Improving menopause care in Hong Kong with Dr Laurena Law
Dr Laurena Law is a general practitioner working in Hong Kong who has a special interest in nutrition and lifestyle medicine to improve healthy aging and prevent chronic illness. When Laurena gained personal experience of perimenopause and saw the impact it was having on her own life, she decided to learn more about hormone health and evidence-based treatments for the menopause so she could help herself and her patients.
In this episode, Louise and Laurena discuss cultural differences and similarities between British and Chinese approaches to menopause from both an individual and healthcare perspective. Laurena emphasises the importance of educating women so they know how to recognise their perimenopause or menopause and to empower them to make their own health needs a priority. She educates healthcare professionals in Hong Kong and further afield to ask women the right questions in consultations and to know how to prescribe body identical HRT.
Dr Laurena’s three tips for women:
- Complete a menopause symptom questionnaire and repeat it every few months. This can form the basis of a conversation with your healthcare provider
- Find a healthcare provider that is educated and updated in menopause care
- Find a support group of women also going through the menopause to talk about the problems and challenges you’re going through – you’re not alone.
Dr Louise Newson [00:00:09] Hello. I’m Dr Louise Newson and welcome to my podcast. I’m a GP and menopause specialist and I run the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of The Menopause Charity and the menopause support app called balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause.
Dr Louise Newson [00:00:41] So today I am going to introduce to you someone called Laurena, who I’ve recently reached out to. And a lot of my work is thinking about women who I’m never going to help through my clinic, but my clinic enables me to reach other people with the education work that I do, both for women, and also for men of course, but also for healthcare professionals. So I’m really keen to talk to you today and hear about sort of you and your journey and who you are and where you are as well. Because the menopause is a global problem. There’s 1.2 billion menopausal women. But we’re here to stay. We want to be looked after. We want to be listened to. We want to be treated. And I think it’s outrageous, actually, that women get different treatment depending on where they are and where they live, because most other conditions, people can access good quality evidence-based care. So welcome to the podcast.
Dr Laurena Law [00:01:39] Thank you so much. Thank you, Louise. I’m so happy to be on this podcast and I have been a follower for just recently in the last 12 months and I’m actually here in Hong Kong, so I work here as a GP in my own solo practice, and I’ve been in Hong Kong since 2002. Originally, I grew up in Hong Kong, but I did my medical education in Australia. So I was having basically experiences in both the sort of Western culture but also in my own Chinese culture. So I speak both Chinese and English, although I have to admit that I didn’t really quite go to a Chinese school. I went to an international school while I grew up here. So I came back to Hong Kong and in 2002, I remember there was an article in the newspaper, in the media reporting some of the risks of HRT, and that was really just – that was it. And ever since then, the conversation around HRT has been fought with a lot of confusion on my part because there wasn’t really much training, undergraduate, in terms of managing this transition. And I really didn’t have to think about it too much because personally I didn’t really suffer many symptoms. And it seemed that there were other strategies to treat menopause related symptoms with other drug therapies. And I kind of just effectively stumbled around for quite some time in managing women with symptoms. And it wasn’t really until I myself personally started going through that transition – and in fact I kind of missed it, I didn’t realise that I was actually going through that myself.
Dr Louise Newson [00:03:25] Yes, we’ve all been there!
Dr Laurena Law [00:03:27] So then I was looking for what potential treatment modalities were and what was the update, because there hasn’t really been anything and to be honest, I didn’t really have a lot of information around it and a friend of mine actually sent me a link to your website and I started looking at your website and realised that there was actually a course for health professionals. So I did the course and it really opened my eyes up to what the updates have been and also what treatments are safe, as well as understanding actually what perimenopause is. Because up until then I didn’t even understand what it was. So that then helped me to treat myself actually and realise that those were not just symptoms of ageing but they were symptoms of perimenopause.
