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Thanks everyone for joining us this evening. It's great to have you here. This is the next in our uh in our menopause series with Vikram. We're gonna be looking at bone health this evening. So I'm gonna in the interest of time passed you straight over to, to Vikram to introduce himself and to and to, and to crack on with the session and the learning. We do questions at the end, but if they come into your head, put them in the chat and then I will cover them through. Um as, as we move for the move for the presentation. Ok. Vra over to you, please. Thank you. Thank you so much, Becky. Uh And today we cover the topics of bone health and cardiovascular health uh in menopause. We've got 40 minutes. So I'll try to keep it brief. 2025 minutes quickly run through some slides as a background information and then hopefully we'll get loads of questions from you. I'm gonna share my screen now and hopefully that works. Uh Let's see what happens. OK? And let me open my presentation. Um Let me go and slide show play from start uh Becky can you see them? Yes, I can Vikram. Yeah, perfect. So let's start with uh bone health first. Uh I'm Vikram, by the way, I work at UC H which is my NHS hospital base for menopause clinic. I do a small private uh service at the 10 Harley Street. Um and I do train lots of GPS and nurses in terms of menopause uh modules for the BM S as well as the F srh. So a quick uh recap on how menopause transition happens because this will be relevant when we look at the impact of lack of hormones on the bone and the heart. So we know that the journey towards menopause happens usually in four phases, you have the premenopause where no hormonal changes have happened. Uh This is when the woman will be having regular periods. Usually once a month, FSH and estrogen levels will be normal. Then comes the phase of perimenopause. This is the first phase where there will be fluctuations of hormones, estrogen and FSH levels will be widely fluctuating. And this phase usually lasts for 2 to 5 years between the ages of 45 to 50. For most women, this is the time when periods may become irregular and there will be subtle other symptoms coming up. For example, mood changes or sleep difficulties or brain fog, some flushes, night sweats, vaginal dryness, a few of those symptoms together with irregularity of periods is usually when we say perimenopause has happened. Next step is menopause. This is when periods have stopped for at least 12 months. It's always a retrospective diagnosis. And if the periods have definitely stopped for more than a year, then this is when menopause has happened. And of course, symptoms will usually be most severe at this point in time because whatever little hormone, estrogen, progesterone testosterone, the ovaries were making now it significantly comes down and final phases post menopause. It's one year since the last period, until the end of life, that whole phase will be post menopause could be 2030 40 years. And this could be one of the most important or productive phases of woman's life. And therefore the importance of long term health. The key in this slide is that symptoms can start as early as perimenopause. And so if the woman is having bleeds, it does not mean that she can't use HRT. If she's symptomatic of menopausal symptoms, then she can be offered non HRT or HRT interventions quite early during perimenopause. When does the menopause happen in the western world? For most women, it will happen at around 51. But of course, 10% of women can have it in the age of 40 to 45 which we call it early menopause. So if menopause happens after 45 it's still within the range expected. But if it happens between 40 to 45 it's early and for one in 100 women, it will be below 40 which is premature menopause, menopause can affect anyone. And for some unlucky women, it can even happen in twenties and thirties or soon after puberty. And that is when uh the menopause can happen very, very early. Uh So never say no to the diagnosis if there are symptoms and signs and there is lack of periods with typical symptoms. It's important to offer hormone profile to young women to make sure that they're not going through premature ovarian insufficiency. Of course, that age at menopause differs in, for example, ethnicity, geography, socioeconomic status, all will determine the age of menopause. Uh And in Asian women, for example, it will be five years earlier. So in Indian women, it's 46 as the average age of menopause, which is five years earlier than the western population. Why are we talking about bones? Of course, if you look at the graph of peak bone mass in men, you can see the bone mass keeps increasing throughout life and around the age of 2030 you reach the peak bone mass. And thereafter, there is a gradual fall in the bone mass as the uh as the age increases. But look at what happens in women is that the big bone mass will happen in twenties and thirties. But around the time of menopause, when there is a sudden decline in estrogen, there's a huge drop in the bone density and that could be very significant, especially if the