59: Making sense of Menopausal Hormone Therapy (MHT) with Dr Ginni Mansberg

[00:01] Sonya: Welcome to the Dear Menopause podcast, where we discuss the menopause transition to help make everyday life a little easier for women. I'm Sonya Lovell, personal trainer, fierce advocate for women's health, and owner of a very distinguishable laugh. Today I am chatting to Dr. Ginni Mansberg and we do a deep, deep dive into menopause hormone therapy, otherwise known as MHT or previously known as HRT. Ginni, thank you so much for joining us on Dear Menopause. It is so wonderful to finally have you here.

[00:33] Ginni: I feel like we have kind of known each other in inverted commas as social media normally enables, but this is the first time we've actually hooked up on a video, not hooking up in the young sense, in our old sense, connected on video. And I feel like I'm meeting an old friend for the first time.

[00:53] Sonya: Thank you. That's so lovely. It is nice to finally actually connect in person as much as we're still over zoom with all these amazing women that I've connected with since running the podcast. So thank you. Thank you for finally getting our schedules together and getting you here today. Janice, for anyone that's listening that doesn't know who you are, why don't you give us a little bit of an intro on who you are and why you're here today?

[01:16] Ginni: I hate doing this because I feel like a bit of a **** when I do this, because I am a bit of a slushy. So I would say my first role is as a GP with a special interest in menopause, but I have a bit of a slushy kind of career. So I also do quite a bit of media. I do TV mainly for channel seven. Sunrise. I also do it for the ABC, but I've been on Channel Nine and SBS radio is for Nine radio. I've got columns in magazines like New Idea, which is our media. And then I've got my own two podcasts. So the first one is Help. I have a teenager which is on the Mama Mia network. And I also have like a one that no one here will ever have heard of because it's for doctors and it's called Drivetime Medical and it's an educational kind of podcast for doctors. And then with all of that, I have started a couple of businesses. So with my little entrepreneurial habit, I feel like a **** saying that, because whatever. I have a skincare company called Evidence Skincare which was kind of an fu to all the rubbish that was in the skincare industry that drove me insane. And then the next thing is one called Don't Sweat It, which I think is how we particularly connected, which is all about menopause in the workplace. So I think I'm sure you and I will chat about this, but it's a shared passion of ours about the impact of menopause symptoms on women at work and I guess the overdue but increasing recognition around how menopause impacts on work and how that then flips back onto women and firms who lose these women. So our aim is to keep midlife women having choices and being able to be connected with their workplaces and for workplaces to step up and nurture their midlife women so they don't lose them.

[03:11] Sonya: That is a lot of hats that you are wearing. But you know what? There is one hat that you forgot of all of those slashies that you just mentioned. You are also the author of The M Word.

[03:24] Ginni: Yeah, I write books, so I wrote The N Word, I think it was in 2019 now, which was like a whole funny story about how writing The M Word all came out and I had sworn black and blue inside out. I was never, ever, ever going to write another book because the two books before that were a terrible experience and I hated it and I decided I'd never do it again. And actually writing The M Word got me back into it. So now I've just released Save Your Brain, which is my latest thing. I also teach at university. I do a whole lot of other things as well. I do some consulting. But yeah, you're right, I did forget the author thing and the speaking thing.

[04:01] Sonya: Wow. I feel like a complete underachiever right now. Just quietly, people tell me that I have a lot of irons in the fires, so to speak. But yes, you are one busy lady. But I think that the thread that runs through all of that is obviously your passion for menopause, your passion for education. And I'm really excited to hear about your podcast that you do for the GPS or the medical industry. I think that's fantastic and that makes me really excited because it means someone is out there actually educating our doctors.

[04:33] Ginni: Of course, consumption of these things is on a selective basis, so you might choose not to listen to my podcast because you're not particularly interested in learning about. We do everything from we're actually in the middle of a four part series on menopause, actually, for GPS, which I'm sure you would agree is much needed, which I wrote all the content as well. And then I'm interviewing various experts, but osteoporosis and heart disease and cancer treatment, everything. Pain management, back pain, everything. We cover the gamut for GPS, which is really good. It's a great podcast.

[05:06] Sonya: Yeah, that's awesome. Okay, that's made my day. Thank you very much. Across all the topics. Like you said, it doesn't have to just be menopause. I suppose it's an ongoing education kind of opportunity for the GPS, which is brilliant. All right, I think that we have a lot to talk about and we should really kind of drill down into what it is that we have decided is our main topic to talk about today because there were lots of options that we could go in. One of the areas that I would really like to deep dive with you is around MHT. So menopause hormonal therapy look, it's been touched on in different episodes that I've done with different experts and doctors that I've had on, but I've never really done a deep dive. And I know I often get asked questions by women. I've been in different community support groups and it has become really evident to me that even for women that have perhaps seen their GP and they've been given a prescription, they have all these questions afterwards that are kind of they're throwing out amongst their friends or these support groups. And I thought, let's do a deep dive into MHT. And I've also got a few questions that I'll throw to you at the end that came from my online community as well.

