Rethink Menopause Logo

blog

  • Understanding the Menstrual Cycle

    There are many questions and misconceptions about the menstrual cycle. From period pain to hormone fluctuations, it’s crucial to understand what’s normal and what might be worth discussing with a healthcare professional. In this post, we’ll explore key aspects of menstrual health, including cycle length, pain, heavy menstrual bleeding, and much more.

    What is Menstrual Health?

    On average you’ll have around 450 periods in your lifetime. One person’s experience of menstruation is their only experience. We don’t know what someone else’s normal is, we don’t know if our experiences are normal. To be able to identify if something’s wrong, we need to start with an understanding of what’s normal. I’m going to try and help you make sense of the menstrual cycle, for you and your friends/daughters/colleagues.

    So, let’s begin with the basics: What is a “normal” menstrual cycle?

    What is a Normal Menstrual Cycle?

    It’s important to know that only about 10% of people have a 28-day cycle. A normal cycle can range from 24 to 38 days, with most people experiencing periods lasting between 4 and 7 days.

    Irregular periods are common, especially during times of hormonal transition, such as puberty and perimenopause. Irregular periods can also occur with changes in weight, stress levels, or underlying health conditions like PCOS (Polycystic Ovarian Syndrome) and RED-S (Relative Energy Deficiency in Sport).

    What are the Different Stages of the Cycle?

    The menstrual cycle is divided into different phases. Here’s a quick breakdown:

    The first day of your period marks the start of the follicular phase, which is more oestrogen dominant. This phase lasts until ovulation.

    Ovulation occurs on day 14 in a 28-day cycle. Testosterone surges just before ovulation, so our libido peaks just as we are most fertile, and then from ovulation oestrogen and testosterone fall.

    After ovulation, is the more progesterone dominant luteal phase. Progesterone peaks 7 days before our next period and then in the few days before our next period, we may experience PMS symptoms as our hormone levels fall. In our language, we talk about PMS as when we are hormonal, but actually, it’s related to hormone levels falling.

    Should You Expect Some Period Pain?

    In terms of period pain, we have hormone-like substances called prostaglandins in the womb, and these trigger the period through contractions of the womb. They also regulate how much blood we lose. It’s the prostaglandin effects that can lead to cramps, aswell as other effects like looser stools.

    Pain that interferes with our daily activities though is not expected, we shouldn’t be feinting with our periods, or having to take time off work or college. Pain that affects us like this may indicate a medical condition like endometriosis, where cells similar to the ones in the lining of the womb grow elsewhere in the body.

    How Do You Know if Your Bleeds Are Heavy?

    A typical period involves a blood loss of around 5 to 80 mls. If you’re losing more than that, it’s considered heavy menstrual bleeding. This can mean needing to change period products after 1-2 hours, needing to double up on period products, flooding through clothes or experiencing a bleed lasting longer than 8 days.

    Heavy bleeding can be due to fibroids, polyps, or adenomyosis. It’s also common during perimenopause. Heavy menstrual bleeding commonly leads to anaemia and can affect your quality of life, energy levels and cognition.

    Does Everyone Get PMS?

    Around 90% of people who menstruate will experience some form of PMS (premenstrual syndrome). There are over 150 physical, emotional and behavioural symptoms ranging from breast tenderness to lack of co-ordination to bloating. For about 30% of people, PMS can be more severe. Additionally, PMDD (Premenstrual Dysphoric Disorder), a more severe form of PMS, affects 5-8% of people and can cause extremely distressing symptoms.

    How Does Hormonal Contraception Affect the Menstrual Cycle?

    Hormonal contraceptives, like pills, injections, or implants, essentially pause your menstrual cycle. The bleeding you experience on the pill isn’t technically a period; it’s a withdrawal bleed, induced by the hormone-free week of the pill. A hormonal coil (like a Mirena) may or may not stop ovulation and typically leads to lighter or absent periods. So with a pill we bleed but don’t cycle, and with a Mirena we cycle but don’t bleed.

    Why Track Your Cycle?

    Tracking your cycle can help you tune into your body and gain a better understanding of your unique cycle. By keeping track of symptoms over 2-3 months—using a diary or a tracking app—you can start to recognize physical and emotional shifts at different points in your cycle. The whole cycle and parts of the cycle, particularly the follicular phase, can vary in length and experience from cycle to cycle as well as over time. The luteal phase tends to be more consistent and typically lasts 14 days.

    After a few months of tracking you may have a sense of your typical experiences at each stage, and may be able to use this understanding to plan work, exercise and rest around it. It may not always be predictable, especially at perimenopause, and there will be some things you can’t change, but you’ll have more awareness and hopefully feel more in control.

    Should You Change Your Nutrition with Your Cycle?

    Hormones can influence appetite and metabolism. In the follicular phase, as oestrogen rises, many people experience a suppressed appetite. However, in the luteal phase, progesterone levels increase and appetite tends to rise, often leading to food cravings.

    Here’s how you can tailor your nutrition to support your cycle:

    • During your period, focus on a whole-food, plant-based diet rich in iron and vitamin C to optimize iron absorption. Fruits, veggies, pulses, nuts and seeds are excellent options. Many people will get gut symptoms with their period, so limiting foods that stimulate the gut like coffee, alcohol, fatty and spicy meals, can be helpful.
    • In the follicular phase, your metabolism speeds up, you need more calories and you are primed to access carbohydrates for fuel.
    • In the luteal phase, your body burns more fat for fuel. Fats like those in avocados, nuts, seeds, and olive oil, can support hormone production.
    • Omega 3 (oily fish, nuts and seeds); Magnesium (nuts and seeds, dark chocolate, pulses, banana, avocado, and leafy greens); and zinc (wholegrains, pulses, dairy, nuts and seeds) can be helpful for PMS symptoms. You may find it helpful to limit caffeine, alcohol and ultraprocessed foods to support PMS too.

    What About Exercise?

    In terms of movement, well hormones impact your body in so many ways – from metabolism, how well you tolerate heat, reaction time, breathing rates, muscle cell turnover, and more.

    When we think of how we may want to move with our period, there are no set rules. Some people will be low on energy and may prefer yoga, and low intensity workouts. Other people may have lots of energy and can really go for it at this time. Paula Radcliffe broke the world record for the marathon while she had menstrual cramps! When you exercise your body increases endorphins, which can help with period pain.

