00:00
Hey everyone, it's Mikki here, you're listening to Mikkipedia, and this week on the podcast I have Drs Nikki Keay and Lara Briden.

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Lara and Nikki and I have a discussion around hormones, HRT and women's health after crowdsourcing questions from social media. It's an in-depth and engaging discussion of current issues, beliefs around HRT and their recommendations. Truth be told, it's a discussion that I facilitate more so than that I'm a very active participant in it.

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For those of you unfamiliar with either Lara or Nikki, they've both been on the podcast before, and I will pop links in the show notes to their previous episodes. Lara Bryden is a naturopathic doctor and bestselling author of the books, Period Repair Manual and Hormone Repair Manual. These are practical guides to treating period problems with nutrition, supplements, and bioidentical hormones.

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With a strong science background, Lara sits on several advisory boards and is the lead author of a 2020 paper published in a peer-reviewed medical journal that discusses some of the very things we're talking about on today's show.

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perimenopause and many other hormone and period related health problems. Lara is about to release her third book on the metabolic challenges of menopause and so I'm really looking forward to chatting to her about that on a future episode. So I have links as to where you can find Lara over on the show notes, including as I said the previous episode that we had recorded together, and also Dr Nikki Key who

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Visiting New Zealand from the UK, she is a medical doctor with expertise in the field of exercise endocrinology.

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She graduated from Cambridge University and is an honorary clinical lecturer in the Division of Medicine, University College of London. Nikki's clinical and research endocrine work is particularly with exercises, dances and athletes, with a focus on relative energy deficiency in sport, and also with women experiencing perimenopause and menopause. So I have links as to where you can find Nikki and also to her book,

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in the most recent episode that I did with her and Nikki's been on the show twice and they've both been fabulous conversations. Before I crack on into today's podcast though, I'd like to remind you that the best way to support the podcast is to hit subscribe on your favourite podcast listening platform. As this increases the visibility of Micopedia in amongst the literally thousands of other podcasts that people could choose to listen to. So whilst you're at it, why not leave a five star review?

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that I have on the show really deserve it. Alright team, please enjoy the conversation that I have with Doctors Lara Bryden and Mickey K.

03:22
Dr. Bryden, Dr. Nikki Key, Gavin. So great that you guys are here and I feel really honored that you're in my house and we have this opportunity to have a discussion about latest research and also of course just about the really common questions that come up for me at least on social media around the topic of HRT, around symptoms in perimenopause.

03:50
premenstrual syndrome as well, and also postmenopause. And that's one that has been increasingly sort of discussed in the social media space. So it would be great to just get your, I suppose your perspectives because of your, you know, clinical and research experience. Speaking of research experience, actually, one of the questions was about latest research in the field of hormones and menopause, et cetera.

04:19
And Nikki, can you just update us on your current sort of projects and what you're working on? Well, I know Lara will be very pleased that I'm discussing this because the menstrual cycle, the sort of highlight, the purpose of it is to ovulate. But this is not just for totality, of course, that is important. But actually, it's because the production of

04:49
the full repertoire of the hormone is only comes to be when you ovulate. And so actually detecting what might be very subtle issues with this. So what we call subclinical ovulatory disturbances. So in other words, women might be reporting, yes, I'm having a regular menstruation, a regular period, but actually this might underneath the surface. There might be a problem with ovulation, not.

05:16
producing a decent level, if I can put it that way, of progesterone. So that is really fascinating and I know something that Laura's going to back me up on. And also Geraldine Pryor in Canada, Professor Geraldine Pryor, she's a sort of pioneer and that was also someone that really opened my eyes to this being such an important thing that we're not discussing. And I'll tell you why. Because it's difficult. It's difficult. And I love difficult. I love challenges. I love hormones. I love that.

05:42
you know that's what we're talking about we're not talking about something obvious we're talking about something very subtle but something crucially important so absolutely this is what i'm really excited about looking forward where the research i think should go and um i'm doing a study myself with dancers in training because dance young dancers in their 20s early 20s in training you know um intensive training in in dance

06:08
That's going to put a lot of stresses and strains on the symptoms, maybe some under-fuelling. And so these are a prime candidate for women that might be experiencing these subclinical ovulatory disturbances. So that's what I'm looking at now, right now, to see what's going on, seeing if what I believe is correct, that there is an issue, and that they're going undetected through. And we're going to talk about that. How do we detect this?

06:36
how do we detect this? If a woman's having regular cycles, then regular periods, then it's obviously, as I say, not obvious, so you're going to have to look at the finer detail, right? The finer detail of is she producing a decent level of progesterone? And we know it's laborious and tedious to do blood tests and difficult with the timing, etc. So for example, one way would be to measure what's called the basal body temperature. We know if you produce a decent amount of progesterone,

07:03
this will raise the basal body temperature slightly but you have to obviously be measuring it to have an idea if this is happening. So in this particular study I'm keeping a track of their training load, how much exercise they're doing, sort of a rough idea of their nutritional habits, not full diet, I can't do that over a year because it's not going to happen, but also I am doing some blood tests now and then see what's going on with hormones but also the basal body temperature.

07:31
putting all these bits of information together then I will get a hopefully a clearer picture for all each individual dancer what's going on with it because it's important why am I going to all this trouble by the way you might be wondering and asking these participants to go to this trouble why what's the point the point is that these hormones are crucial not only for reproduction but for health so it's their health and you know ultimately their performance and

07:58
for a dancer it's obviously I'm talking about dance performance but for any woman being at her best performing doing whatever she wants to do whether that is dancing whether that's running walking going to the gym whatever it is you're only or achieving something really good at work you're only going to be able to do that if your hormones are on your side so that's why we should definitely go to the trouble of looking at this in more detail I believe. Yeah I love the hormones are on your side that's just a really nice framing of it

08:28
And the other word that Professor Pryor uses for a good production of progesterone is a robust luteal phase. I love that too, looking for this robustness in the system. And yeah, the term subclinical ovulatory disturbance, that means like there was ovulation, but the luteal phase might've only been, you know, eight or nine days. And certainly there can be cycles when ovulation has not occurred at all and a woman can still have irregular bleeds. So those are subclinical or sort of invisible.

08:57
ovulatory disturbances and they're both a sign, a signal, a symptom that something is not right, usually under fueling or something or stress or something else that's going on over training. And also conversely, it means the woman has not had the full dose of the hormones that she needs for performance, all the things you just listed. So one of Jerelyn's phrases that I love, I might've said this on the podcast before, is that a regular ovulatory cycle is both.

09:24
a barometer and a creator of good health. Oh, what a great way of putting it, because I often say that the menstrual cycle, having a regular period is certainly a barometer of internal health hormones, and so your free monthly medical check, but- I love that, your free monthly- Your free monthly medical check, but looking at the detail of it, and that's important because you say then that is the producer in itself of overall good health, because these hormones aren't just limited to reproduction as we keep-

09:54
saying, stressing, all aspects of physical and mental health, mental health as well, I think is really important. So, you know, these hormones are amazing. They set in motion our path to health and performance. So, you know, we need to nurture them and know them, understand, and get to grips with the nitty gritty. And sadly, a lot of, we were just talking actually a little bit off air, a lot of the science that has happened and is happening is not properly tracking ovulation or understanding when that's happening. And as...

10:23
Dr. Nicky said, I mean, that's partly because it's hard to do, and it's labor intensive. But I mean, the the basal body temperature is arguably an easier method than the daily blood draws. And and non invasive because you could do you could try and shoot for a peak hormone progesterone production during the lead to your face. And to be fair, I am actually doing that in my study. But it's very much directed at not just a day 21 progesterone, which is so vague, because

10:53
As we were also discussing off air, every woman's menstrual cycle is individual to her timing. She might have a longer or shorter follicular phase, and so what might be day 21 for one woman might indeed hit the peak of the testosterone production, but in another woman it could be way off. It could be either too late or too early. And so actually tailoring that blood test, if you are going to do a blood test, then tailoring it to try and maximise where you're hitting that peak production. That's what I'm doing in my study.

11:23
I know what their menstrual cycle length is, and so I can try and target that peak. But even that, it's still invasive. Even if you do capillary, that is still invasive, right? As simple as that. Whereas the basal body temperature is non-invasive and, you know, pretty unobtrusive, not massively difficult. But you're right, Lara, that I agree that the focus sometimes is on...

