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  • 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

  • Non-hormonal treatments for menopause


    non-hormonal treatments for menopause

    Non-hormonal treatments for menopause are sometimes overshadowed, but not everyone can or wants to take HRT. This blog will cover the non-hormonal treatments for menopause that are available, including for those with hormone sensitive breast cancer and menopause.

    I’ll be focusing on prescribed medications, what’s available now and new developments that are coming soon. Much of the available evidence is for vasomotor symptoms like hot flushes and night sweats, but some medications can also help with sleep, anxiety, low mood and pain.

    Antidepressants for menopausal symptoms

    Antidepressants are the most widely used group of non-hormonal treatments for menopause symptoms. Aswell as helping with anxiety and low mood, they can reduce hot flushes by up to 50%. High doses of antidepressants are not usually required to see the benefits. Some women respond better to one antidepressant than others, so it can be a matter of trial and error to see if you respond to a particular medication.

    Not all of the antidepressants are suitable for all women with breast cancer to take. Some (Sertraline, Fluoxetine, Paroxetine) can reduce the effectiveness of Tamoxifen treatment. Others (for example Venlafaxine) are safe with Tamoxifen treatment.

    Antidepressants are recognised for treatment in women with breast cancer and menopause but not licensed for this use. They are included as recommended options in the British Menopause Society consensus statement “Non-hormonal-based treatments for menopausal symptoms”.

    Initial side-effects of antidepressants can include nausea, dizziness and increased anxiety. These effects are usually transient and settle over time. It can help to start with a low dosage. Sexual dysfunction is a recognised possible side-effect of all antidepressants, and unfortunately does not always improve when the medication is stopped.

    Gabapentinoids for menopausal symptoms

    Gabapentin is used for the treatment of epilepsy and nerve pain. It is used for menopausal symptoms in women with breast cancer but not licensed for this use, and can help with vasomotor symptoms, sleep and pain.

    Pregabalin is used for the treatment of epilepsy and anxiety. It is used for menopausal symptoms in women with breast cancer but not licensed for this use, and can help with vasomotor symptoms and low mood.

    Both drugs have been designated as controlled drugs due to the risk of abuse, and the effects can be increased by alcohol, leading to drowsiness and sedation. Side-effects can include weight gain, dry mouth, dizziness and drowsiness.

    Clonidine for menopausal symptoms

    Clonidine is the only licensed non-hormonal treatment for menopausal symptoms.

    It reduces blood pressure, and so is not suitable for those who have a low blood pressure. It is important to reduce the dosage gradually on stopping treatment to prevent a rebound increase in blood pressure. Side-effects can include sleep disturbance (especially at higher doses), dry mouth, nausea and fatigue.

    Oxybutynin for menopausal symptoms

    Oxybutynin is prescribed for urinary frequency, urgency and urge incontinence. In one relatively small randomised controlled trial, oxybutynin improved sleep quality and vasomotor symptoms. It is not currently included in the British Menopause Society consensus statement “Non-hormonal-based treatments for menopausal symptoms”. 

    Side-effects are common, including a dry mouth, constipation, blurred vision and dizziness. Using oxybutynin in the patch formulation rather than the tablet formulation can moderate these effects.

    Neurokinin receptor 3 (NK3) antagonists for menopausal symptoms

    The exciting new development is an entirely new class of drug, the NK3 antagonists, which had remarkable effects for some people in the trials “switching off” their hot flushes within just a few days. Currently they are not able to be prescribed in the UK, but will hopefully be approved for use soon. They have been approved for use by the FDA in America.

    For more info

    Women’s Health Concern

    Complementary & alternative therapies

    MacMillan

    Breast cancer treatment and
    menopausal symptoms

  • Cervical screening, what you need to know.

    Cervical screening ribbon, cervical cancer awareness

    A cervical screen, or smear test, takes just 5 minutes and can help us to know whether we are at risk of developing cervical cancer, yet so many of us put it off. This blog will give you more information about what’s involved, to inform your decision making.

    Cervical cancer

    In the UK <1% people with a cervix will develop cervical cancer. Risk factors for developing cervical cancer include:

    • smoking
    • combined contraceptive pill usage
    • HIV
    • maternal history of DES usage (a medication given to some pregnant women for miscarriage until the 70s)

    Cervical cancer mortality rates have reduced by 70% since the start of the UK screening programme.

    The invite for a smear test

    To receive an invite automatically you need to be registered with a GP surgery, be aged between 25 and 64, and be registered as female with your GP surgery.

    If you have a cervix and are not registered as female with your GP surgery the screening is definitely still recommended and although you will not be sent an automatic invite you can request an appointment from your GP surgery, and ask them to automatically invite you themselves next time. More info is available from Jo’s trust.

    Invites for your screening appointment are sent by post from the screening office, so do keep your address up to date with your GP. If you don’t book after the first invite the screening office will send a reminder 18 weeks later. They then let your GP know if you haven’t taken up the offer, and your GP surgery may well then text you or contact you directly by phone or letter.

    The interval between appointments depends on your previous result, and may be 1 year, 3 years or 5 years. Or you may be invited direct to colposcopy for an additional examination.