Dr Louise Newson [00:04:15] It’s really interesting isn’t it? Because as many of you listing know, there isn’t a single diagnostic test we can do for the menopause or the perimenopause. And I remember actually when I started doing more menopause work, I had all the theory in my mind and I had all the knowledge of the basic science and the pathophysiology. But it’s a practical treatment sometimes, isn’t it? When you’ve got a patient sitting in front of you for a short consultation, how do you treat them optimally and also how do you make the diagnosis? And so if we think someone might have diabetes for example, it’s very easy, often we do a blood test, we look at the result. If we think someone’s got raised blood pressure, we take their blood pressure. And, you know, whereas it’s really difficult for perimenopause and menopause. And so I learnt the most actually by sitting in other people’s clinics. And that’s not always practical to always sit in and travel and it’s not so fair for the patient also, when they’re discussing often quite intimate symptoms and details with a complete other stranger sitting there. So that’s why we decided to create this educational course where we’ve used actresses to pretend to be patients suffering with different scenarios. And so people can be a bit of a fly on the wall in a consultation, but we’ve sort of gone beyond that and linked it to evidence as well. So people can really read for themselves what the evidence is showing us and how we are enabling people to make choices as well. Because like you, I wasn’t given any proper education and no one would have mentioned perimenopause at all in any of my training. But actually, that’s really important that we pick up people early so that they can make the treatment choices that are right for them. And often it is in combination with hormones. But we have to also, I really strongly feel and I’m sure you do too, that as a menopausal woman, I have to look after my future health in looking at diet and exercise and everything else. And it all works together, doesn’t it?
Dr Laurena Law [00:06:13] It does. And in fact, I think one of the biggest gaps that I have seen is unless as a health practitioner, we’re consciously aware of this, we don’t actually ask the right questions. And so it’s not necessarily because we dismiss patients, but it’s just because it’s not in our awareness to check for the constellation of symptoms because there are so many. And it’s not just hot flashes or vasomotor symptoms, there are so many other symptoms, and they can be grouped and confused with other conditions like stress, for example, that again, those things actually do play a role and impact on each other. So I also find that a lot of women in Asia are very scared because they’re very conserved in terms of reporting symptoms. So I really have to sit down and just ask them if they’re present and if they are experiencing those, because unless you ask those questions, they’re not necessarily going to volunteer because they may not realise they are associated with menopause.
Dr Louise Newson [00:07:16] And that’s very interesting. And in fact, even when I go to menopause conferences, there’s still a lot of talk from other healthcare professionals about the menopause causing hot flushes, which of course it can for a lot of women. But it’s almost like that’s why we treat is for hot flushes. And then people don’t always realise the other symptoms. And I even was reading something last night that quite an esteemed healthcare professional had written saying about all these symptoms that people are claiming to be menopausal, such as headaches and muscle and joint pains and mood changes, and saying it’s ridiculous that people think they’re menopausal. Well, actually, it’s not because there are a lot of people that it does cause those symptoms. But if we don’t talk and understand, we’re not going to move the needle at all. And certainly, when I did some menopause training, I was told that Chinese people don’t get hot flushes, so therefore they don’t become menopausal. And I just thought, actually whether you have symptoms or not, you have low hormones, don’t you? And then it’s really difficult. You’re not defined as a menopausal women by your hot flushes.