[06:19] Ginni: Amazing. Perfect.

[06:20] Sonya: Cool. Okay, so why don't we get really simple and literally just explain what MHT is.

[06:26] Ginni: So, I guess the first thing to understand is when you go through the menopause transition, as you know, I need you well, Sonya, but for all your listeners, there are two phases to that. And the first phase is when ovulation falls off a cliff. So your progesterone levels, because that's a hormone that is only made after you have ovulated. If you don't ovulate, you won't make progesterone. The progesterone levels get lower, but your estrogen can either be lower or higher, day to day, week to week, it does change and that's why it's called hormone hell. It's really difficult to lose your progesterone. You get out of balance and you can have high estrogen days and low estrogen days in the second half of your perimenopause, your estrogen really does tend to fall off a cliff and it does get much lower and that will cause a very different constellation of symptoms. And menopause is a single day. It is twelve months from the first day of your last period and you didn't know it was your last period at the time, because who ever knows when your last period comes? And sometimes you can't remember when it was and you just go, I can't remember having a period for a while. And you're probably in menopause, but you can't actually remember when it happened. But it is a single day. Your estrogen levels hit their nadia their lowest .2 years after that day of menopause. Can I ask question there?

[07:39] Sonya: Yes, sorry, one question I'd like to know this so I don't forget to come back to it is if you are a woman like myself who went into medically induced menopause or a surgically induced menopause, does that oestrogen still hit that low two years after? Is that the same?

[07:56] Ginni: Yeah. So you have some non ovarian sources of oestrogen as well, and it's mainly from fat. So bigger women have more oestrogen. And that's why being obese is a risk for uterine cancer and for breast cancer, because you're making fat. So it's actually your ovarian reserve that dwindles to zero at that. To your point. So there are women who have medically induced kind of menopause in inverted commas because they have a hysterectomy, but their ovaries are left in size, they're actually having cycles, they just wouldn't know when their periods are. For those women, they will still follow the normal pattern, although studies do show that you will hit your menopause about two years earlier than you would have had you never had a hysterectomy. So that's just one thing to note. But for women who have had what we call an oopherectomy, their ovaries removed, it is day one, you go from zero to 100. And all evidence suggests that when that happens to you, either that or whether you go on some sort of oestrogen blocker as part of a breast cancer regimen, a treatment regimen, that the symptoms of menopause are just multiplied in such an exaggerated way. And the reason for that is that your cells don't have an opportunity to slowly wind down. So it's a much more severe form of menopause, both surgical and medical menopause, if it's not because of just a hysterectomy, where we've left your ovaries in.

[09:31] Sonya: Yeah.

[09:32] Ginni: So in terms of menopause hormone therapy, it is the reintroduction of primarily oestrogen, which does most of the heavy lifting in terms of the symptoms and the medical problems that are associated with menopause. So we're talking about, on one hand, it's your aches and pains, your hot flushes, your vaginal symptoms, your bladder symptoms, your itchy skin. All of those things are alleviated by estrogen, as are your lack of bone density and your poor cardiovascular health. With all of those things, we don't aim to get you to premenopausal levels of oestrogen in your body. So we would never be giving you the oral contraceptive pill, which is a much higher dose of oestrogen. We're just looking to give you, I guess, the minimum viable dose of oestrogen that will relieve your symptoms, that will help you medically, but that will not raise you to premenopausal levels. And that's really important to know that you might be on HRT. And still, if you were to have a blood test, which we totally do not advocate, ever, but if you were to have a blood test, it could still show you being in kind of borderline menopausal levels. And that's fine because it's all about your symptoms. It's not about the blood levels.

[10:52] Sonya: Blood levels, yeah.

[10:53] Ginni: Okay.

[10:54] Sonya: That's really interesting what you said about the OCP, the oral contraceptive pill, because I do know some women that were put back onto their pill by their GPS as a way of managing their peri symptoms. So what is likely then to happen to them when I'm assuming they get to a point where they stop taking the pill.

[11:15] Ginni: So there is a lot to unpack there. So the first thing to say is, at this stage in this country, in Australia, hormone replacement therapy does not have an indication, which means the government has signed off on it being used for perimenopause. It is only for post menopause or symptom relief or management of bone density. So that's the first thing to say. So a lot of doctors are inherently nervous about using any drug off label. Because I'm so passionate about it, my preference would always be to use MHT. But because it has that lower dose women in Perry sporadically ovulate and can still get pregnant and MHT is not contraceptive at all. So if you still have a uterus even though we're using oestrogen to do the heavy lifting, if we give you oestrogen without balancing that out with progesterone, there is a small but it exists risk of giving you cancer of the lining of the uterus and also very heavy bleeding from an overgrowth of that lining of the uterus. As a result, we have to give you some form of progesterone and that comes in a few forms. The safest form is micronized progesterone. So that's the form that you can't get in the oral contraceptive at the moment, but that is the form that is used in MHT. So we can use that again, remembering that you will still need to use alternative forms of contraception. Or we can put the progesterone directly into your uterus in the form of a contraceptive device called a Marina and that has enough progesterone to protect your endometrium from any of the effects of the estrogen that you're taking. And it's contraceptive. So we can kind of get two things for the price of one. I have a Marina for my Perry symptoms and for contraception and for heavy bleeding. So I have got my Marina doing a few things for me and then I take my estrogen separately.

