Welcome to the VP Life Podcast, the show
where we bring you actionable health
advice from leading minds.
I'm your host, Rob.
My guest today is Sarah Ball, a medical
doctor specializing in menopause, HRT,
and personalized
female hormone optimization.
Expect to learn what menopause rarely is
and how it differs from perimone emples
and why the symptoms vary
so widely between women.
Why hormone replacement therapy became so
controversial after the Women's Health
Initiative and what the evidence rarely
says, and how personalized HRT can be
safely implemented using genetics and
metabolic testing to see
the best possible results.
Now, on to the conversation with Dr.
Sarah Ball.
Good afternoon, Dr.
Ball, and thank you for
joining us for the podcast today.
This is a
conversation I'm excited to have.
As I know, there's just a lot of
confusion about menopause, everything
from what it actually is to where the
hormone replacement
therapy is safe and effective.
We've got a lot to
cover for that's for sure.
Before we dive in though, would you mind
just running us through your background,
your origin story as it were, and how you
got into this space to begin with?
Yeah, sure, and thank you, Rob.
Thank you for inviting me.
So I'm Dr.
Sarah Ball, and I am a medical doctor.
So I trained at medical school and became
a GP as quick as I could.
I always wanted to do kind of general
stuff, but I always length towards the
female side of medicine and women's
health and contraception and things.
And I qualified as a GP in 2002, the
summer of 2002, which was literally, it
was three days before this big trial that
I'm sure we're going to talk about was
suddenly broadcast to the world about how
unsafe HRT was having previously been
thought to be the best
thing since sliced bread.
So it's literally, as my career started,
menopause kind of
became something that people
stopped talking about and were scared of
and were confused about.
So really just through my career as a, I
carried on being a GP, so I
was a GP for 20 something years.
And just found myself feeling, although I
was keeping as up to date as it was
possible to be with women's health,
including menopause, it almost felt like
we were living in the dark ages.
You know, we could manage all other
conditions really well with all this
evidence and trials going on and great
big conferences and all sorts of things,
but it felt like we were quite behind.
And then the NICE, the National Institute
of Clinical Excellence Guidance came out
in 2015 and kind of slightly started to
turn the corner a bit in terms of, oh,
actually, you know, there is a chink of
light that we could maybe
start to improve menopause care with.
And so in 2018, then I started to also do
private menopause work.
And I trained with the British Menopause
Society, so I'm an
advanced menopause specialist.
And so now, well, the demand for that
private menopause work
just absolutely skyrocketed.
I mean, Exponential doesn't even begin to
cover the demand for it.
And so for the last six years now, I've
done purely private menopause work.
And so you really get a chance then to
dive into it in a much more deep way and
to really focus on the extraordinary
extent that it has been neglected.
We've sort of had 20 years of neglect and
it's trying to bring everything more into
the 21st century and actually support the
half of the population that are going to
be directly affected and the other half
of the population who are going to be
indirectly affected also.
So yeah, so I now work at a clinic called
Health in Menopause.
And yeah, it's the most wonderfully
rewarding job because it feels like
finally after a drought, there is help
that we're allowed to give and that the
public are now more receptive to thanks
to lots of conversations now
happening in the public arena.
So that's me.
That's perfect, thank you for that.
I'm glad you mentioned these guidelines.
I'm sure we'll get to them later.
Yeah, so I reckon we might as well dive
straight and thank you
for that introduction.
It really sort of covered a lot of bases.
And I'll ask you this question, which I
suppose, what fundamentally is menopause
and how does that differ from sort of
period and post-menopause?
I know many clinicians will sort of refer
to menopause as a single day.
But yeah, could you break down what these
terms mean and then walk us through maybe
some of the common symptoms that one
would sort of associate with, we should
associate with menopause that are
oftentimes put down to maybe other life
circumstances that women and especially
men will often miss.
Yeah, absolutely.
And you're right, it's trying to pin down
the definitions of the words can be
confusing and tricky.
And I would still say that menopause is
one day in a person's life,
a person that has had ovaries
or still has ovaries but they've stopped
working or they've been removed.
So it's that one day if you're having a
natural, a naturally occurring menopause
where your follicles, the parts of the
ovaries that can produce eggs have
stopped working and you've gone a whole
year without a menstrual period.
So yes, it's that one day, but unless you
have a surgical menopause or a menopause
that's induced by some kind of medical
procedure, which can be quite sudden,
most people's naturally occurring
menopause doesn't just happen, it takes
anywhere between two and maybe 12 years
for the buildup or the decline in the
ovaries to actually then
become them not working anymore.
So the average age of menopause is 51.
So that means a woman could be starting
to experience some
issues with changing hormones
while her periods are still going on and
she may be just in her late forties, but
she might actually be in her late 30s.
And so we have this usually decade, which
for most of us is in our 40s where there
could be all sorts of shenanigans going
on with symptoms and health complaints
and life happenings.
And previously we didn't, my sixth sense
and another clinician sixth sense was,
there's gotta be some hormonal
involvement, but there wasn't a kind of
permission to call it something and to
actually then be able to
give it a label and therefore be able to
start to help to manage that.
So yeah, so we have this perimen pause,
which previously was really poorly
understood really, and it's probably what
I would say is the biggest change or the
biggest sort of light bulb moment where
you go, oh, right, okay,
yeah, that really helps.
If all medical doctors knew
that, that would be helpful.
And then you have this one day
which is your menopause, and then forever
after, you are postmenopausal.
So you could have your
menopause at the average age of 51.
And then if you live to 100, well,
actually for the next, for 49 years, you
are postmenopausal and there can still be
issues arising because of that.
So it's, I think, conventional or history
has sort of taught that menopause is, you
know, a couple of years, maybe have a few
symptoms done and dusted,
and then you can move on.
But of course it really, really isn't
because for, you know, the average age of
women in this country, anyway, at the
moment, if life span goes to sort of 83
to 84 years, then actually you're gonna
spend about 50% of that, yeah,
but more, you know, if you start from the
beginning of perimenopause, which from
maybe average is sort of early to
mid-40s, then, you know, that's a hell of
a long time to not understand what's
going on with your own body and to risk
that your health professional also
doesn't understand what's
going on with your body.
So yeah, symptom-wise, I think this is
where another big area of confusion is
that there's so many symptoms and they
can start all at different times for
different people and you might have
completely different symptoms to your
sister or your mother or
your friend or your neighbour.
And so it's trying to, it's constantly
trying to join the dots.
So there's this, maybe the slightly
better known symptoms or the more kind of
physical symptoms, the symptoms that
people find a bit more easier to talk
about, which would be
things like hot sweats, flushes,
fatigue,
maybe headaches, migraine,
joint pains.
Actually joint pain is actually,
worldwide, is the commonest symptom of
menopause, but again, not a lot.
Everyone thinks it's hot sweats and
flushes, but actually only three quarters
of people will ever have
a hot sweat or a flush.
A quarter will never have one.
Yeah, it doesn't mean,
yeah, it doesn't mean they're not
suffering in other ways.
So yeah, so there's another sort of
physical, you know, poor sleep.
