S4 E8: Perimenopause, Menopause and Migraine

A National Migraine Centre Heads Up Podcast transcript

Perimenopause, Menopause and Migraine

Series 4, episode 8

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[00:00:00] Did you know migraine can be called a spectrum condition because attacks range from mild and infrequent through moderate impact to severe and seemingly relentless. Understanding how migraine changes through life can help you manage your migraine.


[00:00:21] Welcome to the Heads Up podcast brought to you by the National Migraine Centre, the only UK charity treating migraine and headache.


Dr. Katy Munro [00:00:31] Welcome to this episode of Heads Up podcast. And today I’m delighted to be talking to Dr. Louise Newson, who is a GP and menopause expert and campaigner. Welcome, Louise. Thank you so much for agreeing to do this because I know you’re super busy.


Dr. Louise Newson [00:00:49] It’s great. Thank you for inviting me.


Dr. Katy Munro [00:00:51] Can you just give us a little bit of background on how you got to be a menopause campaigner?


Dr. Louise Newson [00:00:57] Yeah, it wasn’t on my plan, actually. So I’ve got a background of hospital medicine, so I spent a few years doing different hospital specialities and then I decided to go into general practice, really because at the time, in the nineties, it was really hard to work part time. My husband’s a surgeon. We’d just got married and I thought, this is really not conducive to family life. So I decided to go into general practice, which I really, really enjoyed. But I was also very interested in education, not just for healthcare professionals, but for patients as well. So I worked part time as a GP for 15 years and I was a medical writer and I also did a lot of evidence based writing for healthcare professionals, but also for patients. So I had quite a portfolio career and I’ve always been interested in the menopause because when you help women who are menopausal, it’s really transformational medicine actually, because women tell you they feel better and that’s great, isn’t it? To be able to improve someone’s symptoms. But actually more importantly for me, I know that giving HRT reduces the risk of diseases, which we can talk about in a bit. So it’s sort of win win, but there was always a lot of opposition to what I did to the extent that I sometimes actually had stand up rows with some of my partners who said, ‘How dare you prescribe HRT? These women are going to just get breast cancer from what you’ve done’. And I said, ‘No, that’s not right. The evidence is not clear about that’. But they refuted the evidence. And then in 2015, the NICE menopause guidance, so NICE, as you know, is the National Institute of Health and Care Excellence, they produced their one and only menopause guidance in 2015. And it was really pivotal actually, for me, changing my career because I read it and it rubberstamped everything that I’d been saying for the last 20 years about menopause and how safe it is. And so I thought, right, I’m going to do more training, actually. And so I became a menopause specialist and I naively thought I could run a menopause clinic in primary care, because it’s a lot cheaper seeing people in primary care than the NHS paying for them, as you know, to go to secondary care and see a gynaecologist or a specialist. But there was no funding. I went to different CCGs, I went to different hospitals and they said, ‘No, no, menopause isn’t a priority’. Meanwhile some of my friends actually were telling me that they were getting all these symptoms and they were being given anti-depressants. And I thought, ‘What? That’s not a treatment’. And they said, ‘No, the doctor says HRT is too risky for me so I’ve been given these tablets called venlafaxine or citalopram’, and I said, ‘this is terrible’. So one of my mentors said, ‘well, just set up a clinic privately’. And I thought, I don’t really want to, but it was the only way I could help some of my friends. And I also then developed this website, MenopauseDoctor.co.uk, because I was really shocked at how little good quality evidence-based information there was for women. So I started writing all this information out. And then quite quickly in my clinic, I was seeing women who would travel, because it was pre-COVID times, they’d travel for sometimes 3/4/5/6 hours from Scotland, from Wales to the south coast, telling me how awful their symptoms were and how they’d had to give up their jobs and some of them, their partners had left them and I thought, goodness me, I’ve never seen people suffer like this in my general practice. I’d never let them. And I thought maybe this is just a few. And then it became busier and busier and busier. And I thought, this is- I can’t do this on my own and what can I do? So I sort of ended up, like you say, campaigning really, because I think it’s actually morally wrong that women aren’t allowed their own hormones back. And I think there is so much evidence to support the use of HRT and the minority of women still take it. And I’m not here to say every woman on the planet has to take HRT, but I am here saying that every woman should be able to make a choice that’s right for them, in all walks of medicine, but I think especially when it comes to hormone health. I’m sort of driven by the stories that I hear not just through my patients, but on social media and on different platforms. So, you know, it’s a very long answer sorry, Katy.


Dr. Katy Munro [00:05:05] That’s absolutely fine. And what strikes me from the story that you’re telling is that it’s actually very similar to my story of how I became a migraine specialist for all the same reasons. You know, the NHS provisions are overwhelmed or the education is not there. And the reason you and I have connected is because we’re both passionate about raising awareness of these conditions. And there’s so much overlap.


Dr. Louise Newson [00:05:27] Absolutely.


Dr. Katy Munro [00:05:28] So, so many of the people that I see in my migraine clinic are women who are in the perimenopause or menopause and I’m sure you see a lot of women in your clinic who are getting worsening migraine.


Dr. Louise Newson [00:05:40] We do! Yeah, absolutely. And it’s really interesting because I know when you told me about you developing migraines when you were in your forties, and I’ve been a migraine sufferer for many years, it’s hereditary- my mother, my grandmother and now my daughter has horrendous migraines, and it’s one of those things I’ve just sort of learnt to try and manage rather than it managing me. But actually when I was developing my Menopause Doctor website, I was really getting quite severe migraines. They were really severe and really crippling. And I thought it was because I was working too hard, because I was trying actually to work late into the night because I always work late at night. But I felt like I’d been drugged. I was incredibly tired and very irritable. And I kept saying to my husband, I feel dreadful. And he kept saying, ‘yeah, you look awful as well’. And I just was turning into something that I wasn’t and I didn’t understand what was happening to me. And actually my father died from a brain tumour when I was nine and he presented with a headache and everyone said to my mother, ‘Oh, he’s stressed, he’s tired’. And my mother said, ‘No, I think he’s got a brain tumour’. And they said, ‘Don’t be so dramatic’. And this was in the seventies, a long time ago, when brain scans weren’t as easily readily available. And she actually took him up to London for a scan because she was convinced that he had a brain tumour and indeed he did, and sadly he died. And so when I was getting these crippling headaches, I kept thinking, ‘Oh no, this is it. I’m the same age as my father was. I’m going to, you know…’, and it’s awful because but- even so, I had all these symptoms, my memory was really bad, I was really worried I was going to have to give up my job. And every night, I’m writing about symptoms of the perimenopause and menopause, and I didn’t identify myself as one of those women. And even- I remember going on a holiday and we only went away for three days and two and a half of those days, I was in bed with a migraine and I thought, ‘This is just awful’. And why didn’t I realise that it was me with my worsening hormones? And, as you know, perimenopause is terrible for migraines because you get these fluctuating levels of estrogen. And as you know, it’s more the change in estrogen that triggers a migraine rather than it being a steady state low or a steady state high, it’s this fluctuation. And we see it so often. And because I’m so interested in migraine as well as the menopause, I’ve read and read and read, but as you know, there’s very little good quality research in this area. So a lot of it is guesswork and a lot of it is only because I have now seen thousands of women who are perimenopausal and you learn through your patients, don’t you?


Dr. Katy Munro [00:08:13] Yes, definitely.


