Dr. Diana Castleman, is one of only 10 naturopathic doctors who is qualified by the North American menopause society as a certified menopause practitioner. This place has her in a unique position to be able to prescribe natural alternatives alongside or instead of hormone replacement therapy. But she wants to put her patients in the driving seat, guiding them with her experience and lots of lots and lots and lots of evidence to ensure they make the right choice. That is right for them. So welcome, Dr. Diana. I am so happy to have you on the podcast today.
Yeah, I'm so happy to be here. Thank you for having me.
Well, let me be really honest, I have just hit the big four. Oh, and so topics around the perimenopause and menopause, kind of getting personal for me. And we both know that conventional training in the menopause is not well done in medical school. So yeah, I feel like really need to go right back to basics here. So I thought we would just start there. Let's get really clear on what the menopause is. And I think what might be harder to grasp, certainly for me, is perimenopause. You know, when should we expect symptoms? And what symptoms can we expect to know whether or not coming whether it is here? Fill me in?
Yeah, that's, that's a great place to start. And those are some great questions. I think a lot of women are actually surprised when they can start to experience perimenopause, right, because it's a lot earlier than we really talk about. So we kind of do a little bit of math here, the average age of menopause is 51. Right? But what's considered normal is anywhere between you know, 45 to 55, that a woman can have her last menstrual period. But you can be in perimenopause for eight to 10 years, right. And so that means women can really start to experience pre menopause 35 years of age or older, right. And so I will get a lot of questions, you know, but I'm 38. Like, can I be experiencing this? And yes, you totally can be. So when I refer to perimenopause, those are the years that are leading up to your final menstrual period where you're starting to see changes happening. Okay, so if we actually look at the definition of Peri menopause, it's diagnosed clinically, okay, it's not diagnosed on lab work. And I really, really want to emphasise that if there's one thing for listeners to take away today is, is that piece because I will have a lot of patients who go to their medical doctor and say, you know, is this perimenopause, I haven't been feeling well, and they sort of list their symptoms. And then their doctor says, Okay, let's get some blood work done. They get that bloodwork done, and everything looks quote, unquote, normal. But they're like, I don't feel well. It actually like really minimises how the patient is feeling because the blood work was normal. And so that's what I really want to highlight. The reason we don't test bloodwork during this time of perimenopause is because hormones can fluctuate so much right from cycle to cycle. So you went to the lab at that one time point and that time of your cycle, that's just like one snapshot in time, right? And we know during this time, hormones are really fluctuating. That's why women don't feel well because their oestrogen, you know, for example, is changing from one month to the next. And it's quite a drastic change. That's why she doesn't feel well. Right. So that's one thing I really want to highlight where we can use bloodwork is to make sure we're ruling out anything else that could be going on. So for example, if you have hypothyroidism which is an underactive thyroid condition, that could present very similarly to perimenopause symptoms, right, because you can still have sleep disturbances and potential night sweats even with you know, a hypothyroid condition. So that's where bloodwork can be really helpful is to make sure okay, we're not missing anything else here. Another really common symptom of perimenopause is actually heart palpitations. And so that's where, you know, my patients will go through the screening, they'll get a Holter monitor done, you know, EKG, that kind of thing. And everything again, looks normal, and then that really is what can lead us closer to the potential. You know, a discussion around okay, this, this could be perimenopause. Right. So that's what I really want to highlight is we're looking at clinical signs and symptoms. And the other thing I really want to highlight is that it can really vary from woman to woman and what those symptoms are. It's very difficult for me as a clinician to predict what your you know symptom is Experience is going to be but just recognising that it can be quite varied. So I know we talk a lot about hot flashes and night sweats and yes, that that can be part of it. But for some of my patients, it's not necessarily that it could be, you know, increase PMS symptoms, right in those two weeks leading up to your menstrual cycle, just way more breast tenderness, trouble sleeping, I could have vaginal dryness, there could be joint pain, musculoskeletal pain, that's a big one that often gets missed. There could be dizziness, lightheadedness, tremors, so I've seen varied symptoms of it. And again, every woman presents differently. So just know that even if it's not necessarily hot flashes and night sweats, it could look at many different symptoms. And what we're using bloodwork or additional workup is to make sure nothing else is going on like right for Joint Pain. Yes, let's make sure it's not rheumatoid arthritis or those kinds of things for sure. Like, that's what we're using bloodwork to rule out. So hopefully that kind of helps explain things.
So it's kind of like a diagnosis of exclusion, really.
I mean, in a way, right. I don't love to use that terminology sometimes. But yes, in a way it is because we're just again, one making sure nothing else is going on. But also like just letting women know, understanding that this can start happening, you know, in your late 30s, this can definitely be very common in your 40s. And knowing that you can start to experience symptoms before your menstrual cycle length begins to change. That's another big one. So if we look at the definition of perimenopause is when your cycle starts to change plus or minus seven days. So let's say used to have a, you know, 28 day cycle now it's 20 days or 40 days, you know, it really starts to change in length. And we often see that cycles will get shorter before they get longer. And so late, perimenopause is kind of where you've gone now you're going, you know, two to three months at a time without a cycle and then getting a menstrual cycle, right. But even before you see this menstrual cycles changes, you can still experience symptoms. So that's another key thing that I like to also tell my patients.
