Chronic pain and menopause: what’s the link?

About 28 million people in the UK are thought to be living with chronic pain – that’s 43% of the population, according to the 2011 Census.

But what is chronic pain, and how can it overlap with the perimenopause and menopause?

In this week’s episode Dr Louise is joined by Dr Deepak Ravindran, a consultant in pain medicine and author of The Pain-Free Mindset: 7 Steps to Taking Control and Overcoming Chronic Pain.

Dr Deepak unpicks the science behind chronic, or persist, pain and the two discuss the relationship between hormones, inflammation and pain.

Dr Louise and Dr Deepak have co-authored a new article which offers 10 top tips for primary care practitioners on improving care for women with fatigue and/or pain. You can access the article here.

Follow Dr Deepak on YouTube, Instagram, LinkedIn and X.

Click here to find out more about Newson Health

Transcript

Dr Louise Newson: So today on the podcast, I’ve got with me Dr Deepak Ravindran, who I’ve known for a little while, who is a leading expert in pain. And pain is very common, we’ve all experienced pain at some time. And actually, I was reading some of the stats which are huge about chronic pain, so long term pain, and how common it is. And I know how poorly managed it is for a lot of people.

So we’re really privileged to have Deepak here to share his knowledge and words of wisdom. So thanks ever so much for joining me today.

Dr Deepak Ravindran: Thank you Louise, so much for having me on your podcast.

I’ve been listening to a number of the episodes over the years, so it’s really a pleasure to be on your channel today.

Dr Louise: That’s kind.

Someone said to me a while ago, I can’t believe your podcast is still going. Surely you’ve spoken enough about menopause. And I sort of get it, but I was still also annoyed as well because there’s so much to talk about. There’s so much that I feel every day that I’m learning and I feel really cheated that I didn’t know about it before.

And I don’t know about you Deepak, but in medical school, even if I went back now and redid the course, there is still a lot that I should have been taught that I wasn’t.

Dr Deepak: I share that sentiment. I mean, you’re saying that about menopause, Louise, pain itself, the most common thing that comes for 70% of all GP consultations, that’s really changed so much since what we’ve been taught in medical school or all of your listeners and the general public understands about pain.

There’s a complete sea change in how we now advance and understand the neuroscience that I feel that we really need to be talking about these things and the understanding now of the links between pain and menopause.

My God, there’s enough to fill enough podcast episodes for you for another few years at least.

Dr Louise: Totally, I totally agree.

So before we get into too much detail too quickly, I’m really keen to learn, so you’re a practising physician. And you’ve been you’ve been doing pain for many years, I know.

And you’re an author of I’m just going to hold it up for these people that are watching, but it’s called The Pain-Free Mindset: 7 steps to taking control and overcoming chronic pain.

And when we talk about chronic, it’s not chronic really bad. Chronic is that it’s persistent.

So some people with the way they use language can be different to how we use language, but chronic is it doesn’t go away very quickly.

So how did you get into specialising in pain Deepak?

Dr Deepak: So I’ve, as you said, I’ve been now practising for over 25 years in medicine there.

I’ve trained in India and I’ve then come over to the UK and I’ve been in the UK for more than two decades now. And I’ve done, my background is in anaesthesia. So most pain physicians in the UK come from a background of anaesthesia and I trained in Oxford and in London. And at that time itself, I realised that… obviously from an acute pain setting, I was very good in blocking nerves, doing all the procedural aspect there.

But it was around that time that I really got interested in the research potential and the newer discoveries that we were making about pain signs, the brain, the nervous system, receptors, pathways.

And that’s what led me to do my fellowship in London. And I joined as a consultant in the Royal Berkshire Hospital in Reading. From 2010 onwards, I’ve been there. And pretty soon within the first two, three years of my consultant life, I realised that the skills that I had been trained in, which is giving medications and doing interventions and blocking anything with a needle, was really not helping a lot of patients with chronic pain.

