In this podcast episode, our host Sarah sits down with Dr. Nicky Keay, a medical doctor specialising in hormones, to discuss hormone replacement therapy (HRT). They delve into the various situations where HRT can be used, with a particular focus on hypothalamic amenorrhea (HA).
Dr. Keay explains how HRT can be utilised as a temporary measure to protect bone health in individuals with HA. She provides valuable recommendations for the appropriate use of HRT in this context, emphasising the importance of personalised approaches to treatment.
The conversation then delves into the psychological aspects of HA, exploring the potential impact on mental well-being during recovery. Dr. Keay also addresses the issue of misdiagnosis of polycystic ovary syndrome (PCOS) during the recovery process, highlighting the need for accurate diagnosis and tailored treatment plans.
Moving on, the discussion shifts to HRT in postmenopausal women. Sarah and Dr. Keay address common concerns and misconceptions surrounding HRT, while also highlighting the potential benefits it can offer. They stress the importance of seeking professional help and finding the right approach to HRT that suits individual needs.
Follow Nicky on instagram @drnickykeay
Sarah (00:00:00) – A big, warm welcome back to the show. Nikki, how are you doing today?
Dr. Nicky (00:00:04) – I’m fine. Thank you so much for having me back on to talk about more more about hormones today.
Sarah (00:00:09) – I know. I’m so excited. I’m so excited. This episode has been a long time coming because we’re going to talk all about HRT, a very highly debated topic. But before we dive into that, just in case our listeners, this is the first time they are hearing your voice and not knowing much background about you. Can you tell our listeners a little bit about who you are and what you do?
Dr. Nicky (00:00:38) – Sure. So I’m a medical doctor and I’m working in London, UK. I work in terms of clinical work and research work. So clinical work working with men and women, although I have to say probably more. I see more women than men. I must say anything and everything to do with hormones. So that sort of covers the whole range, whether you’re in the younger age groups, you know, periods gone missing or struggling from that point of view, or of course, in the whole female hormone journey.
Dr. Nicky (00:01:12) – Maybe you’re getting older now and want to discuss how to feel at your best. You can you can still keep going, by the way, when you get older. That’s me. So you know what? So that’s my sort of clinical work day to day. And then research in a similar vein, I research all things to do with hormones at University College London, and I’ve just recently written a book called Hormones Health and Human Potential, and that puts together a lot of the things I’ve learned over the last 30 years or whatever, working in hormones, working with people. It’s got little hormone stories in it, therefore people to have a look at. And then so people know me. Who am I personally? I love doing exercise sport. I used to be a competitive swimmer, tennis player, etcetera. But my main passion and love is dance ballet specifically. And I’m going into the dance school later on because we’re doing a study there, for example, to talk to the dancers. So that’s always a good opportunity to go there.
Dr. Nicky (00:02:14) – And when I was in Australia many years ago, I was also doing research. I was doing a similar thing, research, which fortunately also included lots of research with dancers. So again, I know all the good, I know the dance schools. When I was in Sydney and Melbourne where I would go myself to speak to the dancers, but also to get in a sneaky class myself.
Sarah (00:02:35) – I mean, you have to take that opportunity. You’d be unwise not to. So you’ve a few things going on, but hormones are definitely your passion, which I’m excited to pick your brain on today. Specifically today we’re going to talk about it, which is hormone replacement therapy. Can you tell our audience, I guess, a summary of what HRT is?
Dr. Nicky (00:03:03) – So it’s a generally speaking, it’s a combination. It’s for women and it’s a combination of estrogen and progesterone. Those are the two main hormones produced by the ovaries. So it’s a combination of those. Yeah. And as the name suggests, it’s replacement or topping up or whatever words you want to use, which will occur in different situations according to to your age.
Dr. Nicky (00:03:35) – So that’s essentially what it is, a combination of those two hormones. Um, the only exception being is, which will probably come on to later on if you’re in the older age group and considering HRT, if you’ve had a hysterectomy, i.e. you haven’t got a uterus anymore, then you can just give the estrogen by itself. But that’s sort of like an exception. Generally speaking. We’re talking about a combination of estrogen and progesterone taken in different ways, different methods, etcetera, which we can go into and for different reasons according to the age group.
Sarah (00:04:10) – Yeah. And I wanted to also ask you quickly, what are the differences between HRT, obviously, because you’re talking about, um, I guess estrogen and progesterone being topped up in the body. What’s the difference between height and hormonal birth control?
Dr. Nicky (00:04:29) – Yeah, the clues in the name. Yeah, you’re absolutely right that they both contain on the surface, you put them side by side and if you read the packet for what’s in both of them, you will see the word estrogen in some guys and you will see see the word progesterone in some guys.
