Louise Newson: So if we look at the menopause first, even if you just break down the word meno-pause - meno means menstrual cycles, so when we have our periods, and pause obviously means a stop. So with the menopause, you can't officially be menopausal until you've had at least a year since your last period. So actually on that day, a year, since the last period you are menopausal. And after that time, a lot of people say are post-menopausal - so after the menopause.
But a lot of women find that they start to experience menopausal symptoms before their periods stop. And when we talk about this, that, that means these women are peri-menopausal, so peri is a medical term for “around the time of”. A lot of women find their periods start to change a few years before their actual menopause. Sometimes it's a decade before. And so it can be very hard to know that their symptoms are related to the changing hormone levels.

For most women, the menopause is natural and it's just something that happens as we get older because our eggs in our ovaries run out, and the associated hormones decline. For around one in a hundred women under the age of 40, they have an early menopause, and we call this premature ovarian insufficiency.

And it can affect one in a thousand women under the age of 30. So no one's ever too young to be menopausal. My youngest patient is 14, actually. She never had her periods, they never started. And once a woman has gone through the menopause, she'll always be post-menopausal. So she’ll always have low hormones. And it's really important that it's addressed because there are numerous symptoms - which we can talk about - that really affect women. But also there are health risks as well. And because as women we're living longer, we're here to stay longer than we perhaps were a hundred years ago, it's really important that it's addressed and, and acknowledged because women's lives are suffering. Their health is suffering. And actually is having a big impact on global health and the economy as well.
So this is a huge problem that has been sort of pushed under the carpet and not discussed in the right way, I think, for many years, and that has to change.

Claudia von Boeselager: And you're bringing it to light. You touched on a lot of interesting points there. I'd like to start with some of the main symptoms and health effects of the menopause.
Can you talk about that?

Louise Newson: Yeah, absolutely. So the most important hormone for women is estrogen. And when you think we have cells that respond to the hormone estrogen everywhere in our body, there's - I can't think of a cell that doesn't have an estrogen receptor on it. So, when you think about that, then you think, well, actually, what does low estrogen do? Which is what happens, obviously, during the menopause and afterwards. Well, it can affect all these cells, so they don't function as well. So cells in our brain can be affected. So a lot of people find they have memory, concentration problems. They’re feeling more anxious, lower in their mood, reduced self-esteem, poor sleep, poor concentration, apathy. Just less enjoyment of life. And this is because the brain isn't working properly. People can have dry eyes, dry, sore mouth, even have tinnitus. People find often that they have headaches or worsening migraines. Palpitations can occur. People can get muscle and joint pains. People can get urine infections. People can get vaginal dryness sometimes, because estrogen lines the vagina as well. And, obviously, hot flushes and night sweats are very common symptoms, around 75% of women will experience them at some time. But actually those aren't the symptoms that affect people the most. They're not the ones that really affect the way that they live and function.

But then, because estrogen is so important in our bodies, we know that when the hormone levels reduce, then women have these health risks. So there's an increased risk of diseases, such as heart disease, diabetes, osteoporosis, dementia, and even different types of cancer can increase because the hormone estrogen is so critical to the way our bodies function. So it’s quite doom and gloom, actually, being in menopause.

Claudia von Boeselager: That’s quite a long list of symptoms, so all the more important to actually address it early and understand more about it. And one point you also touched on is, you know, why in your view is there's so little information - and obviously you're bringing this more and more to the forefront - but why is this not discussed more? Especially the generation of, sort of, my mother, no one really talked about it.

Louise Newson: I think it's because there's been a lot of misunderstanding. I think for many years, people have just thought that the menopause is due to hot flushes and sweats, and it's something we just need to get through because other generations have. They haven't seen it as a marker for future disease. So I think that's one issue.

I think also for the last 20 years, women, the media, healthcare professionals have been given really inaccurate information about the evidence, about the safety and effectiveness of HRT. So we've all been told that it has risks and it's dangerous. So when you think there's no treatment for something, there's no point talking about it, you might as well just get through it or just survive or soldier on.

Whereas obviously a lot of the work I'm doing is about giving women, and men, evidence-based information, and then they can make the decisions themselves. And, so, I think decision-making has to be done based on the good available evidence, which has been not, available, actually for women and healthcare professionals for many years.

So it's trying to change the narrative, actually, about it is really important.