    In the follicular phase we tend to be motivated, and can adapt well to intense training. There is some evidence to say injuries are more common at this time though. More strength training in the follicular phase can lead to up to 15% more strength gains than spreading training evenly throughout the cycle.

    Often in the luteal phase, we may have less motivation. This can be a great time for slow and steady endurance-type activities such as yoga, although we can sometimes feel more clumsy or uncoordinated.

    In the pre-menstrual phase it can be good to build in some feel-good energy lifting and anxiety-relieving movement practices, perhaps a dance in the kitchen or a walk outside in nature.

    Is Sleep Affected by the Cycle?

    Yes, our sleep is affected by our hormones. Both oestrogen and progesterone can support restorative sleep. It varies with our menstrual cycle, typically being at its best just after ovulation in the middle of the cycle, and at its most disturbed at the end of the luteal phase just before and then during our period.

    Resources for Further Information

    If you want to dive deeper into menstrual health, here are some great resources:

    By understanding the menstrual cycle and tracking its patterns, we can better navigate the ups and downs of each phase, making informed choices for our health and well-being. Listen to your body and seek advice when something doesn’t feel right.

  • Connection

    Menopause is a time of change. It can feel like we don’t recognise ourselves. Cultivating our connections to ourselves, to others, and to the natural world can be an important part of self-care.

    Many people at menopause feel unseen, in their experience and the impact it has on their life. This can be especially true for those who don’t identify as mid-life white, middle-class, cisgender, heterosexual women, and also for those who are neurodiverse, who are carers, and many others.

    The symptoms many of us experience at perimenopause can particularly affect our close relationships and our feelings of intimacy and connection with our partner. We know rates of divorce for women peak between ages 45 and 55, and the main reasons cited for divorce are communication and lack of intimacy.

    In the workplace, research has shown that only a quarter of women who had been unable to go to work due to menopausal symptoms had felt able to tell their line manager about the real reason for their absence. It can be difficult to talk about, and of course, when we don’t feel able to talk about it we can feel more isolated in our experience.

    Loneliness has the same outcomes on our health as smoking 15 cigarettes per day. It affects our mental health and physical health, increasing the rates of conditions like heart disease and stroke. We need to take this seriously. So what can we do?

    “Listen to your body when it whispers so it doesn’t need to shout”

    Connecting to yourself

    Cultivating self-awareness, self-compassion, and self-acceptance is helpful, and journalling is a great practice to support this. When we’re busy and overwhelmed it’s hard to tune in to what our body is telling us. Mind-body practices like yoga can be really useful to support self-awareness. 

    connection - joy

    To cultivate self-compassion I often encourage people to think of what they would say to their best friend. We are often very self-critical, and much kinder to others.

    Spending time to understand and work towards acceptance of this new stage will be harder for some of us than others. Some of us will look forward to the end of periods and PMS. Others of us may need to work through some grief and some sadness before we can embrace the opportunities that the future holds, for the second spring as menopause is known in Japan. Support for this through counselling or coaching can be invaluable.

    Do you nourish yourself every day, spending time on things that bring you joy? Could you put yourself first, even if just for 5 minutes today, think about what you need and make it happen? Are there ways you could give back to your local community or volunteer for a charity close to your heart?

    Connecting to others

    Investing time in supportive relationships is key. Having a social network and being satisfied with this network is protective against loneliness. Could you make plans to meet up with someone who really understands you, someone you are at ease with?

    There can be lots of positives to working from home, but many find it socially isolating. The virtual online world can be incredibly convenient, but many of us find an in-person exercise class a very different experience from an online class. Doing something with others connects us. The power of community is evident through the successes of parkrun, book clubs, and choirs.

    So if we are working from home factoring in a daily walk, building in time for fun, and connecting with neighbours or friends can be helpful. If we work from home we aren’t commuting, many of us will make use of this time to keep up with the household chores, let’s prioritise social connections too.

    Mealtimes are another key opportunity for social connection, and research has shown that when we eat with others we are likely to make healthier choices and eat less.

    Connecting to the natural world

    connection - natural world

    Could you make some time to get outside today? To feel the cold air, listen to the birds, pause and tune in to your surroundings. A morning walk can not only help with your sleep and mental health, but can connect you to the changing seasons, and will encourage you to notice the natural world.

    Menopause support groups

    There are menopause support groups in workplaces and community centres all over the country, perhaps your local group could connect you to others who identify with a similar experience? Local to me is M power, held on the first Thursday of the month at the Greenway Centre in Bristol. Your workplace may host a menopause cafe where you can connect with others who have similar experiences. If not, perhaps you could start your own!

    Resources around connection

    Reflection.app journalling

    Insight Timer meditation and breathwork

    Lesley Waldron menopause coach

    Black Women in Menopause

    Queer menopause

    Surgical menopause

    Daisy Network (POI)

    Mothering and the Menopause

  • Contraception, is it still important in perimenopause?

    When can I stop using contraception?

    So not all of us will need contraception, but it’s important to remember that even long cycles over 50 days can be ovulatory, so we can still conceive at this time.

    The advice as to when we can stop using contraception, using age alone, might surprise you as being at age 55. Before age 55, if we are not using hormonal contraception we can stop contraception 1 year after our last period if this happens over the age of 50 and 2 years after our last period if this is before the age of 50. 

    If I’m using HRT do I still need to consider contraception?

    HRT itself is not contraceptive, unless we are using the hormonal coil for the progesterone component. Although there are similarities between hormonal contraception and HRT, the doses of hormones in HRT are much lower and do not suppress ovulation, so they do not provide reliable contraception.

    What options can be used alongside HRT?

    If your HRT regime doesn’t include the IUS (Mirena) your options include barrier methods, the IUD (copper coil), progesterone pills, and progesterone implants. The IUD usually lasts 10 years, but when fitted from the age of 40, it can be used for contraception until age 55. The progesterone injection, combined pill, combined patch, and combined ring are not usually advised from age 50.