And as you said, it’s what we now call persistent pain. It’s something that lasts for long and is

difficult to get rid of. But I think we’ve approached it wrong, Louise, in a sense that by assuming that it can be got rid of with medicines and interventions, we’ve forgotten what actually pain is. And it’s that knowledge that I began to understand. And when you look at the research and

literature, there’s so much that has happened in the last 10,15 years that I realised, well, actually, more and more has to be done about making other people understand so many different ways of managing and overcoming and actually getting rid of pain, but not by the conventional mainstream ways of medicine and surgeries or injections.

And all of that knowledge is what I realised I needed to get out to the public.

And so progressively over the last 14 years, I’ve done less of anaesthetics, more of pain management to the point now that I’m a full-time sort of consultant, pain physician, working in Reading.

I have a private practice, but I’m also very interested in research. And so I’m what we call these days a physician researcher. So I have a professorial post at the Teesside University.

I’m a senior visiting fellow at the University of Reading locally. And I’m interested in a lot of research around trauma, around lifestyle medicine.

And I see all of that as being very vital to understanding the different ways we can overcome pain.

Part of the book is partly condensing some of that knowledge now in a book form, but a lot of it is around getting that message out to say, if we open our eyes, if we understand pain neuroscience, it gives us so many different ways to overcome pain than feel restricted by the straitjackets of drugs or interventions. And that’s really what I’m doing these days.

Dr Louise: It’s so interesting isn’t it when you’re talking about straitjacket of drugs and I was talking recently about people being given a chemical straitjacket as well with some of the you know treatments people give where they’re inducing menopause indirectly actually not even realising some of the psychiatric drugs like anti-psychotic drugs and certainly you know when I reflect my time as a doctor, you know, a lot of it is about listening to patients. It’s a hands off approach, actually. Some of the best doctors I know have spent 80% of their time listening and making a diagnosis and making a treatment plan that’s appropriate for that individual.

Of course, often we use diagnostic tests, but actually it’s putting it into context. And I think with pain, it’s so important because…As you say, there are some great drugs. You can numb all sorts of people, all sorts of things, can’t you?

But it’s not actually treating the underlying cause. And so, and there is a real problem.

And we see a lot of people that are on painkillers, quite strong ones, especially even opioids as well for muscle and joint pains that they’ve had no diagnosis for, and then they realise it’s related to their hormones.

But you’re just putting a sticking plaster on sometimes, aren’t you? If you’re not treating the underlying cause, but then also the way we perceive pain can be quite different.

So, I mean, this is very simplistic and hear me through, but I hope it makes sense.

As you know, I get migraines and often my migraines will only, only I say last like 24 hours, 48 hours if they’re bad, but I know I’ll come through it and I just have to wait for them to and I will take medication.

But if I don’t catch it early enough or whatever, but last week I had a migraine that lasted for five days and it’s not just the pain, it’s the cognition. I can’t think, I slur my words, I find it really difficult to concentrate. But my father had a brain tumour and he had, he was 40 and he presented with a headache. And so if I didn’t have the knowledge that I have, I would then be worrying, have I got a brain tumour? Is there something else going on?

And there’s no doubt with migraines. I know that they’ll get better. I know they’re self-limiting.

I just have to, and I’ve got a really supportive family and my husband, you know, because I forget to eat and then not eating makes it worse and not drinking makes it worse. And it’s just awful. I have to give into it. But actually, if I was worried, my pain would definitely be worse.

And it might not be the actual pain. It’s the perception of that pain and the anxiety that’s associated with it. And then if I don’t eat, things will get worse. If I don’t sleep my pain gets worse. And it’s that cycle sometimes. And I can see that that’s just for a few days.

But if I was having pain for a lot longer and I, does that happen with some of the people that you see? It sort of snowballs in some ways.

And I know it’s probably the way the brain is reacting as well sometimes with this pain as well.

Dr Deepak: I think Louise, I mean, thank you for sharing that really.

And it does what I try to teach people and not even forget teaching, just try to help people understand.

You’ve really highlighted the importance of that aspect of listening and feeling validated.

So that’s one aspect of supporting the patients. However, fundamentally, what we now know,

and you rightly point out that overlap between there, is I talk about in the book as well, and I

talk about this concept of and difference between what I call nociception and what we have as the pain experience.

