# Menopausing: The positive roadmap to your second spring by Davina McCall >[!Abstract] Description > > Menopausing is more than just a book, it’s a movement. An uprising.  > > Menopause affects every woman, and yet so many approach it with shame, fear, misinformation or silence.  > > Why is no one talking about this? Who has the correct information? And how can we get it?  > > That’s how this book has come about. We are going to tell you the truth, so you can make an informed decision about your life and your body ... mic drop.’  > > For too long, women have had to keep quiet about the menopause – its onset, its symptoms, its treatments – and what it means for us. Menopausing will build an empowered, supportive community to break this terrible silence once and for all. By exploring and explaining the science, debunking damaging myths, and smashing the taboos around the perimenopause and menopause, this book will equip women to make the most informed decisions about their health... and their lives. > > Menopausing will also celebrate the sharing of stories, enabling women to feel less alone and more understood, and talk openly and positively about menopause. > > - No more scaremongering: just evidence-based info > - No shame: real women, real menopause stories, real empathy, real community > - Honest, no-holds-barred advice: Dry vagina? Zero sex drive? Hair loss? We’ve got it covered > - The start of a movement: to get everyone talking about the menopause in every home, GP surgery and workspace - Good for case studies and to hear other's thoughts %% ## Annotations ### Introduction: This is Happening, People … Menopausing ### [[nobody should have to lose years of their life to menopause]] > Because nobody should have to lose years of their life to menopause, or perimenopause. No one. ^ku-6- [Link](yomu://content/annotation/0F607616-B0DA-4575-A037-D43FA6E9DE4F) **06/01/2023, 14:32** > And yet it is absolutely one hundred per cent going to happen to fifty-one per cent of people in this country. It’s crazy. [Link](yomu://content/annotation/AC644B1F-0F3C-4FD8-A28F-A478FB4FD31F) **06/01/2023, 14:34** > Cut to two years later. I’d already called a doctor, worried that I had Alzheimer’s. The doctor said, ‘You haven’t got Alzheimer’s, because if you did you wouldn’t be calling me to ask me if you had Alzheimer’s, one of your relatives would be calling me to ask me if you had it.’ She said, ‘What you’ve got, probably, is cognitive overload. You are very stressed out, you’ve got a lot going on, and you’ve got three small children; you’ve just got too much on your plate.’ [Link](yomu://content/annotation/174D9F4D-13D6-4952-A36D-CC0515176DB0) **06/01/2023, 14:37** > My gynae did something that should happen to every single woman as a matter of course, whether you are seeing your local NHS doctor or going private: he actually listened. He sat me down, looked at my lifestyle and medical history and step by step took me through all of my individual benefits and potential risk factors of taking HRT. TOTAL game-changer. I wish GPs were able to have longer appointments. [Link](yomu://content/annotation/8EC51DB4-A9B4-4CB1-93F8-6906C78FF675) **06/01/2023, 14:38** > He then told me that in order to be able to take the transdermal HRT patches, which I put on my hips, I also needed to take progesterone, another hormone. He started me off on pills, but the pills made me feel ill, so after a while I went back and asked him if I could have the Mirena coil put in. Interestingly, I’d had the Mirena a long time before, and it hadn’t agreed with me. But actually I think that it wasn’t that it hadn’t agreed with me, I possibly was perimenopausal then, because when I had it put in to counteract the oestrogen in the patch, it was absolutely fine. I’ve had a Mirena ever since – swapping every five years. And, for me, that’s worked really well. [Link](yomu://content/annotation/9D818B7D-F1CF-48C9-9CFF-91F332E158EF) **06/01/2023, 14:39** > Then came the dark times of deceit, because I spent the next few years trying to pretend to everybody that I wasn’t on HRT. Trying to pretend that I’d always been this bubbly and bouncy. That this newfound kind of togetherness that I had, and energy and focus, and ability to read the autocue, was just me feeling great at forty-seven! I lied to friends of mine – I’ve got a couple of great friends who I love and respect so much, who are homeopaths and naturopaths, and I was so ashamed to admit to them, in particular, that I had gone down the HRT route. I felt that in some way I had failed as a woman, that I was weak. How come other people could soldier on and I couldn’t? [Link](yomu://content/annotation/14CB8023-B506-4C18-9E35-BFFE64450539) **06/01/2023, 14:40** > A huge change happened when I started to take testosterone as well. Testosterone has been amazing. After being on HRT for a while, I went back to see my gynaecologist and I said, ‘I still feel a bit lacklustre, like I don’t have much energy, a bit unfocused and bleeeugh.’ And he said, ‘Ok, well, let’s just test your testosterone levels.’ He told me, ‘Yes, you are low on testosterone, why don’t we just put you on that for a bit and see how it goes?’ [Link](yomu://content/annotation/4E853F93-D93B-48D1-818D-A0986FD3DC20) **06/01/2023, 14:41** > Testosterone can take a lot longer to take effect in your system, so improvements can take a while. It was not as big a ‘ta-da’ moment as I had when I took oestrogen, as you’re taking such tiny amounts daily; there are limits and you should be within those limits. I was taking what I should for a woman my age. It really, honestly felt – without being a complete cliché –the final piece of the jigsaw. And that’s what I call it: it’s the final piece of the HRT jigsaw. It is the one hormone that is still incredibly hard to get, and for some reason bathed in shame. [Link](yomu://content/annotation/C4A2D827-A010-49C0-B03C-8022B1792DA1) **06/01/2023, 14:42** > Remember, too, that we are not abusing these hormones to become body-builders or superhuman in some way; we are just replacing what we’ve lost. That is all it is: it’s hormone replacement, not extra hormones. And that’s really important. [Link](yomu://content/annotation/483D944A-0479-4B82-A894-B5EA05A9A0F1) **06/01/2023, 14:50** > So why did I lie about being on HRT? Because there is such a stigma around it, which stretches back two decades. And that explains why just one in ten women in the UK who would benefit from HRT actually take it.1 [Link](yomu://content/annotation/D279F8A7-D5F4-4802-91FC-7BFCDC062378) **06/01/2023, 14:51** > The crux of the problem lies with data released from the Women’s Health Initiative (WHI), a study carried out all the way back in 2002, and the damaging headlines that followed its publication. This study of American women and HRT claimed that HRT increased the risk of developing breast cancer, heart attacks and strokes. But re-analysis of the data has found that the average age of women taking part in the study was sixty-three (remember, the average age of menopause is fifty-one). The fallout was so damaging that women were literally flushing their HRT down the toilet, and numbers of women taking HRT plunged to an all-time low. [Link](yomu://content/annotation/8F462EBD-8A60-4F48-B131-544C2606A900) **06/01/2023, 14:51** > Sadly, the negative headlines have stuck, and to this day women find it difficult to access HRT from their doctor, even though it is the gold-standard menopause treatment. [Link](yomu://content/annotation/F1857C48-CCA1-413D-8B74-9A65AE134AFD) **06/01/2023, 14:52** > In 2021, my documentary Sex, Myths and the Menopause [Link](yomu://content/annotation/47A1F719-13A9-41BF-986F-AEF356FAB1AF) ### Chapter 2: Knowledge is Power: Perimenopause and Menopause Explained **13/02/2023, 15:05** > OSTEOPOROSIS Osteoporosis is a condition that makes our bones more prone to fractures. About three million people in the UK are thought to suffer from osteoporosis, but the condition is a lot more common in women.2 Our bones are at their strongest in early adulthood, but we all start to lose bone density from our mid-thirties onwards. Oestrogen helps to maintain our bone structure and strength. The loss of oestrogen after menopause can accelerate the loss of bone density and put you at risk of osteoporosis. Osteoporosis isn’t a painful condition, which means it often only gets diagnosed after a fracture which can be from something as minor as a bump or fall. Taking HRT can improve bone density.2 [Link](yomu://content/annotation/DBADA968-A63B-4667-B270-0BC0F9EB507D) **13/02/2023, 15:05** > CARDIOVASCULAR DISEASE Heart disease is the number one killer of women in the UK. In fact, coronary heart disease kills more than twice as many women as breast cancer. 