Dr Laurena Law [00:08:20] That’s exactly right. And I often find that Chinese women or I think, I’m not trying to generalise, but I do find that a lot of women, they feel somehow a sense of weakness if they come to reach for help and advice around menopause. So they almost feel as if if they don’t have hot flashes, then it’s like they don’t have a right to complain of these symptoms because they just have to push through it. And this is a conversation that I keep having because even before I was perimenopausal, I worked out. I was probably, you know, I’m very passionate about my fitness. I went into medical school because I wanted to learn how to prevent health, how to detect disease early. So I was very much trying to role model what I was trying to teach my patients in terms of lifestyle. And I was exercising. I was doing all the things about eating whole foods. I rarely ate any junk food, in fact. And yet I was still having migraines and I was fatigued, for the first time in my entire life I just had no motivation to exercise. And at that time, I actually even thought that I had to cut down work hours because I was just not coping and it didn’t make any sense to me. So saying that it’s just hot flashes, I think we’re just really minimising some of these symptoms and they are very, very debilitating because I found that with the brain fog that I experienced myself, that I couldn’t remember words, I couldn’t remember what I was trying to say. I’d be mid-sentence and forget something which I had known for a very long time. So I think having been there and having been able to find resources and to educate myself, to understand more about this really helped me to create a very non-judgmental space for women to talk about these symptoms and to ask these questions and explain that there is a biological reason that they’re going through this and to be able to support them through whatever decision that they make, but to at least give them the evidence around HRT and how that’s changed. And also to explain how the imaging around menopause is negative. And so there’s so much tied around our hormones and how we age. And because we’re living longer and women are also in the workforce. It’s something that’s very important to discuss. In fact, I was doing a seminar for India online and 50% of their staff are actually women and they realise that if they don’t address this early and they put it as a last priority, then kind of, you know, really not taking care of their health. So I think it’s important that we prioritise this and start to have conversations and educate women that they have options.
Dr Louise Newson [00:11:16] It’s so important, isn’t it? And I do often get very frustrated and feel very sad about the injustice to women and the barbaric nature that people are deciding the future health of women by refusing them to have hormones. And I was reading some papers the other day about osteosarcopenia. And for those of you that don’t know what it is, there’s osteoporosis, which is thinning of the bones. We’re more likely to break under very little pressure, actually. We know how common osteoporosis is. I’ve spoken about it many times before. And sarcopenia is this loss of muscle mass that happens. So when we exercise or even when we fall and we want our bones to be strong, we have to have good muscle strength as well, because our muscles are supporting our skeleton. And so we know with age and I’m sure you got taught at medical school, it’s an ageing thing. Is this sarcopenia, this loss of muscle mass? And that doesn’t sound too bad. You know, a lot of people don’t want their so-called bingo wings on their arms, but actually far more than that, we want to be able to use our zimmer frames. We want to be able to take ourselves out of the bath. We want to be able to put our maybe our grandchildren or our partner if they’ve had a fall. We want to be strong, physically, skeletally as well. And we know that there are receptors for estrogen on our muscle cells, on our brain cells, and they’re really important. So when estradiol stimulates these cells, there’s a whole cascade of events, isn’t there? There’s lots of cytokines that are very protective and building. So these cytokines, these chemicals work throughout the muscles in the bones. And they’re so important for our bone architecture and our muscles to work and function. So you go through or forward through the perimenopause and menopause, and what you’re describing is very classic. But we know there’s a pathophysiological process going on because if you haven’t got estrogen stimulating these cells, of course you’re going to get reduction in muscle bulk. You’re unable to exercise, you won’t have the same stamina, your muscles won’t have the same endurance. And so – and then we also know how important hormones are in our brain. So like you clearly say, if you don’t have the motivation because your brain isn’t being stimulated by hormones, then your brain’s not telling your muscles to exercise. There’s you know, the hormones are everywhere. So this whole thing that we’ve been denying the world female hormones, actually, even if you think about just allowing women to exercise more efficiently, that’s really important, isn’t it? And to be able to think better and then obviously spill over into the workplace. How can you remember things the same way if you haven’t got the same hormones in your brain, you know, you wouldn’t cut off other hormones to our brain that are really important. I’m not saying that everybody misses their hormones, but actually, you know, we should have a choice because you wouldn’t deny people other hormones that are biologically active in the body. I can’t think of any other hormones that are denied in the same way.
