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Mood issues, whether that's due to discomfort um from night sweats, those kind of things or whether it's due to other things, um such as low mood anxiety, um can be exacerbated by the menopause uh libido. Um So again, increasingly we're seeing people coming through wanting um some help to support the libido. Um women are or people are, are having sex well into their eighties now. And so if you go through the menopause at age of 50 then trying to maintain a degree of sexual function is something that we need to consider. Um right up into old age, um impaired memory and concentration, brain fog. Um You'll often hear described and again, on the news, people are always talking about sort of not feeling like you're in the room feeling like you're floating around, not quite with it. Um And that can be really distressing. Um And these symptoms last a long time. So you may get symptoms starting around the time of your perimenopause of 45 46 47 and they can last all the way through the point where your periods stop and then beyond. And some people find that they're troubled by them for much longer. It's also important to say that the majority of people will not have major issues with this. Um And the menopause is not a disease, it is a, it is a phase of life um that causes symptoms that are troublesome and are manageable. Um But it is not a disease. So why, why does this happen? Why do women spend 30 years of their life um in the post reproductive phase? Well, to answer that question, um we're going to dive into the ovary in a little bit of detail. Um So the structure of the ovary is similar to the kidney in that you've got er cortex around the outside, which is where the ocys um and the follicles live. And then there's a supporting um medullary stroma in the middle, which is where your blood vessels and nerves come in. And that's where you get the blood supply from and obviously where the hormones go out. And it's also the sort of the supportive connective tissue that holds everything in place. Now, the x uh uh surrounded by support cells and that sort of collection of cells, the eggs surrounded by supportive cells um for the majority of, of life will be what are called primordial follicles. Um So that is your primary oocyte, which is an egg that is arrested in the first meiosis. Um The first meiosis division in prophase. Why it does that? We have no idea. It doesn't seem logical, but it sort of enters meiosis and then freezes and stays there until you ovulate if it ever does. Um which is unusual, but there we go. Um And they're surrounded by supporting cervical granulosa cells and the base of membrane. And that collection is called a primordial follicle. And the primordial follicle is basically the functional unit of the ovary. Now, what do I mean by that? Well, when you're born, each ovary will have about a million primordial follicles within them. By the time you get to puberty, um the majority of those will have died. So rather from a million, you'll drop down to maybe 300,000, 400,000 of these little follicles left. Ok. And basically what these follicles are is they go on to um at random intervals seemingly. Um and there is some kind of trigger that we don't know what it is. Um that starts these follicles to develop. Um, and eventually every month, one of them will be ovulated. So, the basic process is every day or every few days. Some trigger um will cause the supporting granulosa cells to start to multiply um and increase in both size and number and you start to get a secondary collection of cells around them. They are called er, theca cells that produce er, a slightly different set of hormones over time. Those cells um become more and more in number. Um, you start to get growth of the egg So the amount of cytoplasm around the egg starts to develop, the nucleus doesn't change, it doesn't progress through meiosis. It stays the same, but the amount of um activity within the egg increases as well. Um until you get to a point where we can see it and it becomes what we call an antral follicle. So when you're scanning, someone, um say for a fertility clinic and you're wanting to assess how many follicles they have at that moment in time to assess their response to the stimulation drugs that we use in IVF. And those are the follicles that you're measuring. And so if you were to scan every woman who's having um ovulatory cycles, you would expect to see 1012 maybe follicles which look like little cysts sat around the ovary. At that point, they start to respond to FS H and enter the menstrual cycle. The key thing there is that because they're coming in every day. If you imagine one set one follicle entering that process every day, um they need enough FS H to survive and enter the phase where they develop and then eventually ovulate. And so the vas there is only one day where the FS H levels are correct um to maintain an egg or a follicle, sorry to maintain a follicle. And so the vast majority of those will develop, become an antral follicle. But because the levels of FS H aren't right when they reach that point they then break down and die. So the vast majority of the eggs or the follicles that start to develop, get to the antral phase and then break down and disappear and, and die off. Um And that's why every month you release normally one egg, sometimes two. Um but more, normally it's one egg from one side and that's it. And all of the others that are developing in the 14 days before ovulation and the 14 days after ovulation all die off. And so for every egg, you release, you maybe lose ie 20 to pick a number. OK? And that process is happening constantly. Um So over time, your supply of follicles reduces. Um Now, it's not just the process of um follicle developments and then atresia an ovulation that loses them, there's oxidative damage, there's aging genetic damage, various other things that can happen, surgery, endometriosis, whatever that gradually damages these little follicles. Um and you reach a point eventually where you're running out. Um And when you run out of follicles, you stop ovulating. Um and you go into menopause essentially and simple as that. So the important point with granulosa cells is that they produce estrogen uh predominantly. Now, I'm hoping you're all familiar with the graph of the menstrual cycle on the right hand side here. Um It always looks like estrogen goes down to zero. It doesn't estrogen levels. There's a basal level of about 50 ish um that fluctuates up and down, but never goes below that baseline level, um which is slightly different to things like progesterone where there is more of a trough and then a big spike and then another