: So tell us a bit about DHEA, because I know when people go on websites, they look at anti-aging and going through hormonal changes. DHEA comes up a lot. So, Lisa, can you tell us a bit about that?
Lisa: Sure. So I tend to think about DHEA as being like the mother hormone from which our steroid hormones, such as testosterone and estrogen, can be cleaved. And it's primarily produced by the adrenal glands. So in perimenopause, we would hope that we would have relatively healthy levels of DHEA so that when the ovaries kind of decline in their production of those steroid hormones, the adrenals are producing DHEA, and we're making other steroid hormones from that cleavage. But what you will typically see in someone that is depleted and definitely, the patients that I see that are having those perimenopausal complaints where they are finding it difficult to lose weight, there's low sex drive, low energy, because they've had a long period of prolonged stress, the adrenals aren't able to pick up, the kind of pace of that, and they're not producing adequate amounts of DHEA. So they're not getting that extra production of testosterone that would or androgens that would otherwise kind of help with their symptoms. So DHEA is associated with better muscle mass and healthier aging. But I think we're not seeing that in a lot of the patients that present with perimenopausal complaints. And that's in part why they are presenting in that way.
Lesley: Okay, look, thank you very much for that. Emma, I just want to chat to you about signs and symptoms of perimenopause. And, you know, I was listening to a podcast the other day, as so many women do, and they go through this period of time. And it reminded me that estrogen receptors are everywhere. They're not just affecting the reproductive system. But, you know, when you've got estrogen levels that are dropping to very low levels through this period of time, it affects so many parts of the body. So can you tell us a bit about the signs and symptoms of perimenopause and many menopause? Because I think for some people this might be a surprise.
Emma: Sure, I'd love to. I want to start with hot flushes, because that's the thing that I see mostly in patients when they come and see me. And around 57% of women will experience hot flushes and night sweats during this life stage. And the symptoms commonly begin between the ages of 45 to 49. So often women will come in and they don't actually realise that they're getting these hot sweats before their period. And, you know, you've really got to take that out of them. But these hot sweats and the flushes can last on average around ten years. They mostly affect the face and neck, and they can also affect the whole body with that classic kind of rising heat sensation.
And, you know, as you mentioned, the lower levels of estrogen have a significant impact on the whole body. But in the hypothalamus, which controls body temperature this fall in estrogen, really affects the hypothalamus. It causes confusion. So the hypothalamus senses that the body temperature is too hot, which triggers the hot flash, which is designed to cool down the body. More blood rushes to the skin and that causes redness and sweating. Now, if you think of the picture, if you add in on top of that, some anxiety or stress, a little bit of caffeine or a little bit of alcohol, it's the perfect storm for hot flushes and sweats. Super common to see this in our patients.
Lesley: You know, we hear a lot about women who find they can't tolerate alcohol at this period of time. And I think you've just described why. So that was super helpful.
Emma: No problem. No problem. The next one I want to talk about is libido. That declining estrogen level can really compromise libido. It can cause vaginal dryness and sexual pain. More than 32% of women aged between 40 and 65 experience low sexual desire that causes them personal distress.
Now, you just interestingly, one study I read concluded that women who have sex weekly as opposed to monthly, are predicted to have a later age of menopause. And this is thought to be because if there's a possibility of pregnancy, that primitive response is to continue ovulating. So how's about that for a little bit of a side on sex and libido?
Lesley: Good trivia tip.
Emma: Now, what about all those vulvar vaginal symptoms? You know, 50% of postmenopausal women have symptoms like vaginal dryness or itching, burning or painful sex and urinary symptom and, you know, reduced lubrication leads to discomfort or pain during sex. And then we get that chicken and the egg situation of painful sex and low libido. These are super common presentations in clinical practice, and I cannot emphasise how impactful they are to women and how we really have to, you know, get into the nitty gritty about these things and really create that safe space for women to be able to talk about these things.
Another one that I do see a lot, though, is digestive changes. You know, they can include things from constipation, diarrhea, bloating, heartburn, lactose intolerance is the one I see quite frequently, but a lot of. Yeah. Most commonly, I would say constipation, bloating and heartburn and just the hormonal drivers that are causing those. And then another one I see is around the allergies and the histamine. So those estrogen receptors are located on mast cells and the hormone fluctuations experienced can really increase histamine production by the mast cells. I often see symptoms like hives or sneezing, headaches, sinus congestion. Interestingly, the production of the DAO enzyme is impaired when estrogen surges. So we see these as, you know, those cyclical symptoms in perimenopause, they tend to flare around ovulation and with PMS.