So yeah, sort of physical symptoms, but
then there's the genital urinary
symptoms, which people struggle to talk
about often because it can
be slightly more embarrassing.
So-- Fertional dryness, things like that.
Dryness, the vulva dryness, the bladder
issues, the lack of libido.
So that's kind of a tricky thing to talk
about, especially if you're still in your
40s and you think, you know, things are
going a bit wrong down there, it can be a
difficult thing to talk about.
And then there's the emotional symptoms.
And actually, of all of the symptoms, I
would say it's the psychological
symptoms, which are the most troublesome
to women that would come and seek help.
And it's the unexplained anxiety that
comes in midlife for no apparent reason,
or the feeling overwhelmed with life when
previously you were able to kind
of-- That massive drop off and gather.
Yeah, absolutely, yeah, the paranoia, the
rage, you know, and that's
real and scary for some women.
It's the lack of, or the losing
self-confidence and self-esteem.
It's delightful being female, isn't it?
Delute, yes, an
absolute challenge to navigate.
I mean, there's some, I often think,
well, you know, we have this,
for many of us, luckily, this amazing
ability to reproduce,
but there's a hell of a lot of
complicated biology going
into allowing that to happen.
And then of course, when it, even if it
starts to not work in the
proper way, that's challenging.
And then, you know,
there's extremes of that.
So there are some women who sail through
the menopause, and that's wonderful, but
there are literally some women who, it is
the start of the end in terms of, you
know, physical symptoms could just be
completely overwhelming, or it could be
the start of the decline of their future
health, because menopause not only
affects you in the day-to-day sense, but
it affects your
future health and wellness.
And, you know, it changes people's lives.
It takes one in 10 women out of their
job, because they can't cope anymore.
It, you know, the highest divorce rate is
in females in their 40s, because the, you
know, relationships
become more challenging.
You know, people literally, you see some
people, not everyone, some people fall
off their perch completely at menopause,
someone that was very capable, very, you
know, managing life,
multitasking, you know,
absolutely confident and fine, and just
becomes a different person, and no one
previously really understood, you know,
they were usually just
treated as being depressed,
or their individual
symptoms were treated.
They might be sent to a cardiologist,
because they had palpitations, or they
might be sent to a neurologist, because
they had migraine, or sent to a
gastroenterologist, because their bowel
habit changed, or whatever, and what we
have to get so much better at doing, and
medical person is joining the dots,
going, actually, have we thought about
whether there could be a common cause
that's linking all these problems, rather
than seeing them all as
the individual issues.
Yeah, I mean, you touched on a lot there.
I'd love to come back to what you
mentioned earlier about someone with a
woman sailing through menopause.
In my experience, well, not that I have
much experience in this respect, but I
find that women who do transition sort of
more easily through this period in life
are generally healthier to begin with,
and I'm sure we can discuss some of the
lifestyle factors later.
Do you find that A to be the case, and
then sort of on a similar note, what do
you make of this notion that women are
sort of entering menopause sort of at an
earlier and earlier age?
I mean, that's a whole
rabbit hole in itself.
Obviously, we could have a whole podcast
in that, but do you think that there are
any sort of environmental factors that
might be, if it is indeed the case, sort
of speeding up the sort of transition
into menopause for some woman?
I mean, we know that, for example,
smoking tends to bring on menopause on
average three years before
it would otherwise happen.
When we are not looking after ourselves
properly, and of course, in this modern
world, that's very difficult.
So, yes,
on the face of it, we're talking about
getting a good night's sleep, doing
regular exercise, eating healthy foods
that are nourishing,
but we know it's increasingly harder to
do those things these days with all the
financial strains on people and people
trying to be a million
people and have a million roles.
So, and I think we've never,
we've always underestimated the role of
stress in all conditions, haven't we?
And the cortisol and how that's gonna
affect how we make our
hormones in the first place.
And things like that.
And there's so many things we don't
understand and how other
medications that we might give.
So, contentious issue, but we give out
statins now like Smarties, but actually,
is there an argument that if you give out
statins and you decrease cholesterol,
that therefore you're gonna make less
reproductive hormones?
And so sometimes we're
robbing Peter to pay Paul.
So, yeah, and I think we have a lot more,
in a way there's a positivity in that we
have, with childhood and teenage cancers,
for example, the treatments for them and
survival rates are now much better, but
for the females that are suffering those
cancers, they will go into often a risk
of going into an early menopause.
So, we have a lot more, we used to always
quote, I always used to say, a one in 100
women under the age of 40 will be a
menopause and there's unexplained reasons
for that, but for some reasons, there is
an obvious medical treatments for other
conditions has caused that, but actually
now we've redone the figures, it's
actually four in 100.
So, one in 25 women will be in menopause
before the age of 25,
before the age of 40, sorry.
So, again, it's not a
really uncommon problem.
This is everybody.
So, it's really trying to shine a
spotlight on it and not only for women
themselves, although that is the most
important thing, but actually for society
in general and for economics, social
economics, if women become less
productive because they are suffering
around their perimenopause and beyond,
then that has a real knock on effect on
their work and their employers and the
GDP and all of that, this is a much
bigger thing than just medicine.
I love you did, you
sort of brought up stress.
I mean, I sort of, as we
all talk about or fair,
this sort of this functional medicine
approach and even within that sort of
paradigm where you sort of take a very
sort of individualistic approach to
treating these sorts of issues,
I think a lot of practitioners will sort
of overlook the stress component.
And when you sort of start to look at how
stress affects biology and how it starts
to create high levels of inflammation
that then sort of force cells into these
states of sort of
being inert essentially.
It's not surprising that we're sort of
seeing that these sort of generally,
broadly speaking, these endocrine
problems in general, I mean, the same
thing obviously applies to men too.
I think, well, I know that,
what's the easiest way to put this?
If you want to put someone through hell,
completely mess up
their endocrine system.
And one of the fastest ways to do that
short of sort of chugging plastic-laden
water is to just be under this constantly
high stressed state where your body is
fundamentally put into a state where it
can no longer, is no longer worried about
reproduction and where it is no longer
worried about these hormones.
And it's just worrying about getting
through each day as it comes.
And yeah, as you've alluded to already,
I suppose it's actually nature's sort of
cruel irony ultimately, the moment a
woman has sort of transitioned through
her child-bearing edges, she
evolutionarily quote unquote, has no
purpose, said very delicately.
And all of a sudden, as an individual,
you are just sort of left in this state
where life is untenable
and can be unbearable.
And I think, which is why I'm sort of
excited about the initiatives that are
starting to come out with regards to
endocrine health in general, specifically
for women, because for years, I think
it's been far more acceptable as a man to
go to your doctor if you have low
testosterone and they'll say, well, stick
a needle in your ass once
a week and problem solved.
But for women, it's been, yeah.
I don't know why, but the
uptake has just been much slower.
And maybe that has something to do with
the women's health initiative, which
we'll discuss in a moment.
But anyway,
Dr.
Boyle, I'd like to pivot into talking
about how you treat patients in a bit,
both in terms of HRT and whether you
think there's space for some of these
natural remedies as well, things like
black cohosh and red
clover extract, et cetera.