trough. Um So you have a constant level of estrogen um from around two or three years after you um start going through puberty, up until the point when you start going through the menopause. And it's been constantly produced by the granulosa cells in the ovary. Um So as they develop, you get more of them, and there's a constant number around the ovary that's developing, producing estrogen. And then that one follicle that develops and eventually releases the egg. You get a huge increase in the number of granulosa cells, which is why you get the big spike in estrogen um during the menstrual cycle. Um and then when that follicle ruptures and breaks down, that falls back down and then you go back to the basal level that's being maintained by the follicles that are never going to be um that are never going to ovulate. How do they do this? Well, they are part of a metabolic pathway. So, um it's is a steroid hormone, all steroid hormones come from cholesterol. Cholesterol initially gets converted into a progestogen of some description. So, um that's the starting point and that's why if you give people um progesterones, um they do get some estrogen or they can get some estrogenic effect from it. Progesterones get converted into androgens. And then androgens get converted into oestrogens. The enzyme that converts androgens into estrogens is called aromatase. Um And your granulosa cells have quite a high concentration of aromatase which explains part of their function. The other type of cell that contains a lot of aromatase is fat, um which we will come on to a little bit later. So as the supply from all the follicles reduces, not only are you losing eggs, you're also losing granulosa cells. Um which is why you get a significant drop in estrogen. So, the reducing number of follicles means you're getting less periods and the hyper estrogen symptoms that we've spoken about before. I that makes sense. So what's the problem with that? Well, in one sense, there may not be women generally live longer than men. So, you know, clearly being hypoestrogenic is not a major barrier to having a long healthy life, but there are some complications or there are some side effects of having a low estrogen state that we know about. Um the most clear is osteoporosis. Um And I don't know if any of you have been on an orthopedic rotation. Um But if you do and when you do go onto an orthopedic rotation, you will notice that the female trauma ward is noticeably bigger than the male trauma ward. And that's because women are much, much more likely to fall over and fracture their hip, their arm, whatever because of osteoporosis men. Whilst the testosterone and the sort of general um hormone levels do fall with age, there's less of a marked decline than there is in women. Um So that is a major cause of morbidity and mortality amongst the elderly cardiovascular disease. So, again, there is some evidence that uh lower estrogen levels can have a negative impact on your cardiovascular health that can increase their risk of er heart attacks in particular and also strokes, potentially. Um although that is slightly less clear cut and it seems to depend on age and various other risk factors as well. And then in terms of your sexual function, we're looking at genital atrophy. Um so that can contribute to sexual dysfunction. If you have dryness, vaginal thinning, it can be painful. Um And obviously, if you, if sex is painful, it can impact on your desire to have sex, your ability to orgasm and all of these other things that go along with that. Um If you lose the sort of the structural support and integrity of the vaginal walls, so that can exacerbate any preexisting prolapse. Um So again, there's a reason why the rates of prolapse increase when you get through the menopause urinary dysfunction. Now, this is slightly less obvious if you've got um a prolapse or if the bladder neck has fallen down below the pelvic floor, that can cause stress incontinence, but it can also cause overactive bladder. I don't quite understand why that is, but we know that if people have got overactive bladder uh dysfunction or have got stress incontinence, then vaginal estrogens can improve those symptoms. And that constellation of urinary dysfunction, vaginal dryness prolapse. The sort of genital impact of the menopause is collectively known as the genitourinary syndrome of the menopause. And these risks um generally increase the longer time er, that you go without estrogen. So initially, you might not notice a major difference after 2030 years, you certainly would. Ok. So the next question then is what do we do about it? Um Now I'm not going to talk a lot about H RT, but I think it's important to have a brief understanding of the principles surrounding it and what we use it for. So, first of all, what is the point? What is er the aim of H RT? Well, um fundamentally, if you are estrogen deficient and you have symptoms that are distressing you that are caused by estrogen deficiency, then we need to replace that estrogen. Um There are several ways of um doing that. So there's systemic H RT, which can be with tablets, it can be with patches, there are gels, there are sprays lili and primarily those are used to treat symptoms of the menopause. So your vasomotor symptoms, brain fog concentration and sexual dysfunction, those kind of things. Um as a secondary benefit to that, you can tell them about the reduced chance of an osteoporotic fracture. You can tell them about reduced coronary artery risk as well. Um There is also the option for vaginal treatment. So, if you've got genitourinary syndrome of the menopause, then offering vaginal treatment with estrogen cream or pessaries is a really good option for people and it does have a big impact on people's quality of life. Um So as I've mentioned, it improves symptoms of prolapse by increasing the support around the vaginal walls. It can improve symptoms of urinary incontinence through a mechanism that I'm sure is logical, but I don't fully understand. Um and it can also improve things like vagina lubrication, reduce sexual pain. At this same point, it's important to think about other things that you can do such as recommending lubricants and those kind of things. Um which er is something we do quite a lot actually is, you know, recommending different types of lubricants and those kind of things to a woman. So that's the good side as with everything that's good. There is a downside, unfortunately. So the main ones that we need to worry about are if you give estrogen er to someone with a uterus, er you massively increase their chances of developing an endometrial cancer. Now, the reason for that, as I'm hoping, you know, from the, from the