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  • 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!

  • Fezolinetant (Veoza®), what you need to know about the new non-hormonal treatment for hot flushes.

    The new non-hormonal drug for hot flushes and night sweats, Fezolinetant, is part of an entirely new class of drug, the NK3 antagonists. Fezolinetant has now been approved for use in the UK, having been approved for use in the USA since May 2023.

    White tablets spread on a blue background

    Currently the non-hormonal options available for hot flushes and night sweats include 

    • antidepressants
    • epilepsy medications
    • a blood pressure treatment 
    • a treatment for urinary urgency and incontinence. 

    It’s so great to see a new treatment option that has been specifically designed for supporting symptoms at menopause, because of course not everyone can or wants to take HRT.

    Fezolinetant works on the part of the brain that acts like our thermostat, influencing changes in neurotransmitters which regulate the underlying mechanism that causes symptoms, reducing the number and intensity of hot flushes and night sweats for most people.

    NK3 antagonists had remarkable effects for some people in the trials, “switching off” their hot flushes and night sweats within just a few days.Some people commented that their sleep improved as a result, but as NK3 antagonists do not affect oestrogen levels they would not be expected to improve any other symptoms of menopause.

    What happens for a new drug to be prescribed?

    When new drugs are developed there are vigorous procedures that are followed before they come to be prescribed by specialists or GPs.

    Fezolinetant has been approved by the MHRA (Medicines & Healthcare products Regulatory Agency), who as their name suggests regulate medications in the UK. This means it will shortly be available to prescribe, initially only on a private basis.

    A review by NICE (National Institute for Health and Care Excellence) is pending. NICE makes recommendations on the use of new and existing medicines and treatments within the NHS. These recommendations are based on a review of the available clinical and economic evidence.

    Local areas will then review this guidance, and may make an application to their prescribing formulary for the inclusion of any new drug. This process decides whether a GP can initiate the new drug, or whether it will be recommended for specialist initiation only.

    So who can take Fezolinetant?

    • The licensing is for the treatment of moderate to severe vasomotor symptoms (hot flushes and night sweats).
    • Participants in the studies were 40 to 65 years of age, so unfortunately currently it has not been studied for safety and effectiveness in those over the age of 65, so no dose recommendation will be made for this age group at present.
    • It can be used by those with a diagnosis of breast cancer.

    How is it taken?

    Fezolinetant is a prescription only tablet, taken once daily, with or without food. 

    Liver blood test monitoring may be recommended for some people.

    What about side-effects?

    The most commonly reported side-effects in the studies were headache, diarrhoea, abdominal pain and difficulty sleeping.

    Some people had changes in their liver function blood tests, that seemed to resolve when the drug was stopped. Other people noted changes in their blood glucose levels.

    Medications are studied very closely before they come to be prescribed, and all new medications continue to be monitored closely, to allow for the prompt identification of any new safety information. Side-effects of drugs can also be reported by those who take them at yellowcard.mhra.gov.uk/.

    So overall, a really welcome positive development that increases the options for us in moderating hot flushes and night sweats at menopause.

  • Osteoporosis, the impact of menopause, and holistic strategies for optimising your bone health

    Xray of hand and arm with broken wrist

    In my experience, bone health is not something many people are that concerned by, unless they have seen first hand how significantly osteoporosis has affected a family member. However, the implications of falls and fractures, especially for postmenopausal women, underscore the importance of proactive bone care. In the UK, 50% of postmenopausal women will break a bone, often because of osteoporosis. Even seemingly minor fractures, like a broken wrist, can disrupt daily life, affecting work, mobility, and independence.

    Other fractures, particularly of the spine and hip can be potentially life-changing and even life-threatening. Women have an 11% lifetime risk of a fracture of their spine, versus 2% in men. A woman’s risk of hip fracture is the same as the risk of breast cancer, womb cancer and ovarian cancer combined. Women’s risk is higher than mens due to a number of factors – hormones, lower body weight and typically living longer being some!

    The Hidden Threat: Osteoporosis and Osteopenia

    Osteoporosis and osteopenia signify a reduction in bone density, often described as ‘bone thinning.’ While bones may appear normal externally and cause no immediate discomfort, this internal thinning weakens the bones, making them more susceptible to fractures. Bone health is influenced by age, gender, ethnicity, weight, alcohol, smoking, and family history. Other factors like early menopause, anything that has stopped periods (for example lower body weight or high levels of training), medical conditions (including type 1 diabetes, rheumatoid arthritis, coeliac disease), and certain medications (including high dose steroids, some cancer treatments, some epilepsy treatments and the depo-provera contraceptive injection) are also key.