I did not know that I did not know that. And so I guess, you know, it's just really important to as a clinician, just to be aware that this could be happening. Sounds like a lot of very nonspecific symptoms that women could be experiencing that may relate to a stage of perimenopause. And unless we think that we're not going to catch it. So that's really important,
I think that you hit the nail on the head, so to speak there, it's that it's not the forefront of clinicians mind that it comes back to the point of what you said at the beginning. We're not trained, right, we're not trained to support women in this area. And obviously, it's something and I know, every clinician I know, hopes to see change, you know, in our school system. And this goes for both medical doctors and naturopathic doctors, like, you know, I didn't feel like I could support them in this area. When I graduated, it was through my additional training, right, that I felt really well equipped to do this. So it's just recognising too, that it may not be at the forefront of your doctors mind. But it's not that, you know, they don't want to help you. And I always explain that to my patients, they obviously doctors have the best of intentions. It just, it may be you're maybe bringing it up more because you've done more research or you've done more reading. And so you may know more than your doctor in this area. And that's okay. It's just about having a conversation. And hopefully, hopefully you have a clinician who you can have that conversation with, right?
Absolutely. And do you know if there's any research, this is a this is a question that came up this morning, when I did a shout out to my community asking if there was anything they want me to ask you directly. And the question was, do you know if we are going through perimenopause any earlier than previous generations? Or is it just that awareness is starting to grow so we are catching it sooner or identify as
I think awareness is starting to grow? For sure. However, we do know there also are certain things that can put you out an earlier menopause. So for example, cigarette smoking is a really common one, right? So we know that women can enter menopause up to two years earlier, if that they've had a history of cigarette smoking. Another one is if you've had your first menstrual period before the age of 11, that can actually put you at an earlier menopause. And again, when we're looking at overall, you know what the research that has been done, they're saying it's about you know, on average for most of these things, one to two years earlier, we're not talking about you know, 10 years earlier difference right but just again, for your clinician who knows your history and knows a lot of about you like this could be more as guidance to say, okay, you know, here's your history of birth control use here's when you when you had your first menstrual cycle and like we can sort of use some of these pieces. But overall, I would say I think it's really the awareness piece that has come for sure. As with a lot of menstrual cycle and conditions we know related to the menstrual cycle like PCOS and all those things like there's so much more awareness now, which I think is fantastic, right for us to be able to speak to this talk to these topics. And again, women really not feeling alone, right in this.
Yeah. And so what can we do to alleviate the symptoms? What can we do? Perhaps what should we do? Is there anything we can do to delay the onset of men menopause? So I guess that's several questions wrapped into one so that, you know, break it down as you will.
So, in terms of the delay piece, it's I actually get asked this quite a lot. You know, again, menopause is a biological process, for sure. It's a natural stage of life that is going to happen, you know, besides some of those things, let's say smoking, and you know, that that we know, can bring menopause earlier overall, it is a biological process that is going to be happening. So my goal with patients is our treatment, like part of our treatment goal is not how can we delay this, if that makes sense, right? That's not really our, our purpose. It's really my what I always talk to patients about is you do not have to suffer through this time. Like that is if you if there's one takeaway, and one main message is that we as women, and I feel like as a collective, through many areas and aspects of our life, we push through so many things we push through, and I think a lot of women can really feel that, you know, whether it's related to pregnancy or postpartum, like so many things, we just push through our symptoms. And for a lot of my patients, and even just me saying that they, you know, just they just feel so heard, and they feel like, okay, like, I really, I don't have to separate this time, because what they get told is, well, this is ageing. So you'll just get through it, you know, and what I see in office is, so many women are, whatever symptoms they're coming with. But I also do a lot of vulvar and vaginal health, for example. And they are having pain with intercourse and vaginal dryness and the tool, there's nothing they can do about it. And they are crying, because they're also grieving what their life once was, like, this is actually really deeply rooted. And we have to recognise also, as clinicians how deep this goes. And sometimes I'm actually really shocked at the things that my patients get told, because it really is impacting their quality of life in such significant ways in probably more ways than they've ever experienced in the past. And so even if, for example, we don't necessarily have a treatment, you know, for someone, it's literally just having the conversation to say, this is where the research is that now here's what we know, let's have a conversation. And in a lot of the times, we actually do have things available for women and treatment, it's just that that conversation was never being had. So I just kind of wanted to start off with that, because I for any listeners, today, I really just wants you to know that you're not crazy. And if you don't feel like yourself, I believe you like you don't feel like yourself, no one is going to know, you and your body better than than you. Right. And so I just wanted to start off by saying that, but in terms of treatment, so yes, I am a naturopathic doctor, but I'm also, you know, trained in in hormone therapy as well. And I will say how I approach this is, I do think that hormone therapy is not something you have to use, I'm not going to be that clinician. I also know many patients who were one maybe not a good candidate for hormone therapy or two couldn't tolerate it. What it well, and actually, for my patients who couldn't tolerate hormone therapy, well, I actually feel like they felt a lot of shame and like guilt around it because they're like, all these women and all my friends are doing so well on it and why can't I tolerate it? So I just want to highlight that aspect of too that we don't really see on social media is like yes, hormone therapy can be life changing for some woman, but it's not the only option. It's a tool, right? We have