Claudia von Boeselager: Excellent. I'd like to take a step back and ask you about your journey to becoming a menopause specialist. And why has this been such a passion for you?

Louise Newson: Yeah, it's really interesting, if I'd met you five, six years ago, and you told me that I would be doing menopause 24/7, I would have just laughed and said actually, no, I don't really think so.

And I think it's - the more stories that I hear, the more compelled I am to work harder. And the menopause is one of these things. Someone said to me the other day, actually, once you start to see it, you can't unsee it. And when I started to think about the bigger problems of the menopause and the - all the symptoms - every single woman actually, pretty much, certainly every woman over the age of 40 who used to come and see me in general practice, I would somehow get menopause into the conversation.

And, you know, even one lady once, she just came for quick consultation, she needed a top up of her eczema cream, and she's 52. And I thought, right, let me just see. And I, I said, oh, eczema, yeah, has that got worse recently? Oh yeah. A lot worse. What are your periods like? She said, look, Dr. Newson, please do not talk to me about my periods. I'm here for my eczema cream. And I knew her quite well, so she was laughing. And she said, well, actually they stopped two years ago, my periods. And you're right, my skin has got so much worse. It's very dry. It's very itchy. My eczema has flared up beyond recognition. And then I gave her the symptom questionnaire that we have on our app Balance, and asked her to fill it out.

And she had lots of these symptoms. And I said, but how are they having an impact on you? She said, well, I have given up my job as a lawyer because I just couldn't concentrate, but I thought it was -

Claudia von Boeselager: Wow.

Louise Newson: I'm 50, I'm older and I shouldn't be working this hard. And so anyway, she obviously went out with a prescription of HRT and three months later, she came back and she said, my goodness, me, I'm applying for another job. I had no idea this is related to my hormones. And I was sort of a bit cheeky. I was playing with the consultation cause I knew her well. She knew I was getting an interest in the menopause. But I then thought, wow, I've missed hundreds, if not thousands of patients over the years. You know, even when I was doing an A&E, a casualty job in Manchester, lots of women would come in with dizzy spells, with palpitations, with headaches. I didn't even think about their periods because no one had taught me how important these symptoms are.

So yeah, it's, it's one of those things though, that - I do a lot of work, obviously in my clinic, but then I'm always thinking about how can we reach other women who are disadvantaged? How can we reach women who don't have English as a first language? How do we reach women who maybe can't read or can't access good quality healthcare. And, and it's just such a difficult problem because it affects every woman. No one can hide from it. But we need to reach all women. Everyone should have the same opportunity to receive good quality advice, treatment, and education about their own menopause.

Claudia von Boeselager: Yeah. I love that anecdote that you said as well, really fantastic. And you touched on a few points also about bringing positive change and spreading the word. Maybe you can talk about some of the successes you've had in raising awareness. And you've also created an award-winning app, the Balance app, that I’d love you to talk a bit about as well, to hopefully make information more accessible.

Louise Newson: Yeah, I think when I first decided I wanted to become a menopause specialist and do more work, I went to some conferences, which I go to regularly obviously to keep updated. And I was listening to all these really learned professors thinking, actually, women aren't getting HRT. You're telling me how safe it is, but what's happening? Why aren't they getting it? And so then I started to think women need to actually be given information and how are we going to do this? And, you know, when I graduated after being at medical school, there was no internet. It was really hard to get information. And thankfully, obviously, it's so easy to get information, but it's also so easy to get wrong information.

So I was determined to give women the ability to have proper education, where it wasn't sponsored by anything. I don't work with any pharmaceutical companies. I don't have any endorsements on my website. So I wanted women to have a place where they could go that was safe, and that they got the right information.

So I started to reach women through my website and then I thought, actually, I really want to do it bigger. So I'll try and approach the media because sadly they've been given wrong information and got it wrong. And so, the more media work I've done, the more I've realized how important that is. But also social media is really important. And, one of my daughters taught me how to use Instagram a few years. And now I have this tradition where I post every morning when I wake up. And it has a great following. And it's - it's made me realize then how women can help other women, actually. And I can't do everything, I'm only one person.

So I wanted to create an app, again, to try and reach women. Because a lot more women have phones than the internet sometimes, or I just thought it would be a really useful tool. But it took a lot of time to actually develop and obviously a lot of resources as well. But we found something, I think, that's really special and unique because with the free app Balance, women can monitor their symptoms, they can track their periods, they can report how various treatments have helped or not helped them.