Dr Laurena Law [00:14:19] Yes, I do agree with that. And I think definitely when I talk to some patients who have been referred by other patients, they often get the message also that if they have been taking HRT, that they should come off it at some point and that they have been on it for ten years. And so therefore they need to come off it and from doing your course actually start it to, you know, again, realise that that’s actually a very individual choice and it really depends on the woman and their past health. And many of these women are physically active and they have maintain physical activity. Their blood pressures are good, they are not diabetic, they don’t have any kind of contraindications for HRT. And yet they’re being told that they now need to come off it. So that’s also another concern, in my opinion, because if they come off it and they’re symptomatic and actually some women are, they again start to get hot flashes and there’s no age limit as to when they stop. We all think, oh, well, it will stop in the ten years, but it doesn’t. It doesn’t necessarily occur that way. So again, there’s no one size fits all in terms of symptoms.
Dr Louise Newson [00:15:31] And that’s really important to know, isn’t it? I think I remember when I did my first lecture actually about menopause, it was to a group of GPs and before me there was a gynaecologist talking about fibroids and she just stayed for my lecture and one of the questions at the end was ‘What age do you stop taking HRT?’ And I said, ‘Well, there isn’t an age actually, because it’s just a hormone. And even if women don’t have symptoms, as soon as you stop it, you’ve got health risks such as osteoporosis and heart disease.’ And this consultant stood up and she said, ‘Louise, I completely disagree with you. I stop every single woman at the age of 70. A lot of women don’t thank me for it, but I don’t feel comfortable prescribing after 70.’ And then I thought, ‘Well, what are you doing to women if they want to carry on?’ And I’ve seen a lot of women who have really deteriorated physically and mentally when they’ve stopped hormones. And there’s some people who have very openly actually, in some of the Twitter abuse I get have been talking about how the hormones are addictive, the addictive quality of hormones and how we have to be limiting women hormones. And I have a real issue with that because exercise is quite addictive. Eating good food is addictive. You know, how do you define an addiction? Not all addictions are dangerous, actually. So does it matter that women are feeling better? Does it matter that women are able to exercise more and work better? What are the harms? I don’t know. Maybe you could tell me. Am I missing something?
Dr Laurena Law [00:16:55] I also have to share another personal experience, actually in my mother. And one of the reasons why I started weightlifting and resistance training was because my mother actually had a low impact fracture when she was in her late forties, and it was because she was osteoporotic at that age and at the time I had no idea. And she never mentioned about menopause or perimenopause. And this is another issue is that we’re taught about fertility and getting our periods, but there’s never been a time where someone has a conversation about menopause and how important it is to really start looking at lifestyle and the things that we can do to mitigate some of these things, regardless of whether or not we choose to take HRT for symptoms. I think that’s still another part of the piece because we have this false sense of security that, well, we don’t have as high a risk of heart disease as men, that once we go through menopause, the risk is just the same. And I was also reading research that women are less likely to be treated for heart conditions because it’s assumed that we have less of a risk. But the reality is that we do still have the risks. And if we don’t start treatment early, we are putting ourselves at high risk of heart attacks and heart disease. So there’s so many issues around not having knowledge about this earlier, which I honestly wish that my mother had had that because subsequently she went on to have two more fractures after. So although she’s relatively physically fit and healthy and very independent, I still believe that her quality of life would probably be that much better if she had been offered that early on. So I really wanted to talk about not just osteosarcopenia like all those things are really important for women to consider because we tend to look after other people.
Dr Louise Newson [00:18:56] Yes.
Dr Laurena Law [00:18:56] And we don’t really place ourselves as a priority until the very end. But so many of these risks can be mitigated if we know early how to do that. So that’s the reason why I’m so passionate about doing the education and the programming for women and just opening the discussion in this area.
Dr Louise Newson [00:19:17] Which is fantastic. And so in Hong Kong, I can’t imagine it’s better than the UK and it’s probably worse, isn’t it? So how are people responding to the work that you’re doing? Because, you know, you haven’t been doing it for that long. But I know you’re having some great conversations with all sorts of people and also companies as well, which is great, who’s starting to listen. But I mean, over here women are really loving it because there’s a lot of women who are really being very transformed by the knowledge. You know, they’ve got the power to decide what’s right for them. And I love this feeling that they’re helping themselves and in many different ways. But that’s really important. So is it empowering the work that you’re doing over there?