    The hormonal coil

    hormonal coil Mirena

    The IUS (Mirena) usually lasts for 5 years, this has now been updated to 8 years, and when it is fitted from the age of 45 it can be used until age 55 unless it is also being used for HRT when it needs to be changed every 5 years. It reduces vaginal bleeding by around 60%, provides very reliable contraception, and can be used as the progestogen component of HRT. Oestrogen can then be added to the Mirena in the form of a tablet, gel, patch, or spray.

    Many people worry about how painful it will be to have a coil fitted. Like most things, it varies person to person. Researchers have asked women who have had a coil fitted, and without any painkillers most say the pain is mild-moderate and within 5 minutes at a low level. This has been my experience of fitting coils over the last 20 years or so, and having a few myself. If you are having a coil fitted and find you are having severe pain, you can of course ask for the procedure to stop. Pain relief is available too, including taking something at home beforehand like ibuprofen or paracetamol, and through local anaesthetic sprays at the GP surgery.

    What about the pill, can that help in the same way as HRT?

    Combined contraceptive pills can be a good option, especially if we are also in need of contraception. There are certain situations where combined pills are less suitable, such as for people over the age of 35 who are smoking as the risks outweigh the benefits. Combined contraceptive pills can also suit some people with an early menopause really well.

    Traditionally contraceptive pills have contained synthetic hormones, and some people find these types of hormones haven’t suited them so well. It’s great to see some newer contraceptive pills coming through, like Qlaira, Zoely and Drovelis, with other types of oestrogen.

    natural family planning

    There is also a newer progesterone only pill, Slynd, that can be used in an HRT regime as the progestogen component, and this can be helpful as another option if we haven’t got on with other commonly used progestogens.

    Natural family planning and “digital contraception”

    Much spoken about on social media, but not recommended in the perimenopause as menstrual cycles are less regular and changing, and these approaches rely on regular cycles.

    Resources for more information

    Decision aid – what’s right for me Contraception choices

    Contraceptive Methods

    The Lowdown

  • HRT, your questions answered

    HRT examples

    Should everyone take HRT?

    I’m a big fan of HRT, I’ve seen it transform people’s lives. I don’t however believe there is any drug or medical intervention that is always right for all of us. Saying that I strongly believe everyone should have access to accurate information to make their own informed choices. There has been a lot of misinformation about HRT over the years, and there are now types of HRT that are very similar to our natural hormones with a better safety profile, for example not increasing the risk of blood clots. I would strongly advise anyone with POI (menopause before the age of 40) to take HRT until the natural age of menopause, to protect their long-term health. I’m also a big advocate of local HRT, which is very low in dosage and can be used long-term by almost everyone to support the genito-urinary symptoms of menopause.

    With all the different types of HRT available, how do I pick which to use?

    Certain medical factors play a part in decision-making, so your clinician looks at your medical history, any medical conditions in your family, and any medications you already take. Personal preference is key too – some of us prefer the convenience of a daily tablet over applying a gel with a separate progestogen, some of us find an oestrogen patch easy to use alongside a hormonal coil, and some of us like the oestrogen spray. Local HRT can be added, or used alone, and some people find great benefit from adding in testosterone. We’re all different, so an individual approach is needed. Sometimes there’s some trial and error too, to get the right product that suits you, and at the right dosage to support your symptoms.

    Why do some people take it every day and not others?

    If we start HRT when we are still having periods, when we are perimenopausal, we initially use HRT in a cyclical pattern, to replicate the menstrual cycle. Oestrogen is used every day and progestogen usually for 2 weeks out of 4 to give a withdrawal bleed. Over time we can change to a continuous combined HRT where oestrogen and progestogen are used continually. If we go straight on to the bleed-free continuous HRT before our body is ready we tend to get lots of random bleeding. If our periods have stopped for a year or more when we begin HRT we can go straight onto the continuous combined bleed-free HRT.

    I’m 64, is it too late for me to consider HRT?

    If you are over 60 and have troublesome symptoms, HRT can still be beneficial. It is a good idea to start at a low dose and to go for a transdermal (through the skin) oestrogen, your clinician can advise you of the options that might suit you best. For the potential preventative benefits of HRT relating to the heart and blood vessels, research has shown there is a “window of opportunity” of starting HRT within 5-10 years of the onset of menopause, so if we start HRT after this it is to help our symptoms. 

    What are your thoughts on starting HRT earlier rather than later?

    There is much less research and evidence about starting HRT for early perimenopause, between the ages of 40 and 45. For POI (menopause before the age of 40) there is a lot of robust evidence to show the benefits far outweigh the risks, and when HRT is started before the age of 40 it would be strongly advised to continue until at least the typical age of menopause, 51.

    Starting at age 40-45 we presume is likely to be very safe, our background rates of medical conditions are lower, and we are likely to have more to gain regarding longer-term preventative benefits if we go through menopause earlier, but there is a gap in the research data here to know for sure.

    It has taken me a few years to sort out my HRT and manage my symptoms – when do I need to think about stopping it, or do I continue for life?

    HRT can take a while to stabilise, there’s no one-size-fits-all approach and we can all respond differently to different formulations, and need different dosages. The dosage we need to support our symptoms can vary over time too. There are no arbitrary limits now on the duration of treatment, an annual check is advised but some people do now choose to stay on it longer-term. In POI (menopause before the age of 40) it’s advised until at least 51, the typical age of menopause. If you are benefitting from local HRT I would advise you to continue it lifelong. So it depends on factors like our individual medical history and the type of HRT.

    HRT tips and tricks

    How do you get the black sticky patch marks off without scrubbing til your skin is raw?

    Patches can leave an annoying plaster mark on the skin when you take them off, this comes off with baby oil or alcohol gel. There’s a new spray out, nudi, that works well too.

    Where is the best place to apply the gel?

    It’s usually applied every day to the outer upper arm, or inner upper thigh. It’s important to avoid hormone-sensitive areas, so if you use it on the upper arm, remember that the breast tissue extends into the armpit area. If you use the inner thigh, avoid the genital area. It’s been shown that ideally each pump of gel should be applied to an area about the size of an A4 piece of paper and if you use the sachets of gel each sachet to an area about the size of your hand. You don’t rub it in, just apply it and leave it to dry.

    My friend uses 4 sprays each day, and I use 3, who is correct?