They can be part of a community. And there's a great community already that we really want to expand on. And what I want to do with the app is to enable women to have the right support and information. So they can be really empowered to the point of seeing their healthcare professional. So whichever the country they're in, they can get help. And really help with their consultation process, actually, help with their healthcare professional to be given the right information because too many women are either fobbed off, or given unnecessary antidepressants or alternative treatments, or referred for more investigations. And so this way I'm hoping it will really help. And we've already had some great feedback about how it's changed their future, actually, which is really rewarding to hear.

Claudia von Boeselager: That's really excellent. And also to have more informed and educated conversations with their doctors.

You touched on one point before that during your medical training, you didn't really have training in this area. Is this now - is menopause taught better in medical school than it used to be? Or do you see this still as a gap in medical training?

Louise Newson: I'd love to say yes, but I can't sadly, because so many people are still not educated. And it's not just doctors, actually, nurses, but any healthcare professional that sees adult women as part of their work, in my mind, has to know something about the menopause. Even if they're not prescribing, they still should know, to acknowledge and recognize the symptoms or potential symptoms.

So it's still very much, sort of, hidden in a lot of curriculum. A lot of people are taught by gynecologists and I'm really not sure why gynecologists have been lumbered, almost, with the menopause because the menopause is when our periods stop. So why would I go and see a gynecologist if I wasn't menopausal, it's - they're experts at problems with the pelvic organs and they're surgeons as well. And so the menopause should be managed really by physicians by primary care, so GPs mainly, also nurses, - pharmacists as well - I think, have a really important role to play. So I feel it should be seen as a female hormone deficiency with health risks, and we need to get it into every specialty actually. So we're setting up a menopause society where we've already got people who are neurologists, urologists, rheumatologists, cardiologists, who are involved, and also pelvic floor physiotherapists, and other practitioners.

So we can listen to women at all angles as well. So if a woman goes to her chemists to get medication for a headache, and the pharmacist has trained, they might still say, look at this questionnaire, download the app, think about your hormones, headaches can worsen during the menopause, rather than just saying, here you go, have some paracetamol and brufen, this will help, you know.

So, the more the conversation is normalized by everyone, then it helps, you know, someone goes for a smear, a cervical screening test, for example, and it's a bit uncomfortable, rather than the nurse saying, oh, it will be over soon. The nurse will say, oh, is this uncomfortable? Are you finding intercourse difficult? This is a really common symptom of the menopause. There's some treatments available. Have a leaflet, go and have a read. Come back, if you'd like to talk again. All these little conversations are going to make women's future health so much better.

And, actually, it's also going to reduce them going back and forth to different health care providers, which will then free up more appointments, so people with other problems can then get appointments, because there's a lot of perimenopausal and menopausal women clogging up healthcare system. It’s not their fault, but because they have these myriad of symptoms, they are feeling ill, they’re getting symptoms, they're not being addressed properly, and they're just being either referred or treated, and given wrong information. And that's a real shame for these women, but it's also a real shame for health economies as well.

Claudia von Boeselager: You discussed or mentioned HRT, or hormone replacement therapy. For people unfamiliar, I'd like to just take a bit of a deep dive into that. Can you walk us through the different types of hormones, the benefits, potential side effects and risks?

Louise Newson: Yeah. So over in the UK, we call it HRT - hormone replacement therapy. Some other countries call it MHT, so, menopausal hormonal therapy. It doesn't really matter what it's called, it's just hormones. And it's actually not even replacing, it's giving back what's missing. So a lot of women who are perimenopausal their hormones, just start to decline. So we don't replace the hormones, we just top up the missing amounts. And so I've already said estrogen is the most important hormone. So estrogen is a hormone that we give back in HRT, or MHT. And the safest way of having that is through the skin as a patch gel, and there's a spray as well.

And that way, it goes straight through the skin, into the bloodstream. There's no risk of clot or stroke with it. So it's very, very safe. And then if a woman still has her womb, then she has a progesterone. Normally we give a body-identical progesterone. Some women have the mirena coil, which is a synthetic progestogen coil. And that protects the lining of the womb from the effects of estrogen.

