MENOPAUSE, PERIMENOPAUSE
AND HRT
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Episode 209:
Show Notes
This week’s podcast starts our Menopause Series. In this discussion,, Dr Lucy Burns and Dr Ceri Cashell provide a thorough exploration of menopause, perimenopause, and hormone replacement therapy (HRT), shedding light on these critical phases of women's health and the associated treatment options. Dr Ceri Cashell is a well-respected GP with a significant interest in women’s health, particularly focusing on the treatment and management of menopause and related conditions. She is known for her holistic approach and her commitment to advancing menopause education.
- Menopause and Perimenopause:
- Definition and Symptoms: Menopause signifies the cessation of menstrual periods, typically occurring around age 50, while perimenopause refers to the transitional phase leading up to menopause.
- Symptoms: They categorise symptoms into brain-related issues such as memory problems and mood swings, and physical symptoms like hot flushes, night sweats, joint pain, and changes in sexual health. Dr Ceri identifies three basic symptom categories: brain symptoms (e.g., cognitive decline, mood disturbances), neck-down symptoms (e.g., hot flushes, night sweats), and sexual symptoms (e.g., vaginal dryness, decreased libido).
- Individual Variability: Emphasising the variability in symptoms among women, they stress the importance of personalised approaches to managing menopause-related symptoms.
- Hormone Replacement Therapy (HRT):
- Purpose and Benefits: HRT involves the use of eostrogen and sometimes progesterone to alleviate menopausal symptoms. Benefits include relief from hot flushes, improved sleep, and protection against bone loss.
- Considerations: The discussion covers the controversies surrounding HRT, including potential risks such as increased breast cancer risk and cardiovascular issues. They advocate for informed decision-making based on individual health profiles.
- Progesterone and Testosterone:
- Progesterone: Dr Lucy expresses caution regarding progesterone due to its potential to increase insulin resistance, a concern that needs balancing against its benefits, such as improved sleep.
- Testosterone: Dr Ceri discusses testosterone's role beyond libido enhancement, noting its benefits for cognitive function, mood stability, pain management, and overall energy. However, she advises careful monitoring to avoid side effects like voice changes and hair growth.
- Treatment Approaches and Strategies:
- Personalised Care: They highlight the significance of personalised treatment plans tailored to individual symptoms, health history, and preferences.
- Non-Hormonal Alternatives: Beyond HRT, they explore non-hormonal treatment options such as lifestyle modifications, cognitive-behavioural therapy, and alternative therapies to manage menopausal symptoms effectively.
- Research Needs: Both doctors underscore the need for ongoing research to better understand the long-term effects of HRT and to explore new treatment modalities that enhance women's quality of life during menopause and perimenopause.
- Special Considerations:
- Breast Cancer Survivors: The discussion addresses the complexities of HRT for breast cancer survivors, highlighting the importance of individualised risk assessment and the potential benefits versus risks.
- Metabolic Syndrome: Dr Lucy emphasises the relationship between metabolic syndrome and increased breast cancer risk, advocating for a holistic view of women’s health that considers both metabolic and hormonal factors.
In summary, Dr Lucy Burns and Dr Ceri Cashell provide comprehensive insights into menopause, perimenopause, and hormone replacement therapy, offering a nuanced perspective on managing symptoms and optimising women's health outcomes during these transformative stages of life. Their discussions underscore the complexities and individual variability in menopausal experiences while advocating for personalised, evidence-based approaches to treatment and care. This series aims to empower women with knowledge and options for navigating menopause with confidence and informed decision-making.
To stay connected with Dr. Ceri Cashell and gain more insights into menopause and women's health, follow her on Instagram and LinkedIn at Dr. Ceri Cashell. Excitingly, she is also launching a menopause education platform for doctors, which will soon be available to patients as well. This platform aims to provide essential knowledge and resources.
Downloadable checklist
Previous episode 206
Dr Ceri Cashell
Book recommendation: Estrogen Matters by Avrum Bluming
Episode 209:
Transcript
Dr Mary Barson (0:04) Hello, my lovely friends. I am Dr Mary Barson.
Dr Lucy Burns (0:09) And I'm Dr Lucy Burns. We are doctors and weight management and metabolic health experts.
Both (0:16) And this is the Real Health and Weight Loss podcast!
Dr Lucy Burns (0:23) Good morning gorgeous ones. How are you this morning on this beautiful Tuesday morning? This is the start of our Menopause Series. I'm super excited to be bringing new really expert guests who are going to be delving into all the different aspects of menopause. And I thought we'd start this series off with one of the best experts I know. Her name is Dr Ceri Cashell. She's a GP with a significant interest in menopause and runs a fabulous menopause clinic. Ceri, welcome to the podcast.
Dr Ceri Cashell (0:52) Hi, Lucy, thank you very much for having me.
Dr Lucy Burns (0:54) Oh, you are welcome. So what I want to know, and I've spoken about this a little bit is that, you know, I feel like I'm a bit late to the menopause party, I haven't and then I go in and find out actually, I'm not that late, but you're like a forerunner and I'm really interested to hear how you found yourself in this space and how you helped women navigate this period.