    Just like with other common medications such as thyroxine, different people need different dosages for the same effect. The right dose is the dose that supports our symptoms. It is important to talk to your prescriber about your dose, and not to increase it without them knowing, as at some levels of oestrogen more progesterone is also recommended. So I can’t tell you what the right dose will be for you, it’s like finding the right pair of shoes, some fit better than others even if they’re both a size 6. So there can be some trial and error needed, both with the product and the dose. That can be hard if you’re experiencing lots of symptoms I know, you just want it to work straight away.

    How can I know if the spray has run out?

    It can be tricky to know when you’ve run out, the device doesn’t feel empty. There is a tick chart on the box to count down what’s left. There are 56 doses in each device, so if you’re using 2 sprays a day another option is to set a reminder on your phone that it will run out after 28 days.

    HRT tablets

    My nurse told me I should change off tablet HRT now I’m 60. Why is that?

    Oral HRT is very convenient but is less suitable for certain medical conditions that can affect us more with age like strokes and blood clots, so if we take oral HRT at age 60 it is often recommended to change to transdermal HRT like a patch, gel or spray to reduce these risks.

    Does HRT cause weight gain?

    Weight gain is typical in mid-life. Research has consistently shown no evidence of weight gain with oestrogen and progestogen HRT. There can be some weight gain for some people with testosterone HRT.

    Why isn’t my HRT covered by the HRT pre-payment certificate?

    Not everyone is aware that the HRT prepayment certificate is available, and lasting 12 months at 2 prescription charges it can lead to big cost savings over a year. It includes HRT products that are licensed for the treatment of menopause, so all of the oestrogen tablets, gels, patches, and sprays, aswell as the local oestrogen treatments. Most progestogens are covered too, but not the vaginal micronized progesterone capsules or some of the synthetic oral progestogens. Testosterone is not included either. You can get a prepayment certificate from your pharmacy, or online via the NHS Business Services Authority, but not your GP surgery.

    Does testosterone help brain fog?

    Thanks in part to Davina, testosterone is now well known for its effect on libido. The other effects though are still being debated. People using testosterone as part of their HRT often report improvements in mood, memory, concentration, and energy levels, aswell as strength and vulvovaginal health. These effects have not been proven in studies, but more research is needed. For some people adding testosterone certainly seems to significantly improve their quality of life.

    What about breast cancer? Can I take HRT if there’s breast cancer in my family?

    Breast cancer is the most common cancer in women, with a lifetime risk of 1 in 8, so many of us know someone close to us who has been affected. Breast cancer is age-linked, and genetics can affect our background risk, so an assessment of family history is important and your clinician will be able to guide you as to whether your family history is higher risk. Other factors are important too, such as being overweight, smoking, and drinking alcohol increasing our risk, and exercise decreasing our risk. In terms of HRT, the risk relates to the type of HRT we use, the dose, and the length of time we use it. The risk from HRT is less than the risk from a glass of wine every day. So again, it’s a personal decision to talk through with your clinician.

    I’ve started to get migraines linked to my cycle again. I’m 47 and using HRT. Is this likely to be a perimenopause symptom? Is there anything I can do to help?

    Hormonal migraines are common and usually relate to fluctuations in hormone levels. They typically start at puberty and are common with a lowering of oestrogen so pre-period or on the pill-free week of the pill, they often stabilise in pregnancy, flare at perimenopause then improve again in postmenopause.

    A brain that is prone to migraine likes stability, so thinking holistically and more broadly than just about hormones is important. So steady caffeine, exercise, stress, alcohol, etc is great to support prevention. In terms of HRT, transdermal oestrogen regimes like the patch or gel with the hormonal coil or continuous progesterone are often preferred. Standard HRT doesn’t stop our natural background cycle but sometimes higher doses can help. Migraine-specific reliever treatments like triptans are important to look at too for when symptoms do occur. 

    I’m not sure what to do

    For personal advice about starting or optimising your HRT, you can book a consultation with BMS Accredited Menopause Specialist Dr Sam Morgan here. We’ll have the time we need to talk through your medical history and preferences and work out a regime to suit you. We can talk about your lifestyle and non-hormonal treatments too.

  • The importance of rest

    Rest, does it really matter?

    Throughout August I’ve been posting on social media about the importance of rest, with ideas of how to build it in every day. The summer holidays are often long-awaited, but the reality can sometimes be difficult. The juggle of supporting children and working often means that it’s downtime that gets squeezed. On top of that things that top us up like exercise classes, and choirs will often pause for a Summer break and friends may be away. 

    So many of the people I see in the clinic are constantly on the go, with few opportunities for rest. Many feel guilty at even the thought of it. Does it make a difference? Yes, it really does…

    Stress and hormones

    We’ve probably all heard of fight or flight, feeling tired and wired, which is our sympathetic nervous system, preparing us for danger. Then there’s the parasympathetic nervous system, known as rest and digest or feed and breed. 

    When we are in a chronic stress state our cortisol levels are high. Cortisol is really helpful if we’re in imminent danger, but we don’t want it to be high all the time. When our body can see we are in a stressed state it wants to keep us on high alert and it prioritises our stress response as opposed to other functions like reproduction. It also has an impact on the part of our brain that stimulates the release of other hormones (the HPA axis). Our body is not going to think it’s a great time to have a baby if it senses we’re in danger and we may have seen the effects of this on our hormones personally and missed a period after a particularly stressful time or major life event.

    So stress can certainly affect our sex hormones.

    If we go back a step to thinking of the effects of our hormones, oestrogen stimulates serotonin, is linked to endorphins, and blocks cortisol. Progesterone is calming for most of us, a natural sedative that relaxes bodies and minds. Testosterone improves our mood, energy, and motivation. Cortisol however has a negative effect on memory and cognition and increases insulin resistance, affecting our metabolism. So we can see that a comnbination of lower sex hormones and higher cortisol levels can impact many different symptoms of menopause.

    Perimenopause is a time of real flux for our hormones and our nervous system. Our body is changing, it can feel like we’re not in control. It’s a time of life where we’re often pulled in so many different directions – supporting children and parents aswell as reaching the peak of our career and running the household. Any vulnerabilities we have often make themselves known and for many of us, our biggest vulnerability is the level of stress we’re under every day.