But after all of that, I just want to point out that many women don't experience all of these symptoms. And for many women, menopause, it's a relief for menstrual symptoms and it's a relief from any concerns around contraception or conception. So it is possible.
Lesley: Emma, I think that's a really important point, because if we focus too much on all the things that can go wrong, we don't think about the fact that actually for a lot of people, these are not major problems at all. They're not significant problems or they're easily remedied, you know, with a few changes in possibly diet and lifestyle as well. And they're not really big. But it does make me think about how many women might get prescribed sedatives for their sleep issues or anti-depressants for their mood issues when in actual fact it's all linking back to the hormone changes.
So it does make you think about how many misdiagnoses might be out there and whether there's lots of missed opportunities to safely navigate through all of this. But using a different perspective, looking at it from a hormonal perspective. In fact, it does make me wonder with naturopaths, GP's and clinicians in general, how often is perimenopause or menopause a differential diagnoses? I think it'd be easy to miss, you know, like you were saying, with digestive changes, you know, allergies and histamine as well. I guess there’s a lot of people that wouldn't put that together.
Emma: I think it's really common and to see it all the time in clinical practice that a patient comes in and and she's got had this sort of shotgun approach and she's got all these different kind of labels. But then when we dig deeper and we look at what's driving everything, that classic naturopathic philosophy we can see the commonality is the hormonal shifts.
Lesley: I can only imagine how in practice, once you recognise that with a patient and you actually go directly to the cause of the problem, looking at the hormones, how it would seem almost miraculous when so many things would come back into place where they should be.
Emma: It's very empowering for the patient, which is great.
Lesley: Yeah, and I can't I can only imagine there was a 2021 study that found that 83% of women in the workplace experienced challenging menopausal symptoms. However, only 70% would actually feel comfortable seeking support from their employer to manage their health. So while Australia currently does not legislate for menopausal consideration or leave in the workplace, the Equality and Human Rights Commission has provided guidance suggesting that for some people who experience extreme symptoms that in fact it could even be considered a disability.
Lesley: So Lisa, if somebody presented into your clinic with some of these symptoms, what would be the best way to confirm that they are perimenopausal or menopausal and it's not something else, especially considering we know that perimenopause can start so much earlier than many people realise. How do we differentiate this from other conditions so we do avoid those misdiagnoses?
Lisa: Sure. So we know, Leslie, there is no blood test for perimenopause. It's something that most practitioners will diagnosed with taking a good case history on the basis of new symptoms, such as mood changes, hot flushes, night sweats, and usually possibly a change in that pattern of menstrual bleeding. We know there isn't that much merit in testing estrogen because it can fluctuate wildly in perimenopause. So I think it really is about taking a good case history and understanding what's going on. Of course, other conditions can present with similar presentations. So if it's not perimenopause, then what else could it be? Well, for me, the most common differential I'm thinking about is often Hashimoto's hypothyroidism. I see lots and lots of patients present in this way.
We know that both perimenopause and Hashimoto's present with changes to mood, increased anxiety, depression and changes, body composition, night sweats, hair loss, low libido, irregularities with the bleeding. So I would always be testing for thyroid function. Test- TSH, T4, T3 and thyroid antibodies. And even though we're considering it to be a differential, I would also say it's a very common concomitant and the research is unanimous that preexisting unmanaged hypothyroidism can worsen those high levels of lipids and hypertension that we see with perimenopause.
The other differential I might be considering would be HPA Axis dysfunction, because we see a lot of patients presenting in this age group with lots of stress, poor coping mood changes, weight gain, sleep disturbance. So they kind of fit with both that perimenopausal picture and the HPA axis dysfunction. I do like to test cortisol and DHEA, but again, I think we could determine this quite easily with case taking. So, not just a differential but also a concomitant.
Now in terms of actually testing the menopause. Again, as Michelle said in the beginning, it's really something that is determined retrospectively when a woman hasn't had a period for a year. But we can test follicle stimulating hormone and luteinizing hormone and estradiol. And what we will see is these continuously high levels of follicle stimulating hormone and luteinizing hormone as they go on uninhibited. And there will be those very low levels of circulating estrogen, though small amounts will still be produced by conversion of testosterone via the adrenal glands, if that patient isn't very depleted.
