Symptoms and effective treatment for women experiencing the menopause – Dr Sarah Ball & Dr Louise Newson

In this first episode of a new podcast series recorded by Dr Louise Newson, founder and menopause specialist GP at Newson Health Menopause & Wellbeing Centre, Dr Newson discusses the symptoms and experiences of different patients with fellow GP and menopause expert, Dr Sarah Ball.

Find out more about Dr Sarah Ball

Podcast transcription: 

Dr. Louise [00:00:01] Hello, I’m Dr. Louise Newson. I’m a GP and menopause specialist working in Stratford-Upon-Avon. And this is the first of a series of podcasts that we’re recording for women to learn more about the menopause and their hormones. So I’m here today with one of my lovely colleagues, Dr. Sarah Ball, who’s a fellow GP and menopause expert. So we are going to discuss today – and in fact, in all the series – we want to discuss different patients. So it’s a bit of a fly on the wall experience for the women to listen and hear what we get up to in our day to day practice. So hi, Sarah. So tell me about a lady that you saw recently in the clinic.  

Dr. Sarah Ball [00:00:50] So a lady that has especially resonated with me recently is a lady who is 53, and she came along to see us really because she’s been experiencing symptoms, which she was, thought were related to her hormones for a whole ten years. And she had been to her GP on three occasions over that time. And each time had asked about whether it could be related to hormones, but each time, unfortunately was given quite inaccurate information.  

Dr. Louise [00:01:29] So what symptoms was she getting?  

Dr. Sarah Ball [00:01:31] So initially, so back when she was 43, she was experiencing, she was aware that her periods had always been regular clockwork, and they just weren’t quite so regular. Nothing too out of the ordinary, but sometimes they were just a bit later, sometimes a little bit close together. But mainly she had quite a full-time, high-powered job, and she was normally quite confident, easy going sort of person. She just didn’t feel quite like she was functioning at a high level, felt a bit anxious in certain situations which normally wouldn’t have worried her.  

Dr. Louise [00:02:11] So this must have worried her though, if it was affecting her work. 

Dr. Sarah Ball [00:02:14] Yes, she’s in quite a male dominated environment and she coped OK, but she just felt slightly uneasy doing presentations in meetings, and she just felt that there was something that wasn’t quite right, but she couldn’t quite put her finger on it. But because she’d noticed the change in her periods, she did wonder if it could be the beginning of…  

Dr. Sarah Ball [00:02:43] So what information that she’d been given by her doctor at that time.  

Dr. Sarah Ball [00:02:46] So when she went to her GP at the time, she was simply told, You’re too young. It can’t possibly be anything to do with the menopause  

Dr. Louise [00:02:53] They’re not too young are they, she’s 43. So her periods were changing. Is that quite typical?  

Dr. Sarah Ball [00:03:00] Yes. So, we know really that often 10 years before the average age of the menopause, women can start to enter what we call the perimenopause. So periods slightly changing, moods may be slightly changing, subtle symptoms, physical symptoms.  

Dr. Louise [00:03:15] And the average age in the UK is..? 

Dr. Sarah Ball [00:03:17] So 51.  

Dr. Louise [00:03:18] So she’s well within that at 43.  

Dr. Sarah Ball [00:03:20] So, yeah, so really any woman in her 40s can potentially start to experience symptoms. And you know, and I think it’s really important that women know that, because they presume a lot of women ,wrongly presume, that until your periods have completely stopped, yeah, it can’t possibly relate to menopause.,  

Dr. Louise [00:03:39] Is there a difference between perimenopausal symptoms and menopause?  

Dr. Sarah Ball [00:03:43] To be fair, a lot of the symptoms are extremely similar. It’s really just a way of classifying them. So, you know, we would say a woman is menopausal when she’s, you know, when her periods have stopped. But because you don’t know when that’s going to be until you look backwards, then you wouldn’t actually know until a year after their menopause that they were at the end. So perimenopause really just implies that someone’s periods are changing and there could be symptoms around it. 

Dr. Louise [00:04:18]  I find a lot of people say to me, Well, I’ve read all these symptoms, but they talk about menopausal symptoms when I’m not menopausal, so therefore they’re not mine. You know, when we reached menopause and we should also think perimenopause, shouldn’t we?  

Dr. Sarah Ball [00:04:30] I think it’s important, really, that women almost consider it a journey through the end of their reproductive life. It’s not just a one day that hits you. 