    Many of us don’t think it’s ok to do nothing. We feel we must always be busy, that busyness equals success. When we have too much to do we prioritise doing over being. We deem looking after ourselves a luxury we can no longer afford. We feel we will lose control and everything will fall apart. In overwhelm we rest less. We are restless. I think rest needs a rebrand..

    The Rest Test

    18,000 people filled out the Rest Test survey, describing what rest meant to them. They compiled a list of the activities people found to be most restful, and this was the top 20:

    mindful image of nature, restful
    1. Reading 
    2. Sleeping or napping
    3. Looking at, or being in nature
    4. Spending time on your own 
    5. Listening to music
    6. Doing nothing in particular 
    7. Walking 
    8. Taking a bath or a shower 
    9. Daydreaming 
    10. Watching TV
    11. Meditating or practising mindfulness 
    12. Spending time with animals 
    13. Spending time with friends/family 
    14. Making/drinking tea or coffee 
    15. Creative arts
    16. Gardening 
    17. Travelling on long train journeys 
    18. Engaging in physical activity 
    19. Chatting 
    20. Drinking socially

    Most of this list is tech-free, and encourages a flow state and engagement of our senses. What works will be different for all of us, for me it’s a matter of valuing rest and building it in regularly. For many people, it can be hard to prioritise rest for themselves, and much easier to book into a gym class than to choose to do some mindful crafting. Sometimes thinking about trying to role model rest, particularly if you have daughters, to help your children see the value of rest can be useful.

    Moving from the sympathetic towards the parasympathetic nervous system

    restful yoga pose

    The good news is there are some quite straightforward hacks into our parasympathetic nervous system. Yoga works a treat for me and the National Institute of Health America agrees that the research suggests yoga helps with menopause symptoms.

    Breathwork is helpful too, particularly the rate and the length of the exhale. Just 5 minutes of breathing exercises each day is enough to help. Many of us don’t think about our breath, but how we breathe matters. The “perfect breath” has been shown in studies to be 5.5 seconds in, and 5.5 seconds out, which works out as 5.5 breaths/minute. Interestingly this is the type of breath used in many chants and prayers. 

    Other good activators of our parasympathetic nervous system include laughing, singing, cold water, and acupuncture. So perhaps this September is the time to sign up for a choir or try some cold water in the shower? It may do you more good than you realise…

    Resources

    The Art of Rest by Claudia Hammond

    Insight Timer breathing and meditation exercises

    National Institute of Health America Yoga: what you need to know

  • Movement at menopause

    I’ve always loved to move, and I’m so thankful I love it. I know how hard it is to build it in regularly if you don’t feel the same, and if it’s tied up with what you should do to look a certain way or control things about your body. I exercise because when I do I feel well & I feel strong. At menopause, it’s particularly important to help with symptoms and long-term health and well-being, especially heart, brain, and bone health. I recommend a combination of cardio, strength, restorative movement, and attention to our pelvic floor.

    Moving with the menstrual cycle

    In terms of movement, hormones impact physiology in so many ways – from metabolism, how well you tolerate heat, reaction time, breathing rates, muscle cell turnover, and more.

    When we think of how we may want to move with our cycle there’s no right or wrong way to exercise during your period. Some people will be low on energy and may prefer yoga, and low intensity workouts. Other people may have lots of energy and can really go for it at this time. Paula Radcliffe broke the world record for the marathon while she had menstrual cramps! We know that exercise releases endorphins, which can help with period pain.

    In the follicular phase, the first half of the cycle, we tend to be motivated, can adapt well to intense training, build muscle, and recover better. Oestrogen is anabolic, it builds muscle and bone and studies have shown that building in resistance and strength training in the follicular phase can lead to up to 15% more strength gains than spreading that training through the cycle.

    Often in the luteal phase, the second half of the cycle, we may have less motivation, and feel more chilled and calm. This can be a great time for slow and steady endurance type of activities. We can sometimes feel more clumsy or uncoordinated at this time.

    In the pre-menstrual phase it can be good to build in some feel good energy lifting and anxiety relieving movements, some of us may prefer to dance in the kitchen, and others prefer a restorative yoga session.

    What motivates you? 

    Gretchen Rubin’s book The Four Tendencies is an interesting way to explore motivation by thinking of your personality type. She describes four tendencies of people – upholders, obligers, questioners, and rebels.  

    For upholders scheduling a run and keeping track of their step count could work brilliantly. Obligers benefit from accountability, and so may find committing to a run with a friend works for them. Questioners need to understand the benefits of exercise and if they accept those they’re likely to do it. And rebels, well they are a law unto themselves and will do it in their own time and in their own way, but definitely not if someone tells them to. 

    So for any of you who are questioners, at menopause exercise helps our symptoms and our long-term cardiovascular and bone health. In one study of women in their 40s, those with high fitness levels were diagnosed with dementia 9 years later than those with low fitness levels.

    Daily habits

    Over the years as a GP the most effective ways I’ve seen exercise change people’s lives and health have been when they’ve embraced “active travel” and decided to give up the car and walk or cycle to get around and also when people get a dog, and go for a walk each day. Movement doesn’t have to be runs, sessions in the gym, or long bike rides. Just 10 minutes of walking each day is enough for our brain, to support our mood, creativity, and long-term memory. 

    Cardio exercise

    Cardiovascular exercise is any activity that raises your heart rate for a sustained period of time. Aim for 20 minutes a day or 150 minutes per week. If at perimenopause you’re in sympathetic overdrive feeling stressed and tired then you may benefit more from brisk walking and some weights than an intense HIIT session. So in our 40s, we may need to rethink our movement – what has worked for you to date often stops.

    Strength training

    Strength training has many benefits at menopause. It reduces fat stores & increases muscle mass, supporting our metabolism. It improves blood pressure, improves immune function, reduces symptoms of hot flushes, helps our mood, and helps us sleep. It increases bone strength, joint strength, and mobility. 

    A study of over 110 000 people aged 65 to 74 including 70000 women found strength training at least twice a week was associated with a lower mortality from all causes.

    So what counts as strength training?