many tools it's a tool and yes, I have many patients who do fantastic on it. And some patients you know what we go a different route and that's totally okay to like it doesn't have to be one way and this is why this area it is very individualised. So I'm ever gonna have the same treatment plan for you know any two patients because it's so individual to their history, their personal history, medical student family history, like we have so much we need to take into account. And I think this is again, with the really hard part about the current medical system. I don't know how it is in England, but here with your medical doctor, you know, you're getting on average about seven minutes per visit with your with your family doctor. And to be honest, if you were asked me, I think it's actually impossible to have an informed consent conversation in seven minutes, especially when it comes to hormone therapy. I mean, because there's so much to cover. And for some my patients who were given like a prescription for hormone therapy, they're coming to me because they're saying, Well, yeah, I got this prescription, even, let's say they were a good candidate, and it was a good option. But they're like, but it causes cancer. So why would I take it right? And it's like, immediately, that's where our mind goes. And I think we should talk about the Women's Health Initiative, I think we can't talk about therapy without talking about the Women's Health Initiative. That's, you know, over 20 years ago that the study was first published, and that's still in the forefront of our minds. Like, that's how much fear sticks. That's a perfect example, how heuristics and, you know, research has changed exponentially over the past two decades. But we're still thinking right of that, like headline, like a 30 causes breast cancer. So it's important to talk about, I'm never going to prescribe hormone therapy and say, there's no risks are 100% with anything that you, you know, medication wise, but we need to talk about the benefit versus the risk relative to you, right? Like it, that's a very different conversation than just like a blanket statement of this causes breast cancer, right. So I can dive into one and self initiative,
say, Let's fast, let's just get really, really specific and really, really clear about busting the myths. Because as you say, this, I think the message has come through that, you know, HRT does not equate to breast cancer, and that through, you know, a few very, very prominent doctors in the field, particularly, yes, Dr. Louise Newman, is really leading the way and drumming this message home. So I think that I think that the message is coming through, but as you say, it's been it's taken 20 years to, actually to, to sort of make any, any progress on that. So let's just really bust that myth. Last, you know, loud and clear so that people know where that confusion has come from. And what we know now,
I'll give a little bit of history because I always like this sort of aspect. So the first oestrogen pill, which is called primer, that was our first oestrogen pill, that was introduced, actually 1942. That was the first time that we ever had any sort of hormone pill that was created. At the time, though, we had a whole bunch of other therapies that were using, that were being used for women and I say, these poor women, because things like electric shock therapy was being used for women, for menopause. And, you know, you can actually look at some of the posters and that that they used for women during this time, it would say things like, there was one that said, Mabel isn't stable. She can't help being impatient. It's that time of her life, to see her through menopause, there's gentle daytime sedation. This is what was marketed to women at the time. I don't think a lot of people know this. Which again, it's like looking at history, right? Like, we need to look at that and how it's progressed. We had a surge of hormone therapy around the 60s 1966. And it was actually though being promoted to women as having a full sex life. Okay, so it was marketed in a very different way. And then in the 1960s, and 1970s. A lot of the marketing was geared towards men. So they would have a lot of posters that would say, he is suffering from oestrogen deficiency, and she is the reason why. And when a woman is put on Premarin, she's pleasant to live with once again. So just to give you some backstory, to how hormone therapy started, I know we're all probably all shaking our heads at this, but this really was how it was marketing. Then we progressed to the 1980s and 1990s. A lot, a lot of the large scale, observational trials, they were seeing a 40 to 50% reduction in developing heart disease. And this was actually the main reason why hormone therapy was being prescribed for women. And this was actually the main reason that really initiated the Women's Health Initiative because they were like, well, we're seeing such great data and these options probational trials, let's create a randomised control trial which is like the highest rate that we can, can do and see is this real, like they actually had the best intentions going into the Women's Health Initiative. And to this day, it's still the largest randomised control trial ever done, which is wild, right? They had over 160,000 postmenopausal woman enrolled in this study, like it was massive. And we still have data that's been coming out right after the initial data that came out even they have follow ups now over 20 years, like it's a massive, massive study. So we have she have so much data to extract from it, which it started, just wanted to kind of give that background. But the Women's Health Initiative for those who don't know, was a series of clinical trials that was put out by the National Institute of Health and 19. It started in 1991. And again, it was meant to address the major cause of morbidity and mortality in postmenopausal woman. So like I said, it was over 160,000 postmenopausal woman and hormone therapy, that was one of the trials, right, they had many different arms to the trial, but hormone therapy was one of them. So that hormone therapy arm was stopped 3.3 years early. Okay, so after 5.2 years of ball goes meant to go on for eight years. But after 5.2 years of follow up, the trial was stopped early, because they were seeing risk after risk after risk of showing up specifically with cardiovascular disease. Breast cancer was one of the things they saw too, but it was actually mainly the cardiovascular disease piece of why it was stopped early. And again, because the trial was designed for primary prevention, right? Like we're trying to prevent cardiovascular disease from happening, that was an obvious reason why they stopped it. Now, again, the Women's Health Initiative wasn't a bad study was a really well controlled well laid out study. It was the fallout and how it was portrayed to social media that I think was really the biggest downfall because, again, we had a lot of great data from it. But that just, you know, the way that the information came out to me, I think was really what what was problematic with it. And mean, and