[13:20] Sonya: Okay, cool. So even a woman who perhaps had not used a Marina previously for her contraceptive purposes could find that she's being recommended a Marina because of the progesterone protectiveness and the double whammy of the contraceptive. Okay, cool. That's good to know.

[13:38] Ginni: Yeah, it's a really good one for Perry women. If you speak to Professor J. Shree Kulkarni, who is from the Her Center at Monash University, she's probably the leading the world's leading researcher into the mental health effects of Perry. She would argue that the Marina is dreadful for mental health. And given that Perry is the peak time for anxiety and depression for women, one of her first things is always to pull women off.

[14:06] Sonya: I'm assuming that's perhaps more for women that are also having depression, anxiety, mental health issues.

[14:12] Ginni: Yeah, only that. So you would never see her if you did not have that. She's a psychiatrist especially.

[14:17] Sonya: Yeah, she's amazing. She's an incredible woman and love her.

[14:22] Ginni: Love her and she's so knowledgeable. But for any women who are not I'm just thinking for anyone who's listening and connecting dots there and has all of a sudden found that they are getting very depressed through their perry. Don't worry. One in three of you. It's very common. One of the options could be to remove the marina, and what we know is that the micronized progesterone is a better option. And honestly, a lot of women in their forty s and fifty s are not rooting like rabbits. It's not like they need a contraceptive every single day. A lot of my patients are going once a week, every two weeks, once a month. You could use a condom for that.

[14:59] Sonya: Exactly.

[14:59] Ginni: As long as you know that you don't have contraceptive protection from MHT alone.

[15:05] Sonya: So we get no menno babies. And interestingly, just keeping that topic of mental health going for a moment, I heard a fascinating statistic recently which blew my mind, which was that the age of women when they're at the highest risk of suicide is between 45 and 55.

[15:24] Ginni: Yeah. It is the highest risk. And I think, rightly, our community focuses a lot on postnatal depression for good reason. Very happy with that. The problem is that's not the peak time. The peak time is women in midlife and who get absolutely, very little support if you are in postnatal depression. Your mental health care plan that is made for you by your GP will allow you to access 20 sessions. If you're in Perry or menopause, when the risk is the highest, you're stuck with ten. That's all you can get ten sessions with your psychologist. You can't have any more than that because the government simply does not recognize what is a glaringly it is such a huge fact, the evidence is overwhelming that women our age are the highest risk for poor mental health and suicide.

[16:14] Sonya: And homelessness as well. Right now.

[16:16] Ginni: Homelessness? Well, I mean, that all goes into our shared passion about women at work and how so many women leave work because they don't put two and two together and no one tells you this is menopause. The fact that you've had no sleep, you haven't had a decent night's sleep for six months, the fact that you've got hot flushes, the fact that everybody ****** you off and that you're having terrible fallouts with people at work no one is saying that is hormonal. Go and get your hormones sorted. You'll get all of this under control. But instead there are so many women who are just walking off the off work or just going, you know what, I'm just going to take a job three days a week at a local cafe, a 75% pay cut, they lose their super. Yeah. The Australian Institute of Superannuation Trustee said that women in Australia are losing $15 billion a year and lost earnings and super because they're working. Because they're quitting.

[17:14] Sonya: Yeah. And we're already predominantly, as women, behind the eight ball with super anyway, because we have the gender pay gap, we have the years that women take off to raise a family, if that's something that they do. Yeah. There are so many issues here that we need to sort out some equality around in divorce.

[17:33] Ginni: A lot of women get divorced, and I'm not saying that these marriages are Eden and that they shouldn't have left, but you have a gut fall much quicker when you've got depression and anxiety and the rage that comes in as part of your perion menopause or depression and anxiety. You get this rage and you just go off at everybody. So your kids hate you, your husband hates your kids. Divorced and homelessness is not a fast stretch for a lot of women.

[18:00] Sonya: No, that's right. Okay, so let's get back on track with EMH T. We've talked about taking Oestrogen separately. We've talked about taking Progesterone separately. Let's talk about ways that a woman might be prescribed. So I know there's gels, there's patches, there's all sorts of different ways that MHT can actually be delivered into the system.