menstrual cycle, um estrogen causes proliferation of the endometrium, it causes it to grow. And so if you don't have a progesterone to either stop the growth of the endometrium or withdrawal of that progesterone to cause a bleed, then you just get unopposed growth of the endometrium, which over time can accumulate genetic damage and can become malignant. And the chances of, of that are actually massive, particularly over longer term use. So anybody who has a uterus, um or in small letters, if they've had endometriosis, um then you need to consider gi well, if they have a uterus, you definitely need to give them a progesterone. If they've had endometriosis, you would consider giving them a progesterone as well. Cos if there's any endometriotic deposits left, they can be estrogen um sensitive. Um And again, they can also develop into a malignancy. So it's just worth thinking about risk of blood clots. So, again, as with all the estrogen, whether that's the combined pill, whether that's H RT, um there is an increased chance of developing DV TPE. Um and this is especially so with um oral treatment. So with a patch, the risk is basically no different. But with a tablet, it is why that is, is presumably something to do with metabolism in the liver. But again, I don't really understand why that is, it just is. Um and also with combined. So if you've got estrogen and progesterone together, presumably, that's because progesterone gets converted into testosterone and estrogen, both of which will increase your risk of DVT um Coronary artery disease. So, if you're starting H RT over the age of 60 then you actually increase your risks of getting coronary artery disease rather than reducing it. Um So there is a benefit to starting early and that's why we tend to say start early and use the lowest effective dose for the shortest amount of time. Um Risk of stroke is also increased with oral H RT started over the age of 60 not so much with patches and again, presumably that's to do with the metabolism and then breast cancer. So, um this is a big issue. Um So you've got increased rates of breast cancer with combined HRT and it's actually the progesterone, not the estrogen that increases your risk. Um And there's been some information recently suggesting that even the progesterone only pills can increase the risk of developing breast cancer if used long term. Um which is something that we haven't counseled patients about previously, but it's probably something to be aware of, particularly if they're using it for years at a time. Um The risk of only H RT is much, much less um to the point where it's almost nonexistent. Um The important thing to say is that while there is an increased rate of breast cancers, there is no increase in the rate of mortality. Um But because of the hormonal nature of most breast cancers, particularly amongst older women, for those with previous breast cancer or with active ongoing treatment for breast cancer. H RT is not recommended. Systemic H RT is not recommended. Vaginal treatment can be considered because it does not get absorbed in, in massive quantities. So the the blood levels are basically zero. So that is OK. But that is a real problem. So if you have breast cancer at 40 then you have chemotherapy and and sort of ovarian blockers to, to, to put you into the menopause from the age of 40 then you're going to be estrogen deficient for an extra 10 years and that's got a big impact on your, your long term life. So this is a brief kind of summary of systemic H RT. So we're looking at, do you have a uterus? Yes or no? If you don't estrogen only oral transdermal, various ones don't worry about whether it's horse based or urine, but it doesn't matter. Um for you guys perspective and then if they do have a uterus, then they need a progesterone. The Mirena coil is an acceptable progesterone and the Mirena coil is licensed for endometrial protection for four years. So that is an absolutely appropriate thing to, to consider, particularly if they've already got a Mirena for heavy bleeding or for contraception. There's no reason you can't leave it in and then start H RT um in the background as well. Um Sequential therapy basically is where you are, have someone who's had bleeding more recently. So maybe they've had a bleed within the last year. Um but are wanting H RT for vasomotor symptoms and memory issues or whatever. Um the sequential treatment means that you basically have a monthly period. So it regulates your cycle. It reduces the amount of dysfunctional bleeding. So the irregular, erratic unpredictable bleeding that people get, um, and it reduces the chances of endometrial hyperplasia and endometrial cancer. If they have been. Um, if they're postmenopausal, they've not had a period for a year. Certainly, if they're not in a period for two years, then you would give them continuous combined. So that's a lower dose of progesterone constantly, which is designed so that you don't have any bleeding. Um In theory, it can take months to settle in and people do have bleeding for up to 3 to 6 months after starting combined H RT. If they are having unusual bleeding or progesteronic side effects, you may need to change the dosing may need to change the type. And again, there's an element of trial and error with this. So, um when I was working in GP, when we did this a lot, um we were basically advised, pick one, use that get used to it. And then if there are problems, you can try something else, but broadly speaking, other than what we've already said in terms of the risk of dvts and things you go for what is safest and what works best for that individual and you can try and chop and change a variety of different things. So that's H RT in a nutshell. It's not as complicated as people make it sound, um There's just a lot of different options and a lot of drug companies trying to sell a lot of different things that are all basically the same. So what are the challenges now? This is something that's been a moving target when I was a medical student uh back in 2013, 2014, um the, the general consensus at that time was that people were warned off H RT because of the risks of brea other concerns around breast cancer. So when I was at medical school, lots of people weren't having it and lots of people were suffering because of the fear surrounding breast cancer. There's also concerns that people have regarding heart disease, stroke, dementia, um which as we've said is a bit of a mixed bag, really dementia. There's no particularly good evidence one way or the other. Um and VT as well. No. Um like I say that was more of an issue a few years ago. It is still something you're more likely to hear or ii hear from older women. So