Menopause, diagnosis and treatment options. 

It's a pleasure.

HI Sue. Thank you for your kind words. Im sorry to hear that. I would go back to your GP, with a copy of the NICE guidance and ask him to look up oestrogel and utrogestan for HRT in his copy of the BNF. Good luck. R

Dear madam, Can you provide us with the name of that private hospital, please? Thanks in advance.

Jessica Jager ah my pleasure. Good luck. R

Wonderful!

Julie Mountford Hi Julie. I’m so pleased, that’s exactly the aim. Good luck. R

Dr Renee Hi again Unfortunately my GP appointment didn’t go very well. She was very lacking in knowledge and spent all my appointment frantically reading the BNF then admitted she didn’t know what to prescribe (as I asked for patches) and would speak to the practice pharmacist and leave a prescription at reception for me. I got my prescription later that day and was prescribed Evorel Conti patches which I’m not sure about as I’ve had about 4 very light periods in the last year, the last being 7 weeks ago. Also I would have preferred one of the newer patches made from yams which I don’t think this is, though I could be wrong as it’s very difficult to get a definite answer on google. I would love it if you could do a more in depth video on the different types and brands of HRT. Thank you for all the fantastic videos, I so wish my GP was as understanding and knowledgeable as you, your patients are very lucky.

Julie Mountford Hi Julie. I have actually done a VLoG on this already. Just hope over the difference between body and bio identicals . This is a body identical oestrogen but you should be on sequi not conti if you have had a period within the last year I’d over 50 and 2 years if under 50. Hope that helps.

Thank you so much for your reply. I will make an appointment to go back to my doctors, and try to get a different GP. I will find your other video so I am fully prepared next time.

Debra Cannon Ah that makes me sad. But if I can help one person in each topic then this is worth it! Thank you for your support and spread the word; the more subscribers the more word spreads! Enjoy your new HRT life! X

Simon Cuthbert Ah what a lovely comment. Thank you Simon.

Debra Cannon Hi Debra. The bloating will be caused by the progestins in the tablets. This is not actually progesterone and so for some people has hear effects. The way to avoid this is to have oestrogen through the skin, either as a gel that you rub in once a day (oestrogel) or an oestrogen path and utrogestan ( bioidentical progesterone) this is the tidally bioidentical method and gives you progesterone, not progestin. If your GP is unsure of the way to give utrogestan, it is in the BNF which they will have e to hand. Hope that helps. Thanks for watching. Renée

Debra Cannon Hi Debra. As you haven't had a period for 4 years you. An have continuous HRT. Why not either have a Mirena Coil put in and have no progesterone just an oestrogen gel that you run in once a day. The could can stay in for 7 years. Or have Everol conti patches. This way you have safer and different absorption and will hopefully feel better. Hope that helps. Renée

Paula & Zac adventurers Hi Paula. Thank you for that lovely comment. I do a VLOG every 2 weeks.. so keep subscribed and you will get notified !

Shan C Hi. Have had a look at the studies and transdermal oestrogen (through the skin) does not seem to affect liver parameters or increase thrombosis in immunosuppressed transplant patients. Clearly this needs to be done with your consultant but it looks fine from the limited look at studies I have seen. Hope that helps. Renée Here is some info: www.ncbi.nlm.nih.gov/pmc/articles/PMC4828501/ www.ncbi.nlm.nih.gov/m/pubmed/9688245/

Debra Cannon well it sounds like that is a reaction to the oral HRT,. So hopefully taking it a different way will not have the same reaction. Good luck

Hey. Thanks for the comment and the watch, Am always keen to learn. So have dug around. Whilst you are partly correct in that child mortality skewed the figures, not totally. We are definitely living longer now, at least another 13 years as demonstrated here. We certainly did not live to 85 as a normal life expectancy and a girl born in London in the next decade may well live until 100. That's a long time without oestrogen. The graph is quite graphic in demonstrating this but yes, often longer than 50 years.Thank you for allowing me to learn another fact or two today! :-) ourworldindata.org/life-expectancy/

This isn't the case. 150 years ago the average life expectancy of a woman was 49. Today it is 83 (depending where you live int he UK).

Heidi S. Hi. Thanks for your comment. I have a VLOG on menopause which covers all menopause, including surgical. Hope it helps. Renée

Heidi S. I am sorry you are suffering so awfully. Sometimes it takes time to get the correct dose. You needs. Good gynaecologist who can work with you to adjust doses and try different formulations. It is possible that you have depression along side your new menopause, it's a big change and a hysterectomy can often result in this as it is a massive adjustment in anyone's life. Can I suggest you see a doctor as soon as possible and explain everything you have explained to me, including your darker feelings and despair. I wish you well. Renée

Paula Rustage Hi. So glad it has helped. No the GP should prescribe. You are in a great position because you don’t have a uterus. This means you just need oestrogen gel or a patch. There is actually a reduction in breast cancer risk this way. It will also protect your heart. Oestrogel is the gel. 2-4 pumps once a day the normal dose.