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you know, scientific research, absolutely very super important for academic pursuit. But actually, if we think about what is going to really help in a clinical context with women's health, then this is the key thing, which we I think we all agree is something that needs looking into more detail, the ovulation and the production robust robust, robust, and decent level of a progesterone. That gives you, you know, the best chance you possibly have of attaining your

12:18
personal full potential and optimal health. Yeah, and that was great, Lara, that you mentioned what was currently happening in the scientific space because that was going to be my question. So what are the research groups, how are they measuring and what's their marker, I suppose, of the menstrual cycle? So clearly it's not ovulation. Well, yeah, we'll get Nicky's.

12:42
opinion too, but I think from what I said, they're often using LH, blood tests for LH or urine tests for LH. Yeah, so urine ovulation strip, which is very, again, non-invasive, very straightforward. And it will, you know, the very cheap, these ovulation strips, you can purchase them over the counter, it will give you a smiley face. If you, or whatever the measurement is, if you've got an LH surge and the LH surge is the trigger for ovulation. So that's brilliant. And it certainly...

13:11
some way to being reassuring that, okay, at least the body's trying. But you have no evidence. It's just like, you know, I always compare it to dancing. Because I love my dancing. But for example, it's like when the curtains open at the beginning of the performance and you know what the set will you're expecting for the Nutcracker, you're expecting to see a big Christmas tree. So this thing opens the Christmas tree. It's like, great. But then you go out. You don't have any evidence that production will carry on. It may be there was just an empty set and nothing happened.

13:40
Or it may be that one of the dancers didn't turn up on stage, you don't know. So this is what the LH surge is. It's very it's reassuring to a certain extent and definitely very useful for the timing, especially if you are looking to get pregnant. So, OK, the LH surgeon now, I'm probably fertile now or very soon. But like you say, it doesn't give us any evidence of having a robust luteal phase. It just is a starting, but it's more about the timing and the

14:07
full production of the hormones. Yeah. Well, and this could be why I think some of this confusion around tracking ovulation could be why, as I think you know, some of the signs that we have so far around menstrual cycle and athletic performance, it was a little bit nonconclusive or inconclusive. And I think that part of it is probably just not the it's just too messy that the muddy the waters are muddied by sort of not quite knowing where women actually are. Yeah, the timing is very important for this. Exactly.

14:35
you know, the evidence we know comes out in a big meta-analysis published that actually there's no difference in performance where you are in the menstrual cycle, but then you have lots of questions. How were they knowing exactly where they were in the menstrual cycle? Were they in the reserve follicular, late follicular, at ovulation just afterwards or whatever? And was that, if it was in the luteal phase, was it associated, was it a true, a full-blown, robust, luteal phase or not? We don't know. The timing is a little bit suspect.

15:04
But also, I think it basically comes down to the other thing. It's all very well, and I think it's important. We talk about the details of the timing, the production of the hormones, da-da-da, yeah, important. But guess what? We missed out the third crucial element, the individual response to these hormones. So even if a woman produces, or you gave her exactly the same amount of progesterone, whatever, you had a whole room of women, they would respond in different ways. Some would say, oh, I feel great. Some would say, oh, my goodness, I feel awful. Some would...

15:32
You see what I mean? So it's not, how can you measure that? It's their individual response. And also there are other things going on in their lives. They might have had a bad performance that day because they had a bad night's sleep or they had an argument or stressful event happening in their family or something. Who knows? There's so many other things to do with performance, but certainly at least knowing that you've got a full robust menstrual cycle is a good starting point. You can be reassured and feel

16:01
secure in that, but it's very such a personal individual thing. How you're going to feel and the effect on performance. And actually, although it might come out in a whole meta analysis statistically, it's insignificant. Guess what? The gap between the gold medal and the silver medal for a hundred meter dash. Guess what? That's minuscule. Yeah. So again.

16:24
Statistical significance is totally different cattle of fish sometimes to clinical significance or on the field performance. So that's why it's all a bit hazy, isn't it? For sure. And you mentioned something, Nikki, in your initial discussion of what you should measure in that a woman might think she has a normal cycle. And I think that's, I guess my question is, well, if a woman thinks she has a normal cycle,

16:52
How would you like, are we, cause we're talking about it from a research perspective, like how important, what are the other signs and symptoms, I suppose that it's not normal, because everyone's really different. Right, but anyone can do basal body temperature. So that I would, so the phrase for that is a beautiful, another beautiful phrase called body literacy, is knowing if and when you ovulate. And it's, I mean, in some circles, it's extremely popular, proper cycle charting and charting temperatures and.

17:19
I think many women find it quite empowering just to actually understand what's happening with their cycle and where they are within, even within a robust luteal phase. I'll just point out, hormonally, the different parts of the luteal phase are quite different. So the late luteal phase, I've been having this conversation with a few scientists recently, like the late luteal phase is a time of hormone withdrawal. It is quite a different time from the early luteal phase. So under any, any individual, if they're curious.

17:45
can track this. So there's various apps and wearables that help with the temperature tracking, but it's not rocket science. I mean, when people are doing it within a scientific context, there's a more quantified proper way to do it. But for individuals, you can just put on a armband or... Yep. I'll tell you something. I'm very old. And listen, we didn't have all this fancy technology and gadgets. Just the mother of head. No, listen, even that.

18:12
Well, actually, to be fair, my mother did use a thermometer. That's true. Even my mother, in order to get pregnant, she even she knew about doing the basal body temperature anyway. But my point is pen and paper. There's nothing wrong with that. It's true. Free, totally free. You don't have to spend anything on actual fancy stuff, which slightly can be bamboozling. And especially some apps, which I'm not that happy with, shall we say, that dictate.

18:39
you should be feeling like this, you should be feeling like that, which actually I hate, I hate to be told how I should feel, actually I might be feeling totally different, but then you would get really worried. It's like, oh gosh, something's wrong with me, and in fact there isn't, it's just you, it's always that particular cycle, it's fine. So I think actually a good starting point is the old, the humble pen and paper. Just record your cycle, just note down how you're feeling, what's going on.

19:06
And then you'll, as you say, body literacy, you'll get to know your own body, what is normal for you. And then you'll be able to have a baseline. If something does seem, well, that seems a bit strange, what's going on there. Then you'll be in a better position to detect it. So be curious.

19:21
for your own detective for your body. Yeah. There are so many options with how to test and of course the Dutch test is one that I get asked about all of the time. And I don't know that I've, I think I've asked Lara this before about whether or not you use it and I understand that you don't and if there's an update there then of course you'll correct me. And Nikki, just from what you've said I don't think you're a...

19:40
particular fan of the dried urine test for comprehensive hormones? No, I'm being trying to be as objective as I can. Which is great. And there is, but there is absolutely not. I've spoken to people in the UK, medical doctors and scientists, and they look at me like I'm mad. I just say, oh, what's your view on measuring metabolites in the urine? Yeah. As my husband says, it's a bit like searching through the rubbish bin to look for an apple core to have evidence that there may be someone's eating a nap. It's just like very, very inconclusive. Why do you want to measure metabolites?

20:10
Why don't you want to be measuring the active thing if you are going to be measuring? Or more crucially, like we said, don't you want to be measuring the effects of these hormones, like the base of body temperature and what's the effect? There's a certain level might of the metabolite after all might not. What is the clinical significance of that? And also if you look at the website which I have in great detail, I've looked at the references and actually, you know,

20:36
they do say that it's, oh, the urine is very related if you correct it for 24 hour creatinine clearance. It's like, yeah, but I'm not interested in that. I'm interested in what that related to the blood level and what's it related to the clinical picture. And as we all know, the Dutch test produced beautiful graph, really colorful, looks lovely, brilliant, great, lovely. But I asked the patient.

21:01
I say, what do you understand by that? They said, I don't have a clue. What do you make by it? I said, I haven't a clue either. And I'm medically trained and I've been in this business for a long time, looking at hormones and I don't know what that means. I've no idea what this dial means and what's going on because I have nothing to relate it to. So, sorry, that's my summary and it's quite expensive, I understand. And I think you've just saved thousands of people several hundred dollars. Quite. Yeah, so that's...