particularly if you've got someone who say in their early seventies who's come in with prolapse or incontinence and I'm and vaginal atrophy along with that. And I'm recommending vaginal estrogen cream as treatment for that. People will often say, oh no, I don't want HRT I'm really worried about the breast cancer risk and then you then have to spend a bit of time explaining that it doesn't cause breast cancer, it doesn't get absorbed that it is safe. And if you don't do that, people don't take it. And, you know, you see a lot of people coming back who just haven't used what has been suggested because no one has actually addressed the patient's concerns about the treatment that you're doing that you're offering. And it's one of the reasons why, um, the concept of ideas, concerns and expectations are really hammered into, into us at medical school because it is essential. And unless you understand the patient's agenda and their concerns and preexisting ideas about a problem, you are never going to get anywhere. And even if they do agree to take a prescription that doesn't mean that they use it. Um And you see that a lot now to put the various risks in context. This is quite a good chart. This is from the British Medical, not British Medical British menopause society, the BMS. So it's showing that if you're using combined H RT, there are four additional cases of breast cancer. And for those between the age of 50 59/5 years, which is the same risk as those taking the combined pill, which is roughly the same as those who drink any alcohol, which is roughly the same as those who are smokers, which is significantly less than anybody who is obese. And this is something that again is a real challenge at the moment. That um women with obesity um are significantly more at risk of coronary artery disease, DVT stroke, dementia, breast cancer, and then giving them an HRT. On top of that, you're adding those risks together. The other point to bear in mind with people who are obese is that they are less likely to be hypo to have low estrogen because the amount of fat tissue that they have has a lot of aromatase within it, which can convert the androgens that the adrenal gland is producing into oestrogens. Um And often H RT, it theoretically is required less in theory. Um It doesn't always work, obviously. Um But it's something that's really important to consider when you're counseling people about the risk that if you know, if you're, you've got a BMI of 20 you're otherwise well, and you're active and everything else, your risk of A DVT is tiny if you're someone with a BMI of 5060 which unfortunately is not unusual anymore. Um That would be a very different conversation and, you know, I it wouldn't stop me from using something like a patch because that doesn't increase the risk of DVT. Um necessarily, but I certainly wouldn't be offering tablets because of the, because of the increased chances. And again, we're trying to do this to improve someone's quality of life. What we don't want to do is kill them with a massive pe by trying to make them less sweaty at night and you know, trying to improve their concentration. So it's about that balance really. So the next challenge, which again, I think is something that you are seeing or will see in all areas of medicine really is patient expectations. Um both good and bad. So um I'm sure it won't have escaped any of you. Notice that there's been a lot more talk about the menopause in the media and in culture, like I say in the Guardian on Tuesday, there was a new report from Australia talking about how we've all got a negative attitude about the menopause and how, you know, reviewing it as a, as a disease rather than a stage of life. And that we need, you know, we're too quick to prescribe medication and that drug companies are getting too involved and all this kind of stuff, um which was followed immediately by people, you know, the, what was it, the story about the um the train company who made menopause bags, which was just deeply patronizing. Um and the concerns that people have about, you know, people not being willing to hire women when they're younger in case they have Children. And then when they get older in case they get menopausal. And it's kind of, it's adding to that view that hiring a woman is going through more trouble than it's worth, which is not true and is deeply harmful, but there are some positives that come out of that. So women who need help are more willing to come forward. The more sort of recognition that actually we need different temperatures and offices that having more access to toilets, sort of simple things like that is really important and is something that will, that is going to be a benefit. I think it's just about balance. There is also an issue amongst about unrealistic expectations and an assumption that um if you're around your fifties, any symptoms that you have are going to be due to menopause and that H RT is going to make you better. So, at this point, I'm going to bring in a case and this is a real case that and I saw last year this is of a, a lady I've said 53. I can't remember how old she was but it seems seems fit. So she attended um outpatients to discuss H RT. Um she had 18 months of amenorrhea. Um So it's, it's post menopausal, you know, she's over the age of 50 she's not had a period for a year. Um And the symptoms that she was reporting were her fatigue, poor concentration, poor sleep and hid Donia, which for those who haven't done psychiatry is a lot of enjoyment of day to day activities and a low libido. Now, question for the group and again, there's no right or wrong answers here. I was curious to know your thoughts to put your answers in the chat. If you're happy what do you think your differentials would be in this circumstance, let's say, imagine you're a GP, rather than a gynecologist. What are you thinking might be going on for this lady in particular, just with those symptoms? Yeah, I like that. I hadn't thought of that, but, yes, absolutely. I've, I've forgotten about thyroid disease this week. It's been quite embarrassing. But, yeah, hypothyroid, potentially depression. Yeah. Absolutely. I must confess that was my thought. Anything else? I'm not, like I say, I don't have a right or wrong answer here. You know, I'm a gynecologist. My, my er, differential diagnostic diagnosis was not long. Um So, yeah, I didn't think of hypothyroidism. That was a good thought. Um Yeah, potentially, potentially. Um Absolutely. Um So my thoughts are from talking to her and there was more about this. Um, so it could be menopause. Now, as you said, a lot of those symptoms are features of the menopause. So, loss of libido, loss of concentration, drop