3 Cardiovascular disease (CVD) refers to conditions affecting the heart or blood vessels, including heart disease, angina, heart attack, high blood pressure, stroke and vascular dementia. > > CVD affects around seven million people in the UK, and you are more at risk if you have diabetes or a family history of heart disease, and if you are a smoker. > > Declining oestrogen during and after menopause increases the risk of CVD. Oestrogen helps to keep the arteries (which carry blood away from the heart to other parts of the body) smooth and flexible. Once oestrogen declines, your arteries are more prone to developing a lining of fatty plaque, which narrows the arteries and makes you more likely to have a heart attack or stroke. Oestrogen also helps to regulate cholesterol levels and body fat distribution – too much fat around your mid-section also increases the risk of CVD. [Link](yomu://content/annotation/DFF6A853-BC3D-46A4-830C-0C5AD2166FBC) **13/02/2023, 15:06** > DEMENTIA Worldwide, women with dementia outnumber men two to one.4 The exact reason behind this is not yet known. > > We do understand that oestrogen protects against vascular disease, and one of the causes of dementia is vascular dementia. It is therefore logical to assume that HRT can prevent vascular dementia. > > There are a number of different types of dementia and there is emerging evidence that HRT may well protect against those as well, but further research is necessary. [Link](yomu://content/annotation/89DA2A73-32A2-4136-A3B0-E271CF70ED42) ### Chapter 3: From Dry Vag to Zits: Signs You Might Be Perimenopausal or Menopausal **13/02/2023, 15:11** > WHY DO HOT FLUSHES HAPPEN? > > It’s thought that lack of oestrogen affects the hypothalamus, the part of the brain that helps regulate body temperature. When this is disrupted, the brain can think the body is overheating which causes blood vessels close to the surface of our skin to dilate to try to cool us down. This gives us the hot flush. > > In addition, our bodies try to cool us down by making us sweat. Food and drink can also trigger hot flushes, or make them worse, such as alcohol, spicy food and even smoking. [Link](yomu://content/annotation/75CA04BB-4BA3-44C0-9E07-58332D07FE80) **13/02/2023, 15:11** > COLD FLUSHES Nope, believe me, you haven’t left the freezer door open. > > The opposite of a hot flush is very possible. A cold flush is a sudden onset of shivering, chills and an icy cold feeling through the body. A cold flush can immediately follow a hot flush, or can occur in isolation. [Link](yomu://content/annotation/1F6DBDFF-F5E6-4E72-8DCE-FC2F146BEA6A) **13/02/2023, 15:12** > It didn’t happen all the time; it would come and go. But sometimes it would break out, often while I was trying to get the kids into the car on the school run, and I would feel so bad and I would look at their little faces because they’d be thinking, Who is this? I hated myself, and I didn’t understand what was happening to me. Rages [Link](yomu://content/annotation/C09847A9-403A-45B6-A78A-9D7886576E0B) **13/02/2023, 15:13** > We have lives that are so crazy and so busy, and look, there are plenty of reasons why we might seem stressed out. > > But moods aren’t always down to whatever job you do, or a tricky relationship, or trying to get the kids to school, or whatever you’ve got on your plate. Sometimes it is actually down to chemicals. Rage [Link](yomu://content/annotation/AE2B2E12-FC82-472C-A7E5-391D38314516) **20/02/2023, 18:20** > Religion can also play a huge factor in seeking help. Some see health issues as a test from Allah or something you have to bear as a testament to your commitment to your faith. [Link](yomu://content/annotation/FA573EB3-D681-4A02-A75E-26A906BEE572) **20/02/2023, 18:20** > Then there is the language barrier when seeking help. Women for whom English isn’t their first language can struggle to express what their symptoms are. Menopause doesn’t cross the language barrier in some cultures and women can find it hard to vocalise their symptoms in terminology Western-trained doctors will understand. In my native language Punjabi/Urdu there is no direct translation for the word ‘menopause’. The closest word is banjee, which means ‘barren’. Having to rely on relatives to translate just adds to the feelings of embarrassment. [Link](yomu://content/annotation/1B5951DB-61D8-4584-8499-5A23B7555DDB) **22/02/2023, 14:17** > ELECTRIC SHOCK SENSATION This isn’t a symptom that I’ve ever had, but I’ve spoken to friends of mine and they say it is a really weird sensation and not one that they had ever associated with perimenopause or menopause. It’s a bit like getting elastic bands twanging under your skin, and it can also be associated with restless leg syndrome, or you can feel like they are twanging under your hair, in your arms, in your legs. It can happen on its own, it can be a bit of a precursor to a hot flush, but it’s very annoying. It often happens in bed, and it’s about the messages that go between your nervous system and your brain. And sometimes they misfire [Link](yomu://content/annotation/BF46AD3D-CE89-4F18-BD55-267BF4C497CF) **22/02/2023, 14:19** > THE (DRY) EYES HAVE IT What’s really interesting is that I went to the optician the other day, to have my eyes tested, and she said to me, ‘Oh, you’ve got dry eyes.’ I’ve never had that before, but this is a symptom that I’d developed over the last few years. My eyes didn’t feel gritty, or sore, but she did say that it is important to keep your eyes lubricated. > > Every time we blink we leave a thin layer, called a tear film, which helps keep our eyes nice and moist and comfortable, and our vision clear. Dry-eye syndrome can make you feel gritty and sore, but it can be something that you’re not aware that you have. That’s why it is really useful to still go and see an optician, especially when you’re perimenopausal or menopausal. Dry-eye syndrome is when they feel tired, or itchy, or – weirdly – sometimes they can water a lot – especially in cold or windy weather, so you look like you’re crying, which is what I had. [Link](yomu://content/annotation/32D342DB-BEDE-4D75-8D32-055F25EBF7E8) **22/02/2023, 14:19** > Studies show that skin loses about a third of its collagen during the first five years of menopause.5 And it’s not just collagen that we wave goodbye to, we’re also losing the fatty lipid layer that sits on the skin barrier and protects. And because that layer is compromised, we lose more water via the skin, which can leave the skin dry, dull, flaky and more sensitive. [Link](yomu://content/annotation/64E457E0-171D-4612-932B-42753E7C02A7) **22/02/2023, 14:20** > It may sound like something you get up to in the bedroom, but formication is the name for a sensation of ants crawling on your skin. The scalp and calves are most often affected, and again it all comes back to oestrogen and the depletion of the fatty lipid layer on the skin. [Link](yomu://content/annotation/3DFAA730-3DEC-4DEF-AA08-A5C74359BD05) **22/02/2023, 14:20** > Declining oestrogen can affect the texture of our hair, leading to breakage and a receding hairline, especially around the temples. On the flip side, you might find you are sprouting more facial hair – it’s those androgens (male hormones like testosterone) taking centre stage again. [Link](yomu://content/annotation/428E55F8-8560-4BBA-8ABA-DBD66D3296FD) **22/02/2023, 14:21** > Tinnitus is the term for any ringing, buzzing or whooshing sounds in one or both of your ears. At best it is an inconvenience that comes and goes, at worst it can be debilitating and disrupt your everyday life. About one in eight people in the UK suffers from tinnitus and, guess what, it can be more common in perimenopause and menopause. Sadly, the exact cause isn’t yet known. [Link](yomu://content/annotation/B3F802D0-E07B-4B71-8E77-80C5303E9A6D) **22/02/2023, 14:22** > A growing area of research is the interaction between oestrogen and histamine levels. Histamine is a chemical we produce when the body thinks it’s under threat from foreign invaders, but it is also found in foods like tomatoes, avocados, pulses, dairy, alcohol and caffeine. > > But what does this have to do with perimenopause and menopause, I hear you say? It’s thought that fluctuating hormone levels may interfere with the way we get rid of the histamine, or lead to overproduction of histamine. There are loads of symptoms linked to histamine intolerance and a lot of them crossover with other perimenopause and menopause symptoms, such as hives, itchy skin, headaches, joint pain, fatigue and urinary symptoms like cystitis (inflammation of the bladder that triggers that awful burning sensation when you have a wee). Histamine intolerance can also trigger shortness of breath, a sore throat, stuffy nose and cough. [Link](yomu://content/annotation/0EC8FCEA-047F-49F7-ACE2-94D4292B1DCC) **22/02/2023, 14:22** > The issue of histamine sensitivity is a recently identified phenomenon and only just becoming widely known. The paradox is that in perimenopause, lower levels of oestrogen seem to trigger histamine sensitivity, but treating lower oestrogen levels can also trigger histamine intolerance. Women with these symptoms find accessing the appropriate care challenging but treatment generally involves cautious use of HRT and the lowering of histamine triggers, including possible dietary changes. [Link](yomu://content/annotation/FC3E61F3-29AA-4C76-8DB8-3637B40E64E3) ### Chapter 4: Early Menopause and Premature Ovarian Insufficiency **22/02/2023, 14:28** > WHAT IS AN EARLY MENOPAUSE AND WHY DOES IT HAPPEN? [Link](yomu://content/annotation/43CA218E-1BB6-480B-9D56-A2D83F7B8AEE) **22/02/2023, 14:28** > So, we know the average age of menopause is fifty-one. ‘Early menopause’ describes menopause under the age of forty-five. Menopause under the age of