Dr Ceri Cashell (1:17) Yes. So I actually feel a wee bit of a cheat because most experts in this space have got this quite tragic personal journey. Whereas, I feel I kind of sneaked in before anything too awful happened. And I'm for me, it started with a patient back in 2021, who came to speak to me about her menopausal symptoms. She had already started eostrogen and progesterone and it wasn't really cutting the mustard for her. So she'd gone off to see somebody else and got started on testosterone. So she came back to me and said, I want you to take it on. It's changed my life and I was like, I have no idea about testosterone. She said, well, you need to do this course you need to look at this doctor in the UK. And it took me a couple of months. But it did and started, I did this course, which is the Dr. Louise Newson's Confidence in the Menopause Course and then I started to listen to her podcast, and I was running up and down our local beach, which is Palm Beach, I just my head would explode every day that I listened to each of those stories or each of the interviews with other experts. And I realised that really, I had essentially slept-walked through the past 20 years of Women's Health Medicine. And I could see a patient who matched those stories. And pretty much in every single case. From that point on, I started to look at women with an entirely different lens, women of all ages. So it was really like a without sounding too evangelical. It was like an awakening, really in medicine for me. And I have I have never enjoyed my job so much as a DNI, since I've changed our practice.
Dr Lucy Burns (2:58) I love that. And I think it's amazing when you do find something that makes such a big difference to what you were doing. And you know, when I first found sort of low carb as our one of our pillars, I had a business that I called Epiphany Medical Weight Loss. Because a bit like you I thought I've had this epiphany, this awakening. But then I changed the name because two things happened. One, some people didn't know what an epiphany was. And so then I had to kind of explain it, which sort of lost its impact. Some people thought it was there were some religious connotations to my practising. And then the third lot of people were calling it epi-funny. And so I thought actually, I'm not gonna call it.
Dr Ceri Cashell (3:40) I like that I like epi-funny medicine.
Dr Lucy Burns (3:43) I know, well, actually in the menopause space, it really is a bit about the epi and the bit of funny. But yeah. Let's move on. So I think a couple of things that I've noticed is that the symptoms that people have, I mean, if you ask anybody if you ask about menopause symptoms, they'll talk about hot flushes, and maybe night sweats. But there's a whole lot more going on. And I thought that you would be the perfect person to explain what are the symptoms that people may be having as part of their menopause transition.
Dr Ceri Cashell (4:15) Yeah, so that's such a good question. And that I think really underpins the whole of women's health. And that's what I've loved most about my learning about menopause is I understand everything a little bit better. So I always go back to eostrogen or really important eostrogen in menopause is Estradiol, and I do think it's important to understand those subtle differences. So every single cell in our body has got eostrogen receptors on it. And Estradiol when it clicks with those receptors controls those cells and keeps them organised, keeps the energy up. So once you understand that principle, you can see that any single symptom that a woman experiences, could be down to changing hormones, and that applies in our menstrual cycle, that applies after we give birth or when we're breastfeeding, that applies when we're on certain forms of hormonal contraception, and then it really applies and perimenopause and menopause. So I would say almost any symptom a woman experiences could be down to perimenopause and menopause. But the absolute importance is that it isn't always the case. And that's very much what we as doctors are always trying to navigate as there's a perimenopause or menopausal symptom, or is it something else, because women in their standard age range for perimenopause and menopause are getting a bit older and do have an increased risk of other diseases. So I break down the symptoms into three groups that you probably can split them into in different ways. But I like to think of them as symptoms that happen in the brain because they're often the earliest symptoms. And I think they precede a lot of the classical changes that most doctors and most women have heard of, which would be your periods changing, or the hot sweats, or the hot flushes and the night sweats. So the brain symptoms, I think, are the ones that really cripple women, and make them reduce their hours and make it harder to manage life. And that would be things like anxiety, insomnia, engine brain function, and difficulty with verbal fluency finding words. And also even the temperature regulation thing does come from your brain. So there's hot flushes and night sweats. The do have an origin in the brain. So I like to think of the brain symptoms because most of us really value our brains, they tend to live our day-to-day lives. And then when I sort of go neck down, and then it's basic, it's really anything. So common symptoms that women get in early, earlier stages of perimenopause would be palpitations. So you've had all these women that I've referred for multiple investigations, ECGs, and heart monitors, and off to cardiologists and off for echocardiograms, and such like, and then it was probably just perimenopause, and then got symptoms, really, I looked back at all the women who've been back and forward to gastroenterologists and had endoscopies for changes like reflux, or constipation, or diarrhea, and our bones really start to, you know, be affected well before our last period, which I didn't appreciate at all. And we think that's even more to do with progesterone, dropping the poor eostrogen. And so really looking at bone density as soon as a woman is in menopause, but women often get joint pain, you know, I have a good friend who's a physiotherapist, and she was seeing me with a really sore feet. And, you know, we both run Palm Beach, and she was sort of hobbling along trying to manage about 20 