in mood, all of those things can be related to the menopause, but it could also be depression. I didn't feel hypothyroidism. Um, primarily cos I didn't think about it. Um, but that's a very good thought. Um And this is one of the dangers of referring to a specialist rather than keeping things within general practice because general practitioners know more than we do about more stuff. Um So anyway, I felt from talking to her. Um, and there was more to it than, than, than, than what I put down there. So, things about body language when someone comes in, they sit down, they're quiet, they're looking at the floor, they're not making great eye contact. They, you know, there are lots of things that go along with, um, sort of a depressed affect. Um, that would make you lean in that general direction. Um, now she could be menopausal but she doesn't have any of the classic symptoms. You know, it's not like she's been having any vasomotor symptoms and those really are the most common. So again, if you don't have vasomotor symptoms, you've got to be thinking, is this something else? Um because like I say, over 80% of women will have those to some extent. Um The other thing that I neglected to mention was that she tried three different types of H RT before. So she'd been referred by the GP with low libido discussed H RT came in to see us and had been seen over the previous year or so, um or six months um and had tried multiple different types of H RT, none of which had helped. So she'd had tablets, she'd had patches and she'd had sprays. Um No, this is one of those situations where the expectation of the patient differs wildly from what my um or what your agenda as the doctor is um compared to the patient's agenda. Um So her idea or her concern was that she had a low libido. That was because she was menopausal and she wanted testosterone to treat it. Um which is fair enough. Um As a thought process, the reality of the situation is that's not quite how it works. So the majority of the time, if you have low libido, estrogen therapy alone is going to be good enough. Um The evidence around testosterone is patchy. Um And I'll come onto that a bit a bit more later. Um And we don't generally use testosterone unless they're stabilized on H RT first. And there are various reasons for that. So you've got side effects, you've got testosterone gets converted into estrogens. And so if you're not adequately replacing estrogen, you get preferential diversion of the testosterone into, into um into oestrogens anyway. Um you get more er androgenic side effects so you get more facial hair, um voice deepening acne, those kind of things. Um And there's also no relationship between serum levels of testosterone and um sex drive. So it's slightly controversial. Um So with that in mind, um I'm going to deviate slightly, I'm gonna take sort of a, a leftward jaunt down into sexual dysfunction cos this is something I'm assuming you don't get taught much about. I know when I was at medical school we had um a whole day with the psychosexual therapist talking about this kind of stuff, but I think they've got rid of that now, which is a shame. But sexual dysfunction and I apologize for the name as well. I hate the term female sexual dysfunction, but that is what it's called. Um And that's not, that's not on me. Um I don't like it but it is what it is. Um It's broadly split into three and the DSN five has recently changed this and made it simpler, which is good for me. Um So it split into the loss of desire or arousal, um which is sort of lumped into something called hypoactive sexual desire disorder, which is another horrible name, but there we go orgasm disorders and dyspareunia is that sexual pain. Um Now, in the menopause, loss of sexual desire is the most commonly reported. However, obviously, these often coexist because if you don't, um if you're not interested in sex, um you're not going to er, respond in the way that you'd like, you're not going to get your vagina lubrication and things like that, which is going to make it hurt and if it's hurting and you're not interested, you're very unlikely to orgasm. So that is all a vicious circle. Um And separating it, I think is more to do with trying to identify what was the initial problem rather than necessarily separating them into different diseases because they all go together. Um The etiology of these, the causes can be a multitude, there's loads of medical conditions, loads of drugs. So really commonly SSRI S can have a real impact on sexual function, which again, if you're depressed and your sex drive is lacking and then you're given a drug that makes that even worse, that can have a real negative impact on your relationships. And if you're having a negative impact on your relationship and make your mood worse and the whole thing's again, a horrible spiral. Um, there are psychological traumas or psychological um, er, psychological concerns. So again, body image concerns mental health issues, depression, um anxiety, things around, um increasingly again, concerns around body image and request for genital cosmetic surgery because people feel they don't look normal, which is ridiculous cos everyone is normal, there is no such thing. Um and then there's sexual issues as well. So whether that's um sexual pain, whether that was previous sexual assault, um and again, that's depressingly common as well. Um All of those things can have a negative impact on you. Um And like I say, the role of falling levels of testosterone is not fully understood and there doesn't seem to be any relationship between your level of testosterone and your satisfaction with your sex life. Now, obviously, the trying to gauge what someone views as a satisfying sex life is really difficult cos what one person review is being absolutely fine. Thank you very much. Would be another person's idea, but deeply unsatisfying um life and vice versa. Um And so the one of the, that's one of the issues is that there is no standardization there is no normal. Um So we have to be guided by is the symptom distressing the person. And if the symptoms are distressing the person, then that we can then say is likely to be pathology of some description. So, in the menopause, we're talking about what can cause a loss of libido. So obviously, we've spoken about pain, we've spoken about atrophy, prolapse the body image. And again, it's not, it's I had a aging clinic last week, um who really wanted to have sex, but her partner didn't want to because he was worried about damaging a prolapse that she had. Um And so part of my job then was to reassure, not just not her cos she was fine but him that it was going to that it wouldn't cause any damage. Um and is