Let me introduce you to Dr Hannah Short: an accredited specialist in female hormonal health (menopause & premenstrual disorders), GP and medical writer. Dr Short has undertaken extensive training in menopause management, under Dr Caroline Marfleet, with the British Menopause Society (BMS) and the Faculty of Sexual and Reproductive Healthcare (FSRH). In December 2018, she was awarded the Advanced Certificate in Menopause Care. She is a member of the British Menopause Society, The Primary Care Women’s Health Forum and The British Society of Lifestyle Medicine.
We cover quite a lot in this episode which includes:
- The medical profession’s lack of menopause training
- Why lifestyle changes aren’t always enough
- Who can take hormone replacement therapy (HRT)
- Explaining the difference between regulated and compounded hormones
- And lastly premature menopause, from a variety of causes including surgery and breast cancer
We start the conversation trying to understand why the medical community are failing women in menopause; their lack of understanding and unwillingness to change is impacting millions of women.
GP education is lacking
In her early days as a GP, Dr Short noticed women in their early 40s and upwards were visiting her with symptoms like insomnia, anxiety, fatigue, depression and physical symptoms such as aching joints. She recognised that these may be hormonal symptoms although had never been taught this during medical training, where GP trainees are offered a one-two hour lecture on menopause which many don’t even take. A discussion with the senior partner at the practice left her feeling very frustrated with how GPs were handling these consultations as they seemed unable to join the dots for their female patients. Thus started her interest in the subject.
Female patients go to their doctors with only a 10 minute appointment to try to explain what their symptoms are, which as we know can be a nigh on impossible task. Many women don’t even realize that the symptoms they are experiencing are hormonal, so don’t direct the conversation in this direction. On the other side, GPs are inevitably overworked and overstretched, and – as we mentioned – may not even be trained in menopause to get to the root cause. This leaves both patient and doctor with no resolution. My own personal experience was very similar, where my primary care doctor didn’t recognize my symptoms and, at the time, I had no knowledge of what menopause was. I was then subjected to too many unnecessary medical tests which lead to no conclusive answers.
The education of GPs is starting to change in the UK, but the change is very slow. Over here Stateside, I see the growth being very stunted, but the movement is happening; we just have to keep raising our voices, educating the masses and advocating for ourselves.
Lifestyle changes aren’t always enough
You know me folks, I am a huge proponent of lifestyle changes for both long and short term health, but sometimes living your healthiest life just isn’t enough. I am living proof of that, and I hear stories from you telling me the same thing. Menopause isn’t going to discriminate; just because you are drinking your green smoothies every day doesn’t mean you will be immune to symptoms. Of course there will be women who sail through menopause, but we know they are in the minority. Women tend to just forge on until they can’t cope any longer, often going to their doctor as a last resort. I was one of them, we feel ashamed that we are not coping and dealing with menopause, despite everything we do to promote our health and wellness.
Dr Hannah was at a yoga in healthcare conference recently, speaking to some yogis about evidence that shows the positive impact of yoga on anxiety, cardiovascular disease and diabetes (which is great news for us all!). Unfortunately, at that same conference, many of the yoga practitioners were against HRT because they thought they were immune to the symptoms of menopause. There is an element of ignorance and shame which needs to be broken down, because life isn’t fair and your genetic makeup is what will shape your experience and you can’t out yoga that!
Who can take HRT?
Hormone replacement therapy (HRT) is a very confusing and sometimes contentious topic, but it shouldn’t be. So, we need to clear up the confusion and give clear guidance on the good, bad and ugly of HRT.
The British Menopause Society (BMS) and the North American Menopause Society (NAMS), amongst many other medical communities, support HRT as the most effective medical treatment for menopause. You can start this at any stage during perimenopause (the years leading up to your final period) or after your final period. HRT is of particular importance if you experience menopause below the age of 45 as the long-term benefits include reducing the risk of cardiovascular disease, osteoporosis, dementia and diabetes.
For the vast majority of women who start HRT below the age of 60 years, or within 10 years of menopause, the benefits outweigh the risks. If you are over 60 years old, then you should not be refused HRT, but instead be assessed on a case-by-case basis to see if all your health markers align with starting this treatment.
Women are still afraid to consider HRT as a valid form of treatment largely because of the Women’s Health Initiative (WHI) study published in 2002, which claimed that it caused breast cancer and heart disease. Overnight women stopped taking estrogen, and the press had a field day, running amok with the scaremongering headlines. Since that date, the report has been widely dismissed as flawed and some of the authors have written public apologies. Unfortunately, this hasn’t got the publicity it deserves and in fact some women have died as a result of coming off HRT prematurely, on their doctors’ advice. HRT, on the whole, has more benefits than risks and can prolong a woman’s life, it isn’t just a way to subside menopausal symptoms, it is a way to help women fight major diseases that kill thousands of us annually.
Here is a great illustration by the BMS to show associated risks of breast cancer using HRT compared to lifestyle risks such as smoking, drinking and obesity.