21:27
That's a bonus. Yeah, get your relation thermometer very cheaply instead. Very good, done. And your pen and paper. Yeah, and your pen and paper. Totally. So actually, one of the first questions was, you know, what is the misinformation out there? And I suppose that we've actually just tackled two of those sort of major highlights in the space of sort of hormones and tracking and measuring. What about updated research on hormone replacement?

21:53
therapy? Like, is there a new understanding of, you know, when a good... So I've got quite a few questions on HRT actually, and it's sort of under the umbrella of, should I use HRT if I have no symptoms around my perimenopause and in that sort of transition? And also, when is a good age to start HRT?

22:21
And also how old, like what if I'm post-menopause? Is HRT still something I need to consider? So, I mean, there are a lot of questions. Well, this is a in progress. I mean, I think the scientists are still trying to work out a lot of this and there's different viewpoints and different camps out there. I mean, certainly in the last few years, there has been a growing opinion that all women need.

22:46
estrogen replacement, I mean, not replacement, I used in therapy. What the new term actually is menopausal hormone therapy rather than HRT, because it's not technically replacement because menopause is normally a time of lower hormones. So it's unlike it's quite different in that way from say thyroid replacement, where if the thyroid becomes underactive, then obviously you do need to replace that hormone. So it's it's much more nuanced around

23:13
menopause, I suspect the coming 10 years is going to bring even more insights. I can give my like just broad strokes what I think and then we'll hear, you know, Nikki and I think we're similar. I mean, I think, um, officially there are the recommendations for, again, estrogen specifically, if that's what we're talking about, would be certainly for anyone with premature menopause or primary ovarian insufficiency for sure.

23:40
I think no one really debates that those, that is more of a situation of replacement. Like they need the hormones that they should have had in their 30s or 40s or whenever time they went into early menopause. So that's not really up for debate. The other really clear indication that most people seem to agree with is if there is compromised bone density for some reason, maybe from years of amenorrhea or corticosteroids or something, and there's a high risk of osteoporosis, then I think unless there's a reason to not take estrogen, I think most people are in agreement about that.

24:09
And then beyond that, I think officially at the moment anyway, the consensus is women should, if they're able, if they don't have a breast cancer risk or something, should take estrogen therapy for symptom relief, primarily for hot flashes and maybe mood and sleep disturbance. And so basically I agree with all that. Of course, my view is a little more nuanced because I have with my book, my perimenopause book, hormone repair manual, zoomed in a bit more on

24:38
the perimenopause transition itself. And a lot of this is inspired by Professor Jerelyn Pryor, who has done research and is adamant, and really I feel is correct in pointing out that the early phases, like the early number of years in a naturally occurring perimenopause, again, not early menopause or anything like that, is actually a time of high, at times high estrogen compared to progesterone. Estrogen's fluctuating, it's going up and down. And some of the symptoms are from

25:06
rapid withdrawal from those higher estrogen spikes. So actually, Jerilyn just published something recently. I don't know how she publishes so many papers. She just sent me something about more growing evidence that some of the very distressing, especially neurological and emotional symptoms and even sleep symptoms that women can experience during the perimenopause transition are from that estrogen withdrawal. And there's different ways to stabilize that. And of course, Professor Pryor has published a couple of papers on using progesterone.

25:34
to try to stabilize that. It can give symptom relief, it can to some extent counterbalance those really high estrogen spikes. So she would argue for, especially if in a very symptomatic perimenopause, that progesterone alone is an option for like the seven or eight years that it might take to transition that. But even Jerelyn and me and everyone will agree like later in perimenopause when estrogen does bottom out quite a lot for everyone, some women, many women are

26:04
benefit potentially from taking estrogen therapy for symptom relief at that time is still in combination with progesterone. And I think that's reasonable. And then of course, you know, the question is, how long do you continue it? And the million dollar question right now is, does, you know, for the for the average woman, and again, averages, a lot a lot gets lost in the store, we start looking at averages, a lot gets lost. But, you know, does taking estrogen reduce the risk of heart disease, reduce the risk of dementia? And how do you weigh that against?

26:34
potentially small increase in breast cancer risk, although one big thing that's happened in recent years is the breast cancer risk is a lot less than thought. And part of that's to do with using modern body identical forms of hormone therapy, which are safer. Just one final point on it, through my lens anyway, and thinking about metabolic health and insulin resistance and the way

26:59
insulin sensitizing, I suspect when they if they were really to look at the details in terms of what degree does estrogen therapy reduce the risk of say heart disease or even dementia to some extent because that could be metabolic. I would say it depends on metabolic health. So I would suspect women, I'm just hypothesizing, I don't know that this research has been done, but I suspect women who are tending more to insulin resistance are potentially going to benefit more from

27:29
mitigating treatment on their long-term risk. What do you think, Nekki? Well, I agree with you, well, as always on many of those points, but just pick up on a few of those things. This trend, there seems to be a trend, it's swung so many ways that HRT is evil and causes breast cancer and don't touch it, to like you feel almost certainly in the UK there was a certain celebrity went on TV

27:56
and almost people, women feel, oh gosh, I should be taking HRT. So in my myths of menopause, I'm portraying this as Scylla and Charybdis, you know, when they have the Odyssey, what Odysseus is doing making his voyage, it's like you've got these two camps. On the one hand, you have some people calling out, oh no, you're weak and feeble if you consider HRT and you're throwing in the towel. On the other hand, you have these other people saying, oh, absolutely, you should take it. It's the elixir of youth. And it's like very, very confusing. But the bottom line is, it's down to the individual woman.

28:26
But my view is very much, no surprise like Laura's, that it is for the individual. And I think there is definitely a benefit of HRT for quality of life is currently what it's given for. If a woman is having experiencing troublesome symptoms, interfering with the quality of a life, whether those are heart flushes, whatever, then HRT, that will definitely help. But there is also, we do know, certainly in the UK, it's now the primary,

28:55
treatment for poor bone health, okay, at any age by the way. So that would be my only thing, only thing I would slightly, you know, HRT, hormone replacement therapy, whether we like that or not, if we call it menopause therapy, then actually, this is going to be a real turn off because I work a lot with younger women who I do recommend HRT to temporarily, who have FHA and poor bone health and stress fractures and...

29:24
you know, not great on Dexascan and that is the recommendation of the IFC. To temporarily give a little bit of HRT, I typically give it six months. So for those women, that's why I don't want to change it to menopause therapy because I think it could be confusing. But what we have, we should say before we even, what I should have said even before I started talking about HRT, is that actually the first thing is for a woman in perimenopause and indeed menopause, first thing is lifestyle.

29:51
So this is an excellent time and opportunity to revise what you're doing in terms of your nutrition, your exercise, your sleep patterns, you know, have a spring clean and overhaul. So that, and that's what we say in the UK, that's the recommendation from the NHS that, you know, you talk about the lifestyle. Then we talk about the HRT or symptom relief. And in terms of, I totally agree with what Lara said about, there is a little bit of a, I suppose it's simpler to say,

30:21
isn't it? Everyone's heard of estrogen and estrogens. So we say, oh, the estrogens go low and that's why your bones get worse and da da da. But actually, we are, if we're glossing over the detail of it, and that, you know, like Gerilyn prior points out, actually the estrogen sometimes is doing, going quite high and quite low, but it's actually the progesterone, the humble progesterone that we've already talked about. That is the one that's declining. And it's really, really interesting that Gerilyn has published these studies showing that giving

30:50
micronized, the body identical progesterone by itself improves hot flushes. And she's done a big study of this. And yet there is still a resistance, I know, in the UK. It's like, and I suspect elsewhere, it's like, oh, this is a bit weird. Why are we giving progesterone? Because people don't think that that's an important, or not as important as the oestrogen you see. But actually, so, but I think that's going to take time to sink in, by the way. All right. So, so for the time being,

31:18
We have to at least stick with what we know, talk about the lifestyle, absolutely discuss the pros and cons of HRT, but it is literally can be transformative and I'm slightly speaking from personal experience here in terms of all the relief of the symptoms. And also I know my bones are not great, so it's like I feel I'm doing something for my bones and also there is, as Laura says, not clear evidence, but certainly

31:48
something to be said for the cardiometabolic health by taking HRT, depending on the way you take it, like you said, and which one, but assuming we're taking the real McCoy, the body identical ones, the molecularly identical to what you produce, and you take the estrogen through the skin, through gel or patch, and avoid the first pass metabolic effect by taking it in a neural form through the liver, then I think, you know, it's difficult to say,

32:16
I can't say, look, I think at least you should try it. For the woman that's uncertain, who's done all the lifestyle things, and is saying, look, I'm still not feeling great, and I am concerned, you know, I'm thinking about my long-term health, I would say to the woman, look, let's at least try. You're not throwing in the towel. What you're doing is being sensible. Let's see how it goes. Start a really low dose and see how we go. So that's the other fault, that people go a bit gung-ho. And certainly in the UK, we've had a problem with a certain...