Lesley: Thanks for that, Lisa. Certainly a lot to think about, particularly with some of the differentials that you're seeing in your clinic. I think that's just fascinating.
Lesley: Michelle, I want to turn to you now in terms of your practice as an integrated GP, what other tests or investigations would you consider or differentials that you'd add to Lisa's list?
Michelle: Well, as Lisa mentioned, the best way to diagnose perimenopause / menopause is by a really thorough history. And it's also important to check, you know, breast health in a woman at that particular age. So there's a lot of opportunities for testing for prevention and early screening and early detection of other relevant diseases as well. So what I'll often do is I will check their breast health and suggest that if their timing is right, if they're over the age of 50, and also have a family history or other relevant history to suggest they do a mammogram plus or minus a breast ultrasound, if that's applicable.
Also to note her past history in terms of things like clotting or stroke risk, and also bone loss risk and exercise. The other tests that I think is really beneficial during this time is to check a woman's stress levels. As Lisa mentioned, that HPA Axis disregulation, particularly when women are not sleeping well, and also if there is a prevalence of a lot of external stressors within their life. And it's really important to bring stress into the conversation because it's very normalised and often hidden and there's a lot of personal issues that can make the transition through these hormonal changes much more challenging.
Obviously, too, it's really important to think about anxiety and depression as an issue around this particular time. And of course, the hormones will increase that risk of depression. But there are other psychosocial or particular issues that occur around that time. And also we need to consider different populations. So gender diverse populations, patients from different socioeconomic backgrounds and people of different ethnicity have different menopausal journeys. And so that's a really important thing to consider when you're in that early stages of diagnosis.
The other investigations which I think of worth considering is a bone scan. Now that's not given under Medicare, but I do actually recommend it as a great time to do a baseline considering the significant drop off of bone after the time of perimenopause / menopause.
So and then there's other things like kidney function, too, which is another risk factor for metabolic syndrome. And it's kind of in that ballpark. And really one of the only ways to test for that early is to do a urine electrolyte test. And then, of course, there's other things like doing a fecal occult blood and other preventative screening, things like eyesight, etc. around that time.
Lesley: So in terms of prevention, I just want to talk a bit about bone scan. So I'm assuming you’re talking about DEXA as well as ultrasounds. I mean, if you are on a perimenopausal and there was a genetic predisposition in your family to osteoporosis, you know, would it be unreasonable to get one, say, in your 50’s?
Michelle: Oh, absolutely. Reasonable. I mean, and look, it's not it's not a very expensive test. You know, it's not it's way cheaper than an MRI, for example. And I highly recommend it because, I mean, I sometimes see people with osteopenia or even osteoporosis as early as 30 years of age, you know, particularly in women that have had long histories of eating disorders. And there is a lot of women in my clinic that have never even spoken about disordered eating or eating issues, you know, and they're 50 years of age. And so this is this is a burgeoning area where we're learning a lot more early. And I think I mean, I highly recommend my patients, if they can afford it, to have a bone scan even without the Medicare rebate.
Lesley: Yeah, look, it makes a lot of sense because if you can put in place some simple protective measures to improve your bone mineral density or at least protect it or slow down any kind of degradation, why wouldn't you?
Michelle: Yeah, absolutely. I agree.
Lesley: Yeah. So, look, Michelle, I need to talked about how HRT now several decades ago it got a really bad rap and I know a lot of people got very scared there was a lot of scare mongering, but the science has progressed, so I really would love you to tell us more about where is the science now with HRT? But also I know there's a lot more options, HRT options than they used to be as well. So can you bring us through all of those?
Michelle: So HRT has been around for a long time and when I was going through medical school in my early days of practice, HRT was given to women that had significantly impactful symptoms during that time of menopause. But little did we know kind of at that time that we were using or we did know, but we didn't realise the risks of it, but were using a synthetic estrogen that was derived from pregnant mares urine. So that's pregnant horses, urine and a synthetic progestogen. And that was the oral combined HRT that was given to most women during that time.