So nociception is essentially when chemicals get released. So when you have chemicals get released at the migraine zone that triggers your migraine, when people might have a flare up of IBS or might have a flare up of their endometriosis or a pelvic pain that comes along or for any any other surgery or injury, you have chemicals that are released at the site of that physical structure. Those chemicals get converted into signals within the nerves. That conversion part, that word is called nociception. That phenomenon there is nociception.

That signals have to then travel along these electrical nerve pathways and they go around pinging different parts of the brain, different areas, the hearing zone, the memory zone, your emotional zone.

So there are receptors in every part of the brain.

Now, we were taught in our medical school, the health school, that there are, there is a pain centre and there is a specific pain pathway, but that’s entirely wrong now. There are no pain pathways. There is no specific pain centre. So then that information gets going to every part of the brain and the brain has this complicated aspect of saying, how can I predict the context in what this is happening? How is the signal going to be processed?

And ultimately, if the brain decides that it needs to protect you, it needs to kind of tell you that this is a threat that I did the previous time, the first time when it happened, this is what I did to protect you, then it will bring about the protective element.

That protective element is what is manifested as the pain experience.

And so realistically, nociception may be one aspect of the problem, but the pain experience is determined by the context, by the decision to protect, by other life experiences you may have, by all other emotional factors that go into it.

And so the intensity of your migraine that you may have, what lasts between five days or 24 hours, for every other patient I get in my clinic, when I tell them, why do some days your pain last for a few hours, other days it goes on for days, then it means that it is influenced by so many other factors.

And surprisingly, even things like sleep, nutrition, lack of activity, lack of social connectedness, all of those aspects make a difference to the intensity of pain experience. And I think understanding fundamentally the distinction between what can influence your pain experience versus what is the nociception that comes out, really is eye-opening to a lot of patients and saying, well, you know what, those are the things I can still influence. Can I make a change?

And that is the opportunity I think that’s there in trying to modify the pain experience.

Dr Louise: So important, I’m very interested in neuroscience and I’ve been reading lots of neurophysiology papers recently. And I’m very also interested in inflammation and neuroinflammation as well and how we protect our brain, but our body as well.

Of course our body is important, but without our brain, you know, we’re nothing, aren’t we?

But how our…nerve cells work, how our brain cells work, what influences them?

And there is a lot more talk about inflammation. I’m very interested in mitochondrial functions, so mitochondria are the powerhouse of the cells. And we’ve got trillions of cells and goodness knows how many trillions of mitochondria, but they’re really important and they can be influenced.

And whenever the brain is sort of twitched and the nerve cells are twitched, of course pain, but the perception of pain is going to be different as well.

And so, looking at all of these things, which is something we weren’t or I was never taught at medical school, is that, you know, the way we eat what we eat, the timing that we eat, the exercise, the mindfulness, how we worry or not worry about pain or things that are happening in our lives, any trauma that’s gone on.

But also, you know, that sort of micro environment. And it’s not just when we’ve got the pain, because when I have a migraine, for example, there’s no way I could do any yoga, I can’t do a headstand, I can’t do any exercise. And I will only eat because somebody gives me food. But, and this is a big but, if I don’t do yoga, and eat badly when I’m pain free, my migraines would be a lot worse. But I need…I’ve learned that myself, but if I didn’t know, I would need someone to tell me, Louise, it’s not just about the acute phase. It’s what you’re doing. And I know that I’m very anti-inflammatory in the way that I function and also my hormones that I take are very anti-inflammatory too.

But that’s really important. That bigger picture, isn’t it? When we’re trying to dampen down the

inflammation in our brain, because presumably when we’ve got more inflammation, our our pain receptors are on hyper alert and our pain perceptions are different. Would that be fair to say?

Dr Deepak: You’re absolutely right, Louise, because when I talked about the nervous system being protective and making a prediction and a processing and a finally decision, the other big player who actually tells the nervous system, do we protect or not, is the immune system.

And actually, the immune system and nervous system are doing this real yin and yang dance throughout the body, constantly looking out for protecting us.

Now, why is that important there?