32:42
clinic there, that's been pulled up by the British Menopause Society anyway, who are literally giving the woman massive doses of estrogen, right? Yes, you know what I'm talking about. And actually, that can be counterproductive, because the body might already number one have a lot and also you're flooding it with stuff. So, so my, my general view is on the individual talk about the lifestyle, discuss the pros and cons of HRT like Lara said, just to emphasize.

33:10
that there is a small increase risk of breast cancer at extra four cases per 1,000 women, but in contrast to reducing a risk of breast cancer by seven cases per 1,000, if you do two and a half hours of exercise or more per week, you know, you have to weigh these things up and you've got nothing to lose by at least trying and seeing how you go and how it progresses. Just one other point about how long to stay on a, when to start and how, timing, as soon as possible is bottom line. It used to be...

33:38
old fashioned, oh, you have to wait till you've suffered for at least a year and then men and laws and then we might contain to call talk about HIT. That's changed. It's like, no, as you start to experience symptoms with the hormones doing, you know, the over is going working part time. So that's definitely a good time to start that conversation as early as possible. And then how long to take it again, that's now changed. It used to be five years, but this makes no sense. The British Menopause Society has come out very firmly said there is no arbitrary limit.

34:08
is again like, oh, you're allowed five years of good quality life, then we're going to take it away from you. It's like, what? That makes no sense. So now, of course, one has to be sensible. If it's if the woman is happy with their ghost of HRT and everything's going fine, then why would you stop this? That's helping. I mean, I just got this image of people prising the HRT out of my hand. It's, oh, give it back. So it's a very individual thing, you know, and choice, but it's about making those informed.

34:35
informed decisions as an NRA, giving people the information, the evidence, and then ultimately, you know, it's up to them to make that choice and be supported along that journey. So the other thing I've come across is that women, okay, fine, I'm going to try HRT, and then literally a couple of days or a week later, I get an email saying, oh, I don't feel any difference. It's like, yeah, you have to give it just to point out at least three months before, I will not know, we're not going to change the dose, at least until three months, and then we see how things are going. So and also if the first...

35:05
round of HRT that doesn't suit you for whatever reason, then there's plenty of options out there within the body identical remit. So definitely that's always the thing, but there's all sorts of different preparations and ways of taking it. So, you know, again, it's this having this nuanced flexible approach. I think this is super important. And is so

35:30
couple of clients, their doctors do things like they have perimenopausal symptoms and they put them back on birth control. Oh, no. And or IUD or a marina was same thing but different, you know, they either take the oral. So what's what's the go there? What's the opinion there? It's not as good as body identical hormone therapy. So once I was just going to respond to something that he said, I think it's very interesting. Yeah. So for this goes back to the question of whether it's hormone replacement or not.

35:59
It is replacement for younger women. And I almost think the same medicine, maybe that's a little confusing, but I think it has to have a different name if it's being prescribed for someone with reds or FAH and premature menopause versus someone who has gone through a natural menopause at age 50. Just because I do feel like, and the other thing I want to respond to is, as you say, treat the individual, reassure the individual. And I think

36:29
that I have seen happening and it's not new in women's health. Maybe it's not new in health in general, but particularly for women, there's a lot of fear based messaging around this. So there was all the fear around paramedic because of breast cancer. And now the fear on that has hopefully been dialed down and rightly so, because it's, as you just pointed out, exercise, even reducing alcohol can reduce the risk of breast cancer. There's so many ways that are actually bigger levers to pull in terms of reducing breast cancer risk. And then not also not

36:57
making women fearful of not taking hormone therapy. That's what I don't like to see is like this panic of, let's say it's a healthy woman, her bones are healthy, she's had 30 years of natural cycling and she's had pregnancies, she doesn't have insulin resistance, she doesn't particularly wanna take hormone therapy, she shouldn't have to, and she should not be made to feel fearful that she's maybe not treating the disease of menopause or something. So that's...

37:23
I wanted to say that. And the other thing I want to say that is, I think it's an important detail that people do need to know, especially if they're going to go on to hormone therapy for a while and maybe come off. And I agree with you, there's no arbitrary time to come off. Like if you're on it for bone health, especially for a serious bone health situation, I think you're probably on it for life actually, for bones. But if it was just for some troublesome symptoms during the later parts of the perimenopause transition,

37:49
And if women want to get off, or depending on what the future research shows, one thing to, because I've seen this time and time again with patients, this would often happen before they came to me there, but like I was on hormone therapy, and then I didn't want it, so I just stopped it, and they didn't taper it down. And the thing is, I mean, it may be a little bit of an oversimplification, but estrogen is addictive. It truly is in a way that progesterone and some of the other hormones aren't. So if you've been on it,

38:12
Like our own estrogen is addictive to some extent when we've gone through our high estrogen years and then certainly if you've been especially on a higher dose of estrogen and then you can't just stop it cold turkey, it needs to be tapered down and stopping it just completely going over the estrogen cliff. Women can interpret that as like, well, I must need it. It must be a deficiency, but they actually, what they needed was to let their body adjust because like you said, right at the beginning, it's not just the amount of hormone in our body. It's.

38:40
how the receptors, how many hormone receptors we have, how they're calibrated, how they're responding. And the way receptors respond to certain hormones is affected by lots of things, including other hormones and the nervous system. This is the kind of orchestra or ballet performance of hormones that you talk about in your book, Nikki. So in an answer to your question of the pill is not a solution for like,

39:09
the pill is not suitable for perimenopause just because, I mean, just so much better having the body identical hormones. That said, it is still possible to be fall pregnant during perimenopause. So I guess if women and body identical hormones cannot be used to prevent pregnancy. So yes, if they need a method, I guess I will because everyone probably a lot of your listeners do want to know about the marina or the hormonal

39:36
and I'm happy to hear Nikki's thoughts about this too. Just to be clear, there's no progesterone in that. That's a medication called, I believe, an oedestral. It's a progestin, but it is a much lower dose than you would get in a pill, or it's a lower dose than you'd get in some of the other kinds of old-school HRT, some of the other progestins. So it does seem to be, I personally, it does affect the brain. I think it does affect, kind of negatively affect metabolic health potentially a little bit.

40:04
But it's quite a small dose. And the good thing is, you can just for what it's worth, I mean, you can also take body identical progesterone along with the Mirena. It's not one or the other. And you can take estrogen together with it, obviously. And it does the good thing about the hormonal coil for what it's worth is it does light and flow. So for anybody who's dealing with the paramental plosal symptoms of crazy heavy periods, the hormonal ID can be a reasonable solution for that. There's obviously other solutions. It's not the only one.

40:33
But it's something to, so I don't want women, again, back to the not scaring women, I don't want women to be frightened of hormonal birth control or all types or anything like that. It's just knowing, you know, what might suit them for their. And what it does, because the combined oral contraceptive pill is an excellent contraceptive for someone who has got regular cycles. Okay. It's, it's super effective, but it's a case of knowing what that does.

41:02
So, you know, it does not regulate period, it stops your periods because it dampens everything down from the top control center downwards. So it's very effective contraception for sure and for younger women, brilliant, go for it. But definitely not if your periods are stopped, you've got FHA because that will not help bone health and certainly not in this situation of perimenopause where the hormones are struggling a bit. So now you're going to take the contraception pill and dampen it down even further, makes no sense.

41:30
definitely that's off the cards, but just to back you up on that marina coil. And it is licensed for use with as part of HRT. So, and it is very effective, as you say, it's a contraception. So we tick that one off. Uh, but also you'll, I agree with you, Lara. It's, I see it often, uh, used and I advise that if there is a problem with lots of heavy flow and irregular cycles because of the unopposed estrogen, right? And the progesterone, that's why, by the way, you have lots of problems with the flow. Uh, it's actually the progesterone. So guess what?

