Episode 2: Menopause

TRANSCRIPT

Speakers: Mr. Vikram Talaulikar, Olivia Moir

00:00:02 Olivia 

Hello everyone and welcome back to It All Starts Here, a podcast focusing on the communication and education of topics in reproductive science and Women's Health. I am your host, Olivia Moir, and we are back here today to talk about menopause. We are going to be diving into the basics on what it is and what to expect, and then some ideas on how to optimize lifestyle in this stage, as well as various, sometimes, conflicting views on treatment and management options for individuals going through menopause. 

00:00:36 Olivia 

And to do this I have none other than a certified British Menopause society menopause specialist, Mr. Vikram Talaulikar, who is coming to us with a strong clinical background as an associate specialist at the Reproductive Medicine Unit at UCLH and an honorary associate professor here at UCL. 

00:00:58 Olivia 

It is a pleasure to have you with me today, Vikram, and I think to start us off, why don't we hear a bit about your background and of course, where it all started for you? 

00:01:07 Vikram 

So thank you, Olivia, first of all, for having me today and including a topic like menopause in one of your podcasts. For me it all started really around 2013. So I was a gynecologist before, I trained in India. I did my MD in India, then came over to UK around 2009. Then I did exams here and some training here. But it really kind of took off from menopause perspective around 2013/14 when I joined the clinic at UCLH. And what I realized was that there was so little research done in the field and you probably hear this with many things related to Women's Health. But menopause particularly was very poorly researched. 

So gynecologists do a lot of good work in terms of fibroids, heavy bleeding, menorrhagia, endometriosis. 

But menopause is usually never formally properly taught, whether for medical students or whether, as postgraduates in gynecology. So a lot of gynecologists may not be up to date with what is out there in terms of menopause help, and that's where the interest got sort of first into my mind as to focusing on menopause. 

And then in the last 10 years, it's been a long journey in kind of developing the clinic more at UCLH, and doing a lot of research related to menopause. 

00:02:30 Olivia 

That's amazing and I can't wait to talk more about this. I mean, as you said, it's true with Women's Health, there's a lot of things that people say are not probably researched, well, definitely not researched enough. 

So I look forward to talking about this today. It's such a pleasure to have you with me, Vikram. And I think to start us off, why don't we hear and dive into: what is menopause broadly. 

00:02:56 Vikram 

Well, menopause is when a woman stops her periods for 12 months and that's the easy technical definition. 

But menopause is not same for everyone, and that's why it's often difficult to kind of put it into that one bracket of not having periods for 12 months. So most women, as they go through their reproductive journey through their life as they come to midlife after 45, at some point we'll stop, periods. 

And when it happens for more than 12 months, technically it is thought that the individual has gone through menopause and then the post-menopausal phase begins. But that varies from one person to another. So while most women will do that between 45 to 55, which is a very broad range, others may have menopause much earlier - they will stop periods between 40 to 45 and they often say that's early menopause, which will happen to 10% of women. 

1% to 2% will stop periods before the age of 40, and so that's premature menopause. And it's never too young to be going through menopause. The important message there is there are women, individuals, who even just before or after puberty in their 20s and 30s may be unlucky to go through menopause so it can happen very, very early and diagnosing it at that point and not dismissing symptoms is really important. 

00:04:24 Olivia 

Got it. Yeah, I think, I mean, I'm sure that everyone at one point or another has heard about menopause and what that means, I guess mainly people understand that that means that women you know are no longer of reproductive age. And I think that's something that's really focused on and and it kind of feels like we all skim over everything else that's associated with that and the different changes that can happen and I guess something that feels like a really common topic within the community of people that are experiencing the menopause is you know: w What can we expect? It's sort of like we don't talk about it. So should we prepare for this and and and what's going on. And yeah, I guess what can be expected in this? How would you advise someone maybe entering into that period of life? 

00:05:19 Vikram 

As you rightly said, it's not talked about often and that often creates confusion, mixed messaging for people. 