My feeling is that these molecules, these
supplements, they can help maybe manage
the symptoms, but because they're not
really replacing anything, they're not
gonna support an individual from a sort
of a longevity or health ban perspective.
Before we jump into all of that though,
I'd like to talk about what I've just
mentioned, which is the
women's health initiative.
As I think it really set back sort of the
HRT space, specifically within menopause
by a good 20 years or so, if not longer.
Different, longer, yeah.
Yeah, so, but yeah, I'll hand it over to
you because I'm not well-written the
space, but I have a feeling you are.
So maybe you could break down what the
WHI is, what it was about, and then maybe
why it was an issue.
Yeah, sure, yeah.
So essentially, so HRT was started to
become available in
the world in about 1960.
And so for sort of 30, 40 years, women
who were usually about 50-ish and were
going through the natural menopause
started to, if they started to have some
hot sweats and flushes, they were usually
offered some HRT, and they usually took
it for a couple of years.
And- This being oral
HRT, is that correct?
Yeah, so yeah, we used to have, most HRT
used to be what we call combined oral, so
a synthetic estrogen with a synthetic
progestogen, all in one easy capsule.
But these women, it was sort of noticed
in the 90s, particularly, well, these
women that take HRT, they seem really,
you know, really healthy and lots of
vigor, and they look great, and they're
often the ones that are
still being physically active.
And, you know, HRT
was, you know, popular.
Women, you know, wanted to get some of
this if they felt they
were having symptoms.
And then, sort of medical trials started
to notice actually, that women that used
HRT actually seem to have
much less heart disease.
They seem to break less bones.
And there was also starting to be some
consideration that they
also seem to get less dementia.
They just seem to be
generally healthier for longer.
So essentially, and again, I'm very
simplistic about this, but
that's how my brain works.
The American National Institute for
Health, you know, quite, you can
understand why they thought it, thought,
well, okay, well, this is great.
So actually, if there's this relatively
cheap drug that we could give to women
and it reduced their risk of heart
disease, well, wouldn't that be amazing?
You know, we'd save, you
know, gazillions of dollars, yeah.
So yeah, you know, that kind of stands to
reason that they would
want to look at that.
But that's where things slightly started
to go wrong because what actually then
happened was that women were recruited in
America to this trial, but they weren't
around the time of menopause.
They were actually much older.
So the average age of a woman in that
study was between 63 and 64.
So they were usually at least
10 years past the menopause.
And then they were given the old
fashioned HRT that was popular at the
time, but it was quite high dose as well.
And there was one big arm of the study
was women that had still got their womb
and therefore they were having the
combined HRT, so the
oestrogen and the progestrogen.
And then there was another arm of the
trial, which was women
that had had a hysterectomy.
So they were just
given the oestrogen part.
And so they started to watch
these women and what happened.
And then, I mean, you
can't even make this up.
I'm sure there'll be a film about this
one day because it's just
so, such a travesty to women.
They started to notice some figures that
didn't look quite
what they were expecting.
Obviously they were hoping to find that
women had loads less heart disease, but
they weren't seeing that.
It was sort of, ooh, actually, was there
a bit of extra heart
disease in this woman?
Wasn't quite sure.
And then, ooh, actually there's been a
few more blood clots in these women in
their lungs and in their legs.
And ooh, was there a couple more strokes?
And then, was there a bit more breast
cancer in these women?
And then, so what actually happened
behind the scenes was that some
investigators, so quite junior
investigators, were looking at the
numbers, did some statistical number
crunching, but made some mistakes,
didn't go to the senior investigators to
talk to them first to come up with a
plan, but essentially went straight to
the media and the press.
And so in 9th of July, 2002, suddenly it
was announced on the news that HRT was
associated with a higher risk of heart
attack, strokes, blood
clots, and breast cancer.
And it was advisable
for women to come off HRT.
And literally overnight, about half of
women came off for HRT, and then over the
next five years or so, a load more did.
So it literally, it just kind of tumbled.
But the problem was
the statistics was wrong.
The conclusions were wrong.
So yes, so when you actually look back at
the data, and I'm not a statistician, I'm
not, but I've studied the WHO, I used to
study for donkey's years, and I kind of
feel like I know it inside out, that
actually when you look back at the data,
if you look at the very few women that
were around men of Paul's age when they
started their HRT in this trial, they
actually did really, really well, and
actually everything
was protected and good.
And the women, the average women in
there, 90% of women that were much older,
there wasn't actually an
increase in heart disease.
It was a neutral, it was neutral, but
they got the P values wrong for the areas
of statistical significance.
So what it did tell us was yes, there is
a higher risk of blood
clots with oral estrogen HRT.
And we can now get around that by having
different ways of having estrogen.
So it did help to show that.
But then the breast cancer, that was
always the one, that's the most emotive
issue around HRT still is.
And this gets really complicated, but
essentially HRT wasn't causing an
increase in breast cancer in these women.
It was actually, and this is kind of hard
to explain, but it was actually women,
when you broke down the numbers even
more, it was women that had been
recruited into the trial that had
previously used HRT.
They were actually
protected from breast cancer.
So it made it look like the people taking
HRT from scratch were at
risk, but in fact, they weren't.
It was the other group
were relatively protected.
So there were conflating
variables irrespective.
Okay.
So big, big, like huge mess.
And actually that fear has stuck solid in
most people's minds.
I mean, I'm one of the lucky ones that
has been able to really look into it.
And I know that it's not true, but it's
so difficult to take that fear away from
people from the health clinicians
themselves, but also from patients.
So we have got a generation out there.
So my mum's generation all believe HRT is
associated with breast cancer.
And if they were on HRT, they came off it
and probably never restarted it.
And they probably told their daughters
like me not to go on HRT.
And most daughters would just listen to
their mums because they
wouldn't know any better.
So we still are trying to reassure women
that the association between HRT and
breast cancer is still
not 100% eye and doubt.
But if there is a risk at all, we are
talking about a tiny risk.
So around about, so this
is with old fashioned HRT.
So I'd have to give a thousand women in
their fifties old fashioned HRT for five
years for one extra woman per year to get
breast cancer who
wouldn't have already done so.
But we now tend to use more modern sorts
of HRT where the risk has been proven to
be even lower and may
well be very close to zero.
And so essentially the risks
of getting breast cancer with
or without HRT are the same.
And actually it's
lifestyle we should be looking at.
And if we can actually get a woman
exercising, not drinking too much alcohol
and being a healthy weight, that has a
big statistical impact
on her breast cancer risk.
HRT has virtually zero effect.
So it's trying to condense that into a
way that a woman can understand and feel
reassured is tricky.
That's fascinating.
I always was under the assumption and it
speaks to my ignorance on the matter that
there was far more of an issue with the
oral progesterins and the oral estrogen.
Yeah, and that was the
other complete tragedy.
Thank you for reminding me.
So all women came off HRT because nobody
told them there was a difference in the
results between the combined group and
the oestrogen only group.
So, and the oestrogen only group, they
were doing brilliantly.
