Dr Sally Hope - Interview 47
Sally Hope is a GP in Woodstock, Oxfordshire and also does research on women’s health in the Department of Primary Health Care, University of Oxford.
Brief outline:As a GP and the co-author of several books on the menopause, Sally brings considerable expertise to this website, presenting a medical perspective on the menopause. As well as a professional interest, Sally is also a menopausal woman who can genuinely empathise and understand how women feel.
You can’t predict when it’s going to happen. It’s going to be some time between 45 and 55. The average age of the menopause in the UK is 50 years and nine months. Very interestingly, it hasn’t changed through time. We know that the time your periods start, your menarche, has altered wildly over times. In Elizabethan times it was about 18 and now when I was a girl 40 years ago the average was about 14 to 16 and now it’s right down to 9 or 10. And so girls are having their periods at primary school but the interesting thing is the age our periods stop, the menopause, hasn’t changed through time. In fact, Hippocrates wrote a really interesting little bit about an extremely old woman whose periods stopped and she was 50. So it hasn’t changed for two thousand years and the reason for that is because we are born as babies with the eggs in our ovaries and they have a sell-by date and so the menopause is actually, when your ovaries run out of eggs. You don’t produce any more eggs so you don’t cycle and that has a sort of standard ticking sell-by date that hasn’t changed.
The menopause is medically defined as your last period ever, which seems very simple but there are a number of problems with that. Firstly, how do you know if the period you’re having is going to be your last one? You don’t. You only know retrospectively that it’s got to be for a year so you have to actually write them in your diary and then, because I can’t remember anything these days, so you look back and think, “Oh, yes. I haven’t had one since June 2009.” So that’s the first problem. Second problem is some women, who’ve had a hysterectomy, taken their womb out, don’t have that menopause, the menstrual marker of having a period every month so how do we know that they’ve gone through the menopause. And also a lot of women now have the Mirena intrauterine contraceptive device levonorgestrel progesterone, which stops you having periods. And there are also other long acting contraceptives like the injection in your arm Depo-Provera or Implanon and those all stop your periods or the mini-pill and all those people don’t know where their periods are either. So there are some problems with that.
Some women in the perimenopause get irregular periods and that’s often why they come and see me, as a GP, because they’re worried there has been a change. And what happens is, when your perimenopause is starting, is your periods actually get closer together and that drives women mad because, you know, you can just about put up with a period once a month, every five weeks but if it comes to be every three weeks or sometimes even fifteen days you just never get a break from being premenstrual and bleeding but that is actually very common. So they go closer together for a year or two and then gradually come further apart and you get a period every six to eight weeks and then they stop or you have one every three months and then they peter out. So there’s a change. Also women may get heavier bleeding. And that’s really due to fibroids. Those are benign lumps of muscle in the uterus that every woman has over the age of 40 but it stops the womb contracting down and stopping the bleeding and so your periods can get heavier. And the factor of heavier periods and more frequent periods means that we all become anaemic and that makes us tired and grumpy and lethargic. And so it’s quite important if you’re feeling very tired to go to your GP and check that you’re not anaemic because you may just need iron to feel better or there are other ways to lessen your periods.
The first thing to say is a third of women have no symptoms at all and that’s fine. One of the fascinating things from my point of view trying to have an interest in the menopause, is we really don’t understand it. Why is it that you and I can be going through exactly the same thing of our ovaries running out of eggs and us not producing the cycling anymore, our periods, and yet I have ten hot flushes a day and someone else might have none, and someone else has a thousand. It doesn’t make sense to me. I think there’s a sort of hot flush molecule that is yet to be discovered. So the basic symptoms are hot flushes. In American literature they’re called hot flashes, which sound even worse I think, and it’s a feeling of great heat going through your body and sometimes people sweat quite profusely with it and you can actually watch it happening on the screen, measure the skin change, so it has a very profound physical basis. And we know that some women may have two or three hot flushes a day, sometimes at night.
I always get them when I’m trying to lie down and go to sleep. Some women have a thousand hot flushes in an hour, you know, and we don’t understand the difference. We know that it can be made worse by stress and so a lot of the complementary therapies for relaxation and yoga do have a basis in that if you’re very calm your cardiovascular system is calm, your blood pressure drops, your pulse drops and you feel better and you seem to have less. They are sometimes precipitated by alcohol, alas, or hot curries or spicy food or hot drinks even.