woman has other risk factors for bone loss. And that's why we really give importance to this phase during menopausal transition. Because a bone healthy lifestyle at this point may prevent some of the bone loss from happening as well as there are other interventions that can be chosen depending on the presence of risk factors. Osteoporosis is really what we are talking about the risk of bone density loss because of lack of estrogen causing a condition which we call as low bone density starts with osteopenia, which is a minor version of low bone density. And of course, if it continues further with the bone loss, going into a severe category, that will be osteoporosis, significant bone loss. It's a symptom less condition and that's why it's even more important that we have a conversation actively with women of menopausal age or perimenopausal age, talking to them about the importance of looking after the bones because it's a symptomless condition. Women will only find out that they are osteoporotic when they have had a fracture because it doesn't cause symptoms. And it is responsible for a lot of fractures, hip fractures deaths following fracture. And the cost to the health care runs in billions. Women of course are more prone than men. And that's because of the hormonal changes that happen around menopause. And it's the lack of estrogen which decreases the bone mineral density and the high rate of bone turnover that happens in this time that causes the risk in terms of bone density loss. And that's just a pictorial uh image uh that serves a normal bone with lots of trabeculae and good bone density. On the left hand. And you can see the loss of the bone and the trabeculae uh in on the right side. That is osteoporosis. Again, what can it cause it can cause fractures? And of course, spinal fractures may lead to deformities as the age advances. How do we recognize loss of bone density in terms of investigation? So, if you have a woman who is menopausal but has additional risk factors for uh bone density loss, then we often do an individualized assessment for those risk factors and you have a scoring system, something called E frea or other scoring methods, which you can use to find out what particular risk that individual has uh because of the risk factors and the menopause. And if there are multiple risk factors, usually you will perform a bone density or a dexa bone scan that will tell you where that person's bone density is in relation to their age and their height. And it will give you a, a score called T score that is determined to make an assessment of osteopenia or osteoporosis. It is estimated that about one in two women will suffer a fracture after the age of 50 a 50 year old woman has 2.8% risk of death related to hip fracture during her remaining lifetime. So it's a significant condition, a symptomless condition which needs attention. All women should therefore be offered healthy lifestyle advice at this point in menopausal transition. So what's the healthy lifestyle in terms of bones? Of course, diet is important that includes having Vitamin D and calcium in diet. Now, Vitamin D on its own is a different topic. So I'm not going to go into too many details now. But if you have plenty of exposure to sun, if you eat oily fish, then sometimes you may not need supplements. But for majority of the population, the exposure to sun is limited and often diet doesn't contain a lot of foods rich in Vitamin D So a supplement, 1000 or 2000 units of Vitamin D is required for most individuals. Calcium can be obtained in diet. So a diet that's rich in dairy yogurt or broccoli cereals or eggs and you can find out more uh rich sources of food for calcium. It's preferred in diet. Uh because there was some indication that some forms of calcium taken is may end up in the arteries and cause increased cardiovascular risk. It remains controversial. We don't have a definitive big data about that. But generally, if you can get enough calcium through your food, then that along with the Vitamin D supplement should drive enough mineral into the bone. Other lifestyle measures would be stopping smoking, making sure there is no excess alcohol, making sure you do weight bearing exercise, weight bearing exercise is very good for bones. And so therefore, things like running, jogging, yoga, any antigravity exercises, skipping, trampolining, those are very good for bones. It's a good time in perimenopause menopause to discuss such bone health issues and fracture risk with the woman. So it's important to find out. Has she ever taken long term steroids? Uh has she had premature or early menopause, which is a risk factor on its own. Is there any family history of osteoporosis? Is there smoking or excess alcohol intake? All that would mean you may have to perform a dexa bone scan to assess the baseline bone density for the individual risk of fragility fracture is decreased on HRT. So we'll come to rule of what HRT uh has to offer in terms of bone health. So, of course, before we look at the treatment options or preventive options, individual risk assessment, as I said, is really important. So when you see the