There was a huge study that was done in the UK with tens of thousands of women and it was called the Women's Health Initiative. So there's a huge amount of data and that started around the mid nineties and was suddenly called off around 2001. Now the media got a hold of this and the reason why it was called off prematurely was there was an increased risk of stroke, blood clots and breast cancer. So when the media got a hold of that, they created these alarming headlines that really caused millions of women to stop their HRT overnight. Now, some women were fine with that and they didn't get a return of those symptoms, but other women were significantly impacted for long periods of time. Some were so desperate to get back onto their HRT that they had to beg their doctors, you know, to get them back on to the HRT and take on the risks of what the HRT was was giving them.
So what happened was a whole group of researchers after that, after the media sensation died down, is they took that data and they started to really look deeply into that data and found that the average age of starting the HRT in the group of women because of the criteria that was laid down in that studies was 63 years of age. Now, many of those women had gone into menopause around 50 or 51, so some women were starting HRT over ten years post menopause. So that was significant. They also found that the women that had the greatest breast cancer development were those that were actually taking the progestogen. So the synthetic progesterone. And they realised this because there was a group of women that weren't taking the synthetic progesterone and those women had had a hysterectomy, so they weren't taking that. And so they found that that was the significant impact in the breast cancer risk.
And so there's developed a whole lot of safer. HRT is now on the market. So about ten years ago, what became available was the actual use of body identical hormones. Now this is really important because it makes women feel a whole lot better when they're taking something which is identical to the hormone that they make. So that's really important. And you can get estradiol in formulas now and natural progesterone. And so the trade name for that is prometrium, and it's available to take early.
The other big difference between that study with the Women's Health Initiative is we were taking estrogen orally. When you take estrogen orally as opposed to topically, you have to break down that estrogen through the liver. So you often have to have higher amounts, and also you have to have, you know, you can then potentially have issues with liver detoxification problems, if somebody has fatty liver or just has some genetic aberrations within the liver detoxification pathways, you're going to have different responses. So HRT has changed dramatically over the last couple of decades and we have at our disposal a lot more choice that we can give to women and different ways in which we can apply those different hormones, I think.
Lesley: So, are you saying that there's lots of different types of different ways of taking HRT now, you know, from what I've seen in the pharmacy, there are, there's gels and sprays. What are the kinds of things you're seeing and what are the benefits of those?
Michelle: Okay, So a lot of the estrogen is given topically nowadays through a gel. So you can either get it as a gel that you apply like a pump or an actuation, which is like a measured amount, and you apply it to the fatty tissues of the body. So I like to suggest to women back of arms is often, you know, a nice juicy spot or belly, buttocks or thighs. And so you apply the estrogen through a gel like fluid. And so it's very easily absorbed. You know, it's absorbed within a couple of seconds and away you go. You should apply it after a shower. And often we're careful around being intimate with your partner, too, because there can be some some giving over of that.
Lesley: Transference? Are you talking about you talk about having estrogen gel on your arms and you give your partner a hug?
Michelle: Yeah, I think that's right. To be safe smooching the back of your arms. And they might be very little at a dose of estrogen, which could be quite good for some husbands, depending. But there's also estrogen creams that are available as well. And we use them per vagina. And there's no there's been some really good long term studies to show that there's absolutely no increased risk of breast cancer or other long term side effects by using estrogen cream per vagina.
And so that is their either estriol, which is another type of estrogen or estradiol creams. And both can be really useful for dryness of the vagina and bladder issues associated that Emma mentioned before.
You can also still get the old HRT that we were talking about in that women's health initiatives. That's really important for women to understand that if they do go to their GP and are offered HRT and they do want to have a body identical formula, they really need to make sure that all they really need to know that those old formulas that a non body identical are still available on prescription.
And so a lot of GP's still do prescribe them. So I think that that's an important thing for people to know. And then progesterone is often given orally so you can take in progesterone through the patches. So estrogen and synthetic progesterone is available through patches and that's again something that people would like to know is that it's body identical estrogen combined with non body identical progestogen. And so that's available through a combined patch that people wear and replace every five or so days.
The other options for HRT is a group which is called SERMs, and that is a selective estrogen receptor modulator. And so there are some SERMs that are pro estrogenic. So they actually increase estrogen and they're an oral tablet and they're given for people with low bone mass mainly. But it does have some support from things like hot flushes. And overall the research shows there's a decreased risk of fracture by about 40% when we use these things. They are a synthetic steroid. They have estrogenic, progestogenic and androgenic actions. And so they're indicated for the symptoms associated with menopause and for the prevention of osteoporosis. So that's another option for people that do not want to take the actual hormones as well.
