I recently had the pleasure of meeting and interviewing Diane Danzebrink. Diane is a Psychotherapist, Menopause Expert and Wellbeing Consultant who specialises in working privately with women and couples guiding and supporting them through menopause, midlife and beyond. She also provides bespoke menopause training and support solutions for businesses and organisations and menopause training for therapists.
Diane believes that every woman should have access to information, education, advice and emotional support to empower them to take control of their health and wellbeing during menopause. Her own experience of menopause made her acutely aware of just how little support was available to women and their families and as a result she created menopausesupport.co.uk which offers telephone or Skype consultations and private therapy & coaching programmes. She also hosts a closed Facebook group, The Menopause Support Network, and runs educational workshops.
It would be really interesting to know more about what you do in your role and how you came to work in women's health.
Diane: I’m a psychotherapist and I suppose really my interest has always been there, but because of my own experience of menopause, which was six years ago, which was pretty horrible - I had a hysterectomy and unfortunately didn’t have lots of, or didn’t have any, advice or counselling beforehand to know what the impact of menopause might be once you’ve had a hysterectomy. My own experience was pretty horrible and that got me thinking, I wonder how many more women are struggling? Once I realised actually that was thousands of women, it made me want to look a little more deeply at what support and advice really was out there.
Sadly, when I did start to look at that, there was very little available, so I decided that when I felt better, probably took me about 18 months to kind of feel back to myself, I decided that I would set up some kind of support service. So I created menopausesupport.co.uk and Menopause Support does two things really. It offers support, advice, education information to women, also to my fellow therapists and also to businesses and organisations. I run a private Facebook group which has, at the moment, about 3000 members called The Menopause Support Network where women can come and ask their questions, and we do our best to support each other, but also to give factual, evidence-based information.
And then in my private work, I work as a menopause counsellor. Menopause is about an awful lot more than just hot flushes and there is definitely, it’s a very transformational time of life and that can take many forms, and for many women they really want to work with somebody who understands that transformation from a personal point of view, but also from a research point of view. That’s kind of very much what I do and as you’re probably aware, I’m also a passionate campaigner for women’s health and menopause specifically. So Menopause Support has three campaign aims that I campaign at every opportunity for.
Can you tell us a bit more about what happens during menopause?
Diane: Yeah sure, so it’s starting to change, we’re starting to see more evidence-based information out there for women, but the process of menopause itself, it starts for many women, so we’ll maybe go on a little bit later to talk about early menopause, but it starts for majority of women, what’s called peri-menopause, starts probably in the late thirties early forties and that's when the hormone levels start to fluctuate. The hormone levels are starting to fluctuate. Essentially the ovaries are running out of eggs and as the hormone levels start to fluctuate, symptoms start to occur, but as I said it earlier, it’s not just hot flushes.
Menopause symptoms can be very varied, and every woman is an individual. Peri-menopause can last, for some women, it can last months, for the majority of women peri-menopause will last several years. Menopause itself is quite confusing because the clinical definition of menopause is actually just one day. So the word menopause clinically is 12 months and one day without a period. That's your menopause day. Everything after that is post-menopause, but post-menopause doesn’t necessarily mean no symptoms. The whole menopausal transition for many women, lasts between four and eight years.
For some women, there’ll have absolutely no symptoms at all. Twenty-five percent of women will have no menopause symptoms whatsoever, apart from their periods, probably getting lighter, more irregular and then eventually stopping. The other 75% of women will have some symptoms and25% of women will have what are referred to as debilitating symptoms. So severely affecting quality of life in some way, shape or form. So yeah, it’s a very very individual experience.
Are there any links to how your mother, for example, has experienced menopause?
Diane: Yeah, so we don’t have enough research in this area but yes there certainly are some, and it’s probably more about what we kind of know from the field, so what we know from women. So if your mother had, particularly if your mother had an early menopause, it’s likely that you could also have an early menopause. If your mother had a very trouble-free menopause, you may be fortunate and have a very trouble-free menopause. I think the thing is we need a lot more research to know but certainly what we hear from women is that there can be a link there.
Many women suffer from severe PMS or PMDD, are there any links between PMS and experience of menopause?
Diane: Yeah, so if you’ve experienced severe PMS, then the research that we have tells us that it is likely that you will experience probably a tricky menopause, but again I think what we need to be really aware of is that there are lots of things that can be done, with the right information and support, it doesn’t have to be like that, andI think we’re just kind of starting to explore as women, how we can arm ourselves with the right information, rather than menopause coming along somewhere in our mid-forties and slapping us in the face.
It’s really important that we start to talk about this earlier so that women and men, are very aware that there is support there, but it’s about accessing it’s and also about empowering yourself with the right information about taking control of your own health, so that when those symptoms start to come on and you perhaps go to see your doctor or whoever it is you choose to visit, you know what’s going on for you, and you have the facts.
I’m 32 at the minute, what should I be thinking about in terms of preparing my body and mind for the transition?