    Screening rates are falling, and currently nearly 1 in 3 people eligible for cervical screening don’t take up the invite. There can be many different factors that contribute to this, including difficulties in getting appointments through to experiences of pain with the appointment, embarrassment of the test itself, and fear of what the results may show. Rates of uptake are known to be lower for those with a disability, those who do not have English as their first language and those over the age of 50.

    Symptoms to report

    Any new symptoms such as a change in vaginal bleeding or persistent vaginal discharge should be checked with your GP or ANP. Don’t just book for a cervical screening appointment.

    The smear test itself

    The testing has changed over the last few years, and now in England, Scotland and Wales the cervical screening test checks for the HPV virus. If certain types of the virus are present then checks are made on the cells themselves. This has made the test more accurate for us, and means less of us will need to have further examinations.

    The testing is done via a speculum examination. Depending on the position of your womb (uterus), the clinician may ask you to raise your hips by placing your hands under your buttocks. Our wombs are all positioned differently, and the position can vary through the menstrual cycle, don’t be worried if you are told yours is tilted!

    The sample is sent to the lab and the results are then sent to you directly by post, so do make sure your GP surgery has the correct contact details for you to receive your results. You should get your results within 2 weeks and your GP surgery will receive a copy of the results when you do.

    Jo's cervical Cancer Trust image of a cervical screening examination with a speculum

    HPV

    Human papillomavirus (HPV) is a very common virus, and most of us will have it at somepoint in our lives. It is transmitted through skin to skin sexual contact. HPV can infect the skin and any moist membrane, including the cervix, vagina, vulva, anus and mouth. There are over 200 types of strains of HPV, and <10% of the strains are linked with the development of cancer.

    90% of the time when we have HPV it goes away within 2 years without causing any problems.

    On occasion though it can be persistent, and if this is with a higher-risk strain it can lead to pre-cancerous changes in cervical cells. HPV is more likely to be persistent if we smoke. We don’t know when we have HPV or pre-cancerous changes in cervical cells, which is why the screening test for persistent high risk strains is so useful for us.

    >99.5% of cervical cancer is caused by HPV. Pre-cancerous cell changes can usually be treated effectively.

    Young people are now offered HPV vaccines at school. The screening programme is still recommended even if a young person has received the vaccine. The current vaccine being used protects against 9 types of HPV, which cause >95% of cervical cancers.

    Your cervical screening results

    When you receive your results you may see

    • HPV negative – no further tests needed, “routine” recall e.g. 3 years
    • HPV positive, no abnormal cells present – no further tests needed, “sooner” recall e.g. 1 year
    • HPV positive, abnormal cells present – you will be automatically referred for a colposcopy, an extra examination to further assess (and treat) the abnormal cells
    • Inadequate – the sample could not be analysed well enough to give a reliable result – you will be asked to attend for a further test in 3 months time

    Cervical screening at menopause

    The rate of screening in those over the age of 50 is at an all-time low. A survey by Jo’s Trust of those over 50 reported that 29.1% of women over 50 had found the screening test painful since becoming older.

    The genito-urinary syndrome of the menopause (GSM) can be treated though. For cervical screening the use of local, vaginal oestrogen for at least 2 weeks prior to the test can make a considerable difference. Different labs will have different guidelines about when treatment needs to be stopped before the test – usually a few days. You can check with the practice nurse at your surgery.

    GSM can also mean we are more liekly to receive an “inadequate” result, which can be extremely frustrating, especially if the procedure was painful.

    Top tips if you’re worried about attending for a cervical screen

    If you can, do try to share any worries you have about the test with the clinician. They are very likely to have heard those same worries before, and can give you some personal advice.

    These things sometimes help:

    • You can ask for a chaperone.
    • You can ask for a clinician of a particular gender.
    • You can bring a friend to the appointment
    • You can bring something to listen to during the appointment.
    • Wearing a dress or skirt may help you feel less exposed. It’s fine to keep your socks on!
    • Try to prioritise the appointment in your diary, as you would for a child or partner’s essential healthcare appointment.

    It can be very difficult to attend for a screening appointment if you have experienced any type of sexual violence in the past. You can book an appointment to talk the test through, to see whether there is a way the appointment can go ahead in a manner that works for you. Sometimes people like to see/feel the speculum, sometimes people prefer to insert the speculum themselves with the clinician then taking the test.

    The future of smear tests

    Hopefully soon cervical screening tests will be done at home with a self-sampling kit. The You Screen study trialled this in certain parts of the UK in 2021.

    There are private kits available to buy online, but the results of these are not acted on by the NHS screening programme, so it is best to attend your GP surgery for screening if you feel able to.

    Whether or not to attend is your choice, you can opt in or out of the screening programme at any time.

    Cervical screening is certainly a test I’d recommend if you feel able to attend.

    For more info..

    What is cervical screening – NHS

    Colposcopy information – Jo’s Trust

    Macmillan – Cervical screening awareness week

    HPV vaccine – NHS website

    Vaginal dryness – Women’s Health Concern