meters, a metre there the other day, and we ran the beach up and down twice together, you know, both of us feeling delighted with our physical fitness. And I think the joint pain is a big thing. And you know, and women know that they need to exercise at this point in their life, you know, to stay fit and healthy. But if you're so sore, that you can barely get out of bed in the morning, we bet rich for me to say,--no, take yourself off to the gym, you know, just work a bit harder. And I think that's a you know, that's certainly a symptom that people find really difficult. And the other thing that people get as this sort of the effect of the nerves, you know, in the rest of your body, so that tingling feet, or that creepy crawly feeling on your skin, you know, and just feeling like there's ants crawling is my only symptom. As I say I was a complete cheat, and was a cheat back actually back and the occasional itchy ears, which I think are hilarious symptoms, but then equally quite annoying, you know, be I can probably scratch my back row. And I do quite a lot of oral because I still do a lot of general practice as well as menopause. And my older neotys who have these raw backs, you know, they've got a thing called nodular prurigo, which is just basically intractable itching and scratching, and they scratch themselves raw. And that continues and that's loss of eostrogen and your skin and probably also testosterone and progesterone as well. You know, keeping that lovely moisture in our skin, keeping the collagen and the elasticity there. So, yeah, mean best yes. So that's the thing. It really can be any symptom. So it's always trying to juggle not assuming it's menopause, but equally not over-investigating somebody when it probably is because as we know, common things are common. And all women, if they live long enough will go through menopause. And most of them won't have brain tumours, you know. So it's a juggling game of general practice.
Dr Lucy Burns (9:26) Yeah, I love that. So the idea being then that any symptom and I do recognise that, as you're saying the eostrogen receptors are in all of our cells. So any symptom could be menopause. Obviously, we need to exclude serious conditions because we don't want to write everything off as being menopause. But if we've done that, and I think this is where women in the past have had difficulty where somebody has perhaps investigated them and then said, Oh, no, there's nothing wrong.
Dr Ceri Cashell (9:56) Yeah, I think that's huge because what's happening is really at a cellular level so it's not necessarily translating into a full disease process. So you know, you've gone off and you say like, as there are my memories, not as good as it was, or my joints are and our joints are really sore, and I'm in a lot of pain. And you go and see whatever specialist or just your GP and they run your bloods and they go, your bloods are normal, so you're fine. And I suppose that's one of the things that gets called medical gaslighting, you know, and I think not having your symptoms validated, or even just having a reason does compound that feeling that you might be just going a little bit mad. Yeah, just so just to understand, you know, whatever path you choose to take, just understand why I think for women or any peripheral humans knew, wider feel like this is so empowering to go up. That's why oh, well, that's okay. Then, you know, I don't need to worry that I'm going to, you know, have rheumatoid arthritis, like my mom, or I've gotten to have dementia, like my mum or you know, whatever it is, you know, just to know and understand technology is so empowering.
Dr Lucy Burns (11:01) Yeah, absolutely. And I think the thing that a lot of people will say is, I went to the doctor, and they told me it's just my hormones and feel like they weren't heard. And whilst that premise may be correct, that it is hormonal fluctuation, it's really explaining to people what that actually means. And then what their options are, rather than them leaving going, Oh, I feel like I've got no solution because it's just my hormones. Yeah.
Dr Ceri Cashell (11:28) And I think that goes back. You know, I often start off when I'm doing talks saying, Well, what is a hormone you know, so, like, because it's really they've been kind of demonised, you know, we've got lots of hormones and hormones are hardwired body bodies work, you know, if we had no hormones, we'd just be like, I don't know, I'd be just a blubbering pile of jelly on the floor, you know. So nobody, nobody dresses serotonin and dopamine and melatonin and play roxon and insulin and leptin and garlon. You know, so why do we demonise our sex hormones? I recommend the boss be of hormones that go on. Yeah, like I said, the chief executive suite, you know, so the second one wants you to work designed to reproduce. So it makes sense that the sort of hormones that are involved and reproduction do have a very strong role to play and human physiology. And you can see that and then you know, men are able to reproduce usually until they die and they have that lovely testosterone. That little it declines decade on decade, at a time in a boat really pretty much till the end. And it was really noticeable. I was doing that I used to do the park run before my hamstring got fragile. And I was the oldest woman during the parkland, I think there might have been one other woman a bit older than me, and that was at 47. But there was men in their 60s fire and passed. I was like, what are they? What were all the older women, you know, we're not lazy. So why are we not here and present and you just without hormone without the hormones? You just can't maintain that physical fitness? Just yeah, it's just nature, you know, so I'm not up for that. I love to be doing my park run at 65 or 70.
Dr Lucy Burns (12:54) Yeah, 85. Why not? Bring it on? Absolutely. One of the other things that I think comes up a lot is when people have blood tests, and they will have the blood test, and then they'll come away with the impression that, oh, well, my hormones are all fine. So it's not my hormones, or I yeah, I've had my hormones done and I'm through it. So you know, I'm finished. So it's not my hormones. So what what are your thoughts on blood tests and when do you order them? And what do you reckon, is the process that women should be looking for with this?