And then there's another hormone that we produce from our ovaries, which declines as we age, called testosterone, which everyone knows as the male hormone, but we produce about three times more testosterone than estrogen before the menopause. So this declines as we get older, or if our ovaries are removed in an operation our levels will reduce very quickly.

And testosterone is a very important hormone as well. So, HRT is just about a combination of the hormones, if that's needed, or maybe just estrogen, and we can give it at different doses, different types, and very much women should have individualized consultations to have the right dose and type for them.

Claudia von Boeselager: Could you talk about that a little bit. So it's a blood test that is done, and then, depending on different criteria, depending on the person, it's personalized, and the doses and the frequency, is that right?

Louise Newson: Well, yes and no, really. So we don't do a blood test before, usually. So you don't have a blood test to diagnose the menopause or perimenopause because blood tests are really unreliable. And, certainly in the perimenopause, our hormones are fluctuating all the time. So you might do a blood test, which is normal, and that woman might be feeling fine at that time. But in three in the morning, when she's having a really bad night sweat and waking up with crippling anxiety, a blood test result then would be very low. But who's going to do a blood test at three in the morning?

So it's not always helpful. So we usually don't do blood tests. If people are younger, we often do do them, but again, a normal blood test wouldn't stop me giving someone HRT.

We sometimes do blood tests once someone’s taking HRT, especially if they're still having symptoms, to assess whether they're absorbing it properly, whether we need to change it or change the formulation. For example, if a patch isn't sticking on well, the gel is not rubbing in very well, and the blood test is low - then we might change the dose or type. But it's more looking at the symptoms and how they respond and improve to symptoms.

So all we're trying to do is to minimize symptoms because you're treating the underlying cause. So if a woman's symptoms are related to our hormones then they usually improve with having HRT.

Claudia von Boeselager: So the Longevity and Lifestyle Podcast is also about optimizing and catching things early. So from what age would you recommend women start getting on top of their hormones, and what are the main ones? Well, we talked about testing, but you said it's hard to test, so, if you're getting on top of it, or once I get on top of it early, how would you go about doing that?

Louise Newson: So the important thing is recognizing symptoms early, and it's really difficult. Like you say, without a blood test, you might be thinking, well, how on earth do I know?

Well, if your periods are changing in nature or frequency and you're getting symptoms, which have just started, then you just put two and two together and make four rather than 400. And it's usually very much likely related to hormones. We often start with the lowest dose when people are perimenopausal, and within two or three months, women usually say “I've started to feel so much better, I've got more memory, more concentration, more stamina.” None of my other symptoms have improved. So then you've answered the question - is it related to my hormones? With the whole ‘longevity’, if you think about estrogen as an anti-inflammatory agent, we know it reduces inflammation in our bones, in our muscles, in our heart. And so that's why it's so important at reducing risk of all these diseases.

If we don't have estrogen, or our levels of estrogen are low, we get this pro-inflammatory state, which is actually very negative for the body and can accelerate aging. So I'm sure you're aware of this whole term called ‘inflammaging’. So it's inflammation due to - and it accelerates - aging.

And this is really pivotal. We've known for many years, decades, how important estrogen is at reducing inflammation. And we've also known that inflammation causes lots of diseases, even including diseases such as clinical depression, or some types of cancer as well. And I've also got an immunology degree, actually, as well as a medical degree. So looking back at some of the immunology I learned in the nineties, it all fits into place, actually, about how keeping a really healthy immune system is really pivotal, not just for helping fight infections, but helping reduce disease, and keeping really healthy as we age, which is so important, isn’t it?

Claudia von Boeselager: Completely.
Is there cases where you would recommend people to get onto estrogen because of its effects and its power pre-perimenopause even? Or is that not necessary or not helpful.

Louise Newson: Only - if someone's got PMS or PMT, so, premenstrual syndrome - often they feel worse just before, the few days or so before, their periods. And that's because physiologically what happens is estrogen levels decline just before the periods.

And so some women, we do give estrogen usually as a gel, just for those few days. To top up, again, just to replace the missing hormones. So those women, we often start a bit of hormone replacement therapy for, but it's having your hormones optimized because we know that once people start to reduce their estrogen, that's when you get this rapid bone turnover, more inflammation in the body.

So, the key is picking it up early. You know, I see and speak to a lot of women who have been suffering with symptoms for 5, 10, 15, sometimes longer, years. And then they can still take HRT, but it's, their bodies have had this sort of long period of time where they haven't had a hormone that is so important for the way that we function.