First of all, I think one of the statements we were taught in our health care schools is that the brain is an immune privileged organ.

That was at least the teaching until the early 2000s, which meant that there was no representative of the immune system in the brain.

But that is now absolutely wrong. We now know and the way I kind of explain

it is.

Imagine that a signal arrives at one nerve ending and then has jumps. So the synapse, that is a junction where a signal travels from one nerve cell to the next nerve cell at each junction.

And so there are billions of synapses, but at each of these synapses junctions, there is a representative of the immune cell constantly moderating the traffic, looking at the signals, deciding to ramp it up or lower it down.

And this is what the immune cell is doing. And so when the immune cell and let’s backtrack one bit, 80 to 90% of the immune system is present in and around our gut. The next biggest place for our immune system is the skin. Clearly, these are the two parts of the body that are in contact with the outer environment, the micro and the macro environment. So this is where the immune system needs to be present. Our defence forces need to be maximally aggregated at these two points to keep a watch out.

So when they watch for these things, they are going to react and they then inform the nervous system to actually say, this is what you need to do mate to protect yourself.

And so if they are inflamed, the brain is going to have that neuroinflammation, as you put it, and that can affect, you know, one of the big things I realised when I set up sort of, I’d set up a community pain service in 2015 for my local area of Berkshire, and I then helped set up the Long COVID service. And conditions like this made me aware of this importance between conditions like ME, like fibromyalgia, like Long COVID, where we are now understanding that there can be changes to how the immune system gets inflamed and how it impacts on the nervous system.

And fundamentally within the nervous system and immune system, how it changes the functioning of the mitochondria. And as you rightly said, there are about 400 to 800, maybe thousand mitochondria in each cell. If those functions are affected, it has an impact and on what makes the impact to the immune and nervous system?

Well, it’s things like diet, things like nutrition, things like sleep. But at a second level, it’s the impact on the hormones. What changes they bring to the thyroid hormone, to the sex hormones, to the growth hormones. Those are the changes we are now beginning to take apart and piece apart and understand that each of these can be modified, can be modulated before rushing to drugs. And I think that’s exciting times for us in this field because we now have so many other ways to modulate the immune system and the nervous system to be less protective maybe, or at least to be assured of safety in another way.

Dr Louise: And it’s so important. I don’t know if you know, I did a pathology degree a long time ago in 1992, but about 20% was immunology. And so we did a lot of work looking at, especially macrophages and monocytes as well, looking at what happens when the body is anti-inflammatory or pro-inflammatory and how very little can make a big difference.

So the cells, especially the macrophages, they sort of gobble up anything bad. So our body’s constantly protecting us, not just from viruses and germs, but from diseases as well. And so we need these cells to work really, really well. And when they work well, we’re really good. We’re protecting our bodies from future illnesses and disease and being in health. Whereas it doesn’t take much for them to go against us.

And not only do they not work, but they become pro-inflammatory. So they produce these chemicals, which go against us, which feels a bit strange really, doesn’t it?

But…when you look at how different levels of hormones and I know I did a lot of reading in COVID like we all did because we had a lot more time and I remember like reading something about when there’s an optimal oestradiol level then your inflammatory cells work really well they’re very anti-inflammatory but when you have low oestradiol becomes pro-inflammatory and I remember going up to the attic and digging out my notes from my pathology degree. And thinking gosh it’s all there like it’s quite basic science and then I’ve been reading a lot more about progesterone which is very anti-inflammatory.

We were just told progesterone protects the lining of the womb if you have oestrogen. Of course it’s a really important neuro hormone it’s produced by the brain and testosterone.

I’m increasingly as you know, I don’t stop talking about it – about the role of testosterone being anti-inflammatory and how these hormones affect pain and neuromodulation as well, and the way they interact with our immune system.

And then when we look at autoimmune diseases, it all fits into place really, but it’s been siloed and ignored in medicine. And it’s such a shame because it’s not just hormones, it’s not just diet, it’s not just sleep, it’s everything together and everybody’s different who responds most to what.

But we’re missing big bits of the jigsaw if we’re ignoring hormones in men and women actually.