Dr. Louise [00:04:38] I don’t know about you but when I was at medical school, I just thought menopause, periods stop, game over, that’s quite easy. Isn’t it? Is that what you… 

Dr. Sarah Ball [00:04:46] Yeah, and it’s it’s not… it’s a journey, isn’t it?  

Dr. Louise [00:04:49] Yeah, yeah. So because some people find their periods get heavier and closer together, don’t they?  

Dr. Sarah Ball [00:04:56] Yes. And yeah, and then for other people, it’s the other. And they get more spread out and they feel they’re missing periods and then they have a bit of a catch up. Yeah, so it’s sort of a lack of routine takes over, doesn’t it?  

Dr. Louise [00:05:10] Yeah. I mean, I know when I was getting some perimenopausal symptoms, I had no idea because I wasn’t thinking about my hormones. And it often happens at a time when we’re busy and that we’ve got this sort of sandwich generation. We’re busy with our children, we’re busy with our lives. I’m certainly quite chaotic with everything. And then you just say, ‘Well, I’m tired because I should be tired’. You always think there’s a reason for it. And maybe I guess this woman’s probably no different if she’d been told it wasn’t related to hormones.  But then what did she do about it? She’d been three times to her doctor.  

Dr. Sarah Ball [00:05:45] Yes, so well. So she went at that stage and was sort of told, you’re too young. So she sort of got on with things. I mean, she managed to work okay. She just knew she wasn’t quite the same as before. But also she’s a very keen runner and does a lot of exercise and has a very healthy lifestyle. So she concentrated on keeping up exercise and eating healthily. And you know, she’s, you know, she’s sort of muddled through, because she felt that was the best.  

Dr. Louise [00:06:21]  And that’s hard, isn’t it? Because we know how important it is to optimise our lifestyles and we know how diet, exercise is really important. But actually, for a lot of women, I’m sure you find – I certainly do – that they find it really hard to optimise their health because they feel so awful.  

Dr. Sarah Ball [00:06:37] Yes, exactly. I think this is the prime sort of stage in life, isn’t it? When you say the, you know, busy, busy women, mums often, that are struggling, especially with mood swings and juggling as they do, they then end up adopting unhealthy lifestyles to try and cope. So, you know, drinking perhaps to help sleep, or just to help mood…  

Dr. Louise [00:07:04] Yeah, I mean, I’ve had a lot of patients said to me, “Oh, I just drink alcohol to numb my symptoms.” It’s awful.  

Dr. Sarah Ball [00:07:10] Yeah. And then of course, that worsens your sleep even more than that. And it’s a depressant, so you end up in a worse state 

Dr. Louise [00:07:18] And that’s not good. And then a lot of women I speak to also say that they get quite a lot of sugar cravings. And I think it’s related to low estrogen levels. It’s a bit like before your periods, when you are teenagers. I quite liked it when I was young because I got an excuse to eat a bit more chocolate because my period’s coming. But it’s the same, isn’t it? That drop of estrogen that you get… 

Dr. Sarah Ball [00:07:43] Like in the first trimester of your pregnancy, you have those carbohydrate cravings because it’s all hormonal. 

Dr. Louise [00:07:47] Yeah, yeah. And then but people put on weight around this time anyway, don’t they?  

Dr. Sarah Ball [00:07:53] Yes. So I mean, metabolism changes, doesn’t it? And people often blame the menopause, but actually it would happen around that time regardless. And then when you make less than sensible lifestyle choices, the problem gets worst.  

Dr. Louise [00:08:10] It’s the combination, isn’t it? I think our metabolism slows down as we get older, we can’t eat the same as we used to. But also, there is some theory that I’d read that if you’re not making enough estrogen, your fat cells make small amounts, so your body clings on to the fat to try to do that…. 

Dr Sarah Ball A bit like going into hibernation.  

Dr Louise Yes. And it’s often in that midline area where people just – I know I looked down and thought gosh I’ve got a tummy, I didn’t have one of those before. They become apple-shaped. But that’s a risk for heart disease isn’t it? Having a fatter tummy? So but then having low estrogen is a risk for heart disease as well, isn’t it? A lot of women don’t realise that, do they?  

Dr. Sarah Ball [00:08:51] No, not at all. So, yeah. So going back to this lady, so she, you know, she actually she did well for five years and then her periods did stop.  So in a way, she felt relieved because she then thought, well, OK, so now I can, you know, see my GP again. Hopefully, you know, see what, what I should be doing about this. But sadly, she was then told, ‘Well, you’re not actually having any hot sweats. So, you know, we’re a bit worried these days that HRT is quite dangerous. So, you know, I think you should just push on with what you’ve been doing.’ 

