More than skin deep: menopause, skin and HRT doses with Dr Andrew Weber
Dr Andrew Weber is Medical Director of the Bodyvie Medi-Clinic in London and has more than 40 years of experience as a GP and 25 years specialising in advanced medical aesthetics and cosmetic procedures.
In this episode, Dr Weber and Dr Louise Newson discuss the impact of the perimenopause and menopause on the skin and throughout the body, the importance of hormones and benefits of HRT, and why it is crucial healthcare professionals listen to their patients.
The episode also covers how HRT has advanced and the importance of individualising treatment to find the right dose – Dr Weber likens HRT to buying a bespoke, made to measure Savile Row suit, rather than an off-the-peg outfit.
For more about Dr Andrew Weber and the Bodyvie Medi-Clinic visit bodyvie.com
Follow Dr Andrew Weber on Twitter at @drandrewweber
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. Today in the studio I have someone with me who I’ve never met face-to-face, like a lot of people I seem to meet now, but he’s another doctor who’s actually got far more experience than me. I reached out to him, actually, and spoke to him, I think, on New Year’s Eve over some posting that he did on our advice and guidance platform and we started to talk and now I’ve hoicked him into the studio to talk even more. His name is Dr Andrew Weber and he’s a GP and has lots of experience in general practice, but also in menopause as well. So thanks for coming to talk to me today, Andrew.
Dr Andrew Weber: [00:01:21] It’s my pleasure.
Dr Louise Newson: [00:01:23] So we started a conversation about dosing, actually, of hormones, didn’t we? But before we get onto HRT, menopause, how we can individualise treatment, do you mind just telling me a bit about your background?
Dr Andrew Weber: [00:01:37] As you said, I’m a GP, I have now retired after 33 years as a GP principal from the NHS. However, I had contact early on with women’s services even when I was on my VTS, so I ended up running a once weekly well woman stroke family planning clinic for about five years, which I finally gave up because general practice was taking over my time. I’ve drifted in and out of other bits and pieces with clinical assistantship in diabetology, which led on to being an associate specialist in erectile dysfunction, which actually makes general practice much more interesting. I have an FP (cert), so I still have my LoC IUT, which has come in very useful now that we’ve got engaged much more with menopause management. So that’s my background. Within general practice, I think, retrospectively, we were actually pretty poor at managing menopause in view of what we know now and we stuck to the old Prempak and Premarin and things. Gone are those days, I think we have a much fuller understanding now. In the late 1990s we developed an interest in medical aesthetics with IPLs, lasers, Botox, fillers and with a certain amount of knowledge in dermatology we took over skincare as well. And it’s really only, sadly, after the knockback of 2002 and the WHI report that about six or seven years ago we took a step back and thought, well, they’re treating all these women, 95, 96% of our patients are women, most of them are 35 to 65 years of age and they’ve all got one thing in common, and it’s the menopause. So we started opening discussions with women about the effects of menopause on skin and the benefits of HRT, not primarily for the skin, but for general wellbeing. So, since then it’s developed and we now have quite a large following of patients who are on HRT.
Dr Louise Newson: [00:04:01] And it’s so interesting, isn’t it, because over the years people have changed in their perceptions of HRT and the number of prescriptions have changed a lot, but actually women still have had many symptoms, often don’t realise they’re related. Skin changes are very, very common during the perimenopause and menopause and estrogen, but also testosterone actually, are very important for our skin. And I always sort of have a bit of a joke with some of my friends because they always say, I bet you can spot who’s on HRT just by looking at them. And it’s sometimes because these people are happier, they often feel better, but you can tell by their skin. There now is a big narrative that HRT is taken for a lifestyle because women want to have nice skin and I really push back on that because, you know, yes having nice skin is important, but there’s other things. The other thing that I think we all forget as physicians, but also in the public, is that skin is an active organ, it’s a very large, active organ in our body. If our skin is looking well, it means that often our circulation is good, that our collagen is good and so forth as well. But if our skin as an organ is healthy, it’s more likely that our other organs are healthy as well, so it’s just a reflection of what’s going on. We’ve sort of forgotten often how anti-inflammatory estrogen is actually on other organs, so on our heart and our bones and our brain and so forth as well. So, it’s sort of the skin is a window often isn’t it, as to what’s going on inside our bodies.