Dr. Louise Newson [00:08:14] That’s what you do. And the problem is, we can mention in a bit, is that HRT was only three letters. And often when you read about HRT in migraine, some of the work’s been done with older types of HRT which don’t equate to the newer types of HRT so it can be a minefield for healthcare professionals and really difficult actually for women to unpick what they can and can’t do with their hormones during this time.


Dr. Katy Munro [00:08:37] Yes, I think the fear and the myths about what’s safe and what’s not safe, again, overlap between our two specialisms, don’t they? So I know there are a lot of women who’ve been told, ‘Oh, you can’t take HRT because you have migraine’. And that’s very definitely not true. Just to clarify what we’re talking about, can you just define the perimenopause? Because I’ve mentioned to patients about it sometimes and they say, ‘what’s the perimenopause?’ They’ve heard of the menopause. So can you just say a couple of words about that?


Dr. Louise Newson [00:09:08] Really good question, because, we’re now, thankfully, talking more about the menopause. It’s still a taboo, but we are talking more. And as you know, if you break down the word menopause, meno is menstrual cycle, pause is stop. It’s a weird diagnosis because you actually have to have your period stop for a year before you can officially be called menopausal. But it doesn’t just happen overnight. Unless the woman has their ovaries removed, obviously, then she’ll be rendered menopausal straight away. But for most of us, our ovaries just reduce the way they work so the number of eggs reduces, the hormones associated reduce. And in this time where they reduce, people’s periods start to change either in nature or frequency, and they often start to experience menopausal symptoms. And this is called the perimenopause. So peri just means around the time of. But the time is very variable. So some women find these symptoms can last for a decade before their periods stop, but they come on very insidiously. Sometimes they come on every day. Sometimes it’s just a few days. Classically, they start a few days just before a period when hormone levels are naturally at their lowest. But symptoms such as the low mood, the anxiety, migraines, headaches, joint pains, often people don’t realise are related to their change in hormone levels and then they improve. So they think, ‘I’ve just had a bad day at work or maybe it’s because my children are stressing me’ or something else, so they don’t put two and two together. And you know, it can just be a gradual, gradual decline. And then sometimes people find their periods stop and their symptoms actually are better. So some people think that perimenopause is just trivial and the menopause is when the real symptoms happen. But I see a lot of women who are really crippled with their symptoms in their perimenopause, but we don’t know when it’s going to happen and there’s no test for it. We know that the average age, not that any woman’s average, but the average age of the menopause in the UK is 51. So many women in their forties will be perimenopausal. But we also know one in a hundred women under the age of 40 and one in a thousand under the age of 30 have an early menopause. So this means that there will be many women in their teens and their twenties who will be perimenopausal. And most of us, and you’re probably the same, Katy, I had no menopause training. I was never trained to ask any woman with any symptoms of migraine in their twenties, ‘What are your periods doing?’.


Dr. Katy Munro [00:11:27] Yeah.


Dr. Louise Newson [00:11:27] It just was not in our radar. And now lots of girls and women and young women have the implant for contraception or they have a mirena coil so they won’t have periods. So then how do you know if it’s their hormones? And this is where it’s really important for people to, you know, download our free app, called Balance, where people can monitor their symptoms and there’s a menopause symptom questionnaire. So just because it’s called menopause, it can still be the perimenopause. And if women are experiencing those symptoms, which are changing and worsening, then the first thing they need to exclude is their hormones. And like I say, there’s no test. So that’s really difficult to know. You can’t just do a blood test because the hormones are changing so much. So then sometimes we actually give the hormones and say, ‘Well, let’s just see what happens’. And if people improve, then you know what’s going on. And if they don’t, then you can stop them because it’s completely reversible. But we have to be primed as healthcare professionals, but we also have to be primed by our patients. So it’s a lot easier if the patients can do their homework, if you like, and say, ‘look, doctor or nurse or whoever they’re seeing, I think these symptoms are related to my hormones and I would really like to try hormones’. Because if we’re thinking about migraines, as you know, there’s lots of medication, thankfully, lots of choices for women and men. But actually, if I had a choice of taking some of these more heavy duty drugs or hormones, I would always go for hormones first because they’ll help with other things as well and our future health.


Dr. Katy Munro [00:12:58] Yes, absolutely. I agree. I think what I get asked quite a lot with women going through the perimenopause and menopause is, what about a blood test? ‘Should I ask my GP for a blood test?’ You know, and because of the fluctuating nature of the perimenopause, blood tests are really not particularly helpful. It’s really more about the symptoms, isn’t it?


Dr. Louise Newson [00:13:19] Absolutely. And so we work out of the NICE guidance, obviously, and they’re very clear that if a woman is over 45, there’s very little point in doing blood tests. If they’re between 40 and 45, they say they may be helpful. If they’re under 40, they actually suggest that we should do this hormone called FSH, follicle-stimulating hormone. But to be honest, in practice, if I don’t do it, I’ve stopped doing it for any age because it fluctuates so much. And I’ve seen women with normal levels and then a month later, high levels. And so what’s the point of delaying? And in medicine we’re always taught only do a test if it’s going to change your management. So there’s no point doing a blood test. And I’ve also seen a lot of women have had normal levels and just been told it can no way be your hormones. Of course, when our hormones fluctuate so much and as you know, a lot of women experience symptoms such as night sweats or very crippling anxiety at 3:00 in the morning. Well, at 3:00 in the morning, their estrogen level will be very low then. But at 10:00 in the morning they might feel fine and that might be when their blood test is done. So actually an estrogen level might be more useful. But again, it’s not diagnostic. If I have a low estrogen level, it doesn’t mean it’s caused my migraines, for example. And if I have a normal level, it still doesn’t- so it’s not helping. And we know actually- it’s staggering- we know over £9 million a year is spent on inappropriate hormone blood tests. And I’ve already said that the NHS doesn’t have any money for menopause care. £9 million would pay quite a lot. It would go a long way for menopause care. So we need to sort of think. And I think for women it shouldn’t be used as a delay for treatment. So if they’re offered a blood test, they should really say, ‘well, why? How is it going to change?’ And if it’s not going to change, they should say, ‘well, can I start HRT in this consultation actually?’, because I think that’s important.


Dr. Katy Munro [00:15:14] The other question I think people often ask is, ‘well, aren’t I too young?’ Is there an age that you should be starting or on the other end of the scale, is it too late?


Dr. Louise Newson [00:15:25] No one’s too young at all. My youngest patient’s 14, actually. She had one natural period and then didn’t have any more. And my oldest patient actually started HRT when she was 91. She’d read about everything and decided for her 91st birthday present, she would treat herself to a consultation.


Dr. Katy Munro [00:15:44] That’s amazing.


Dr. Louise Newson [00:15:45] And we know even lower doses of estrogen can help with bones and we know how common osteoporosis is in women. And so when I was saying about how hormones can help with diseases, osteoporosis- it can definitely help strengthen bones. It can also help reduce risk of heart disease, diabetes and dementia as well. So there’s no reason why women are certainly too young. No one is too young for hormones. Older people, there’s always been this confusion because the guidelines say the maximum benefit is starting HRT within ten years of the menopause. And this is based on the big study, the WHI study, the Women’s Health Initiative study, because they found that women actually had worsening heart disease if they started it in their sixties. But we have to remember that the women who they started HRT on were women who had had heart disease already. And so they had diseases in their arteries, but they also gave a tablet estrogen with a very synthetic progesterone. And we know tablet estrogen has risks of clot and a synthetic progesterone has risks of clot but also risk of heart disease itself. Yeah, so that’s what I was saying at the beginning. I would never give that type of HRT to older women. But now we’ve got these body identical hormones. So basically they look exactly the same as the hormones we produce ourselves and the estrogen is given through the skin. So it means it goes straight through into the bloodstream. So it bypasses our liver which produces clotting factors. So this means there’s no risk of clot, there’s no risk of stroke, there’s no risk of heart disease. And also with the natural body identical progesterone, there’s no risk of heart disease or clot with those that there is with the synthetic. And this is also really important when we think about migraines, because most of us have been told you can’t have any hormones when you have migraine because there’s a very small risk of stroke with a tablet estrogen and all types of combined contraceptive pill, as you know, contain an older type of progesterone. So it’s a double whammy you really should try and avoid, especially if you have aura with a migraine, the oral contraceptive pill. But this isn’t the same for all types of HRT. You shouldn’t have the tablet combination HRT or any tablet estrogen because of this small risk of clot and stroke. However, through the skin as a patch, a gel or a spray with the natural progesterone is absolutely fine for women with migraines.