Dr Ceri Cashell (13:29) So yeah, so once again, that's like hormones, just a messenger and my second key point is blood tests don't diagnose perimenopause. So perimenopause is, as you obviously know that our hormones are up and down and all over the place. You know, spiking eostrogen will spike high and trough really low progesterone probably is running generally a bit lower than it was, but because they're different day to day and our snapshot blood tests don't tell us a huge amount. And you know, there are some testing protocols there that are quite expensive and complicated. And there's not a huge amount of evidence that they make a huge difference to what we do. You know, hopefully, in the future, we will have ways of, you know, maybe diagnosing perimenopause, but we don't have it at the minute so blood tests do not diagnose perimenopause when their ovaries are producing eggs, you know, occasionally on eggs of less, maybe a poorer quality, but occasionally the eggs will be great quality and your eostrogen will be super great in so the blood tests that we do, as I said earlier, are to just make sure those symptoms of perimenopause or menopause or not dying to something else. So we're checking you know that your iron isn't low because of heavy periods, or that you're not hiding something sneaky in your gut. We're checking your thyroid, we're checking, I would tend to do a metabolic screen at this stage to see where your sugar controllers and your cholesterol and your level of function and you know, maybe unchecking that you're not anemic, and I do often check testosterone because I'm a big advocate for test checking and seeing if testosterone has a role to play. So I will tend to check a testosterone level, but eostrogen levels and progesterone levels in my experience don't have a huge role except when you're trying to see if treatment of drugs is being absorbed. So we're really using blood tests and other investigations to realise the other than not perimenopause. And then in postmenopausal women, you will see a change in blood tests or when there's been consistent failure of ovulation. So the periods have stopped for a while, and the ovaries really have become senescent, which is not a word I like kind of retired, retired.
Dr Lucy Burns (15:33) So they're finished?
Dr Ceri Cashell (15:36) Well, the healthy postmenopausal ovary I think, should still check out some testosterone, but it can't make it into eostrogen anymore. So they're still doing the job. Because we know women who have their ovaries removed do tend to suffer worse health consequences, even if it's done at a normal age of menopause. So yes, bloods after menopause, again, is to check for the other, and certainly to keep an eye on things like cardiovascular risk factors. But also we can see they do confirm that you are menopausal, but it's not really recommended because if a woman is over the age of 45, and her periods have stopped, then that's there. She said very much in the normal age range of menopause. But the problem is our guidelines confused doctors. So they say that women under the age of 45 should have blood tests to confirm menopause. And we've missed therefore the nuance that women under 45 or under 40 are under 35, and so on. If they're in perimenopause, it doesn't matter what age they are, their bloods will still be normal. So that guideline, I think, has misled doctors a bit. So it's really important that we diagnose early menopause or primary ovarian insufficiency, which is women who go into menopause under the age of 45, or under 40. But if they're in perimenopausal, excess blood tests will still be normal.
Dr Lucy Burns (16:47) So for our listeners to make it really clear, how do you diagnose perimenopause?
Dr Ceri Cashell (16:53) So it goes back to one of the best investigative tools that we have, which are the two big floppy things that sit on side of either side of our head. So just listening, just you know, that's the way we, I had a brilliant GP training and really taught that you know, 90% of your diagnosis is just in the history taken. And history taking, you know, can be a bit of a challenge for me, because I do like to talk. So really, just sitting there keeping your mouth shut and just letting the person talk. You know, and, and so many women will say, you know, I think it might be my hormones, you know, but if you just let them talk, you'll often see all these different symptoms. And yes, there are usually a lot of social factors in a woman's life, when she's going into perimenopause that you could think well, maybe you're just doing too much. But I think if you listen, you can hear the story. And that's and I think that's something we need to go back to the basics and just sit there shut up and let the patient sort of lead. You know, the consultation.
Dr Lucy Burns (17:55) Yeah, absolutely. And I know, there are lots of checklists out there, and we've created one for our website to again that people can download and, you know, fill in and go, yep, I'd have this, I have this, I have this. I don't have that. I haven't got that, but I've got this and this is a little bit not much. And so I think if women can take this checklist to their doctors, and then they've got sort of a framework to work with and go, well, these are all the symptoms I'm experiencing. And I know that you know, each one individually again, you know, isn't necessarily diagnostic, but when you look at it as a whole, it becomes pretty clear what's going on. Absolutely.
Dr Ceri Cashell (18:33) And I think it's very persuasive. You know, I mean, I obviously because I am so hormone focus, like if those checks to exit and do those checkers with women because still a lot of lot of women haven't considered their hormones, they think it is stress. But for the women who have thought maybe it is my hormones coming in with one of those symptom checkers with the word menopause branded across the top, as a nice, gentle nudge to the doctor to think well, somebody else has made one of these, these checklists. Maybe there's something that you know, this woman clearly hasn't isn't making it up. So think it can really help nudge a doctor that maybe isn't so perimenopause, trained and which most of us aren't, you know, because we had all of us had zero training and perimenopause and just, you know, lip service training and menopause and it was really just that your period stopped and you got some sweats and flushes and none of us were taught anything really about the cycle. I certainly wasn't told about psychological symptoms of perimenopause or neurological symptoms, or indeed that every single cell in the body had eostrogen receptors and I think that was already well-established knowledge back in the 90s. But it just seemed to exist in the shop.