patient or a woman in front of you and who is in perimenopause, it's important always talk about bone health and bone friendly lifestyle role of HRT. Now, hormone replacement, which is replacing estrogen and if required progesterone has been shown to have significant protection against osteoporosis and any related fractures. So HRT is considered first line treatment option for and prevention option for osteoporosis in women, especially with poi. So those below 40 who've had premature menopause or menopausal women below the age of 60. Now, previously, guidelines often mentioned below the age of 50. But now we think HRT should be a first line option for anybody for prevention and treatment of osteoporosis. If the woman is below the age of 60 especially if she has menopausal symptoms, the there are alternatives to treatment of uh osteoporosis which are nonhormonal and I'll just touch upon them at the end. Why does estrogen remain the treatment of choice? Of course, because it is uh it basically builds bone in a more physiological way and it certainly has a different set of side effects and risks as compared to many of the other non HRT medications, especially women with poi. It is one of the best forms of treatment of bone loss. The bone protective effect of course, will depend on how long and how much estrogen is used and it depends on individual as to what dose works for them. It will the effect will decline gradually after stopping the HRT uh mention about muscles, uh bones and muscles work together. So, sarcopenia or loss of muscle mass happens together with the bones during menopause and post menopause. And it's important that any exercises which are often uh taken at the time of menopausal transition includes some strength training, resistance exercise, specifically designed to improve muscle mass and strength HRT does help improve muscle mass. But the data for this is not as strong as the data for bones and more studies in future will determine how much impact HRT has on various different muscle groups, the other treatments for osteoporosis. And again, this is a topic on its own and I'm not going to go into details today, but it includes the bisphosphonates, raloxifen. Uh And of course, you have the parathormone uh calcitonin and there are fall prevention strategies which go hand in hand with this medication. Uh Some of these will be preferred if the woman can't take HRT or as contraindications for HRT, such as breast cancer or hormone dependent cancers in the past. And for those women, non HRT options are really important. I've recently also come across the vibration treatment just like the uh exercise, weight bearing exercise for building up bone. I haven't looked much into the data for that new treatment, but I'll, I'll probably update uh in future. Once I look at the research closely how low frequency vibration may be useful, especially for women who can't take HRT. So that's about the bones. And hopefully we'll come for more questions at the end of the session. Well, let's look at the cardiovascular disease, menopause and HRT. Now, about 2524 25,000 women die from coronary heart disease every year in the UK. And we know that heart disease remains the leading cause of morbidity and mortality in women. And before the menopause, women will always have a lower risk of being affected by heart disease, that is because of hormones and mainly estrogen. After menopause, of course, the risk will increase and we'll start catching up with the risk for men. Why do we think that happens? Because lack of estrogen during menopause will have certain significant effects. The estrogen keeps the bad cholesterol. LDL cholesterol low. It reduces the risk of fatty atherosclerotic plaques in the blood vessel. So once the hormone is lost, it increases the risk of coronary artery narrowing, atherosclerosis will start accelerating. And of course, the blood vessels may become stiffer causing high BP. This is really more important if for premature menopause or early menopause before 40 or 45 without hormone replacement, they will have a higher risk of premature coronary heart disease. So, hormone replacement is really crucial in premature and early menopause. Let's look at what the big studies say. So there were results from the WH study which was one of the biggest randomized trials, uh which published its results first around 2002, 2003. And there was a lot of negative publicity and scare about HRT at the time when the first results were published, it included women from all age groups and initial results about HRT suggested an increase in risk of cardiovascular disease in women who were using combined HRT. But of course, the data were reanalyzed and age specific analysis happened. And we now know that the long term follow up data showed no evidence for such detrimental effect with combined age. So they are much more positive about effects of HRT. Now, in women below the age of 60 who used estrogen alone, HRT, a significant decrease in coronary events was noted. So younger the woman and earlier the HRT gets in, you certainly have benefits for long term cardiovascular health. If you look at the