Bio or Body Identical Hormones
For me, this is where I see the most confusion. There are a myriad of terms thrown around, from body-identical, synthetic, regulated bio-identical (rBHRT) to compounded BHRT (cBHRT). So let’s attempt to clarify: In the UK the term body-identical is used for HRT that has the same molecular hormonal structure as your body. All body-identical hormones are regulated, licensed and safe to use, and are prescribed by a doctor. In North America, the term body-identical hasn’t be adopted but the term rBHRT is now being widely used to identify those hormones which are regulated and are bioidentical. Read more about it here.
cBHRT are hormones that are also of the same molecular structure, but instead come from a compounded pharmacy. Both the BMS and NAMS recommend staying away from these hormones which are not regulated and have not undergone scrutiny or standardised testing. There is also a huge safety concern with compounded progesterone. Progesterone is needed as part of an HRT regimen in women who have not had a hysterectomy as it helps reduce the risk of endometrial cancer. However, unregulated compounded progesterone has not been found to provide adequate protection due to possible absorption issues. Both organisations and most medical professionals state it should be avoided. These hormones can be obtained from private clinics, over-the-counter or online (YES! Amazon sells hormones!). There is no guarantee that these hormones “do what they say on the package”, there is no accountability for their effectiveness and they can also be expensive.
This clearly freaks me out and I am very vocal about the issue, but I also completely understand what drives women to do this. As mentioned earlier, inadequate advice from their doctors, leaves women feeling desperate and looking for help. Even if these private clinics and online stores are doing this with the best intentions, the research shows that it is much riskier than taking regulated hormones. There is also the misconception that cBHRT is safer and more “natural”, when this claim is simply not supported.
It’s clear that the terminology needs to be standardized to remove this confusion and the conversation around the safety of HRT needs to be highlighted. The number one reason that women still do not to take HRT is because of their perceived increased risk of breast cancer. There is currently no risk below the age of 51 for combined HRT and you are still more at risk of cancer if you are overweight, sedentary or drink alcohol. Heart disease remains the biggest killer for women in the western world, far more so than breast cancer, and the benefits of taking HRT, for the majority, still outway the risks.
Having personally experienced premature menopause, after a hysterectomy and ovary removal aged 35, Dr Hannah Short has been an advocate in supporting women in similar situations. This is a chronic condition that has to be medically managed but is often dismissed. 1 in every 100 women under the age of 40 will suffer from premature ovarian insufficiency (POI), the cause of which is often not found. Women will also experience premature menopause from other causes including surgery or as a result of medical treatment for breast cancer. POI or premature menopause is often misdiagnosed and therefore not treated correctly. Patients are frequently told their symptoms are caused by stress or other factors, when in fact they are in menopause. Premature menopause/POI can be diagnosed by two blood tests 4-6 weeks apart, monitoring a woman’s levels FSH to rule out other things.
Dr Short explained that as a result of a ovary removal or some breast cancer treatments, women will effectively go immediately into forced menopause. In hormone-dependent breast cancer estrogen receptors are switched off with drugs or as a result of radiotherapy, leaving many women struggling with unexpected menopause symptoms. If a woman has an estrogen dependent cancer, they are usually advised not take HRT. However, working with their oncologist and a menopause specialist can determine if hormone therapy may be an option for them further down the line; every case should be treated individually. One thing these women may be able to use, even if taking tamoxifen and aromatase inhibitors, is vaginal estrogen therapy, which administers an amount of estrogen so tiny that it doesn’t impact overall estrogen levels in the body.
She continued to emphasise that all is not lost for breast cancer survivors who are struggling with menopause symptoms. Antidepressant medication like venlafaxine can be administered for vasomotor symptoms like night sweats and hot flashes. Cognitive behavioural therapy (CBT) may also be beneficial. Herbal medicine can help too, but it is important to ensure safety by using an accredited medical herbalist who understands the interactions between herbal and prescriptions medicine. There are some emerging studies which show some symptomatic relief from black cohosh and sage; they are not as effective as HRT but can help. In addition to this, using vaginal lubricants and moisturizers, positive lifestyle factors, well-balanced nutrition and exercise can all be helpful. It is clear that more effective medical treatments are necessary for this set of women, but she insisted that you don’t lose hope as new non-hormonal drugs are on the horizon.
Whatever stage in peri-to-post menopause you are, it’s important to know that there are valid options available to everybody. Finding an expert and somebody who is working in conjunction with the latest research is essential. Heading over to NAMS or BMS website is a great starting point where you can look for a menopause specialist in your area.
Dr Hannah will continue to write and talk on behalf of all women’s health issues, but in the meantime if you want to know about her work, please find a list of resources below.
Dr Hannah Short’s website + useful links
Facebook: Dr Hannah Short
A charity website for girls and women diagnosed with POI or premature menopause
A comprehensive website on surgical menopause. Not a medical site, but lots of interesting and useful information and discussion.
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