Dr. Katy Munro [00:18:18] And yes, I would agree.


Dr. Louise Newson [00:18:21] You have a factsheet about it on the Menopause Doctor website and also on the Balance app, because, as you know, if you look in the insert, if women get their estrogen as a patch, gel or spray it will say risks with it and the risk are wrong. So it can be very confusing and very confusing for healthcare professionals if they don’t know as well.


Dr. Katy Munro [00:18:42] Is that because pharmaceutical companies are playing it safe, do you think?


Dr. Louise Newson [00:18:47] It’s all due to the MHRA, so the Medicines Health Regulatory Authority have not updated their- to be in line with the evidence. And I’ve been challenging them for the last three years and they said, yes, we’re looking at it, we’re going to update it.


Dr. Katy Munro [00:18:59] But things move slowly in those kind of fields, don’t they?


Dr. Louise Newson [00:19:03] And it’s a real stumbling block for people because also that information is linked to our computers. So if we prescribe through our computer system, it will come up as a warning.


Dr. Katy Munro [00:19:13] Yes.


Dr. Louise Newson [00:19:14] So if I’m prescribing for someone who’s been coded as migraine, it will come up with a warning risk of stroke. And I’ll think, ‘oh, my goodness, this sounds very dangerous. I’ll give them an antidepressant instead’.


Dr. Katy Munro [00:19:23] Yes. Yeah.


Dr. Louise Newson [00:19:24] And so you can see why people are scared. And I’m working now as an adviser for NHS England. I’m part of their national menopause programme and it’s one of the key things that we are trying to address because it’s really important.


Dr. Katy Munro [00:19:36] That’s really good to hear.


Dr. Louise Newson [00:19:39] You know, people get very scared with the way medicines are labelled and the indications and we also prescribe quite a lot of testosterone, which is another female hormone, which probably helps with migraine a bit. There’s been very little research, but any research looks probably positive towards migraine. But we don’t have it licensed. So a lot of people say, ‘Well, off licence must be really scary and we shouldn’t do it’. But actually it’s a regulated product. And then I think, well, actually a lot of things that we give for women with migraine are not licensed for that use but-


Dr. Katy Munro [00:20:15] Yeah, that’s very true.


Dr. Louise Newson [00:20:16] But they’re regulated products so it’s fine. So, you know, even doctors, when they say, ‘well, you’re using a higher dose’. So actually, when you look at the licensing for HRT, it should be all for post-menopausal women. So we shouldn’t even be giving it to perimenopausal women, that’s off-licence. But if we’ve got good evidence, then it’s absolutely fine as doctors. We can just work towards the evidence. And that’s what we do with migraine, as you know, don’t we? There’s medications like epilepsy medications we sometimes use. They’re not actually licensed for use in migraine, but they do work well for some people.


Dr. Katy Munro [00:20:49] Yes. That’s absolutely- yeah. That’s true. And so going back to what you were saying about the body identical hormones, I was reading your book, because both you and I have been very excited about our books that are coming out soon mine about migraine, yours about the menopause. And it was saying about the difference between body identical HRT and bioidentical products. And I’ve really got the strong sense of the warning that you are giving out about these bioidentical hormones, which are not good, by the sound of it?


Dr. Louise Newson [00:21:22] No, It’s quite scary, actually. And it is worth mentioning about them because it can cause quite a lot of confusion. And what happened was this study that I mentioned, this WHI, the Women’s Health Initiative study, came out in 2002, and it was wrongly reported to the media and to healthcare professionals saying that there was a risk of breast cancer with HRT. Actually, when they’ve looked at the evidence, there’s no statistically significant increased risk of breast cancer. And actually women who take estrogen on their own have a lower risk of breast cancer. But because everyone was very scared of HRT, some companies decided to make this compounded bioidentical HRT, which means it’s not licensed, but we know that’s not such a problem, but it’s not regulated. And not being regulated is a problem because it means you don’t know what it contains. And so they set up these compounding pharmacies, people prescribed them and give them and they’re eye-wateringly expensive. They often say, ‘we’ll match your hormones, we’ll do saliva, blood tests’. We already know that’s a waste of time. So these clinics have been set up all around the world, actually, and it’s a multi-billion dollar industry and it’s getting big over in the UK as well. So people go, they often have lozenges or creams of these potions- for want of a better word, and sometimes they will feel a bit better because they will have some estrogen in them. But it’s very hard to know exactly how they’re being absorbed, whether they’re being absorbed orally or through the skin, or whether there’s enough progesterone to protect the womb. And so all the regulatory menopause societies have all said that there’s no evidence to support their use at all, and they could potentially be dangerous. And we see women who come to the clinic who’ve been on them, and they often- when we do their blood tests, we find their estrogen levels are very low or their testosterone levels are very high, or they have bleeding and that they haven’t had enough progesterone. So it’s a real concern. So we’ve coined the term body identical hormones to try and differentiate. Some people call them regulated bioidentical hormones. So it can be quite difficult to know. Well, regulated means, obviously, it’s regulated. If it’s compounded, then it means that it’s not. But it still quite hard. But I think as a rule of thumb, if you’re spending a lot of money on your HRT, it won’t be regulated. So even privately, the body identical HRT that you can get privately is exactly the same as what you can get on the NHS for the estrogen and progesterone and it’s cheap. It’s not expensive even privately. So you should be really questioning it. The testosterone. The real problem with that is, it’s not licensed yet in the UK. So we use a regulated product that is licensed for women in Australia. So again, you just need to ask where it’s come from and if it’s expensive, it’s warning bells really. But you know, these people have got a lot of money and they spend a lot of money advertising. And so it all looks very lovely on their websites and their clinics, often, in very desirable areas of London. And women are desperate for help. I understand it. I absolutely understand it, if you can’t get it from anywhere else, then you don’t care what you spend because you want to feel better. You just have to be really careful.


Dr. Katy Munro [00:24:35] It is sounding as if a lot of the women that you come across are having a battle. They’re having a battle to find good information and fighting a battle to find a clinician who understands menopause and who takes it seriously and who will prescribe with a background of training. And I know that you’re doing training for GPs as part of your menopause charity, aren’t you?