    Well basically we need to be working our muscles by pulling or pushing against a force – to grow muscle it needs a stimulus. So this can be done by using your own body weight like doing press-ups against the kitchen counter, it can be by using weights and also with resistance bands. Aim for “high load and low reps” – so it’s better to try a bigger weight and only manage to lift it 3 x than go for an easier one and lift it 10 x. The exception can be if one of your symptoms is joint pain, when you may want to go for a lower weight and more reps. Dr Rangan Chatterjee’s 5 minute kitchen workout can be a great place to start with strength training, no kit or special clothing is needed! Joe Wicks has developed two strength based home exercise routines for menopause too: Strength Workout 1 and Strength Workout 2.

    Pelvic floor health

    If the thought of jumping around and lifting heavy weights has you crossing your legs and worrying about your pelvic floor you might want to consider a pelvic physio assessment first. They are incredibly knowledgeable and can help you assess what types of exercises will benefit you and your pelvic floor, how to use your breath, and if there’s anything that may be best to avoid at the moment. There’s no one size fits all for pelvic floor exercises, some of us will need to strengthen, and some will need to focus more on relaxation so specialist help can be really useful here.

    Why do I recommend restorative movement?

    Many people I see at mid-life feel overwhelmed, and are living day to day in a fight or flight sympathetic nervous system state. Rest can be a really key part of the jigsaw to consider when we are looking to support both our day to day symptoms and our long-term health and wellbeing. It can be hard to schedule time for rest, but sometimes easier to prioritise time for a yoga or pilates class. Yoga and pilates can build a lot of strength, but often will also encourage us to tune in, to be, to notice our breath, and this can be very powerful.

    More resources

    Stacy Sims’ book Next Level

    Jennis app tailoring movement with menstrual cycles and at perimenopause

  • HRT

    With all the different types of HRT available, how do I pick what may suit someone best?

    HRT for everyone?

    So full disclosure. I’m a big fan of HRT, I’ve seen it transform lives. People have repeatedly told me how it’s helped them feel like them again, how it’s saved their marriage, their job, even their life. I don’t however believe there is any drug or medical intervention that is always right for all of us. I will never be a menopause specialist who says all women must take HRT but I do strongly believe everyone should have access to accurate information so that they can make their own informed choices.

    When it comes to thinking about what type of HRT is best, certain medical factors play a part in decision-making, so understanding your medical history, any medical conditions in your family, and any medications you already take is important.

    Personal preference is also key – some of us prefer the convenience of a daily tablet over applying a gel with a separate progestogen, some of us find an oestrogen patch easy to use alongside a hormonal coil, and some of us like the spray. We’re all different, so an individual approach is key.

    Oestrogen is the main hormone that helps our symptoms. When oestrogen was initially prescribed it was given alone and there was an increase in cases of cancer of the womb lining (endometrium). Progestogen was prescribed alongside it, and this reduced the womb lining cancer. So progestogen is essential for us to use with oestrogen if we have a womb, to protect the lining. Local oestrogen is oestrogen used around the vulva and vagina, which can be used on its own or in combination with systemic (whole-body) HRT. Testosterone is another important hormone and is sometimes added to oestrogen and progestogen to support libido, especially if the ovaries have been removed or menopause has been experienced very early, where the effect on testosterone can be marked. 

    If we start HRT when we are still having periods, when we are perimenopausal, we initially use HRT in a cyclical pattern, to replicate the menstrual cycle. Oestrogen is used every day and progestogen usually for 2 weeks out of 4 to give a withdrawal bleed. Over time we can change to a continuous combined HRT where oestrogen and progestogen are used continually. If we go straight on to the bleed-free HRT before our body is ready we tend to get lots of random bleeding, but if our periods have stopped for a year or more when we begin HRT we can go straight onto the continuous combined bleed-free HRT.

    HRT tablets

    Oral HRT is very convenient, and there is good cycle control (so often less erratic bleeding). Most types contain synthetic hormones, similar to the contraceptive pill. Synthetic progestogens do not suit all people so well and are associated with a slightly higher risk of breast cancer than the body-identical progesterone. Oral HRT is less suitable with certain medical conditions, such as if we have migraine and also increases the risk of blood clots, which is not the case with transdermal HRT. The absolute risk of blood clots with oral HRT though is very small.

    Body-identical HRT

    Transdermal oestrogen in the form of patches, gel or spray is often used with micronised progesterone, a capsule that you swallow at night. These body-identical hormones are most similar to our natural hormones and suit some people better. If libido is low it can improve more with transdermal oestrogen than with oral oestrogen. Oestrogen patches are applied twice weekly, and gel or spray is applied daily. Micronised progesterone often helps with disturbed sleep, but there can be more erratic bleeding than with synthetic progestogens.

    Contraception

    The IUS (Mirena) coil can also be used as the progestogen component of HRT, with the added benefits of reducing vaginal bleeding by around 60% and providing reliable contraception. 

    HRT is not contraceptive unless the IUS is used as part of the regime. Hormonal contraception can also be used by some people in perimenopause to support symptoms. 

    It’s personal

    I can’t tell you what will work for you straight away, it’s like finding the right pair of shoes, some fit better than others even if they’re both a size 6. So there can be some trial and error needed, both with the product and the dose. That can be hard if you’re experiencing lots of symptoms I know, you just want it to work straight away.

    Just like with other common medications such as thyroxine, different people need different dosages for the same effect. Different brands can give different absorption levels too. This has been difficult with the supply issues over the past few years, with people needing to swap between different preparations and different brands.

    Specialist Menopause Consultations

    Here at Rethink I offer specialist menopause consultations. I have the time to work with you to understand your preferences aswell as your medical history, both when initially prescribing HRT, aswell as when tweaking and optimising existing regimes. I can show you the different options, and help you know how to get the most out of each product. If you have any questions about what’s involved in a specialist menopause consult you can email [email protected].

    Resources

    HRT – types, doses and regimens Women’s Health Concern

    Testosterone for women Women’s Health Concern

  • Nutrition

    What’s the best diet to follow at perimenopause?

    I’m often asked about the best diet to follow at menopause. Nutrition has such an impact on how we feel day to day, aswell as on our long-term health and wellbeing. In this blog, I’ll explore what to consider when you’re thinking about your nutrition at menopause.