Well, depression is common all the time anyway. One in three women have depression at some point in their lives and it’s often incredibly difficult, as a GP, or in myself to know whether I’m depressed because I’m grumpy and emotionally labile [likely to change] because I’m having terrible night sweats and I haven’t had a decent night’s sleep for a month, or whether I’m depressed because it is such a difficult time in our lives. I mean we are in the middle of a cog of perhaps looking after elderly, frail parents or in-laws, perhaps having a partner having a midlife crisis, perhaps having problems with our own work and image as we’re facing the menopause and not wanting to be old in this culture where everything is about youth.
And then we have stroppy teenage children, who aren’t leaving home and not getting a job and not working or we’ve got slightly older children who are going through marital problems or having babies or we’ve got absolutely everyone from every possible aspect coming in on us as the woman provider fixing everything. So it’s not surprising we feel a bit stressed. And then we’re feeling hot, menopausal and can’t remember the name of our cat. So it’s a rather tricky time and I think we need to recognise that and actually recognise that perhaps we need some us time. And not be super human wonderful people all the time. Just give ourselves treats. Feel better.
So it’s actually a tiny minority of women that want medication or talk about it. Now, this subject has changed wildly due to two very important enormous studies. One in England, called the Million Women Study run by Professor Valerie Beral, where she’s looked at one point three million women and followed them through from the peri to postmenopause and seen what they’ve taken and what it’s done to them. And she’s produced very strong data to show that combined HRT, that’s oestrogen plus progesterone, which women need if they have a womb, doubles the risk of breast cancer. And that changed the whole of medical information because prior to that we thought HRT was safe and good for you and we now know that, although it’s good for symptoms, women must understand the breast cancer risks before they take it. And there was a Committee on Safety of Medicines’ edict following the publishing of that data advising prescribers of HRT that women must understand the pros and cons and you must prescribe the lowest possible dose of hormone replacement therapy for the shortest time - but not actually defining either of those.
There is also the Women’s Health Initiative study from the States, and the two studies are slightly different, but if women are interested they can read both and that actually, again, showed a substantial increased risk of breast cancer in combined HRT. It showed interestingly, that for seven years women on oestrogen alone, so women who’ve had a hysterectomy who only need oestrogen, after a total hysterectomy, had no increased breast cancer risk. So some people argue that it’s much safer to take oestrogen alone if you’ve had a hysterectomy. And also they were giving fat American women large doses of hormone replacement therapy and it did show that it actually increased the risks of strokes, heart attacks, and dementia. So the current view is that women can take hormone replacement therapy for short term control of symptoms - without defining how long that is, but most people in this country think two or three years possibly.
The only thing that has really got a good evidence base that really reduces hot flushes are what are called the phytoestrogens. Phytoestrogens are very interesting molecules that you get from eating the beans and peas legumes so it’s tofu, soya, lentils, chick-peas, any beans, peas. And there is something called red clover, which comes in a variety of different preparations, and good randomised controlled trials on red clover tablets have been shown to reduce hot flushes and symptoms of anxiety by 80 per cent.
There are some Chinese herbs that actually were shown to cause liver failure. And black cohosh was the one where there have been a number of liver failure things so I don’t advise that.
I think a lot of people think because it’s over-the-counter and herbal it must be safe and they’re surprised when you tell them that black cohosh has actually killed six people from liver failure or that actually they’re quite powerful things. Like you must tell your doctor if you’re on other medication because things like St John’s Wort actually interact with a huge number of different drugs including anti-epileptics, anti-depressants, warfarin, chemotherapy. So they have a powerful action.
I think there are a number of issues. Firstly, in general practice we’re so focused on government targets, which we have to do, the government is pelting us with targets on things like cardiovascular disease, diabetes, asthma, cancer, mental health, that menopause is a Cinderella subject. We get no payment for doing it and so a lot of GPs have it as an extraordinarily low priority and really I happen to have an interest in it both personally, because I’m going through the menopause, and I’ve been working in this area for twenty years. So I have that knowledge base, which I’ve found personally very helpful to keep me on a even keel but I think most GPs, to be honest, don’t have the time, don’t have the interest, don’t have the information in their minds about all this. And often I find women coming in who’ve read some excellent websites or books and are actually much better informed than the average GP and that’s nice because you educate us as you come into the surgery. But quite often we don’t support women very well.
You’re not alone. You know, because sometimes it’s three in the morning when you get up and you’re soaking with sweat and you feel so tired and you’ve got a busy day tomorrow and your husband is snoring away and you think, you feel so alone - so you’re not alone. It’s self-limiting, even though it feels as though it’s going on forever, it does get better for most people, the vast majority, everyone really. Use it as a way to get yourself healthier. Use it as a positive lever to get the right weight, get fitter, lower your blood pressure, lower your risk of breast cancer, be kind to yourself. Use it as a way of giving yourself a bit of you time to do whatever you like, as you’re going through the menopause you deserve it. Do something that pleases you just for you rather than doing everything for everyone else.