Dr. Louise [00:09:32] In what way did they say it was dangerous?  

Dr. Sarah Ball [00:09:34] I mean, she didn’t, you know, really sort of, you know, she was just put off. Most people are worried about breast cancer. People are worried about blood clots and heart disease and that sort of thing as well. And mostly, sadly, it’s just from media hype. Yes, we’re still living with the hangover of badly reported studies. 

Dr. Louise [00:10:02] Should we talk about that for a minute? Because I think it will be good.  

Dr. Sarah Ball [00:10:05] Yes.  

Dr. Louise [00:10:06] So let’s go back then so –well before we talk about that. So her periods had just stopped. She’s not officially menopausal yet then is she, she’s got to wait a whole year. [8.4s] 

Dr. Sarah Ball [00:10:15] Well, so this was five years ago her periods stopped. 

Dr. Louise [00:10:17] Yes, because that’s confusing as well. I see a lot of women that get told, “come back and see me” by their doctor “when you officially, when you have that whole year”. Nothing happens to us, does it in that year? It’s just a day in our diaries, and this is that we don’t need that date for anything do we? It’s just, so if we started HRT when we were perimenopausal, that’s fine and it would make far more sense. So people worry about HRT. So I would say the number one worry is breast cancer. So should we go through it. Who doesn’t get a risk of breast cancer with HRT, then? 

Dr. Sarah Ball [00:10:55] It’s very much a case of trying to individualise a woman’s risk and actually go through some of the basics with her about whether she would be at any increased risk to start with. So that just involves us needing to know whether she’s ever had any biopsies to her breast, or had any previous worrying biopsy results and also the family history is often the most important. It’s quite common to have someone in your family that’s had a breast cancer purely because one in eight women do get breast cancer.  

Dr. Louise [00:11:35] That’s a lot, isn’t it? One in eight, in a course of a lifetime. So most of us will know someone. Or at least one person that’s had breast cancer. 

Dr. Sarah Ball [00:11:42] But also, I think the important thing, you know, one in eight is a lot, of course, but seven in eight of us won’t get it. We often forget in life and in medical profession to remember the flip side of the coin.  

Dr. Louise [00:11:55] Yes. So breast cancer isn’t the most common condition in women, is it? Is not going to kill the most, is it?  

Dr. Sarah Ball [00:12:02] No. So we’re far more likely in this country, in this day and age, to die of dementia and heart disease and some lung things.  

Dr. Louise [00:12:14] So we need to think about, when we’re looking at our health, it’s looking at cardiovascular disease, dementia, anything that can help with this. OK, and then the one in eight, most of those aren’t in the family, are they? They’re not familial breast cancer.  

Dr Sarah Ball No, very few, very few. 

Dr Louise So if I had an auntie, great auntie, who was 82 had breast cancer, that’s no concern whatsoever. So that might be quite reassuring for people to realise that, it doesn’t always run in families. 

Dr. Sarah Ball [00:12:39] No. And if there is what we call a first degree relative, so that’s your parents, your brothers and sisters and your children. If there was a first degree relative that had had breast cancer at a relatively young age that will sometimes raise alarm bells to want us to look into a bit more, or sometimes if you’ve got more than one first degree relative with breast cancer or possibly ovarian cancer, that’s also something that we might want to think about.   

Dr. Louise [00:13:06] And that’s usually those people who have had it when they’re younger, isn’t it? So if even if, say, this woman had a sister who’d been 40 and had breast cancer, once she’d got to 50, then her risk is the same as yours and mine. One in eight. It’s sort of – it’s might be slightly higher, but it’s not as high as often people realise. Is it?  

Dr. Sarah Ball [00:13:26] Yeah. And I think the other important thing for ladies to realise is that, yes, there will be some people with a family history that means that they are at a slightly increased risk to the normal population risk. But even if they were to consider having HRT, that doesn’t make their risk any higher. 

Dr. Louise [00:13:45] So they can still have HRT can’t they? There’s a lot of women that are told they can’t because of their family history. And it’s knowing and a lot of women don’t realise other risk factors for breast cancer, do they?  

Dr. Sarah Ball [00:13:57] No not all. So often the ways they’ve tried to manage their menopause themselves by drinking more than two glasses of wine a night, or becoming overweight, is actually far more risky for your chances of breast cancer than taking HRT is.  