[18:23] Ginni: So I'm going to start with progesterone, because I guess this is the important piece of the puzzle. So some women will elect to have a marina, in which case we now no longer need to deal with your progesterone. We only need to deal with your estrogen. You also might have had a hysterectomy, in which case we don't need to talk about progesterone because if you don't have a uterus, we can't give you uterus cancer. So if you've had that out, we don't need to even have this discussion. But if you do have a uterus and we do need to talk about progesterone. Most menopause experts like me will by far and away prefer micronized progesterone because it's what we call body identical progesterone. It doesn't break down into products that are potentially harmful for the body, and that is the preferred type of progesterone for the vast majority of doctors. There's also one called dietrogestrone, which you can also use, which also seems to be in one of the safer ones, the one that was used in the study that caused all the drama, that made everybody throw their HRT in the bin and think that HRT is dangerous, is called Medroxy Progesterone Acetate. Now, no one should be on that. It is still available in Australia, which I find weird.

[19:34] Sonya: Wow.

[19:34] Ginni: Just to hang up. Yeah, you can still prescribe it. It's really we have better forms out there and it's what we know is how it breaks down and it sits on cortisone receptors, for example, and causes some other issues. There is one called Norath esterone as well, which is not as bad as Medroxy Progesterone Acetate. But my preference would be definitely the micronized Progesterone or the digestrone. If you couldn't do the micronized progesterone, let's say we're going to do the micronized progesterone. They come in tablets of 100 micrograms. In the UK, they have tablets of 200. We don't have them here. Right. So that means that for women who go on cyclical HRT. Now, what that means is you're in Perry we're just going to give you a regular cycle back again. And the reason to do that is to avoid breakthrough bleeding. Because if we try and put you on we call continuous HRT. Sometimes a lot of women do get breakthrough bleeding. I'll talk a bit to that in a second. But if you were going to do cyclical HRT, you would take your micronized progesterone on day one of the month to day 14 of the month. So today, let's say we're recording sometime in May, you would go from the 1 May to the 14 May, the 1 June to the 14 June, and you'll take two of them and you'll take none in the second half of the month. We're trying to mimic a normal cycle and if you are on continuous HRT, you will take that 100 microgram level every single day. When I have perimenopausal patients, a lot of them don't want to go back to having a four weekly cycle. They just don't want to do it, which I completely get. And as long as they understand the risks around breakthrough bleeding and the fact that it usually sort of settles down after about three months, a lot of my patients are happy to take daily progesterone because it's easier and to deal with the breakthrough bleeding. So I normally offer that as a choice to women to say, do you want to do cyclical or do you want to do it continuously? You'll probably get some breakthrough bleeding. It'll probably settle down over time. And we normally say with the breakthrough bleeding, if it's brown spotting, just keep going. If it's full on Frank Red period, then we say stop taking it for four days, have a period and then go back on it again. So that's how we normally handle that one. Okay, so now let's talk about estrogen. The most common is oestrodiol. That's the most common form. And exactly as you said, you can get that across the skin. We call that transdermal oestrogen and that comes in the form of patches. But that's not all within patches, there are big patches that last a full week. Very good for people who are very vague and don't want to have to remember patches twice a week. Some of my patients love these, but they are tend to be a little bit big and a little bit manky by the end of the week, particularly if you get a bit sweaty. I often see patients coming at the end of the week and they've got micropore tape sticking it everywhere. It's just awkward. Very few of my patients love the weekly, but for vague people, that's a good option.

[22:51] Sonya: Okay, and quick question while we're on the patches, so I remember to come back to this one. Where is the best place for a woman to put her patch? Because I get that question a lot.

[23:02] Ginni: Anywhere on the upper half of the body. So you could put it in your arm. You could put it on your chest, you could put it on your belly, above the belly button. You can put it on your back. I'm really agnostic. Just anywhere on the upper half of the body, sort of below the neck and above the belly button. Most women want to put it where it's not going to be seen if they wear a T shirt. All patches can be a bit of a problem. If you have an amazing mumbod and get out into a bikini all the time, or if you're embracing your mumbod, whatever it looks like, and go out in bikini, it's pretty obvious where it is, so some people don't like to do it. So, yeah, there's the smaller patches that are really small and they are put on twice a week. I normally say Monday night, thursday night or Monday morning, thursday morning, after a shower. Really completely up to you. And then the last one, there are two gels, there are sprays overseas. We do not have them here in Australia, so there are two gels. There's generally sandrina and EstroGel. I'm a doctor, so I'm not allowed to say which one I prefer, but one of them I definitely prefer, one of them falls all over the floor. And so there was a long time.

[24:07] Sonya: Like, a big mess.

[24:08] Ginni: Prescribed gels, it's a big mess. It goes on your bathroom floor and then you're like, oh, can I pick that up and put that on me? Again, not a big fan.

[24:15] Sonya: Licks it off the floor. Hello.