Well, the holy grail that everyone is looking for is a hormone replacement therapy that makes us look beautiful, keeps our memories absolutely razor sharp, helps our bones, helps our hearts but doesn’t give us breast and womb cancer. And if somebody invented that molecule I would take it straightaway. And those are called SERMs, Selective Estrogen Receptor Modulators. SERMs, Selective Estrogen Receptor Modulators.
Now, the first SERM is tamoxifen, which is used for breast cancer treatment because it switches off the oestrogen receptors in the breast and prevents new breast cancers and prevents metastases spread of breast cancer. And you might think if you took something like that it would be very bad for your bones but it’s not. You actually have brilliant bones on tamoxifen. So it actually turns on the oestrogen receptors in the bone but it turns off the ones in the breast.
So people got very excited about that but the problem with tamoxifen is it gives you hot flushes because it’s doing something in the brain, switching off the oestrogen receptors. So everyone is looking for the molecule that will switch on the oestrogen receptor in the brain, so you don’t get hot flushes and you don’t lose your memory but switch it off in the breast, switch it on in the bones.
What are some of the reasons why women would go through an early menopause?
It’s actually a very complicated subject and if there’s anyone watching this who has had a menopause before the age of 45 they need specialist help. That’s the first thing to say. There are a number of factors.
It can be hereditary. If your mum had an early menopause and I’ve got a few families whose mums had the menopause at 32 and they’ve gone through the menopause at 32. It’s actually very important to know because, obviously, you cut out twenty possible years of child bearing so you need to plan your life. They’re very rare but it has a strong hereditary familial risk. Other reasons for going through a premature menopause are all very rare. There are autoimmune ones, that’s your own body’s immune system attacking your body so it’s linked with other autoimmune diseases like thyroiditis or Addison’s disease of the adrenal gland. There are also genetic reasons like if you’re unfortunate enough to be born with Turner’s syndrome that’s an X0 chromosome, you may actually go through the menopause before you hit puberty but that’s incredibly rare. But that’s why it’s such a complex group of women and you need a proper diagnosis and treatment. So anyone with a premature menopause needs to seek specialist help.
An increasing group are girls who are childhood cancer survivors because a lot of children who survive acute leukaemia now or other very rare cancers, they’re all rare, but they have often whole body irradiation and chemotherapy and obviously, that’s toxic to the ovary. And at the time, you’re trying to save that child’s life. Which fortunately happens now but a late consequence of that is the ovaries pack up early. Or if you have surgery for any reason like if you have to have your womb and ovaries removed for a cancer then obviously, if your ovaries are taken out you have what’s called a surgical menopause.
What about urinary problems, bladder problems, those sorts of things? Are they more common around the time of the menopause?
Yes. What you have to realise is that oestrogen affects the whole body. It affects our collagen, the springy stuff that affects our skin so that’s when we get more wrinkly after the menopause and there is a lot of collagen in our pelvic floors. Our pelvic floor is the webbing like in a chair that stops your womb and bladder falling out between your legs and we’re not really evolved for standing upright. If we were on all fours it would be all right but we’re standing upright so there’s a huge pressure on our pelvic floor to try, with all the organs there, against gravity and during the menopause and after the menopause our oestrogen levels go down, our collagen becomes more saggy so the whole pelvic floor sort of sags like a chair that needs reupholstering and the bladder and the womb, the vagina and the bowel can all slip down through the support buttress of the pelvic floor. So you can get faecal incontinence, which is mortifying, bladder irritability or incontinence and also your womb can come down, or your vagina can come down and that’s called a prolapse.
So women can feel something coming down. Especially a lot of women in our age-group are being more active, they’re doing aerobics, they’re running the London marathon and these things can get in the way because they can actually feel it when they’re doing exercise. It pushes it down if they do a lot of weights.
And what can they do about it?
You can do pelvic floor exercises. There are specialist pelvic floor physiotherapists and if you do your pelvic floor exercises it really does work. Also you can take local oestrogens, if you don’t want full hormone replacement therapy, which I think we’ll come on to in a minute, you can put local oestrogen, so that’s a tablet or a pessary, ring or cream, in your vagina so it’s absorbed locally into the vagina and it actually can help lessen urinary problems because it gets into the bottom of the bladder and stops it being so irritable and also helps local vaginal dryness and pain with sex. So for a lot of women that’s a good solution because they don’t want the risks of full HRT and you can stay on local oestrogen forever.