    This risk checker has been produced by the Royal Osteoporosis Society and is a really useful tool that anyone can use. You can complete it online and will be emailed a report that if you wish you can share with your Menopause Specialist or GP.

    Screenshot of the Royal Osteoporosis Risk Checker website

    In a consultation I would use a similar tool to calculate a FRAX score to assess the likelihood of fracture risk over the next 10 years and help to assess whether more information is needed, such as via organising a DEXA scan. Currently there is no national screening programme for osteoporosis, although in 2012 NICE (National Institute Clinical Excellence) did suggest that 10 year fracture risk should be estimated in all women over 65. I build this into all my consultations and health checks here at Rethink.

    How does menopause affect bone health?

    Bone is essentially like scaffolding, composed of essential elements such as protein, collagen, calcium, and various minerals. This living structure undergoes continuous remodelling, characterised by the breakdown of older bone tissue and the simultaneous rebuilding of new bone.

    In childhood, the emphasis is on bone building, facilitating the expansion of the skeleton in size, density, and strength as we grow. Remarkably, during this phase, the entire skeleton renews itself every two years. Although bone growth halts in our late teens, maturation persists, and we reach peak bone mass during our 30s. As adults, the process of complete skeletal renewal takes approximately seven to ten years.

    Up until the age of around 45, a delicate balance is maintained between the removal and creation of bone. Oestrogen has a pivotal role,its anabolic nature supporting the development of tissues, including muscles and bones. We can experience a loss of up to 20% in bone density during the five years following the last period.

    It’s worth noting that men also undergo bone loss as they age, albeit in a more gradual manner compared to women.

    Building Strong Bones

    Promoting bone health involves a holistic approach encompassing nutrition, exercise, lifestyle choices, and, if necessary, medications. Adequate protein, along with vitamins D and K, as well as calcium, forms the foundation of a bone-friendly diet. Vitamin D supplementation of 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 vitamin D from sunlight. In Spring and Summer, ensuring sun exposure for at least 20 minutes a day should meet our needs; but we may need 2 hours of exposure if we have darker skin, and may not absorb so well if we are wearing a high SPF. Leafy greens are great sources of both vitamin K and Calcium, and the Royal Osteoporosis Society has a link to a useful calcium calculator if you’re not sure you are getting enough.

    Regular weight-bearing and strength training exercises contribute significantly to bone health. Weight-bearing exercises involve the skeleton supporting the body’s entire load, promoting bone density through adaptive responses to force. The impact we need to support our bone density will depend on our baseline. Someone who is sedentary will see a significant benefit from a short walk each day, but someone who is very active needs to work a bit harder. Running, jumping and tennis are great for bones. It’s worth noting that swimming doesn’t count as weight bearing exercise. We should aim for this every day.

    Strength training, involving resistance against force, is a key component in preventing bone loss, maintaining strength, and reducing the risk of falls (particularly in older adults). Personalised approaches, whether using body weight, resistance bands, or weights, are crucial. It’s useful to aim for 2-3 bouts of strength training each week, and to progressively build this up over time. Post-exercise protein intake within 30 minutes aids muscle repair and overall bone health.

    Medications and Hormone Replacement Therapy (HRT)

    For some, medications, including Hormone Replacement Therapy (HRT) and specific osteoporosis drugs like bisphosphonates offer valuable options to enhance bone health. HRT at standard doses or above for 2 years duration or more has been shown to prevent osteoporosis related fractures and treat bone loss. Some studies have suggested this benefit may persist for several years after HRT is stopped.

    Conclusion

    Prioritising bone health is a proactive step toward a healthier and more resilient future. By adopting a holistic approach that includes nutrition, exercise, and lifestyle choices, we can optimise our bone health, supporting active independent living into later life. Noting our bone mass peaks in our 30s, encouraging our young people to keep active can support their bone health too.

  • Menopause Yoga

    Sam practising yoga

    Yoga has been around for thousands of years, originating in ancient India. There are lots of definitions, most helpful to me is to do with the idea of union – of the body, mind and breath. We tend to think of it as making shapes on a mat, to improve our flexibility and build strength, and there’s nothing wrong with that. It didn’t start out like that though, and some would say the purpose of the asana (postures) is to prepare the body and mind for meditation. There are ancient texts which set out the yoga way, that include ethical principles to live by, breath-work and meditation as well as the asana. Adding in the breath-work and meditation can certainly make it an even more beneficial practice.