42:00
we give, okay, not the real thing, but we give progestin, but it's also slow release there right where at the business end or the different business place, I can put it that way. So that's really can be very useful in that context. And as you say, you can add in eutrogest, well, micronized progesterone in the UK, we call that eutrogest, yeah, right. Or papirometrium, I think, in Australia. Anyway, so that's certainly a good option for those women in perimenopause.

42:29
who are also thinking about, I want some contraception as well, then the Marina coil, you know, that's a good shout actually. And just to say, so just to clarify, like if someone was going to decide to use both Marina and the uterine or progesterone, that would, the progesterone in that case would be for some of the neurological symptoms like sleep and calming mood and whether on its own or in addition to a trans, an estrogen patch. Yeah.

42:59
If a woman takes, if say her GP sort of gives her the OCP as a regulator for her perimenopausal symptoms, is she kicking the can down the road? Like once she comes off it, is it all just going to be, you know? My clinical experiences have women who, well, I mean, again, there's individual variation, but I have found that being on a combined estrogen pill,

43:24
can potentially set women up for more difficult transitions. So to be clear, I mean, it's only masking the situation. It's not letting you go through sort of the hormonal recalibration or adjustment that you're needing to do. So eventually, so basically put it this way, here's another way to frame it. Here's another way to frame it. And I guess this is something else I wanted to say earlier. So the combined estrogen pill is, I don't know how you'll feel about this word, but it's kind of like a substandard version of HRT.

43:53
Like they're not nice hormones. They're not hormones. They're contraceptive. I mean, they're hormone-like. They're definitely hormone-like, but it's a progestin combined with the ethanol estradiol. To be fair, some pills do use real body-identical estradiol. So I guess what I wanted to say earlier is so recently in the last 10 years, which I'm very grateful for, there's been pretty much a universal embracing the fact that

44:17
menopausal, perimenopausal menopausal women do better on body identical hormones. Yeah, that's like, and lots of talk about is beneficial for bones for the brain for cardiovascular. And then part of the I'm like, but why is that not true for young women? Why is it there for okay to routinely switch off their estradiol and progesterone with the pill? They also need it for brain and bone. So there's, it seems to be this weird disconnect, like, and maybe it's sometimes even the same doctors saying, well, it's fine to use the pill to switch off hormones in young women.

44:47
but we really must give real hormones to older women. I'm like, the young women deserve it just as much. So I guess in answer to the question of during paramenopause, I mean, women at any age benefit more from actual hormones compared to those substandard hormones. And that's true. That's fact. That's just true. That's, yeah, absolutely fact. And that's one of the side effects of the contraceptive pill in younger women.

45:11
the, you know, about altering mood and all these... Formal deficiencies. See, it's so many times, exactly. So the thing is, of course, people are going to be saying, oh, but what about the young woman that wants contraception? We are going slightly off track now. So, yeah, absolutely. But again, it's all about choice. Yeah. Going through all the options with her. Old-fashioned barrier methods. Condoms are the only ones that also protect you from STDs. So, you know, let's start with the basics there.

45:40
and let's go through the full repertoire and then they can make their choice. Because we know that the depot injections of the synthetic progesterones, the progestins, that's really bad for bone health for young teenage women. But now there's evidence emerging that, guess what, the same applies for the combined oral. Doing the same thing, it's switching off all the hormones. So again, it's giving the woman the... We're not going to stop women taking the contraceptive pill, right? But we're just saying...

46:09
make sure that they have all that information that they know because I still find the majority of women look at me flabbergasted when I show them the graph of what their hormones normally look like during the menstrual cycle, the beautiful choreography and then I show them this is what your hormones look like if you're on the contraceptive pill. Everything found flat and they look at me and it's like oh my goodness I didn't realize that's what it what it did. You see so again it's just getting that correct information there.

46:36
so the woman can make that informed decision. She might see that and say, okay, that's fine. And I feel fine on it and my bones are fine and that's all good and that's great. But there are lots of women who just absolutely look at me aghast and said, no one explained that to me. Right now I'm gonna make a different decision. So the same thing with HRT. It's like, let's see what the options are. Is HRT a sort of standard prescription post?

47:04
a hysterectomy if a woman has her ovaries removed as well? It absolutely should be. Because if you take the ovaries out, because as we discussed perimenopause, the ovaries are still doing something. And even after menopause, it's a very low level, but it's measurable because they're still there and maybe just doing a little bit, teeny weeny bit. It's about 10% of the ovaries.

47:25
So they still do something, but if you can imagine if they're whipped out, if it's a full hysterectomy, so you're right, we should make that decision. So hysterectomy means taking out the uterus wound, right? So if that's taken out but the ovaries are left, that's all good. It will be difficult to tell when you are going through peri Of course you have the symptoms, but you don't have the symptom of what's happening to your cycles, so it makes it a little bit more complicated, but that's okay. But if it's the full hysterectomy with oophorectomy,

47:55
me, the ovary is taken out as well, then this is a totally different ballgame because you've got no possibility of making any, clearly, and so absolutely this is when HRT should definitely be given at least until the time of natural menopause and then the person can reassess and see how they're feeling. There is also an argument that maybe this is also a situation where you might consider or discuss adding testosterone as well because there's no

48:22
And as I say, there's no variant, there are no ovaries there to produce anything. So this is definitely a different situation. And we know this, unfortunately, from experience of women, you know, several years ago, who did have the total hysterectomy, the oophamorectomy and weren't given HRT, and then turn up and say to me, well, 10 years ago, I had this out. And why have I got these fractures and why I'm feeling so dreadful and no libido and what's going on is like, and I just feel so awful.

48:49
that they weren't given that information. Yeah, I agree. Now, what ovaries out is a very different situation. And the ovaries do make, exactly, exactly. As you say, they pump out some androgens and a little bit of estrogen. A little bit of something. After, even long after menopause. And actually that was gonna be my next question was about testosterone. And I feel like it's getting a little bit more airtime. I'm not sure it's just information that I'm seeing, but I've got a couple of questions here from people on social media asking about the importance of testosterone.

49:19
Like one woman in particular said she's on HRT, but not testosterone. Her libido is shot. Like is, you know, what is the, I guess, best practice for assessing requirement for testosterone? And is it under the similar umbrella of the other hormones that we are either replacing or using as therapy? Like you measure it, you see where you are in line with where it should be, and then you supplement accordingly? Like, I mean, in the UK,

49:49
The only indication for testosterone is libido, right? And the British Menopause Society do suggest, I mean, clinical symptom is the first thing, the woman comes and says, look, but also then getting into the nitty gritty of it, as it were, is it vaginal dryness? Is the reduced libido, frankly, because they just don't feel like it, or frankly, they're a bit nervous because they know it's going to be uncomfortable, dysglaria or even uncomfortable. So if it's the uncomfortable side of the things, as it were,

50:17
then local estrogen and estrogen pesteri. And that can be taken in combination with systemic HRT that we've been talking about. And even in women who've had breast cancer and for whom HRT is contraindicated, taking that local estrogen in itself could be the thing. So it's finding out what is going on here. But if you've treated that, and you know, vaginal tissue is fine, but actually it is reduced libido, then that would be...

50:45
situation to discuss the possibility of testosterone. That's in the UK anyway, that's the main clinical indication, not for other things that have been promoted maybe on social media and elsewhere that it will make you stronger and etc etc. And a very obviously small dose, it's not the same dose as the men would take for example, and Australia are leading the way in this, they're the only ones that have got a female dosage of the testosterone. In the UK we have to use the

51:15
But again, it's very much down to the individual and discussing are there other reasons for the reduced libido? Is it the vaginal dryness? Is it just a general lack of confidence in your body? Is it just you're feeling really tired and exhausted because you're not getting good sleep? So there's lots of things behind reduced libido. So again, exploring I think those other things. First, rather than going straight for the medicine and this is coming from a doctor who says I think that that's often as doctors we are a bit prescription happy.

51:43
You know, and I'm very much, let's look at everything first. And then of course, we have the medication as a possibility. Yeah, I have a couple of things to say about testosterone. It's super interesting, actually. I think I want to get into a little bit some of the metabolic risks around testosterone for women. But before that, I have a question. Can I ask Nikki a question? I'm not the interviewer officially, but I'm just curious because it's sort of come onto my radar recently.