fine. Likewise, incontinence, if you leak urine when you have sex, not ideal. Um Again, that only has to happen once and that really again puts people off really negatively affects your body image. It, it's just a horrible thing to happen to people. And again, it's more common than you'd think psychological things. So stress. Again, if you think about the, the age when you're going through the menopause, you've often got teenage Children, you've often got elderly parents, you're often in a busy stressful work. Um There's a reason why lots of chronic pain, sort of chronic functional diseases have a spike around this age. Um So if you go to rheumatology clinics. If you go to orthopedic clinics, if you go to gastro clinics, if you go to Gyne clinics, there are lots and lots of women around this age, um who are suffering because of the, the general pressures of life, um causing symptoms that we can't fully explain depression again for those reasons. You know, if you, if, if your entire life is difficult, then depression is, is common. That's why it's also common amongst doctors. Unfortunately, previous trauma, as we've mentioned relationship problems. So again, if you've got teenage Children, your parents are sick, you're at work all the time, their money is tight. Your relationships breaking down all of that is a problem, negative body image. And unfortunately, quite a lot of this was true for the lady I was seeing. Um So the point I'm trying to get at is that it is essential to try and tease out what is going on. When did it start? What is causing it, what is contributing to it? And is this a cause of your problems or a consequence of other problems or is it a bit of both? And often it's a bit of both cos things are psychical. Um So in this particular instance, um while hypothyroidism would have been very clever and I probably should have thought of it. I felt that while menopause may be a contributing factor in the way that she was feeling, I thought that it was more likely to be depression. Um which then means that you're at an impasse because your views are different to hers and you need to have a negotiation. So what does this involve? And finally, we're on to the point of the talk. So as I've mentioned, you need to explore their ideas, concerns and expectations. So in this case, for example, I feel like this because I am going through the menopause, I am not depressed. This is a hormonal problem and I need the correct H RT to make me better. That is not the same as my thought process. So you have to explain why you don't think that is the right option but be open to the fact that you might be wrong. And that's the other thing is there's, you know, there's trying to explain rationally why you think something different, but it's really important not to be dismissive. Cos again, if you get dismissive, if you imply that someone's being daft, then their defenses go up and they stop sort of communicating with you. So again, you've got lots of symptoms of depression and H RT has not worked for you so far. So in this case, I said, look, you're adamant you want to try H RTI don't think it's going to work cos you've tried three different types, but we can try 1/4 1 if that's what you really want. But I think it's important that we look at other things as Well, we look at your psychological wellbeing, we look at psychosexual therapy, we look at relationship counseling and there's lots of other things that are available to people um that can be helpful. Um There is no good evidence to support the use of SSRI S or depression associated with the menopause. But psychological therapies have been shown to be helpful and psychological therapies can also help people deal with things like night sweats, um and hot flushes. So that is now recommended by nice as an option, particularly if hormonal replacement isn't appropriate. If you have tried topical estrogen, you can use lubricants and various advice about sex and and sexuality can be helpful as well. Quick point about testosterone. You do not need to know this because it is controversial and the evidence is changing all the time, but we use it if H RT alone has not improved symptoms and following a thorough biopsychosocial model. So that's what we've just been talking about in terms of looking at the physical medical problems, the mental health, psychological problems as well as the sexual function, just looking at everything in the round and that is complicated and not everyone is trained to do that. There is evidence that testosterone can improve symptoms of reduced sexual desire in certain cases. Um But the recommendation is to be used alongside H RT and you need to monitor dosing um because it is quite easy to overdose people with testosterone with the side effects of, again, it's not just facial hair and acne, but various other issues in terms of, again, blood clots, cardiac risk, stroke, risk those other things as well. Cos you don't want to kill someone who's just trying to have a better sex life quick point about premature ovarian insufficiency. Um just to bring things to a close co this is another area that is quite challenging. So what is it? So, premature ovarian insufficiency is essentially menopause that is diagnosed under the age of 40. So, if you have the menopause between 4045 that's defined as early. Um but before the age of 40 is premature, um so you can diagnose it if they have oligo or amenorrhea for at least four months and they have elevated FS H on two occasions, 4 to 6 weeks apart. Now that differentiates it from something like Polycystic Ovarian Syndrome because of Polycystic Ovarian syndrome. Um they would have oligo or amenorrhea, but the FS H levels would tend to be low. The reason for that is because in um ovarian insufficiency, um estrogen levels are low and therefore, you've got less negative feedback on the pituitary gland. So your FS H levels rise in PCO s, your estrogen and testosterone levels tend to be high and therefore you get more negative feedback, suppressing your FS H OK. That is a classic exam question. For my level depressingly causes lots. So there's genetic things. So, you know, classic things and things like Turner syndrome. Um It does not, it is known to run in families. There's probably other polygenetic and epigenetic causes as well. Medical problems, autoimmune diseases, infections, things like mumps, um can cause premature insufficiency. And also if you've got endometriosis on the ovaries that can impact on your ovarian reserve as well. And then iatrogenic and probably most um pos caused by doctors. So that's chemotherapy, radiotherapy or surgical removal for cancer. So, um why'd you remove it for cancer? So, if you've got an