Dr Lucy Burns (19:40) Yeah, I had no idea either and it only came to me. I did a talk quite a few years ago now for Low Carb Down Under on Menopause. And so I was doing my research I go – Oh my god, this eostrogen receptors everywhere and you know, you go through every system brain, you know, musculoskeletal cardiovascular, as you've said, gut, an eostrogen input tequila is so protective. It's such a great hormone. Like I tell people, you're gonna love eostrogen by the end of this, like, Who wouldn't want to have eostrogen as their best friend, and then it just runs off and disappears. It's like, Oh, yeah.
Dr Ceri Cashell (20:15) You know, so all you know, and I'm a huge advocate of lifestyle as well, you know, I've certainly I think, you know, threw everything at it. I do worry for people who really focus on the lifestyle only because we know there's better return you know, with weightlifting, if you've got a little bit of eostrogen running in there, you'll get more muscle, you know, return and you know, all the nutrition in the world, I'm not sure you can eat your way back to eostrogen. Because if you could, we wouldn't need ovaries in the first place, you know. So we do need a wee bit of everything there. And I've gone on a wee bit of a deep dive into, you know, the whole why. Why have we demonised eostrogen so much. And I do think that women were getting a wee bit out of control back in the 90s. And somebody decided that we needed to be put back in a box. And suddenly, we had a big, we had a big trial that came out and said eostrogen was you know, was the devil's work. And women were scared off for you know, the next 22 years. So it's been hard to work to run that back.
Dr Lucy Burns (21:14) Yeah, absolutely. Women and doctors, obviously. So doctors are the, you know, the gatekeepers of HRT, and yeah, we, were all told that we've done a huge disservice to women by giving them HRT, and that, you know, we're responsible for killing them with cardiovascular complications. And so everyone went– Oh, you know, that's not what I signed up for, so stopped.
Dr Ceri Cashell (21:36) Yeah, no, my mum, my mum was a GP. So she's 25 years older than me. So she remembers that coming out, you know, when she was and she would have been a menopausal woman herself at that point, and saying how awful they felt that they'd been prescribing less awful drugs. And doctors just do we're just humans as well. And we do tend to hold on to bad news, like anybody else. And it's very hard to undo those, you know, those negative sort of stories where like our brain, wait, we're scared of hurting people.
Dr Lucy Burns (22:05) Oh, of course. But I think also that, you know, there's been some evolution in the way we can prescribe eostrogen in particular and progesterone actually, which have made it therefore, the people that were affected by oral eostrogens, and synthetic a students had can now take it in a different format. So that's super helpful.
Dr Ceri Cashell (22:26) Yeah, so I think so yeah. So our new type of hormone therapy, whether you call it menopause, hormone therapy, or hormone replacement therapy, or just hormone therapy, or just sweet potato juice, I call it because it's made from the yams. And that is the closest thing to plant-based medicine that we have. So yeah, so we know I tend to prescribe I keep my toolbox really simple because it works for the majority of women. And that would be a Estradiol, which is the good eostrogen, the anti-inflammatory, buttery, sparing eostrogen and as a patch, or a gel, mostly a gel because you can't get patches for love or money. And so that goes in in through the skin. And when something goes through the skin, it bypasses the liver. And without going over a technical, it means that women who might have an increased risk of blood clots, you know, whether they've had a history of one or a family history or a clotting tendency, they can still have eostrogen. And you know, it is really safe and SCFM woman with a history of heart disease, that really makes the eostrogen as safe as it can be by going through the skin, although some women do have a real shock or they don't absorb it, and that they can be difficult. So there is because it's quite complicated how drugs get in through the skin. So we need a wee bit more work in that area. But the majority of women tolerate the gel or the patch pretty well. And the eostrorate, the big change was the change to have the progestogen and the progestogen has largely been they're really playing second fiddle to eostrogen and considered to only protect the lining of the womb for when people who still have a womb at the time of menopause or perimenopause, and because some people have had a hysterectomy, but it actually does a lot more than just protect the womb. So natural progesterone is like nature's anti-anxiety and sedative drug that works on the same receptors that volume does, you know, and it gives women beautiful normal sleep not all women but you know, a great number of women. And they've done studies and they've shown that, unlike Valium, you actually maintain your normal cycling of sleep, you get your dream stages and everything and it's certainly you know, part of why women really love their hormones because they sleep and if you sleep everything is better. Yeah, so there's so yes or progesterone. We have to give it orally though. You can't give it through the skin because you just don't get enough to get into the womb. Some women you know who've had a hysterectomy do not want to have progesterone or don't need to have it the eostrogen does enough. But some women even those who've had a hysterectomy can have progesterone to help their sleep. You can have a Marina which also keeps the Marina's progestogen IUD. So it's a coil that sits inside the womb and has a very low dose of synthetic progestogen. So it's still very, very See if and doubles up by controlling the nightmare-heavy periods that many women get. And peri also works as a contraceptive if you're, if you're in a heterosexual relationship, and your partner doesn't want to have a vasectomy, which is still my number one choice for contraception and perimenopause has gotten duelists no risk to women. And, but you can have, you can have a Marina and you're gonna have oral progesterone on top, you know if you want for your mood and your anxiety. So those are the sort of things that are wee bit out of guidelines, but can make women feel quite, quite nice.