that was a time and if you you know, you're a clinician at that time working with women and hormones, like it was scary, right? Even for doctors, like doctors, that was a time where every single doctor was picking up the phone, calling their patient and saying stop hormones, like everyone was so scared, not just patients. So you know, I understand, like, there was so much fear around, we just didn't know, like, you know, so what we saw after the whi is that, you know, hormone therapy, obviously, just limited right as as a tool to help women. And because women were still, you know, suffering, they had symptoms, they needed something into the press and new skyrocketed. Do you see a plummet in hormone therapies, and then antidepressant use skyrocketed. So that became sort of the main therapy that women were, you know, trying to manage their their symptoms. But yeah, what I want to say about the Women's Health Initiative, there's a lot of key takeaways. And here's some of the things that I want to mention, when we looked back at that data, what we saw was that if we actually took that data and grouped it by age, so we looked at women who were recently menopausal versus woman who are, let's say, over 60 years of age, the average age of woman in the Women's Health Initiative was 63. Okay, so we have to keep that in mind. A lot of women were past 10 years after their last menstrual period, when we looked at the data and saw that, okay, if you were recently menopausal, so they, you know, describe that as between 5059, there was actually benefit over risk, right. So when we actually go versus just saying everyone is at risk, now we're grouping it into age categories, that made a big difference in the data. And that's where the some of that's called the timing hypothesis came to be the timing hypothesis says that if you are less than 60 years of age, or with within 10 years of your last menstrual period, then the benefit can outweigh the risk of being on hormone therapy. Right. So that's really the golden rule now, and with any sort of menopause expert in the field, you know, we all are very aware of that. Right? So this is what I'm saying is that it's very individualised in terms of how we're approaching this. But, you know, knowing when you went into your last menstrual period, things like that, that that really is very important for us to know. So that was a key thing. A lot of the women in the study were also smokers, overweight, had high blood pressure. And these are things that we know contribute to cardiovascular disease as well. So it's just important to keep in mind like Well, so what the baseline status was for a lot of these women and then, you know, you throw in hormone therapy on top of that, if you're 10 years post menopause, that can obviously really increase the risk. And then I think the really big thing other the other big aspects of how the data was portrayed is they really talked about relative risk numbers versus the absolute risk. And not to get into too much of the science. But whenever we're reporting relative risk numbers and research, they tend to be these big scary numbers, right? So they're like 26%, increased risk of breast cancer 29% increased risk of heart disease. And so it's just important to know that when we're talking about absolute risk, we're actually talking about giving the actual difference between the groups, and it's a lot of a smaller number. But that's the number that typically we're talking about when talking about and research but they're obviously going to report the relative risk numbers because that's what catches attention in the media and draws attention to it. But like I said, overall, it really wasn't a bad study. We learned so so so much from the study. And even when it comes to the breast cancer side of things, they did see an increased risk of breast cancer when a woman was on the conjugated equine oestrogen, which is the synthetic oral oestrogen, and the synthetic progestin, which was the Provera. So those were the two types of hormone therapy that we had, then we have a lot more options available now. But that was what we had available then. So those women had an increased risk of breast cancer versus women who were just on the oestrogen alone. And you could be on oestrogen alone, if you've had a hysterectomy, stupider uterus removed, you don't need to take a progesterone as well. And so those women actually had less of a risk. We still don't know why that's the case. To be honest, we actually saw that there was a protective benefit, or you know, of just being on the oestrogen alone, they had lower incidence of breast cancer. You know, there's definitely some experts in the field to talk about, well, you know, when you're on hormone therapy, you're actually
you know, more likely to be on that regular mammogram screening. So maybe if you're on regular mammogram screening, maybe you're more likely to detect something. So that's when maybe we see an increased incidence of it. So there's, you know, a lot of talk about why that is, we don't know exactly why even for the why women had less risk of notice on oestrogen versus the oestrogen plus the progesterone. But that's something to really keep in mind as often people think it's Oh, the oestrogen that causes breast cancer were actually, you know, burned actually to the progestin. So what we see overall with the up to date research now, 20 years later, is that if you are on an oral micronized, progesterone, also called prometrium, it's up what you would call your bio identical progesterone that actually has less of a risk than doing a synthetic progestin like Provera. So that's really interesting. But again, the reason I say it's really individualised in the conversations I'm having with patients in office is, you know, we have to take everything into context. Let's say you went on hormone therapy for three to five years to really help treat your symptoms, you know, what is the risk of breast cancer if you came off in five years, right, like, that's what we have to look at. There's calculators online, also, that I'll go through with my patients. Again, it depends on your family history, your personal history, of course, if you have a personal history of breast cancer, we're not going to initiate hormone therapy, like, you know, there's some absolute contraindications where we wouldn't do it. But I also like to position it to my patients to say, what is the risk of us not treating this? What is the risk of you not sleeping for six years? Because you have really, you know, debilitating night sweats, what is the rest of we know that that has also a really massive impact on your long term and your longevity? So I think sometimes when we flip the coin, and we ask the question a different way, it really helps women consider, okay, if I, you know, based on my personal history, based on my family history, I and all my other blood markers look good, I don't have high cholesterol, I don't have high blood pressure, or it's being managed all those things, and I'm good. I'm a good candidate. You know, what is the benefit versus the risk for me? I kind of help explain that.