52:09
And I haven't totally fact-checked this. I'm actually just getting your input. So it kind of makes sense to me when this was said that progesterone, so body identical progesterone that we've been talking about, one of its many effects is it does potentially down-regulate both estrogen and testosterone receptors back to the whole receptor things, it's not just how much hormone you have, but how well your body's responding. So for that reason, you know, one possible indication would be even post-menopause, like even longer term hormone therapy is actually

52:39
kind of taking estrogen steady state, but cycling on and off the progesterone to kind of release those receptors, if you will. Does that make sense to you? Have you heard that before? Yes. I mean, they're all interact. Yeah. So, you know, any suggestion that this hormone might be interact with that is like for sure. Yeah. And certainly take how do you take HRT? Yeah. There are two options. Let's assume you have

53:04
got a uterus still so you will always have to take both estrogen and progesterone. You must never take estrogen alone because that will just thicken up the endometrial too much. So then the progesterone you can take it continuously, like you say at a steady state as it were, along with estrogen and typically you won't get a withdrawal bleed with that or you can take it in blocks, so the uterogestan. And there is a choice. I mean I chose to go for the blocks because it just seemed more natural to me. Yeah.

53:34
doing also I want to continue that but my friend said no way in heck I'm not I've had enough all this you know blood loss and whatever and she said no I want to take the continuous progesterone but also even if you do but if you do take the block form like I was right like to mimic I suppose you could say the menstrual cycle it's recommended that after five years you switch to the continuous yeah because although it's a very low risk of breast cancer like we said there is some evidence as even lower for taking the continuous one

54:03
That's a really interesting point. Yeah. If like me, for example, maybe I was making a little bit of testosterone, maybe. Um, but now I'm taking it continuously. Maybe that's downregulated. Progesterone does suppress libido. Unfortunately. I mean, I love, I love progesterone. But I have, you have to sort of acknowledge that it has an anti-androgen, anti-testosterone effect and actually just one more question. So yeah.

54:26
But if estrogen dose is low enough, will cyclic progesterone always produce a bleed in a postmenopausal woman? If they're taking enough estrogen. So it's a threshold estrogen? If the woman, for example, I'm thinking more of my ladies athletes with reds, who I've advised to take, call it HLT for now, and it must be in a cyclical form, and that's one of the indications I know that actually I've got them on a good dose of estrogen.

54:55
Because if they're very low and in a bad way, then actually I say don't worry if you don't get a withdrawal bleed the first round. But then if they say no, I'm not getting anything, actually I've been too cautious with estrogen dose. So you should would be anticipating withdrawal bleed if you're on the correct dose of estrogen with your progesterone. But that's for a young woman. But what about a postmenopausal woman? I think the same would apply because what might happen though is you might start off.

55:22
having the withdrawal bleed on the cyclical progesterone. But then maybe as she goes further into menopause and the ovaries are going down to their 10th, right? Then actually she might stop having the bleed because her own internal production was supported a bit. Then that's it. But again, we're not treating it for, are you getting a bleed or not? No. I would say, are you feeling any different? If she says, well, actually, some of the hot flushes have come back or this, that, or the other, then yeah, I would put up the oestrogen a bit.

55:51
So, but that wouldn't be, I wouldn't be worried that she's not having withdrawal bleeding, but that's more the other way around. We don't want any postmenopausal, unscheduled bleeding. No, exactly. You don't really want to see bleeding postmenopausal. I guess that was my quick, because I had assumed if it was, as long as the estrogen dose wasn't too high, they could do somewhat cyclic progesterone, even if it's like one week on, sorry, three weeks on, one week off.

56:14
to kind of release those androgen receptors. No, I think that's a very reasonable thing. So long as if you're taking in the cyclical, I mean, I'm going to talk about uterogastan, I'm not so more familiar with that. So for example, let's say, let's have this hypothetical woman who's taking, you know, one pump, roughly a milligram per day of estrogen gel as a thing. And then she's taking blocks of uterogastan, 200 milligrams, two soft capsules at night for,

56:43
14 days or 12 days. And, but I say, do it on the calendar month if you're not having a bleed. So you just remember when to take it anyway, right? But if she's going along like this and whether she's having a bleed or not, I'm not gonna be that fussed. Unless she comes to me and say, look, I'm getting more symptoms, then I will, then I would say, okay, we increase the estrogen. But so yeah, the cyclical progesterone, I think is a good call because it just feels more natural, doesn't it anyway? Well, that's what the body does. But the only thing is that if you've been on the...

57:10
for one for five years like I was, and actually it's recommended that now you do take the continuous progesterone. For breast cancer protection. Yes, because it's meant to be slightly low, I mean, still very low, but it's a slightly lower risk. That's the advice from the British Menopause Society. So I'm just literally quoting what's being said there. That does speak to the fact that potentially, I mean, this is Gerlin believes, I mean, I guess future research will bear this out, but that just to be clear.

57:37
body identical progesterone that we're talking about now seems to slightly decrease the risk of breast cancer. Progestins, all progestins slightly increase it. And again, I emphasize on the slightly because I have women, it's so women have had enough of being frightened of all of this. But, but so that's a key difference. But back to testosterone, the reason I got onto it, so I've sort of taken over the interview here, Mickey. That's great. Is because.

58:01
Yes. So testosterone is libido stimulating for sure. But I guess what I was trying to get at, there's other ways to increase your exposure, if you will, to androgens and dialing back the progesterone at times might be one way. I mean, another way, there's just other lifestyle things, increase your exposure to and to be clear, and I'm saying androgens slash testosterone kind of same thing. It doesn't so

58:26
In both men and women, androgens are on a, my understanding anyway, a slow steady decline through life. Androgens testosterone does not go, does not have a menopausal cliff, if you will. Like it, it, it is on a slow decline. It's actually, I found a little bit of research, which is quite intriguing that actually during the early years of perimenopause, the adrenal glands, it does actually like a slight tick, tick up in androgen production is temporary. And then it just resumes its slow decline, which kind of feels quite adaptive because

58:54
Obviously, androgens are the source of our estrogen. So that's quite an important thing that the body might do. And, you know, I think androgens are testosterone is interesting for women. Testosterone is a mood enhancer for women, especially at a certain dose. So almost anyone who takes a little bit of testosterone, I think arguably could get at least an initial kind of mood. That could be why it's become so popular in certain circles.

59:19
And we normally get a bit of angiogen testosterone surge just before ovulation, which I think is part of the pre-ovulatory kind of euphoria that we, and it's actually only a 40% increase, but we really feel it, right? Cause we don't have that much testosterone. So in terms of taking testosterone, I think it's reasonable, as you say, I agree, like for libido, if that's what someone wants to do, I think as a general rule, I would think always take it in combination with estrogen and progesterone so that...

59:47
because the problem with androgen excess, whether that's androgen excess of PCOS or polycystic ovary syndrome, or the relative androgen excess of paramanopause menopause. I talk about this in both my paramanopause book and my new book on metabolic health that's coming out. Women do enter what's called a relative androgen excess, which is really just because estrogen and progesterone have dropped away. Relatively speaking. Yes, and both estrogen and progesterone have anti-androgen effects.

01:00:15
via different mechanisms. But when androgens shine through too much in the female body, so we need a small, we need some, for bone density and muscle and mood and everything, so, and precursor to estrogen, so androgens are not bad. But androgen excess from any cause does promote insulin resistance in women. So androgen testosterone does cause weight gain in women.

01:00:40
Androgyl testosterone excess. And it's that waking around the middle that I just learned, I didn't know this, but the, you know, the visceral fat, the bad fat, the other, it's also, its other name is Android fat. So, um, that's in the name. Yeah, the clue is in the name. So I think if someone's really struggling with insulin resistance and they, in fact, you can have me for a future podcast where we'll talk about how to diagnose insulin resistance. Um,

01:01:02
they just need to be careful with testosterone. And I guess if it's a small dose, a woman appropriate dose. That's such an important point, just to jump in there about the parallel with PCOS, which is what we talk about, the insulin resistance. It's a syndrome, PCOS, that sounds like a syndrome, polycystic ovary syndrome. So that's really important. And also it goes back to this whole hype about HRT and testosterone. In the UK we had, as I say, this celebrity giving a series and making out the HRT.

01:01:31
every woman would be stupid not to and same for testosterone. And I've been really scared that I have seen women who have been given, you know, really high doses of testosterone. And yeah, not really scary. And I'm surprised, surprised not feeling great on it. So I think it's all about this migration and being aware and being cautious. Common sense, you start off with the lowest possible dose, you see how you go. And whatever just titrating according to the individual.