Dr Deepak: I agree really, you know, when you talked about the silos, Louise, that is a big problem.

For example, in pain management, even in the fellowship that I did and as I did my pain clinic and the work that I have with my team, which is, you know, I work in a multidisciplinary team with fellow pain consultants, with nurses, with physiotherapists, with occupational therapists, with psychologists. We don’t have a dietician as well, but we’ve got some physios who are trained in there. But what we as a whole team never really understood until the last four or five years. And some of it is due to the work like people like yourself is this overlap between menopause and perimenopausal periods and pain. Because I did some sort of limited audit and it’s, you know, it’s very common to know that chronic pain and autoimmune conditions are much more common in women.

And when I looked at my practice and sort of thought, you know, let me just see over the last two weeks how many women come in what age groups. About 70 to 80% of my women patients who came to my clinic are between the ages of 30, 35 to about 60, 65. And we understand the overlap between perimenopause and pain, or rather perimenopause in this age group, but it has never really occurred to us in the pain clinic that do we need to be actually thinking more actively whether… exactly as you said, the influence of oestrogen, progesterone, testosterone, thyroid hormones. What does it mean?

We do a thyroid function test before they come to the pain clinic that we understand that relation between low thyroid and fatigue and pain or vitamin D being low and pain. But we have never really tested or looked for and understood the challenges of having possibly low sex hormone levels or low testosterone levels and pain.

And the data, as you said, is there. There is enough to suggest that we probably need to work that on that level.

And in terms of treatment, it was a very interesting question. A GP asked me recently saying, we have all these problems with the pain medication. You know, the antidepressants are really getting hammered in the press because of their long-term issues and challenges. Gabapentinoids like Gabapentin and Pregabalin have their challenges in terms of weight gain in women as well as their dependence problems they have.

So they asked me actually, when we have the drugs for fibromyalgia or for persistent pain, they are having so many side effects and you have patients who are in the perimenopausal age period as well.

Should we be thinking about giving them something more safer now like HRT rather than medications. And I must say, well, actually, that seems like a very fair question to ask.

And is it that pain clinics across the UK in the NHS need to be actively thinking about how do we assess for that? How do we recognise that? How do we make people aware of the holistic options and maybe more safer options to managing this age group of pain, fatigue, and all the other symptoms rather than just doling out more medications that we now know are probably not that safe?

Dr Louise: I wish that would happen. I would love to do joint pain clinics and hormone clinics and help educate because you’re absolutely right.

And there is evidence that actually people perceive pain differently just before their periods when oestradiol levels at their lowest. And with oestrogen, even if you’ve got the same stimulus, your perceptions of pain will be very different when you’ve got hormones and all the anti-inflammatory effects. And certainly… fibromyalgia I used to, I shudder really when I think back to general practice because I would see a lot of women in their 40s with fibromyalgia, I would be the one with prescribing the Gabapentin and the Pregabalin but because the pain clinic had asked me, never once did I ask the women about any periods, any PMS, could it be related to their hormones I never even had prescribed testosterone until about 10 years ago because I didn’t know women even had it. And now if someone comes to me in the clinic and has fibromyalgia, I will always say, look, I’m going to optimise your hormones, all three of them, to a physiological response. And then let’s see what’s left.

And fibromyalgia usually melts away. And it’s usually the testosterone that makes the biggest difference and might not get them completely better. But I’ve never once seen a patient that hadn’t improved when she’d been given hormones. And I’m giving the hormones for their other symptoms and their future health, not for their fibromyalgia, because we don’t know whether it will help.

But actually there’s no harm and in medicine it’s always balancing and it’s always very easy isn’t it to say they shouldn’t be on the opioids, they shouldn’t be on these drugs, but what do we give to them instead? Do we just say sorry, have nothing and suffer?

Of course we can’t do that as doctors, but actually I parallel prescribe, so I’ll give them the one that they’re on already, add in hormones and then I tell you within three to six months they’re reducing the doses of their other medications and often stopping, which is wonderful isn’t it as a doctor if we can stop and deprescribe as well.