Dr. Louise Newson [00:24:57] Yeah, so I set up a not for profit company a few years ago called Newson Health Research and Education and we developed an education programme for all health care professionals. And we did it remotely, actually. And it was sort of a stroke of genius, really, because we did it before COVID, even before we knew COVID was going to be a thing. But I did it actually, Katy because, I’m sure you’re the same, I’ve been to so many courses where I’ve taken a day off work. I’ve travelled, I’ve had my children looked after. I’ve sat in a too hot, too dark lecture theatre thinking, really, I’ve learnt nothing or I’ve learnt very little, but I’ve had to have this big day out and it’s probably not worth it. So I decided to put on lots of lectures that myself, some colleagues have done and get them videoed and then we also had a day of filming where we got actresses and we asked them to be different patients. So one is a lady who’s got migraine, so she comes in talking about her migraine and her perimenopause, and in 10 minutes- we time them so they’re only ten minute consultations, we prescribe and we advise and we give information. And so these can be watched by health care professionals. But we’ve also got questions before and after so we can assess knowledge. And then we’ve got links to all the relevant information. So the key guidelines, the key papers and also links to patient information as well throughout. And so we’ve done this so that people can just learn in the comfort of their own home and they can do as little or as much as they like.


Dr. Katy Munro [00:26:27] At their own pace.


Dr. Louise Newson [00:26:28] Yeah, that’s right. But when the charity, the menopause charity that I founded was launched a few months ago, I decided to give a free programme to every GP practice in the UK and we extended it to Southern Ireland as well, and we’ve had over 11,000 downloads.


Dr. Katy Munro [00:26:48] That’s fantastic.


Dr. Louise Newson [00:26:48] It shows that people really want to know, you know. There’s a lot of people out there criticising healthcare professionals and I think you don’t know what you don’t know because you’ve not being taught. And I look back and I must have missed the menopause and perimenopause in hundreds, if not thousands of people. And I feel really embarrassed about it because I didn’t think to ask the questions. You know, every woman I saw with a migraine, I shouldn’t have asked about their periods. Every woman with a urine infection, I should have asked if they’ve got any vaginal dryness. Every woman with joint pain, I should have asked about their periods. I didn’t because I didn’t know. So we need to change this narrative. And I think if we can get the women saying, ‘I think it’s my hormones’, and if we can get healthcare professionals have access to really easy, straightforward knowledge, but also the how to prescribe, because what I’m also hearing from a lot of healthcare professionals is, ‘oh yeah, well, I know how to diagnose now, but I don’t know how to prescribe’. And then you open the BNF, or you go and prescribe online and as I’ve already said, all these warnings appear, so then it’s quite scary.


Dr. Katy Munro [00:27:48] Very confusing, isn’t it. And I think as you said, you know, as general practitioners- you and I have both worked in that field, you do have to be prepared for anything to walk through the door. So it could be a septic toe or it could be a suicidal patient, or it could be somebody who’s got abdominal pain or migraine or menopausal symptoms and having your radar out and trying to sort out all of those things in 10 minutes. I feel great sympathy for overburdened GPs.


Dr. Louise Newson [00:28:19] It’s really hard but I also- my, sort of, pushback to some of this when people say to me, ‘Well, how do you expect everyone to know everything’ is that I cannot think of another condition that affects 51% of the public.


Dr. Katy Munro [00:28:30] Yes, absolutely.


Dr. Louise Newson [00:28:32] I think it’s inexcusable. If I said to you, ‘I’m a GP, but I know nothing about raised blood pressure, I forgot- I didn’t bother learning that bit, Katy. So if I have someone who’s got raised blood pressure, I’ll go and get another doctor to see them’. You’d think, ‘well, Louise, you’re not a very good GP actually’. Whereas, you know, it’s more common than that. And I think if we try and get menopause into every consultation, especially women in their 40s, we will reduce a lot of referrals. So all referrals for, you know, even headaches, all the scans that are being done for palpitations, all the heart tests that are being done for joint pains, all the X-rays and scans that are being done. We know that- we did a survey and around 10% of women have at least nine GP consultations just to get the diagnosis. So we’re saying, well, if they can do the diagnosis themselves or even reduce it to two consultations, that will free up 750,000 GP consultations in a year. Well, if I said to the chair of the Royal College of GPs, ‘I can save you three quarters of a million consultations at a time of real crisis out there for primary care’. Well, that’s going to be pivotal, so we need to think about how we can help and it will do. Because most of my patients I see never go back to their GP. They’re well, they’re feeling well. They’re feeling great. They go back once a year for a review, whereas before they tell me they’ve gone most weeks, or at least every month with all these different symptoms.


Dr. Katy Munro [00:30:03] Do you think- I mean, with migraine as well as with menopause, I think there’s been this sort of pervasive stigma about it. It’s a women’s condition. We know that three times as many women get migraine as men. Even though it’s very, very common. One in seven in the population globally get migraine. But I think it’s been almost dismissed in the same way as, ‘oh, it’s just the normal headaches or oh, everybody gets hot flushes’. There’s a certain dismissiveness about these conditions.


Dr. Louise Newson [00:30:33] And then you don’t- you feel embarrassed almost making a fuss. And I think- absolutely. And I think as I said to you before, I mean, your book on migraine is so brilliant. And my daughter has been taking photos and sending it to some of her friends and saying this is how bad it is for me. And she’s had some lovely messages saying, ‘I had no idea. I had no idea that’s why you slurred your words. I had no idea why you kept being dizzy. I had no idea why you missed so much school’. And it’s been really empowering for her to be able to admit how bad it is for her actually and how crippling it is and how terrible it is to have your life ruined by some symptoms. And then you transport that into the perimenopause and menopause. And it’s the same but worse actually because it’s more symptoms and you’re almost not allowed to talk about it because it’s a natural process for a lot of people. So how can we complain about something that future generations have been through? Well, for a start, they haven’t been through it for quite so long because they used to die earlier than us. But also we think about the health risks as well. So actually we should be looking even more at why we are suffering in this way? And certainly if you look at migraine, the number of people that can’t work or have to change their work or reduce their work is huge. If you look at the perimenopause or menopause, the number of people that have to reduce their work- we did a survey recently and we found that 50% of women had either given up their work or retired early as a direct consequence of their menopause symptoms. It’s huge.


Dr. Katy Munro [00:32:09] Yeah. And combining that with worsening migraine. Because I think I was reading a review by Professor Anne MacGregor and she was saying that it could be almost 30% of women actually get worsening migraines as they go into the perimenopause. So combining that with everything-


Dr. Louise Newson [00:32:27] I think it’s probably more, actually, and I think a lot of people don’t realise, like myself. Because I think a lot of people don’t recognise their symptoms. But, certainly this fluctuation, this change of hormones, especially in the perimenopause, you know, migraines can really, really be a lot worse, either more frequent or more severe or both. So double whammy. And so it’s a real warning sign actually. And sometimes people notice that they’re worse just before their periods, as I say, when the hormone levels decline. But sometimes it can be in the middle of their cycle, when they get a surge or it can be any time. So just because it’s not linked- you know, when women are younger, we spend a lot of time asking about periods and trying to track it. With migraines in the perimenopause, you there’s no way of knowing, really. You have to have this low index of suspicion. And certainly when I give HRT to women, I often suggest they have the estrogen patch because it gives them a constant amount of estrogen, because some of them are very sensitive to very small changes so even rubbing in the gel, they can get like a little peak and that can trigger. And then with the patches, again this is off-licence but you can cut the patches up. So if someone has really bad migraines, I’ll say to them, ‘cut your patch in a quarter and just use a quarter for a few weeks’.


Dr. Katy Munro [00:33:42] Yes.