They had far less heart
disease and far less dementia.
And actually even their risk of breast
cancer was reduced, but they all came off
it because no one kind of broke down the
difference in statistics
for another couple of years.
So yeah, complete travesty.
There have been apologies since from the
investigators, but no one ever publishes
good news or it's just bad news.
A list of knowledge is a dangerous thing.
And there was so much positives in that.
I mean, actually, if you look at the
data, I mean, the reduction
in fractures was impressive.
The reduction in diabetes was impressive.
All cause mortality.
So in other words, your analysis
oversimplification, but your risk of
dying from anything went down in the WHO
trial, no matter who you were.
But it just, you know, that never got any
wind behind it at all.
Yeah, never got published.
It's like you said,
nothing sells like bad news.
So trying to sort of refute that is going
to be an uphill battle.
Dr.
Bow, you mentioned this specifically,
this idea of women sort of in this, sort
of maybe earlier to mid
60s getting on to HRT.
Now, this was going to be a question I
was going to ask later, but I'm going to
ask you all to talk about it now.
Is there a point at which a woman who has
sort of transitioned into menopause or is
now perimenopausal should
not begin an HRT regimen?
Yeah, good question.
So we have a concept now called the
window of opportunity, which essentially
means that the best time to start HRT is
either during the perimenopause, if
you're having any problematic symptoms,
or within 10 years of your last period,
or before the age of 60,
whichever comes first.
So you could go through your menopause at
the age of 56, for example, and actually
your window of opportunity
then extends to being 66.
But unfortunately, sort of myth and
Chinese whisper and simplicity means that
most doctors and healthcare professionals
get very wobbly about
anybody starting at over 60.
But there are many people who just there,
menopause was sufficiently late that
they're still, their window of
opportunity is still open.
But what, if we were to use the old
fashioned HRT, what we would think was,
well, within that window of opportunity,
the benefits outweigh the risks.
If you're beyond that window of
opportunity and maybe trying to start old
fashioned HRT in a say a 68 year old who
whose menopause was at 50, then the risks
potentially outweigh the benefits.
But actually now that we've got newer
types of HRT, the more modern types, to
be fair, the risks never really start to
show up on a radar no
matter what age you get to.
So the benefits for almost everyone
continue to outweigh the risks.
They're just not, there's just not a
bigger, a difference between the risks,
the benefits and the risks when you're
still within your window of opportunity.
So even if you're much older when you
start HRT, you will still
get benefits to your bones.
We know that for definite.
And many, many women will still get
improvements in their day to day
symptoms, which that can then lead onto a
much healthier lifestyle and then much
greater future health
via indirect mechanisms.
So, you know, if I've had quite a lot of
women who may be in their late sixties or
early seventies, who are perhaps caring
for a poorly spouse and they are
struggling with hot sweats and flushes
themselves, because they've just had
that, you know, it's possible for hot
sweats and flushes to go on for 10, 20
years, even longer after your menopause.
And so they're up and
down every hour at night.
And then they're weighing a lot because
their genital urinary syndrome of
menopause hasn't been dealt with.
And so actually they're exhausted.
They're fundamentally fit and healthy,
but they're exhausted because they're
getting no sleep and
they can't stop weighing.
And the stress of their
caring role is all accumulating.
But I give her a little
bit of the best type of HRT.
The hot sweats, flushes
go away, she sleeps better.
Her bladder calms down.
Suddenly she's completely able to do her
caring role and actually
feels like she's, you know.
Human.
And I know that she's much less likely to
trip over and break a hip if she stumbles
against the toilet as well.
So we've got another win in there.
Yeah, I think I'm trying to remember the
stat particularly, but I think that
fractures in people over 60 or 70 is one
of the highest leading causes of early
death, just because
you're going to, well,
you're going to get into the sarcopenic
state, you lose a lot of muscle mass and
you're then going to have this massive
sort of metabolic
derangement that then follows.
And then as we know now, health is almost
all completely metabolic in nature.
So if you sort of lose that glucose sync
of all that muscle, then all of a sudden
you are in a pretty precarious situation.
I think that's difficult as well.
So if you're in your mid-40s and you're
starting to think about your hormones,
the last thing most people at that stage
are thinking of is what happens if I fall
over and break my hip and I'm 75 and I'm,
I don't know, maybe I don't have
dependence around who
are going to care for me.
People aren't on that wavelength.
But actually, if you start the process of
protecting your bones and your muscles
and your metabolism way
back in your perimenopause,
you've shifted the dial so much to a
healthier life when you're much older.
So it's again, trying to
focus medicine on thinking ahead.
And that's what's been one of another big
frustration of trying to get more
awareness about menopause in the public
arena is that, you know, the NHS, for
example, they will worry about their
budget for the next 12 months.
So they're not willing to spend it on
something that could make a massive
difference in 20 or 30 years time,
because it's just not, that's not how
finances kind of work, but it's a massive
public health option.
You know, if you think about all the
older people in care homes and
residential homes and all the social care
that takes up and all the heart disease,
all the strokes, all the things which
could, you know, if you have a fracture
as an older woman of your hip,
you've got a very high risk of being dead
within 12 months, more so than most
diagnoses of cancer.
And yet we don't tend to think of it as
something that's
important to try and prevent.
I think that's the term prevent.
There's no money to
be made in prevention.
You can't sell a drug
based on prevention.
So yeah, it's going to be
a complete uphill battle.
Dr.
Boyle, I think we've covered the basics
and some of the sort of the underlying
physiology sort of really nicely.
I'd like to talk about
how you work with patients.
Now, for context, as you've probably
gathered, I'm very pro-HRT and whenever I
do again, council a woman in that
respect, it's sort of just providing
guidance as to what they maybe should
start thinking about before, sort of
sending them on to someone like yourself.
I always make sure to point out that HRT
isn't, as we've just discussed about
symptom relief, it's about health, band
longevity, and that these hormones are,
as you've alluded to again,
are cardio neuroprotective.
And we always have the discussion around
lifestyle again, making sure, from that
preventative standpoint, and it's always
very much grounded in this sort of
understanding of getting your metabolic
health as good as you can get it.
Now, of course, that's
difficult for a number of reasons.
And I suppose I tend to emphasize the
lifestyle and nutrition
side of things because,
as a chemist and biochemist,
that's sort of my wheelhouse.
So, with regards to that, I'll often
point to things like making sure that
your detoxification
systems are working effectively.
Because if you are going to think about
getting onto HRT, you want to make sure
that your body can metabolize the extra
levels of these hormones effectively.
So, if there's impaired sort of phase one
or phase two detoxification, you've got
an issue with glucuronidation or
something like that,
maybe taking in using HRT at that point
in time is maybe not the best strategy
relative to sort of improving your health
and then considering getting onto HRT
when you've got those
basics sort of taken care of.
Now, I have a bunch more questions
relating to testing and of course, I'm no
expert here, but what do you think of
that sort of as a model?
Do you think that we should, I suppose,
as a community, be educating women on
their health in
general before starting HRT?
Or do you find that it's best just to get
someone who is struggling onto a protocol
and then sort of maybe dealing with these
other sort of this one you show off to
the fact, does that make sense?