Dr Andrew Weber: [00:05:33] And we’ve used that as an entry into perimenopause, menopause, what the symptoms are. And we actually start that as part of our discussion about skin management, some protection, vitamin C, vitamin A, retinols, and also talk about what’s happening as women are getting older, they’re losing, let’s say, 1% of their collagen every year, post menopause it becomes 6%, so it opens up that particular conversation about HRT. A lot of the time we will give them a list of potential symptoms, not 90 but 34 symptoms, the main ones, and I’ve had women in their late 30s sitting there going: yes, yes, yes, yes. Ticking off all the symptoms that they have. They’re still in their below 40, but then we know that one in 100 women has menopause below the age of 40. So, there they are, they’re actually diagnosing themselves. Some of them come back to us for the management, a lot of the other ones go to their GP and they say: ‘Look, I’ve got all these symptoms’ and this is because they’ve come in for an aesthetic treatment. So, we’re using our position where we have a lot of women who will, are, going to go through the menopause and we can open that discussion and have a word with them about it and what can be done and what the benefits are. And that’s what we sell it on, it’s the long-term benefits. It’s one, the control of symptoms, and two the longer-term benefits as well.
Dr Louise Newson: [00:07:21] Yeah, which is so important. I think often even today on my Instagram, actually quite a few people have posted that they’ve diagnosed themselves, they’re in their 30s and 40s, yet they’ve been told they’re too young to be menopausal. I feel very sad actually, because no one’s too young to be menopausal or perimenopause, are they?
Dr Andrew Weber: [00:07:40] No. And then there are the women who’ve had a hysterectomy, which again, can interfere with the blood supply to the ovaries and they can develop premature symptoms as well.
Dr Louise Newson: [00:07:51] Absolutely. And often, actually, we know from some studies that women who have an earlier menopause, their symptoms can be more atypical, so not as classical. And a lot of younger women tend not to have as many hot flushes and sweats and it might be that they have more mood changes or they have more joint stiffness or, like you say, skin changes. There’s all sorts of symptoms. I think the most important thing is that women are listened to and have thought about hormones as an option. And I’m sure you’re the same as me, I often say to women, I have no idea how many of your symptoms are related to your hormones but what I do know is some of your symptoms might be related and I do know that for most women HRT is safe so we can try it and see. And if it doesn’t work, we can stop. We do that a lot in medicine, actually, we often try, you know, if someone’s got raised blood pressure we’ll try one treatment and if that doesn’t work let’s give them something else. I think in general practice, we’re quite good at adapting and changing aren’t we?
Dr Andrew Weber: [00:08:45] We are. But as you say, I’ve had patients in who’ve been referred to cardiologists because of palpitations and it may be the sole symptom they’ve got. They may have other ones as well, but we’ve tried them on HRT and it seems to have controlled everything. I mean, they went to see the cardiologist, or this particular one went to see the cardiologist, everything was normal, they couldn’t find a single problem and she was better on HRT. So, that was her sole perimenopausal symptom. My wife’s cousin, her only symptom was joint pain. She was, let’s say, coming up to 60, late 50s. She was referred to the rheumatologist who couldn’t find anything, she was put on anti-inflammatories and painkillers. Eventually ended up on HRT and she felt her proper age again. The pains had gone.
Dr Louise Newson: [00:09:42] And we see that a lot. And I know personally sometimes if I forget the days of the week and I haven’t changed my patches, the first thing I notice is stiff knees and stiff joints in my hands. It’s really unusual, well it’s not unusual, it’s not even uncommon but I’d never have thought about that before I started to do as much menopause work as I do. When I did a rheumatology job as a trainee, as a general physician, no one taught me about the role of hormones in our joints, and they’re very good. They work as an anti-inflammatory, don’t they, in our muscles and joints?