Diane: I think the thing is, as I would say to anybody, man or woman, it’s so important for us to live a life in balance so the first thing that I would be looking at, if you and I were working together is:
What is your life-balance like?
How are you looking after yourself?
How much time do you have to do the things you need to do?
How much stress do you have in your life?
What does your lifestyle look like?
What does your diet look like?
Do you drink, do you smoke, do you take exercise?
The better we look after ourselves, the better we will be as we come into the later stages of our life. It’s so important that we care for ourselves, and again I think that’s about education. It’s about educating young people, into if you look you look after your body well, as you come into these, because let’s face it, it is a natural stage of life.
It’s just about us being prepared and as far as specifically what you can do, I think it’s about understanding your own cycle, and what’s going on for you. I would probably be, you possibly do it already if you suffer from severe PMS or PMDD, I would be encouraging you to track your cycle, I would be encouraging you to keep notes of the kind of emotions that you have at certain times of the month, and then I would be saying to you, as a woman of 32 who does experience PMDD, OK so if I was you, I would start to look at some of the resources that give you factual, evidence-based information so that you know that when those first symptoms of menopause start to happen, you’ll recognise them. Because for many women, that’s one of the issues is that they don’t recognise those first symptoms because they’re symptoms we don’t talk about in relation to menopause.
What are some of those other symptoms?
Diane: Some people will tell you there are 34 symptoms for menopause, some people will tell you there are up to 66 symptoms of menopause, but there are some that come up time and time again and it’s really the mental and emotional symptoms that tend to be the ones that come up first in peri-menopause for many women and that’s because it's as our progesterone levels fall, one of the jobs of progesterone in the body is to act as one of the body’s calmers, so as that starts to fall, quite often, one of the first symptoms for many women is anxiety or panic, or difficulty concentrating, or what lots of people call fuzzy brain or cotton wool head. Perhaps just feeling low or unhappy or what lots of women describe as depressed. They’ve probably never experienced anything like depression in their lives before, but they start to feel down, and they don’t understand why.
So, very often it’s not physical symptoms that come first, it’s those mental and emotional symptoms and that leads to women thinking, what's going on? What’s happening to me? I can’t tell you the amount of women that I have counselled who have started to wonder about their cognitive function and their capacity and when you explain to them, actually this is your hormones changing, it’s a huge relief because then they start to understand what’s going on, so then add into that that as your progesterone levels start to fall, then your oestrogen levels start to peak and dip, which for those of us that suffered with PMS, you will recognise this, but it’s then that you can start to add in some of the other symptoms. So you might then start to have more or less headaches or headaches when you’ve never had headaches before. You might start to be experiencing muscle and joint pain. You might start to have some hot flushes or some night sweats. Quite a lot of women talk about crying for no reason, just out of nowhere. Lots of women talk about suddenly developing palpitations that they’ve never had before and the ones that we don’t talk about because it’s embarrassing are the vaginal symptoms and urinary symptoms. So, for a lot of women they start to struggle with urinary tract infections or more recurrent urinary tract infections or vaginal dryness, soreness which can lead to vaginal atrophy and so they’re things that are really important, that women are aware that those symptoms can be related to their menopause because then they can do something about it.
But again, all of these things can be managed if women know what the options are, and I think that’s the key is it’s fine to know what menopause is, what the symptoms are, but then we need to be empowering women with, OK so this is what you can do about it. But we need to be teaching men too because if we taught boys and girls, age appropriately, then it can be that if the woman is starting to experience some of those mental and emotional symptoms, it actually might be a brother or a partner who might start to recognise those and actually be able to start that conversation and say, do you think this could possibly be? Because it can be that you can have all these symptoms and your periods haven't changed dramatically.
So if you’re thinking menopause is hot flushes and heavier or lighter periods and neither of those things have appeared, what I see a lot of, is women in a highly anxious state because they’re really worried about what’s happening to their bodies and their minds.
But once you explain that this is what’s happening and that actually there are things that they can do about it, there’s this huge sense of relief, but we don’t want to be reactive about this, we should be being proactive about it, because very often I’m speaking to women who are saying but I’ve been to my doctor and my doctor hasn’t mentioned menopause. They’ve maybe sent me for a cardiology appointment to see why I’ve got palpitations or they’re sending me to see a rheumatologist because of my aches and pains but nobody’s mentioned it, or they’ve given me anti-depressants because I’ve said I’m depressed. And this is another issue is that we desperately need to address the lack of education for our healthcare professionals.
Women’s health within GP education, garners very very little attention and I know that there are some moves to try to address that, but we need it now and as we don’t have it, that’s even more reason for women to actually get the information themselves because I don't know how long it will be before that improvement comes. Not just for our doctors but also for our practice nurses because our practices nurses can be such a fabulous resource and whilst they're all very busy and all got a huge workload on, we need to find a way to get this information out there, not just for menopause but for all women’s health issues because if we don’t it’s doing two things. It’s meaning that far too many women are suffering in silence from all sorts of issues and conditions but it also means that they’re going for repeated appointments with GP’s and practice nurses and so they’re appointments that are being taken up when actually if you went and saw somebody that recognised what was going on with you and could diagnose you at that point, it’s win-win situation. The woman is empowered because she understands what’s happening to her and we take up less GP appointments.