Dr. Nicky (00:04:48) – But the big difference is that the type of hormones, those hormones in the contraceptive pill are synthetic. They’re not it won’t say estrogen, by the way. It will say ethanol estradiol. And it won’t say progesterone. It will say north estrogen or something like that, a derivative of it, which is made synthetically in the lab. And the purpose there is, is they are, of course, derivatives of those hormones. But because they’re derivatives, not like the real thing, if I can put it that way, in the contraceptive pill, they act to stop ovulation happening. So that’s why they’re contraception, by the way. Okay. So they switch it all off. And although these synthetic versions of these hormones in the contraceptive pill, they fall the controller of all the hormones, the conductor of the endocrine orchestra, the gland, which is located in the brain, although they fool the pituitary to say, look, don’t bother sending any messages to the ovaries. We don’t need them. Thanks. We’ve got this.
Dr. Nicky (00:05:52) – So they fool the pituitary gland, but they do not fall. For example, the bone and other tissues which look to these hormones. You know, it’s just to point that out, that the contraceptive pill is a very, very effective contraception because it just stops ovulation, stops the ovarian production of hormones. So and so that’s what that is. Whereas in contrast, HRT, again, there are different formulations and things, but in general terms, the hormones in HRT are more similar or indeed sometimes identical and body identical, as we say to what you would be expecting to produce yourself. And so in that case, you’re not looking to suppress ovulation, you’re looking to top the hormones up, hence replacement, you see. And so therefore it won’t be contraception, which is an important point to clarify. And the other confusing thing, I think it is confusing to be honest, that if you look at a blood test, if I don’t know anything about the woman and she has a blood test and you show me the blood test of someone who is on HRT and someone who is taking the contraceptive pill, the woman’s blood test on the contraceptive pill, everything will be low.
Dr. Nicky (00:07:08) – Because the test in the lab does not measure these synthetic hormones. We’re talking about this in the contraceptive pill. So the blood test, everything is reading low, just like a woman with functional hypothalamic amenorrhea. Mm hmm. Right. So that’s by the way, we’ll come on to that, I’m sure. Why not? A good idea to reinforce that suppression of hormones with the pill. Whereas if you look at the blood test of women or HRT, especially if the hormones she’s taking are body identical, same to hers. Surprise, surprise, they will show up on the blood test and you’ll see them. So that is the that that’s the contrast. I think that hopefully that’s clarify that point.
Sarah (00:07:49) – That’s that’s so helpful. And I think where the kind of conversation leads next is one that you have led us towards anyway, which is the use of, I guess. Different forms of HRT in supporting women that have functional hypothalamic amenorrhea. Because I think a lot of times women seek medical care, which is very necessary during their because they’re seeking, you know, what their options are while their period is missing.
Sarah (00:08:25) – And a lot of the time, you know, a GP or sometimes even a specialist will go, oh, just take the contraceptive pill. And like you mentioned before, obviously suppressing ovulation in a state where ovulation already isn’t happening, probably not the smartest idea, but in this population of pre menopausal women who are in this functional hypothalamic amenorrhea state, why might be helpful and are there specific forms that a person would be more suited to taking versus other forms which are not as suitable?
Dr. Nicky (00:09:05) – Yeah. So just to absolutely reinforce that point, it’s worth doing if you’ve got FHA. And anybody, even a doctor, as you say, says, oh, just take the pill. This will. Give you a period or whatever the words might be. I’m afraid to say that that is not correct. And please seek advice from a different doctor. It’s very clear in the Endocrine Society guidelines and here in the UK, I’ve got our sort of monitoring body called Nice National Institute of Clinical Excellence to change the guidelines. So there’s really no reason why this is still being proffered.
Dr. Nicky (00:09:47) – I know why it’s happening because it makes everyone feel better. You know, the doctor has done something written prescription, and you will get a withdrawal bleed If you’re taking it sequentially, the contraceptive pill, you will get a withdrawal bleed. So it kind of gives you a false sense of security and a psychological boost. It’s like, hey, something’s happening, but it’s not really something happening that your body’s doing. It’s just because you put these extra external synthetic hormones on. So just to reinforce, please don’t do that. But so what do you do? Well, the main the most important thing is, of course, work with either of us or somebody and try and get your own periods rebooted. So try and look objectively with guidance at what you’re doing in terms of your nutrition, the timing of the nutrition, the exercise, etcetera. The main goal is to try and restore your own periods as quickly as you can. But we know that that’s not always easy. We accept and it can be a slow process, especially overcoming psychological, you know, things and changing your behaviours.