Dr Andrew Weber: [00:10:14] Yes, they do.
Dr Louise Newson: [00:10:16] I’m not meaning to be rude about your age Andrew, but you were around practicing, and indeed I was too so it’s fine I can be rude about my own age, before the WHI came out, this big study that came out 20 years ago, the Women’s Health Initiative study, which was a real nail in the coffin for HRT. And before that time we would give HRT a lot, wouldn’t we? It would be quite a standard first line treatment for the menopause?
Dr Andrew Weber: [00:10:42] But it was one dimensional.
Dr Louise Newson: [00:10:44] Yes it was.
Dr Andrew Weber: [00:10:46] It was ‘Here’s your tablets, you’re on HRT’, that’s it. Today’s approach is different, it’s titration versus control of symptoms. So I think, you know, we’ve come an awfully long way from just ‘Here’s your Prempak-C’ or whatever it was and you’re on it, that’s it.
Dr Louise Newson: [00:11:07] It’s very interesting isn’t it because I think we’ve come a long way in one way, but then we’ve become the wrong way as well because there’s two things that has happened, there’s a group of people that have become very scared about HRT, both women and healthcare professionals, because of the WHI study which a lot of you who are listening will know already that it was a big study that said to the world that HRT caused breast cancer. Yet we know that it’s unfounded and most types of HRT are not associated with this risk and any risk they showed was not statistically significant anyway. But then, like you say, it was this pregnant horse’s urine HRT with a single dose and also a synthetic progestogen single dose. So, there’s a lot of people I used to give HRT to in that time and they’d still come back with feeling, you know, a bit tired, joint pains, reduced libido and I’d say ‘Well, it can’t be the menopause because I’m giving you HRT’ and now 20 years later, like you say, we spend a lot of time personalising HRT and making it very individual. I tend to prescribe the hormones separately because then you have better control of the estrogen, the progesterone, the testosterone, and it’s all this body identical hormone, so it’s derived from yam plants, there’s no horses involved at all and you can really tailor it. So, I often say to women, I’m going to get the most beneficial effect from your hormones and then let’s see what’s left. We often try and achieve a physiological dose, so really replacing what the body was producing before. We can do that in a tailored way, which we couldn’t do 20 years plus ago, could we?
Dr Andrew Weber: [00:12:45] Absolutely. My analogy is HRT these days, it’s not like going to M&S and buying an off-the-peg suit, this is a Savile Row made-to-measure. You can have 100 women, they’ll each need a different balance of hormones, a different amount, they’ll all have different blood levels and they’ll have different control. It’s like a plane, the hard work is actually taking off and landing, once you’re up there you’re on autopilot and you just keep an eye on it every now and then, but otherwise, once you’ve achieved that control and it’s working, then you’re probably OK for years to come.
Dr Louise Newson: [00:13:25] It’s so true. We often say to patients, it’s a bit like chasing a moving target initially, especially when you start in the perimenopause because your own hormones are changing, you’re giving hormones, and it’s very hard to even monitor with blood tests because you might do a blood test at three in the afternoon when you’re feeling fine but at three in the morning when you’re having a night sweat, obviously your hormone levels are going to be different. So, blood levels can be a guide for some people on HRT, but we often give different doses. I know personally when I started HRT, I was really hoping to be feeling amazing and I’d been on it for about two months and I felt a little bit better, I wasn’t getting as much night sweats, but I still felt miserable and my joints were bad, my migraines were worse, I couldn’t think, my memory was terrible. So, my consultant I was under actually did a blood test and said ‘Oh, Louise your blood test is low, let’s give you two patches’. And I was very scared because I’d never prescribed a double dose of HRT and I said ‘Oh, I’m not sure I should do that’ and he said ‘Why? You’re getting symptoms and your level is low’. So, I put on an extra patch and felt so much better within literally a few days. It made so much sense to me that we need to replace what’s missing like we do if we’re giving a patient with diabetes insulin or a patient with an underactive thyroid gland often need different doses of Thyroxine. So my clinical practice now is tailoring it to their individual needs. Actually, some women don’t absorb through the skin very well, my patches crinkle a bit, so I know I’m not absorbing them very well, but it’s just convenient to put a couple of patches on rather than putting gel on. Some women use the gel and it slides off their skin, it’s like their skin is such a good barrier they can’t absorb it through. So, the dose that we use externally often isn’t the dose that’s going in through the body either, is it?