It absolutely makes sense for me, but we need to find a way to get this information out there, and for me,I think that one of the ways that we could do this is with information films via the internet. It totally makes sense to me. So many people now have access that if we had, probably most people that are listening are too young to remember but many years ago we used to have infomercials that were created at government level. I think probably the last one was the HIV campaign which was a fantastic campaign and gave out lots of information to lots of people. I think now we don’t have to worry about it being on TV, now it could be something that was created, that everybody had access to, that they could watch on their computer screen or on their phone, yeah that’s a no-brainer for me. That totally makes sense.
Why do you think we've arrived at this place?
Diane: I believe that the reason that we’ve arrived at this place is because of history, essentially. If you look back through history, you will see that for centuries women health has been medicated by men. We only have to look back to Greek and Roman times when the word hysteria was used around women’s health. That became very popular again in Victorian times when women, particularly during menopause, were described as hysterical and confined to asylums by husbands who found them, I think the word was “troublesome” and unfortunately, if you think about it, the Victorian era didn’t end until the late 1800’s early 1900’s. We're only about 100 years down the line. We didn’t have women doctors, we didn’t have female physicians. Women weren’t allowed to train as doctors. Actually, there were a couple of efforts to get women into medical schools, but it didn’t really happen in any numbers until about the mid-1940’s.
Sixty years ago and I think the thing is essentially we’re dealing with the weight of history. Not the fault of anybody alive today but we are being reactive to something that is part of the woman’s lifecycle. We haven’t addressed it in proactive way.
I think back to my grandmother who had six children, who was a housewife. I know I was young, but I think my grandmother just locked herself away for her menopause. That’s not that long ago. I think my own mother, she had a horrible time. I probably wouldn’t have known so much about it if she hadn’t had had such a difficult time, but I think it’s not that long ago that women just used to get on with it and I think the idea of, well women got on with it in the past, why can’t you just get on with it now? This is not a race to the bottom. If women struggled in the past, that doesn’t mean that women should struggle now, any more than if there were men’s health issues that men have struggled with in the past, they certainly shouldn't be struggling now either. This is about improving things for everybody.
So I think we’re kind of playing catch-up in massive way. Fortunately, I think this generation of women have felt far more confident to be able to speak about their menopause, or we have women now who can talk about their PMDD, which is something that we need to talk a lot more about because so many women aren’t aware of it. We’ve had a great campaign around trying to raise the awareness around endometriosis, we also have to address adenomyosis, another incredibly painful condition that most women don’t even know they’ve got, they just very often are told, no go away.
Putting up with heavy bleeding or bleeding for weeks and months, it’s not normal, but we shouldn’t be normalising these things, and we certainly shouldn’t be just medicating them. What we need to be doing is we need to be finding out why this is happening. So I think for a long time, women have put up and shut up. I think for a long time the knowledge; the professional knowledge has not been there. We do certainly have some passionate experts now which is great, we also have lots of patient experts and we need to be listening to those people because if you have experienced this and it’s something that has made you passionate about sharing that information, then that’s a valuable resource, and we need to be listening to that too.
We talked earlier about early menopause, what is early menopause and why should we be aware of it?
Diane: Early menopause is menopause that occurs before the age of 45. Premature menopause, which is clinically referred to as premature ovarian insufficiency, that’s menopause that happens before the age of 40. So currently in the UK, the figures are that one in a hundred women under 40 will experience premature menopause, one in a thousand under 30 and one in 10,000 under 20. So my youngest client, the youngest woman that I’ve supported through premature ovarian insufficiency, is 17. That’s really really unusual but we’re a population of getting towards 70 million, 51% of us are women, so if you think one in a hundred under 40 will experience premature menopause, and one in a thousand under thirty, we need to be aware of it because very often it takes a long time to be diagnosed.
If we can encourage women and give them the information that they need, not necessarily for themselves, but if it’s one in a hundred under 40, if you work within a big organisation, it’s quite likely that there will be somebody in that organisation that will be experiencing premature menopause. And premature menopause, the reason that it’s so important that it’s diagnosed and that the woman understands her choices around how that can be managed is really about the long-term health effects of a lack of oestrogen. So once oestrogen starts to deplete, we have to look at how that affects bone, heart and brain health. So we have oestrogen receptors all over the body which is why the symptoms can be so varied but particularly around our bone, brain and heart health, it’s really important for those women who are experiencing rapid depletion of oestrogen in their teens, twenties or thirties particularly, that we focus on that and that they understand that there are management tools out there to help them because, I’ll give you a for instance.