Dr Lucy Burns (25:30) It's interesting, just back to the progesterone because I'm a little bit nervous about progesterone in some ways, because of its effect on increasing insulin resistance. And we see this just in your standard cycle like when people are not taking hormones, just their normal natural menstrual cycle, they have a temporary increase in insulin resistance in that premenstrual phase. And so I've always been a little bit wary of prescribing progesterone if they don't need it, like if they've as in they don't need it for womb or uterus protection. But I guess it's imbalanced, isn't it? Because if you're not sleeping, we know that poor sleep increases insulin resistance as well. So, therefore, if we can improve sleep, then we will improve insulin resistance. And so like everything, I think there's always nuance, isn't there?
Dr Ceri Cashell (26:24) Yeah, I think that's and I sort of feel, yeah, and I wasn't aware of the increasing insulin resistance thing. But I wonder if when you're giving it more in that sort of top-level if it actually is at the chip, I think there's so much in that premenstrual phase that's more about rapidly changing levels, rather than the absolute levels. Like I wonder almost given progesterone if we actually studied. Oh, that second half, would you see a bit of an improvement in insulin sensitivity? I think that's what's really interesting is when a woman that you obviously have bad PMT, you know, they tend to get you know, they get cravings, and they overeat. And you know, all sorts of weird things happen, which are clearly hormone-mediated. But yet, if you give them progesterone and eostrogen, all of that goes away. And I just yeah, I think yeah, I think there's some wonderful research that could be done there. That might be quite exciting.
Dr Lucy Burns (27:14) Yeah, absolutely. And again, it's that the hallmark has always been for me noticing people with type one diabetes, their glucose control, is often more brittle or up and down in that premenstrual phase. And yeah, I agree. There's definitely room for some research there by someone way cleverer than me.
Dr Ceri Cashell (27:35) Yeah. That probably fits into all the women who get premenstrual epilepsy and all of those. Yeah, there's a lot of stuff and they've got, there's hardly any data. And I'm thinking this is huge, like, these are women that live a quarter of their life with increased risk of, you know, diabetes complications, or serious epileptic fits, you know, come on.
Dr Lucy Burns (27:54) Yeah, absolutely. And I know we're going to be talking further about this in the future on mood disorder, but also, all the things that happen in that premenstrual period, migraines, everything like it's yeah, it's your hormones, baby. It's your hormones and then you touched a little bit on testosterone. And I know that's controversial at the moment, for many reasons, but I thought we would spend some time talking about it, and how you use it and when it's appropriate, and when it's maybe not appropriate. What are your thoughts?
Dr Ceri Cashell (28:22) Yeah, So testosterone was, as I say, that was the new one to me, although I was quite excited to find a letter that had been sent back 11 years ago to the menopause clinic asking if they would consider it for somebody with low libido. So there's been a lot of research, you know, really driven by people in Australia, and we are the only country in the world that has a licensed product testosterone product for women, so that's pretty cool. But it's only licensed for a hypoactive sexual desire disorder, which is a long way of saying reduced libido, for no other cause than just reduced libido, you know, which can't be caused by illness or drugs. So I, after listening to Louise Newson, and quite a few other thought leaders and doctors who are doctors in the menopause space, started to think a little bit outside the box like they do. And I've started to prescribe it for reasons other than reduced libido. And I find it can be an absolute game-changer for women who have persistent cognitive symptoms. So reduced memory or brain fog or verbal fluency also does seem to help mood and can really stabilise mood and also has an effect on pain and, you know, certainly joint pain. There is some good data showing that improves bone density, there is evidence that it stabilises the lining of the womb. So I wonder how many of those women with heavy periods actually have low testosterone? There's evidence that it stabilises breast tissue, and there's evidence that it's anti-inflammatory and liquid in our joints and the joint matrix. So it does have good evidence for sexual desire and dysfunction but I would say the effects on libido are probably the most underwhelming and what's overwhelming as women just go in. Yes, I feel back to myself, you know, not necessarily Beto. I think sex drive and relationships that are so complicated, you know, and that does require a lot of work. You know, you need to know, it's hard and midlife, certainly when most women are in perimenopause and menopause deprioritise sex because you're doing 7000 other things women need, women need hours of foreplay, whereas we expect to get ready in two seconds. You know, and if you think back to when you were a teenager, or you know, in your early 20s, you know, you shaved your legs for a club and got your nails done, you know, and how do we dance around your bedroom, there is ours of sort of psychological foreplay going on. Yeah, time for that. It's not just that we're older, it's just we're so much busier. But you have to testosterone, I really have seen it in some women, absolutely. Not all women, some women do not notice any difference at all. And that is probably not hugely linked to their levels. So some women have undetectable testosterone. And that's partly because our assays are not good enough for women. So they're still very much based on testing for men. But where it works, it can be really great. It can be good for younger perimenopausal women. And I also use it for an older postmenopausal woman. And so I do start HRT and women over the age of 60, and even older, and because when you start HRT at that past menopause, it can trigger some vaginal bleeding, which might take a couple of months to settle. Those older women really don't like that. Some of them really don't like that. And testosterone can actually seem to work to do most of the symptoms, give them their sleep, give them a wee bit of extra energy, you know, I've got women in their late 70s, who are back at the gym lifting weights, I'm just, that's just, that's what I want. I want these women to be able to move and you know, live their best lives. So yeah, testosterone has definitely got much more effect than just reduced libido. And it definitely does not always work for libido. And it definitely does not work for everybody.