estrogen, responsive breast cancer, um and we need to stop you from producing estrogen. One way we have of doing that is by giving you an injection every month um to um suppress your ovaries using GNRH analogs. Um The other way of doing it is by doing a laparoscopic sophy um which they do quite a lot in cancer centers. Um The advice if you're going to take um do that or do use radiotherapy or chemotherapy. So, in childhood cancers, I mean, you know, one of my friends had lymphoma a couple of years ago and she had um fertility preservation surgery beforehand. So, the physical health impact of this. So eastern deficiency, the issues with that are more marked at an earlier age. So again, if you're 35 osteoporosis is gonna be a big issue, your cardiovascular risk is gonna shoot up your cognitive impairment and risk of dementia is also higher. And so the recommendation is to give estrogen replacement, whether that's H RT or the combined pill up until the age of natural menopause, which is about 50. And unless they've had an estrogen responsive cancer, such as breast cancer, which makes breast cancer surgery very, very difficult. Um in terms of the risks, basically, by giving H RT in young women, you're returning them to the baseline risk of the general population. So you're not increasing risk, broadly speaking above that of anyone else. Fertility is the other side of this. So again, if you're having, you know, chemotherapy for a lymphoma when you're 25 um you're, well, you're unlikely to have had Children, you're unlikely to have thought about it. And that may be something you want to think about in the future. So if you're having treatment for that, then you need to offer fertility preservation. And that's one of the few areas of fertility medicine where there is very few restrictions on practice within the NHS. And if you're doing surgical management, so let's say you're um you've got BRCA and you're going to have a risk reducing oophorectomy or you've got breast cancer. Um then you try and do that. Um if you can, after they've had their family and then you would do the surgery. So we tend to do for BRCA surgery around the ages of 35 to 45. Um It's worth noting there is a small chance of ovarian activity again, just because you've got very few follicles left, doesn't mean you have none. And there's a reasonable chance that randomly one of them could generate at the right time, which means that it gets rescued by FSH and gets ovulated. Um The chances of that happening is about 5 to 10% per year. Um And their best chance of getting pregnant is likely to be with IV F particularly using donor eggs. Cos in order to get access from IVF, you need to get eggs. And if you don't have many follicles left, you're not going to get a good response to the ovarian stimulation. Um You can use vaginal estrogen replacement for genital ovary syndrome. And again, if you're 25 and you've got significant vaginal atrophy, that is not ideal, it's not ideal at any age. Um But particularly when you're, when you're younger, it's got a, you know, a really significant impact on your body image and mental health and wellbeing. Um And essentially the point I'm trying to get at here is that while you're talking to someone, you need to take the whole picture, you need to think about the physical health impact. You need to think about the mental health impact. You need to think about the fertility impact and the sexual health impact. And these women are at increased risk of lots and lots of other health problems that we need, looking at and sort of careful monitoring over the next few years. As well. It's difficult. Um It's not common. Um But it's common enough that we see it and like I said, I know, I know people who have it. Um So just a thought for the end there. So in summary, menopause has a significant or can have a significant physical, psychological, sexual impact on women. And that has a knock on impact on their working life, their home life relationships, whatever social life as well, treatments have significant benefits, but also some significant risks that people need to be aware of. And the risks associated with the menopause are magnified. Massively when it's premature, it's essential to think about the patient's ideas, concerns and expectations and address these if you can and it's important to try and look at issues as a whole rather than doing the more focused quite surgical opsal. Let's give you H RT view, which you will probably see when you go into clinics. And importantly, don't forget this is a quality of life issue. Therefore, the interventions that you're doing should be targeted at improving their quality of life and what's technically best may not be best for that individual and their quality of life. So just bear that in mind. Some references, the British menopause society is brilliant as a resource. If you want more information, the nice guy in the management of the menopause is also pretty good. Um although he's probably due an update, but there's lots of good resources out there with information both for medics and for patients. I would, I would recommend the BMS. They're a good, a good place to start. And that was all I had to say. Did anyone have any questions? And if you don't want a message on the chat, um, that's fine. That's my email address. Feel free to message me about anything you want as well. That's not a problem. Um, I was wondering how long you would treat someone with systemic H RT for if you have to balance between the risks and then symptoms getting worse as you get older. That's a fantastic question. Um To be honest, most of the time. So things like hot flushes and your vasomotor instability gets better. So what tends to get worse is things like your osteoporosis risk, but we don't use H RT purely to reduce the risk of osteoporosis. Um uh Things like genitourinary syndrome and again, that's not best treated with H RT. Um but things like your vasomotor instability tends to resolve over time. Um The correct answer is that it depends. So you use the lowest effective dose for the shortest amount of time that's acceptable to the patients. Um When I was in GP land a few years back, I had a lady who was in her mid seventies who'd been on HRT for 20 years and there was nothing we could do to get her off it if they want it and they know what the risks are and they're happy to keep going with it. You can keep giving it. Um, but ideally for most people, five years would probably be recommended. Certainly not getting beyond the age of 60. Um, but again, it very much depends on the individual. Thank you. And, um, just answering a question we had at the beginning, uh, if you want the slides and the recording just