So why I'm really getting is that, you know, working with my biggest takeaway from this so far, is that working with someone who is really well versed on the up to date, research around menopause, is going to be the best way forward for anyone who is considering or not, because there's a lot of nuance, and there's so much nuance, and there's a lot of
factors that need to be considered on an on a case by case basis. So that's really, I think, a really key takeaway from me and I and, and I think that anyone listening to this will get a sense of just how, how I was going to say complex but not necessarily complex, but multifaceted and The decision making process is for each person. So you mentioned a couple of pieces there that I just want to pick up on, because I've heard I've heard this term biology bioidentical hormones going around and I just want to really understand like, what's the difference between a bioidentical hormone? More standard preparations? When and should they be considered? And why?
Yeah, I would say definitely bioidentical is a buzzword that is going around for sure. And you'll definitely see it a lot in the online space. And again, I will agree with a lot of what the experts say. So when we're talking about bioidentical, we're talking about, it's mimics what your own body produces. Right. So that's kind of where the term came from. But I think the reason why it's become so big is because women don't like the idea of beyond synthetic hormones. And I really do think that that's what it really comes down to, especially with the more information that we have. Now, where it really gets confusing is that a lot of women will think if it's bioidentical has to be compounded. And that is not the case. There's a lot of approved, right? Whether like Breast Health Canada approved or FDA approved products that are bioidentical.
Okay, it's not just for people in the UK. So this, what you're seeing is that you can actually get over the counter or prespore standard prescriptions for a binary operations, they don't need to be made up on a certain exact formulation by a specialist pharmacy.
Exactly. And that's really important to know, because then it's can be covered by your medical insurance. So that's why it's also really important to know that, because then people think they're spending like some people are, can be spending 1000s of dollars out of pocket for these compounded hormones, but that's not what we're talking about here. So, obviously, when you have approved products, you know, the standard of care is definitely here. And, and I agree, like use the approved products that we have, they are bioidentical. So I think that's the common misconception of thinking that it has to be created in the lab by a pharmacist and it's out of pocket expense. And that's not actually the case. And if you wanted like you personally want to choose bioidentical hormones because I felt better for you. They go ahead, right, like I have absolutely no no issues with that. It's always based on patient preference, of course. And again, depending on like, even for, you know, there's then there's a whole conversation about oral oestrogen versus transdermal oestrogen. So using Astrakhan the skin versus taking oestrogen orally, you know, that's a whole conversation. There's so many different routes and formulations now that we have. And again, this is like personal opinion and personal preference, I'm happy to share. You know, for a lot of the cases we see transdermal is can be just as effective as oral and oral can have a lot more of the impacts on cardiovascular systems. So for example, or oestrogen can increase triglycerides, which is a type of cholesterol, it can have more impacts that way. So for a lot of women, you know, I definitely transdermal can be the route to go because you're still getting a lot of the benefits of what we see in terms of 70 80% symptom improvement and have all the other impacts that it can have, let's say on bone health and bone density and things like that. So that's a conversation of course to have with, again, a practitioner who really knows and is specialised in the area, because there's definitely many different routes and formulations to consider, but that's what your conversation should be with your clinician.