I went to an organisation recently and gave a menopause awareness talk to the staff, and it was a staff of all women, and there was a young woman there who is now in her probably mid to late twenties and when we’d finished she came and found me and I’d been talking about the effect of rapidly depleting oestrogen on women who experience premature ovarian insufficiency and how that can affect their bone health and that in later life, if that’s not addressed with replacement hormones, how that can lead to osteoporosis. And she came and found me and said that she was really glad that she’d come that day, even though she was only in her twenties because her grandmother, her mother and her four aunts had all had premature menopause, none of them had been advised about the need to consider hormone replacement therapy and all six had osteoporosis. So that’s six women who are now experiencing the effects of osteoporosis, so that’s six women that the NHS is treating for osteoporosis. Osteoporotic fractures in women are hugely more prevalent than they are in men over 50, so this is gonna be about their long-term quality of life and for her, she now knows she has a choice. It will be up to her to decide but she now knows and, of course, she knows that’s in her family line but now knows that she has a choice over that.
So we really do need to inform and support those women. And, of course, the other thing about premature ovarian insufficiency is that it’s very important that those women have some kind of emotional support, some kind of professional emotional support because not only are they going to be experiencing menopause in perhaps their teens, twenties, thirties, but for those women, if they’re women who were hoping to have a family, then obviously they have that to cope with too. If they’re also women who are experiencing their premature ovarian insufficiency as a result of medical treatment for perhaps a cancer, they then have that added to the fact that they have menopause and they have then to consider if I’m now no longer fertile how do I think about my future, how do I think about creating a family, if that was in their life plan. So that needs huge specialist, professional, experienced emotional support. We have the mental, the emotional and the physical and the long-term health.
So I know I sound like a well-worn record but it’s all about education and it’s about education before these things come along. I don’t believe it’s happening in all schools, but I know that there is generally some talk of periods. I believe we touch on pregnancy. It’s as if women have periods, some not all are able to become pregnant or choose to. But it’s as if after pregnancy that’s it and that’s simply not true. For most women, if their menopause comes in their mid-forties, the majority of women alive today, will be predicted to live well into their mid-eighties and those women deserve to live happy, healthy productive lives and they can only do that with the right information and support.
What do we need to be teaching in schools?
Diane: I believe that we need to be teaching both boys and girls, so I think it’s equally important that we teach both boys and girls about the reproductive life cycle of a man and a woman. Certainly we want to talk about periods, we want to talk about cycles. We also need to be talking about PMS we also need to be talking about PMDD, we also need to be talking about things like endometriosis, poly-cystic ovaries because the thing is, some of those girls could already be experiencing some of those things. I can’t tell you the amount of young women that I’ve spoken to who have been told that they’re too young to have endometriosis or they’ve been told, heavy periods is just part of life. And the thing is, if those young women, if they’re aware of that and if a young man is dating a young woman or if a young woman is dating a young woman and one of them is experiencing, if their partner is experiencing one of those things, then they should both have the information that actually that’s not quite right. Because if we start to teach, I would be advocating to be teaching this from around the age of 11, 12 and I think it needs to be taught appropriately.
It needs not to be taught as, you need to be worried about this, you need to be scared about this. I think it should be taught as, you need to have this information because, and this is how prevalent this is within society, but if this does happen, these are the things you can do about it. This is who you can ask, this is where you can go. And I think that one of the things we really need to do, is we need to encourage our young men and women to be mutually supportive. Because if you understand why a woman is experiencing her PMS, then it makes sense. If it’s just, oh well she gets grumpy and she gets ratty, but you don’t understand why, then that’s not helpful to either of you, that’s not gonna be helpful as you go on to form longer-lasting relationships, it’s certainly not gonna be helpful as that woman then comes into menopause.
But equally, I think we also need to be talking about what happens to men and we need to be talking about your testosterone levels are going to peak at this age, and then they start to deplete, and I think the fact that we still struggle very much to talk about our reproductive organs with the right words. The amount of people that seem to think that the only part of a woman’s reproductive organs is called her vagina. No, what about the vulva? Even in this day and age we still seem to struggle with that. So I think if we started at the age of 11, 12 etc., and we started to introduce this conversation to everybody then it would normalise it. It is just part of life, it is part of who we are. It would make for much less stress for individuals, it would make for much less stress within partnerships and couples. Parents would feel so much more comfortable talking to their children because the parents would feel informed and they would feel as though, this is normal. Why would I call a vagina a foo foo or whatever the other ridiculous names that they get, or a mini or whatever? It’s like no, it’s a vagina, it’s a vulva, that’s what they are. I really think we need to get over this massively because there is just still so much silliness around it and I think it would make, well I don't think I know, because I see these people, I speak to these people. The amount of relationship breakdown that comes because of this lack of information and this lack of communication.