message us, uh, we're not sending it to everyone, but if you request it, then we'll send it to you. And the feedback form will be emailed to you once this talk ends and you'll get the certificate almost immediately from meal. Thank you so much, Jamie for doing the dog. It was really useful and very insightful pleasure from your, from medical school exam perspective. The key things that they really want you to know are do not use each and only H RT in someone with a uterus. Um what the symptoms are, what the risks are. So things like osteoporosis, cardiovascular disease and then what the risks of HRT are in terms of DVT and those kind of things. That's the mainstay of it. And they're not going to expect you to pick specific H RT in specific circumstances because that is something that is difficult for us. Um, let alone for you guys. So it's more of a general understanding of the issues. Um and some of the safety things rather than having a really in depth understanding of all of this stuff. Mhm. So, if, um, no one has, there are no more questions, then I think that's a very good question. Um I would say it's a balance. Um I think fundamentally the risks are very small so the chance of getting breast cancer are relatively high. Um, the increased chance as a result of progesterone treatment are small. Um, it's up to them really. Um, you know, the one in nine women will get breast cancer. So if you're talking about, you know, an additional risk of one in 1000 one in 100 you know, that is a negligible risk on top of what is already a very high chance. Um And we also know that when you stop taking progesterone, your risk falls over time. So if you're using progesterone only medication for 20 years, the chances of you getting a breast cancer are going to be very, very small, not zero, but very small. Um And when you stop taking it, then your chances of getting breast cancer start to fall back towards the general population. It's similar to things like smoking. Um So yeah, I would say when you're young, if you're going to get a breast cancer and you're going to get a breast cancer, almost certainly because there's some genetic predisposition or real bad luck rather because you're on a progesterone tablet. Here's what I would say. But if they're worried and they want to stop it that's also fine. They just need to think about what they want to do in terms of alternative contraception. The other thing is, it depends on why they're using it. You know, if they've got something like endometriosis, um, then the next step up from that would be GNRH analogs, um, which would, they would need H RT to go with that. So you're then running into exactly the same problem. Um So the main thing is just reassuring people that the risk is tiny. That's the main thing, but it is difficult. You know, it's like anything in medicine. Now, you have to tell everyone everything that could happen and then try and reassure them that that's very unlikely to. So, you know, I was consenting a lady for a section today and I had to tell them about the risk of death like to admission a bowel injury and stoma and bladder injury and, you know, injury to the baby and all this kind of stuff. It's like that never, I've literally never seen any of that. Um, but I know it has happened and you have to tell them that it might. So, um, yeah, it does make things difficult. It's important we should be doing it, but it does make things difficult. Ok. So like I said, feel free to email me anything. If there's anything you think of later, that's absolutely fine. I don't mind. Um, as I say, I'm employed by the university, I'm not, I'm a, I'm a slave laborer for the university. Couldn't pay me. Um, but I'm obliged to help if you have any problems. So, yeah, do let me know if you have, if there's anything you want to write? I think that might be all the questions. Yeah, that's fine. Thanks again. Thank you for doing this pleasure. And have you got, what other talks have you got lined up? So, we have a talk in two weeks on academic careers in obs and research in obs and, and then we're hoping to do a talk on endometriosis because March is Endometriosis Awareness Month. Yeah. So, um but that hasn't been confirmed yet. If you know anyone that wants to do that doc then um let us know that's actually my area of interest. So how is it endometriosis? Is that something you'd be interested in doing then? Yeah. When, when were you looking at uh whenever the feedback, right? You know, people hate it, then I bother. So we'll send you the feedback that we get from today, but I'm sure people loved it. Um I think any time in March when whatever works for you would be great. Ok. Fine. Uh Yeah, cool. And I mean, we got really great feedback on the revision sessions you did last year. So I think everyone loves your teaching, you know? Yeah, that, that would be maybe, yeah, 21st, maybe 21st. Ok. So we can um email you and, and get in touch about that. Yeah. Absolutely. Fine. Absolutely fine. I don't actually, other than nights on the last week I don't have any, anything in any evening. Really. So, um, ok, great. So, um, cool. Yeah, let me know if not. Um, there are some, there are some other people around. So if, if it doesn't work how I can as well. Ok, great. Thank you so much. Um, yes, who's doing the dog? Um So honey, you know, Annie, someone, I can't remember her last name but uh Blue. Annie. Blue. OK. Um I think she's actually based in New Goo but um she was at a conference so we just uh we got in contact with her through that. Fair enough. Yeah. Um If there's any other specific talks you're wanting, let me know and I can put you in touch with people. There are actually we have some ideas, it's just getting people to do the do. Yes, we were hoping to do one on fertility uh and like development in fertility treatments. Uh quite an interesting topic and um we have some other ideas that the, the current fertility suspect trainee in Sheffield is called Emma. How? And she's lovely and I'm sure she'd be happy to, I'm sure she'd be happy to help with your fertility talk. One of the new consultants is also she's called Monica and she's very good as well aggressive. But I think um Emma and looks tackling and we probably be more willing to help. Ok. Yeah, cool, good. Yeah, let yeah, let me if there's anything I can do to help, let me know because again, ii um and quite good at persuading people to get involved and to be fair, there are lots and lots of people who want to. So again, if you want to have a year ago, anyone if you want to, you know, there's lots of people who are very keen on teaching and very enthusiastic. So, yeah, let's know. Ok, great. Thank you so much, Amy. Have a nice day. Bye.