So the earlier the better, you know, in an ideal world, there wouldn't be a menopause because we would all be on it and working out what's wrong early, picking it up, getting the right treatment.

Claudia von Boeselager: Just speaking with friends as well - have had children, you have that brain fog, etc. - which, you know, I think there's a bit of an overlap of symptoms that happen. And I guess for some it's unclear, you know, - is this just baby, sort of, years and baby brain, as some people call it, or is this to do with perimenopause years of, sort of, your late thirties. And do you find that in patients it's very difficult to differentiate?

Louise Newson: It is very difficult, but it's exactly the same etiology. So obviously when people have babies, their hormone levels drop very quickly. So - and lots of women who are breastfeeding often get night sweats, but that's also because of the drop in estrogen. So some people find that they improve when their children get a bit older, but if they don't, then it's likely that it is still related to their hormones.
And, in fact, one of my patients recently had a baby, her first baby when she was 48, so quite old in some ways. And then she had very scanty periods, but she breastfed for a couple of years. So everyone just said, oh, it's because you're old. You're an old mom and you've got a baby and you're still breastfeeding.

And she realized she thought something else. It wasn't quite right. And so anyway, she came to see me and I gave her some hormones and within days she started to feel herself. And so it's difficult. I mean, I was 40 when I had my third child and I wish I had started taking HRT a lot earlier. But hindsight's a good thing, isn't it?
So I think - but also, you know, HRT is really safe. It's one of the safest things I've ever given as a doctor. So if a woman takes HRT and doesn't feel any better, then you just stop it, you know. It's not like giving something that's going to have potential problems. For the majority of women, the benefits outweigh the risks. The whole breast cancer risk of HRT - it hasn't been proven with the sort of HRT that we prescribe - the body-identical hormones. So, actually, when people don't know, you know, doctors don't know if women themselves didn't know, then we often say, well, just try it and see, and then it doesn't feel right you can stop it. So it's, it’s very easy.

Claudia von Boeselager: I’m tempted to myself, but I mean, estrogen is good for anti-, anti-inflammation.

Last week I watched an interview with Dr. Peter Diamandis and Dr. Jennifer Garrison of the Buck Institute, who I'm sure you know, and she's working on the female reproductive longevity inequality. And one exciting point that she discussed is what she's working on in a research lab - is how to postpone and potentially completely avoid the menopause for women.

More from a youthfulness longevity perspective than from a childbearing perspective. What is your view on this, and the opportunity that this potentially would mean - you touched before on the economic impact as well - how do you see the future of what's going on in this space?

Louise Newson: Well, I mean, there is some research looking at giving a transplanted ovary, or actually you can preserve some ovarian tissue and have it put back into your body when you're older.

But my, sort of, argument is why not just take HRT, which is derived from yam plants, it's the same structures we produce ourselves and it's dirt cheap as well. You know, every single woman on the planet will go through the menopause. So therefore most women will benefit from HRT. So actually we want to make it cheap and easy and available.

And we've got good evidence that it works. So there's - I think our energy should be giving women what is available that's evidence-based rather than trying to get more or different treatments, really, for women.

Claudia von Boeselager: We asked our audience for some questions, we have some interesting questions here, so I'm just going to jump over to that.

One member of my audience recently turned 52. She says she has hot flushes, which are really her worst symptoms. She doesn't understand where they come from. She knows it's hormonal, but she wants to know what it stems from, how it manifests and what she can do.

Louise Newson: Yeah. So the vasomotor symptoms, hot flushes and night sweats are the commonest symptoms, as I've said, of the perimenopause and menopause, and it's due to the thermo-regulatory part of our brains, so the part of the brain that affects the way that - our temperature control, if you like, the thermostat of our brain. And it's thought to be due to shifts in estrogen - so when estrogen levels drop very quickly. And, so, a lot of women find they're a lot worse during the perimenopause and the early menopause.

But we also know that vasomotor symptoms actually are a marker of disease. So even if women only have a few compared to women who don't have any, they have an increased risk of heart disease and osteoporosis. So the most important, or the best, way of managing them is obviously treating the underlying cause. So having replacement estrogen. And usually they improve very quickly.