Dr. Louise Newson [00:33:43] ‘And then a half and then gradually increase’. And sometimes, I know myself, if I don’t have enough estrogen it can- I have this sort of threshold and I’ve just got this low grade headache and sometimes especially when- I think I’m probably menopausal now, but I had a few years of certainly being perimenopausal and there are days that I just felt worse and I sort of experimented a bit, which you can do. That’s the beauty of hormones, because they’re changing all the time anyway. So even though I used patches, I used some gel as well. And so I’d sometimes try, thinking ‘I can’t have another day with a headache’, giving myself a bit of gel and then it’s gone. Oh, it’s amazing. It’s like a threshold you’ve got to get through. But what’s very easy is that a lot of women go, ‘Oh my God, it’s my hormones, I’m going to rip my patches off’ and they might feel better but they’re not getting the benefits of their HRT. So it’s being brave enough to know that nothing awful is going to happen. There isn’t sort of a magic amount or there’s not an excess that you can have or a dangerous amount.


Dr. Katy Munro [00:34:43] Yes. Yeah, I really hear that. And I think some women, you know, especially when women first go on to a patch in the perimenopause, they may be getting intermittent bleeding and worried that that’s a sign of something cancerous or- and then get scared and think, ‘oh, gosh, it doesn’t suit me and give up’. And I’m very conscious- in your book you mention about, you know, just just keep going, carry on, keep trying to find the right recipe for you.


Dr. Louise Newson [00:35:10] Definitely, you know, we use a natural progesterone and a lot of women find that helps with migraines, but some people find it triggers migraines as well, and you don’t know until you try. And so sometimes if people don’t know, I give the estrogen first just for a few weeks and then add in the progesterone. So you’ve got the two different things. And then you can use the progesterone vaginally rather than orally, because then it gets absorbed less into the body. So if women are feeling that their HRT is triggering their migraines, don’t just give up. And I’ve seen quite a few women now who have been to various menopause specialists and been told, ‘well, we’ve tried everything’ and I don’t give up easily, so actually you take it back. Sometimes these women have needed very high levels, actually, sometimes two or three patches, which again is above licence, but that’s what they’ve needed and you can measure their estrogen levels, make sure they’re not too high and they’ve come out the other side of this threshold, if you like. And then, like I said before, testosterone can make a difference. But also, it’s looking at other things as well. And people often neglect themselves during the perimenopause because they feel so bad. So they forget taking supplements, they forget exercise, they forget sleep, they forget routines. It’s just- everything is a nightmare and their sleep is often really, really adversely affected. So the hormones can help actually improve your lifestyle, because if you’re feeling better, you can sleep better, you can exercise better, you can eat better. Also, people get a lot of sugar cravings when their estrogen levels very low. And as you know, if you just reach for Mars bar, if you’re a migraine sufferer, it’s probably going to trigger a migraine. But if you’re feeling really awful, you’d think at that time, I don’t care because I just want to feel better and your body is telling you you need sugar and you don’t care that you’ve not exercised and all these things that it’s really hard to explain unless you’ve been there. But then, you know that the next day is going to be awful because you’ll get a migraine.


Dr. Katy Munro [00:37:05] Yes. Yeah.


Dr. Louise Newson [00:37:07] You just think, ‘ugh’, and it’s this downward spiral, really. So I think it’s really important, and I know you’re the same, as a healthcare professional. We look at the whole big picture.


Dr. Katy Munro [00:37:17] Absolutely.


Dr. Louise Newson [00:37:18] There’s been a study of 3000 women and we found that only 24% had been given any information about health and their lifestyle. And I think, actually, that’s inexcusable because the three questions asking, ‘do you drink? Do you smoke? Do you exercise?’ Takes what? About 5 to 10 seconds, doesn’t it? And I think it’s really important that we look at that as well, especially with migraine. And, you know, I was staying away recently and lots of people were coming to the table, having gone for a jog in the morning before breakfast. And I said to my husband, ‘God, I’d love to be able to do that’. He said, ‘Well, yeah, that’s because you don’t run very well’. And I said, ‘No, I cannot exercise unless I eat. I’ll get migraine’. He said, ‘Oh, your migraines ruin your life’. And they do but, you know, it’s really hard, isn’t it? And that individualisation, you know, not everyone with migraine will have that. Some people will be able to exercise. Of course they will. But others we just have to work it out.


Dr. Katy Munro [00:38:14] Yeah.


Dr. Louise Newson [00:38:14] You might find that you’re in this lovely routine with your migraine and then perimenopause comes and everything is just like…


Dr. Katy Munro [00:38:20] It changes.


Dr. Louise Newson [00:38:21] ‘Oh, I thought I got there’. And so that’s why it’s really important to invest in a bit of time working out this- so reading your book, reading my book, working out this overlap and making it right for you and not comparing yourself to other people because I think that can be really- you can feel a real failure if you compare yourself to others and it’s not working.


Dr. Katy Munro [00:38:41] I think you’re right. And I think migraine changes throughout people’s lives and they often don’t realise that. So sometimes that getting migraine more because they’re into the perimenopause, but sometimes the symptoms change and they may get more dizziness. And we find that a lot of perimenopausal women get more vertigo and dizziness in their attacks and maybe less of the aura or maybe less of the vomiting. And so it is a lifelong condition. And the impact of the perimenopause on migraine is really huge. So once somebody is settled and happy on their HRT, again, I’ve been asked, ‘oh, when should I come off it?’ And I was already aware, but your book confirmed it, that you don’t have to come off it. As long as everything else is fine there’s no other reasons why you should come off it.


Dr. Louise Newson [00:39:29] It is very interesting. So, you know, estrogen and testosterone and progesterone, they’re just hormones. So if I said to you, ‘oh, you’ve got an underactive thyroid gland, you need thyroxine’, which is just another hormone and you said to me, ‘well, when do I need to come off it?’ Well, you probably wouldn’t even ask me because you’d say, ‘well I need that as long as I live, because it’s just replacing the hormone that I’ve not got.’ And because people are so scared about HRT, they think the longer that they’re on it, the more likely they’re going to get breast cancer. But actually, when you look at this evidence, I’ve already said, there’s no study that shows there is statistically significant increase. The studies that show there is an increase have usually been with the older progesterone. But even if you look at the worst case scenario, it’s always best, isn’t it, in medicine? I always think what’s the worst thing that’s going to happen to patients if I do this? So if I give women the older type of HRT, which I don’t give anyway, but if I did, what would be the worst case scenario? Well, the worst case, looking at the worst study, show that there might be a very small increased risk of breast cancer incidence. That increased risk actually is less than the increased risk a woman has if she’s overweight, if she drinks alcohol, or if she does no exercise, because they are risk factors for breast cancer. So actually, we know women who take HRT often drink less alcohol because they feel better, they often exercise more and they often lose weight. So actually their overall risk is probably reducing. But then we look at what are the benefits of taking HRT for a long term? Well, the benefits are they’ve got a lower risk of dying from breast cancer, whatever type of HRT they take so that’s good. But also a lower risk of dying from all causes and a lower risk of all these diseases so heart disease, osteoporosis, dementia that I mentioned before. So it’s sort of win win really. So why on earth would you stop taking something that works so well for you? And I’ve reflected about it quite a lot recently because I’ve been thinking about all the people, when I’ve been to talks, that have been telling me how they take women off HRT when they’re 60 or when they’re 70 or at a certain time. And they often say this flippant remark, but women hate me for it or women get really cross that because they feel so good on their hormones. And it’s almost like they feel it’s wrong that we feel so good taking HRT.


Dr. Katy Munro [00:41:47] Yes!