Dr Renee thank you so much for the reply so quickly. Is there a particular brand that I should be requesting. I am a little clueless as to types and brands etc. It is good news yes that I don’t need to take progesterone. X

Paula Rustage Hi. No. Oestrogel is the brand of gel. Patches are evorol, oestrodot and a few others. Good luck.

HI Debra. Sorry to hear this. I am going to do two answers, the first for you because you are confusing two things and the second for you to show your GP. For you. Testogel is not Oestrogen gel. You are correct that oestrogen is much safer and kinder way to deliver the oestrogen part of HRT. However, what you are asking for in Testogel is testosterone and this is unlicensed. It is recommended by NICE if HRT on its own does not improve libido. HOWEVER, it can only be prescribed on the advice/recommendation. So for this you would need your GP to either email Gynae which sounds remote as an option or refer you in to a menopause clinic and I would ask for that if I would you. Next answer is for you to print off and show your GP!

As a working GP I have been on the BMS weekend course on menopause and a GP Update course where menopause treatment is covered well. NICE Guidelines filtered down to GP's 2 years ago when issued and are found here: cks.nice.org.uk/menopause#!scenario. This is what is says in particular re testosterone for low libido: Sexual disorders Limited evidence showed that testosterone may increase the frequency of sexual episodes for women in surgical menopause when compared with placebo. Given the limited evidence and the fact the testosterone does not currently have a marketing authorization for this indication in women, the GDG emphasized that it should only be offered as an option for improving low sexual desire when hormone replacement therapy (HRT) is not effective. CKS has extrapolated this recommendation to include women who are unable or unwilling to take HRT. The GDG advised that the prescriber should follow relevant professional guidance, taking full responsibility for the decision to prescribe testosterone and that consent should be obtained and documented. CKS advises that specialist advice should be sought before prescribing testosterone for this indication in primary care. In terms of general advice from NICE: 1. Transdermal HRT is safer and more natural. This is due to liver metabolisation of oral HRT. With this delivery the is NO risk DVT/Stroke. The endometrium needs to be protected and this is best done with Mirena coil or utrogestran either daily 100mg (if not bleed required) or as per BNF if bleed required. Using oestrogel pump for this, dose can be titrated from 2-4 pumps depending on results. 2. If a woman is presenting with low mood for the first time around menopause then treat as menopause in the first instance.

Hi Paula. Thank you. Just post here and happy to answer. R

Thank you. I am 48 and my periods are regular with one heavy day, but short otherwise. I have just had a couple of small endometriosis lumps removed from my navel. None was found in or around my womb, etc... I am about to visit my doctor to discuss being put on progesterone only pill, recommended by the consultant to stop the return of the endo. What I am wondering is the link between oestrogen and endo and my upcoming menopause. Shall I just stick to the POP for now until my menopause starts....will I notice if I am on POP? Should I just start the HRT? Also, just to add to the mix, I have a very low libido, which has slowly gotten worse over the past 10 years or so. I feel hot all the time, but not flashes, I wake up hot in bed, but not drenched. Thanks for your support.

Paula T-L Hi Paula. You sound perimenopausal. Oestrogen encourages endometrial tissue to grow. Having said that we use combined oestrogen/progesterone pills to treat endometriosis. The oestrogen in HRT could help the symptoms you describe and combined with progesterone (preferably utrogestan) could be enough to control the endo. You could, with your Gynae's consent, consider continuous progesterone which would stop bleeding. But then would need US every 6 months to check the uterus lining. Re the libido. This often is restored by HRT but if not Gynae can prescribe testosterone. Hope this helps.

It can, as can all allergies.

Zoe Moorcroft Hiya. No its the direct effect of the radioactive iodine on the ovaries, not the thyroid condition.

Hi. Yes the patches plus utrogestan capsules are body identical. I can't advise you on your individual dose as I don't now you history etc. I do usually advise patients to give it a little longer however and see how it goes over 3 months.

Carolina Hi. Thank you for your lovely words. I’m sorry to hear you are suffering. It can take a few months for HRT to work. I am wondering if the side effects are mainly from the utrogestan and whether a trial of using them vaginally instead of orally would help and then you would be able to increase the oestrogen. An alternative to this is a mirena coil with oestrogen. Have you tried oestrogen gel?