forty is known as premature ovarian insufficiency (POI). As the stats at the [Link](yomu://content/annotation/8ADF0C03-DEEE-4ABA-8942-F5423248B292) **22/02/2023, 14:29** > start of this chapter show, early menopause and POI are more common than you think – one in 100 women will go through POI menopause before the age of forty. [Link](yomu://content/annotation/F025333E-D6D1-4D37-AAEF-9C10E7AE174A) **22/02/2023, 14:29** > So why does it happen? It’s not always known exactly what causes POI, but in most cases it is down to one of the reasons described below: [Link](yomu://content/annotation/E259E38D-3E03-4762-8AB6-0BC878D1FC56) **22/02/2023, 14:29** > Autoimmune conditions, where your immune system mistakenly thinks a part of your body is a foreign invader and starts to attack rather than protect it. There are any number of autoimmune conditions that affect many organ systems including thyroid, skin, hair and joints. There is a correlation with women who have POI and other autoimmune conditions. [Link](yomu://content/annotation/E346C48F-F7A7-4B73-A3E0-AAD655260E3A) **22/02/2023, 14:29** > Genetic conditions, one of the most common of which is Turner syndrome. Genetic conditions like Turner syndrome are more likely to be the cause of POI if you are very young at diagnosis [Link](yomu://content/annotation/667D5BC0-D034-496B-ADD5-6FF42BB21440) **22/02/2023, 14:29** > Cancer treatment, such as chemo or radiotherapy to your pelvic area which causes temporary or permanent damage to the ovaries. [Link](yomu://content/annotation/CDC65ABC-D1B2-4821-8646-9A18CF9FF1A6) **22/02/2023, 14:29** > Surgery where the ovaries are removed, which could be due to a number of reasons, for example a painful condition where tissue similar to the lining of the uterus begins growing in places such as the ovaries. Surgical menopause tends to give more extreme symptoms as the source of the hormones is removed overnight. [Link](yomu://content/annotation/78A438B4-6603-4EFF-B750-329E2D1F2933) **22/02/2023, 14:29** > Infections causing early menopause are rare, but there have been cases where mumps, malaria, HIV or tuberculosis have been identified as the cause. [Link](yomu://content/annotation/B13B53A9-5E59-4A5F-88A5-6229697CFB72) **22/02/2023, 14:30** > WHAT CAN BE THE SIGNS OF POI? > > You might experience any menopausal symptoms, but these are the ones which may help you identify POI if you are under forty: > > Missed or irregular periods Problems getting pregnant Low libido Hot flushes and/or night sweats Mood swings/worsening PMS Vaginal dryness or soreness Recurring urinary tract infections [Link](yomu://content/annotation/940FFD55-02FC-4F2A-8E29-E95500CF5F4C) **22/02/2023, 14:31** > WHY EARLY TREATMENT IS SO KEY POI can occur at any age, even as young as the early teens. Because there is so little awareness of the condition, it can go undiagnosed for years but it’s so important it is identified early to protect overall health. > > As we will be covering in the next couple of chapters, HRT is the first-line treatment for menopause. It helps with symptoms, but also has an important, long-term protective effect against health problems like osteoporosis and cardiovascular disease. > > Getting a diagnosis of early menopause, particularly POI, is so important because having depleted oestrogen levels at an earlier age puts you at greater risk of long-term problems like osteoporosis and cardiovascular disease. > > The current guidance for healthcare professionals from the National Institute of Health and Care Excellence (NICE) is that women with POI or early menopause should take HRT at least until fifty-one, the average age of menopause. > > Surgical menopause (when the ovaries have been removed at operation), can cause symptoms to be particularly severe and distressing because of the sudden total loss of oestrogen (and decrease in testosterone). > > When you are younger, your oestrogen requirements will be higher, so you may need a higher dose of oestrogen in HRT. In addition, younger women can also be more severely affected by the loss of testosterone, so you may need it earlier, and in higher doses (you’ll find more advice on HRT in the next chapter). > > Another option that younger women may prefer is the combined oral contraceptive pill, which contains both oestrogen and progesterone. There are some brands better suited to treating menopause than others, so please do discuss this with your doctor. [Link](yomu://content/annotation/B44507AF-5DD3-495E-B826-55EAE9B4C4F4) **22/02/2023, 14:31** > WHAT ABOUT FERTILITY? > > There is roughly a 5–10 per cent chance of getting pregnant naturally following a POI diagnosis.2 And as we get older, the chance of getting pregnant, along with the quality of our eggs, decreases and the risk of miscarriage goes up. > > If you have POI and think you may want to have children now or in the future, make sure you get referred to a fertility specialist to talk about your options as soon as possible. The Daisy Network is an excellent charity which offers support to women with POI (www.daisynetwork.org.) [Link](yomu://content/annotation/5F2E0D48-3419-4990-A235-899216BFACEA) **22/02/2023, 14:31** > WHAT ABOUT CONTRACEPTION? DO I NEED IT? > > Yes, if you still have ovaries and want to avoid getting pregnant, because HRT is not a form of contraception. Even women with a long-standing history of POI still need contraception if they want to be certain not to get pregnant. [Link](yomu://content/annotation/98C21215-F594-4E8C-ABE2-1C2FDE094595) **22/02/2023, 14:31** > HOW LONG TO TAKE IT FOR? > > Typically, if you are under fifty, you should take it for two years after your last period. (When a woman is over fifty, it should be taken for one year after the last period.) It is slightly different in women with POI due to the small chance of ovulation and you should discuss this with your doctor. > > Some good options are the Mirena coil, which can also act as the progesterone element of HRT, or a combined oral contraceptive pill, which has both oestrogen and progesterone. Over the age of fifty-five, a woman is no longer considered to be fertile and so you can cease to use contraception. [Link](yomu://content/annotation/67D834E2-608F-46FA-8761-B1DB0EE4E927) ### Chapter 5: Now For the Science Bit: HRT Demystified **22/02/2023, 14:33** > Even though HRT has been available for half a century, so many of us just don’t know enough about it (and I’m counting myself amongst that number, before I started on my menopausing crusade). I mean really, like, almost nothing. And 10 per cent of women who would benefit from it are actually taking it.1 That is such a tiny number, and I believe that is mostly because HRT is still considered ‘bad’ for us. [Link](yomu://content/annotation/825B0134-590D-429A-9DED-5CC9D634583E) **22/02/2023, 14:35** > Let’s once and for all clear up the misconception that HRT is a last-resort treatment if you can’t cope, or when symptoms get too bad. Look, think about it for a second. If you were thyroid deficient (like I am), is taking thyroxine ‘giving in’? No. If you are diabetic, is taking insulin ‘giving in’? No. If you need oestrogen, is taking HRT the easy way out? NO. If you lack oestrogen, taking HRT is NOT GIVING IN. And no one – NO ONE – should ever make you feel embarrassed, ashamed or scared about opting for HRT. [Link](yomu://content/annotation/4799D939-B595-48F6-B86C-BE327C8A6AFE) **22/02/2023, 14:40** > Back in the 1940s, the Food and Drug Administration in America approved Premarin, an oestrogen product designed to treat hot flushes. And yes, it was made from horse urine. In fact, the name comes from PREgnant MARes’ urine. However, the oestrogen we use now is practically identical to the oestrogen our bodies produce, and it’s rare for Premarin to be prescribed these days [Link](yomu://content/annotation/E7A8D643-1A3D-4E2C-9F25-1B3B0FC5FE47) **22/02/2023, 14:41** > HRT is only available on prescription and it will: Nearly always contain oestrogen. > > Often contain progesterone. > > Sometimes contain testosterone. > > If your HRT only contains oestrogen, it’s known as oestrogen-only HRT. If your HRT contains oestrogen and progesterone it is called combined HRT. If you take oestrogen and progesterone every day it is called continuous combined HRT and if you take oestrogen every day but progesterone for only part of the month it is called combined sequential HRT or cyclical HRT. [Link](yomu://content/annotation/18E5CFAB-F997-404D-9231-2C05C0D0C403) **22/02/2023, 14:44** > Taking oestrogen on its own without progesterone can overstimulate the lining of the womb, which is called the endometrium. If this was to continue over time, eventually it could lead to endometrial cancer. This risk is reduced by prescribing progesterone, or progestogen, as the synthetic version of progesterone is known. [Link](yomu://content/annotation/24FF265F-CEB4-48B1-AEBC-CC0FE857C544) **22/02/2023, 14:58** > DR NAOMI’S HRT MASTERCLASS PART 1: OESTROGEN When you replace oestrogen, whatever method you choose will deliver oestrogen to you daily. The most commonly used oestrogen these days is called 17-beta estradiol. This is a body-identical hormone, which means it has the same structure as the oestrogen made by your body. Oestrogen can either be given transdermally (through the skin) or orally (by mouth). How well one method works over the other will depend on how well your skin absorbs oestrogen. Unfortunately, there is no real way of knowing about absorption in advance, so the first few months can be a case of trial and error. But be patient, trust the process. You will get there. [Link](yomu://content/annotation/ACF9A8EC-2EC6-426B-AB50-867C0C6E4AF3) **22/02/2023, 14:58** > TRANSDERMAL OESTROGEN: This is oestrogen that is delivered via the skin in the form of a patch, gel or spray. Unlike when you take oral oestrogen, transdermal HRT bypasses your liver and there is no increased risk of blood clots, stroke or gallbladder disease. [Link](yomu://content/annotation/91F3A53C-2F72-43AD-A107-593553CBF9EF) **22/02/2023, 14:58** > PATCHES > > A patch will contain oestrogen which is absorbed through the skin and sometimes is combined with progesterone. The oestrogen-only patches come in a variety of strengths. They are small, thin plastic squares that stick to the skin. > > Pros > > + Patches are clear, so they are suitable for all skin colours. > > + It’s a discreet method, as you can fit them underneath a bikini or swimsuit. > > + They are convenient if you are short on time. > > + They come in different sizes and doses – starting at 25 micrograms and working up to 100 micrograms, so they can be a good option if you need higher doses. > > How do I use them? > > Peel off the foil backing and stick the patch on your bottom, thigh or upper leg. It releases a steady dose of oestrogen and normally needs replacing twice a week. > > Cons > > – Some women find the patches are hard to keep in place, especially if they have oily skin. They might come off in the shower, or the edges start to curl. They can be unpleasant to remove. > > – If you opt for a patch you are committing to a set dose, so it can be harder to adjust the dose if you need to. In some circumstances, you can cut the patches up to have a smaller dose, but you should only do this under the direction of your doctor. > > – Some women don’t like the fact that they are partially visible. [Link](yomu://content/annotation/255EEAAE-79F4-4B00-A6BF-380A70091D52) **22/02/2023, 14:58** > GEL > > There are two types of gel available in the UK: a pump bottle or a sachet called Sandrena. The pump bottle, known as Oestrogel, is widely available on the NHS and it is very cost-effective, so there’s no reason why it can’t be an option. There are also versions available in Australia, Canada and the US. > > Pros > > + Like the patches, this is transdermal so it bypasses the liver. > > + Gel absorbs well into the skin. > > + It is convenient because you can use tiny doses, so if you are hormone-sensitive you can start with a small dose and build it up. > > + Some women prefer the convenience of sachets when travelling. > > How do I use it? > > With Oestrogel, you push the top of the dispenser down and it releases a ‘pump’ or little blob of gel. You spread the gel as thinly as possible on the inside and outside of your arm from your wrist to your shoulder, but you can also put it on thighs, tops of legs, bottom, inner thighs – just make sure you avoid the breast area. > > Cons > > – If you are using a higher dose you’ll need copious amounts – four pumps doesn’t sound like much but it is enough to cover all four limbs. > > – Some women don’t like the sticky, cold feeling of applying gel, especially in winter. > > – The sachets can be messy and less precise than a measured pump and create more waste. > > – You need to give it time to dry so it won’t rub off on your clothes, and remember to wash your hands afterwards to avoid rubbing it onto your kids, partners or pets. [Link](yomu://content/annotation/DF639DED-393A-4F23-9633-97B19442F8C4) **22/02/2023, 14:59** > SPRAY > > The spray is called Lenzetto and is one of the newest products, launched in the UK in 2020, but it is starting to become more readily available. It can now be accessed in countries across Europe, the USA and Australia. > > Pros > > + Like gel and patches, the spray is transdermal. > > + Quick application and dries quickly. > > + Less copious and less of an alcohol smell compared to the gel. > > + The dose is easy to increase or decrease. > > How do I use it? > > Take off the plastic cover, hold the bottle upright and rest the plastic cone flat against your skin (a lot of women use the spray along their inner forearm, or inner thigh). Press the pump to release one spray; if your prescription calls for more than one spray, move it further down the arm or thigh for each additional spray. > > You’ll need to let the spray air dry for about an hour before allowing clothing to touch it, and wait at least another hour before showering or swimming. > > Cons > > – It can be harder to get it prescribed on the NHS. > > – It can require quite a few sprays to eliminate symptoms. > > – You need to let it dry before clothing can touch it. [Link](yomu://content/annotation/AD58693B-3829-400C-ADC8-CA6AFB5D1AA7) **22/02/2023, 14:59** > SYSTEMIC OESTROGEN: ORAL TABLET > > When women start HRT they are often prescribed oestrogen in tablet form. It is often combined with progesterone. There is a new product called Bijuve, which is a body-identical oestrogen and progesterone in one tablet. It is suitable for post-menopausal women. > > How do I use it? > > Take one tablet daily. > > Pros > > + A pill can be convenient if you are used to taking a tablet daily, for example the contraceptive pill, and you like that kind of familiar routine. > > + If you have skin sensitivity an oral tablet could be beneficial, as it might be harder for you to find a transdermal (through the skin) product that you aren’t allergic or sensitive to. > > + It can be an easy way of taking both oestrogen and progesterone together. > > Cons > > – Taking an oral version of oestrogen slightly increases your risk of a blood clot, stroke and gallbladder disease. [Link](yomu://content/annotation/15D2CF67-9168-4CD3-ABF1-03EDB86059E2) **22/02/2023, 14:59** > VAGINAL OESTROGEN: > > Vaginal dryness and urinary symptoms can be a huge issue during perimenopause and menopause. Thinning tissues can lead to itching, soreness and painful sex, but also urinary symptoms such as going more often, getting up at night and leakage as well as recurrent urinary tract infections. When systemic HRT (in the form of a gel patch, spray or tablet) puts back the oestrogen, this can help the genital tissues become soft and supple again, but about one in three women will need something extra: topical oestrogen. > > Topical oestrogen includes creams, rings and pessaries that you insert inside your vagina or apply to your vulva. Oestrogen can then act directly on local tissues but because it is minimally absorbed, there is practically no risk. We’ll be looking at topical oestrogen in much more detail in the Dry Vagina Monologues chapter. [Link](yomu://content/annotation/27D7B92C-DB1C-441E-BFC3-EB2C006DE2A3) **22/02/2023, 14:59** > DR NAOMI’S MASTERCLASS PART 2: NOW FOR THE PROGESTERONE BIT If you take oestrogen and you have a uterus you will need to take progesterone, too. Two of the best options are micronised progesterone (Utrogestan, Cyclogest and Lutigest) and the Mirena coil [Link](yomu://content/annotation/8E0036A3-401F-4989-A267-911B4385C78B) **22/02/2023, 14:59** > MICRONISED PROGESTERONE > > Micronised progesterone is the most body-similar progesterone available. This means it has practically the same chemical structure as the progesterone in our bodies. > > Pros > > + This is the safest progesterone for breasts. > > + It is body identical – it has the same chemical structure as the progesterone in your body. > > + It has fewer side-effects than older types of progestogen. > > + Has a sedative effect – so it is recommended you take it at nighttime. > > How do I use it? > > If you are post-menopausal you take an oral tablet daily. If you are in the perimenopause you take an oral tablet for part of the month as a cycle. It is sometimes prescribed by specialists off-licence to be used vaginally if you have progesterone-type side-effects. > > Cons > > – Bleeding can be a side-effect in the first few months. > > – Some women – particularly those who have had PMS in the past – can be particularly sensitive to progesterone. It can trigger PMS-type symptoms like anger, rage, tearfulness, breast tenderness and bloating. If you experience these symptoms, please speak to your doctor about changing your dose or the method of delivering it. [Link](yomu://content/annotation/EC9DECE5-D46C-4B76-BBA7-88D4D5128B6D) **22/02/2023, 14:59** > MIRENA COIL > > A Mirena coil is a soft, flexible, T-shaped device which releases progestogen at a slow and steady rate. It can be used as the endometriol protection component of HRT. It can stay in place for up to five years. It’s an excellent option if you are looking to combine your HRT with a contraceptive. > > Pros > > + It helps control bleeding. > > + It acts as a contraceptive. > > + It releases a steady amount of progesterone that is minimally absorbed, so it is a good option if you are sensitive to progesterone. > > + It stays in place for five years, so you don’t have to remember to take tablets. > > How do I use it? > > This must be fitted by a doctor