Dr. Louise Newson [00:41:48] It’s just the weirdest thing ever actually. I was doing a talk a few years ago and I was very nervous, because it was in front of a gynaecologist and someone very high up from the Royal College of GPs, and I was giving a talk, just some myths about HRT. And one of the myths was that you have to stop it after a certain length of time. And afterwards the chair from the Royal College of GPs and this gynaecologist said, ‘Oh no, Louise, I always stop people at the age of 70, there’s no need and, and actually they won’t thank you for it, but in the long term it’s better’. And I said, ‘I cannot understand why you do this? Why do you choose the age of 70? What magically happens to them at 70?’ They said, ‘well, I don’t know, but we’ve just always done it. That’s always been the rule.’


Dr. Katy Munro [00:42:28] Yeah.


Dr. Louise Newson [00:42:29] It doesn’t make sense. And actually, I’ve always been taught you listen to patients as well. And it’s not like they’re taking, you know, heroin or something. It’s actually just their own hormone and it’s the same if you stopped thyroxine in someone who needed it. They would feel dreadful as well.


Dr. Katy Munro [00:42:45] Yes, of course.


Dr. Louise Newson [00:42:47] So why would we want our patients to feel dreadful? It doesn’t make sense.


Dr. Katy Munro [00:42:49] I’m also very aware that, you know, osteoporosis is such a major thing for women as we get older. If you haven’t had any HRT or haven’t had any awareness of whether or not you’re getting osteoporosis, which is that insidious condition that creeps up on women and they don’t even know until they fall over and break a wrist or break a hip or collapse of vertebrae. And so, you know, having HRT, which we know is really good to prevent osteoporosis, is preventing all sorts of other damage and disability in the future.


Dr. Louise Newson [00:43:21] Yeah, absolutely. I mean, we know around one in two women over the age of 50 develop osteoporosis. One in three will have a osteoporotic hip fracture and that costs the NHS £3 billion a year. So and we also know the mortality, so the death rate, after a hip fracture is about 20% in the first year for these people, it really can affect them. You know, they have to go to hospital. Their mobility goes. They can get chest infections after the surgery, all sorts of things. And none of us want osteoporosis. But actually it’s never really spoken about because it’s a bit of a sort of silent disease. We don’t know it until we’ve got it. Sometimes it’s too late. One of my patients told me recently that her mother tripped down the stairs. She was carrying a bowl of washing and she just lost her footing on the stairs and, sadly, she broke her neck and became paralysed for her neck downwards. And she broke her neck because she had osteoporosis and it just crumbled on the floor. And I mean, that’s very dramatic. But there’s a lot of- we’ve all heard of incidents where people don’t know. So anything that helps protect our bones is good. And certainly vitamin D, exercise but estrogen is the best treatment for increasing bone strength.


Dr. Katy Munro [00:44:32] So going back to what you were saying about lifestyle, and I was really pleased to hear all of those things because I’m always banging on about lifestyle in migraine prevention. But one of the things people ask about is, what should I eat? And I’m aware about these sort of soya isoflavones and menopausal loaves and things like that. Do you think people have to go searching for menopause food?


Dr. Louise Newson [00:44:57] No, it’s a bit like diabetes foods, isn’t it? I always say to patients with diabetes, if it’s got diabetes on the label, ignore it.


Dr. Katy Munro [00:45:04] Yes, I say that to.


Dr. Louise Newson [00:45:08] And it’s the same with menopause, even supplements anything with menopause on, forget it, because it’s a marketing ploy. These isoflavones or phytoestrogens, they can stimulate the estrogen receptor. So some people think that they’re good if they don’t want to take or can’t take HRT. Well, we haven’t got good quality research in how they work, how they stimulate the estrogen. And my thoughts are that if they’re good enough to really make a difference, so to improve your future health with the heart disease prevention, osteoporosis prevention and so forth, well, if they’re good enough for that, then you need to have progesterone to protect the lining of your womb, if you’ve got a womb. So you shouldn’t be having unopposed estrogen and you shouldn’t take estrogen without some sort of monitoring or someone advising you, but we know they’re not that strong, so what’s the point of taking them? You might as well just take a blue smartie as a placebo. I just feel like you either take HRT or you don’t, but you don’t do this halfway house because it doesn’t make sense. Some of the other supplements, again, there’s not good quality evidence. And so I think you should be really looking at your diet is crucial. We should be looking at gut health, again, crucial. Everyone should be taking vitamin D, men, women and children for their bones. And then, you know, sometimes people do take a probiotic, but again, it has to be a good quality one. It can’t be just- some of the ones you buy are terrible. Magnesium supplements I think can be good especially for migraine.


Dr. Katy Munro [00:46:36] Yeah.


Dr. Louise Newson [00:46:36] But we know that they can help with hundreds of different cell processes so they can sometimes help with heart health and brain health and joint health. So as you know, we can’t measure magnesium levels. So I think some people do take it. Some people take a good quality fish oil as well, which again, looking at heart health as well. And we’ve got some evidence, haven’t we, about migraine as well.


Dr. Katy Munro [00:47:00] Yeah.


Dr. Louise Newson [00:47:01] Some of these things can be beneficial. You just have to be careful because sometimes they’re very expensive. So I think if I had a choice of buying a supplement or eating a really good diet, I would prefer the diet. But it’s just being mindful and trying to get the right advice from someone who understands the difference between different supplements because the more expensive ones and not necessarily the better ones.


Dr. Katy Munro [00:47:24] No, again, I completely agree. And a lot of the things that you have spoken about are exactly what we’re saying for migraine. Omega three, magnesium and interestingly, the blood tests, sometimes people do find that their GP send off a magnesium blood test and then it comes back normal and they go, ‘I don’t need it’. But of course that tests the extracellular magnesium, not the intracellular magnesium, which is where the deficiency lies. And there isn’t a blood test on the NHS for that, so not worth chasing that. So there are some women who genuinely cannot take estrogen because they may have estrogen dependent breast cancer and they’ve been told that they can’t take it for whatever reason. And there are alternatives, aren’t there? I’m aware of tibolone and then things like venlafaxine and citalopram have been useful for preventing hot flushes. Any comments about those?


Dr. Louise Newson [00:48:14] Yeah. Well the first comment is there’s actually no evidence that women who have had an estrogen receptor positive cancer, which are mainly breast cancers, can’t take HRT. And we’ve all been grown up really saying that estrogen is, sort of, causes these cancers or it’s an estrogen fuelled or estrogen driven breast cancer. Well, all it means is it’s got estrogen receptors in it, but we have estrogen receptors all over our body. So you know, if I had a cancer in my leg and had it removed, it would have estrogen receptors in it because that’s what happens. We’ve got estrogen receptors in every single cell but it doesn’t mean that estrogen has caused it. And so we don’t know that. What some people think is that people who have a cancer already, the estrogen might make it grow a bit more but it doesn’t initiate, it doesn’t cause it.


Dr. Katy Munro [00:49:08] Right.


Dr. Louise Newson [00:49:08] That’s quite important to realise that. And then if you look at the research, actually, there are more studies showing that estrogen is beneficial for prognosis for women who have had estrogen receptor positive cancers. But most of these studies were very small, they weren’t done particularly well. They also had been given progesterone with them and we know progesterone might be the baddie more than the estrogen. But also they were stopped early because everyone was so scared of HRT in general. So, we haven’t got good results. What we do know actually is before tamoxifen came out, that estrogen used to be given as a treatment for breast cancer, so estrogen can actually induce something called apoptosis, which is programmed cell death. So it’s very complicated.


Dr. Katy Munro [00:49:53] Yeah.