And of course, there are other treatments that are non-hormonal. And I think the one thing that I wanted to talk about here is that some non-hormonal treatments take the form of anti-depressants. And I think that women are often a little bit confused when they're offered an antidepressant for things like hot flushes. And there's a bit of a misinterpretation that the doctor is actually suggesting that the woman has depression and therefore requires an antidepressant, and that therefore the doctor is dismissive of the hormonal symptoms. And of course, where that sometimes is the case, and I have seen it where doctors are giving an antidepressant for something they think is depression and in fact, it's perimenopause / menopause. But there is also a legitimate reason for why some doctors are offering non hormonal treatment for women going through this period of time.
Lesley: Look, thanks, Michelle, for that. There's so much choice now. It's remarkable how things have changed and the old days when there was just a tablet, then moving into patches and now, like you say, this gels. There's bioidentical hormones, there;s so much.
Lesley: I want to talk to Adrian because Adrian, being the researcher in the group, I'm really keen to get your view as a researcher about the original research because it sounds to me like there's been a lot of reinterpretation and also not just reinterpretation, but a lot more research on this. And so I'd love to hear your views on the original Women's Health Initiative study, which was done in 2002. And just further, you know, what's been going on in terms of development options here, too.
Adrian: Yeah, absolutely. I mean, certainly, you know, Michelle's covered a lot of that and a lot of the new research has indicated that, you know, just like any research that's initially done, you know, initially there's particularly there's negative effects that are identified from a research study, then eventually, as you go along, you notice that maybe there were some flaws in the research and you start looking, you get into it even more. And I certainly recommend the podcasts that Michelle did with Professor Cassandra Suzuki. I think that's a great podcast for people to listen to on fx Medicine. So I definitely recommend that.
But I mean, if you think about the research that was initially done and the anxiety that it created in people and initially there's research indicating that you have a greater risk of breast cancer, greater rates of blood clots and you're on this high HRT. So imagine at that time you're on this HRT and this research is indicating that, you know, your breast cancer risk is increased. And that creates significant anxiety in those women at the time. And also even for the practitioners to imagine all those practitioners who are prescribing HRT and then all of a sudden there's this research saying, look, stop it, you know, this is really a negative effect. And unfortunately, when it comes to research, the media will pick on a lot of this negativity and they'll promote it and they'll be these all these media campaigns and newspaper stories back at that time, there wasn't social media so much more at that time. And then it sells newspapers. But then the research starts showing that maybe it's not as significant as as the initial research indicated. But unfortunately, the media then is no longer interested in that. And then the information about the potential benefits of HRT in different age groups. And that, as Michelle mentioned, that the research that was initially done with the Women's Health Initiative was, you know, the average age was over 60. And that has significant ramifications in terms of the conclusions.
And unfortunately, that's the case with a lot of research. You have to really look at the specifics. Often you look at the general, but you don't look at the fine print I suppose when it comes to the research and what we need to do. And I think what happened is that a lot of the personalised interventions stopped people.Practitioners weren't looking at the individual and looking at the potential risks of HRT as opposed to the potential pros that somebody can experience from the HRT. And certainly HRT, as Michelle mentioned, can be very beneficial for many people. And that's really what we've found, as the research has indicated, that no HRT can be beneficial for many women, particularly for hot flashes, and it really needs to be individualised.
The patient and the practitioner need to sit down and look at the pros and cons of an intervention for an individual. And unfortunately, when it comes to hot flushes, often, you know, I suppose it doesn't necessarily cause cancer or it doesn't make you have a heart attack.
And so therefore it's kind of considered this kind of benign symptom. But the reality is that it's an extremely uncomfortable symptom and it can create significant anxiety in an individual. It can affect their socialisation. You know, obviously, I'm not talking about a firsthand experience here being a male, but certainly I can imagine going out and thinking that you might have hot flash out in the community that then will impact your likelihood of socialising. You therefore don't go out as much as you used to, then you socialise less. That has a negative impact on your mood. And then you add and then you feel unattractive and that has an impact on your relationships. And then that will go away and it will have an impact on your mood. And then we know that you're not going out as much. You're feeling less stressed, you feel more stressed, sorry. And then we know that stress will exacerbate hot flushes.