Dr. Louise [00:14:13] Yeah, because I read somewhere that obesity, as you know, is increasing worldwide, isn’t it? But obesity is one of the leading causes of all types of cancer. Is it nearly or has overtaken smoking? Yes – Shocking isn’t it? Yes. So breast cancer is no different, is it? Obesity is a big risk factor. So a lot of women, we’ve already said, put on weight during perimenopause and menopause and drink and not exercising is a risk factor as well. So those three we call ‘modifiable life risk factors’. Actually, women who don’t want to take HRT, because they’re worried about breast cancer risk, are increasing the risk by not taking HRT. So that’s quite important, isn’t it, to make people understand, even if they don’t want HRT, they’ve got to look at their lifestyle, which is interesting isn’t it? So then going back to HRT. Everyone’s scared about breast cancer. So not all types are associated with increased risk are they? [3.3s] 

Dr. Sarah Ball [00:15:12] So if you’re having estrogen only HRT, so if you have had a hysterectomy, then there is no risk. There may even be a slight decreased risk if you have estrogen only HRT. 

Dr. Louise [00:15:22] [00:15:22] because the WHI study – this big, scary study – that was misinterpreted, actually, did didn’t it? It showed that there was a reduction in risk of breast cancer in women that took – that was the older cell, wasn’t it? The conjugated equine estrogen – horses urine, tablet form of estrogen. Do you prescribe it? I never prescribe it. But it is interesting because there might be something about that estrogen that reduces the risk. But other studies have shown there’s no increased risk. So women that have had a hysterectomy, their womb removed, they’re quite lucky aren’t they? And that’s any age, isn’t it? So that’s good. That’s that will probably reassure quite a few women and then what other groups? [31.6s] 

Dr. Sarah Ball [00:16:01] If they are taking the combined HRT, so if you still have your womb, you’ve got to have your combined HRT. And then the important thing for women is understanding that if you have the combination, there is no risk for five years of use…  

Dr. Louise [00:16:19] When you say combination, that’s because they’ve got their womb they need to protect the lining of the womb. So and then certainly the first five years is with the micronized, the body identical progesterone, isn’t it? So it’s a long time, isn’t it five years, no risk. So you can see how you feel on HRT before worrying about breast cancer?  

Dr. Sarah Ball [00:16:40] Exactly. Yeah. And you know, and usually that first five years, it does, because you feel so much better in yourself, and you are able to make more sensible lifestyle choices that you then reverse your other risk somewhat so.  

Dr. Louise [00:16:56] Yeah, I mean, I often say to women when their have lifestyles better, actually all risk of breast cancer is lower.  

Dr. Sarah Ball [00:17:02] Yes, exactly.  

Dr. Louise [00:17:03] Yes. So then after five years, they still argue. It’s probably not even significant that increased risk is it? You’re talking about very small numbers. And certainly the WHI study was quite a skewed population, wasn’t it? 

Dr. Sarah Ball [00:17:19] So it was, I mean, the WHI study came out a year after I qualified as a GP.  So having been initially very keen on pursuing hormonal..  

Dr. Louise [00:17:34] Because before that we used to just prescribe HRT all the time.. 

Dr. Sarah Ball [00:17:38] It was my first year as a GP. I remember we had a menopause clinic in the GP surgery and we were giving it to everyone and we was, you know, it was very much the fashion. Yes, it will make you feel better now, but also it’s going to help you going forward and reducing your risk of fractures and heart disease and things like that. And you know, it was it was very OK. And then within a year, suddenly this WHI hit. What the WHI set out to do was to look to see if – what was suspected at the time – was if actually HRT was helpful for improving your long term health, if this was actually the case for all women, not just women around the time of the menopause.  

Dr. Louise [00:18:22] [00:18:22]Yes, so the women weren’t average menopausal women, were they? [4.9s] 

Dr. Sarah Ball [00:18:27] [00:18:27]They were, you know, there were American women that the average age of all the women in the study was sixty three. [4.8s] 

Dr. Louise [00:18:33] [00:18:33]So those women often didn’t have symptoms, they didn’t have the typical symptoms because they’d gone through the menopause, hadn’t they? [5.7s] 

Dr. Sarah Ball [00:18:39] [00:18:39]Yeah. So that, you know, they were all a long way through the menopause. Some had already been on HRT before the trial started, and that wasn’t taken into account at the time. [9.5s] 

Dr. Louise [00:18:54] [00:18:54]Lots of them were overweight and obese. And quite a few had had heart disease as well hadn’t they? [3.9s] 