Dr Deepak: I have had now patients in that same situation wherein I tell them that, look, you’re in this age group. We have to be aware of the role of perimenopause. I’m still learning about it. So I at least refer them to a women’s health specialist in the local area. Or I ask the GP if they have got someone, can we test it? Can we replace that and then see whether the drugs still need to be taken? When I do a follow up three or six months, I’m starting to get patients more and more who actually say things have improved, I’m now on less of the tricyclic or less of the Gabapentin or Pregabalin or one of the other anti-neuropathics, and they have managed to reduce off that. And I think that I would agree with you that it is something we need more training and, first of all, I think we as healthcare professionals itself need more awareness raising and education. I think the British Pain Society itself recently, have done a webinar just to talk about this overlap between menopause and chronic pain.

And I would be the first one here and both of us, I think, would be first one to say the evidence is emerging. I don’t think there is like awesome evidence that there is causation. But when we take in the simple thing of, you know, what as healthcare professionals can we do that safe, that’s easy to give, that’s easy to control for, I think good lifestyle medicine based principles plus appropriate safe treatments like HRT where appropriate, I would say I’m more and more leaning towards saying, can we control for all of that before we go down the anti-neuropathic drugs?

Dr Louise: I never thought the day would come that I would hear that from you, Deepak!

That is just brilliant. I’m going to frame those words because it’s so important.

And working together is also really important.

In medicine, we get really stimulated working with like-minded people who have got professional curiosity, who are prepared to pivot and change according to the science, but also what we hear from patients, because those two together are crucially important.

We can’t learn everything from papers and textbooks and we can’t learn everything from our patients. But when we join the dots and work together with our patients, it can be transformational.

And I know that you love your job as much as I enjoy mine. So we’re very fortunate in that way. So before I finish, because I’m very, it’s just been great. I could talk all day to you. I would like to ask you three take home tips, if that’s okay. I always do it on my podcast.

So three things that if someone’s listening and thinking, yeah, it’s all very well. They sound really happy and you know, managing pain is really easy, but I have pain and I’m not being listened to because there is a lot of people diminish the effects of pain. Sometimes I hear a lot of stories where people really just say, you’re just stressed. It will calm down and improve. So what three things if people are struggling, do you think they could do to help them receive the help and treatment in the way that’s right for them?

Dr Deepak: I think the first one is for all of your listeners to really understand and take on board that the science of persistent pain and chronic pain is that please don’t feel that you’re making it up.

Yes, you may still have professionals who are in that mindset there, but it is not the case at all.

The chronic pain is very real. There is a very good biological reason why that happens now. And we know that. The second tip I’d suggest is, please try to understand or maybe have a bit more patience with yourself, compassion with yourself to read up about or at least listen to the resources now to say what is the difference between nociception and pain and therefore what are the opportunities for you. So how do you understand your pain so that you can realise that there are other ways to manage it?

And the third tip I probably would say is to really look at the various other lifestyle medicine options. I mean, it may sound corny when I say lifestyle medicine, but it is a solid science. It now shows that if you can find a way to make your immune and nervous system feel safe, the question you ask is, how can I make my nervous system and immune system feel safe? It will open up a world of options in which recovery is possible, overcoming pain is possible and indeed, I have patients who have become pain free after many years of chronic pain.

So getting ‘rid of it’, which we thought was very difficult 10 years ago, we now have patients, if they understand the pain, that’s possible.

Dr Louise: Amazing. And I would add that nothing happens overnight. It can take a while and that’s really important. But starting small steps in the right direction can be transformation of your future health. So thank you so much for today. It’s really wonderful. And I will put a link to your wonderful book in the notes as well, because I think everyone should look at it and learn as well. So thanks ever so much, Deepak. It’s been great.

Dr Deepak: Thank you so much. Thank you so much Louise for having me. Our audio book has also come out now for your listeners a few months ago. So for those of you who like to do your listening running about, then absolutely go for that as well. But thank you once again for having me and it’s been wonderful talking to you today.

Dr Louise: Thank you.

You can find out more about Newson Health Group by visiting www.newsonhealth.co.uk, and you can download the free balance app on the App Store or Google Play.

ENDS