To give a you a really brief example, a few months ago I was in Manchester, I taught a workshop to 30 women and I’d been talking for about 15 minutes and one of the women, she was very emotional, and she said, I wished I’d’ve known what you’ve said already years ago, because I think that could have saved my marriage. And the thing is when communication breaks down, when intimacy breaks down within relationships, this void happens and because nobody knows how to bridge the gap, the gap just gets wider, and unless one part of the partnership gets some information and pulls on their big boy or big girls pants, and gets really brave and says, I think we need to talk about this, what happens is very often, if a woman is struggling with, it could be psychologically, it could be physically, it could be the heat of flushes, it could be the pain from intercourse, it could be the recurrent UTI’s that can happen, what will happen is, she will recoil from any kind of physical contact, because if physical contact then might lead to any kind of sexual activity and she’s trying to avoid that, her partner will start to feel isolated, but if that doesn’t lead to a conversation that just goes on.
And then that starts to become a problem and then that problem starts to turn into rows and then those rows start to escalate, and then tiny little things start to become massive and then you’re heading towards relationship breakdown. And that is probably the most heart-breaking part of my job. It is, it is because it’s so needless, in fact, most of this is needless, the suffering is needless, the lack of knowledge is needless, particularly today. And I don’t just mean in partnerships, there are also issues within families.
We also have the situation where currently the figures from the most recent survey are that one in ten women are leaving the workplace because of the menopause symptoms. Twenty-five percent consider leaving the workplace. Many women will go on long-term sick because of their menopause symptoms but they won’t report that they’re menopause symptoms because they don’t want to say so.
So again that worn record comes back, we go back to education because if all men and all women were educated that means that all bosses whether men or women, even if as a female boss, if you were one of the 25% who had a really trouble-free menopause, fantastic but then you wouldn’t judge everybody else’s by your own. And that is something that we tend to do. As human beings we tend to judge everybody else's experience by ours and unfortunately what happens then is that women who are having a really tough time, if you’re in an organisation where the person heading that organisation up is either a man who, let’s face it, how can he possibly be expected to know what it’s gonna be like, or you’re a woman who’s flown through it, and neither of those have any understanding of what it’s like, they’re not gonna be a boss who is going to think, what we should be doing here is we should be raising awareness and we should be creating a supportive pathway for these women because we certainly don’t want to lose these very productive, very committed employees.
I know that I make things sound very simple but the whole thing for me, you know sometimes I want to hit my head off a wall to be honest with you, because the whole thing for me is just such a win-win situation. I don’t see a downside to men and women understanding ourselves or each other better.
How do menopause symptoms impact women at work?
Diane: It’s fair to say that I probably only see the women who are experiencing probably the more severe end, the debilitating symptoms, so I'm probably never gonna see the 25% that don’t have any. I’m probably unlikely to see the 50% in the middle who have some symptoms, but they are coping with them. It’s probably only those that experience the debilitating symptoms that I’m gonna see and very often, I would say in fact, I could probably say almost 100% the ones that come to see me, come and see me and they sit in the seat you're sitting in now and they say, I don’t know what’s wrong with me, I’m really anxious, some of them are having panic attacks, I’ve been to my doctor and my doctor’s put me on one of several different anti-depressants and I think the reason they’ve probably come to see me is because they know I specialise in working in menopause. Some of them actually don’t, some of them just come along because of what I do professionally and then we start to talk about it and then I say to them, actually has anything else changed recently? And they’ll say, either generally something about their periods or they’ll say about their lethargy or their tiredness or the that fact that they’re not running as often because their knees have started to ache, etc., etc., and then I generally get out my symptom checker, and we start to talk.
It really starts to affect their confidence because they’re starting to doubt their own ability to do the job properly and so I have counselled several police officers, nurses etc. So if somebody has a position of not just responsibility but responsibility for another person or for a group of people, that can be hugely debilitating because they’re not just worrying about themselves, they’re worrying about how they are doing their job, how well they’re doing it for those people that working with. If they’re struggling with headaches or migraines, obviously if they’re people who are spending a lot of time looking at a screen, that’s awful for them. If they’re in a big office with lots of other people they’re very well aware of what’s going on with them and it kind of makes them hyper-vigilant about, is everybody else watching me because I’m worried? So it’s generally anxiety that is overriding. If there are physical symptoms, the hot flushes, then particularly those that I tend to see, are generally those that have to kind of stand up in a meeting, or are in a management position, and all of sudden they feel their authority is compromised because they’re worried about standing up and delivering the next speech, presentation, etc. I have counselled several teachers who have been experiencing repeated urinary tract infections and that’s an absolute nightmare for a teacher because you can’t just walk out the class. That’s really difficult and then it’s the fear of how is the information that they’re struggling with menopause symptoms going to be accepted within the workplace?
We’re in a situation where there is definitely a raised awareness within some organisations of menopause, but we've still got an incredibly long way to go. So, again I’m not going to see those women where there is some kind of guidance within the workplace, but it really only is the last couple of years that there has really been this awareness raising. There are some really useful, for organisations, there are some really useful free tools out there. The Faculty of Occupational Medicine have produced a great little four-page document that gives information to employers about very very simple changes that they can make to help women in the workplace.