01:02:00
And also the other thing I want to say is that I know we're talking about hormones, which I love, by the way, and they see and things, but again, reminding everybody that, you know, the lifestyle is fundamental, because that's what hormones feed on. So not to just go diving in there with high levels of HRT and testosterone, because actually, like you said, Lara, you're already going to make the situation worse. Yeah. Yeah. And we will absolutely finish up with the lifestyle recommendations that I want both of you to address. A couple of

01:02:29
questions just from what you've shared. Nikki and Lara both you've sort of mentioned sort of treating the symptom, libido. What about blood levels of testosterone? Do they not even matter? For the British Menopause Society, it advises that you can do an initial starting level, probably what's called the FAI, the free androgen index, to take into account the bounding proteins. Yeah.

01:02:59
As with any of these hormones, it's not necessarily going to be, you're not going to base it on the absolute level. It's more on the symptoms, but nevertheless in testosterone, they do say it's useful as a baseline. So you can see because then that's the other because like libido is linked with so many other things. If actually you got a baseline and you know, it's not too bad. They're still saying they've got reduced libido. Actually, there is something else going on there or vice versa. It's very low. You give them some testosterone comes up, they still got a problem.

01:03:27
then again, it points out that there's something not quite fitting together to something else to look at. So that's the recommendation from them. To be honest, I don't do that so much, but it depends on the individual. What do you think, Lauren? Yeah, I agree. I'll just point out, I'll just get a little tiny nod before we move on to our other questions about DHEA, which is interesting. That was going to be my question about is it worth supplementing? Well, OK, tiny disclosure.

01:03:56
I am taking a little bit of DHEA lately just as for like energy and, you know, muscle building. And so that's another androgen. It was interesting because about 15 years ago it was kind of on the radar of researchers as a hormone that another androgen that does decline with age and just trying to work out, you know, what role that might play in helping older people, including women.

01:04:20
you know, with symptoms. So I think, I mean, I think it's quite an intriguing hormone. It's definitely not conclusive, like there's lots of conflicting opinions about it. And it does convert to estrogen. So there's that factor. I mean, what do you have any thoughts about DHA? I mean, as you say, it's in its sort of infancy. And it's certainly not like a standard HRT. It's like, oh, we'll give you DHA. And that's the same as giving you soap. We know that. But certainly, it's interesting to see for individuals, it may well help and certainly

01:04:50
actually it's a possibility for local um the pessaries because there's thing called intracrinology which is where this gets converted in the cells into estrogen so certainly that is accepted as it were you know you can prescribe although frankly i'm not sure personally i've never done that because i would just like well let's just take the estradiol pessary and be done with it but there is that possibility but it is certainly an intriguing thing and it's like watch this space for certain individuals it might be helpful

01:05:20
Especially for example, yeah, if whatever for a region, the sort of HRT, the standard HRT, you can call it that, isn't working for them or they want to try something that is an HRT, then that's certainly a possibility. But I think as you've said, Lara, it's down to the individual, but certainly it's an interesting one to watch, right?

01:05:39
I'll keep you posted. Yeah, because DHT is a precursor for testosterone as well, isn't it? Precursor to a lot of it. It's high in the cascades. I'm seeing the chart in my head. And I'll also just give an additional tick to vaginal oestrogen is a lifesaver. So I would just encourage anyone listening, do not be afraid of vaginal oestrogen. It's considered one of the most safe types of... Yeah, well, even women who've had breast cancer and can't take systemic HRT, they can take it. So if they can take it...

01:06:08
I think, again, why would you not? So recurrent UTIs, obviously dryness, libido to some extent, sheer ability to have sex can be improved by that. Other pelvic, yeah comfort and it also reduces the risk of UTIs. So I mean...

01:06:29
Obviously we've talked about all of the hormone side of things and we don't have a whole ton of time left and we could probably spend hours talking about lifestyle. But one of the questions was, if you had one recommendation, which I think has just left you, one recommendation for women in their 40s to be able to manage their perimenopausal symptoms with lifestyle, could you do it with just one recommendation? What's one thing that you would say? What's a...

01:06:58
What's the biggest dial movie you see in your clinic? Or let's say two, let's give two. I'm happy with two. Do you want to go first? Well, I would like to have three of course. Yeah, things always comes in threes and that's my little diagram. But if you really want to push me, I would say it would be the exercise and nutrition. I'm regrettably, I'm leaving out sleep, but anyway, but I think that would sort of follow in that case. So the exercise, if you're not already, then you know, regular exercise.

01:07:27
doesn't necessarily have to be going to the gym, but if you like doing that, fine, I don't, I hate it. So I could do ballet, but you know, whatever it is, some sort of movement, some sort of exercise that you enjoy that you will therefore continue and do on consistent level. And also generally trying to be active during the day. So it's not just the exercise, recent studies showing, of course, it's the exercise you do, intentional exercise, if I can call it that, right? I'm doing a ballet class, for example, but actually being sort of active in the day, you know,

01:07:57
walking to places using the stairs and lift all these little things and not sitting static too long. So exercise would definitely be my top one, but also the nutritionist thing was allowed too, is definitely it's a chance to not do anything drastic with your diet. There isn't a menopause diet right, it's just reviewing what you're doing already. Would you improve it? We can always improve and then tweak things and whatever. So those are my...

01:08:23
top two. What do you think? Can I actually, can I ask you, Nikki, what about the recommendation that all women who go through menopause must now do heavy strength training, six to eight reps in a gym, you must deadlift your way out of this? Well the thing is it's in combination with everything else. So if you just think, oh, I'm going to go and do this. And then miraculously, oh, you'll be amazing. If you're not backing it up with all the other things we've discussed, you know, the, the nutrition.

01:08:53
the other not just just strength training, although strength training, it is true to be fair strength training does become a priority. There are five different types of fitness, by the way, right? Okay, cardiovascular muscular strength, muscular endurance, flexibility and neuromuscular skills. So to say that out of five things, just one of those is going to be the savior. Obviously, you know, certainly it's got to have a place there. Okay.

01:09:20
But I think this can be off-putting for people like me, who I have to admit, I hate the gym, right? I just don't like it, you know, just no. So, you know, that could be a put-off. It's like I'm not even going to touch strength training because that's the only place of the gym. If you like the gym and you want to do that, brilliant, go for it. If you're not so sure like me, then, you know, make some attempt to do strength training of some sort, be it resistance band or Pilates or whatever is your level.

01:09:48
And don't ignore all the other aspects of your fitness just for one thing. Certainly it's an important element, but not the only thing. And in the context of all the other things about nutrition, except. Yeah, I love it. Well, so one thing in answer to the question that hopefully people understand, but I'll just state it, one of the main things that's happening with paramedic pause menopause, as I described in my book, is rewiring the brain. So a lot of it, a lot of the symptoms are neurological.

01:10:18
And so I would just point out, because I second my very number one, I have a number two, but number one is movement or exercise. Yeah. So we're all kind of on the same page on that, but for lots of reasons for metabolic health, but primarily, I would say for perimenopause for nervous system support. So the brain loves the body to move. Right. It's super interesting. The research around that, like it's actually just like a

01:10:43
It's a nervous system, it's a hormonal effect, the brain grows and changes, and it's already trying to change during paramedicine. And just clinically I can say as well, getting out, well I say get outside, because I like outside movement, but get outside and move, maybe get some outdoor light while you're at it. And it really is a game changer. That's where the rubber hits the road. People, if they can start moving in any way, and I shall just refer to a conversation we had yesterday, just briefly, for anyone to make two strict,

01:11:11
of a prescription for the kind of exercise, potentially for some people that can just be a deterrent from doing any. Exactly. Because if they think well, the only type worth doing is strength training, but for whatever combination of reasons, I don't want to do that. I guess I'll just give up. Yeah, exactly. Setting yourself up to fail. Yeah, just do the kind like so for you, it's dance for me, it's walking. I do. Yes, I have said I have taken on board some of the strength training.