Claudia von Boeselager: Another question here is: What are the first signs of menopause? What's the best way to combat it? We’ve touched on this a bit. And then, in the same vein, what is the ways of estimating when you're going to get the menopause? And is there any testing that can be done, like an ovarian reserve scan, etc.?

Louise Newson: Yeah. So everyone's experience of the perimenopause and menopause is very different. And so it's very difficult to know what are the commonest symptoms because some women find they have, lik I say, the hot flushes, some people don't get any hot flushes and they find, they just feel very low, and flat, and socially withdrawn. Some people find their sleep is affected. Some people find they just have some urinary symptoms.

So it really varies. And that's why the questionnaire that's available on the balance app is so important to download because a lot of women you speak to you say, well, how are you having any menopausal symptoms? No. But then you say to them, have you got any muscle, joint pains? Yes. Have you got any pins and needles? Yes. Are you feeling more tired? Yes. Is your sleep poor? Yeah. Okay, well, these are probably menopausal symptoms. So that's why it's really important to know. The only way of knowing what age you're going to be when you're menopausal is having a crystal ball. Which we don’t have.

So, sometimes it’s a clue if you have a mother, maybe an aunt, a sister who's gone through an earlier menopause, then it might be that you might too, so it's worth asking your family members. But there isn't, like I say, a test and you'll Google, or you’ll read about all sorts of tests. But actually often they waste a lot of money and they're not actually going to help. But then it's - if you spin it on its head, like I said before, and think of it as a hormone deficiency with health risks, then even if you have very few or no symptoms, you need to think, well, should I be taking it to protect my heart?

We know that women who are menopausal are about five times more likely to get a heart attack than women who are premenopausal. And if a woman has a heart attack, she's actually more likely to die than a man who has a heart attack.

And so, what can we do to reduce our risk of heart attacks? Well, we obviously need to look after ourselves. We need to eat well. We need to exercise. Some people take a statin, but actually, if you look at the evidence, taking HRT reduces risk of a heart attack more than taking a statin. So, you know, we could be thinking about estrogen as a disease-preventing treatment, not just as a symptom-controlling treatment.

Claudia von Boeselager: Wow, that sounds very exciting.
Next question from the audience, what are the usual gaps or how long can they be between cycles, but for someone who had a very regular cycle and potentially is perimenopausal? And are there any particular vitamins or supplements that could be taken at this stage?

Louise Newson: So women's periods obviously really vary, don’t they? Some women have very regular periods, but they're only every 21 days, others, it might be 31, 36 days, it really varies. So that's why it's really important to monitor periods when you're young actually, and then see when they change. Some women find their periods become closer together. Some people find that they're more spaced further apart.

But also, some people who are perimenopausal just regular periods, but they might find that they're either lighter or heavier. So any change in periods with symptoms suggests perimenopause. When people ask about supplements, it all depends about what they’re wanting to take supplements for. So everyone should really be taking vitamin D because we know it's good for bone health, and there are probably some other advantages of taking it too. But there are lots of supplements that are marketed for menopause or menopause vitamins or supplements. But I usually say if it's got menopause written on the label then avoid it, because it's usually a marketing scheme, actually.

Claudia von Boeselager: Yeah.

Louise Newson: So we should really get as much as we can out of our diets. So that's really important. And that's hard actually for lots of menopausal women, because they often don't feel like cooking, they haven't got the same energy or motivation and they often have sugar cravings as well, which is a direct cause of the low estrogen. But looking at getting as much nutrients and vitamins from our diet is really key.

And then we need to have adequate calcium in our diets to help with our bones - is really important. Oily fish obviously is good for our brains. And then if we are looking at supplements, it's looking at what we're taking them for. So some women will take a supplement to try and help with a hot flush, for example. But that's not going to help reduce their risk of heart disease or osteoporosis. Some people might take a supplement such as magnesium if they're getting migraines, but then migraines can improve with HRT. But then if they're still getting migraines, then a magnesium supplement might be good, or a fish oil might be good as well for other reasons, or some people take a probiotic. So I think it's important to think about supplements and vitamins once the hormones have been balanced, and you're trying to optimize your future health, as opposed to taking a vitamin or supplement for your menopausal symptoms. If that makes sense.

Claudia von Boeselager: That makes complete sense, yeah. Is it possible for a hormone decline to be completely reversed by BHRT? So - bio-identical hormone replacement therapy.