    My practice

    I came to yoga almost 30 years ago now. I had a dislocated hip as a baby, and am hypermobile, and am quite prone to joint pain. I’ve always loved sport, but found I had to stop running in my late teens due to lots of pain. I got into cycling which worked for my body but I still found I was in pain after a decent walk. A physio I saw at the time remarked on my flat feet, so I got some orthotics and the pain eased, but at the same time it didn’t feel right to me to just prop my feet up and I looked into other ways of supporting myself.

    I tried out lots of yoga classes & teachers in Bristol until I found one I clicked with. The teacher quickly spotted I was quite bendy, and adjusted everything for me, not allowing me to cheat by using my bendiness to make the shape, instead teaching me about approaching the posture slowly from a position of power instead. Suddenly it was a challenge, and I was hooked. She constantly nudged me in class about my feet. A few years went by and I could see the newly developed muscles in my feet, and arches that had appeared, the orthotics went in the cupboard and the pain was gone. 

    As I’m sure is the case for many, I started a yoga practice looking for physical benefits and challenges, and found those, but have stuck with it for all this time because of the psychological benefits I’ve experienced. There’s lots of talk about flow states these days, and yoga for me is one of the best ways of experiencing flow. For me the magic comes when I’m balancing, and am aware of my breath. You can’t really think about anything else when you’re in headstand, you have to be mindful! I can still challenge myself and still have some 10 year goals I’ll probably never achieve, but take pleasure in continuing to practice. 

    I start most days on my mat, even if just for 5 mins. It’s a chance to just be, see what comes to mind and get ready for the day ahead. It can really help me tune in to what I need – some days I basically just have a lie down and do some breathing practices. Other days I’m doing handstands and jumping about. If you’re practising at home it can be tweaked to suit what you need on any given day. Practising in a class can give an amazing sense of connection though, and a community with like-minded others.

    Menopause Yoga

    During the menopause transition I think a yoga practice can really support us. It can help us tune in and connect to our changing body and have the space to recognise the different emotions we may be experiencing. It can help us maintain our muscle and bone strength, ease those aches and pains and support us to understand how to engage and relax our pelvic floor. The breathwork can be incredibly powerful for anxiety and stress, and there are practices which can support our sleep.

    As part of my teacher training with the Bristol School of Yoga I researched the evidence for menopause yoga in supporting health and wellbeing in the postmenopausal years in four key areas – cardiovascular health, bone health, mental health and pelvic floor dysfunction. There are many studies out there, and some really interesting research, for example demonstrating a yoga practice in mid-life seemed to reduce inflammation (which is thought to be the root cause of much non-communicable disease, particularly cardiovascular disease). Another study showed yoga may impact brain-derived neurotrophic factor (BDNF), a protein involved in promoting neural growth and plasticity, which can potentially support the recovery from depression.

    One of the most important benefits for me is to come to rest. At menopause we are pulled in so many different directions and many of us never stop. We all need rest.

    I’d love to practice menopause yoga with you, you can find more details of my upcoming classes here.

  • Testosterone treatment in menopause


    Testosterone advice and treatment is one of the most common reasons for women to book a consultation with Rethink. In this blog, I’ll help you understand what testosterone can help with, what to expect if you’re considering a trial of treatment, aswell was the situation with regards to who can prescribe it for you.


    The role of testosterone

    Described by Maisie Hill as the Serena Williams of our hormones, with testosterone on board we feel ambitious, competitive, and active.

    Not just for men, testosterone is produced by the ovaries and adrenal glands, and usually declines from our 30s, although in a more gradual way than oestrogen and progesterone. The effects are more pronounced for women with POI (premature ovarian insufficiency) and those who have had their ovaries removed surgically. Interestingly testosterone levels increase again at around age 65, it’s not yet known why or how. 

    Thanks to Davina, testosterone is known for its effect on libido. The other effects though are still being debated. Women 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 yet been proven in studies, but the studies done to date have not been of very high quality, so more research is needed. Observational studies have shown improvements in metabolic function, with positive effects on blood pressure, glucose and lipids. For some women adding testosterone certainly seems to significantly improve their quality of life.


    Indications for testosterone HRT

    Both the National Institute Clinical Excellence (NICE) and the British Menopause Society (BMS) agree that testosterone can be considered at menopause for women with low libido after a biopsychosocial approach has excluded other causes of a low libido, for example antidepressant medication.

    If testosterone treatment is being considered, firstly, it is important to ensure that HRT is optimised – for example if oral oestrogen is being used, this would be changed to transdermal oestrogen as a patch/gel/spray, to increase the amount of circulating testosterone. Blood tests to look at the level of oestrogen being absorbed from the HRT are important, aswell as blood tests to assess the testosterone levels.