Dr. Nicky (00:10:52) – It’s difficult. So if it’s like, Well, this isn’t going to happen quickly, it’s going to take probably more than six months realistically, right? We have to be realistic and your bones aren’t looking so good. Either you’ve had two or more stress fractures or you’ve had a bonus of Dexa scan, as we say, and that’s showing actually it’s looking lower than we would expect for your age, especially the lumbar spine, very sensitive to oestrogen then in that situation for bone protection. Uh, at taking hormone replacement, i.e. HRT is certainly an option. It’s not a get out of jail card, as I say to people I work with, but at least it’s a temporary housing measure if we’re really worried about the bone health. And so what HRT? Well, from what we just discussed, obviously, like the good stuff, as it were, the stuff that is identical to what your body would produce. So this would take the form of estradiol, the most active form of estrogen taken through the skin, a gel or a patch.
Dr. Nicky (00:11:57) – Personally, I find that the gel is more flexible in dose. But anyway, you take that every day, either via the patch or the gel, and then you add in. Of course we said you must take progesterone. Micro progesterone is identical to what your body produces. So again, that’s the best option. And in some ways we are trying to replicate what the cycle would be. So you take the progesterone bit in blocks of 12 days to correspond to what the luteal phase of your cycle might be once we get it started again, we hope. Okay, so 12 days every calendar month. If you’re not having any periods, for example. And just to remember, I say take it just 1 to 12 on the calendar month, that’s near enough, you know, so at least you can remember to do it. You might get a withdrawal bleed. It’s true, after you come off the progesterone. So again, this is another source of confusion. It’s like, well, the pill also will give me a withdrawal bleed, but it’s for a different reason.
Dr. Nicky (00:12:51) – You see what I mean? It’s because it’s responding. The endometrium is responding to hormones, but in this case, it’s responding to the good hormones, as it were, the body identical ones. So that’s HRT for for a younger age group, women as a temporary measure. In fact, personally, I would say to the person, look, we’re just going to do this for six months and then hopefully by then we’ve sorted out behaviors and everything and then we can come off and hopefully that’s giving your body a breathing space in your in your own cycle will restart. Obviously we don’t want a women who can potentially ovulate to be stuck on HRT forever, you know what I mean? It’s just a temporary measure in that case.
Sarah (00:13:37) – Yeah, that was I mean, you already answered the next question that I was going to ask you anyway, which is often how long should individuals in that kind of premenopausal working on state stay on it? So roughly six months under the care of an endocrinologist who’s checking in on your progress and still working on those behavioral changes?
Dr. Nicky (00:13:57) – Absolutely.
Dr. Nicky (00:13:58) – Really super, super important. Yeah.
Sarah (00:14:01) – Yeah. And reiterating that. HRT does not suppress ovulation. So within that, is there a risk of falling pregnant during that recovery process or is it.
Dr. Nicky (00:14:15) – Yeah, that’s a very good point. It because it’s not contraception. I mean, to be to, you know, realistically, if you’re in FHA and, you know, your energy availability is really low, your T3 is really low, you know, it’s unlikely you’re going to suddenly ovulate the next day. Nevertheless, I always say this is, you know, HRT will do it for a short time. Check in, see how you’re doing, keep an eye on the T3 to see if the energy levels are coming up, etcetera. But I do say your absolute very important point. This is not contraception. And you know, the body works sometimes in slightly mysterious ways and it might suddenly do an ovulation. So don’t count on it as contraception if you’re not aiming to get pregnant and obviously use barrier methods in that case, uh, condoms probably the easiest, just to be sure if that’s not your objective, because otherwise that.
Dr. Nicky (00:15:10) – Yeah, that could be slightly disconcerting. So important to say that. Yes.
Sarah (00:15:14) – Yeah. I mean I’ve had clients who have had FHA and unknown to them caught their first ovulation and fallen pregnant without even a cycle. So it does. Yeah.
Dr. Nicky (00:15:26) – That’s actually really good when that happens isn’t it. I had someone I was working with in hopes that and she did want to get pregnant just to point that out. That was her objective, to get her cycles back. So we’re working on it. And, and then it was like she was so disappointed. Oh, it hasn’t. Nothing’s happening. And it’s like but everything from my point of view was looking pretty good. You know, She was telling me everything. Have you done a pregnancy test? And she thought I was a bit crazy. So it can happen. Or another person that had one period, it’s like, Yeah. And I said, I try and aim. I don’t know about you, but Sarah but I sort of say, let’s aim for getting those three regular periods under the belt.
Dr. Nicky (00:16:06) – Then it’s like, okay, we can feel a little bit more confident on that track. She got the first one very excited. Oh no, the second one hasn’t come. It’s like, have you done a pregnancy test? So yes, it can spring back into action pretty quickly, which is good. But obviously you need to be aware of pregnancy isn’t your aim. Yeah, just keep that in mind.