Louise Newson: Yeah, possibly. What we don't know is how much by. I'm doing some work with a company you've probably heard - GlycanAge - looking at that.

Claudia von Boeselager: Yes. Nina.

Louise Newson: And, yeah, and I think that's really, really interesting. And I think probably yes. My mother-in-law won’t mind me saying this, but she's 85. She had a hysterectomy when she was 36 and when she was 37, she started taking HRT because she was feeling so dreadful. And she got her GlycanAge done recently and hers came back as 36.

Claudia von Boeselager: Wow.

Louise Newson: So that was the age she had her hysterectomy. So that's very interesting. And certainly a lot of people who are taking HRT, their biological age is low. And, you know, mine came back as 20, which is just bizarre because I'm 50

Claudia von Boeselager: I had mine recently done and mine came back as 11 years younger, but you’ve completely-

Louise Newson: Yeah, no, I don’t know why. And it's not just because I take HRT, you know, I, I look after myself, I don't drink alcohol and I don't smoke, so I'm sure that helps, but,

Claudia von Boeselager: Yeah

Louise Newson: It definitely slows down. It's not going to stop aging, but it depends on how you define aging. And I think this is what's really important. So a lot of people think aging is about, you know, some wrinkles or it's about a number, but actually when you look at the aging process causing disease, I think that's where it's really key.

And, you know, some people who want to play devil's advocate with my work will say, well, surely women are designed to be without hormones, and you're just playing with nature, but actually, I don't think we were designed to live without hormones and certainly young women certainly weren't designed to live without their hormones.

And we know from some really good research by someone called Walter Rocca in the States, so that if women have their ovaries removed at an early stage, they have very accelerated aging and a really increased risk of all the diseases I've mentioned. And so that's really important to address actually, and to consider why we should be taking estrogen replacement if we've had ovaries removed, especially at a young age.

Claudia von Boeselager: I have a question here around how does pregnancy during the later years of perimenopause affect the onset of menopause, and does it delay it for instance.

Louise Newson: It's difficult to know because everyone's different. So you don't know what it's delaying it because you don't know what the age would be anyway, if you see what I mean.

Claudia von Boeselager: Okay, the crystal ball effect again, exactly.
How do you screen for the risks associated with HRT, or the assumed risks? And are there any side effects of HRT?

Louise Newson: It's a good question. Most people worry about the risks and if you Google HRT, it always comes up with risks first, before benefits.

If you have oral estrogen, instead of the transdermal preparations I mentioned, there's a small risk of clot. So usually we recommend to have the estrogen through the skin because there's no risk of clot. The other risks that everyone worries about is the breast cancer risk. Now estrogen on its own has been shown to be associated with a lower risk of breast cancer by about 25% actually. So that's really interesting.

The risk with breast cancer has been associated with the older types of progestrogens, the synthetic progesterone, but the risk is still really low. When you look at even the worst study showing the highest risk, the magnitude of risk is similar to the risk women has if she drinks a couple of glasses of wine most nights.
So you don't open a bottle of wine and look at the label and it says risk of breast cancer. And that's not saying that labeling of wine should be different. They should be made more aware of how low the risks are. We also know that any type of HRT that a woman takes, studies have shown that they have a lower risk of dying from breast cancer.

So it's not about getting breast cancer, it's about what happens afterwards as well which I think is really important. We also know that women who take HRT for more than 20 years, have a lower risk of all these diseases, including cancer and death as well, actually. So there are a lot more benefits. Some women do get side effects. Often it's because they're not on the right dose or type. The biggest limiting factor I suppose, would be progesterone, because some people do get progesterone intolerance, where they can feel a bit lower in their mood, some people could be a bloated, a bit more irritable. But there are ways of reducing or changing that. So we do sometimes use progesterone given vaginally, so it's not absorbed in the same way into the body. And there are different sort of ways of minimizing the doses.
So that's why it's important that women see someone who's familiar with prescribing different types of HRT. So many women, I see, just say, oh, HRT doesn't suit me. Well, why would your own hormones not suit you? You know, so it's looking at body-identical hormones are the best because they're less likely to cause side effects or problems.

But some women, especially younger women, need a lot higher doses of estrogen because you want to replace them to the extent that they should be having them. So if women are still experiencing symptoms and they're taking HRT and they should consider changing.