or nurse. It takes about twenty minutes to fit, and is inserted into the uterus. Once fitted, you should not be able to feel it. > > Cons > > – While the vast majority of women have a coil fitted without pain or side-effects, for some women, fitting can be uncomfortable. If you experience discomfort, please ask your practitioner to stop. To reduce discomfort take some paracetamol beforehand. Book the afternoon off work to rest after it is fitted. [Link](yomu://content/annotation/46A4A504-FE5D-45A1-A581-A5652A1D9360) **22/02/2023, 15:00** > Testosterone is a female hormone – we actually produce more testosterone than oestrogen.2 When testosterone levels fall during perimenopause and menopause, it can manifest as loss of libido, strength, power, get up and go, and brain sharpness. Replacing it as part of HRT can be the final piece of the jigsaw [Link](yomu://content/annotation/F2B3E503-A2AA-4905-BD78-0387D110D785) **22/02/2023, 15:02** > Guidance from the British Menopause Society is that: if a woman has been adequately re-oestrogenised with HRT but her symptoms have not completely resolved, especially if she has a symptom of low libido, then testosterone replacement should be considered. [Link](yomu://content/annotation/8E208394-63BE-4DB8-9CC7-CEC8519819F6) **22/02/2023, 15:04** > Every woman’s experience of taking HRT is different, but as a guide this is when you can expect to feel better once you start taking HRT. > > 1 week–1 month Symptoms such as hot flushes and night sweats can start to ease off within a couple of weeks. You may feel like any anxiety is starting to lift. > > 1 month–3 months Mood issues, aches, pains and skin-related symptoms may improve. > > Vaginal dryness and urinary symptoms can also resolve within a few months. If they don’t, please ask your doctor about the possibility of using vaginal oestrogen (see here). > > Up to 1 year Libido can be one of the last things to come back. > > The perimenopause can be a moving target because there will still be your own hormone production carrying on in the background. [Link](yomu://content/annotation/012A395A-51CC-4837-8311-14A04D1BBED8) **22/02/2023, 15:04** > LET’S TALK ABOUT SIDE-EFFECTS Short-term side-effects from oestrogen can include breast tenderness or nausea. Starting on oestrogen can also lead to some irregular, and sometimes heavy, bleeding. This can last for about three to six months. > > Some women can really struggle with the side-effects from progesterone, particularly those who already suffer from PMS. Side-effects can include breast tenderness, anger, rage, tearfulness and bloating, puffiness or swelling, and gastric symptoms such as acid reflux. If this is the case, please discuss with your doctor other ways that you could take progesterone. [Link](yomu://content/annotation/1B40B820-DCBB-423B-9DB6-731002A5545F) **22/02/2023, 15:04** > POTENTIAL RED FLAGS Should you experience any of the following symptoms, please discuss with your doctor urgently: > > Any new bleeding (unless you have just started HRT or have just increased the dose) or heavy or unexplained bleeding that lasts for three to six months. > > Any pain in your calves, or shortness of breath, as this could be a sign of a clot. Oral oestrogen can slightly increase the risk of clots. > > Itching, swelling and shortness of breath could be a sign of an allergic reaction. > > Breast swelling, lumps or tenderness, particularly if it is on one side only. [Link](yomu://content/annotation/886FF00A-05C3-4D00-99AC-B57AD6F02796) **22/02/2023, 15:06** > I’M ON HRT AND SOME OF MY SYMPTOMS HAVE STARTED COMING BACK. WHAT’S GOING ON? > > When some women start HRT, there can be a ‘honeymoon effect’ where symptoms can resolve very quickly. However, this effect can wear off. This can be for multiple reasons; if you are perimenopausal, your initial HRT can work perfectly well at giving you a top-up, but as you move into menopause your body requires more. It can also happen to older women who have been on HRT for some time. [Link](yomu://content/annotation/45254204-FF77-4C18-A2C0-9E6943550384) **22/02/2023, 15:07** > THE BENEFITS OF HRT Addressing troublesome menopause symptoms is only part of the story when it comes to HRT; it also has some really important protective qualities that can be overlooked in the conversations around symptoms, patches, coils and routines. For me, the long-term benefits are just as important as getting rid of the symptoms. [Link](yomu://content/annotation/B0E7DE13-61E1-4AA6-AA75-0D1CE53405DD) **22/02/2023, 15:07** > BONE HEALTH When taken at the start of menopause, HRT can help prevent bone loss.4 It is especially important if you have an early menopause or POI, but it can protect women of any age. > > Some studies have shown that HRT can increase bone density by around five per cent in two years, and that it can reduce the risk of spinal and hip fractures by forty per cent.4 [Link](yomu://content/annotation/CFBB8FEC-BDC2-4B4A-BDFA-57C85953AC61) **22/02/2023, 15:07** > HEART HEALTH Studies show that HRT may actually reduce your risk of heart disease if started before the age of sixty or within ten years of your menopause.5 Coronary heart disease kills more than twice as many women as breast cancer in the UK every year, and it is the single biggest killer of women worldwide.6 [Link](yomu://content/annotation/5EA49428-F448-41FB-8050-7E2A5CCAED37) **22/02/2023, 15:07** > METABOLIC HEALTH There is evidence that oestrogen keeps fat distribution peripherally, which is healthier than being around the trunk. It may also have a beneficial effect on cholesterol7 and sugar metabolism.8 [Link](yomu://content/annotation/15175C00-CB5C-48DC-B814-B49AF7D0944B) **22/02/2023, 15:07** > SKIN HEALTH Oestrogen helps maintain collagen structure, skin hydration, elasticity and skin integrity. Hormone replacement therapy (HRT) has been shown to increase epidermal hydration, skin elasticity, skin thickness9, and also reduces skin wrinkles.10 Furthermore, the content and quality of collagen and the level of vascularization is enhanced.11 [Link](yomu://content/annotation/3439F24A-D25F-4B05-A344-4D378D1440B0) **22/02/2023, 15:07** > BRAIN HEALTH Currently, the effect of HRT on the risk of dementia isn’t very clear – some studies have found women who take HRT have a reduced risk of dementia, while others have contradicted this. > > However, a 2021 study involving more than 600,000 women over three decades concluded that HRT is not linked to an increased risk of dementia.12 [Link](yomu://content/annotation/702C6ED5-8BB3-4A0B-AAB6-8E5BEAC38805) **22/02/2023, 15:07** > A 2022 study from the US reported that taking HRT for six years or more substantially decreases your risk of Alzheimer’s and dementia, and many other neurological illnesses. In fact, women who underwent menopausal hormone therapy for six or more years were seventy-nine per cent less likely to develop Alzheimer’s and seventy-seven per cent less likely to develop any neurodegenerative disease.13 [Link](yomu://content/annotation/AA23BF99-45C1-4045-9FE7-A7302AAD5A9C) ### Chapter 16 **22/02/2023, 15:11** > The WHI was a large clinical trial that started in the USA in 1993. The aim of the trial was to look at the health effects on thousands of women taking oestrogen-only or combined HRT. > > But in 2002, the combined HRT arm of the study was suddenly halted amid findings of an increased risk of breast cancer, heart disease, stroke and blood clots among the 16,000 women taking combined HRT in the trial. > > The findings were released and caused a media storm, making front-page news around the world. It alleged that breast cancer increased by 26 per cent when women took combined HRT, while the risk of heart disease, stroke and blood clots also increased.³ Unsurprisingly, the impact of these findings and how they were reported in the media was absolutely devastating. [Link](yomu://content/annotation/CFF8D5BD-B5A2-470C-9837-D17A95E0A45A) **22/02/2023, 15:11** > Between 2003 and 2007 in the UK alone, the numbers of women on HRT plummeted from two million to one million.3 The labels that ‘HRT causes breast cancer’, that ‘HRT is unsafe’ stuck, right up to the present day. [Link](yomu://content/annotation/FB1C2869-6E6D-49B9-A140-D4FECA00CF8D) **22/02/2023, 15:11** > WHAT WAS WRONG WITH THE STUDY? > > But when we look more closely at the study, there were flaws in its design:4 > > It only looked at one dose and type of combined and at one dose and type of oestrogen-only HRT. In addition, the oestrogen was an older, oral type and the progestogen was also an older type. As we know from Dr Naomi’s HRT masterclass in the last chapter, HRT is not a one-size-fits-all treatment. There are literally dozens of different combinations and dosages that are tailored to you and your health. > > The mean age of women participating in the trial was sixty-three years – more than a decade older than fifty-one, the average age of menopause. In fact, the oldest women involved in the trial were aged seventy-nine. This means that, due to their age, the women already had an increased risk of breast cancer and cardiovascular events. > > Because the trial was stopped early, the preliminary findings were incorrectly applied to all age groups, including lower-risk women in their late forties and