Hmm. Okay, so just to summarise, it sounds like bioidentical hormones is a very trendy buzzword. It seems as though it comes down to patient preference, rather than there being any objective evidence to suggest that bioidentical and other and
it depends what we're talking about, right? Because I will say, for example, the bioidentical the oral micronized progesterone, that's the one we talk about. As part of the hormone therapy, some woman can really not tolerate it well, right. Like I have a lot of women who just as much as they try or there's different doses and all that, like they just cannot tolerate it. And then that's where we have to consider an alternative, right? Like sometimes you have to consider an alternative. So that's what's great is that we have options available to us. For example, like as part of your hormone therapy, you can also use an IUD, right? progestin releasing IUD that still protects the uterine lining. That's what we're doing if you still have a uterus because you don't want that with oestrogen alone, the endometrial lining can grow and that puts you at risk for cancer. So obviously we don't want that. But you could do an IUD as opposed to the oral, you know, progesterone. So there's many different ways to go about this. It just depends on what we're specifically focusing on. And for example, the oral micronized. Progesterone, the bioidentical, you have to do it orally because in the skin or on topically doesn't get absorbed well, but a progestin or synthetic progesterone can be absorbed on the skin. And there's combination patches now, where you have the oestrogen and the progesterone together in a patch. And for convenience wise, like for, you know, patients who, let's say, travel a lot for work or, you know, like, depending on your lifestyle, that could be really convenient. Right? So do you see it really is again, individualised based on your situation and your personal preference as well?
Yeah, Mm hmm. And let's talk about the alternatives. So for someone who actually does not want to use replacement therapy, either because they don't tolerate it, or because it's just not something that they want to use. What alternatives can you offer?
For sure. So there's many different sort of breath to go here. I will say what supplements will start there because it is it's a massive industry. I will say a lot of people, patients end up coming to see me because they tried a lot of these menopause relief supplements that have not worked. So I'm just always very clear that yes, there are some supplements that we can consider. But the research is still not great, not where we want it to be anyways, for where we are now. So a really common one that is included on a lot of menopause supplements is black cohosh, you may have heard of this term, but it's almost in every single like menopause relief supplement. The evidence for a black horse, especially for like things like hot flashes and night sweats is really not very strong. And so I actually find for a lot of patients, it doesn't work, or maybe like it worked for a few months, and then it stopped working. So that's not something I'm actually typically recommending to my patients. A lot of I've even seen a lot of medical doctors now, recommending evening primrose oil, EPO, that's another one that's been commonly used again, for things like hot flashes, night sweats, breast tenderness, I can have some benefit clinically, and even the data is still pretty weak. But even clinically, I can say it's quite hard to miss, like some patients are like, Yeah, you know what it's working, I'm seeing some benefit, or again, they see benefit for a couple months, and then it stops sort of working. So I think it also depends on the severity, right? How severe are your off flashes, night sweats, that kind of thing. I'm always very clear that at the end of the day, we asked, we have supplement routes that we can consider, I have nothing as effective as menopause hormone therapy, I just don't it just nothing is going to work as well as menopause hormone therapy, you can get 70 to 80% relief within two to three weeks of being on on hormone therapy. I mean, there's just nothing that sort of touches that I'm just very clear about the magnitude of benefit we can expect. And again, not everyone's going to be a good candidate for hormone therapy. And that's totally fine. So we have other things to consider there. The other supplement I will mention, because it's not often talked about is actually sage. So salvia fish analysis, we see that it can help with night sweats and hot flashes and help with sleep disturbances. I will say we see about a 50% improvement by about four to six weeks. So not bad i for a lot of my patients who want to go that route first, that's typically the first route I will go and talk to my patients about and it can definitely be be helpful. So that's something to consider as well. In terms of the nutrition aspect, I talked to a lot of my patients about soy. So I feel like still gets such a bad reputation in society. I understand it's a highly genetically modified crops. So yes, we want to go to non GMO organic sources for sure. But soy can be so beneficial in a lot of my patients are like so thankful I talked to them about it, because it can actually really help with again, I'm specifically talking about hot flashes and night sweats here because that's where a lot of the majority is looked at research is looking at right so that's why I'm referring to this specifically, but I'll talk to my patients about ways to incorporate into their diet more. So for example, you could do like a cup of soy milk in your smoothie as opposed to doing you know, like a another milk type of milk. And that only increases your soy content. Also great for calcium and calcium is something I talked to a lot of my patients about for bone, you know, and osteoporosis prevention. So that's a big piece too. And it has some protein in there too. So you're sort of hitting all these different aspects to it. But it just definitely has some research to help there. So we'll talk about how we can incorporate more soy into their diet where you know, edamame, a tofu, things like that, that they can start eating and it doesn't So we have to be every day. But it can definitely be something that we incorporate as well. So that's, that's a big one from a nutrition aspect that I will talk about with respect to symptoms. And then, you know, with lifestyle and exercise Oh, actually sorry, the other thing I wanted to mention about the diet piece is what I see really commonly, I because I work with this population of women will see a lot of weight changes, body composition changes, right? During this time that can happen. And because of that, what happens is a lot of women will start intermittent fasting, okay, and because, you know, days, you know, read a book or online article or something that that it could help. And once they start intermittent fasting, or some of my patients would have see they actually have an increase in their hot flashes and night sweats. That's something to kind of pay attention to, because blood sugar drops between meals can also be a trigger for hot flashes, night sweats. So just something I'm mindful of, not to say that intermittent fasting doesn't work or anything like that everyone's individualised, I'm always going to support whatever works best for you. But that's just something to pay attention to. Like maybe if you started that, and you're doing like a 16. Eight, and you know, you're only eating in that eight hour window, maybe like just pay attention to to see if your symptoms have increased, because that drop could also trigger that. Yeah.