Dr Laurena Law [00:20:00] It is. It is. It’s very empowering. And every time I have this conversation, the women come back and all of them feel that now they have better knowledge. They feel more confident about making choices for themselves. And they understand how to have a conversation with a health provider, what risks to look out for, and just sharing openly that no one person has the same symptoms, but also sharing it with their partners, their employers, the men who they work with. Because I think it’s also difficult for men because they feel that’s such a mysterious condition. So demystifying a lot of that actually also helps open up the conversation and it becomes less embarrassing and not judgmental at all. In terms of treating and treatment options, there’s really only one licensed hormone transdermal product, Estrogel, in Hong Kong. We have micronised progesterone. And apart from that we don’t actually have licensed patches here so we can get them through but very, very specifically through specific imports for each patient. So it is possible, but it’s not widely available even in the public health system.
Dr Louise Newson [00:21:18] And what about testosterone for women?
Dr Laurena Law [00:21:21] Yeah, testosterone. We only have the licensed product for men here in Hong Kong. So a lot of women find it very difficult. But again, it is possible to get that through licensed for women, Androfeme is available through special importing, so that’s something that we are able to do or so far I’ve been able to do. So fortunately, in the learning where to source it and all those things have been very helpful and a lot of women definitely with low libido issues, they do find that testosterone helps them a lot with their relationships and partners. So I have to sort of say that once they start to have the conversation and they go through the process, they actually start to realise – I remember one woman saying that she felt like she found herself again, that she almost gave up and thought that she had lost herself and wasn’t her own person anymore because of the changes in her mood and her energy levels, both mental and physical. And then when she started the treatment, she just felt like she had regained herself. And so these types of stories help me to continue on looking for ways of providing better access to women so that, you know, we all have the option and the choice. And I think that’s important.
Dr Louise Newson [00:22:41] Absolutely. And, you know, it’s such a shame, isn’t it, that HRT isn’t readily available to everybody that wants it, so it’s a real battle, actually. And that doesn’t help the decision to take something, because if, you know, it’s so hard to obtain, then you automatically think, ‘Well, there must be a reason. Is it because it’s dangerous or because there’s a problem?’ And, you know, there are a lot of countries where it’s just impossible to get hormones and, you know, it would prevent a lot of disease if people were given HRT at the right time for the right reasons. We know there’s good evidence, like you say for heart disease risk reduction, osteoporosis, and there’s increasing evidence about dementia, type two diabetes, even obesity. And we know these are global health problems, aren’t they, that are here to stay.
Dr Laurena Law [00:23:27] Yeah. And also, Asian women are particularly at risk because of the slim body frame for serious sarcopenia. And so if we’re not actually looking for that early and having that discussion about that as well, you know, nobody’s actually assessing and screening women for bone health and DEXA scans are very accessible here. They’re not expensive at all to do. They really only add probably about a couple hundred Hong Kong dollars. And the university here in Hong Kong provides DEXA screens. They also provide physical assessments for sarcopenia, and it’s not costly at all. So it’s just surprising that, you know, having access doesn’t always mean that people are aware that it should be done. And healthcare providers are also not screening for this.
Dr Louise Newson [00:24:16] Which is really, really important, isn’t it? I mean, we have a DEXA scan here in my clinic, and when I opened the clinic, I really just fleeced my own bank account of every single penny and got a bank loan. But one of the things I bought in the first few months was a DEXA scan, and everyone thought I was mad because they were saying, ‘Come on, this is not a priority. This is the menopause, you’re not running an osteoporosis clinic.’ I said ‘No, because this is really important, actually, that people are aware of their bones.’ And I think so often people don’t talk about osteoporosis because again, it’s not something that is necessarily easy to know you’ve got it until suddenly you have a fragility fracture and it’s never too late. But what you want to do is prevent it. Like you said at the beginning, you want to prevent disease. And we can prevent a lot of osteoporosis, if it’s picked up early enough and we’re educated enough and we personally choose the right diet, the right exercise, often with the addition of hormones as well. And it’s the same for men too, of course. You know, one in five men will develop osteoporosis and one in two women over the age of 50. So, you know, there’s not many diseases that are that common with treatment, with a preventative plan as well. But it’s just being ignored.