fifties. > > The majority of the women in the study were overweight. Being overweight increases the risk of heart disease, breast cancer and other cancers. > > There was a substantial number of drop-outs from the study. [Link](yomu://content/annotation/6251FC6A-62F8-4A6C-85ED-BFFAD0969847) **22/02/2023, 15:11** > The latest study confirms what we already thought was the case that oestrogen-only HRT does not increase the risk of breast cancer. Oestrogen plus micronised (body-identical) progesterone is also not associated with an increased risk of breast cancer. Oestrogen with synthetic progesterone is associated with a small increased risk of breast cancer.5 [Link](yomu://content/annotation/83154932-9D69-420C-A77F-05B7DB47F71E) **22/02/2023, 15:12** > Twenty-three out of 1,000 women aged between fifty and fifty-nine will develop breast cancer over the next five years. In comparison, twenty-seven out of 1,000 women aged fifty and fifty-nine will develop breast cancer if they use combined HRT with a synthetic progesterone. By comparison, twenty-eight women out of 1,000 in the same age group will develop breast cancer if they drink two or more units of alcohol a day. And the most telling statistic, forty-seven women out of 1,000 aged fifty and fifty-nine will develop breast cancer if they are overweight or obese.6 If you exercise for two and a half hours a week you can reduce your risk of breast cancer by the same degree as combined HRT with synthetic progesterone increases it.5 [Link](yomu://content/annotation/49686B1D-7881-4E43-92AE-7F8B64AB56B1) **22/02/2023, 15:12** > There is a slightly increased risk of developing a blood clot if you take oral oestrogen. There is no increased risk of blood clots from using oestrogen through the skin. The leaflets inside the packets of HRT are inaccurate as they advise that transdermal HRT increases this risk, but that is not the case. > > Studies show that transdermal HRT (through the skin) does not significantly increase the risk of cardiovascular disease, including heart disease and strokes, if you start taking it before sixty years of age.7 [Link](yomu://content/annotation/330E1A4E-533C-4508-B01F-74D23EB3986B) **22/02/2023, 15:13** > CAN I TAKE HRT IF I HAVE MIGRAINES? > > Yes, but I’d exercise some caution with the dose and delivery method. > > Migraines can worsen during perimenopause and menopause because of the hormone fluctuations, so it’s a good idea to start gently on a lower dose to see what happens with those migraines and adjust accordingly. Also, it’s better to have a continuous regime rather than a cyclical one – in this instance a Mirena coil can be preferable. > > If you suffer from a migraine with aura (the type where you get a warning sign that a migraine is on its way, such as visual symptoms) you do have a slightly higher baseline risk of developing a clot, so it’s better to use a transdermal form of oestrogen. > > Women who have migraine with aura also shouldn’t take the contraceptive pill, but this is because the pill uses a different oestrogen usually at a higher dose. [Link](yomu://content/annotation/62EA397A-CF00-4F27-BE92-EADD2985FCA3) **22/02/2023, 15:13** > I HAVE HIGH BLOOD PRESSURE. CAN I TAKE HRT? > > The short answer is yes, but it depends. High blood pressure is not a reason to refuse HRT outright. HRT can be cardio-protective – it can protect the heart and vessels from furring up, and it helps keep blood vessels soft and flexible. If you are perimenopausal or not far into menopause it can actually help your blood pressure, but if you are ten years post-menopause or in your late sixties or seventies it may not be suitable. The important thing to remember is that every situation is different, so it depends on your age and cardiovascular risk. > > Your doctor should be treating you as a whole, looking to treat your high blood pressure and your menopause symptoms. If your blood pressure is very high, then your doctor should be investigating the cause and how to bring it down, but in many cases I would start HRT simultaneously with the treatment for blood pressure. [Link](yomu://content/annotation/5227461C-CD5B-4468-B5ED-A3EA3A7AA4DA) **22/02/2023, 15:14** > I’VE HAD BREAST CANCER. CAN I TAKE HRT? > > Not all breast cancers are the same. Some cancers are hormone-receptor positive, which means tumours may grow under the influence of hormones. About seventy-five per cent of all breast cancers have receptors for oestrogen and are called oestrogen-receptor positive or ER positive (ER+) breast cancer.9 Officially, HRT is contraindicated (not advised as a course of treatment) for any woman with a history of breast cancer. However, sometimes if a woman had breast cancer a very long time ago, or it was very localised, it might be possible to take HRT under the guidance of a specialist. What is key here is looking at a patient’s individual history and weighing up the pros and cons of HRT. [Link](yomu://content/annotation/1139F5AF-5A11-42E0-B184-F74DF45B00ED) ### Chapter 7: Doctor, Doctor … I’m Not Depressed, I’m Menopausal **22/02/2023, 15:18** > Do you know that women between the ages of forty-five and fifty-four have the highest suicide rate of any female age group?2 For every 100,000 women in that age group, seven will take their own life. That’s more than double the suicide rate of those aged fifteen to nineteen.2 In sixty-five to sixty-nine-year-olds it falls to 3.7 per 100,000 women.2 These are really frightening stats. [Link](yomu://content/annotation/59559735-5429-46C1-96D1-C7C1BDDA9671) **22/02/2023, 15:18** > But the one thing I’ve learned from talking to women and doctors (there are lots of doctors and other specialists also spending their evenings trying to help menopausal women online) is this: if low mood and depression is hormonal, then HRT is the first-line treatment.3 [Link](yomu://content/annotation/8CAE2B5C-0678-4425-99E3-31AEBF55DFF1) **22/02/2023, 15:19** > But even so, when listening to you all, antidepressants continue to be given to women with menopause-related depression, anxiety and mood changes. > > A survey of 5,000 perimenopausal and menopausal women as recently as 2021 found that one in four were given antidepressants. However, the NICE menopause guidelines are very clear that menopause symptoms should be treated first with HRT and not antidepressants. [Link](yomu://content/annotation/1125FECE-1987-44AA-A28D-28B59791DABC) **22/02/2023, 15:19** > The danger is that if a hormonal woman is treated with antidepressants and they don’t work, it can leave her feeling even more scared and confused. Then they get prescribed something stronger, or different, and perhaps it still doesn’t work. They think, if the tablets aren’t working, what is wrong with me? [Link](yomu://content/annotation/36A13B5B-0A33-4945-93E4-172E9074703B) **22/02/2023, 15:20** > If, like me, you were born in the 1960s (or earlier), you’ll probably recall that in the sixties there was an absolute pandemic of housewives being prescribed Valium for anxiety, insomnia or to help with the stresses of modern life. Between the late sixties and the early eighties, Valium was the most prescribed drug in the USA.4 ‘Mother’s little helper’, they called it. > > But it must have been menopause. That was perimenopausal and menopausal women all struggling and seeking help, but instead they were handed a pill so they could disappear from life in a sort of plush velvet blanket. > > Constantly over the decades we use prescription drugs to placate without stopping to look at the root cause. [Link](yomu://content/annotation/1ED76721-3242-4404-8E4C-7F56BD20CC36) ### Chapter 8: The Dry Vagina Monologues **22/02/2023, 15:27** > Well, over half of post-menopausal women suffer from vaginal dryness1, and even though it’s one of the most common symptoms, it’s one of the least talked-about. And we have to change that, because vaginal dryness can make the simplest things – like exercising, wearing trousers or, God forbid, sitting down – almost impossible. Because it can make sex excruciating. Because it can make even going for a wee feel like torture. [Link](yomu://content/annotation/574022AE-AE11-4634-A598-F55D5BAAA94A) **22/02/2023, 15:29** > SYSTEMIC HRT Systemic HRT can be an effective treatment for vaginal dryness, along with other symptoms. You should expect dryness symptoms to start to improve within a few months. > > However, HRT may not be enough for everyone, so here are some targeted treatments to tackle vaginal dryness. [Link](yomu://content/annotation/8688C103-B0AD-4A9D-AE8E-BF80157049E9) **22/02/2023, 15:29** > TOPICAL OESTROGEN – CREAMS AND GELS Known as topical oestrogen because you use them directly on the area, these treatments will replace the oestrogen, give your tissues a chance to repair and generally improve symptoms. > > Creams and gels are applied to the skin of the vulva and vagina. Typically, you would apply a cream or gel every day for the first few weeks, then once, twice or three times a week thereafter on direction of a nurse or doctor. [Link](yomu://content/annotation/043E5438-7226-47D8-83E8-07D6CD337692) **22/02/2023, 15:29** > TOPICAL OESTROGEN – CREAMS AND GELS Known as topical oestrogen because you use them directly on the area, these treatments will replace the oestrogen, give your tissues