There’s lots of things coming, but it very much comes down to the willingness of the organisation to engage, butI think also perhaps we’re still playing catch-up here because we've now got more women in the workplace over 50 than we’ve ever had. So I think a little bit like we spoke earlier about the way that women's health has been medicalised and we’re playing catch-up with that, we're also playing catch-up in the workplace. Because for a long time menopause in the workplace wasn’t an issue. It’s only really the last 50 years where we’ve had more and more women in the workplace, so I think we’re still very much playing a game of catch-up here. So, again it’s about being reactive to change, we just need to catch up quickly because it would be really sad to see women who either want to remain in the workplace or for their family finances, need to, having to leave and those organisations losing those valuable members of staff. I think it’s about getting that message out there that again, this is a win-win situation.
What advice would you give to women if they are struggling at work, but they're afraid of asking for help?
Diane: My advice to those women would be to go outside of the organisation, to seek out as much information as they can about what’s going on for them. So, things like,Women’s Health Concern. So Women’s Health Concern, essentially it’s the patient arm of the British Menopause Society. There are pages and pages and pages of information of, again I go back to it, factual, evidence-based information on there that women can access free. There is the Royal College of Obs and Gynae, they’ve quite recently updated all their information. There’s obviously Menopause Support, we’re always welcoming of new people, there is a great website that a colleague of mine has written, a lady called Dr Louise Newson, she’s a menopause doctor. Her website is packed with information, also a fantastic gynaecologist who’s one our absolute menopause specialists also actually probably one of our best specialists around PMDD, Nick Panay, so he has a website, Hormone Health, there’s lots of information on there. Even if you can’t find what you’re looking for there, is to contact, drop me an email or somebody who does something like me to kind of be signposted the right way.
Something that I’ve started to do, is I’ve started to write blogs around issues that come up regularly on the menopause support network. So one of the things that came up was, I’m really nervous about going and seeing my doctor, I don’t know what to do. So I wrote how to get the best out of your doctor’s appointment. Following up from thatI wrote ten things your doctor should know about menopause. So one of the things I would say, is there is a key piece of information that was issued really for healthcare professionals which is the NICE guidelines on menopause. They were issued in November 2015. They’re the first guidelines we’ve ever had in the UK on menopause. It is quite a weighty tome, but you can access it free online, but there is part of it that is written for women, it’s written for patients, so every woman can read it and that’s a great document because it tells you all about what menopause is, tells you everything that your doctor should be doing and tells you everything that you need to know. So in one document, you’ve got lots of information. Now, whilst the NICE guidelines are fabulous and it’s great to have them, there is no enforcement of them. So it’s really up to CCG’s to encourage healthcare professionals within their area to read and implement those guidelines, but my experience is, many doctors have not read them. And again, that comes down to a time issue. There are lots of NICE guidelines and there are only so many hours in any doctor’s day.
But again if we go back to if we taught doctors sufficiently when they were at medical school, then they wouldn’t have to then be trawling all the way through the NICE guidelines. But if your doctor doesn’t have time to read them, then you probably do, so it’s a good thing to do for you to read them, and then when you go and see your doctor, one of the things that I say to women is, if your doctor says, do you know what, I don’t actually know much about this, and you know, fair play for them for actually saying, I don’t, the thing I would say is, say to them OK, well this is what I think I am struggling with, if you don’t know, could you speak to a colleague or go away and have a look at the NICE guidelines and call me when you’ve done that or can I make an appointment for 10 days’ time and come back in and see you, cos I really want to address this but I want to address it with you, when you do feel that you’re armed with all the right information to help me. So, I totally understand what you’re saying, about those women in those positions where they don’t want to be the first one to kind of go and have that conversation, and there is fear, there is no doubt about it, I hear it quite regularly. But the thing is, if they take the steps to be able to address what’s going on for them, then they might be that leader within that organisation that will recognise, OK the next step is we need to raise awareness here. Because once you’ve managed your own symptoms in whatever way that feels right for you, you could maybe then go and say, this was going on for me, it’s not now, it’s still happening but I feel that I’ve managed it in a way that’s appropriate for me but it’s made me think, maybe we should be looking at colleagues and how we can support them.
What are the treatment options for menopause?
Diane: OK, so for women who are experiencing menopause with no pre-existing health conditions the first line option should be hormone replacement therapy or HRT and that’s because HRT is the most effective treatment for menopause symptoms. As you’re probably well aware, there’s been lots and lots of scare stories, particularly since to 2002, about HRT. Thankfully, in more recent years, we have seen that a lot of those scare stories were based on insufficient information and flawed research essentially. So again, I would really urge people to look at what the facts are rather than what the myths that have grown up are.