Dr Laurena Law [00:25:31] Yeah, it’s definitely something that is, I believe, 100% preventable and treatable. And even here in Hong Kong there’s the cultural bias that, ‘Oh, because you’re a woman, you shouldn’t be lifting anything heavy.’ So the idea that I go to the gym and lift 100 kilos, it’s ridiculous. And I could hurt myself.
Dr Louise Newson [00:25:55] God.
Dr Laurena Law [00:25:56] Yet, you know, the studies clearly show that resistance training benefits women, but there’s still that fear. Although I do know that in some circles that’s changing and companies are supporting that. And also some gyms are actually specifically designed for women. I think that’s helped a lot. But still, there’s a lot of women that I talk to about you know, ‘What about your bone health? What are you doing?’ There’s still a lot of resistance because it is quite challenging. It’s scary, especially if it’s not something that we’re used to doing. So again, I say that, you know, you just start with small steps, start with small things and we’re here to support. And a lot of the providers, personal trainers that I know personally, are very, very experienced and they are very supportive of that. So again, we just we have to check it. If we don’t, there’s no pain, there’s no symptoms around that. So it’s something which it’s a silent condition.
Dr Louise Newson [00:26:51] So it’s really important. And I think what you’re doing to educate women and others about what the menopause means, what the future health risks are, and ways of to improve your health is pivotal, actually, and it’s going to make a big difference. So it’s great that you’re doing this. So before we finish, have you got any tips? So I always do these three take home tips and really keen actually to hear the three sort of top tips that you will give patients and women that you speak to to try and improve their future health.
Dr Laurena Law [00:27:25] Well, the first thing actually I say to women is get a hold of the menopause symptom questionnaire and do it yourself, because there’s so many more symptoms than you think there are. And do them regularly because the symptoms will change over time. Just because they’re not there this month doesn’t mean they won’t be there in six months time. So knowing what your symptoms are means that at least you have a talking point with your health provider when you want to know what your options are in your country, wherever you are. And the second thing is to find a health provider who actually has been updated with the information and has done the courses and knows what the contraindications are and what the clear indications are as well, who’s going to be able to help you go through this transition. And the final thing is to find a support group of women who are also going through this, because we’re not alone and we think we are. But until we start actually sharing this information, we don’t realise that other women are going through it as well. And so having that support while we’re having physical changes, I think that’s very important to have someone to talk about the problems and the challenges that we’re going through. I think that’s very important.
Dr Louise Newson [00:28:38] Absolutely. I totally echo that. And I think because as women, we are actually quite good at talking once we’ve got the right information and helping each other and looking out for each other as well, I think is really important and you know, getting men on that journey as well to help. So it’s a big team effort and you know, it’s really good to have a global effort as well. And, you know, being able to access information that’s right for you and the language that you want is really important as well. So I’m really grateful for your time and it’s been really enlightening hearing how things go. And I’m hoping with time you’ll be able to come back and tell us how much work you’ve done and how much improvement there’s been over in Hong Kong for menopause care for women.
Dr Laurena Law [00:29:19] I look forward to that and so thank you so much for having me on this podcast. It’s been a wonderful journey.
Dr Louise Newson [00:29:24] Thanks ever so much and take care.
Dr Laurena Law [00:29:26] Take care.
Dr Louise Newson [00:29:30] For more information about the perimenopause and menopause, please visit my website balance-menopause.com. Or you can download the free balance app which is available to download from the App Store or from Google Play.