So you have all these other factors that are going on that can impact on quality of life. And certainly we know that hot flushes kind of have a negative impact on people's quality of life. So I suppose, you know, with regards to that research, I think like anything, we need to very, very much individualise it when we looking at research, there's the general conclusions that people that we come up with as researchers such as an intervention, might help to improve mood or an intervention might help improve a particular symptom, but it doesn't improve it for everybody or it doesn't cause consequences for everybody. So there are people that will benefit from an intervention and people that won't benefit from intervention. And that's what we really need to personalize the intervention and work with a specific person that's sitting in front of us and consider the intervention that we need to that's going to be most likely to be beneficial for that individual.
Lesley: And Adrian, I know whenever you and I get talking, we always talk about the role of sleep and how if you don't sleep well, it just makes everything that much worse. And I guess you add that it just amplifies everything even further. But I really liked what you talked about in regards to the media and nothing like a bit of of risk and a bit of danger to get some clickbait. And and I know we saw so much of it back then, so I'm feeling a lot more reassured by talking to you and Michelle that things have moved on. We understand HRT a lot more. We understand benefits, we understand risks and there are so many more options.
But it does bring me to another point, and that is medical research. But a lot of it uses men not always that that many women particularly I don't know, Adrian. I mean, women who are perimenopausal, menopausal, do they get included in research in general?
Adrian: And you know what might be the implications there? Well, I think those factors are really kind of we know when you do research, I mean, obviously, I do a lot of research on depression and mood. And, you know, a lot of the time you're doing research on everybody. You don't specifically at a particular cohort of people. And yeah, certainly when it comes to menopausal research, if you think about it from a I financial perspective, if you think about the pharma companies who are investing in research, they have this study that shows that it increases the likelihood of breast cancer. Now, they're not going to be overly interested in supporting more research and funding, more research on menopause. And I know that I've written I did read that, you know, the prescriptions for the it was a multibillion dollar I can't remember how many billions of dollars HRT was bringing in for pharma. And it's pretty much from what I saw from the research, was that it pretty much decreased by 50%, so they saw a massive hit on their profits.
Now obviously because of that, they're not going to invest in research. And so they may as well invest in other areas like antidepressants and other pharmaceutical medications that are likely to bring in more income from that for them. So unfortunately, a lot of the research around menopause, menopausal treatments did significantly reduce and I think it's increasing now. I do see more research now around women's health and menopausal research. And I think that's occurring a bit more now, but still a long way to go. And the reality is that sometimes the research that you do 20 years ago doesn't necessarily apply or needs to change. And so the environment is different. The you know, obviously, if you think about how the Women's Health Initiative and the research, they the media that was done was all paper based, it would have been the newspapers and radio. And now you've got social media and a huge difference in terms of how media portrayals are done. Lifestyle has changed significantly. And so we always also need to keep up with the times and continually do research. And I hope that there will be more interest in this in terms of research from a pharmaceutical perspective, from a nutritional perspective, from also a lifestyle and psychological perspective, because we also know that can affect menopausal symptoms too. So a long way to go, but I'm optimistic.
Lesley: You know, Adrian, it's really interesting what you talk about in terms of investment into research to look at ways to help women manage their perimenopausal or menopausal symptoms and journey. I know you put forward a bit of a cynical point of view there about pharma and profits, but I do wonder about how much we as women might have to blame for that too, by not owning up to the fact that, hey, we want to do better, we want we want something more, what else can be available to us? So that's why I'm really pleased that we're talking about this, just raising awareness. And the more people that talk about this and want to find options to do even better is going to be so important as well.
Lesley: So look, just moving on. The other thing I found really interesting is how in different parts of the world, different options are available and some are government funded and supported and subsidised, and some of them just aren't as do find that fascinating just how access and funding support varies considerably. And I know even in Australia that can be quite expensive for for people which particularly with cost of living pressures might make it really difficult to to make the choice whether they look after themselves and find supportive measures or not. I guess the other thing that this comes down to is like we talked about is attitudes, attitudes in general, you know, people's own sense of self care and what they're willing to do, but equally talking about it.
And do you still think that there's much stigma about talking about menopause, menopausal symptoms amongst women, you know, what are you reading?
Adrian: Yeah, I did read that some research showing that 85% of Australian women with bothersome, bothersome symptoms are not receiving effective treatment or not even asking for treatment. And so those conversations are really, really, really important. And I mean, even for myself as a psychologist, I mean, now that I think about the work that I did and a lot of the assessments that I did, did I do enough questioning around menopausal symptoms and the menopausal transition, and I don't think I did. And part of that is the training that we receive. You know, there's there's limited training and education about, you know, menopause and some of the symptoms there and the increased risks that occur from a mental health perspective, that's from a psychological perspective. But I also understand that even medical practitioners who receive limited education around menopause and it's treatment.