Sarah (00:16:25) – Yeah, definitely. Definitely. Now, within this scenario, let’s imagine a person’s been on hit for roughly six months. They have made significant lifestyle changes where you would expect to see their own hormones kind of kicking into gear when HRT stops, when I guess you decide to end HRT in this pre-menopausal FHA recovery kind of scenario, is it still a little bit of a waiting game as to whether a person’s menstrual cycle will kick in relatively soon, or is there like a period or a window of time you can kind of. Look at to see whether what you’re doing now is sufficient or whether more changes are necessary to ensure that your periods return.
Dr. Nicky (00:17:16) – I think. Well, what I do, I don’t know about you, but generally, you know, going through revising, if the periods, say, the person has been on HRT for a bit, comes off and is disappointed and she’s not pregnant and the periods haven’t returned. So then what? Then let’s sit down. Let’s go through the detail of what’s going on, you know, re revisit because what we might have sort of decided originally when you come and sit down and look at it, it’s like, oh, hold on. But you, you forgot that bit or something, whatever it is, or the person’s as well. I was seeing feeling so much better actually. I did start doing some running or something, so something might have crept in which wasn’t, you know, whatever. So that’s, that’s not a problem. So long as we discuss openly what it is, it’s like, Oh, then we’ve got a reason. So we revise that. And also from the blood test point of view, it’s really helpful to look at the T3, one of the thyroid hormones, which generally will be low if you’re not feeling enough.
Dr. Nicky (00:18:18) – So we’ll see. Is that more in the middle of the range, looking a little bit better? And sometimes it’s useful just getting an idea of what the FSA and LH in particular is doing. You know, sometimes it’s if you’ve got FHA, typically the scudding around sort of 1 or 2, um, it’s merely units per litre, I believe the units for that anyway. But if we repeat the blood test and it’s actually looking like 3 or 4, it’s like, okay, you know, it is a little bit more patients and whatever like that. So that’s reassuring. And sometimes there can be this sort of intermediate situation where the person has put in place all the changes, everything’s going swimmingly and it’s like it is a little bit puzzling, frankly. The T three is okay. It’s like, Oh, I wonder why the periods haven’t started and you do a blood test and then you see that actually if you didn’t know anything about the person and you just saw the blood test, you might say, Oh, that looks like PCOS.
Dr. Nicky (00:19:21) – Because in the rebooting of your cycles you can understand the body is like learning to ride the bike again or whatever. It’s like a little bit clunky at first, and so there can be a little bit of mis timing. So actually you might see the LH is pretty decent level. You might actually see the testosterone up a little bit. And sometimes if people have an ultrasound at that point there will be lots of follicles trying to do it. And this I’m just warning people of this because sometimes this has happened and then the person has been told, Oh, you’ve got PCOS, restrict your carbohydrate. It’s like, oh, no, we just spent the last six months trying to increase the carbohydrate availability because female hormones love carbohydrates, by the way. So just be wary of that. The interpretation of the blood test in in this scenario, the person that’s trying to restore their periods actually this little bit of sort of the synchronization of the hormones, that’s a good sign that things are coming. I mean, I have to be honest, sometimes even I have to hold my nerve.
Dr. Nicky (00:20:28) – And there was one particular dancer I’m thinking of where, you know, it was like, oh, this is going on for quite a long time. But I knew I was confident. We knew her story. And I said to her, Look, I agree. It’s just like being honest and open. I agree this is a little bit high and going on for a bit longer than we thought, but I’m pretty confident we’ve done everything. We’ve discussed everything. I don’t think we’re missing a trick. It will come good. And guess what? Just that almost the reassurance, the psychological aspect of, by the way, psychological reassurance, it’s like, no, hang in there, you’re doing good. We’ll get there. And lo and behold, period started pretty soon after that. So I think that’s the other thing to emphasize, isn’t it? The psychological component. If you feel in control and you know you’ve got a good partnership and this is the plan, this is what the blood tests mean. Explain, then you already feel so much better anyway.
Dr. Nicky (00:21:21) – And that has a big effect on how your female hormones work.
Sarah (00:21:25) – So much so. And I love that you pointed that out. I think that misdiagnosis of PCOS is so common and we often see that kind of sometimes that presence of what looks like, quote unquote, PCOS after or during those first 12 months of recovery. Yeah, but your body is learning this again. It’s almost like a second puberty where exactly.
Dr. Nicky (00:21:49) – Exactly.
Sarah (00:21:51) – Be able to fall back into a pattern. It’s also why PCOS shouldn’t be diagnosed when you’re a teenager because the body is still really learning how to do this whole cycle thing. It takes a little bit of time to get consistent.
Dr. Nicky (00:22:05) – Yeah, very important point. The second puberty. I like it. Exactly.
Sarah (00:22:09) – Yeah. Yeah. So I love that you kind of. You you do what I do. I have a little bit of a checklist. Like, let’s just go back and like, look at all these different points and make sure we’re hitting the nail on the head with a lot of these because that’s when people are like, Oh, actually, no, this has changed or that has changed or I’ve been a little bit inconsistent with X, Y, or Z, and then we can kind of go like, okay, that’s fine, you’re human.