I don't know that.
Yeah. And then I would say with the exercise piece, resistance training is really what I focused on with women at this time. I don't know if you've talked about this on your podcast before. But resistance training, I think is starting definitely starting to make its way into social media. And a lot of women are talking about it. And it's fantastic. I love it, it's all about feeling strong, it is definitely for bone health. We know it's one of the best things that we can do for bone health. But also it does definitely have research for obviously, mood symptoms, and how those can be beneficial. And it actually also is research for hot flashes to which is very interesting. So women who started resistance training three times a week, compared to like non exercising women actually showed a decrease in hot flashes as well, like a significant increase there. So something to keep in mind too. That's I'm focusing on so many aspects to for muscle mass for so many different things. But it definitely has research there in the hot flash space as well.
Yes, such key focused things that we can do just to move the needle a little bit. And what would you say that we there is so much supplements out there there are and you're sort of referred to that. And it's, it's quite, it's becoming a very saturated an overwhelming space to I guess, like pick out the wheat from the chaff. What should patients be looking for, in terms of the supplements that they do choose? So that they, you know, focus on quality rather than sort of ineffective ones?
Yeah, it's a great question. I think it's a little bit difficult to answer in a way because it sort of like patients are bringing their supplements in and being like, hey, like, what do you think about this, this, this, so I will walk through them. And actually, a lot of the time, we are eliminating a lot of the things because you know, we talk a lot about polypharmacy, you know, addressing how, you know, as we age, we can be on like 10 different medications and all the things and then tractions with that, but there's also the aspect of supplement burden. And supplements are not cheap, like let's be honest, you know, certain supplements, right? But it cannot up it for a lot of patients. And I'll actually have a lot of patients say to me, this is becoming unaffordable, like you know, like, but it was a lot of self prescribed like things they read online, and then they started taking so I'm actually more of a clinician and practitioner to say we need to be very targeted with what we're taking, you know, and why you are taking it and I will always come back to that it's so crucial that we look at you know, even things like just like your regular supplements, your iron, your B 12. Like things like that. Well have we done bloodwork, like have we looked at where your your levels are recently? Let's see, like, let's see if we still prioritise this or, you know, like I think that's a really important conversation I'm having with patients I'm actually typically turning tick them off things because a lot of things these days tend to be self prescribed, like they're just going to the health food store and then just grabbing things off the shelf and just trying it out. Right so that I think that's a big conversation for sure. I'm glad you brought it up. The other thing I want to highlight is that the menopause market is currently an estimated $600 billion Hey, it targets women everything from everything you might need special scented sprays, underwear, specific skincare products, you know, beauty treatments. So many things. And it's overwhelming. And I just, I just want listeners to just be very mindful of that there's going to be nothing all the products are not good. There's some amazing products out there. And I'm not saying there isn't, but we just need to be mindful of how much is targeted towards us. Because really profiting off it, right? It's because it's a time where women are just just wanting to feel better. So they're going to reach for many different things, right? Even I've seen everything from, you know, like weight loss, teas, and like promising that you're going to you lose the stubborn menopause weight. And it just, if it was that simple, you know, we, we'd all be talking about it, it is not that simple as it's taking a tea, like we need to be having these these conversations. So just being aware of that it is a massive industry. And if you're ever again, hesitant, or just wondering if this is a good product or not that so it really helps to have a clinician in your corner, who can walk you through that and say, You know what, actually, we do have evidence for this, like, you know, this is something I would recommend, or we don't yet really know how this product works, or these are the conversations again, the nuance, I know, this is sort of the theme for today, the nuance of medicine, but it really is I have to say that really, that's what it comes down to. We've learned a lot over the past, you know, 2030 years with respect to menopause, and I can't wait to see what we learn the next 30 years to come, right. Like I think women are going to feel so much more supported. And we're already seeing that, and I'm so happy to see that overall.
And that's so true. And you know, that's the beauty of science. It's constantly evolving. And we learn from the mistakes of the past, and we try our best to get it right the next time and then we evaluate it, and then we adjust. And that is the process of progress and need to keep on you know, sort of moving in that direction. And I just want to highlight before dodge, Diana, you need to go to clinic. You do and have highlighted to me before about the nuance again, in products such as vaginal gels that can that can contain all sorts of different toxins that I would never have considered to to impact other aspects of our health before. So just a W two overrun. But if you just couldn't speak anything to have of products, such as vaginal gels, because yeah, again, nuance, and what and what we should be looking out for is important in such an oversaturated market. Yes.