Because I work in Oxfordshire, I have a group of very brilliant academic women as patients and they are much more worried about the mental side effects of the menopause. They actually don’t care so much what they look like or whether they’re having hot flushes but they really care that they can’t remember a reference to a mediaeval history paper that they knew just like that or the numbers of their children’s mobile phones any more or their own telephone number. And we do know that there is some short term memory difficulties as you’re going through the menopause that appear to get better, hopefully, after the menopause. And it’s not clear, I mean there are some tests showing that oestrogen does actually help your mental function at this point. Also, because you’re having hot flushes at night, your sleep is disturbed and so when your sleep is disturbed you feel tired and dreadful and so you’re more stressed so you have more hot flushes and you go into this very negative cycle of thinking, “I really can’t stand this. I must get some help.” And that’s usually when people come in and talk to us.
Well, I think it’s good medical practice to see your GP or whoever is prescribing your hormone replacement therapy at least once a year and understand the pros and cons. Because as you get older, you need less hormone replacement therapy than you do, for example, women who have a premature menopause, who are in their thirties or forties, need about five times as much oestrogen as a woman of 55. So as you get older it should be tailored down and changed because there are also a number of different preparations. When you’re in the perimenopause you should have a cyclical preparation. That means you cycle so you have a withdrawal bleed and then as you go through to the menopause and postmenopause you can have what’s called a continuous combined preparation of oestrogen and progesterone, which you don’t have a period with and that’s been shown to have less risk of womb cancer than a cyclical one. So again, as you get older beyond that, the dose needs to come down so you actually shouldn’t be stuck on the same preparation for years and years and years. What I talk to my patients about is the risk of breast cancer, make sure they’re having mammograms regularly, make sure they’re having cervical smears regularly as all women should be doing along the current national guidelines and talk through the pros and cons.
Because of the way drug company trials are run there isn’t so much money in complementary therapies and so very few trials have been done. And the ones that have been done have shown very poor results
There is also something called natural progesterone cream that was very much hyped by the late Doctor Lee from California I think. And that has been shown to reduce hot flushes and some women buy it over the internet.
Is that safe?
They’ve never done decent trials. It certainly doesn’t prevent womb cancer. So I think a lot of people think because it’s over-the-counter and herbal it must be safe and they’re surprised when you tell them, that black cohosh has actually killed six people from liver failure or that actually, they’re quite powerful things. Like you must tell your doctor if you’re on other medication because things like St John’s Wort actually interact with a huge number of different drugs including anti-epileptics, anti-depressants, warfarin, chemotherapy. So they have a powerful action.
What about the contraceptive pill? Is that any use to menopausal women?
There is quite a lot of controversy about the contraceptive pill. The problem is once you’re over 40 the risks of heart attacks and strokes and clots in the legs for the combined contraceptive pill do go up. So most GPs are very unhappy about women taking the combined oral contraceptive pill right up to the age of 50. Although experts in the pill like [name] say it’s safe, I think women have to weigh up the pros and the cons to them for it. There is the mini-pill, which is a progesterone only pill, that you can take up to the menopause and is equally safe in this age group, the over 40 age group. And then as we said, there are hormone coils. There are non-hormone coils. There are contraceptive injections and there are implants as well as good old condoms and caps, if you want a barrier method.
You’re more at risk of acquiring sexually transmitted diseases because you’re more at risk of getting slight, tiny cuts in your vagina because you’re not so lubricated and you’re not so elastic and so it’s actually very important, ladies, if you are sleeping with somebody you don’t know very well, like a new partner, to make them use a condom. Because actually, in the UK at the moment the largest rate of increase in sexual transmitted diseases is actually, in the over 70s and you think, “Well, that’s impressive.” But it’s because they may have got divorced or their partner may have died and they’re footloose and fancy free, go off to the Costa del Sol, meet somebody and they don’t think about safe sex because they’re way past contraception and get STIs [sexually transmitted infections]. But we do see them in perimenopausal women because, again, it’s a time, it’s quite often for people to stay together until the children leave home or until they’ve left school. And so it is unfortunately a time of marital break-up and people are thinking about contraception or not for the first time in possibly twenty, thirty years, if their husband had a vasectomy in the 1970s and they’ve just genuinely forgotten that they do need contraception. So it’s actually very important to practice safe sex, unless you know your partner extremely well, and to think about contraception.