Sarah (00:22:35) – These things happen, but let’s get back on track to make sure that the body feels supported enough to make sure that the cycles return. So I feel like that’s a pretty. Good overview of height for FHA. Now I kind of want to jump on to hit I guess. For its classic use in postmenopausal women. But before I do that, there’s one other question that I have, I guess, which is for women of that typical, I guess, pre menopausal age. Um. There are other conditions where periods might cease. The one I’m thinking that comes to mind most rapidly is primary ovarian insufficiency.
Dr. Nicky (00:23:25) – Yeah, that’s a very good point. So it’s a diagnosis of exclusion, as we say in the trade, as it were. So before we absolutely say that, I mean, already once you’ve spoken to the woman, you know, going through the history, it might sort of seem pretty obvious. Well, yeah, she’s not eating carbohydrates. She’s doing fasted training. She’s concerned about her weight.
Dr. Nicky (00:23:47) – It might all seem that that’s sort of straightforward, but you must always back that up. And if excluded other things, for example. POI So, um, primary ovarian insufficiency. So that is when effectively you have a very early menopause when actually it’s not the master controller, the pituitary gland, the conductor of the endocrine orchestra, it’s not there that has dialled everything down. It’s actually the ovaries themselves have decided to retire a little bit early. Right. Early retirement. Okay. So but you will see that on the blood test. So you see that we’ve discussed, we mentioned the hormones, FSA, LH You know, the ovarian hormones, oestrogen progesterone and the thyroid function test. So I have a little sort of run of blood tests. I just like for everybody, we just do that boomf get that out of the way, those ones I’ve just described. And that is how you, the W.H.O., World Health Organization definition classification of why a woman’s periods have stopped. By the way, first thing obviously check not pregnant.
Dr. Nicky (00:24:57) – I know it sounds obvious to say, but we should say that assuming the woman isn’t pregnant, her periods have stopped. That is like, oh, and she’s, you know, in her 20s, 30s, whatever, it’s like. So then take the history, then do the blood test. The ones I’ve mentioned just tick off. That the PH is low. And the prolactin is normal. Now we’re on the track probably of if the ocean are high, as you would see in the menopause later on. But actually it’s happening in a younger person like hi. I mean, by the way. Yeah. You know, it’s like this is out of the range really high then. Yeah, that is a difficult conversation, but always important to be honest and open about it. And that looks like the ovaries maybe aren’t playing ball or it could be it could be a true PCOS. Woman Okay, so actually our restroom will be fine, but a testosterone will be really high and the history is not suggestive of FHA.
Dr. Nicky (00:26:00) – So that’s a very important point to clarify because it’s really important because it will be totally different. Yeah. The woman with FHA or actually in those cases, those sorts of women, then that’s where HRT will be helpful. You see, especially the pre of course that will be, you know, not just a temporary thing and it will actually be pre goes in there with a decent dose of HRT, whereas someone with like we said, that’s a different, totally different situation. Yeah. Actually there’s nothing wrong with the axis. It’s just it’s got a bit out of, out of sync and so that will need a different approach. So yeah, thanks for mentioning that. Really important to highlight that. Yeah.
Sarah (00:26:48) – Happy to. Now moving into I guess the traditional age group where menopause naturally happens and our body starts producing as much estrogen and progesterone on its own. We spoke last time about the importance of hormones in general, not just for reproduction, but how they have impacts widespread across the body. And those can be really important for our mental health and our physical health and our cardiovascular health and so many more things.
Sarah (00:27:21) – I think classically there’s a really big hesitation to take a hit. Mostly because we hear of horror stories from maybe our parents or our mothers who had taken HRT in a different form when they started menopause and not having a great experience. What are some of the, I guess, pros and cons of taking HRT and how is it different in the forms that we have now compared to the forms that I guess a lot of people hear about those horror stories from before?
Dr. Nicky (00:28:01) – Yeah. Well, what? Really? Uh, was a problem for women was the was a big study which came out of America. It is several years ago now. But what happened was they had done a study about women taking HRT in the menopausal state. And what happened was that the media got hold of the study before it could be properly reviewed and published, blah, blah, blah. And of course, we understand media. They it sells a headline, you know, a shock or a headline. Oh, HRT causes breast cancer and understandably.
Dr. Nicky (00:28:37) – The usage of HRT plummeted. But when everyone had calmed down and everyone had the. The doctors and scientists looked over the data. It was obvious why. It did seem that quite a lot of women were getting breast cancer on HRT because it’s a study in America. And with all due respect, lots of the women were overweight, which is the main risk factor for getting breast cancer. Okay, BMI quite high. And also they’d started taking HRT a long time after the menopause and their 60s when the menopause is typically like 50 or something. So there was sort of flaws in the study from that point of view. And, and it was a long time ago and you’re quite rightly, you know, it’s kind of old fashioned HRT. So what’s the situation now? Well, the situation now is, um, there is in, you know, a slight increase in the risk of getting breast cancer. If you take HRT in women ages 50 to 59, there’s an extra four cases per 1000 women. This is exactly the same risk as taking the oral contraceptive pill.