Yeah, absolutely makes sense.
And again, I think that is maybe a
journey that we're going on with the more
public conversations now about menopause
is that traditionally,
we've had women make their first call to
someone like me because they're in a real
pickle in the throes of perimenopausal or
menopausal symptoms.
And they are maybe
sweating every hour, can't sleep,
anxious relationships are falling apart.
They're so achy that they can't, the
thought of going to the gym is
completely not on their radar.
They are depressed, they are rock bottom.
And we chat to them and we go
through all lifestyle issues.
I wanna know about
what is their sleep like?
Do they snore?
What is their diet like?
What is their bowel habit like?
What is their movement?
Do they have any movement
in their life at the moment?
What are their stress levels?
I wanna know, past trauma, I wanna know
all that stuff, but for each women, I
will treat her completely differently.
So there's some that I just need to put a
bit of, or invite her to put a bit of
estrogen in the system just to kind of,
if we could just get rid of the sweats to
start with so that she can sleep, and we
all know how dreadful it
is to be sleep deprived.
It's a form of torture, isn't it?
And then, sometimes just a couple of
weeks later, it's almost like they're
coming out of a fog, and then we can then
plan a more strategic way forward, which
is about the bigger jigsaw.
So I always, whenever I'm seeing anyone
not thinking about a jigsaw, yes, I have
the ability to put the HRT in place.
And for some people, that's
the big part of the jigsaw.
For some people, it's a very small part.
For some people, actually, it doesn't
need to be a part at all.
So,
there are some people where, and again, I
am so just to be absolutely, I'm a
medical doctor, conventional medical
doctor, but I have done quite a lot of
extra learning of my own volition about
diet, nutrition, functional medicine,
genetics, particularly
I'm looking at people's DNA.
And you just realize that I could see
someone and they'll come maybe and
they'll say, oh, you know, just really
depressed and achy and
maybe a bit overweight.
Maybe there's a bit of thyroid issues in
the family, for example, and then I'll
say, okay, do you take, you
know, what's your diet like?
And do you take any supplements?
And they'll say, you know, got a bit of a
rubbishy diet because at the moment
they've got no energy or
creativity to cook from scratch.
So they're having takeouts or whatever,
and they're not using any supplements
because, you know, they're a waste of
money, in quote, unquote.
And- Some of them are.
Yeah, and then, and they go, okay, do you
take any vitamin D at all?
No, and they work in full
time in an office or whatever.
And sometimes I just
give them some vitamin D
and then they come back a few weeks later
and go, oh, that was miraculous.
And then sometimes I don't actually need,
they don't actually need HRT for a while
longer because actually it wasn't, it was
they were lacking in vitamin D, but
again, the NHS doesn't really deal with
that particularly brilliantly either.
Or, you know, sometimes their thyroid's
completely up the spout.
I was going to ask about that because
obviously I have a better understanding
of male physiology when it comes to sort
of the thyroid testes access.
But oftentimes if you've got that
down-regulated thyroid activity, the
pituitary is not going to, in any way,
shape or form, send out sort of LH or FSA
signaling to the testes to then start
producing testosterone.
But the moment you flip the switch on the
thyroid side of things and you get that
thyroid signaling back,
not only does the HPTA start working
properly, but then at the mitochondrial
level, you're able to start producing
these hormones more effectively within
the testes, within the leg cells, and
then the totally cells.
I assume the same logic sort of carries
over to women as well.
If you can correct a thyroid issue, can
you sometimes maybe just offset the need
for other forms of HRT?
Absolutely, and we do sometimes see this
where people all come to me and they've
been on HRT for a few years and they've
just never really had that much
improvements from it.
And, you know, you're trying to, it's
like being a detective the whole time,
you're trying to work out where can we
change things for this person?
And then you'll look and you'll go, oh,
actually, well, there's a family history
of thyroid issues and actually, you're
maybe a bit overweight, maybe there's
been no vitamin D in the equation.
And I'm thinking, I don't think the
thyroid's working brilliantly and they
have, they usually, they will sometimes
bring to me their NHS blood results.
And you'll see that actually their TSH,
it's within the normal range, but it's
most certainly not a TSH that I'd want.
Yeah.
Nine, two.
Yeah, or even like four.
And I'm thinking, well, okay, technically
it's normal, but I'd much
rather it was a lot lower.
And then you maybe check their
autoantibodies or whatever.
And so, you know, if, I think that's
maybe why being a GP is quite helpful in
this job, because you can see that, you
know, I'm no, you know, I'm not brilliant
at thyroid, but I know when to call
someone in that is,
if you see what I mean.
So I'll say, you know, with this, your
history and your symptoms and your blood
results, I think we actually might need
to treat you as if you have an
underactive thyroid.
And, you know, I might, I stay in my lane
and I do the hormones, but I will make
sure I send them to someone that I
trusted to look after that bit of them.
And equally I've having learned a bit
about the nutrigenomics.
I mean, that's a complete game changer in
terms of, you know, even just being able
to show a woman to say,
look, this is cholesterol here.
And it comes down this pathway and it
makes some progesterone.
And then it comes down this pathway and
makes some estrogen.
And look what happens
if your stress goes up.
It basically steals it from that
progesterone and your progesterone is
getting to your GABA receptors and giving
you this relaxation.
So you can really start to, you know, not
all women need that, not for women.
It's saying they do.
It's a lovely thing to have if, you know,
if people are in that situation that they
can access it, but it can really answer a
lot of questions and really help women.
You know, we have a lot of, you know, new
diagnosis of ADHD and things at this time
of life, because, you know, once the
estrogen drops, the poor old nervous
system then wobbles like never before.
And, you know, women just, you know,
don't know what to do with themselves.
And then when you can help to explain how
this is all a series of complicated cogs
and, you know, once, you know, if your
big methylation cog at the center of
everything starts to slow, which it will
with age and then a bit more with
menopause, then something else is going
to reach a critical, you know, drop below
a critical threshold for working, whether
that's your neurotransmitters or your
fire rod or whatever.
And then we get all the women with the
histamine issues who come and they've
always been fine and they get to the
forties and suddenly they can't control
their hay fever and they've got hives.
And if they have a one drink of wine at a
wedding, they like flush
and faint and fall over.
Yeah,
and so just, you know, and I am no expert
in it whatsoever, but I have a absolutely
fabulous colleague
that I send them off to.
And it's, I mean, the, they just say, my
God, this is so empowering.
This is, you know, to actually be able to
explain to a woman why she's always felt
like she has or why things have got much
worse recently or whatever is, you know,
it's a complete game changer for some of
these women, whether it's their thyroid
we uncover is the issue or their nervous
system or, you know, they've got
adrenaline receptors, which are like, you
know, on high alert or, you know, or they
caught us all, biochemistry
is all, you know, very messy.
Yeah.
And then, you know, it's amazing.
So it's made my job so much more
rewarding because you can start to, you
know, I've had a lot of, I send a lot of
women also to a lovely colleague of mine
who is a breathing practitioner.