    Although much is said about the potential benefits of testosterone, the BMS state “randomised clinical trials to date have not demonstrated beneficial effects of testosterone therapy for cognition, mood, energy and musculoskeletal health.” The National Institute Health Research (NIHR) recently announced a planned trial of testosterone vs placebo to look into other potential benefits in more detail.

    Women who have experienced an earlier menopause, and women who have experienced a surgical menopause seem to show particular beneficial effects in research studies. Testosterone use is not advised unless testosterone levels are low on blood tests.


    Testosterone treatment is not recommended 

    • If you are/could be pregnant  
    • If you are breast-feeding  
    • If you have had hormone-sensitive breast cancer  
    • if you have active liver disease
    • If you are a competitive athlete

    Testosterone is an unlicensed medication

    Currently in the UK there are no testosterone preparations specifically licensed for use in menopause care, so its use is described as “off licence”. This does not mean there are concerns about the safety or effectiveness of the treatment.

    Other medicines are also used outside of their licence. Prescribing must meet criteria set by the General Medical Council (GMC) and the Medicines and Healthcare products Regulatory Agency (MHRA). 

    Off licence means that the manufacturer cannot advertise or make any recommendations about using the gel for women. When using a medicine off licence it does not mean that you are part of a clinical trial. Testosterone gel for women has been shown to be effective, and use is supported by expert groups.

    Previously available licensed preparations were discontinued for commercial (not medical) reasons. The safety and effectiveness of testosterone replacement in women has been demonstrated in randomised studies which have followed women for up to 12 months and reported significant improvements in sexual function. Due to the lack of availability of licensed female testosterone preparations, products which are manufactured and licensed for use in men have been used outside their product licence. The use is therefore “unlicensed”, which means that the manufacturer of the medicine has not specified it can be used in this way. 


    The testosterone leaflet

    As the treatments are licensed for use in men, the leaflet is written to support this use, in men. The dosing instructions on the leaflet inside the box do not apply to testosterone use in women.


    How to use testosterone HRT

    “Male preparations in female doses” 

    The female equivalent dose is 1/10 the male dose, usually 5mg/day, so a sachet used daily for men is used over 10 days for women.

    Testogel testosterone treatment

    Testogel® comes as a gel in a sachet. One 40.5mg Testogel® sachet should last around 8 days. You roll the top and seal it with a clip between uses, storing it in the fridge between uses. 3 months treatment on a private prescription costs around £14.

    Tostran testosterone treatment

    Tostran® 2% gel, in a pump dispenser, given as one     measured pump (10 mg testosterone) usually used three times a week or alternate days. Each canister should last 240 days (4 months). It is currently unavailable in the UK

    Testim testosterone treatment

    Testim® comes as a gel in a small tube with a screw cap. One 50mg tube should last around 10 days. The tube should be kept in the fridge between uses. 3 months treatment on a private prescription costs around £14.

    .

    AndroFeme testosterone treatment

    AndroFeme® is licensed in Australia for women. It comes with a measure for female dosing and is recommended to be used daily. It is only available on private prescription in   the UK, 3 months treatment costs around £95.


    Whichever preparation is used, it should be rubbed onto clean dry skin on the lower abdomen or thighs or inner forearm and allowed to dry before you get dressed. You should not have contact with any other person while it is drying (approximately 10 minutes), and wash your hands immediately after the gel has been applied. The area that it is applied to should not be washed for three hours after application to allow the gel to be absorbed. 


    How long will it take to work?

    It can sometimes take a few months for the full effects of testosterone to work, so a 3-6 month trial is recommended. Treatment helps around two thirds of women.


    What if I forget to use it?

    If you miss a dose, take it as soon as you remember. If it is close to the time your next dose is due (within a day) do not take the missed dose and continue with your normal dosing. It is important not to take two dosages of the gel to make up for missing one.


    Do I need more blood tests?

    Blood tests are taken before starting treatment, repeated after 3-6 months on treatment, and then usually every 12 months. Blood tests are best taken between 8 and 10am. Testosterone should not be used on the morning of a blood test.


    Can my GP take over the testosterone prescription on the NHS?

    The situation is different throughout the UK, according to the local prescribing formularies.

    In Bristol, North Somerset and South Glos testosterone is classified as an amber drug on the prescribing formulary for treatment of low libido causing distress in women with optimised HRT and with either early menopause (age 45 and under) or surgical menopause. So to qualify for NHS prescribing, women need to meet these criteria, be referred to a specialist for initiation of testosterone, and then after the first 3 months the prescription can be continued by the GP, if the GP agrees.


    What about side-effects?