Dr. Sarah Ball [00:19:02] [00:19:02]So it’s kind of no surprsie that their “horse had bolted” if you see, that their arteries had already diseased. And then when they were given HRT too late, then yes, it did set off some, you know, some events, which some events… [17.7s] 

Dr. Louise [00:19:20] That’s why the Daily Mail and all the papers were saying ‘increase risk of heart attacks’ because those women did have, but they had an increased risk anyway, didn’t they? And they were all tablet estrogen, weren’t they? And it was an older type of progestogen as well. So even us that give a lot of HRT, I don’t think I would give those women HRT would you? So it’s very weird. And I also heard that it was reported that the initial results came out in the summer holidays and they couldn’t get hold of any experts so it went to print and before it actually got printed, one of the key people said “No, stop the printing. This is wrong.” But they said, “No, we can’t”. Have you heard that? It’s awful, it’s a real scandal, isn’t it?  

Dr. Sarah Ball [00:20:03] Yeah and to think that 17 years later, we’re still living with the effects of it. And when you think of all the damage that’s been done to all the women across the world, that have not had there their HRT, you know, they’ve, you know, postulated how many heart attacks have happened as a result of all the women that stop their HRT and all the factors that have happened as a result. And finally, it’s actually nice news that the authors have actually apologised. You know, it’s taken a long time, but it’s happened which is good, and they’ve now reanalysed all the data.  

Dr. Louise [00:20:39] They’ve analysed it so many times, haven’t they? 

Dr. Sarah Ball [00:20:41] Taking out the older women and actually when you reanalyse it on the younger women, it proves exactly what we always thought, which is that it helps at the time if you start it at the right time.  

Dr. Louise [00:20:50] Yes. So the right time that’s really within 10 years really of their menopause, isn’t it?  

[00:20:54] The crucial thing is is making sure that women know that if they can start it within 10 years, the menopause or before the age of 60, the benefits are all going to vastly outweigh the possible risks. 

Dr. Louise [00:21:07] So the risk of heart disease is so much lower, isn’t it? 

Dr. Sarah Ball [00:21:12] Up to 30 to 50% lower.  

Dr. Louise [00:21:14] I mean, I read a Cochrane review and it was 52% reduction. And then I was trying to compare it. I don’t know if you know the exact figures – giving a statin, which we use in our general practice, and also giving blood pressure treatments for reducing the risk of heart disease, they’re not as affective are they? So it’s incredible. We’ve got this treatment that reduces your risk of heart attack alone, and we know that heart disease kills more women than anything else, but we’ve been denied it and a lot of women think it increases our risk. So it’s really important, isn’t it?  

Dr. Sarah Ball [00:21:45] Yes and that’s why I find it very strange when some, well many, women come and say, “Oh, our GP says, we don’t give HRT, we don’t believe in HRT.” So we need to think, well, you wouldn’t expect to walk into a GP surgery and be told, “I’m sorry, we don’t deal with high blood pressure, we don’t deal with cholesterol.” You know, it is part of women’s health, it is part of the health of 50% of the population.  

Dr. Louise [00:22:10] Because even though the menopause isn’t a disease, it’s natural phenomenon, isn’t it? Clearly, we all go through it, it can cause diseases. That risk of heart attack is about five times isn’t it once you go through because estrogen works to reduce inflammation in our blood vessels, doesn’t it? And that’s why less women compared to men have heart attacks in their 40s.  

Dr. Sarah Ball [00:22:31] I mean, we were essentially designed as women, evolutionarily speaking, to reproduce and then our job was done. So we would in, you know, in nineteen hundreds, you had your menopause at fifty seven and you were dead two years later on average. And now, of course, you know, times moved on and medicines moved on. Public health moved on, which is all great. We live far longer, but we haven’t got these hormones that we were supposed to have. So actually, when I am explaining, when I’m trying to reassure women about HRT, I do like to simplify things, but I think it’s a bit like we just need to preserve you. So when you get to the age of around the menopause, we just want to try and preserve your body in that healthy state. And that’s essentially what giving hormones can do.  

Dr. Louise [00:23:26] So this is regardless whether they have symptoms or not, really, isn’t it? There’s still enough evidence to show – so they don’t have to have the hot flashes like this lady, they can have anything. But then some people say, “Well It’s anti-aging, we all need to age. Well, why are you giving us anti-aging treatment?”. Do you ever get that at all?  