Dr. Louise Newson [00:49:54] And when women, certainly, who’ve had breast cancer, they often live for many, many years and their life expectancy is so much better than it used to be, which is fantastic. But actually that means that they’ll be menopausal for many years. That also means that most women who’ve had breast cancer die from heart disease and dementia and not from their breast cancer. And I’ve already said HRT reduces the risk of these diseases. So we see a lot of women actually and talk to a lot of women who are crippled with their symptoms. They might have tried alternatives that often don’t work or they might just work with the hot flushes and not some of their other symptoms and they really want HRT. And how can I say, ‘well, no, you can’t’, because there isn’t actually evidence to say no you can’t.


Dr. Katy Munro [00:50:38] That’s really interesting and that will be news to a lot of women, I’m sure.


Dr. Louise Newson [00:50:42] Yeah. So I’ve written a booklet which is under the resources section of my Menopause Doctor website, and it’s all for women who’ve had breast cancer. And it was probably one of the hardest things I’ve written actually. And we actually wrote it with one of the doctors that works for me who’s had breast cancer herself. And we’ve involved a couple of patients who’ve had breast cancer for their feelings about it as well. And some women who have localised symptoms so vaginal dryness, soreness, urinary symptoms, all women who’ve had breast cancer can use vaginal oestrogen because that doesn’t get absorbed into the body. And then some women may choose to take HRT and also look at other, you know, other lifestyle and also alternatives. So there’s never a never in medicine. I’m not here to say that every woman who’s had breast cancer should take HRT, but I’m saying that certainly the longer it is since your diagnosis, the more likely it is that you should consider it for the other benefits. But it’s an individualised personal choice. I’ve got some podcasts with patients and oncologists talking about it as well. Tibolone is a sort of combination synthetic HRT, which does contain a bit of estrogen and people thought it would be a good alternative when it came out. But actually it’s oral. So there’s a small clot risk, it’s very synthetic, you can’t tailor the dose. So I would not bother with tibolone at all. The antidepressants like venlafaxine can be used to help the hot flushes associated with the perimenopause and menopause and they sometimes help, but as you know, we’re sometimes limited by side effects. They don’t help with a low mood. Unless someone’s got clinical depression they won’t help with that. So we shouldn’t be reaching for them first line, really.


Dr. Katy Munro [00:52:22] They can be useful as migraine preventers, interestingly as well. So yeah, it’s worth thinking. But yeah, not every antidepressant has any evidence of benefit for migraine prevention. But venlafaxine is one of the ones that has a little bit of evidence. I think, both you and I would agree, we need more research into both of these areas, don’t we? Really? We need good quality research.


Dr. Louise Newson [00:52:43] Absolutely. Yeah, I would love to do more research or some good quality research looking at migraine. And, you know, the most recent study that I read just showed how migraine incidence increased during the perimenopause and menopause, well you don’t need to do a study to see that.


Dr. Katy Munro [00:52:57] Yes.


Dr. Louise Newson [00:52:58] What we want to know is, you know, what’s the best regime? And what helps the most? Because I think it’s such a bad time for women and there are ways of certainly helping.


Dr. Katy Munro [00:53:12] Yeah, absolutely. And so your book, Preparing for the Perimenopause and Menopause is out on the same day as my book, which is about Managing Your Migraine, on August 26th. Do you want to just tell us about the book and what people should be looking for when they buy your book?


Dr. Louise Newson [00:53:30] Yeah, well, I wrote it really because I just wanted an easy guide, really, that, again, is evidence-based. I have got another book, the Haynes Menopause Manual, but this is slightly different. So I managed to get perimenopause in the title which the publishers didn’t want because they thought it would be too long. But I think it’s very important that people read. We’ve used a lot of my patients or other women’s stories as well, just to try and bring it a bit more real life. And we focussed a bit more on some other people who maybe feel a bit more excluded and neglected. So especially younger women and we’ve got a little bit about women who’ve had cancer as well, not just breast cancer but other cancers, talk a bit about HIV, talk a bit about COVID in there as well. So we’ve sort of brought it- I mean, as you know, it’s so hard, isn’t it, writing a book.


Dr. Katy Munro [00:54:21] Yes.


Dr. Louise Newson [00:54:21] You’ve put it together and then I can’t bear to look at it, actually, because I keep thinking there’s things that I’ve missed.


Dr. Katy Munro [00:54:28] You immediately think, ‘oh, I want to put this in. I wish I’d mentioned that’. But having read it personally, I think it’s a really good comprehensive summary and I would urge not just women who are coming to the perimenopause, but women who’ve been through the menopause and haven’t been brave or, you know, thought that they shouldn’t have HRT should be reading it. And also GPs, I think, you know, as a GP myself, I learned a lot from reading it. It’s excellent.


Dr. Louise Newson [00:54:54] Great. Good.


Dr. Katy Munro [00:54:54] Yeah, really excellent. And anything else you would like to highlight? So you said the Balance app. We need to try and get people to download that and track their-


Dr. Louise Newson [00:55:06] It’s a free app that anyone can download through the App Store or Google Play. We’ve had nearly 300,000 downloads, which is really exciting. And people can monitor their symptoms, they can track periods if they’re having them. They can create a health report which can be downloaded and start as their consultation, really, for their GP or healthcare professionals. So yes, there’s that. There’s the menopause charity, which is really going to work to try and create a helpline so people can really speak to someone who understands and listens.


Dr. Katy Munro [00:55:41] Excellent.


Dr. Louise Newson [00:55:42] We’re trying desperately to fundraise for that because it’s a very new charity. And then we’re doing- working more for education. And like I say, I’m working closely with NHS England who have agreed that menopause care needs improving. So I’m hoping in the next year, there’s going to be some big changes. So I feel things are improving and I think we can only do more by working together and making a bigger noise really.


Dr. Katy Munro [00:56:10] So I was very interested in the- I know there was a TV programme on Channel 4 that you did recently with Davina McCall called Sex Myths and the Menopause. And I think anything we can do like that, you know, to recommend people to watch things like that. Get interested in finding out more. And one of the final chapters of your book, as one of my final chapters is, is about preparing for your appointment with your GP. And I think arming yourself with the information and being very clear that you know what you’re talking about, you are the patient expert yourself.


Dr. Louise Newson [00:56:45] Yes, I think so. I think you have to really- I think doing background information, doing your homework is really important and it will help shape your consultation. And I think things will improve, I think there’s a lot of doctors, nurses, pharmacists, healthcare professionals who really want to help and really want to improve the sort of future for menopausal women. So for people not to be too disheartened and just keep trying really. It’s no different to migraine. Often, as you know, you have to see several doctors and sometimes it’s quite good actually, because you see different people and you can maybe get a bit from each of your consultations and it will help build on things. So, don’t see any consultations as a wasted consultation, but if you’re not getting the right help, go see someone else. And I’m sure you’d agree, Katy, I have no qualms if someone goes and see someone else at all. I think a lot of patients feel that the healthcare professional will be disappointed or sad or upset if they know they’ve seen someone else. And I never do because I think it’s really enriching sometimes to get other opinions.


Dr. Katy Munro [00:57:50] Oh, I completely agree. Yes. I think, you know, I really feel it is the patient who should be the leader. We’re doing a podcast episode about chronic or persistent pain and one of the mantras of somebody in that is, you know, put the patient in the driving seat. You should be the driver of your care and go and see who you need to get on your team, whoever that may be. Absolutely. Well, thank you so much, Louise. That’s been really interesting.


Dr. Louise Newson [00:58:20] Thank you so much for having me.


Dr. Katy Munro [00:58:20] Full of tips for people and good luck with the launch of the book.


Dr. Louise Newson [00:58:24] And to you! Look forward to seeing how they go and hopefully meeting you in real life.