With menopause, what we know is going to happen is a woman is no longer is going to release an egg every month as the eggs decline in the ovaries and they get to so, low numbers less than 1000. Often the hormone production from ovaries will stop. So there's less estrogen coming. There's less testosterone coming. There's almost no progesterone coming as a woman will go through from pre menopause to perimenopause and menopause. Before the periods actually stop, tere may be two to five years when the hormones will be up and down, up and down. So some days estrogen will be good, other days it won't be enough. 

And so women will often have a fluctuation of their periods irregularity and the symptoms which I'll describe in a minute, and all those fluctuations may happen for two, five years, sometimes even 10 years before periods completely stop. 

00:06:17 Vikram 

Now what symptoms to expect? Some women will be lucky will have no symptoms at all, or minimal symptoms which often don't affect them on a day-to-day basis. 

00:06:26 Vikram 

But about 70 to 80% will have some or other significant symptoms, so that's quite a lot of people. 

And out of those 70%-80%, about one third, 30% will have severe symptoms, which will actually significantly impact their quality of life and how they go about their daily routine.  

Now, symptoms can vary from one person to another, from head to toe, so you can have headaches, you can have hair loss. You can have dry skin, you can have acne or excess hair growth you can have joint pains. Migraines may be triggered. The classical ones we talk about are hot flashes and night sweats, which make it difficult even to sleep at night. Sleep becomes disturbed, mood is another one that's often not talked about. So there's drop in mood, increase anxiety, palpitations there may be fluctuation of mood. A lot of anger at this point or irritation. 

00:07:23 Vikram 

Then you can have other symptoms such as the vulva-vaginal symptoms, vaginal dryness, bladder symptoms, frequency of urination, painful intercourse.  

So these are just the the most important ones I have highlighted, but there are up to 30-35 symptoms now which are attributed to menopausal transition as such. 

00:07:45 Olivia 

Interesting. Yeah, I think you hear that, you know it, it ranges. I mean, as does everything in life and it's so important to acknowledge that like everyone experiences their own thing and and their own journey with different health conditions and syndromes and periods of life, but I guess some a common question as well is like when you're entering into that phase, whether it's pre menopause or after menopause or you know right in the heat of the moment, are there certain things that women can do to optimize their lifestyle? 

Or certain things that you recommend, certain things that are proven or maybe just speculation on it. What can be done maybe by the person experiencing it. 

00:08:32 Vikram 

There are a number of things you can do, and we'll talk about the lifestyle ones first before I guess moving on to medical strategies in lifestyle generally it's about optimizing to minimize symptoms. So for example, what you wear in terms of clothing, easy to kind of layered, something which is easy to take off one at a time. Fabrics which don't cause a lot of heat, for example, are useful if someone is having lots of hot flushes. 

This then making sure you have good access to hydration, drinking plenty of fluids because of hot sweats and flushes. Having probably room temperature which is suiting you not too hot, not too cold, the right temperature, especially at work where women will often be busy working the whole day and not notice that they're actually not having a good room temperature that's helping their symptoms. 

00:09:24 Vikram 

Other bits is general health advice, so no smoking. Making sure that you have alcohol in moderation because alcohol can trigger flushes as some women have flushes triggered by spicy foods, so avoiding that as a practical tip, then exercise is really, really important. Not only it helps reduce symptom, but also protects bones, which is probably what we'll talk about in a minute. But protecting bones and heart through regular exercise at least 150 minutes a week, eating healthy Mediterranean diet. Some women find that if they have increasing of soy or some phytoestrogens, tofu, soys, lentils, cereals often may give a weak estrogen like action and sometimes helps with mild symptoms. So all those would be practical lifestyle sort of options to consider to try any symptoms before you consider medical interventions. 

00:10:20 Olivia 

Interesting. And then if we're moving out of that and then into treatment with medical kind of things, one thing that you hear a lot of buzz about is HRT and a conversation that we had, which I thought was, I don't know, you know, certain things stick with you. And you said it's not that it's good or bad. It's just that it depends on you. It depends on what you're experiencing and and your background. And I wonder if you could talk more about that, just you know, as I said, I've I've heard you know it very much in the context of it being either good or bad. And I think maybe if we could explore HRT and you know for those listening that maybe haven't heard of it a bit on what that is would be helpful. 