Dr. Sarah Ball [00:23:47] No. Yes our hair does improve with it, and our skin and our bones and you know, the joints feel better. But again, it’s because your, you know, you’re giving back that main hormone.  

Dr. Louise [00:23:58] I totally agree. I mean, I think some people have said and I say, ‘Well, you wouldn’t deny a diabetic insulin, you wouldn’t deny a blood pressure treatment’, for example. And all of these are known to improve the quality and quantity of our lives. So everything is – but it’s amazing that we’re not looking at the bigger picture more. And so we mentioned about bones. So during the perimenopause – so when this lady, although she was a runner, which is obviously really good exercise, she was healthy, eating great, hopefully taking vitamin D, which we ought to take her bone density woul have been falling quite quickly during the perimenopause, wouldn’t it?  

Dr. Sarah Ball [00:24:35] Yeah, I suspect that she has kept her bones out with relative trouble by running. And I also suspect that she actually kept her emotional health relatively good because she was able to carry on her running and cling on to that. But, you know, I think that’s the main thing. Everyone knows that the menopause is about hot sweats and flushes and we make jokes about it because it’s an easy thing to make jokes about, but actually, I think what we see even more of, especially here in the clinic, is actually it’s the emotional and the cognitive problems, forgetting things. It’s the mood swings. The lack of confidence, is the low level anxiety. Sometimes even, you know, kind of worse than that and depression and women feeling like they’ve lost control, they’ve lost their sense of themselves.  

Dr. Louise [00:25:29] It’s very scary isn’t it? I mean, I’ve seen lots of women who have been suicidal before, they’ve actively thought about killing themselves. And one lady came from Leeds and said, I didn’t know at the time, but she did say to me afterwards, when she was better, you were my last hope, I’d written my suicide note. And she got better. When I did psychiatry in medical school, we were never taught about hormones were you? So there are these women out there that have postnatal depression, after baby and then, PMS / PMT or whatever you call it, premenstral syndrome. And then they often get worse, they’re very sensitive almost.  

Dr. Sarah Ball [00:26:12] Sort of reproductive depression but also they, often, when you talk to those sorts of ladies, they have maybe tried the combined contraceptive pill during their life and they didn’t get on with it. And again, it’s because of that sensitivity to progestogen. Which we all have, we’ve all got about the same levels, but we’re all very different sensitivities to it.  

Dr. Louise [00:26:32] But the combined pill is very different to HRT, isn’t it? 

Dr. Sarah Ball [00:26:34] [00:26:34]So it’s often lumped together to one thing. But actually, you know, the combined pill is quite synthetic and higher doses. Whereas HRT is one of natural occurring product, and lower doses.[10.2s] 

Dr. Louise [00:26:46] [00:26:46]So there’s a lot of people who can’t handle it or couldn’t tolerate the pill, are fine with HRT when you get the right one for them isn’t it? [7.4s] 

Dr. Sarah Ball [00:26:53] [00:26:53]Yeah exactly. [0.0s] 

Dr. Louise [00:26:55] [00:26:55]You can see why a lot of people are misdiagnosed with depression, can’t you? [2.7s] 

Dr. Sarah Ball [00:26:59] Yes, absolutely.  

Dr. Louise [00:27:01] And I’m sure you’ve seen – around 70% of women I’ve seen have been offered or given antidepressants for their low mood. Is yours similar? 

Dr. Sarah Ball [00:27:09] Yes. Absolutely. Yes. So many have and a lot of the women, because usually by definition of the fact they’re in an emotional state where they are being offered antidepressants, a lot of them don’t have the confidence or the self-esteem to actually say to the GP, ‘no I don’t want this. I really want the HRT, which I’ve been reading up about’.  

Dr. Louise [00:27:35] It’s quite scary. I mean, I don’t know – I get quite scared going to the doctor because I’m always look at the clock thinking, ‘Oh, they’re running a bit late. I don’t want to hold their time’. And then I go there and I forget what I’m going to say and I feel a dithery mess. Which is ridiculous. And even when I realised finally, that I had perimenopausal symptoms, I knew I couldn’t see my GP because they are quite anti-HRT. So it must be quite hard for women to know how to get the right help, isn’t it?  

Dr. Sarah Ball [00:28:02] Yes, extremely. And you know, in some surgeries there is a GP that is, you know, bit more interested in the menopause. But you know, many surgeries there just isn’t somebody… 

Dr Louise And you can’t always get to see the person you want to see anyway.  