And if you're not aware of the current research, you know, it's great that Michelle, you know, she's a great practitioner and she keeps up to date with the research and is aware of the different options. But the reality is, as Michelle mentioned, that there are you can still get the old HRT and if you have a medical practitioner who's not keeping up to date with the current research and is not aware of the different options that are available, maybe they're still sticking to the old treatments and I suspect there's still lots of practitioners still saying don't go on HRT because it's going to give you increase your risk of breast cancer. I'm sure that's still happening, which is unfortunate. So then again, women are then expected to just suck it up and experience some of the symptoms that they're experiencing and just kind of ride it out, which is unfortunate. And I think that's where these conversations are extremely important for us.
Lesley: I couldn't agree more. You know, it makes me think about perception. You know, perception can become your reality. And I know that there's some research around that talked about women's perception of their experience, perception of their symptoms and, you know, if they put a positive or negative lens on that, it can make a really big difference to how they experience it.
Lesley: So, look, I want to move to Lisa now and tell us a little bit more about what you've read about people's own perceptions of their menopausal experience. And, you know, we know that in countries like Sweden, Denmark and Norway, you know, aging is celebrated. And in fact, in those countries, less women report unpleasant effects and symptoms through this period of time. Is that something that you've found and what have you read about this?
Lisa: Sure. So I think it's really perplexing that we've seen such a move away from perimenopause as traditionally being viewed as a natural developmental transition period, marking the end of fertility for a woman, where it's now viewed by many women in a negative, unpleasant light, where many women feel devalued and socially invisible as soon as they hit that perimenopausal transition.
And we know, as you've said, that the experience that women have during perimenopause, it's not universal. So not everyone has that same experience. And this does highlight that the experience of menopausal symptoms is influenced by a number of different factors, including individual cultural, social and psychological psychological factors. So if we look at traditional and non-Western cultural contexts, I think they can be more helpful in revealing alternative framings for perimenopause and menopause.
And I was reading some really interesting literature around the African tribes, and they perceived menopause as a period of increased spirituality, and the traditional Egyptian culture recognised menopause as a period of enhanced wisdom. If we look at traditional Asian culture in China and Japan, they have a lower prevalence of hot flushes than women in Australia, the US and Canada, and they often don't associate these hot flushes with the same embarrassment that many of our patients do when they come and see us and they say, Oh, it was so embarrassing. I had to do this presentation and I was dripping with sweat. So in traditional Asian culture, they see perimenopause and menopause as a second spring or rebirth, and they see it in that positive view more of a positive transition.
So I think those differences experienced by women in Asia and certain parts of Europe are definitely attributed to culturally shaped expectations, but also factors such as gender roles and socio economic status. And I don't want to necessarily take away from the experience that many of my patients have when they come and see me, which is a very difficult experience. I don't want to reduce it and say that they should feel wise and okay when they're having insomnia and night sweats and mood changes. But I do want to open up, I guess, the discussion for women to understand that a lot of the patients that have been through menopause, once they get through it, there is a certain freedom and assertiveness and a wisdom and confidence that they have that younger women don't necessarily have.
And so I think for us to learn as practitioners in clinic, it's that if cultural discourse impacts the transition of menopause, then we as practitioners can adopt the perspective that there are many experiences of menopause and we have this opportunity to help reframe that dialog and, help patients understand with the right empowerment and education, it can be a smooth transition transition. And that it doesn't just have to be about the bad stuff. There's lots of good stuff in it too.
Lesley: It's good to hear. And, you know, I was reflecting on when I was growing up and in fact, you know, menopause was never talked about. It was a real taboo secret subject. It wasn't even secret women's business because women didn't seem to be talking about it amongst themselves.
And I think about today in like up here in Australia anyway, the influence of the baby boomer generation. You know, they seem to be a bit more fearless, a lot more strong, women leaders and role models around the place. And I do wonder if they're starting to have a positive impact on their perception of that menopause post menopause period because it just feels different.
It feels like we're starting to talk about it more and we're seeing those strong role models as well, which I think is a great thing.
Lisa: Yeah, I agree. Yeah.
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