Dr Lucy Burns (32:04) And then what are the concerns with that, though? Because obviously there are these, you know, people worried about it, what are their worries.
Dr Ceri Cashell (32:11) So that the worries would be that if you're replacing too much testosterone you might cause and so if you're moving out of a woman's natural range, although we don't have a huge amount of data on what the natural ranges, so I try and keep it reasonably close to the levels that I would see, which is a range of two to 3%. So the concern would be that your voice might change, and it will change. I think once you hit levels of about six, and we see that in gender-affirming care, your clitoris can become enlarged, and that is irreversible. And that will happen. I think that level of like between six and 10, you can start to get increased hair. But this is all in levels that are above a woman's normal range. So most of us are giving testosterone to women, you know, if we're doing it responsibly, we're watching the levels every three months, and checking that it stays in the female range. And it shouldn't cause anything like that. The side effects can be getting a bit of oily skin, you can get some spots, and some women do see a little bit of hair loss, but it's usually temporary. In general, I would say it either works or it doesn't. It rarely causes side effects actually has a lot less side effects than eostrogen and progesterone, and it tends to cause a lot of water retention. And it works really slowly. So it tends to build up in this system over about six months, and you either notice something or you notice nothing at all, that would be my experience.
Dr Lucy Burns (33:27) Absolutely. I love that. So honestly, yeah. So people making sure and again, women, if you've been prescribed it, make sure you get your levels checked and don't overuse it. Yeah, like everything more is not always better.
Dr Ceri Cashell (33:38) Correct. Definitely not.
Dr Lucy Burns (33:40) So I love that. And I love the idea that again, we, you know, I know we had a chat about this. It's not lifestyle only and it's not hormones, only. It's the combination for many women that is where the synergy happens. So yes, you can do lifestyle. And yes, you can have hormones, but when you add them together, they multiply the benefits. And the tricky thing I think is for women who have had breast cancer, and I wonder what your thoughts are for them because I feel like we're all now going on about– oh my god hormones are gonna fix you and make your life amazing. Oh, you can't have them. Sorry about that.
Dr Ceri Cashell (34:17) Yeah, no, I think that's what's so important. And I do think this is an area that we just really need a huge amount more research. And again another surprise to me or shock to me really is when you look at the data and hormones and women who have a history of breast cancer. The research is extremely mixed, and overall actually favours being safe. So there's 25 studies looking at hormone therapy and women with a history of breast cancer, and only one of the 25 studies showed an increase in recurrence. In that one study when they recruited the woman to come into the study. They didn't do a baseline mammogram and the recurrences all appeared within 18 months and breast cancer doesn't develop that quickly. So breast cancer takes years to develop. So it's likely they had a little small recurrent sitting there. And it grew. And even in that one study, when they followed them up for the next 10 years, there was no increased risk of dying from breast cancer. So I think this is an area that we really need to get our breast cancer doctors or oncology doctors to start looking a bit more holistically at women. And I think it's a very individualised discussion. You know, I see women who have had a history of breast cancer, who really feel their life isn't worth living, because of the level of joint pain, or the anxiety or the insomnia. And they've already tried, you know, seven drugs to treat their, you know, 40 symptoms, and they just say, well, I want to know if hormone therapy would make me feel better. And then I can decide if I want to go with it, knowing that we don't know everything that we need to know. But I want to make that decision based on how I feel so and I really very much believe that that's the woman's decision to make, you know if she wants to live the next five years as well as she can, but no, there's a small increased risk of breast cancer. Maybe, then that's her decision. But I don't think it's my job to say, No, I think you know, most women are very able to make these decisions themselves. And I don't think it's my job to forbid them something that we know is going to reduce the risk of heart disease, dementia, osteoporosis, bowel cancer, but I know, we don't know what it says about breast cancer. But we have a reasonable bit of data there that suggests that it's safe. And I think anybody that's listening to this, that, you know, has their interest piqued, should read out from Bloomingburg Eostrogen Matters, which is just phenomenal. You know, he's a breast oncologist, who has really done a complete about fears about, you know, high eostrogen doesn't maybe cause breast cancer. So I think that's, there's definitely, you know, so much that we need, and it's just in the male space, we thought testosterone calls for prostate cancer, and they're currently doing a trial using testosterone to treat prostate cancer. So I'm hoping that you know, in five years, we'll have more trials using eostrogen to treat breast cancer. We do have one running at the minute, but I would love to see more of that.