Dr Sarah Ball And it’s very difficult – you know women are quite vulnerable at that time of life anyway, and they often can’t navigate a complicated system to find the help they need.  

Dr. Louise [00:28:30] Yeah, I mean, I often say to people, print off information from my website or get the NICE guidance and actually when a GP is a challenged, it often works, doesn’t it? But it’s hard.  

Dr. Sarah Ball [00:28:43] And also just getting women talking about it. You know, I find if I’m, you know, at a party or in the pub or on the football sidelines watching my son, that actually, if you just start a conversation with some of the mums, it’s amazing how they’ve actually they’ve all got symptoms. And actually, no one’s ever really talked to them about it or they’ve never really understood it. And they all then think, ‘Oh yes’, it’s like all they want is honest true information.  

Dr. Louise [00:29:12] And I think lots of people are scared aren’t they? A lot of people say, ‘Oh, I, I thought I had dementia or I thought had a brain tumour, because I have headaches’ or… 

Dr. Sarah Ball [00:29:19] People feel quite isolated and actually they really benefit from knowing that actually that virtually every other woman is going through the same thing.  

Dr. Louise [00:29:28] Yeah. So just tell me about this lady again. So you say she’s through menopause, so she’s postmenopausal, so she’s getting symptoms.  

Dr. Sarah Ball [00:29:37] Yes, she’s getting symptoms. And then she started to get sore in her vagina. And actually, you know, she’s a very together, lady. And actually the first time she started to get quite tearful and you know, and talking about sex for a lot of women is not an easy thing to do. And actually, you know, so for the past three years, things were really dry in the vagina. It was really hurting, you know, to have penetration. They had tried lubricants, it didn’t really work. And you know, although her husband was extremely supportive, she just found the whole thing very straining on their relationship because that was a big part of their relationship. So that was the third time she went back to the GP and she was examined, which was good, and it was advised that she had some Vagifem, which is a pessary, so it’s a local estrogen.  

Dr. Louise [00:30:35] So that’s not HRT, is it? 

Dr. Sarah Ball [00:30:35] It’s not HRT, but it just puts estrogen in the vagina, which it can help and it did help her a little. But she was only given one pack of it, which lasts a couple of months. But at no point was she advised, actually, if it works, it’s something you’re highly likely to need long term. Or actually, it didn’t then start a further conversation about the menopause in general…  

Dr. Louise [00:30:56] But it wouldn’t help all her other symptoms, would it? 

Dr. Sarah Ball [00:31:02] No, it was only going to help the vagina problem she was having. So, you know, I really felt for her because, you know, each of the three points in her journey, she done the right thing by having to get help and each time she’d been denied it, you know? And you know, so I’ve explained to her now about HRT in general and said, look, the chances are that taking the HRT is going to help the vaginal symptoms as well as any other symptoms, but not to be concerned if it doesn’t, because actually about one in four women on HRT still need some local estrogen as well.  

Dr. Louise [00:31:37] It’s quite safe to have it isn’t it?  

Dr. Sarah Ball [00:31:38] And you know, a lot of women and doctors seem very concerned about, you can’t have both. But it’s that it’s not like, you know, the dose is tiny. If you put it in the vagina, it’s a drop in the ocean. So there’s really no problem using both at all. 

Dr. Louise [00:31:54] Vaginal dryness is one of those symptoms that often gets worse with time. So once someone’s got it, it probably is lifelong treatment, isn’t it?  

Dr. Sarah Ball [00:32:02] And then also, you get these ladies that I’ve been starting to get problems with cystitis and recurrent urine infections.  

Dr. Louise [00:32:08] Yes. Because we’ve got estrogen receptors in our bladders, haven’t we?…  

Dr. Sarah Ball [00:32:11] …and that’s all tied up with it. And, you know, so sometimes we might see quite elderly ladies that are getting recurrent urine infections, and they may well be quite long past the menopause.   

Dr. Louise [00:32:21] So you wouldn’t necessarily give those ladies HRT, would you? 

Dr. Sarah Ball [00:32:23] No. But certainly you give them hormones down below. You can make a huge difference.  

Dr. Louise [00:32:27] Yeah, I mean, I’ve stopped a lot of women needing antibiotics. Because they keep having courses of antibiotics and then the Vagifem just melts it away. And a lot of women think that having a bit of soreness and dryness is just part of getting older, don’t they? And even if they’re not sexually active, it can be quite a real disability; they’re itching in the night and just not being able to wear trousers the same way.  