a chance to repair and generally improve symptoms. > > Creams and gels are applied to the skin of the vulva and vagina. Typically, you would apply a cream or gel every day for the first few weeks, then once, twice or three times a week thereafter on direction of a nurse or doctor. > > How do I use it? > > You can use it one of two ways: insert the cream directly into your vagina with an applicator – most users prefer to do this at bedtime so it stays in place while you are sleeping. Or you can also use your fingertips to apply cream on and around your vulva. The gel comes with an applicator, or use your fingertips. > > Pros > > + The applicator can reduce mess. > > + You can also use it on and around your vulva, so it’s good for external symptoms too. > > Cons > > – It still can be a bit messy! > > – Currently only available on prescription, but this may change. > > – Some women find them locally irritating [Link](yomu://content/annotation/2DA7F76C-56F0-47CD-8A3E-7C8E2A166D7E) **22/02/2023, 15:29** > VAGINAL OESTROGEN PESSARY These are typically used every day for the first two weeks and twice a week after that. > > How do I use it? > > Some pessaries come with a disposable applicator to insert a pessary into your vagina. There are also lower-dose pessaries that look like little bullets and don’t require an applicator. > > Pros > > + Some people prefer pessaries as they are less messy than cream. > > Cons > > – Unlike cream and gels, you can only use pessaries directly in the vagina. > > – The non-applicator pessaries in particular can produce a discharge when they dissolve. > > – Some women find them locally irritating. [Link](yomu://content/annotation/91AB0C13-A9A7-40E4-920C-FF811175B94F) **22/02/2023, 15:29** > PRASTERONE INTRAROSA This is a pessary that contains Prasterone DHEA. It works by being converted into oestrogen and androgens which then act upon the local tissues. > > How do I use it? > > You can use it with or without an applicator. [Link](yomu://content/annotation/1B6DF7AD-8FDE-4EB6-B2BC-3C26CDAC8DAB) **22/02/2023, 15:29** > OESTROGEN RINGS These rings are placed inside the vagina and the oestrogen is released gradually over three months. > > How do I use it? > > These are soft, flexible silicon rings that you simply put inside your vagina, or a health professional can do this for you on your first try. > > Pros > > + You can pop it in and forget about it. > > + Remove before sex or leave in. > > + An alternative to creams, gels and pessaries, and not as messy. > > Cons > > – Needs to be replaced every three months. > > – Some women find them fiddly. [Link](yomu://content/annotation/B41991C9-14DF-4479-84AF-6706FE0B8512) **22/02/2023, 15:30** > SENSHIO Senshio is an oral tablet. It is indicated for the treatment of moderate to severe symptomatic vulvar and vaginal atrophy (VVA) in post-menopausal women who are not candidates for local vaginal oestrogen therapy. The active substance in Senshio, ospemifene, is a selective oestrogen receptor modulator (SERM). This means that it acts in the same way as oestrogen in some tissues in the body such as the vagina and so helps to reduce symptoms of vulvovaginal atrophy. [Link](yomu://content/annotation/3A502476-6A95-49FA-80EE-2ADFC87F5093) **22/02/2023, 15:30** > WHAT ABOUT NON-HORMONE TREATMENTS? > > There are some over-the-counter products that you can use alongside HRT or topical oestrogen, or just on their own if you are unable to or don’t want to use HRT. These treatments can help make you more comfortable. They won’t replace the hormones in the way HRT and topical oestrogen does. > > Vaginal moisturisers will help restore moisture, soothe tissues and alleviate irritation and burning. The best ones are also balanced to match the natural pH and osmolality of the vagina.3 Like oestrogen cream or gel, you can use an applicator to insert the moisturiser into the vagina, or your fingertips to use on and around the vulva. You can use the moisturiser daily for the first week or so, and then see if you can reduce to a few times a week thereafter depending on how severe your symptoms are. > > Lubricants applied to the vulva and vagina can be used just before sex to lubricate the vagina. Choose one with a pH of between 3.8 and 4.5. > > Try to avoid products containing ingredients like parabens, nonoxynol and chlorhexidine. [Link](yomu://content/annotation/66B4438B-7576-440C-8835-D38DBDD25AF2) **22/02/2023, 17:20** > About one in three women are living with urinary incontinence.4 Ok, it’s not life-threatening, but there is a perception that the odd bit of leakage when you laugh, or needing to have tactical pees ‘just in case’ you get caught short is something you have to put up with after having kids or going through menopause. Nothing could be further from the truth, and these symptoms can make you really miserable and affect your quality of life. [Link](yomu://content/annotation/866FD020-D286-46CD-9A5A-4C930B2795A3) ### Chapter 9: Feeling Frisky: Why Great Sex Doesn’t Stop at the Menopause **22/02/2023, 17:22** > 84% of perimenopausal and menopausal women think having an active sex life is important1 But 80% said the perimenopause or menopause had affected their sex drive [Link](yomu://content/annotation/D1D19540-C45B-4263-ADA1-F4B938D1F33A) **24/02/2023, 14:44** > Think of yourself as an ‘ingredient detective’: a good sexual lubricant is a real investment, so it absolutely pays to take your time and have a good read of the ingredients. > > Ones to watch out for include: > > Glycerin – can cause thrush. > > Propylene glycol – that stinging feeling when you first try using a lube? Often that will be down to propylene glycol. > > Parabens – preservatives used in so many products, including those designed for intimate use, but again, they can irritate the sensitive skin. KY Jelly, often recommended by doctors and other healthcare professionals, contains parabens and glycerine. > > Alcohol – very drying to the skin and even more so to the delicate tissues of our vaginas and vulvas. > > Dyes and perfumes – these might make the lube look and smell nice, but neither are good news for your vaginal or vulval health. > > ‘Tingling’ or ‘cooling’ lubricants – some people use warming and cooling lubricants to enhance sexual pleasure, but I would exercise caution. Often the tingling effect is caused by menthol or chilli, which can be damaging to the delicate tissues of our genitals. > > Glitter – also a definite no-no, unless you want to be picking bits of glitter out of your nether regions. [Link](yomu://content/annotation/9E6C3FEF-3658-43D6-9544-AD12AE7C43A2) **24/02/2023, 14:44** > Just because a product is slippery does not mean it’s suitable for sex. Please, please, please keep vegetable oils for your salad, baby oil for your body and petroleum jelly for your lips. These products are not designed for sexual use, many contain irritating ingredients and can cause infections, and they can damage sex toys and condoms, too. [Link](yomu://content/annotation/F8E50FE1-5E58-4C0F-ADCA-BC4DB21C59F1) **24/02/2023, 14:44** > SO, WHAT LUBE SHOULD I USE? > > The good news is that there are now lots of good-quality, skin-safe lubricants on the market. > > Water-based lubricants are the closest to your own natural lubrication, they are easy to wash off, can be used for any sexual activity, and with condoms and any sex toy material, including silicone toys. > > Oil-based lubricants are longer-lasting but aren’t suitable for use with latex condoms. > > Silicone lubricants have a major advantage in that a little goes a long way, but they aren’t suitable for use with silicone sex toys. [Link](yomu://content/annotation/5DF919AC-B4F5-4954-ADA2-00B60C8BF1AF) **24/02/2023, 14:57** > MASTURBATION AND MENOPAUSE: SAM’S SEVEN REASONS TO GET YOUR SELF-LOVE ON Many people think that sexual satisfaction involves being in a relationship, but not every aspect of your sex life requires a partner. > > Whether you’re single or in a long-term relationship, indulging in a bit of ‘me’ time has a raft of benefits. > > It kickstarts your libido – the more you masturbate, the more pleasurable it will feel and you’ll want to keep doing it – which in turn helps to boost your libido. > > Stress-busting – orgasming releases endorphins and serotonin, which can reduce stress and balance your mood. > > Helps you sleep – the endorphin release can lower blood pressure and induce a state of relaxation to promote a good night’s sleep – much more exciting than a mug of cocoa! > > Natural painkiller – masturbation is probably the last thing on your mind when you are on your period, but orgasming can help relieve cramping from periods by encouraging blood flow to the pelvic area. > > Boosts your chances of enjoying an orgasm during penetrative sex – exploring what works for you helps you be more assertive about what works for you with a partner. > > Safe – there’s no risk of getting a sexually transmitted infection or becoming pregnant. > > And, above all, it is bloody good FUN! [Link](yomu://content/annotation/BB082C70-2C6E-4E98-8B7E-699FBBA8A77F) ### Chapter 10: Batten Down the Hatches: How to Menopause-proof Your Relationships and Make them Stronger **25/02/2023, 15:49** > My top piece of advice for all the partners? Ask, don’t assume. [Link](yomu://content/annotation/86B98D14-B040-4078-BBA1-3FD95038DA70) **25/02/2023, 15:53** > A 2021 survey found that one in five menopausal women passed on the chance to go for a promotion that they would have otherwise considered, nineteen per cent reduced their hours and twelve per cent resigned.