evidence from most recent studies and meta analysis, HRT combined HRT or estrogen alone started before the age of 60 or within 10 years of menopause. Starting does reduce atherosclerosis, coronary heart disease and death from cardiovascular or other causes. So certainly below 60 or within 10 years of menopause, it has benefits for heart health. What about if you start later again? The good thing is there's no increase in cardiovascular events or mortality or all cause mortality in women who initiated HRT more than 10 years. So you may not have a lot of advantage. But certainly there is no excess increase in cardiovascular events even if you start HRT later. But starting HRT early would be important because if you want to derive maximum benefits for preventing the changes that may happen in the early menopause, then that is the key time to go in before any irreversible atherosclerosis has happened. And finally, HRT is not a substitute for lifestyle. So not all women will want to use HRT or take HRT. And therefore, it's still crucial that you have a healthy diet, small portions, less excess calories or sugar exercise, which is really key at least five times in a week for 30 minutes, BP, active control, using lifestyle or medication, managing cholesterol if required, using statins, diabetic control, strict sugar control, no smoking, no excess alcohol and also significantly important is sleep hygiene, not skipping, sleep and stress management. And there are so many things you can do for each of these. Of course, we have time limit today. So I'm not going to be talking about diet and sleep. They are separate topics on their own. But this lifestyle is the key and HRT is an option that adds over it. You can't have bad lifestyle and expect the H RT to benefit. So they both go hand in hand. That's the key message here. So I'm done. All I would say is when we come across someone with menopause who is coming for consultation for whatever reason, this is the time to talk about their lifestyle, their bones, their heart, because we can make a difference by making small changes to the lifestyle. Also consider screening for bone health. There are risk factors for bone loss and heart health screening so that you can advise them whether HRT would be something that would be useful besides treating menopausal symptoms or other lifestyle factors might be uh might be changed to make their long term health better. Thank you so much. Uh That was all as a summary for me, I'm more than happy to take as many questions as possible. So I will stop sharing my slide in a minute. Great. Thank you ever so much Vikram. And yes, please question questions in the chat. That would be absolutely excellent. We, we've got Vikram here. So now's the opportunity to, to ask any questions you have on, on, on those topics. Um Here we go. Right. OK. First of all, Elizabeth are saying it's good to hear such small changes can make such a difference. I totally agree. I mean, the, the, the, the, the number of women and, and the sort of um risk if you like or a chance of getting osteoporosis, it is, it is massive as it starts aging. That's 50% of women, you know, with, with a break. That's, yeah, that's, that's pretty big numbers, isn't it? Alison Johnson is asking is over s if over 60 is H RT. No, no good. So if someone's over 60 is H RT any good? Well, it's individualizing. There's no blanket rule that over 60 you can't start H RT or, or it's not good for you. If you're symptomatic, that's when we really recommend HRT. And the heart and the bone benefits are extra benefits of HRT. So if you're symptomatic and you're thinking of HRT after 60 yes, you can still have it. It will improve your quality of life. It needs to be balanced against the risk though, risk of any blood clots, risk of stroke and risk of breast cancer. If you take the right amount of HRT in the physiological replacement, using the more HRT body identical hormone, your risks are pretty small. So you would still stand to benefit from it as a long term health uh as well as your symptom management. But again, individualize, not a blanket rule, see your health professional and they will be able to advise you. Great. Okie Doke. Um and Zoe's asking if a woman has low bone density but no perimenopausal symptoms. Would you consider starting HRT? Uh Sorry. Uh Becky, I think II missed that question. No problem. Um If a woman has low bone density but uh no per or menopausal symptoms, would you consider starting HRT? It's a good question and one that is a bit controversial. So we say that HRT is for symptoms and not just purely for bone and heart. That's the current guidance because the guidance thinks that risks like breast cancer or blood clots doesn't outweigh just starting HRT for bone and heart. But again, I would individualize, it really depends on, do you have extra risk factors? How bad is the bone density loss you've already had? What is the reason we think you've had that bone loss? And so in, in sort of considering an answer to your question, in certain situations, I would offer it as the first line treatment if you already had bone loss rather than bisphosphonates