Dr. Sarah Ball [00:32:52] I guess, I remember seeing a lady last year who, she was in her late sixties, I think, and her daughter had dragged her in to say that she was really struggling with the vagina, you know, even it wasn’t just about having sex, which she hadn’t been able to do with her husband for years and years and years. But she was uncomfortable just on a day to day basis, and sitting down was getting a lot of urine infections and was itching all the time. And, you know, it was really affecting her quality of life. And so, you know, I examined her and, yes, she did have quite bad vaginal atrophic changes. And I gave her some Vagifem and I saw her again after a couple of months and she came in. I just had the biggest hug and she, she had told everybody in the waiting room, apparently how wonderful her sex life now was and how she’d rediscovered it. And, you know, she had just presumed all that time that this was normal and she wasn’t supposed to expect anything more out of life.  

Dr. Louise [00:33:51] Isn’t it amazing? I saw a lady yesterday in my clinic actually, 62, and she’d had a hysterectomy because she had cervical cancer when she was 38, so a long time. And she only came to see me because her daughter had been to see me before. And I’d been very gradually over the last two years, giving small small amounts of estrogen. No risk of breast cancer as, you know, she had a hysterectomy and she told me, she’s got a new partner, he’s 15 years younger than her, so that’s good going. And she said she used to never think she’d never be able to have sex at all, and she just started to have penetrative sex and she had a real cheeky grin yesterday. And we’re very British. We don’t talk about sex, do we? But it really important so. So this lady’s on HRT?  

Dr. Sarah Ball [00:34:29] She is now…  

[00:34:31] So what, you’ve given her the estrogen as a gel or patch or… 

Dr. Sarah Ball [00:34:34] So yeah, so what we call body identical HRT, which you know, we really believe at the moment is the gold standard. 

Dr. Louise [00:34:43] There’s good evidence, established evidence. It’s not a fad, is it?  

Dr. Sarah Ball [00:34:46] No, absolutely not. You’ve got the safety of the estrogen because it’s going through the skin, so there is no risk of blood clots or stroke. Which is brilliant. And then you’ve got this micronised progestogen, which is, you know, it’s a relatively, it’s not a new concept for us, but in the public, it’s relatively a new concept, but really it just means it’s naturally occurring so it comes from yam plants.  

Dr. Louise [00:35:12] So no, no horses.  

Dr. Sarah Ball [00:35:13] No, no horses involved. And it’s essentially like sort of ground up progestogen so that it gets into our body in a slightly different way and is a lot better tolerated. 

Dr. Louise [00:35:27] So has less side effects.  

Dr. Sarah Ball [00:35:27] Less side effects.  

[00:35:27] So there aren’t any contraceptive pills with that in, are there?  

Dr. Sarah Ball [00:35:29] No, there isn’t, no, and there’s evidence to suggest that it’s safer in terms of our breasts.  

Dr. Louise [00:35:35] Yes. So that is the one to go for really. 

Dr. Sarah Ball [00:35:39] So it’s, you know, you’d have to, there’d be very few reasons to not go for that, that combination. So yes, she’s gone away with that. And I also gave her some Vagifem to help with her vagina because it might be that the HRT is going to help her in that respect, but it’s going to take about three months for symptoms. Hot sweats do tend to go away very quickly with HRT, and they’re a useful barometer. But actually a lot of the other symptoms of the menopause, the more subtle symptoms, the mood symptoms, the joint pain, the vaginal symptoms, they can take a while. So usually three months and then things should start falling into place. 

Dr. Louise [00:36:12]  She had symptoms for so long but people still get better quickly, it’s quite incredible.  

Dr. Sarah Ball [00:36:19] Yeah, it’s such a rewarding job.  

Dr. Louise [00:36:21] Yes. So well, that’s been brilliant. Thank you very much. Think we’ve covered quite a lot, haven’t we, in a short space of time. But I hope, it’s probably put out lots of questions, but I hope it’s reassuring and can just help people think a bit more about their own hormones, really. So if you want more information about the menopause, the NICE guidance, so readily available through the NICE website, but there’s also my website, which is balance-menopause.com which has a lot of information. It has lots of articles, it has some videos, which is all evidence-based, and unbiased information so you can download, print off, challenge your doctor or nurse and just talk. Talking is really important. Thank you.  

Speaker 3 [00:37:10] This podcast was produced and edited by E-4 H. All rights reserved. This podcast is provided for information purposes only. Please consult your health care provider regarding any medical conditions you may be concerned about. Podcast guests. Views and opinions are their own.  

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