00:11:04 Vikram 

So HRT happens to be one of the medical interventions. This is mainly to address menopause symptoms. It remains the most effective medical intervention as compared to anything else. And again, as you rightly pointed out, it's a personal choice. It's a medication you consider based on your medical background and what you feel you should be doing right for you hurt simply means giving back estrogen, progesterone, testosterone, either one on its own or it's a combination of two or three hormones. And the aim is to give back the hormones to the body so that it doesn't feel that it's having the symptoms due to the lack of hormones. 

00:11:45 Vikram 

It probably is the most controversial medicine over the years or decades, and that goes partly back to around 20 years ago, so HRT has been in use for about 50-60 years at least. It was very popular around the end of last century. But around 2001, 2003, there were two big study results published, one from us called WHI Study, which was a randomized trial and an observational study in UK called Million Women Study. And both those studies came up with headlines in the media, that suggested that HRT is not good for you. It can cause stroke, heart disease and it can cause breast cancer. And that's when panic sat in, abd a lot of women were denied HRT, health professionals became hesitant to prescribe HRT for the shortest possible time. 

But actually it was probably a bit of exagerration, because subsequent studies that happened after as well as re looking at some of the results of these two studies, people realised that the risks had been exaggerated. 

So for an average woman going through menopause, around 45 to 55, taking some of the hormones we use now, which are more body identical and safer, the benefits far outweigh risks. Yes, there are some risks associated, such as blood clotting or breast cancer or wound cancer, but there are ways to minimize those risks. 

And the risks are very small in comparison to the benefits for symptoms, for bone, for heart, for brain, that we often attribute to HRT. So the advice would be, if you are somebody going through menopause and finding it difficult to cope with symptoms. You've tried lifestyle options - they're not enough for you, the next step would be go to your trusted healthcare professional and have a very clear discussion about what it means if you took HRT, the benefits, the risks. 

And then you make a personal, informed choice on what's right for you. 

00:13:52 Olivia 

It was so well laid out, I feel like myself more prepared for that stage of my life when that comes not for a while, hopefully, but yeah, that was really well laid out and I think something that comes to mind as you were talking about it is, tt's hard to treat, you know, not just Women's Health conditions and things going on, but anyones like it can be hard because you don't know necessarily what's going on and people don't know how to communicate on it and it's not that they're they don't want to, it's just it can be hard to find the language. And I think something in this field that I I'm curious about is what are the challenges with treating symptoms around the menopause? Like what is a challenge maybe for a healthcare provider, or maybe from the perspective of a patient that someone might be facing. 

00:14:45 Vikram 

I think there are a number of barriers for patients to access good care. So currently for example, because menopause has recently been looked at with the seriousness it deserves, people are getting updated through training to know what's the latest with HRT/non HRT options for menopause. 

Still there are loads and loads of healthcare professionals out there who may not be up to date, so women often don't get the right advice at their first consultation, for example. 

We don't have a lot of research in, say, ethnic minorities or trans populations, and often these are underserved. They will not be able to easily go and have a consultation unique to them. The language barriers exist. The cultural sensitivities are very strong in the field of menopause. And so for all these barriers, often we don't have the universal evidence based clear menopause advice given to individuals across the country, or even across the world. 

00:15:43 Vikram 

From health care professional perspective, there is so much that's happened in the last two decades. You really need to be training yourself, attending courses, accessing information out there because some of the bits that we talk about HRT or how perimenopause menopause evolves, it's outdated information. If you read it 20 years ago. 

A lot has changed in two decades, so if you have not kept up to it, then you might not be giving the right advice to your patients or women out there. 

00:16:14 Vikram 

And also it's important to be responsible. So although we've done so much good work in the 2D kits to know symptoms, to empower women to ask for HRTor non HRT help, it's equally important not to go overboard. So you should never underplay some of the risks associated with HRT. At the same time, not exaggerate those risks and strike the right balance. Not every woman wants or wishes to take HRT. Some can't take it for medical reasons. And there are lots of non HRT options, new medications which are coming in as well as lifestyle options. So discussing both and allowing choice is important. It's not only about HRT but at the same time somebody who is going to benefit from HRT, it shouldn't be denied for wrong reasons or exaggeration risk should not happen. 