Claudia von Boeselager: For women. I mean, we have the balance app, which is fantastic. And for women that would like to see a physician, not everyone is trained in this area. So what would you recommend as the best route? Through the balance app, would that be sufficient, or would you recommend finding a specialist in HRT as well?

Louise Newson: Yeah. I think the training for healthcare professionals urgently needs to be addressed.

I'm sure you know, with the menopause charity that I've recently founded, we've launched a educational program for all UK GP practices and GP practices in southern Ireland to be given for free. So through my not-for-profit company, we've developed a remote learning program for healthcare professionals about the menopause.

So it's got lectures on there and it's got different cases where we filmed actresses actually acting out different scenarios. And so people can learn from that. So that's available for anyone, any healthcare professional across the world to learn from.
What I'm hoping is that women can help educate the healthcare professional by having evidence-based information, and then if doctors, nurses, other healthcare professionals have enough women asking them, then they're going to be almost shamed into having more education. And, you know, as, as a healthcare professional, you wake up in the morning and you want to do the best you can for that patient. But if you haven't been given the knowledge or training, then you're not going to be able to help in the right way. And, you know, like I say, I think back about lots of women I've seen in the past and it - menopause wasn't on my radar. I didn't think. So, therefore, I didn't give them the right treatment. So, it's very important. And I know we've talked a lot about HRT, but it's very important women are given holistic advice and treatment as well.

So, we did a study recently of 3000 women and found that only 24% had been given any information about lifestyle or exercise. And it's really important that we look all over because all of us can improve something about our lives. And, you know, there's no point me having HRT and smoking 20 a day and drinking three bottles of wine every evening. But we need to be looking all over to improve our future health and that's really key, I think.

Claudia von Boeselager: So, just to summarize that, you were saying the holistic areas is also to look at lifestyle and nutrition and dietary exercise. Are those the main areas that you also focus on?

Louise Newson: Absolutely, and I think just sleep and wellbeing as well is really important. I think we're all far more stressed. We can't switch off in the same way.
So I think it's really having time. I've learned the older I've got, probably the more selfish I've got, because I need to carve out time in my diary to do yoga, I need to have time to cook properly, to sleep properly, to rest, because otherwise I can't work as hard as I can. So at the time I'm doing yoga, I think, oh, I've got 50 million emails coming in and I should be doing this, but no, actually, this is my time and I need to exercise, but it's also good for my brain and body and stamina and everything else.
But I think, as women, we're always pulled in so many directions, we're so used to multitasking. But as we get older, we have to look after ourselves, ‘cause I don't think anyone else really looks after us, do they?

Claudia von Boeselager: No, exactly. I found that myself as well, so important just to take that time because if you’ve nothing to give, then you're not much of a use for anyone. Including yourself.

So just before we close up here, for my listeners interested in understanding optimizing for the menopause, longevity. Which are the main online resources or books that you would recommend they start with?

Louise Newson: So, obviously the app Balance, which is a free app, which can be downloaded from the app store and Google Play.

My website is menopausedoctor.co.uk. Also, themenopausecharity.org has a lot of evidence-based information and resources on there. I record a weekly podcast, which is called Newson Health, which - I've interviewed all sorts of amazing people. So that's worth a listen. I have a book called - on Menopause, which is the Haynes Menopause Manual.

And then, the end of August, 2021, I have another book called Preparing For The Perimenopause And Menopause, which is published by Penguin.

So there's lots of resource. There’s another amazing book called Estrogen Matters by someone called Avrum Bluming, who's an American professor, and that's definitely worth a read as well.

Claudia von Boeselager: I’ll link all of this into the show notes also for my listeners.
Do you have a final ask or recommendation, or any parting thoughts or message, for my audience?

Louise Newson: The most important thing, whoever's listening, whatever age, whatever gender, is to get some information, because all of you listening will know a woman who at some stage will be going through the perimenopause and menopause, and just normalizing it.

And I think, what I want to do is try and make people think of the menopause as a really positive time in our lives, actually. It could be a time where we're most productive. And so it's got to be changed from something that could be negative to very positive, but we have to get the right help and support for that to happen.

Claudia von Boeselager: Excellent. Thank you so much for coming on today, Dr. Newson, it’s been so informative.

Louise Newson: No, it's been great. Thanks ever so much for inviting me.