    Usually, there are no side-effects of treatment.

    Some extra hair growth can sometimes be seen where the gel is applied. To minimise this, it is recommended to vary the site of application and spread the gel thinly.

    Weight gain is seen in some women. There can be some acne, and effects on hair growth patterns.

    A deepening of the voice and enlargement of the clitoris can be seen if high doses are used, which push blood test levels above usual women’s range. It is very important not to increase the dose of testosterone without discussion with your clinician and blood test monitoring.

    There is less information on any long-term effects of testosterone treatment than other forms of HRT. Currently data is limited to around 5 years of use.


    Looking after your medicine 

    The instructions on how you should store your treatment will be on the pharmacy label. Keep it out of the sight and reach of children. Do not use after the expiry date stated on the packaging. 


    Resources with more information

  • Hormone blood tests at perimenopause and menopause

    Hormone blood tests samples

    I completely understand the rationale to want to have hormone blood tests checked to see where you are in the menopause transition, and understand your experience.

    Unfortunately the tests we currently have available often aren’t that helpful. They give a level at the particular point in time the test was taken, not an average, and those levels can fluctuate significantly during perimenopause.

    Hormone blood tests for menopause diagnosis

    Current guidance is that the FSH blood test is considered for those aged under 45 with symptoms of menopause. This test cannot be done if you are using a method of contraception containing oestrogen like the combined pill. It can be done on other forms of contraception including progesterone pills, the implant and the hormonal coil. With the contraceptive injection it is best timed when the injection is due rather than when it has recently been given.

    Two blood test results showing FSH levels over 30 are used to diagnose menopause. In the perimenopause though the level does not usually reach 30. It can sometimes be normal, sometimes be on the higher side (15-20). Labs often report levels under 30 as being normal to GPs. There is no agreed level of FSH to diagnose the perimenopause. Normal FSH levels do not exclude perimenopause.

    Blood tests can be really helpful if it is difficult to know what is happening because you don’t have a cycle for example after a hysterectomy it is common to enter menopause earlier even if your ovaries are conserved, but without the change in cycle sometimes it is much more tricky to recognise a perimenopause presentation of fatigue, anxiety and poor sleep for example. Similarly if you are using a hormonal method of contraception that changes your cycle like the hormonal coil and you’re experiencing symptoms blood tests can be useful.

    hormone blood tests can be used to assess when to stop using contraception

    Hormone blood tests & contraception

    Blood tests can be used to help us know when we can safely stop using contraception. Using age alone, it is recommended to continue with contraception until age 55. If we are not using a hormonal method and our periods stop, we can stop contraception 2 years after our last period if it occurs under the age of 50, and 1 year after our last period if we are over the age of 50. 

    If we are not having periods, for example with the hormonal coil, and think we are menopausal and do not want to continue with the coil, the FSH level can help in knowing whether that is the case, and so can stop using contraception.

    Hormone blood tests for understanding symptoms

    Blood tests can also be really helpful in assessing symptoms that could have a number of causes. For example, fatigue is a very common symptom of perimenopause, as is a change in cycle towards longer, heavier periods. Blood tests in this scenario could be useful to check for anaemia and low iron levels.

    There are very few blood tests that are routinely recommended in NHS care, they are largely used to assess for specific causes. When screening blood tests are done sometimes we will find results that are not in the “normal” range, which can cause anxiety. In many situations, for example a slightly low vitamin D level, the result may be difficult to interpret and aiming to normalise the numbers does not always lead to any improvement in how we feel or our long-term health or wellbeing. They may be “normal” for us! There are of course other situations where it is certainly helpful to aim to optimise results.

    Hormone blood tests to assess oestrogen absorption from HRT

    The other main reason for blood tests at menopause is to help with understanding how medications are working for us. They are not needed in most cases, as the best way of knowing if HRT is helping is whether symptoms have improved.

    For example, we know approx 20% of people don’t absorb oestrogen well through the skin and blood tests to measure the oestradiol levels can help us know if this may be the case. Blood tests can’t be used to assess the effects of oral oestrogen, only transdermal oestrogen in the gel, patch or spray.

    Hormone blood tests for testosterone treatment

    Blood tests for testosterone levels are important if testosterone is being considered for use as part of HRT. Before starting testosterone baseline blood tests for testosterone levels help to assess whether levels are low and our oestrogen is optimised, and then during treatment we need to make sure that blood tests for testosterone levels are being kept within the usual range to avoid rare but potentially very significant and irreversible side-effects.

    Further info about hormone blood tests

    Women’s Health Concern leaflet Menopause

    Women’s Health Concern Testosterone