01:11:39
research, I don't ignore that. I do try to do some body weight, you know, lunges and resistance bands. But the thing is, it goes down to that enjoyment. Because if you enjoy doing it, and you're looking forward to doing it, then number one, you say mental health, and the rewiring the brain, you're going to embrace it and look forward to it. I'm looking forward to my ballet class tomorrow. You know, actually, you're looking forward to doing it. And you will continue to do it. Yes. You know, even though I'm very old, I continue to do ballet. So, but so it's about consistency as well. It's not just a, you know, one hit wonder, you just go to the gym once and it's like, phew.

01:12:08
done that, I feel like I've done my duty, but I don't want to do any more. And there's a very interesting study on that topic from Australia. A couple of years old now, and it had split people into two groups. And to one group, this is not specifically perimenopause, menopause, but just in general terms on what you're saying about the mental health aspect of it and the knock-on effect, they split them into two groups to one they did prescribe exercise, you've got to do this stepping up on the box and then anyway, and to this group, you said, look,

01:12:38
here's some equipment or here's some options, you choose what you do in exercise, right? Whatever it is. And then they brought them all back together and they put on a buffet, lunch, whatever it was, right? And they didn't realize this was still part of the study, right? They said, oh, just take what you want. And the ones who've been prescribed, you must do this, you must do that, they were like, oh, thank God, I can choose what the hell I want. And they chose much more calorific, so-called unhealthy foods, fast foods type stuff. Whereas the others who had had this choice

01:13:08
I've got free will, I've got a choice, they're feeling better, they made healthier choices. So isn't that interesting? Don't you love that? The behaviour, the mental aspect is so important, something we overlook a lot. Yeah, I think in the exercise department as well, like a lot of people underestimate, to your point about movement, just the collecting steps, the way that we were talking about today, like, you know, just people think they have to go out and walk, like it's a power walk, and they must like get there, you know, but the central nervous system

01:13:38
the effect on the central nervous system of just that sort of gentle movement, just going outside, just literally moving, like, is I think really valuable because stress is the, you know, such a huge underlying influencing factor for... Should I say my number two? Yeah, yeah. This is an unpopular one. Oh, I know what it is. From clinical experience, yeah, you're just, you're bracing yourself. Yeah, it's alcohol. It is.

01:14:03
Well, have some alcohol. No, it's avoid alcohol during perimenopause. And I just, you know, there might be exceptions, but I've met hardly any. My experience clinically and with friends and with family, especially the later, the peak in what I say to my patients in the crosshairs of perimenopause, you know, when you're, the periods are starting to come further apart, night sweats are ramping up. That is just, I promise you, hand on heart. That is, if you could just.

01:14:31
say goodbye to alcohol for a while. Not to the point of rigidity. I mean, I guess if you wanna have a celebratory drink with your mother's birthday or whatever it is, fine. But like in general, no. And it's not then, cause you just asked me yesterday actually, cause like you've heard me say this before. And now of course I'm three or four years past my final period. So I graduated to menopause. And so you asked me, am I able to tolerate alcohol a bit better? Yes. I mean, I would say, I think.

01:14:58
It depends on the individual. Some people might get off alcohol and just never want to return. But I think I can say that at least for myself and my patients, you do reach the point in that more, deeper into the stable hormone state of menopause, post menopause, where the occasional drink is, doesn't disrupt the nervous system the way it does during paramenopause. And, but to be fair, alcohol is still a breast cancer risk and other negative things, but that's my, I mean, we have to sort of weigh that against.

01:15:28
the pleasure of sharing the occasional. But the thing is, I think, if I can agree with that, alcohol point is so important. I'm glad you brought that up because people think, oh, I'm feeling stressed and I'm going to relax with a drink. But actually, it disturbs your sleep. And guess what's happening during perimenopause? And you're right about the changing hormones. So maybe when things have stabilized. But again, one doesn't want to go overboard. But it's about this rigidity thing. We go back to that.

01:15:56
So it's not saying you have to be teetotal rigidly. Of course, because that would be imposing yourself like on a prescriptive exercise, the same thing. You know, for example, I will have a glass of champagne at Christmas. That's fine. That's fine if you want to, but not looking on it as a crutch that you think is going to help. And it might you might think it does help or temporarily numb things. But actually, overall, it's going to have a negative effect, not to mention that it's, you know, lots of calories as well, by the way. You see, so.

01:16:26
I wholeheartedly and I'm glad you brought that one up, agree with that. You know, that's just the moderation and just pulling back a little bit on it is really going to be helpful. I think, Lara, your point about the symptoms associated with perimenopause being exacerbated by alcohol and a lot of people don't give themselves the opportunity to experience what it's like not to drink. You know, and so sometimes they just need the...

01:16:54
look, if you could just go for eight weeks, let's just start with eight weeks and see what happens. You don't miss it. Yeah, that's the thing. I feel better, I feel clearer. Yeah, and then they're like, well, I will just have a glass, and they have a glass, and then you get a ramp up of those symptoms again. Sometimes it's just understanding how that looks for you. You know, I think that's an individual N equals one. Yeah, another angle on alcohol and paramedicosis, if people like different ways of thinking about things, is circadian rhythm. So our...

01:17:23
So circadian rhythm, I'm sure you've had podcasts, you can refer in the show notes to podcasts, interviews you've done on circadian rhythm, but it's hugely important for health and. It is affected by paramedic. So estrogen actually helps regulate the part of the brain that is in control of circadian rhythms. So I think that's part of what's going on in paramedic. And unfortunately, alcohol also disrupts circadian rhythm. So this can just result in, I think that's part of why the sleep disturbance.

01:17:51
part of the sleep disturbance. And this is why I'll just say, what really convinced me to seriously just take a solid break from alcohol for a few years, with the occasional exception, but it's not just that alcohol disrupts your sleep that night. It's that being off it seems to solidify sleep in a way, like sort of create a more robust circadian rhythm and a more reliable sleep ongoing, which I...

01:18:19
hadn't really understood at first. And I'm like, yeah. So that's a good point. Nice one. Yeah. Nice one, guys. Well, we better wrap this up. And just because, I mean, people will know where to find you, but let's just remind them of where to find both of you and also, of course, your books. Dr. Nikki, you first. So my book is called Fullbones Health and Human Performance. Potential, even.

01:18:45
And so that's available at the moment and I'm writing a new one to which Lara is contributing called The Myths of Menopause, which is going to be very exciting because other people do writing. So that's helpful. So those are my books. And my website is Nikki Kay Fitness. So people can find me there and also social media Dr. Nikki Kay. I post some stuff there occasionally. So, yeah.

01:19:10
Looking forward to it. And Nikki's book's great, I'll just say. It's just very different than other Hormone books. I love the way you sort of framed it in the three acts, or was it three or four acts? Yeah, that's your ballet. It is my ballet background and it won't surprise you to hear that also Mr. Menopause is also an accent scene as well, because it seems to follow anyway. Yeah, it's just a really nice, slightly more artistic way.

01:19:40
lots of science and also for everyone listening. I mean, I just want to say we were about to do a live event in Auckland and Mickey's coming along and we're going to continue the conversation we've just been having. We're going to continue with a live audience, which will be fun and everyone there will get a chance to win one of our books. Did you bring your book to giveaway? I didn't but I will arrange it. Oh, sorry. I was like lucky to get that. Right. And yeah, so I'm Lara Braden. My website is LaraBraden.com.

01:20:09
All my social media is at Laura Bryden. And I've got, well, I've got two and a half books. I've got three books. I've got a period repair manual for women of any age, a hormone repair manual for women over 40. And I'm just about to release a book on metabolic health, which was...

01:20:27
actually, Nikki helped me with that a little bit. So, yeah, so thank you very much for that. It's a big topic. It's a huge topic, and I'm looking forward to discussing it with you on another podcast, Clara. We'll circle back to that. Yeah, we will. Yeah, well, thank you so much, you guys. I really appreciate it.

01:20:56
I hope you really enjoyed that. I just loved being able to facilitate a conversation with two like absolute experts in the field of women's hormone health and they come at it from a very strong clinical and research background and I think this is something super critical when there are so many other people that you could be listening to out there. And next week on the show I have Jose Antonio who is an exercise physiology lecturer and

01:21:26
the sports nutrition space and I think you're really gonna love the conversation that he and I have. Until then though you can catch me over on Instagram, threads and Twitter @mikkiwilliden, Facebook @mikkiwillidennutrition or head to my website mikkiwilliden.com, book a one-on-one call with me. Alright team, you get the best week. See you later.