³ Think how much this is worth to the economy alone. Think of all that knowledge, experience and power leaving the workplace because women in their fifties can’t cope any more. [Link](yomu://content/annotation/CA368FDD-BBA6-4128-AEF5-6FBCB7240FD4) **25/02/2023, 15:57** > Ask about setting up a weekly menopause support group in a space where you can sit and share your experiences. Whether it’s a weekly or a monthly thing, block it out in everyone’s diaries and silence the phones so that everyone who wants to has the chance to attend. > > These groups MUST include men. Men are our colleagues, our friends and our partners. The benefits of a group like that go beyond the walls of an office or workplace. You might have colleagues who have partners at home going through menopause and they have no idea how best to support them. They could really learn from listening and talking to other women about what they are going through, then they can support their partners, their sisters or their mums in the best way possible. Henpicked is a brilliant resource for menopause in the workplace training [Link](yomu://content/annotation/9F718902-99E6-4E60-961C-2F36213741D8) **25/02/2023, 15:57** > We know the NHS is ridiculously over-stretched and access to specialist menopause clinics is a real postcode lottery. There are just under a hundred NHS menopause clinics in the UK,4 which sounds like a lot on paper, but for something that half the population will go through, and thousands upon thousands of these women will need specialist support for, it really isn’t [Link](yomu://content/annotation/FA944486-203D-453F-93C8-C8764F57D0BB) ### Chapter 11: Dealing with Menopause Alongside Breast Cancer: Advice About HRT and Non-hormonal Treatments **25/02/2023, 15:59** > In 2020 alone, 2.3 million women were diagnosed with breast cancer worldwide.1 [Link](yomu://content/annotation/9D63861D-B98B-41E5-BBB4-3C0AC1CBB6E9) **25/02/2023, 15:59** > I’VE HAD BREAST CANCER. CAN I TAKE HRT? > > The latest study confirms what we already thought was the case that oestrogen-only HRT does not increase the risk of breast cancer. Oestrogen plus micronised (body-identical) progesterone is also not associated with an increased risk of breast cancer. Oestrogen with synthetic progesterone is associated with a small increased risk of breast cancer.2 Not all breast cancers are the same. Some cancers have hormones receptors on them and some don’t. If they have receptors they can grow under the influence of hormone. About seventy-five per cent of all breast cancers have receptors for oestrogen and are called oestrogen-receptor positive or ER positive (ER+) breast cancer. Officially, HRT should not be given to any woman with a history of breast cancer.3 However, sometimes if a woman had breast cancer a very long time ago, or if it was very localised, it might be possible to take HRT under the guidance of a specialist. Also, if your cancer was not hormone receptor positive then it may be safer to give HRT but, again, this would usually be under the guidance of a specialist. When making the decision about starting HRT or using alternative therapies, I always discuss every woman’s individual history and own wishes and weigh up the pros and cons of HRT with them [Link](yomu://content/annotation/715C98B0-9135-423D-ACF6-B1D6EC3B1786) **25/02/2023, 15:59** > WHAT ABOUT A FAMILY HISTORY OF BREAST CANCER? > > Women with a family history of breast cancer are often told they can’t take HRT, which in fact is often not the case. If you have a strong family history of breast cancer (for example, your mum or sister were diagnosed with breast cancer before the age of forty) you are more likely to develop breast cancer, but it is not thought that HRT will raise your overall risk. I would advise speaking to a specialist before deciding on whether to take HRT. If you have a family history of breast cancer, you can ask your doctor for a referral to a specialist family history clinic or a regional genetics centre to find out more [Link](yomu://content/annotation/2C431264-93B7-4C2A-B37F-2F3672DE853B) **25/02/2023, 16:00** > ANTIDEPRESSANTS (SSRIS AND SNRIS) What can it help with? Low mood and anxiety, hot flushes and night sweats. > > As we saw in Chapter 7 on menopause and mental health, antidepressants shouldn’t be a first-line treatment for menopause-related low mood, but they might be an option for anxiety, low mood or hot flushes if you are unable or don’t want to take HRT. They can be very effective but side-effects like nausea, dry mouth and low libido can occur. > > Note: if you are taking tamoxifen, a medication that is used to treat oestrogen-receptor-positive breast cancer, you should not take the antidepressants paroxetine or fluoxetine as they can interact [Link](yomu://content/annotation/F6CA5810-E3B9-4FEF-9A59-89BAB7F831CC) **25/02/2023, 16:00** > CLONIDINE What can it help with? Hot flushes. > > Clonidine is best known as a blood pressure medication, but it is also licensed for use for hot flushes and sweats. Side-effects include dizziness. [Link](yomu://content/annotation/35D15062-79F1-477D-AF81-2D68581DCACA) **25/02/2023, 16:00** > GABAPENTIN What can it help with? Primarily hot flushes but it can help with sleep. > > Gabapentin is a drug with many uses including epilepsy and nerve pain. It can reduce hot flushes in about half of patients,4 and it can also help relieve pain and improve sleep. Results vary and side-effects can include drowsiness, dizziness and weight gain. It is a controlled drug, so there are strict rules over prescribing it. [Link](yomu://content/annotation/CED58642-0D13-43F3-B846-34ADDFC15EC9) **25/02/2023, 16:00** > OXYBUTYNIN What can it help with? Hot flushes. > > Oxybutynin is a drug that has been used to treat overactive bladder but has also been shown to help with hot flushes. It is non-hormonal so can be used in women with a history of breast cancer and is usually well tolerated but can cause dry mouth.5 [Link](yomu://content/annotation/F2B7286A-2D5F-432A-984C-49479823219B) **25/02/2023, 16:01** > NEUROKININ 3 RECEPTOR ANTAGONISTS What can it help with? Hot flushes and sweats. > > Neurokinin 3 receptor antagonists are an exciting development in treatment of menopausal flushes and sweats for women who cannot take hormones. Research has shown that oestrogen loss in menopause increases a hormone called neurokinin B. Neurokinin B stimulates neurokinin 3 receptors which in turn affect the temperature-controlling centre in the brain, so the pathway is overstimulated if oestrogen is low. If these receptors are blocked, the pathway can be suppressed, and symptoms reduced.6 [Link](yomu://content/annotation/BF5143AE-2531-4E45-A2CC-7E559C96AB0A) **25/02/2023, 16:01** > VAGINAL MOISTURISERS AND LUBRICANTS Vulvovaginal dryness can be a side-effect of menopause as well as some cancer treatments including breast cancer treatments. Vaginal moisturisers and lubricants can be particularly helpful as they are non-hormonal and risk free. I recommend looking for those which are pH and osmolality balanced – see Sam’s chapter for more details. It is important not to forget that topical vaginal oestrogens do not carry the same risks of systemic HRT and can often be used in women with a history of breast cancer under the advice of their specialist [Link](yomu://content/annotation/AF0F8213-B39C-4AFA-9F6C-4C4B81DE7FC5) ### Chapter 25 **25/02/2023, 16:12** > Hormones play an enormous role in the health of our hair throughout our lives. > > To break it down into really simple terms, our hair goes through a growing phase and a shedding phase. Our hair is in the growing phase about ninety per cent of the time and the rest in the shedding phase – this is when you might run your fingers through your hair and a few strands come loose, or you maybe notice hair collecting in the bottom of the shower. > > But the fall in oestrogen during perimenopause and menopause can throw this all off balance. That drop in oestrogen slows down that growing phase from ninety per cent to sixty per cent and ramps up the shedding phase so you get more hair loss and less hair growth [Link](yomu://content/annotation/0CEADFDA-1AAB-479E-A25D-0926969DDFE9) ### Chapter 27 **25/02/2023, 16:13** > I hate the word menopause. > > It means ‘final period’. It sounds like a full stop. Menopause and then … nothing. A black hole of boredom. An abyss. > > But in Japan they call the menopause the second spring. I bloody love that! Not the autumn, not the fucking winter, the second spring, people. [Link](yomu://content/annotation/C15D8A34-4A6C-4137-BEE6-556A8199A920) **25/02/2023, 16:27** > Menopause is not a women’s issue; it is a human rights issue. Whilst the majority of those directly affected are women, it can also directly affect transgender and non-binary people, too. It can indirectly affect anybody who knows or loves the person going through it – partners, families, friends and colleagues. [Link](yomu://content/annotation/0A1A3767-ACA5-496A-ADD2-092BB5516987)