Dr Andrew Weber: [00:15:18] That’s right. But the advantage of the gel, of course, is much easier to titrate. So, if you’re titrating up, they can just add in an extra pump or a sachet or something, and they can do that themselves with the patches, cutting them in half and then they go and have a bath, I don’t know how much water gets in there and what effects it has on absorption.
Dr Louise Newson: [00:15:40] It can really vary can’t it? And, in fact, I know even the heat can vary the absorption of the patches. I had one lady who’s very young and she’s got endometriosis, so the balance of her hormones was always quite cautious. She said every time she sat in her car it had heated car seats and her endometriosis pain got worse on long journeys and I think it was just the heat and the warmth that made it absorb better. All my consultations I very much put the patient in the centre because I feel very strongly as a patient myself that I want to be in control of my body rather than someone else controlling me and telling me what to do. But I also feel the menopause should be a time where we are as healthy as possible, we reduce disease and individually we’re the best version of ourselves and for a lot of us that is optimising our hormones. And we are all different and, so, as we’ve already said, we absorb hormones differently, but we also metabolise them differently and need different amounts, don’t we?
Dr Andrew Weber: [00:16:42] We do. That’s right.
Dr Louise Newson: [00:16:43] And we know, actually, from evidence… the problem is with the evidence regarding menopause, is it is quite scanty because no one’s done really good studies over the last 20 years and women’s health is neglected for evidence and research,
menopause especially so. But we know that women with POI – premature ovarian insufficiency – so women under the age of 40 often do need higher doses than older women to achieve a physiological response. And there is some evidence that people with severe psychological symptoms so low mood, anxiety, depression, actually need higher levels to affect the brain in a positive way. So, we know that anyway, and some people actually need to have higher than the licensed dose as well. It’s very confusing when we talk about licensing of doses, isn’t it?
Dr Andrew Weber: [00:17:33] I think we use so many other medications off licence that it shouldn’t be that confusing. Just because somebody, or a pharmaceutical company, has done the studies on such and such a dose doesn’t mean to say that somebody else doesn’t need a higher one. We are responsive as well to the patient’s needs and we are happy to go the same way we do with Metformin and Spironolactone for other unlicensed conditions, we’re happy to go beyond the license. We do believe in blood testing, yes it may vary, but it gives you a ballpark that they are in so we can keep an eye on it. But the most important thing is we are responding to the patient’s needs, which are paramount.
Dr Louise Newson: [00:18:19] Yes, absolutely. And I think it’s so important because certainly with other drugs we often give different doses and there isn’t, what’s very interesting, a maximum license dose for Thyroxine, for example. I have, and I’m sure you have, seen some women that need 200 micrograms of Levothyroxine and others are fine on 25 micrograms. I’ve never worried about that at all as a GP giving different doses, I’ve just given what they need. But there seems to be this sort of big worry and we have a lot of GPs actually, and gynaecologists, who write to us in the clinic to say you’ve prescribed a high dose of estrogen we refuse to prescribe and they’re concerned. But when I speak to them and say ‘What are you concerned about?’ they just say it’s above license, but there is no evidence that a high dose causes any harm, that I’m aware of.
Dr Andrew Weber: [00:19:13] No, I’m not either. The first thing you’re taught in medical school is listen to the patient… 99% of diagnoses are based on what the patient tells you. And here they are, they’re saying ‘I’m no better’. So it’s logical that we actually increase the dose because we want to get a response and then they’ll say ‘Oh, I’m much better now’. Then they tweak it a bit themselves and they say ‘Perfect’ and they’ve worked it out for themselves. And also the balance between progesterone and estrogen, we have patients who’ve played and jiggled around with how they take it to minimise any side effects, maximise the benefits and they come back and tell us what they’re doing because they’ve worked it out for themselves.