[24:17] Ginni: Correct. And there's a massive amount of it, but it's to be put on every day. And the starting dose is two pumps. All women will be put on two pumps to start off with. If you are not put on two pumps, there's been a mistake. So that's just a first thing. Why would you choose that instead of a simple tablet? The reason is that there seem to be three particular areas where transdermal oestrogen has it all over oral oestrogen. The first one is there is no risk of blood clots, so there is a small risk of blood clots from oral oestrogen. There is not from transdermal estrogen. So that's the first thing to say. The second thing is migraines. There is a small increased risk of migraines in oral oestrogen, none from transdermal estrogen. So any woman who's had a history of migraine, and I take that history quite seriously, because a lot of women don't say it's migraine, but they just get these headaches that make them unable to go to work once a month, that's migraine.

[25:22] Sonya: When it's that cyclical migraine, it's linked to the hormones, isn't it? It's a hormone related issue.

[25:30] Ginni: Exactly. But that's more for women who have got a cycle. A lot of women don't realize that they have migraines, so I would prefer the transdermal. The thing is, though, that if you're going to take a micronized progesterone tablet at night, a lot of my patients are simply finding it easier to combine that with a 1 Estrodiol because you can get that in a single tablet right now. It is expensive, I'm not going to lie, but I started taking it in that form when I was wanting to get some Progesterone to help me sleep. Because your marina won't help you with sleep at all. Progesterone is an amazing sleeping pill. And when I was traveling, I didn't want to have to take a big bottle of gel because I don't ever take a suitcase with me. I'm one of those I only ever go cabin baggage no matter how long I'm going for.

[26:22] Sonya: I know. I think I remember following you on Insta recently when you did a Europe trip, and you were like, and I'm only taking carry on. I was like, this is impressive.

[26:31] Ginni: I'm doing it again. I still have press events and consumer events in London for Esk, for my skincare. I'm going to my son's graduation. I'm going in a carry on bag. So to save space, I will switch to BIJUVA, which is the single 1 oestrodiol and 100 micrograms of micronized Progesterone just to travel, because yeah, okay. That's just so much more convenient. Some women get a bit of an upset tummy on oral oestrogen. Like, they just find that it gives them a bit of constipation. It might be maybe changing their gut, microbiome, don't know. So that's kind of, I guess, the low down that is your estrogen and your Progesterone cool.

[27:18] Sonya: And just going back to when you were talking about the gels and the pumps. So you were saying that two pumps should be minimum prescription in a support group. I was in, there was a lot of women talking about feeling like they weren't getting the changes to their symptoms that they were hoping for. So they were wanting to up their pump themselves, obviously, because they were talking about it to get advice in a support group rather than going back to their GP. Where does the advice sit on kind of playing around with your prescription yourself? Should you always go back to your GP first?

[27:54] Ginni: The biggest risk from continuing to pump up the dose of Estrogen is what we don't know for sure is, is the 100 micrograms of Progesterone adequate to protect your endometrium? We don't know. And the other thing that we don't so going up to 75 micrograms, so that's three pumps of your gel or supplementing your patch with a bit of gel, that's probably not a problem. But I have concerns about women going up to like 200 micrograms. So there's slime everywhere, and I want to know what are the symptoms that you don't think are being controlled? So to give the entire job of fixing your depression to HRT makes no sense, and for you to just sit in that spiral of despair and just keep upping your oestrogen would be very concerning for. Me, you need to be speaking to a doctor to look at what other options you have. The second thing is, if you are having hot flushes, and I know, Sonya, this is an area that is really important to you. If you have a lot of weight on you, you will be hot flashing regardless of the Oestrogen. Your oestrogen can't get rid of that for you. And we would be much better off focusing on how we can help you get into a healthy weight range or closer to your healthy weight range if you have aches and pains and you are just saying, well, all I'm going to do for my sore hip is to go up a dose. What if we're missing rheumatoid arthritis, which often presents in midlife women? So the reason why I would say it is really good at some point to go back to your doctor, don't diagnose everything as menopause, because not everything is menopause. It is certainly something that causes a lot of different things, but often we have multiple things going on and to use a single solution to a complex problem often won't work.

[29:55] Sonya: Always good to remember. And there are so many different conditions where the symptoms are so similar, it's almost like menopause mimics the symptoms and if you're not following up on those, then there could potentially be conditions that are being missed. I think that's such a great message.