One of the issues around hormone replacement therapy used to be about the way that it was made or produced and if you look at menopause forums, or any online groups, you will still regularly see the issue of, well I’m not taking it because it’s made from horses wee. So hormone replacement therapy, the oestrogen part used to be produced and is still quite a lot in America and Canada, is still produced from pregnant mares’ urine and when I heard about that, I was horrified. But certainly over the last ten probably longer years, there has been oestrogen that is plant-derived. So it’s mainly derived from the yam and we also actually now have a progesterone that’s plant derived. So they’re called body identical hormones, not to be confused with the marketing term, bio-identical hormones. So bio-identical is a marketing term used by private doctors who have in the past, advertised that the type of HRT that they can give you is more effective and safer than anything you can get from your GP. The advertising standards authority towards the end of last year, banned that advertising. They can still advertise, but they can’t say those things because there’s no clinical proof for that. But you can get body-identical HRT both oestrogen and progesterone from your GP. Body-identical essentially means that the molecules in the product are almost identical to the oestrogen and progesterone that we produce naturally.
HRT is not one size fits all. It’s very individual, there are lots of different types of HRT. There are two different ways of taking it, depending on whether or not you’re still having periods, there are lots of different strengths, so it can be tailored to you by your doctor or your gynaecologist, but there are some women who absolutely cannot have HRT. There are far fewer women who absolutely can’t have it than maybe they’ve been led to believe. So again I would urge you to get up-to-date information so women who are overweight, women who smoke, are very often told, you can’t have it. That’s absolute nonsense, they can have it transdermally which means through the skin. So it’s not advisable for those women to take HRT orally because that means doing the first pass through the gut and the liver. So ideally, they should take it transdermally, that would go straight into the bloodstream. And so again there are choices about that. So for women who can have it, you can take it in the form of a tablet or a gel or a patch. So again there are choices and women should be offered all those choices.
But if you absolutely can’t take it, there are other things that your doctor can prescribe, there are other medications that your doctor can prescribe particularly around controlling what are called the vasomotor symptoms, so that’s your hot flushes and night sweats. So even if you can’t have HRT, doesn’t mean you have to put up with hot flushes and night sweats and then outside of medication, there are lots of other options that you can look at.
So, the first thing that I always encourage my clients to look at, is their lifestyle. It sounds really dull I know, but cutting out things like wine, definitely doesn’t help with hot flushes, spicy food doesn’t help with hot flushes. I would also be encouraging my clients to cut out fizzy drinks, to look at what their diet looks like and as I said to you right at the beginning, what are your stress levels like, what is work-life balance? Actually, I think it should be life-work balance. What is that balance like?
But then there are all sorts of things you can consider so there are some small studies that show that for some women acupuncture can be very useful in helping with those flushes. We can look at vitamins, herbs, minerals. Again it’s about getting the right information. I’ve got quite a lot of clients who have spent hundreds, possibly thousands of pounds on pre-packaged menopause supplements. Now it’s important to say that some of those things work for some people but because menopause is very individual and the symptoms, the whole group of symptoms, you’re gonna have one woman who has three, another woman who has a different three, somebody who only has one, and what works for one woman doesn’t necessarily work for another. I always say, if that’s the route that you would like to take, it’s well worth having a one-off appointment with either a registered dietitian or with a medical herbalist or with a naturopath, so somebody who will actually take your medical history, because of course, it's important to remember that there are interactions with some of the herbs, vitamins, minerals that are not great if you have pre-existing health conditions or if you’re taking other medication. So, for instance, you shouldn’t be using St John’s Wort if you’re taking anti-depressants. You also shouldn’t be using it if you’re on Tamoxifen. If you’ve got a family history of liver conditions then Black Cohosh, since about the 80’s that’s been a really popular supplement for menopause symptoms, Black Cohosh is not great. I think it’s really important that women get the right advice around those things.
I’m a huge advocate of meditation, of mindfulness and of yoga because I think calming the mind, if we become over-stressed in any situation and we’re not thinking rationally about it, so when we go into our emotional brain, we’re reacting rather than responding. The more emotional we get, you’ve heard the ’can’t see the wood for the trees’, you can’t think clearly. So I think that ten minutes, it doesn’t have to be half an hour, you don’t have to be sitting on a hard stone floor, you don’t have to have one leg round your neck, it can just be finding a quiet space that works for you where you can just sit and be, absolutely unencumbered by the rest of the world, for 10 minutes at a time, at the beginning and the end of the day. Something else that is hugely beneficial, and I don’t mean this for just menopausal women, just women, all of us, we should all be taught to breathe effectively. So essentially when we breathe in, we’re using our sympathetic nervous system, makes our body tense up. When we breathe out, we’re using our parasympathetic nervous system, makes us relax, can’t help it. If we breathe out for longer than we breathe in for a sustained period, not only are we relaxing the body but we’re focusing on the counting, bringing us into our rational brain. If your meditation for five minutes in the morning is that you sit quietly, breathe in for count of three and breathe out for a count of five, you will start your day in a balanced way. If you go to bed and do the same thing, you will end your day in a balanced way, and you will aid your sleep. If you take nothing else away from this, then I think it would be really useful, five minutes of focusing on your breathing twice a day would make a huge difference to your day.