You're so sweet to reply so promptly, thanks. I will try to persist. No, I haven't tried estrogen gel yet but perhaps worth it. I think maybe trying the Utrogestan vaginally would help and also I'm confused by why he has prescribed them on a continual basis. I will look into this with him when I see him again. Thank you and best wishes.

Carolina yes you should have been without periods for a year before continuous although if you are not bleeding on continuous it will do no harm and longer term is better for the endometrium.

Hi Joy. Yes of course. You may get some erratic bleeding in the first 3-6 months but yes it is possible to restart. Good luck.

@@DrRenee thank you for replying

Debbie Taylor You can definitely do that and safe. The only problem you will have is that Everol are out of manufacture at the moment. The easy alternative is gel and utrogestan capsules

Hey. Sorry you are feeling bad. The symptoms are possibly menopausal and the bone thinning will continue without HRT. There is often a settling in period of up to three months but with your lupus I would go for a continuous patch or gel plus utrogestan. It’s safer and body identical. Hope that helps.

Dr Renee, thanks so much for your reply, and so quickly too! Just one other question if you don't mind answering is whether I actually need to take HRT at all considering I have no symptoms at all? Do you suggest taking it only because of the risk of osteoporosis? Thank you.

Hi. No menopause does not affect iron levels. Your GP should be exploring the cause for this.

Hi Amanda. HRT commencement can bring on headaches. The advice is to go with the lowest dose of oestrogen possible and though the skin. I would recommend changing to gel and starting with one pump and if needed take it to half a pump or one pump on alternate days and see if that helps. You could have an oestrodiol blood test to see if it is very low or high. You don't have to stop HRT if you get headaches but need to find a balance with a dose that helps symptoms but minimises headaches. There is a good fact sheet on this on the BMS website. Good luck.

Hi Dr Renee, thank you so much for your prompt reply. Do you think the increase in the Evorel patch from 25 to 50 caused the headaches or because the oestrogen became the dominant hormone and my other hormones are too low? It all sounds very complicated. Do I need to up my progesterone with a gel, if so can I buy this or will I have to ask the GP?. Regards Amanda.

Amanda Green Hi Amanda. We are not sure why hormones cause migraine but assume it is the swing of hormones rather than the hormones themselves in most cases. Your other hormone is progesterone and you have a continuous release of that in the patch so I don’t think hormone imbalance will likely be at play. The progesterone has very little role other than to protect the lining of your womb so it is absolutely necessary. R

I can't advise you individually, your GP must do tnhis with knowledge of your history. Generally, the pills can be used vaginally at the same dose as orally but this is off license. In terms of the gel, this is used daily without a break.

Oestrogen but only if you take it as a tablet. It does not if taken through the skin.

hln1969 you don’t need blood tests because of your age. If you are having symptoms then you can be treated for those symptoms with HRT; that’s the NICE guidelines. The mirena coil will help your bleeding but not your peri menopause symptoms but it is easy to add. Oestrogen for this and I use oestrogel which you rub in once a day. I would go back to your GP and show them this!

@@DrRenee thank you so much for replying. I have an appointment booked mid April (best i could do) so i will mention this 🙂

@@DrRenee sorry, should i ask for the mirena for the pain, heavy periods and fibroids? I just don't like idea of an object inside or is there an alternative? Thanks

It’s personal choice. I have one and it is fab. It’s gold standard treatment for heavy periods but depends how big n what position your fibroids are in terms of if you can have one.

@@DrRenee thank you 🙂

All of those thing can be menopausal symptoms, and coupled with the anxiety it sounds quite likely.

Thanks I can't function with the flu like symptoms that carry on constantly all day every day sometimes it feels like a virus . I'm having the mirena coil fitted Monday with a oestrogen patch because tablets and patches don't work ,I'm on my seventh year now and it isn't getting any better 😓

Debbie Taylor This is a common theme I’m afraid. But usually sorted quickly and smoothly with oestrogen. I would add the gel to the mirena.

@@DrRenee went to have my coil fitted and my cervix is very narrow or something , I had a hysteroscopy once and they had a job to get in there , it was very painful so now I have to wait for a hospital appointment to get it fitted 😓

Debbie Taylor Ah sorry to hear that Debbie. This does happen to some women but should be fine under sedation.

Debra Cannon Hi Debra. That's good news. So essentially, if your last period was more than a year ago, you don't need to have them anymore. So you either have a Mirena coil(ideal way) or you need utrogestran as a tablet 100mg every day. If your last period was under a year ago then you will need to carry on having periods for a year, unless you go for the Mirena coil and then you likely won't bleed at all and don't need to. Hope that helps. It's complicated. R

Mary jo Waszkiewicz Hi Mary. This is likely to be from vaginal atrophy. The good news is that it’s pretty simple to treat with no age restriction. Your GP can prescribe a vaginally oestrogen in the form of a cream. There is no systematic absorption so no age barrier. It works really well. Good luck.