Yeah, I think that's such a great discussion to have. I talk a lot about vulvar and vaginal health in practice, I think it's just an area again, that women are not having conversations with their clinicians. And I call it the silent epidemic, because women are suffering in silence, right? We're not having these conversations. And even if let's say they're talking to their girlfriends about, you know, what they're experiencing, we're all sort of in that boat of like, what do we do about it? Right? It's sort of that area, there's both non hormonal and hormonal options. And a lot of it is really safe. And we have really great data. And that's really the positive area of this area of research. By nonhormonal. I'm talking about, you know, products that you can use on the ball in the vagina to help with dryness and irritation and help with those changes that can happen there. And really, when we're talking about why these changes are happening, they're a direct result of the loss of oestrogen oestrogen deficiency is at the root of this right. So we know estrogens has many different roles, of course, but with respect to woman vaginal health, it really helps lubricate the area brings blood flow to the area helps maintain the vaginal microbiome. And so it has many, many key roles even helped keep out pathogens, right. So this is also why women can see an increase in urinary tract infections, post menopause, and you'll see a lot of women be on chronic antibiotics, you know, month after month after month. So really the key there for prevention is actually being on a vaginal oestrogen. So that's the key there. And like I said, we have a lot of safe products that are approved, which is fantastic. And I actually I think I've looked in the UK for they're they're really inexpensive options. Like you know, we're talking like, I think it's like I think when I looked it was like six pounds a month. Like you know what I mean? It was like really effective options that are that are again safe and can be used for a long term. Again, something to be talking to your healthcare provider about I know some experts in the menopause space are saying like these, even these oestrogen products should be found over the counter because they are so so you know, safe. Maybe Maybe we'll get there but for right now you still need a prescription with your doctor. So the key difference with non hormonal products what I talked to my patients about one of the key ingredients you want to look for is hyaluronic acid. Acid, not something that is really great for the vulva and vaginal tissue, it is something that we are starting to lose, you know, after our 30s. And really hard rock acid is found in many areas of our bodies, right, but about 50% of it is found in the skin. And so that's a great ingredient to have in a vulva product. And so we at the clinic carry product that has Hallmark acid and vitamin E and I love the combination of those two can be really again, suiting to the area and just bring a lot more moisture to the area, which is really nice. And then when we're talking about hormonal products, we're talking about low dose vaginal oestrogen products. Okay, and there's, again, depending on your country, and where you live, that could look, you know, different in every country. But for the most part, most countries have a lot of options available to women to use, again, that can be prescribed by your doctor. And with the current evidence that we have, which is really nice, is even if you're on like systemic hormone therapy, so like a, let's say, a topical oestrogen or progesterone 40 to 50% of women still need a vaginal product. So that's something to keep in mind, even if you're on systemic hormone therapy, you might still need a local product to help with with those changes. The key thing that I want to emphasise with these vulva vaginal changes, is it gets worse over time, it's progressive. So the longer you go without treatment, you know, the worse your symptoms are going to be. And then it is might be a little bit more difficult to sort of reverse if you sort of leave it, you know, really long. So what I say to my patients is just be aware, like just be mindful be see when symptoms are going to come up. It's, you know, it's not like it happens to all women in their 40s or things like that, but just something to really be mindful of the earlier you start treatment, the better your outcomes are going to be. Because again, it does progress we even see. So the vagina again, the muscular to within us, it can also narrow as well. So that's something to keep in mind too. Again, when it progresses, that that can also really make intercourse a lot more painful for women as well. And because the labia like the tissue, around the ball, but can also really thin, it can get a lot thinner. And so that can also cause what I call it micro tears, you know, when you have any sort of friction there. And so 60 to 80% of postmenopausal bleeding is actually due to vaginal atrophy. Right, where women have these like, sort of like micro tears that are happening, and they're seeing it on their underwear, right? So that's something that's definitely preventable, right? When we're looking at how do we help you know, the stage of life, but there's definitely really safe effective therapies, whether you want to go hormonal, non hormonal, again, talk to your doctor about it. But that's my key message is there's actually a lot of support in that area. And please do not suffer. Because that's also it's not just about the, you know, the intimacy aspect of it, it also I will see in practice, it impacts woman's ability to exercise comfortably and impacts the clothes that you're going to be wearing. Right because it just feels so uncomfortable. So that's, I would say hopefully that answers your question. There's, there's a lot to explore there, but there's so many effective supports.
That's great to know and again, highlights the need to really speak to an experienced practitioner if you are struggling, there is support there are products that can be used. Symptoms can definitely be alleviated in multiple ways and so the key is don't suffer it alone and that your suffering can be alleviated with the right support so thank you so much doctor your experience your knowledge it's yeah just been a jam packed podcast episode was so much really rich information that I know my listeners will absolutely love so really, thank you so much. Thank
you so much for having me. Really appreciate it. Thank you everyone.
And I'll put Dr. Dr. Diana details in all the show notes so that you can follow her along but just before you go Dr. Diana, what's your handle?
Oh yes, people can follow me I'm quite active on Instagram. It's at Dr. Dr. Diana but my first name is spelt D Ay ay ay ay ay Castleman Dr. Dana Castleman, and I will
pop that into the show notes, give her a follow. She's posted. She's posting really useful stuff that I save a lot of. So thank you very much for sharing your wisdom and across all the ways and for the work and passion that you bring to your work.
Thank you so much, dude, I really appreciate it. Thank you so much.