[30:12] Ginni: I always get women back six weeks after starting NHT, and the reason is because I write down all of their symptoms or we'll do a symptom score and I'll write down all of their symptoms and some of them have complete resolution of their aches and pains. It's absolutely amazing. Some of them are completely better from a mood perspective, but some aren't. And I need to follow up with them and see where are the gaps, what have we been able to do? And I can tell you that I very rarely up the dose if a woman is going to be having who is of a healthy body mass index, and she's gone down from 50 hot flushes at night, so absolutely no sleep to ten. I would say the proof that the MHT is helping you with your hot flushes is pretty clear. Let's, as an experiment up it a little bit and see what happens. But I am aware that there are clinics in London where the answer to everything is up your dose, up your dose, up your dose. And we're starting to of Oestrogen and we're starting to see some concerning effects of that around the endometrium. And I am very concerned if a woman like that, who is taking four pumps of gel or five pumps of gel a day, which oh, my God, you'd run out of body space. I didn't know where you'd put it all if you were going to be doing that, and only on 100 micrograms of progesterone would be if she starts bleeding, I'm worried. So when I see patients, I'm often bringing them down. And there was some really at the Australasian Menopause Society meeting, annual general meeting last year, we had some amazing talks, but one of them was by Professor Bronn Stuckey, who's from the University of WA, and she had some very reassuring data that when it comes to osteoporosis, it is not about the dose. Just being on estrogen is enough to protect your bones. If you have osteoporosis, you don't need to go up a dose. And that's been a really we didn't know this before, and there are a lot of women who ended up being put on very high doses of oestrogen for the sake of their bones. We now know you don't need to do that. It's just having some oestrogen in your body is what you need.

[32:23] Sonya: And a bit of strength training. Perfect.

[32:26] Ginni: Well, with 100% with strength training and the thing about strength training and all training, and of course, you are about holistically helping midlife women, particularly in that fitness world, but there is only so much HRT can do for any woman. But what is critical at this time of your life is to look in the mirror and go, right, now is the time I've got to get my body mass index sorted, I've got to get my fitness levels up, I've got to be doing weight bearing exercise to be protecting my bones, my mental health. You can't tackle poor mental health and not exercise. It's just not going to work. So there's just so much about exercise. It is a critical part of this transitional phase of your life and you can't extricate them. They have to be seen as a holistic group.

[33:12] Sonya: Yeah. I think it's such a prime opportunity or opportune time for women to really I've been talking about this a little bit with people recently. It's almost a little bit like taking a stock take of your life and kind of going, okay, where's my nutrition at? Where's my exercise at? How's my mental health? What other kind of lifestyle areas, how much am I drinking? All of those sorts of things. It's a great time to assess all of that and kind of go, okay, so what would I like the second half of my life to look like? Because if this is midlife, then we've got a whole second half of life to look forward to and what do I want to take into that? And then we're looking at being able to do amazing things like increasing our health span and living healthier for longer, which is just such an exciting concept to me.

[33:59] Ginni: 100%. I mean, this is a great opportunity, as you say, to do a stock take on your health.

[34:04] Sonya: Yeah, brilliant.

[34:05] Ginni: Yeah.

[34:06] Sonya: Okay, so we've talked about the types of MHT, how it can be applied or taken. How long would a woman likely be prescribed her MHT for?

[34:22] Ginni: There is no answer for that. Every woman is different. So it depends on what you went in the MHT for. So let's say you went on your MHT primarily for hot flushes. And I'm just going to challenge that notion because I've never met a woman who is completely fine for everything except for hot flushes. But anyway, let's say that's what she went on it for. The average length of hot flushes is about 7.4 years. And it seems that being on it for that long would be completely reasonable and very low risks, if any, particularly if you were using transdermal estrogen and a micronized progesterone, for example, that you would have any increased risk at all of breast cancer for that length of time. And we would encourage you to get two yearly mammograms through BreastScreen. But the quantum of increased risk is very low. But the quantum of benefit for your life is incredible. I am happy for any of my patients to go off MHT at any time they want. However, I would have some recommendations with that. Number one, let's not do that in February. I think we are all menopausal women in February, regardless of your age and gender, everyone hot flushes and you'll have no clue what is going on. So I would do it around middle of the year, so somewhere between May and August. And I wouldn't just go off a cold turkey. So if you're using two pumps of a gel, I'd go down to one pump of gel. If you are using a patch, maybe cut it in half, see how you go before you jump off it all together and just see, just keep an eye on your symptoms. It often takes about two or three weeks to actually everything to come spinning back if that's what's going to happen. So that would be what I would do. If you are on it for osteoporosis, I do offer everybody bone density at the first menopause check. The reason I do that is in my clinical practice, in my experience, I have been very surprised by who does and who does not have low bone density. It's actually been amazing. And a lot of people have extremely low bone density that I would never have picked. And there are other people who I think would have been terrible and their bones are fine. So I like to get the numbers in front of me. Osteoporosis fracture is one of the nastiest impacts of menopause. And if you fracture your wrist or you fracture a toe, it's annoying. But like you're fine. If you fracture your hip, there's a 50% chance you end up in a nursing home or dead within twelve months. So I really, really don't want you fracturing your hip and I want you to do whatever you can. And that includes weight bearing exercise and includes ensuring that your diet has adequate calcium and that you have adequate vitamin D in your blood. But I would like you to do whatever you can to keep your bone solid. One in 20 women is a superflusher she'll flush for life. And what we say is that it is okay to be on MHT for life if the benefits outweigh the risks, and the risks are low. So it's a very individualized. We really like the idea in menopause world of shared decision making. So explaining all of that to our patients, answering all their questions and letting them make that decision for themselves rather than us being the dictators of it.