00:17:05 Vikram 

Just a quick example would be women with premature menopause, early menopause or surgical menopause - when the ovaries are removed overnight, you go into menopause. These can be quite strong in terms of symptoms in terms of persistence of problems, the impact on bone heart is much stronger because it happens so early. There are fertility implication, so really trying your best as a healthcare professional to diagnose this early, refer quickly get the right advice, that is the key, that always doesn't happen right now, but hopefully we are moving in the right direction. 

00:17:42 Olivia 

That's so interesting. And I guess something that I wonder as well, like from your practice specifically and as a menopause specialist, do you find that there are certain misconceptions that patients will have when they come to see you and or you know, are there common things that you know come up that you have noticed and maybe they guide your research in this field. What do you think is currently something that you're focusing on within relation to menopause or your practice everyday? 

00:18:16 Vikram 

Well, there are many, many things I could talk about them forever, but I think some of the misconceptions which always come up are, for example HRT causes breast cancer. It's such a common one. It's one of the commonest reasons why women hesitate to take HRT or doctors hesitate to prescribe. I think we've come a long way to establish that HRT, at least in the modern safer versions, have very little risk of breast cancer, and if you take one hormone, almost no risk of breast cancer risk compared to combined HRT. 

00:18:48 Vikram 

So a lot of women may be suffering thinking that I'll get breast cancer by using HRT- that's not necessarily true. So getting that message out there, then a lot of women feel embarrassed to talk about vaginal health or genital urinary symptom. So again, getting the misconception out that vaginal estrogen will be very safe for your bladder health for preventing UTI for sexual health, and there's no there shouldn't be any embarrassment to talk about it. It's another physiological process that's happening. So these sort of messages which get hidden are the ones that we need to keep readdressing in the clinics and clearing the myths. 

00:19:29 Olivia 

Yeah, it's so important. And you know, as you said, it's a really hard subject to bring up. I think a lot of people struggle with anything related to that, including myself, like it can be very challenging, you know, when talking about yourself to a health practitioner. So you know, I think it's important to think about how we can make that easier. Maybe going forwards? I mean, I'm sure that there's a whole body of work that we could talk about that probably focuses on exactly that.  

Something that I that just came to mind as as well like after the menopause. I mean something that I've heard about in different talks that I've listened to with relation to the menopause is it's sort of like a new beginning or women sort of feel like their life is really happening. And you know, for the first time, it's like all this mental clarity and you know, it's interesting to me because definitely like, you know, when you're on your period and you're going through your cycle like women talk about it more and more today. And I'm very grateful because  you experienced such a fluctuation throughout the month depending on your hormones depending what's going on, you know within and it influences how you act and how you are of course. And so I guess I'm I'm curious like is this true and when you're finished, going through menopause is that is there people studying that? Is that something that we're researching? 

00:20:58 Vikram 

Yes, we're researching it now, but haven't done justice to it before. And again it's individual. I think every woman's menopause experience is unique. Every individual's journey is unique. And there are a lot of women who find that once they don't have to worry about periods, the pain, the bleeding, they don't have to worry about contraception or pregnancies. And it's a time of life that many women will be reaching a senior role in their careers. And sometimes you have children have gone away and you have a lot more time for yourself ,and so a lot of women in the clinic share that experience and say this has been the best time of their life. They're able to do something, pursue things which they couldn't think of before because life was so busy. But this is a very good time in their life. But they don't have to think about physical issues and concentrate on what they like.  

But it's individual, though, and there may be others who might have a difficult transition and might need medical support to take them through and make them feel as good as some of the individuals who don't need the medical support. 

00:22:01 Vikram 

So all I would say is one day that time will come when we will be able to support each and every individual with the information, with medical options, so that everyone feels this is the best, last 30-40 years of their life. 

00:22:15 Olivia 

That's amazing. That's so good to hear. And I think what a great way to kind of closeout the episode, I mean, I'm sure we could talk for hours, as you said, about the different things that come up for you and and I'm sure we will again.  

But I'm sure everyone listening feels the same. We appreciate so much hearing from you on this. So thank you. 

00:22:33 Vikram 

Thank you.