What has shocked and surprised you most in your work?
Diane: OK, let’s start with shocked. I think what has shocked me most is just how many women are suffering. I don’t think at the beginning of this journey I was prepared for the depth and breadth of suffering in silence. There go the dogs! I don’t think I was prepared for just how huge this issue is. The most common things that I hear are how alone women feel and how so many of them use the phrase, I’m so glad I found you, I thought I was going mad. I knew that it was there, but I don’t think I realised just, just how almost epidemic that it is. And I’ll be really honest with you, I think it’s a national disgrace that we’re in this situation.
What has surprised me the most is, and it is, I have to say, I’ve spoken about the most heart-breaking part of what I do, but the most joyful part of what I do, is to see the transformation that happens once women are supported, and advised, and empowered to see how suddenly, because we’ve talked a lot about the mental and emotional symptoms, actually this hormonal shift is absolutely transformational because things have changed hugely. So as your oestrogen levels change, your oxytocin levels change, so the oxytocin that made you want to kind of gather everybody to you and nurture everybody and look after them, it doesn’t suddenly disappear, but it’s certainly not at the levels that it was and what that does is that make us focus inwards. We reflect on what life has been, but then we start to look at, OK so what would I now like the next stage of my life to look like and for me, that’s just the most joyful part of what I do because supporting another human being to embrace the next part of their lives and supporting their journey towards what it is that they want to achieve, is a massive privilege and it is just, it’s the best bit, absolutely the best bit.
There are some fantastic things coming from some of this and we’ve talked all about menopause but the men that I work with, that is equally a joy and there is, we talk a lot less about, there’s a shift there too, but I would do that every day, because it is just the best bit, andI think the thing is if we could reframe this whole menopause conversation away from, oh it's all really awful and it's all really negative, there is a massive positive to come out of this, if it is supported in the right way. So if we came towards it and still think we’ve got a way to go, even with menstruation, and with how we interact with each other and supporting relationships, but because menopause has for so long been so ignored, we have a bigger journey there. But because there is such a fantastic opportunity at menopause, I think if we could reframe it a little bit and say, do you know what, it might be tricky for a while, but it doesn’t have to be. You have all these options and if at 39 you’re suddenly thinking, well something’s changed, if you were taught at 16, do you know what kind of late thirties, early forties, this might start to happen, you would suddenly kind of reflect back to that and you would think, do you know what, I need to go to such and such a resource because it's time for me. But also it’s likely that your girlfriends would be talking about it and you might even talk about it with your partner or your mum but whereas we don’t really now. If you’re experiencing when you're in your late thirties, early forties now, most people don’t wanna be the first person to talk about it, because you’re getting old and heaven forbid the kind of social stigma, particularly for women around getting old, but don't get me started. But if we could talk a bit more about some of those positive stories and about some of the amazing transformations and about the opportunity that it presents, I think it would make the whole thing a completely different conversation.
From the research you've done, are there any countries that are getting menopause care right?
Diane: It’s a really interesting question and funnily enough I have just read a really interesting article about menopause care in the States, and it’s not a very positive story, and again it all comes down to education. It’s probably less about how menopause is supported and cared for, I couldn't tell you if there is one country, I’m not aware of one particular country that is doing it brilliantly. Having said that different parts of the world, women have a different menopause experience. So in the west menopause symptoms seem to be more severe and they seem to have a greater depth and breadth. If you were to look at Asia in general, their symptoms don’t tend to be as broad or as wide and there is some suggestion that that’s to do with diet and with it being quite high in soy-based products or beans, lentils etc. etc. phytoestrogens, so natural oestrogens, maybe there isn’t the need for as much intervention but as far as, is there a stand-out country, is there a top of the list for how to, there might be, I haven’t come across it yet?
What is the one message about menopause you want people to take away from this?
Diane: It is, in the majority of cases, a perfectly natural part of life. It absolutely can be managed to a point where it doesn’t have to be debilitating and I would say, knowledge is power, and I would advocate for women and men to take responsibility in as far as you can, because obviously there are some things that you can’t do for yourself, but I would advocate for taking responsibility for your own health, throughout life, as much as you can and I would also say, empower yourself. If you’re not somebody who has been given the information, educate yourself.
Educate yourself as much as you can before it comes along and if you’re somebody who’s now in your mid-forties listening to this thinking, hang on a minute, I can’t really do it before it comes, along, I think it’s here, I would say go and use some of those resources and educate yourself because it’s key that as individuals, one of our key human needs, as individuals, is a need for autonomy.
It’s a need for some kind of control over our own lives and the thing that I hear regularly, is I don’t understand what’s happening to me, I feel out of control and so if you can take that back, even just with knowledge, then you can do something with that knowledge, you can go and see whoever it is you need to see, or you can reassess your fitness regime, or what it is that you choose to put in your body or you can and find somebody that can work with you to help you manage your way through menopause and on to that third stage of life.
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