And, you know, we, we either to stop them
snoring or we send their partner if
that's, you know, cause it's almost as
bad sleeping with a snorer as it is to be
a snorer in terms of your health.
So yeah, it's just, it's lovely to be
able to try and work out, you know, so
I've never got the same
formula for any two patients.
It's always a
different, a different journey.
I was, I was going to skip over this, but
then you mentioned genetics.
So I'm sorry, you shot yourself in the
foot a little bit there, but, but
testing, I assume going into, well,
actually this is a good question.
Are you doing a sort of a
lot of testing off the bat?
Would you just sort of go off symptoms?
Because I assume if somebody's coming in
with these perimenopausal symptoms, you
can be sure that things like FSH are
going to be through the roof and AMH is
going to be all over the place.
Do you sort of worry about
that straight off the bat?
Or are you?
Really, really individual.
So usually, again, I'm generalizing
somewhat that a lot of women come to me
for the first time if they're not already
being treated for their menopause are in
quite a state or they
can be in quite a state.
They might not be able to retain any
information because their brain deserted
them long ago with brain fog.
You know, they might be, they're usually
really anxious to actually have the, you
know, they're tearful.
They're, they're, they feel like they're,
that, you know, that
they're completely losing it.
And it must be that there's, there's a
massive problem with them.
And then I can listen to them and expect
that you are, you know, this is
absolutely classical of
your changing hormones.
And I can explain why
that's all happening.
But then if I,
you know, there'll often
be things they throw in.
And I think, oh, it's almost like you,
you can sort of see their
genes beneath their skin.
It's like, oh, I bet
you've got that gene.
But I usually, not all the time, but
usually won't throw that into a first
consultation because it's
like too much information.
But there's some where actually they've
already been to a
million different providers.
They've already researched their own
condition, you know,
upside down and inside out.
And I do feel that they've got the
capacity on that day to talk about it.
And so I will say, look, there is this
other test that I could send you for,
you know, and I have to
say, you know, it's private.
It's not cheap.
It's not cheap at all.
But you know, if money were no object,
then wouldn't it be great if we all had
our DNA mapped out the day we were born
so that we knew what
our vulnerability was?
Of course, the full
genome sequencing was amazing.
Wouldn't that be amazing?
But I know most people aren't in that
privileged position, but there's lots of
people that I might not even need to
think about it for, you know, a couple of
years where we've got
this right and that right.
I've had a woman recently who starting
HRT was quite helpful.
We then she became a lot more healthier,
was brilliant with exercise
that all got a lot better.
We just that we could not, despite she
brought her BMI down to normal, she was
generally doing really well, but we could
not get her HPA1C under control and no
family, I couldn't work out why it was,
but so eventually we got a genetics done
and she has got all the
dodgy glucose processing genes.
And so now she's on rather than the more
generic supplements that I
might talk about with them.
She's now on a very much more
individualized regime.
Did you reduce her carbohydrate intake
alongside that at all?
Oh yeah, she's so on it with, yeah.
What genes are you
looking at specifically?
And are you doing
things like a Dutch test?
Are you doing more of
a generalized DNA test?
Yeah, I don't.
So again, I send, I don't, we don't do
them within health and menopause, but we
send them to somebody that we've worked
with for a long time and that is a
menopause specialist themselves and
therefore understands the intricacies of
what we're trying to achieve.
And so we really individual, so we might
do nutrient core and methylation are
often really helpful, but a lot of our
patients, we do their hormone, the
estrogen pathways as well.
They might want their metabolic doing,
especially if weight is an issue or
cholesterol issues or we think there is
sugar processing issues.
Histamine, although often you do find
that the histamine is only the tip of the
iceberg and it's usually a methylation
issue at the heart of
the problem as for my,
unexpert, my--
No, you're right on the money.
When you've got impaired histamine
processing throughout the body, it's
quite often the case that that individual
is potentially estrogen dominant and that
individual is
potentially estrogen dominant.
You've got to start looking at, well, why
aren't they clearing
estrogen effectively?
Which is why I think these tests are so
interesting because they can also then
govern, I think, the way that you
potentially would treat somebody with an
estrogen, because if they aren't
effectively very effective at clearing
estrogen from their system, then maybe
you won't sort of bias and the therapy
towards being
completely estrogen dominant.
Yeah, let's shift
your constipation first.
There's absolutely no point putting a
load of estrogen in the top if it can't
get at the bottom because
that's going to be toxic.
Yeah, definitely.
That's my very simplistic look at it.
And it's helpful, we also at Health and
Mentals, we actually also specialize in
helping women that have a history of
cancer, any type, but
particularly breast cancer.
And so, again, sometimes if you can look
at how someone is clearing their estrogen
through, you know, their four hydroxy
pathway or whatever, it just gives you a
little bit more information to be able to
more accurately direct an individual
rather than a population of
women, if you see what I mean.
It's very much an individual level.
Dr.
Baugh, I'd love to talk about the history
of management all day, but for the sake
of time, I'd like to talk about the
elephant in the room and that being the
use of testosterone in HRT.
Now, I don't know of any medical
governing body in the UK or abroad that
advocates for the use of testosterone
replacement therapy in women or TRT,
which I think is a little absurd because
it's a hormone that is, well, naturally
produced, woman number one, and B is
crucial to well, life.
Just being sort of happy, functional, I
mean, if you look at the sort of the
Adams questionnaire for men for low
testosterone, I mean, the same things
apply to women as well,
sort of low libido, low mood.
Yeah, dysregulated insulin sensitivity,
poor metabolic health and inability to
maintain and hold them to muscle, et
cetera, et cetera, et cetera.
Now, as I mentioned, there are of course
no governing bodies approving this, so
there are no guidelines on the use of
testosterone in women's HRT,
which again, I think is daft.
I'd love to get your take on this though.
What do you see in clinical practice when
a woman gets onto testosterone or some
sort of TRT therapy as
part of a world sign protocol?
Is it generally a needle mover, maybe
when they haven't had that much success
with just manipulating estrogen and
progesterone levels, or is it just
another cognitive machine?
Yeah, it can be a
complete and utter game changer.
I mean, it's literally like flipping a
switch between night and day.
For some people, for some people it's,
yeah, definitely have some benefits.
You know, it's not a game changer, but
it's definitely been helpful.
Some people doesn't actually help much at
all, and very occasionally, some people
find they feel worse with it.
But in general, the positives are so much
more numerous than any negatives.
And so the nice guidance says that if a
woman is, well, they're supposed to be
postmenopausal, if a postmenopausal woman
is settled on HRT and the HRT is
essentially sorting out all of her
menopausal symptoms, except that she
still has a low libido, which she finds
distressing, and for which there is no
other obvious cause, then we're allowed
to consider a trial of testosterone
transdermally, so through the skin.
But only for low libido.
Yeah, only for low libido.
The joke about that is that you go, oh,
okay, well, this woman actually fits all
those criteria, so let's go, and they go,
well, what are we gonna use?
Oh, we don't have a licensed female
product in the UK for this.
Oh, well, so what are
we supposed to do then?