Now the sad truth is everyone puts on weight, even my dog has put on weight now she’s had a hysterectomy. And the average weight gain in the menopause is two kilos and I certainly notice I put on weight much more easily than I did. I think one’s metabolism really does change although there’s very annoyingly little data on this but again that’s just a little prod to make us be healthier, perhaps take a bit more exercise, a little bit less carbohydrate, make sure our calcium is good and stay fit, slim, beautiful and healthy.
So has the weight gain got to do with losing oestrogen? Is that why we put on weight?
I think it must. But the other thing you’ll notice is your shape actually changes. It’s not so much overall weight but sadly, we go from being Marilyn Monroe, well, I never had a Marilyn Monroe figure but the hourglass Victorian sort of breasts going in at the hips, sorry, breasts, going in at the waist, out at the hips, Marilyn Monroe or hourglass figure of a nubile, fertile woman goes and your breasts shrink and your hips shrink and your legs shrink but your tummy gets bigger. Your tummy falls out so you sort of go from looking like Marilyn Monroe to looking like a toffee apple on a stick. And that’s somewhat depressing and one has to work very hard to keep one’s tummy in and diet accordingly.
And all the rest of us who are going through the menopause need to look at our bones and there is a brilliant website, the National Osteoporosis website, Stay Healthy, and we know that actually the menopause is a very good time in our lives because it’s a time when women are open to changing their lifestyle for a healthier one.
Even I’ve started exercising and eating better and so it’s a great time to lose weight, if you’re slightly overweight, to gain weight, if you’re underweight, because you need a BMI of around 20 to 24, because if you’re too thin and scrawny you’ve got a risk of osteoporosis. To stop smoking, smokers have an earlier menopause, that’s why they’re all wrinkly and old than the rest of us. Unfortunately, reduce your alcohol intake because one of the sad things the Million Women Study showed that if you regularly drink two or more units a day you double your risk of breast cancer and that received no publicity at all. It was all headlines on Radio Four about HRT but an equal risk of alcohol never got that publicity and I think certainly a lot of women seem to drink a lot more than they used to. And I think that’s very important. Similarly, obesity doubles your risk of breast cancer and again that got very little publicity. So you can actually lower your risk of breast cancer by healthy eating, healthy exercise, being a healthy weight and not only does it reduce your risk of breast cancer but it improves your mental wellbeing. It improves your bones because we know that twenty minutes exercise a day, weight bearing, so carrying the shopping back from the Co-op, improves your bone density, reduces the risk of osteoporosis and also helps your cardiovascular system. So it really ticks all the boxes.
I think there are a number of issues. Firstly, in general practice we’re so focused on government targets, which we have to do. The government is pelting us with targets on things like cardio-vascular disease, diabetes, asthma, cancer, mental health that menopause is a Cinderella subject. We get no payment for doing it and so a lot of GPs have it as an extraordinarily low priority and really I happen to have an interest in it both personally, because I’m going through the menopause and I’ve been working in this area for twenty years. So I have that knowledge base, which I’ve found personally very helpful to keep me on a even keel but I think most GPs, to be honest, don’t have the time, don’t have the interest, don’t have the information in their minds about all this. And often I find women coming in who’ve read some excellent websites or books are actually much better informed than the average GP and that’s nice because you educate us as you come into the surgery. But quite often we don’t support women very well.
What do you think women need?
I think they need access to information to reassure themselves that they’re not going mad, that it’s self-limiting and it will get better. Because I think women put up with everything all through their lives and they just want to know, “Is this normal? Am I in the realms of normality because I’ve never felt like this before.”
People often come in, sit down in my surgery and say, “I think I’m going mad.” Or, “I’m worried I’m going demented like my mother did.” And actually that reassurance of, “No, you’re not mad. You’re not abnormal. This is the menopause. It will get better.” Is all women want and then they’ll get on with running Marks & Spencer, looking after their husbands and everything else that we do all the time.
There are some brilliant websites and I think the best one is Menopause Matters written by Heather Currie, who’s an expert in the menopause. It’s constantly up-dated. It’s very accessible. It’s free and it’s extremely good. The British Menopause Society have some information for women but that’s mainly a professional organisation for medical experts, nurses, GPs and gynaecologists but they do have a bit of information for women on the basic evidence base on their website. And the National Osteoporosis Society tangentially have very good information about keeping healthy, keeping healthy bones and good dietary data on how to have enough calcium and vitamin D.
The British Menopause Society have written some booklets for women on managing the menopause and booklets for health professionals on managing the menopause. And a lot of my patients like to read the health professional one because it’s very clear and has all the evidence base that they want to know but there are several books on their website that are easily accessible.
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