Dr. Nicky (00:29:43) – I repeat, it’s the same as taking the oral contraceptive pill. And no one talks about that, do they? And it contrasts. Like I said, if you are leading a slightly unhealthy lifestyle, you’re overweight, you’re not taking exercise, you’re drinking a lot of alcohol, you’re smoking all those things. Then that whopping increase of 24 cases per 1000 women. Whereas if you’re a woman who’s taking 2.5 hours of exercise or more per week, then it decreases the number of cases of breast cancer by seven. So if you do your maths. The most important thing, a message for for women going through perimenopause. Menopause is, number one, it’s a good opportunity to revise what you’re doing in terms of lifestyle. So, you know, exercise, strength, exercise. Are you doing your exercises, you know, whatever that might take ballet. I don’t know. Whatever it is. And just have a look at your nutrition. How’s it going? Are you eating in a consistent way? Not too little, not too much sort of thing, and lots of protein.
Dr. Nicky (00:30:47) – If you sort of ticked off those things, then you can actually you know, there’s no harm, in my opinion, trying HRT because at least then you’ll see the main indication for taking HRT is quality of life. And like you said already, Sarah, that, you know, as these female hormones dwindle, there’s going to be, you know, negative effects potentially on mental health, mood swings, etcetera, and also physical health, you know, hot flushes, poor sleep, which forcefully makes everything seem worse, doesn’t it? You know, bone health, actually, that is now a new primary indication for HRT. There’s also the increased risk in cardiovascular health disease as we get older in menopause. So, you know, there are certainly benefits from HRT and fortunately, there are there’s only the only women for whom it is contraindicated is if you are a woman and you’ve had unfortunately breast cancer, which is oestrogen positive, then obviously clearly and you’re taking medication to lower the oestrogen, then obviously that’s it’s not going to work for you.
Dr. Nicky (00:31:50) – But there are other non-hormonal things. So that’s generally when I see women coming to me in perimenopause. So the periods are becoming irregular, erratic, um, or they’ve just recently reached menopause and not feeling so good. Yes, we do a quick it’s like the FHA in that sense. Let’s go through what you’re doing in terms of your nutrition, your exercise. Let’s really nail that and make sure that’s as good as that can be. And then let’s have this discussion about HRT and let’s try you on the best form and a low dose. In England, we have had a bit of a problem. There has been a certain celebrity menopause doctor who is being doling out very high doses of HRT as immediately. So it might be some women will only need higher doses. Now there’s obviously we’re all different, but general rule of medicine start off at the lowest possible dose and then we try to titrate up. And the forms, like you said, very important to emphasize, much improved to the old fashioned horse, horse, urine and all this stuff.
Dr. Nicky (00:32:51) – Um, now the best way of taking the estrogen is through the skin so you don’t have to take a tablet patch or gel. I’ve already mentioned I think the gel is even more flexible and discreet, frankly. And there’s little sachets of them you can get in the pump, but actually little sachets. So you don’t have to pump a hike, a whole pump through customs. It’s just like, oh, you know what to call it. No, not to the, you know, the fluid control thing. It’s like so yeah, that one, it’s like, no. Anyway, so the gel is really flexible, comes in really small sizes, and then you can sort of mix and match and see how you go after three months and we might increase that. And then the progesterone, we’ve already mentioned microRNAs progesterone typically in a soft capsule in the UK, the brand name is Uterus Chest and I think it’s also available, I believe in Australia or Promethium as the other brand name of that thing. And then you have a choice.
Dr. Nicky (00:33:46) – In the younger women we mentioned, you take that progesterone and blocks right to sort of mimic a cycle, as it were. But in the perimenopause, well, if you still having some sort of periods, then actually you might as well try and sync it with what your own body’s already trying to do. But if your periods have stopped entirely, you have an option. You can sort of reproduce in a sort of a crude way the menstrual cycle, take it in blocks or you can take the progesterone continuously every day. Me personally, I just kind of thought, well, I’m going to take it in the blocks because it kind of seemed logical to me. But my friend who reached menopause at the same time, she said done. And and I’ve had enough of all that bleeding. Like I just want to go on the continuous one because typically you don’t bleed. So it’s entirely your choice. And then if anyway, five years after the menopause, all women, we advise them and I have just recently converted taking the progesterone every evening.