or other non hormonal medication for treating or preventing osteoporosis or osteopenia despite you not having symptoms. But again, uh it needs to be individualized. So do see the healthcare professional uh and they will be able to advise you but can be done. Yeah, great. Thank you. Um And Tony's asking should Dexa scans be ordered in primary care? And what's the level of risk again? Uh It depends on how confident you are in ordering and then getting the interpretation of the results and explaining to the patient. I certainly have a lot of GPS who do Dexa scans for their patients and then manage patients in terms of their osteopenia, osteoporosis, diagnosis or treatment. They sometimes do seek advice through emails or through referrals. If there are complex presentations. On the other hand, we tend to sometimes do flex assessments or bone assessments in the clinic in the hospital. Do the first Dexa start patients on some form of treatment if required and then pass on to the GP with a plan. I think it's a, it's a bit of individualization here. Some GP S will be happy to take over that. So other GP S may not be confident if they haven't had that experience. Uh I would, I would be happy with either approach as long as the hospital and the GP work together and the patient is involved in that decision making all the time. That works well. Great. Thank you. Um We've got quite a few questions here. So that's really good. Um Kerry is asking is hypertension a contraindication to H RT. No hypertension is certainly not a contraindication. Uh I would say that control high BP first using lifestyle or medication and then start HRT. Now, if your symptoms are terrible, you can start on a very low dose transdermal HRT in the form of patches gels, which can be going through skin rather than oral tablet because the skin HRT doesn't induce blood clotting. And the risk with the high BP is of course stroke or blood clotting and HRT becomes an additional risk. So if you're using a tiny dose through the skin to start with while your BP is being controlled, that's the key. But eventually, remember, you must have a tight BP control once you start HRT and you continue it, but it's not a contraindication per se. Brill. Thank you. And Victoria is asking, she says, thanks Victor. First of all, um I do a Frax Act. Does that make sense to you for patients? However, I do not know how to interpret these and convey into layman's terms for patients. Is there a scope for a training session on this in the future? So we'll keep that in mind, Becky. And at some point, maybe once we exhaust the current topics in the series, it may be good to have that topic. It's a good suggestion. We can just concentrate on how we do bone assessment and how we, uh, interpret the results and what advice we give patients. Excellent. Thank you. Ok. Um, and di di, I hope I've got your name wrong. I'm sorry. Uh, right. Even not wrong. Sorry if I haven't. Um, what are the risks of H RT? And how do you counsel women on these? Well, it's a big topic on its own and I think we did cover HRT at some point in the past and hopefully again, in future generally, just to keep it very simple in a minute. The main risks of HRT today are blood clotting. If you're on oral forms of HRT breast cancer, on any combined form of HRT estrogen with progesterone. Uh if you're taking a charity, no neural form, risk of stroke or blood clotting doesn't apply, but the breast cancer risk will apply if you're taking estrogen progesterone and not if it's estrogen only. And that risk is very tiny. Uh There are some other small minor issues, side effects, risk of gallstones, theoretical risk of ovarian cancer. Those all need to be balanced against your medical history and what preparation and what your symptoms are and how uh uh how the HRT should be tailored to you. But the benefits will be good quality of life, bones and heart benefits. And so it's a balance between the two that we strike. Uh more hopefully in a, in a detailed seminar or webinar just on HRT. Brill. Thanks and on the H RT. Note, uh Bridget's asking, when would you stop H RT? Uh Again, the BM S has given a very good guidance on this. There's no arbitrary limit to stopping HRT. It depends on your symptoms. It depends on your medical history. Once you're on HRT, we expect you to see a health care professional, whether it's your GP or gynecologist or nurse or pharmacist, they will do a detailed assessment of what benefits you're getting, what the background risks are for you. And if you feel the benefits for your quality of life, for bone and heart outweigh those potential risk, you can continue as long as required. Most women will take a charity between 50 to 65 and then taper and come off. Others may continue into seventies and eighties. Brill. OK. And uh a question from Andrew, is there any information supporting lifestyle changes? I guess, you know, specific menopausal related um lifestyle to you might want to access information. There's one very good guidance on uh on the uh I MS. If you Google International Menopause Society, they had one year where they dedicated the whole year to theme on bone