    Self-compassion

    Firstly, it’s really important to acknowledge that menopause is a common time for disordered eating. Our metabolism shifts, our microbiome changes, our sleep is compromised and our mood can change. These are all factors that can contribute to central weight gain, even with the same nutrition and movement, and play out in our relationship with food. Self-compassion is often really key, aswell as accessing the right support as and when we need it. Laura Clark runs a programme to support women around nutrition and weight and has a really great compassionate approach. There is more info on her website:

    The Menopause Dietitian

    In terms of nutrition, for me, it’s coming back to basics. Focusing on what it’s helpful to include, rather than exclude. Getting into positive routines, and establishing these habits as the default option for the whole family, most of the time.

    Supplements

    Nutrition is complex, and our bodies and minds gain so much more than the individual nutrients from a meal. So for me, nutritional supplements and meal replacements aren’t something I tend to recommend. Of course, in certain circumstances, supplements are essential, such as B12 for those following a vegan diet and not regularly taking foods fortified with B12. For most, a balanced diet is far superior to a multivitamin.

    Vit D supplementation 10-20 mcg per day is recommended for everyone in the UK in the Winter months (and for some people year round) as we mainly get it from sunlight.

    Whole food plant based diets

    Whole food plant-based diets have been shown to be associated with better symptom control at menopause and improved long-term health outcomes – a lower risk of heart disease, diabetes, cancer and low mood. The Mediterranean diet with plenty of fruit and veg, legumes like lentils and chickpeas, nuts & seeds and extra virgin olive oil can be a great place to start. Spicy foods, ultra-processed foods and caffeine can all trigger menopause symptoms in some people.

    Carbs and fats

    Carbs and fats both get a bad reputation but are both really important for us as at menopause. What are the right carbs and the good fats? Well, ideally complex carbohydrates (e.g. root vegetables, beans, oats, wholegrains) & fats that aren’t trans fats (e.g. nuts, seeds, avocado, extra virgin olive oil). Complex carbs regulate glucose and provide fibre. Fats support hormone production, helping symptoms aswell as being important for our long-term cardiovascular health.

    Protein

    Protein helps us feel full, regulates glucose which tends to trend upwards at menopause, and supports our muscles and bones. If we don’t eat meat we can still get our protein requirements, but it perhaps needs a bit more thought. Tofu, buckwheat and quinoa are complex proteins, containing all the amino acids we need. Try to aim for 20g of protein per meal if you can.

    • 20g – 3 eggs or ½ block tofu or 1 pint milk or 4 tbsp cottage cheese 
    • 15g – 1 portion Greek yoghurt
    • 8-9g – 1 handful nuts or 1 cup beans/lentils or 1 cup dairy or 2 tbsp peanut butter, 1 portion cheese
    • 5-6g – 1 handful seeds or 1 serving cauliflower/broccoli/spinach or 2 tbsp houmous or 1 avocado

    The gut microbiome

    We’re understanding more and more about the significance of our gut microbiome every day. This virtual organ is essential for our immune system, plays a key role in regulating our hormones, affects our mood, our metabolism and weight and is being studied at the moment as being the likely reason for the different responses between individuals to prescribed medications. This is where diversity matters, it’s the key to a healthy gut microbiome – so it’s helpful to shift our mindset from 5 a day to 30 a week.

    It can be helpful to think about eating the rainbow and the alphabet. Nuts, seeds, whole grains, herbs and spices all count towards the 30, and for the diversity impact it doesn’t need to be a full portion of each. I keep bags of mixed veg and mixed fruit in the freezer and have a jam jar of different nuts and seeds to sprinkle on top of meals. Some meals like a vegetable curry or bean chilli lend themselves really well to lots of veg in one go and can be batch-cooked for easy midweek meals.

    Phyto-oestrogens

    There’s a lot of interest in phyto-oestrogens, plant-based oestrogens. Some HRT comes from yams, so we know plants are an important source of oestrogen and progestogen. There are 3 types of phyto-oestrogens, and most of the evidence is for the first, isoflavones (edamame beans, tofu, tempeh, chickpeas, red clover supplements). There are many studies looking at the effectiveness of these food substances, and the results are variable.

    Our ability to metabolise isoflavones seems to vary quite a lot, and this may be one factor in the mixed results. 30-50% of us seem to have the ability to produce equol, which is what gives us the benefits. Ethnicity and genetic variability seem to matter. Those of us who follow a largely plant-based diet seem to be more likely to be able to metabolise, maybe due to microbiome effects again as it’s a gut bacterial modification that takes place. Other phyto-oestrogens include lignans (linseed, whole grains, veg) and coumestans (sprouted seeds).

    So instead of focusing on what to restrict, or on how many calories you’re taking in, perhaps it’s time for a rethink, towards what you can add to your diet that can support both how you feel today aswell as your long-term health and wellbeing.

  • Migraine, the impact of menopause


    Migraines affect 1 in 5 women, with three times as many women being affected as men. The symptoms can be really debilitating and include much more than headaches.


    Triggers

    There is often a history of migraine in the family, suggesting a genetic susceptibility.

    It can be helpful to look at whether there are triggers for an attack, sometimes it’s a combination of these triggers rather than one alone. Common ones include lack of sleep, increased stress, missed meals, alcohol, caffeine, and weather changes. True dietary triggers are less common, but it is known that some people will crave particular foods early on in an attack. Some people find attacks will strike at a weekend or the start of a holiday. So stability is often key for a brain that is potentially susceptible to migraine. Headache diaries can be a really useful way to explore triggers and patterns.

    The effect of hormones

    Hormonal, menstrually related migraine usually begins at puberty. These attacks are often more severe than migraine at other times. Typically migraine will be experienced during the period, as oestrogen levels fall. The prostaglandins released with a period are also linked with migraine, so those with heavier more painful periods can be particularly prone to hormonal migraine.

    If we take the combined pill, migraine is common in the first few days of the week off, (the pill-free interval) when oestrogen levels fall. The way pills are taken can be customised to promote hormonal stability and reduce migraines. Combined pills aren’t suitable to take if we have migraine with aura.

    In pregnancy, many women experience fewer migraines, as oestrogen levels are steady, but the postnatal period with hormone levels dramatically falling, is a common time for migraine to flare.