Dr. Nicky (00:34:38) – The reason we take the progesterone every evening, by the way, is because it has a slightly soporific effect, which is great, a natural sleeping aid. And so you take it last thing at night. And what we’re looking for is for you basically to feel better. So the quality of life so you can get on with your job, get on with what you’re doing, just enjoy life a bit more. And but the other thing to say is if we start off at a low dose, then I say to women, let’s leave it three months and see how you’re doing on this. Come back. Let me know if you’re still noticing problems like low mood feeling, you know, hot flushes. Whatever it is, if that’s still not quite right, then we can gradually increase the dose and just go like that and you’ll and your requirement might change as you get further away from the menopause is what I found because the ovaries, although they have retired sometimes they were maybe think about a little bit and you know but definitely you might need to increase the dose anyway as you get further and further away from the menopause.
Dr. Nicky (00:35:43) – But it’s a very individual thing. So if you haven’t got a contraindication for taking HRT and you’re, you know, not sure, um, then actually, as I say, I think and you know, the risk benefits then actually that you’ve got kind of nothing to lose by at least giving it a go and you’ve sorted out your lifestyle. So that’s my approach to HRT. Yeah.
Sarah (00:36:08) – And I think just to kind of refresh in people’s minds, like as we go through menopause, the main risk factors are obviously cardiovascular health. We know that women post-menopausal have such a higher risk of cardiovascular disease and heart attacks and things like that because estrogen is cardioprotective. And when we don’t have that and maybe when we’re not feeling our best and not engaging in as much movement as we did when we were younger. Good point. Our risk really increases as well as bone health being another really, really big one to come.
Dr. Nicky (00:36:39) – Yeah, that’s a really big one. The bone one. And recently certainly in the UK, HRT, the main thing is for quality of life.
Dr. Nicky (00:36:46) – So you feel better. But actually we now know that it’s actually a can be really almost the primary treatment for, for bone health. And certainly because I had in the past, my bones weren’t so good. Even back then, people were saying to me, Oh, you should think about HRT and I’ve got a family history of osteoporosis. So listen, it’s not you know, we have to do everything we can ourselves as well. It’s not like a get out of jail car, like I said, for the women with taking HRT. But at least it gives you gives you a fighting chance and you feel proactive and you’re backing that up with everything you can do. So it’s the combination which is really important to consider.
Sarah (00:37:28) – Yeah, I mean, there are like, no, no magic pills exist, but.
Dr. Nicky (00:37:32) – I’m afraid it’s not the elixir of youth. Just to clarify that again. But it’s not. Oh, now you’re going to be 21 again, but at least it will hopefully help you to get continue to get the most out of your life.
Dr. Nicky (00:37:44) – And as we’re living longer, especially women, you can be spending a third of your life. Uh, post menopause. So actually, that’s a big old chunk of your life. You want to be at your best, don’t you? And getting what you can out of your life, even in, you know, I want to keep doing my ballet classes for examples. Exactly. You know, so you have to think, what do you want to achieve and what’s right for you?
Sarah (00:38:04) – Yeah. And my last question is, in that post-menopausal group, um, is it safe to continue with HRT and how long are we taking it for?
Dr. Nicky (00:38:16) – Well, that’s a really good question. And again, things have changed a lot. It used to be they would say, Oh, you take it for five years and then you stop. Seemed a bit crazy because it’s like you feeling better and now you take away the thing that’s making you feel better. So now the most recent advice from the British Menopause Society and no doubt the same in Australia and throughout the world is that there is no arbitrary limit on how long you take it for.
Dr. Nicky (00:38:44) – Personally, I’ve got this image of the prising out of my hand when I’m really old, right? So, you know, but I think it will sort of become obvious for you as a woman if you’re feeling good on it and you’ve got no problems and everything like this. And then certainly in the UK, we have five yearly mammogram screening is on offer. So, you know, and it’s making a difference and you feel good, then actually there’s no reason why you would stop, is there? But on the other hand, if either you get I don’t know, you might get fed up of taking it or whatever it is because my mother was taking actually. But then actually she got older. She’s, you know, there were other things going on and, you know, it became a bit fiddly. And she had other medications for other things. So, you know, there might come a point anyway when it’s like actually, you know, no, you kind of make your own personal decision when that is.
Dr. Nicky (00:39:34) – So yeah, really important to highlight that. So in contrast to the younger women where I would advise, let’s just use a temporary measure unless you’ve got of course, and you’re going to be taking it continuously. But the same for, you know, menopause, use of HRT. It’s very individual personal choice. We must titrate the dose according to the individual, what they need. And also, again, personalisation when you want to stop this or do you want to keep taking it like me or whatever. So that’s so then that’s a really good to know that there is no arbitrary limit. But again, you know, not all doctors are totally up to speed. Obviously, hormones are my passion. This is why I know everything that’s been changing and made some of the changes myself. And you know, a member of the Menopause Society done their training course, whatever. So, you know, again, make sure you’re getting, you know, someone with the really most up to date advice and information.