So then the woman then either has to go
privately to be able to access,
yeah, so we have Androfem, which is a
testosterone cream that
comes from Perth, Australia.
So we've been using that in the UK under
MHRA guidance because we're allowed to
import it because we didn't have our own
product for, I don't know, probably a
good, maybe up to nearly 10 years now.
Now, it actually got its license a week
ago, which is brilliant, amazing.
Although, of course, in practice, all
that means is that now NICE will maybe
look at it as a possibility, but of
course, it's really expensive, so I'm
afraid I'm not holding my breath thinking
that it's actually gonna be available on
the NHS anytime soon.
Maybe a couple of years, but the other
option that women have is to have one of
the male testosterone products, but it
needs to be prescribed at a female dose,
which is
approximately 10% of a male dose.
Now, of course, I can do it in my sleep
because that's all I do day after day,
but most healthcare professionals aren't
used to doing it, and that's when we see
mistakes happening in women
being given the wrong doses.
Enginealized.
Yeah, but it is,
when you explain to women and say, look,
when you're in your 20s, your late
adolescence in your 20s and early 30s,
you had loads of testosterone, far more
testosterone actually
than you had estrogen,
and then from your kind of mid,
early to mid 30s onwards, it just
gradually started to decline, and it was
nothing, it was maybe one, 2% a year, not
that much, so maybe by the end of your
30s, you're thinking, well, okay, my
libido's not as good as it was, but maybe
I've been with my partner for 10, 15
years, we're not swinging from the
chandeliers anymore, we've now got kids
and jobs and stress, and people, we're
more worried about who's emptying the
dishwasher than what sexual position
we're gonna do tonight,
and so it's subtle, and most people don't
notice, but I also think there are some
women out there where when you really
carefully go into their history, their
chronic fatigue syndrome, or their
fibromyalgia, or their depression that
seemed to come out of nowhere has come
about around that time, and we've tried
all other ways of treating it, and
actually then you add the testosterone,
and it's like, bingo, that was what the
problem was, there was no
testosterone in the system.
So testosterone is not, for most women,
it's not actually about the menopause, it
started before the menopause started to
happen, it's just that by the time you
get to your menopause and your estrogen
and progesterone have also gone right
down, I think it's more exposed that your
testosterone's low, but then of course we
have got the women, the younger women
that have the premature menopause, they
often really do well with testosterone
because they're still much younger, and
that kind of need that extra energy and
stamina, and then the women that have a
surgical menopause where their ovaries
are removed overnight, they lose 50% of
their testosterone in a bucket overnight
in the surgery, so they
often do really well with it.
And when you actually explain to women
and say, "Look, all I'm doing is giving
you back a hormone that you've had in
your body since puberty,
and I'm only giving you back a tiny, I'm
giving you 10% before I give to a man,
and we will actually measure it in your
blood just to prove to you
that you're still female."
And the worst thing that could happen is
you'll get a bit of acne back if you were
prone to acne in the past or a few darker
hairs, and then it's reversible.
You stop the medication, it comes back.
So it's amazing, and actually, the
problem with testosterone is that we
don't have enough evidence in terms of
worldwide, big enough randomized
controlled trials to prove that it's
effective for anything
apart from low libido.
From a day-to-day point of view, we see
it all the time, people's mood gets
better, their stamina gets
better, they can work out.
I mean, I definitely, when I started
testosterone, I mean, I was training a
lot anyway physically, but when you're
measuring everything on a Garmin, every
spin pass and every run, and it clearly
jumps up a massive knot
from using physiological levels of
testosterone, you go, "Well, why would
anyone not want to try this?"
But we don't have, there is no data out
there because no one
will fund the studies.
The British Menopause Society, just a
couple of years ago, put in a bid to say,
"Look, we wanna see, "does this help bone
density and muscle strength and mood?"
No one will fund it.
Now, quite, I'm not gonna get on my
political high horse
about what sort of
misogynistic political,
people say, "What would the world look
like "if women had the same rights as men
"to having their own physiological setup
"restored to them at this time?"
There's some stupid quote, isn't there,
about there's more CEOs in the UK called
John than there are female CEOs in total.
It's that sort of stupid, it's like,
"Well, why is that?"
It's because we all are far perched.
And you started the podcast by talking
about what is our use after menopause.
I'm a big fan of the grandma hypothesis.
So, that families, and they found this
in, I think it was, was
it dolphins or whales?
I think it was whales.
The families with a grandmother in them
had far better survival rates.
So the children did better, the
grandchildren did better with a grandma
because they're there.
And to make a grandma a grandma, you need
to make her unproductive.
Yeah, so you've got to stop her
reproduction so that she can just
concentrate on looking after and
nurturing and baking cakes
and cleaning up and things.
So that's my kind of slightly nicer take
on why we have the menopause.
But actually, now we live in a society
where women have to keep working.
We can't just not work at all or stop
work when we get to 45.
And so, yeah, testosterone
can be a massive benefit.
But then equally with some of my ladies
that have had genetic testing doing, you
actually see that if they have the genes,
which mean that you turn your
testosterone a bit too readily into
estrogen, and they're already a bit
estrogen dominant, you'll find that they
don't feel any better.
In fact, you wobble their
nervous system a little bit more.
Would you not maybe blunt that with some
sort of compound like aromatase
inhibitors or aromatics to sort of...
I think that I have
certainly heard of that.
That's way beyond certainly my scope.
And maybe I think that's maybe more in
male kind of medicine, but it's certainly
not something we're doing.
Okay, you're not trying to actively
manipulate aromatase activity?
Not usually, no.
I mean, obviously some of our breast
cancer patients may be on an aromatase
inhibitor, but no, we wouldn't normally.
We'd be looking more at the kind of
dietary ways of doing that or some...
Dim and all of that sort of stuff.
Yeah, but of course I'm a
big fan of just don't...
I get them sprouting their own broccoli.
Fair enough, yeah.
That's a starting point, yeah.
Yeah, perfect.
And it also brings...
Sorry, do you mind me just mention it?
It just also made me think something you
said earlier was that convention says
that HRT is about
estrogen and progesterone,
but actually now that the pendulum has
sort of swung with menopause and it's
more of a common conversation.
I do get women coming earlier and earlier
now, so they might be in their early 40s
and then they might not be in too bad of
a place, but they're coming in a
proactive, preventative
way, which is brilliant.
And sometimes when you talk to these
women, they're just getting the symptoms
of low progesterone at that point.
So their sleep's gone a bit, their
menstrual cycles changed a little bit and
they're getting anxious, but actually
they haven't got the hot sweats and
flushes, their joints are still okay,
they haven't got the
genitourinary symptoms.
And so for some of them, you can just
give them some natural progesterone.
Bob's your uncle, they feel
great for another few years.
And then you just, as long as I say to
them, at some point you may well need
some estrogen, but we can do this in a
very gradual journey.
I think progesterone has been
completely overlooked as well.
Testosterone has been overlooked and
progesterone has also been, we've
concentrated a bit too much on estrogen,
although it is a brilliant hormone.
Yeah, again, it's so much easier being
male, all you've got to fundamentally do
is just, right, so what do you need?