Dr Renee thank you so much for getting back to me , I have a appointment Tuesday the 30th I couldn’t get into a doctor so I hope her assistant can tell if this is my problem . I love your videos so informative glad I found you 😊

Mary jo Waszkiewicz it’s a pleasure. Thanks fir your support. Good luck with the GP.

Ps. Im 52

Yes it is possible that your periods will commence again on a sequential patch.

Debra Cannon Hi. You need to do this with your GP. There are standard doses and you can then work up if needed to control symptoms. If they are unsure re the utrogestran they can look up the regimen in their BNF. Good luck. R

Debra Cannon Hi. Testosterone is only for libido. HRT should address the rest of the issues if the correct type and dose. It can only be started under Gynae guidance. All Gynae departments should have specialist menopause clinics and they should do the prescribing of your HRT regimen initially and your GP can then carry on. I have never heard of a Gynae clinic telling the patient to do the research. I suggest you get referred back and his time say "No, I need you to prescribe please". Good luck.

Debra Cannon Hi. Not normal practice. Evidence is for oral tablets not transdermal progesterone for breast cancer risk.You would also likely find side effects from using them long term. Vaginal irritation/thrush. Also need to consider partner absorption. R

Evorel conti are a good combination patch. Hope its working.

No. That any woman if any age does not need to bleed again once they have been without a period for 12 months.

@@DrRenee thank you.

@@DrRenee I have spoken to my GP today about changing Utrogestan to continuous and she didn’t seem to know a great deal about taking it continuously, I told her what I knew that I’d picked up from your vlogs. I’m currently only 8 days in and would like to take it continuously instead of sequential as I haven’t had a period for at least 7 years, she had to call me back after she’d looked it up. She said she read that Utrogestan can be taken everyday for 25 days with 3 days free to bleed. She said she can’t advise me to take one daily as it didn’t state that in the ‘medical bible’. She basically admitted that I seemed to know more than she did. I feel more confused than ever now on whether I can start taking the Utrogestan daily from today or if I have to wait until the end of this cycle and have a bleed. Your work is amazing and GP’s need to be educated more on menopause and HRT. Thank you so much.

Essentially any woman could go to 100mg every day at any point in the cycle and should not take a break at all as per the women’s health forum prescribing guide.

@@DrRenee thank you.

Kat G No.

Debra Cannon As long as you are over 50 and no period in the last year, or under 50 its 2 years.

Becky M Hi. If you go through the videos I have done one on progesterone. Not everyone gets a bleed but you must be taking 200mg for 12 days. The length of your vagina is not important; just get them as high as possible.

@@DrRenee Thanks for replying. Yes i am taking 200mg for 12 days. Doesn't womb lining need to shed after taking progesterone? Which means a period? So you don't get a build up of too much oestrogen and increase risk of getting anything you don't want?! I'll watch your video on progesterone about contraception, i didn't know you talked about hrt for progesterone on the video too. So thanks for recommending i watch it.

I have a video on progesterone in HRT and one on contraception and HRT. You may find as you go on with your HrT that you have small bleeds. The progesterone can suppress the lining enough that bleeding is very light and some months absent. It could indicate that continuous would work for you.

Yep. Its certainly more difficult.

Najia1977 Hi. Do you mean in menopause?

Yes

Najia1977 Hi. It isn’t a symptom I see commonly but it is indeed possible. Here is some information www.womensinternational.com/what-does-tinnitus-have-to-do-with-hormones/

sallyanne scarbrow hi. I’m sorry to hear this. I would see a different doctor or see her with a copy of the NICE guidelines 2015. There is no weight contraindication to HRT, or smoking. If you have symptoms then you can start at any age as long as no real risks; uncontrolled high blood pressure or existing heart disease for example. Hope that helps.

Dr Renee .Thank you for your reply !! Since march I have been taking one 2.5mg blood pressure tablet per day as it was an average of 150 at the time . I have been attending gym since then and lost nearly a stone and BP for example today was 110 / 95 after so I assume things are better with the combination of the two. I already take the mini pill to help with peri symptoms but I reckon I only felt better for about 6 months. Do I need to give it time like my doctor has said - they make me feel like I am a nuisance.

sallyanne scarbrow sonthe answer firstly is WELL DONE! You have done the hard work. There is no age reason for not having HrT. The NICE guidelines say that over 45 treat to symptoms. I would see her again and point her towards the guidelines or see a different doctor.

Thank you Dr Renee xxx