[37:39] Sonya: Okay, cool. That's nice to get clarity on that because I know that one of the outcomes of the Women's Health Initiative and that whole mess that we ended up in, where you referred earlier to everyone just threw all their HRT into the bin and never went near it again. There was a lot of fear, I think, that came out of that around, particularly breast cancer, but it was also built into, like, how long you took it for. And we now know that data has all been debunked, and there were so many flaws in that research. So that's really great to get that clarity.

[38:11] Ginni: There was a study that was done, I think, ten years after the Women's Health Initiative, that sort of put a dollar number on the number of deaths that were caused by women prematurely going off their HRT that were attributable to heart disease and particularly osteoporosis fractures, also bowel cancer, things like that, that were increased in the non HRT group. And it's really huge. I mean, there's a lot of women who die by giving it up, so we've got to really think about that.

[38:37] Sonya: Absolutely. Yeah. Okay, so other areas of a woman's health that MHT can be beneficial for can kind of work as a bit of a preventative. So obviously osteoporosis is one of those we've talked about that does MHT have some benefits when it comes to heart health?

[38:55] Ginni: Yeah, so the data is really intriguing because it's the newer forms of HRT that have not been around for a long time, and heart disease tends to strike women later, closer to their 70s. However, what it looks like the data is telling us is it's all about the timing. So that if you go on HRT either during perimenopause or very soon after going on to menopause, it looks to be cardioprotective. In other words, it helps your heart and helps prevent heart disease. If, on the other hand, you have gone onto it, particularly six years or after stopping your periods altogether, it looks like it actually flips and does the opposite and actually is bad for your heart. And that's because six years without oestrogen, your arteries have managed to harden, they've become full of plaque, and to reintroduce oestrogen at that point actually makes the whole situation worse. Interestingly. It looks like it's the same for brain health, including strokes and dementia. And it's early data. But what looks like from the early data is that starting HRT during Perry or very close to menopause is protective of your brain, and then doing it too late might actually have the opposite effect and increase your risk of dementia.

[40:08] Sonya: Okay, cool. Good to get clear on that. And the last question that I've got for you, really, before I move on to the questions that I got on from the online audience, is for a woman like myself. So this very much my horses well and truly left the stables, but for anyone that's listening and look, I do tap into this audience quite a lot for women like myself who are ineligible for MHT. So for me personally, it was due to a breast cancer diagnosis that was oestrogen and progesterone positive. There are other reasons why women do become ineligible, but predominantly it is linked to a breast cancer or a cancer concern. What options as a GP do you feel should be explored for these women to provide them with some support?

[41:01] Ginni: So until now, there's been an over focus on, a real over focus on vasomotor symptoms, which is your hot flushes and your night sweats. And we do have lots of medications for that, a lot of medications that have side effects. But my favorite one is one that's actually used for what we call urging continents. So that's the trips to the loo in the night and when you think, I need to go to the toilet, oh, wait, I really need to go to the toilet right now. For those women, there's a medication for that. And by the way, it reduces hot flushes by 75%. There's some antidepressants that do the same thing. So when I'm faced with a woman who can't take MHT, I'll normally look at what's going on for her so that we can try and get two things for the price of one. So she has a mood disorder and hot flushes. I'll try and help her by you selecting an antidepressant that has got evidence for reducing hot flushes. But it's not great. I mean, we're talking maximum with the antidepressants of 70%. Some of them are only 50%. There are things like clonidine, gabapentin, but they have a lot of side effects and don't work that well in everybody. So I need to be declarative in that I would definitely look to your lifestyle. And we have had studies of exercise for relief of hot flushes in particular, and they haven't been great, but it's probably down to the design of the studies. And the reality is getting into a healthy weight range and just looking at some strength training is always going to be good for your mind, body, and spirit. And this is a time where you need to be doing that because very few women that I see are only worried about a hot flush and nothing else. I'm shocked at how many women are freaked out by their weight. It's just amazing that's a really big and often unaddressed issue for women. I see women multiple times a day who say they put on 16 kilos since yeah. And, and they are, you know, their comfort eating, their mood is bad. They've they've got that confidence cliff that, you know, things are not going well at work there. Maybe their relationship is not as fulfilling as it used to be. They're worried about their kids. They're often worried about their parents. Women at Periomeopause are in sandwich generation. They are too busy to go to the gym. They had a gym membership. But now work is like a 24/7 kind of thing. It is a very common thing for women's weight to just explode around this time. And to me, it's a biomarker of lack of self care and very poor self esteem and very low levels of confidence. And we need to address that. Holistically and it's certainly not by even though my patients told me my biggest concern is to lose weight, I normally say, that will come. Can we just park that? That will come. We need to look after you and once you are feeling better in yourself, this weight will fall off. But right now, me just putting you on a diet is going to be another form of self flagellation that I.