Dr. Katy Munro [00:58:29] Maybe meeting in real-life! That would be really nice. Thank you.


Dr. Katy Munro [00:58:36] We’re now going to hear Marissa’s story and Swati talked to her about how HRT had really helped her migraines. Marissa had been found to have Factor V Leiden and was under the impression that it would be too risky for her to have HRT, especially if she had migraine as well. She had a consultation with my colleague and as you will hear, life has become a lot better for her since she started the HRT. Her migraine intensity and duration has reduced and she’s taking fewer migraine medication. She’s feeling much better with more energy and much better mood but let me let her tell you her story.


Swati [00:59:26] Hi, Marissa. Thank you for joining us on our podcast today. Could you start off with telling us a bit about your migraine journey?


Marissa [00:59:33] Hi, Swati. Yes, of course. I started getting migraines at university and didn’t really know how to deal with them. Actually, a lot of panic around how to treat them when I got them. And it wasn’t until many years later when I was pregnant that I realised that there was some sort of link between my migraines and my cycle because I had nine months of absolute bliss with no migraine whatsoever. OSo that for me was already a clue as to what kind of migraine I was now having and that obviously it was cyclical.


Swati [01:00:19] Okay. So did it get worse around your pregnancy time or it was better on pregnancy?


Marissa [01:00:26] So, sorry, yeah, when I was pregnant, I had no migraines. I actually rather looked forward to being pregnant second time round. And it was the same. It was absolutely fantastic not having a migraine. Just because my migraines really affected my quality of life. It would take up three or four days and I’d find it very difficult to try and treat and manage it. And as years went by, they seemed to actually be getting worse. And so now I’m in my mid-forties, I’m 47, and actually the migraine intensity has been getting worse. The frequency of the migraines. I seem to be getting them every three weeks, sometimes every two weeks. And it wasn’t actually until I listened to a podcast, to a Heads Up podcast that I thought why have I not thought of contacting the National Migraine Centre sooner? And I couldn’t believe that I could actually contact them without making an appointment with the GP first and then waiting for a referral. That it was a direct appointment with the National Migraine Centre. So that was, yeah. A moment that I really wish I’d done years ago actually.


Swati [01:01:48] I’m glad we could help anyhow, whether it was through our podcast or through our clinic services. I’m just gonna ask you, are you in a perimenopause or a menopausal phase right now?


Marissa [01:01:59] So it wasn’t even on my radar. I thought menopause happens to someone in their fifties. I thought it would announce its arrival with hot flushes and that it would all be very obvious. So if you’d asked me this six months ago, I would have said, ‘no, I’m neither’. I’m 47 and I’m way too young to even be thinking of perimenopause. So when I contacted the National Migraine Centre, they got me to download the app, and my appointment was in five months time. So every night I put in, you know, how the day had gone, the various questions that you need to answer. What have you eaten? What activities have you done? Are you having a period etc.? And it was only really when I had my appointment with the doctor and when she was looking at all the data that I’d put in over the last five months that she said to me, ‘I can tell you what kind of migraines you’re having, but are you also aware that you are perimenopausal?’.


Swati [01:03:16] Wow. Okay.


Marissa [01:03:19] And I was so relieved to hear that because I actually thought that I was going mad. My symptoms were so vague really. I wasn’t sleeping that well. I was just getting very irritable, quite moody. You know, symptoms that you really wouldn’t say are perimenopausal symptoms. Could be PMS or it could be lockdown. It could be a variety of reasons why I could be feeling like this or this could be happening. So that’s really when the penny dropped.


Swati [01:04:04] Okay. Did your migraines change during this phase that you saw? How did they change?


Marissa [01:04:11] So. Yes, it did. It was more frequent. I was getting much more frequent migraine attacks. They were happening every two, three weeks. The intensity was much more severe. But I just thought they’re just getting worse. I didn’t think it was because I was perimenopausal.


Swati [01:04:35] But the migraines and the way it sort of changed, did that have an impact, in general, on your life, your social life in general?


Marissa [01:04:43] You know, they’re so debilitating that you don’t want to go out. Well, actually, we weren’t going out. It was lockdown anyway.


Swati [01:04:57] Because of COVID.


Marissa [01:04:57] Exactly. But migraines really do take the joy out of life. You know, they can do. They just can completely- if you start making or changing your plans to work around your migraines, yeah, that would start happening. But yes, it was definitely the intensity and the frequency that was becoming more problematic. I was also just worried about, you know, how many migraine tablets I was taking. I just thought, this can’t be right. And surely, you know, there’s more that I could or can do possibly to help manage that better.


Swati [01:05:42] What treatment are you taking at the moment? Is there anything that’s working for you at the moment? Anything you’d like to share?


Marissa [01:05:48] So yeah. So from the appointments- during the appointments, she just said to me, right, we’ve got a treatment plan for you, so triptans and when to take them. I’m also very bad at- when the migraine starts and actually identifying, that’s when a migraine is starting. Being cyclical, trying to predict when that migraine is going to start and taking evasive action or trying to do stuff before the migraine starts. So I’ve actually stopped drinking wine and gin. I’ve been making non-alcoholic gins instead. Especially when I know a period is due. And that definitely taking alcohol out of the equation has helped a lot. But the most important thing with the perimenopausal link is part of the treatment plan was then HRT.


Swati [01:07:01] Okay.


Marissa [01:07:02] So when the doctor said to me, ‘right, you’re perimenopausal and you have hormonal migraine, this is how we’re going to treat it, and HRT is going to help with both’. I was so relieved really, to be speaking to someone who understood migraine. Secondly, that I wasn’t going mad. And thirdly, that there was a solution. So I shed a little tear, which was also obvious that, you know, just being perimenopausal, you are a bit more fragile and moody.


Swati [01:07:38] Absolutely.


Marissa [01:07:39] So, yeah, just knowing that there was something that would help meant a lot. I would definitely highly recommend that anybody out there who suffers from migraines contacts the National Migraine Centre. It honestly has been the best thing I’ve ever done. And the reports that I got that I could then take to my GP and say, ‘I’ve spoken to the National Migraine Centre. These are the kind of migraines I’m getting. I’m also perimenopausal and HRT is an important part of my treatments’. That helped a lot in terms of getting HRT from my doctor. I also made sure that I spoke to a female doctor with an interest in women’s health at my local GP and that helped too. She was very supportive. I also think the app of yours is fantastic because that tracks things and finds patterns that you might not be aware of. My Fitbit actually was also tracking my period and has been for years, so only later on did I look back. I’ve always thought I had a 28 day cycle but some months are 21 days, some months are 24 days. But just having a log that you can look back on, my memory is just shot. So when you can actually look back on notes or apps or anything like that which can then support, you know, your trip to your local GP if you think you’re perimenopausal. Yeah. That all helps a lot.


Swati [01:09:40] That’s- I mean, from all of it, it sounds like you’ve got an understanding of what your treatment plan should look like and you’re probably following that. Thank you so much for sharing all that information with us. I’m sure everybody who’s out there listening to this episode can easily connect to your story, and I really hope your migraine- I really really hope they get better. But thank you so much, Marissa. Thank you so much for joining us today.


Marissa [01:10:07] Thanks, Swati. Thanks so much.


[01:10:12] You’ve been listening to the Heads Up podcast. If you want more information or have any comments, email us on info@NationalMigraineCentre.org.uk. Till next time.

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This transcript is based on a past episode of the Heads Up podcast and reflects information available at the time of broadcast – some facts may have changed or new treatments become available since.

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