Dr Lucy Burns (37:13) Yeah, absolutely. And in fact, there was that trial that just paper recently published that showed that women who were using just eostrogen so again, they've had a hysterectomy, so they don't need the progesterone protection, just eostrogen have a reduced risk of breast cancer. And I love that I'm thinking right. So what that signals to me is that there's clearly more to this picture than we know.
Dr Ceri Cashell (37:36) Yeah, absolutely. I mean, I don't see how something can reduce the risk of breast cancer, but simultaneously cause it, I think there is definitely nuance in there. And there's, you know, that we know, there are things that do increase a woman's risk of breast cancer, and it's really important and this often becomes a wee bit of a battle between hormone therapy and breast cancer. And it shouldn't be it's about the health of all women and all of women's health, for breast cancer is really important. And it's really important that women do self-examine and do get screened. But it's equally important that those women get informed, you know, consent about treatment and options for menopause. And I don't think that's happening at the minute.
Dr Lucy Burns (38:13) No, absolutely. And I think that in the space that I work in, we know that metabolic syndrome, which is often the symptom that people present with metabolic syndrome or obesity, and we know increases breast cancer by miles more than eostrogen replacement seems to so it's like we're missing the big picture.
Dr Ceri Cashell (38:35) I can't see like, you know, if you're because a lot of women get terrible joint pain, and especially on the treatment. I think, well, maybe if those women had a little bit less pain and a bit more energy, and we're at the gym and eating well, and sleeping well, I kind of feel that even if there is an increased risk of breast cancer, it's still going to be negated by all of those other benefits, you know. but I can't see how I Estradiol I think eostrogen, which is a more inflammatory eostrogen, I can't see how Estradiol controls are a little cells, and you know, turns off, you know, bad cells high, it can cause cancer, it just doesn't make sense. It might make things grow that are already there. And I think that's why cancers do appear on the HRT maybe more quickly, but I don't think it starts the cancer cells.
Dr Lucy Burns (39:14) Yes, so interesting. It's so interesting. I'm just excited because I just think, you know, watch this space, ladies watch this space, there's more coming for us that, you know, again, it gives us options, that's what we want is choice, options, and, you know, education so that people can make informed decisions.
Dr Ceri Cashell (39:32) Absolutely. I think, you know, it's really we've been too much sort of in this power dynamic that doesn't favour the individual and I think you know, in, in medicine, it should be a partnership, you know, a shared decision making, whereas, yes, I can go off and interpret information but if you're going to bring me stuff and say what about this doctor, I should be listening to you because it's your body. And you know, and you are the expert about your body. I might know a bit more medicine but you definitely know more about you than I do.
Dr Lucy Burns (39:59) Absolutely. Lately, I love that. So Ceri, if people want to follow you, and connect with you, where do they find yo, what's the best place?
Dr Ceri Cashell (40:06) Yeah, so I currently live far too much of my life on social media these days and imaginatively named Dr. Ceri Cashell on Instagram and also Dr. Ceri Cashell on LinkedIn. But we are launching menopause education platform for doctors and hope to make it patient-facing in the next few months so that women can get that knowledge there too. And that's healthyhormones.au So that's exciting.
Dr Lucy Burns (40:31) That is it's very exciting. And listeners Ceri is as you can hear from her accent Irish so she has an Irish way of spelling Ceri, which is C E R I. Before I spoke to Ceri, I looked there going is it Cheri is very well how do we pronounce this but it's just Ceri. So yeah, Dr. Ceri Cashell - C E R I. lovelies, we will have all of the links in the show notes, including our menopause checklist if you want to go and check it out. Or you can just go to our website, rlmedicine.com/checklist. And that will give you all the things that you need to know because we want you to feel empowered and be able to have open and frank conversations with your doctor about your symptoms. And then the two of you can decide the best treatment going forward. Ceri, this has been delightful. I've been so inspired by your knowledge and hope that our listeners have found great value in what you've offered today and I'm looking forward to our other talk coming up in the menopause series on PMDD, which is Premenstrual Dysphoric Disorder, I think is the way we pronounce it and we've got lots more goodness coming your way.
Dr Ceri Cashell (41:43) Thank you very much.
Dr Lucy Burns (41:44) All right, lovelies, have a beautiful week and I will talk to you all next week. Bye for now.
Dr Lucy Burns (41:52) The information shared on the Real Health and Weight Loss Podcast, including show notes and links, provides general information only. It is not a substitute, nor is it intended to provide individualised medical advice, diagnosis or treatment, nor can it be construed as such. Please consult your doctor for any medical concerns.