health. There is plenty of patient information resources there about lifestyle and non HRT uh management of bone health. Also the British Menopause Society and its charity on women's health concern has lots of resources and there are other resources such as for example, you could see the FSR the Faculty of Sexual reproductive health, there's an endocrine society guideline which gives you lots of information. So I think there are lots of valuable resources on the net. Uh And if you read those, you should get loads of information and, and then get other references to look up other papers. Cool. And I'll add to that actually, the primary care women's health forum as well. It's got some good information and it's all clinicians and, and experts there as well like that are inputting into that. So that's, that's a good resource. Um So Tony's saying we have a number of patients over 70 insisting on staying on their oral H RT. What is your view as a, as a prescriber? If they, if they decline transdermal and try and weaning them off, I would try hard to explain to them. I know you uh we all have these challenging uh patients who will be very happy with the one particular preparation, especially oral HRT and will not want to go away from it. I would try and convince them hard and, and the way to sometimes put it across to the women is to say if you end up having a tia or a stroke or a blood clot on this medication orally, it will mean that your HRT may be stopped completely and there will be very few people who will then offer you a chart and you run the risk of going cold turkey. So rather than that, if you alter off, you try to opt for a smaller change, which is transdermal HRT. It's likely that you could continue this longer instead of having to stop at some point. And often that tilts the balance, you introduce that at one consultation, they come back, they think about it and they might say actually I might change now because I don't want to stop this for the next 10 years, for example. So try and give that scenario to the patient that the transdermal is likely to keep you longer on HRT because you will not have risk of blood clots. I think it doesn't take one consultation, takes 234 to eventually get the patient to understand that the risks are lower occasionally though I have had patients who might not want to change. And as long as they understand the risks and you've documented them in your notes, you could continue. Thank you, Jacqueline. I'm gonna read what I, what I translate is your question and I think that is, should GPS be suggesting H RT to patients if it's suitable or should the, the patient be requesting HRT or demanding as it is nowadays? Well, yes, I think uh so if the patient requests it, it's straightforward, you're going to go through HRT option in terms of whether you suggest it depends on what the patient is coming to you for. So if the woman is coming to you to say she's having difficult menopausal symptoms, which are significantly impacting her life. Of course, you will go through all non HRT and HRT options. Yes, 10 minutes is difficult to cover all that. You might have to have repeat appointments or longer appointments to really go through all the option. But charity will certainly be one of the options that you will suggest and discuss. Its pros and cons. It's mainly menopausal symptoms. We are talking about Brill. Thank you. And are there any more questions at all before we uh before we bring this session to an end, uh you've seen the feedback form. So please do we always say this? Um Please fill in the feedback form. Let us know if there's any other sessions that you like. Please obviously also give us some feedback because we do love to hear, hear your thoughts on us. Um I'm reading this from to, oh, I'm reading this from Tony. Oh no, I'm not. Hang on a minute, Tony. Interesting. It keep sorry, my slide. It keeps going everywhere. Interesting with the C OCP. If a lady comes on, comes under UK Med four, we comfortably say no V prescribing Vikram. Can you make sense of Tony's comment at the top there? Just you're on, you're on mute. Sorry. Uh Let me scroll through the questions at the bottom and see. Um I'll also just say to the audience, I'm not clinical. So there are bits that I don't understand. Like if a lady comes under UK four, we comfortably say no to the prescribing. Yes. Again, as I said, it's, it's individual decision. I know of GPS who wouldn't be comfortable to prescribe a charity, especially oral, a charity to any woman above 60. And they would often refer the woman to us at hospital. And that is why I said it's not mandatory that you should prescribe if you're not comfortable. And if you're out of the guidance, this is out of guidance, prescribing. And again, it's an individual sort of decision between the patient and the physician, depending on how comfortable the physician feels, the woman understands her risk. And therefore, if you're not comfortable, always ask your colleague or refer to hospital another clinic where they may be able to give her advice. Uh It's not a compulsion that you should always prescribe out of guidance if you're not happy.