Testosterone, what's gonna happen?
Worst case scenario,
you're gonna over-romatize it.
Okay, we'll give you a drug for that.
And then you can just sort of tweak one
or two variables until you get it right.
Yeah, maybe you've got to look at the
thyroid as well, but
it's definitely simpler.
Dr.
Bo, I'd love to sort of maybe touch on
some of the DHT stuff in a second, but
first, what are your thoughts on DHEA?
Now, I mean, obviously women produce
testosterone as you alluded to earlier,
either in the sort of ovaries or the
adrenal glands, and some women are going
to naturally be biased towards or
inclined to produce more testosterone in,
yeah, the adrenal
glands versus the ovaries,
as, yeah, just based on the genetics.
Now, one would assume that if a woman is
predominantly a sort of a producer of
testosterone from the ovarian standpoint,
that when they get to
menopause, that's going to go away.
But for a woman who maybe has more of a
bias towards producing a testosterone
from the adrenal glands, would a compound
like DHEA, is it a compound like DHEA
that is fundamentally a hormone precursor
be an effective option in these sorts of
women, or is it a bit hit in this?
Yeah, so I only prescribe what I call
body identical HRT, and by that I mean
it's bioidentical as in it's molecularly
identical to our own
hormones, but it is regulated.
So it's all via the MRHA, so it's the
standard kind of things
that can be prescribed.
Some private clinics do what we call
compounded bioidentical hormones where
it's kind of sort of made to
measure, but it's not regulated.
So I see the role of it and why it's
cropped up, but I don't support that
because the safety data isn't there,
because it isn't regulated.
Okay, so prohormans are
to think for you then?
No, no, but I do understand why they're
there, but from my training and my who I-
The way you practice.
The way I practice is that it's the
regulated stuff, but we do have DHEA in a
regulated vaginal pessary,
which can be highly effective if just
using estrogen in the
vaginal vulva isn't helpful.
So yeah, the pessary, again, you know
this, but the simplicity of it is that it
essentially turns into estrogen and
testosterone in the cell, therefore
you're sort of getting, well, I always
want to say you're getting two hormones
for the price of one, but in fact,
probably you're getting two hormones for
the price of two hormones privately, but
yeah, so that can be helpful, but I do
have patients coming to me from IO
identical clinics who want to change the
regulated stuff, and often they are on
DHEA, but I don't prescribe that, so I do
see that there's a role for it because
everyone is different, but in a world
where a lot of the guidelines and the
MRHA deals with, you know, this is the
guideline and it's got to suit everyone,
you know, I sort of explain, well, you're
not losing too much by losing that DHEA
because we're going to give you the
estrogen and testosterone, it's just, you
know, but I recognize there's a much more
detailed minutiae underneath
that, but you know, we're--
That's how do your scope of practice, and
that's understandable, fair enough.
Okay, DHEA, obviously, yeah, I think
that's what most women are worried about
when you mention testosterone, and of
course, just for the audience, what
testosterone is, it's a hormone, it's a
male hormone, which I don't like because
hormones are hormones, I suppose they
have a secondary sex characteristic
development attached to them, but a
hormone fundamentally does the job, but
what testosterone does is it's converted
by an enzyme called anagene called
5-alpha reductase into DHT, and now DHT
is this very
adrenergic, I've got that right,
no, not adrenergic, that's-- Adrogenic.
Androgenic, thank you.
Yeah, that's where you
get the acne in there.
Yeah, hormone, that then drives a lot of
these sorts of issues when it's in
excess, now a certain amount of DHT is
definitely very healthy and it helps with
mood and executive function and all of
that, but excessive amounts can lead to
hair growth, hair loss,
sort of the widening of jaw, all sorts of
things like this, deepening of the voice
that are definitely not wanted,
especially among women.
When you are sort of working with a woman
on testosterone, are you, I think you did
mention it, but are you looking at maybe
any of these genes, are you looking at
ways to maybe modulate this 5-alpha
reductase expression so that you can
control that conversion
of testosterone to DHT or?
Yes, if I had a woman come see me who had
struggled in her life already with quite
bad acne, then that would--
T-c If the skin erupts, you just stop it
and it will come back out of your system,
it's not irreversible.
But then if, again, if they have the
ability to, we could say, we could look
at your genes and then we could look at
more dietary and lifestyle ways of trying
to manage that gene as best we can.
But I mean, we also, I always remember
that lecture when I was doing the
training about that some of the
testosterone goes to
the, goes to, is it Adiol?
Androstenediol.
Which for some people is so relaxing.
So I've had patients that their primary
issue is anxiety and we've done
everything else, we've given them
progesterone, we've given them some
estrogen, we've looked at counseling,
we've looked at, we've kind of done
everything and then you just give them a
little bit of testosterone and suddenly
they go, "Oh, why did you not give me
that eight years ago?"
And I say it's because you were too
anxious to have it, remember, we've had
all these, then again, isn't it?
It's a special issue.
There's obviously the link between
testosterone and dopamine as well.
And the more dopamine you have, Bob's
your uncle, you're going to be in a far
more sort of
parasympathetic rest and digest state.
So I'm sure that plays into it as well.
What about things like, I'm sure I know
the answer but compounds like salt,
palmetto, have you ever utilized
something like that?
Again, it's one of those where I have
heard about it in the lectures and I
understand that it's all to do with the
testosterone thing, but I leave that to
the nutritionist who actually, yeah.
I'll talk about basic supplements with
them, but then when we're getting that
individual, then I say, "Look, I'm not
actually a nutritionist, I'm sort of
signposting you towards one."
Fair enough.
Dr.
Ball, this has been a fascinating
conversation and you've
been an absolute star.
Before I let you go though, I'd just sort
of love to run through a few rapid fire
questions if that's okay.
And yeah, to start off with, what is the
one lab test every woman should, on HRT
should get or consider
getting in your opinion?
None.
Fair enough.
Apart from if she was on testosterone, we
would have to monitor that because the
guidelines say so but the
rest is all too misleading.
All right.
What's your one negotiable lifestyle tip
for women on HRT or considering the HRT?
All of them, but
movement, I suppose is my...
Go to.
That's my go to.
Fair enough.
Okay.
The biggest misconception about the use
of testosterone for women?
That it will turn you
into a bearded lady.
Will not.
I've never in, I've, I don't know how
many tens of thousands of prescriptions
I've done for testosterone for women.
Never had a problem.
So you're telling me you're not
prescribing a hundred milligrams a week?
No.
Fair enough.
And does HRT need to be
titrated down with age?
Usually, yeah.
So in general, you'll need to go up as
you head towards the menopause, plateau
for quite a while and then generally tend
to come down again, but not till, you
know, on average, I would say if I was
giving a 50 year old a normal dose,
I might reduce that by 25% at around 60
and then another 25% around 70 and then
another 25% around 80.
So that they're just on a smidgen at 90,
but they've made it to 90 and they're
still banding up the stairs to clinic.
So.
Perfect.
Dr.
Baugh, you've been a star.
Thank you so much for your time and
hopefully we can do this again soon.
Thank you, Rob.