    At perimenopause with changing and fluctuating oestrogen and progesterone levels, we commonly notice hormonal migraines will worsen. Episodes are more common, last longer, are more severe, and are less predictable when they will strike as cycles become irregular too. Perimenopause is also a time when inflammation levels rise, and periods often become longer and heavier, which also influences migraine.

    Postmenopausally migraine often really improves, although it doesn’t necessarily resolve completely. 

    What about HRT?

    Person with headache

    As migraines are often linked to falling oestrogen levels, stabilising levels with hormones, contraceptives or HRT, can sometimes be beneficial. Some types of migraine though can be triggered by higher levels of oestrogen.

    The response to HRT is variable, it can really help some people but on occasion can worsen migraine, especially when first started. Stability is key, so ideally oestrogen patches with a continuous progestogen is preferred. It’s important to start with a low dose and build up very gradually. Transdermal oestrogens like patches, gels or sprays are preferred over tablets.

    Migraine specific treatment

    It’s also important to look at what medication you use at the start of an attack – the triptan medications can be really effective, and one of these, Sumatriptan, is now available over the counter. There are different types, some work more quickly than others and some last longer, so it can be helpful to try more than one to see which suits you best. It is important not to take them on more than 10 days each month, as frequent use can actually trigger headaches. If you are needing them more than this it’s worth looking at preventative medications. 

    There are a number of preventative options, some of which can also help with hot flushes and night sweats. Preventatives are usually continued for around six months and then slowly reduced. If migraines flare when the dose is weaned, then it can be increased again. We aim for the lowest dose needed to control the migraines.  

    Lifestyle

    Stability is key, so when looking at triggers and thinking about the impact of lifestyle, sometimes we will notice that late night or glass of wine at the weekend, extra coffee or missed meal in the week or an unusually intense exercise session may have precipitated an attack. We may find these factors particularly affect us if we are also at a lower oestrogen time of the cycle, for example around the time of a period.

    Stress levels certainly play a significant part too, so looking at work-life balance, prioritising downtime and support like CBT can be really helpful in the management of migraine too.

    Magnesium citrate or glycinate at a dose of 400-600mg daily can be helpful for migraine, and also support sleep, so is a great option to consider. It can have a laxative effect, so can be good to build up the dose gradually.

    Useful resources

    Managing your migraine by Dr Katy Munro

    Headache diary Migraine Trust

  • Sleep

    Sleep has such an impact on how we feel day to day, aswell as on our long-term health and wellbeing. In this blog, I’ll explore how hormones influence our sleep, and measures we can try to improve our sleep pattern.

    insomnia

    The impact of hormones

    Our sleep is affected by our hormones. It varies with our menstrual cycle, typically being at its best just after ovulation in the middle of the cycle, and at its most disturbed at the end of the luteal phase just before and then during our period. Oestrogen promotes deep dreamy REM sleep. Progesterone is calming for most women, and also supports good sleep. Less melatonin secretion at perimenopause is one of the factors that contributes to poor sleep, and poor sleep itself increases cortisol.

    Sleep and perimenopause

    At perimenopause approx 50% of women experience sleep changes. There’s less sleep, it’s of poorer quality, and we wake more. Human growth hormone (which helps us burn fat and build muscle mass) is released between 11pm and 1am, so poor sleep at this time can affect weight specifically.  

    Women with poor sleep in menopause are two to three times more likely to experience depression. Poor sleep at menopause is also linked with cognitive symptoms like brain fog and poor concentration, which can be particularly impactful at work.

    Sometimes sleep is disturbed because of other symptoms, like night sweats, joint pain or urinary symptoms. At perimenopause we’re more prone to sleep disorders like obstructive sleep apnoea and restless legs, these conditions need specific treatment, so do speak to your health care professional if you think this applies to you.

    Sleep hygiene

    To support sleep, it’s first worth reviewing the sleep hygiene advice

    • consistent morning and bedtime routine including weekends
    • morning daylight for 20 minutes +
    • caffeine before noon
    • exercise is great, but not too late in the day
    • naps before 3pm
    • stop smoking 
    • cut back on alcohol
    • minimise glucose peaks before bed
    • screen free hour before bed
    • dark, cool gadget-free bedroom
    • try not to lie in bed awake.

    We become increasingly sensitive to both caffeine and alcohol during the menopause transition, and so sometimes need to adjust our consumption bearing this in mind. It can be worth comparing how refreshed you feel in the morning with and without any alcohol the night before.

    Sleep support 

    Cognitive Behavioural Therapy-insomnia (CBT-i) is really effective for sleep disturbances that have been ongoing for a little while. It’s available as a computerised programme free of charge in Bristol, you can self-refer to Silvercloud. There are also private CBT-i therapists who see people for individual face to face appointments, local to me is Christabel Majendie.

    HRT is often helpful for the sleep disturbance of menopause, both oestrogen and micronised progesterone can be beneficial.

    Sleeping tablets have lots of risks and are not the answer. Some antidepressants have sedative effects though and can be helpful. 

    Cherry juice, and foods high in tryptophan (chicken, salmon, tofu, dairy, eggs, buckwheat, chickpeas, sunflower seeds) are reported to help but the evidence is minimal.

    Magnesium citrate and glycinate are good options as supplements to try to support sleep. Melatonin has some evidence too on a short-term basis, and is something I can prescribe privately. 

    Exercise, specifically strength training, is beneficial and many people notice better sleep with both acupuncture and massage.

    Yoga and sleep

    Studies have shown the benefits of yoga in supporting sleep. This is definitely an area where trying to build in a regular practice, perhaps even 5 minutes every day, can be really valuable. Perhaps as part of your morning routine, to help with the next night’s sleep, perhaps as part of your wind down routine before bed, perhaps with breathing exercises to use in the night if you wake frequently.

    This could be 5-10 minutes of really gentle movement in the morning linked with some breathwork. In the evening a restorative practice like “legs up the wall” can work well. In the night if you wake counting your breath and if it feels ok for you gently lengthening the exhale can help with sleep e.g. in for 2 and out for 4.

    Yoga nidra practices can be really helpful too, and there are many practices available to try on Insight Timer.

    Sleep well!