[43:44] Sonya: Don'T think you need to add 100%. Yeah, absolutely. Okay, cool. Let's move into the few questions that I had from the online audience that came through. We touched on this one a little bit earlier and I think actually we've got a clear answer to this, but I'll address it anyway. There was a question around, do you have withdrawals when you stop taking your MHT?

[44:09] Ginni: I always make it clear to my patients, if you're going to go off HRT, just see it as an experiment that you're doing for yourself. I'm happy for you to do it anytime. I just wouldn't recommend it.

[44:17] Sonya: In summer thinking about taking MHT, but now her Perry symptoms have decreased and she's wondering if it would still be recommended for her to go on to MHT.

[44:27] Ginni: No. So we don't routinely put all women on HRT as just what you do if you hit a certain age. There's no evidence that at a population level that benefits women. We really do this on an individually tailored basis where we look at your symptoms, your health, and we base it on that. I very rarely do bone density on women who are still in Perry because you've got Oestrogen on board. It might be all over the show, but you still got it on there. So you will never in Perry be having it for a poor bone density unless you've got like celiac disease or rheumatoid arthritis or something. There's another contributor to poor bone density, but no, it's not just routinely chucked in the water.

[45:09] Sonya: Jenny there's one question that we didn't touch on, and that is a more specific Oestrogen that's often used so vaginal dryness, vulvis, that sort of thing, talk us through that type of oestrogen.

[45:22] Ginni: So, yes, thank you for asking that. Even though a lot of women get amazing effects from being on HRT on their vaginal dryness and needing to pee all the time and just discomfort down there, a lot of women don't. And for some reason, a lot of women we need to put oestrogen directly into the ******, even if they're on HRT. At the doses we use in the ******, we're looking at in terms of estrogen, because there's only ever estrogen we put into the ****** one year on a vaginal. Estrogen is like one day on an HRT, kind of an oral HRT. So just to put that in context, it's a really low dose, but it's often something that women are really embarrassed to talk to their doctors about. Dr. Nick Panay, who's a former chair of the British and also the International Menopause Societies, did this amazing study in which only 7% of women ever mentioned it to their doctor. Of women who are going through this problem, which is dreadful. And what I can tell you is, like with hot flushes, 19 out of 20 women, if you can be bothered waiting, you can wait it out and it'll get better. When it comes to vaginal dryness, it will get worse and worse and worse. And so as a result, my strongest recommendation is to get onto vaginal estrogen sooner rather than later and to stay on it for so long as you plan to be sexually active or are having vaginal symptoms that are unpleasant. So discomfort down there, recurrent urine retract infection, which is really common, it can even help a little bit with like, a little bit of prolapse or a little bit of incontinence. It can often help quite a lot down there. So even if you're not sexually active, some women still choose to stay on it and stay on it indefinitely. It's underused. There are, generally speaking, two forms, a cream and a pessary. A pestory kind of is exactly what it sounds like. You shove it up your ******, you start with what we call a loading dose, so it's every night for two weeks. Most men don't want to have their ***** bathed in oestrogen, so you can wait. If you're going to have sex, put the pessary in after the sex so that he doesn't get estrogen all over his willie, because he won't like that. It's much fun for him. And then in terms of the cream, again, two weeks, you just rub it in, you shove a little bit inside. The cream comes with an applicator which is very hard to clean, particularly for an oily substance like a cream. So I would just use the applicator to measure the amount out on your finger so you don't have to worry about washing it. It's just too difficult otherwise. So a little bit on the outside and the rest is on the inside. I find it a bit messy, the cream, but some women like the guy and some gynos just love the cream. They won't prescribe anything other than the cream. I just go through all the different options with my patients and let them decide. It is interesting. Even using a pessary that goes up. Still seems to work on the vulval tissues at the outside.

[48:10] Sonya: Well, okay, great. Awesome. Fantastic. I'm glad we finished off. On that note, Jenny, thank you so much for your time today. I was hoping for a deep dive into this and I think that's what we've achieved. I'm pretty sure we've gone into every nook and cranny that there is around hormone therapy and I truly hope that this episode is something that's helpful for women that are either considering or are currently on MHT and it might answer some of those questions. Thank you so much for your time.

[48:38] Ginni: Thank you.

[48:42] Sonya: Thank you for listening today. I am so grateful to have these conversations with incredible women and experts and I'm grateful that you chose to hit play on this episode of Dear Menopause. If you have a minute of time today, please leave a rating or a review. I would love to hear from you because you are my biggest driver for doing this work. If this chat went way too fast for you and you want more, head over to Stellarwomen.com Au podcast for the show Notes. And while you're there, take my Midlife quiz to see why it feels like Midlife is messing with your head.