Sarah (00:40:31) – Yeah. Yeah. And I love that you reiterated that it’s important to start slow and start with a small dose because also different people are sensitive to medications and different different ways and similar similar to when we advise people who are looking to support their mental health with antidepressants. It’s very much like a case by case basis and it takes time to figure out what’s going to work best for your body. So patience is also really important as well as working with someone that’s really qualified and up to date and knows the best kind of situation for you and and your body and your lifestyle. So always, always, always. Anyone listening to this podcast, make sure that you’re working with someone that’s not just qualified but is specialized in the areas that you need support in when you are going to see that individual. Um, this has been eye opening and hopefully my goal with this podcast was to kind of remove a lot of, I guess, the overwhelm and the barriers that people might have in, in taking hit either as a support for themselves during that recovery or in that perimenopausal kind of state to make sure that they can still support themselves lifestyle wise, but make sure that they’re physiologically giving their body what it needs to thrive and be optimal and function and feel good.
Dr. Nicky (00:42:04) – Yeah. Well, quite that’s that’s the most important thing. That’s why the my title of my book is Human Potential. Whatever your personal potential is, you definitely want to reach that, don’t you?
Sarah (00:42:14) – And yeah, most definitely. And I guess my my last question is, is there anything else that you want to add about the discussion around that we haven’t already talked about today?
Dr. Nicky (00:42:26) – I think one thing sometimes it’s like when you started in the perimenopause. Menopause, right? It used to be again, things have changed because of the strict definition of menopause is a point in time when your periods stop and it’s retrospective, you look back and say, Oh, well, I haven’t had a period for 12 years and I’m in that age group of 45 to 55, right? But now and that used to be like, okay, then you start HRT. But that seems crazy, doesn’t it? Imagine you’ve got to suffer a year of not feeling great and then take HRT like, Oh, now you qualify.
Dr. Nicky (00:42:58) – So actually again, the thing has changed, which I’m really pleased to see, and that now actually, you know, starting it sooner than later if you’re in the perimenopause, i.e. you’ve got really erratic cycles, typically shortening cycle length and again just not feeling great and getting some of those symptoms that the ovaries are retiring, then easing into HRT at that point to sync it almost with your cycles. What’s going on that actually is also now the new a better approach. And I’ve seen it, I’ve seen it personally really work well. And again, this is very fine tuning and certainly if you’re having some periods already still, then it would be definitely a low dose of oestrogen because obviously you’re just doing something and it would be the sort of the same dose of progesterone because probably what happens first is the ovulation sort of doesn’t work so well and actually probably it’s the progesterone that goes lower first, probably we don’t know exactly. But again, it’s all about the fine tuning and starting as low as you can and just seeing how the trying to sort of get it right for the individual.
Dr. Nicky (00:44:05) – So that’s my only other thing. When we said when, how long for how, when do you stop it? But also when do you start it. Yeah. Don’t suffer.
Sarah (00:44:14) – In silence.
Dr. Nicky (00:44:15) – No, no. Absolutely. Better to get it. And as you say, personal for you. Better to try and get in sync with what works for you. And then you’ve got a good idea of, okay, this dose and this way of taking it works best for me.
Sarah (00:44:27) – Yeah, 100%. And since we spoke last time, your Instagram has changed. So what is your new Instagram handle? Should individuals want to connect with you?
Dr. Nicky (00:44:39) – Um, well, actually, um, yeah, that was a whole debacle. But we won’t go into that now anyway. Um, but actually gave me the opportunity to make it all the same across everything. Yes. So insta Twitter and Facebook. So just simple, straightforward. My name. So. Doctor Nick. Nick, Nick, Nick. Okay, there you go.
Dr. Nicky (00:44:59) – And I try and post interesting things and podcasts and stuff like that. And then if people, you know, prefer to look at a book or there is a either I think there’s a Kindle version, but also if you want a paper copy, then please. Some of the stuff we’ve discussed here, we go into that with stories to illustrate, like I said. So yeah, please have a look at the book and my website has got, you know, further information about the book and advisory appointments, etcetera. So again, straightforward Nikki Kaye fitness for the website and Nikki at all the social media things.
Sarah (00:45:40) – Amazing. And I will put all of those links in the show notes so that all of our audience can connect with you and get your brilliant book and pick your mind in an appointment should they need some further support. So thank you so much for taking the time today to discuss all things HRT and to everyone listening, I hope you got a lot out of the episode. If you did, make sure to take a screenshot of wherever you’re listening and you can tag myself at Sarah Liz King or you can tag Nikki at Dr. Nikki K and we will reshare those on our social media.
Sarah (00:46:13) – But until next time, look after yourself and I will be back with a fresh new episode. You can wrap your ears around next week.
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