Dr Louise Newson: [00:20:06] Yes, and I think women are quite intuitive, especially when it comes to hormones. I’ve had a few patients who’ve had a hysterectomy in the past, but they were on HRT before the hysterectomy, and they come back and they say ‘Oh, Dr. Newson, I’ve actually started taking my progesterone again, and I feel so much better. I’m calmer, my sleep is better’. And again, I’ve had people write to me to say ‘How dare they take progesterone when they don’t need it because they’ve had a hysterectomy’. And I’ve said, well, there are actual benefits of progesterone. It’s quite Marmite, I find progesterone, some people really like it and other people find that they’re intolerant. But that’s why we’re all different. But you’re absolutely right, I think if women have the knowledge then they are allowed to try the dose a little bit. And I’ve done it before, I have a threshold where if I’m too low in my estrogen, it will trigger migraines and sometimes I thought if I increase my dose it might trigger a migraine as well. You almost have to get through that threshold and then you come out the other side, it’s a bit like you’re plane analogy, once you’re high up and you’re cruising, you just wish you’ve done it before. It’s really quite difficult.
Dr Andrew Weber: [00:21:16] You’re on autopilot up there, the difficult things are taking off and landing, but once you’ve taken off, it should be plain sailing for years to come with a little bit, maybe, of just slight adjustment.
Dr Louise Newson: [00:21:29] Yes. And I think the years to come is also very interesting, actually, because I’ve posted a couple of videos on my Instagram recently about how long to take HRT for, and it’s had hundreds of thousands of views. There’s still this confusion and concern that we need to stop HRT after a certain time, or after you’ve been on it for a certain length of time and there’s no reason for that, is there?
Dr Andrew Weber: [00:21:54] No. I think our oldest patient is 86, her GP took her off, she was miserable. We put her back on, she’s now got a toyboy of 60 something and enjoying life again.
Dr Louise Newson: [00:22:06] Well, my mother-in-law, she won’t mind me saying, she’s 86 and she started HRT when she was 38 because she had a hysterectomy when she was 36 and had just over a year of feeling absolutely awful. She said a cloud was over her and she managed to get hold of some estrogen, it was a long time ago now, and there’s no way on earth anyone is going to take it off her. It’s absolutely fine, you know, she’s fit and she’s well, she’s independent, she lives on her own, it’s wonderful to see. And of course I don’t know whether she’d be like that if she wasn’t on HRT, but there’s no reason for her to stop and it suits her very well. So, the whole point, I think, is allowing women to have a choice and us as doctors to enabling them to be safe but have the right dose and type of HRT and other medication if they need it that’s suitable for them, isn’t it?
Dr Andrew Weber: [00:23:03] It is, and it takes us back to the point I made: listen to the patient. They will tell you what their needs are and it’s for us to then respond to that. It’s not, you know, you’re on this that should be working. Well, if it obviously isn’t, listen to the patient.
Dr Louise Newson: [00:23:25] Yes, you’re right. I mean, you know, when I trained and certainly the same for you, it wasn’t so easy to get scans, even MRI scans weren’t really around when I first qualified. I did a neurology job and it was very hard, we had to listen and examine the patient really, really carefully, a lot more than now, because we didn’t have the beauty of tests. Menopause actually doesn’t have the beauty of tests, like you say, blood tests can sometimes help, but 99% is in the history and I think we’ve lost this art sometimes. I think the more I read about women’s health, in history but also recently as well, that women are not being believed, they’re not being listened to, it’s almost like we make up these symptoms in our heads. I think we have to change this narrative and really listen and believe women and try and help them actually, rather than being barriers and blocking and saying ‘How dare you ask for your hormones back? How dare you ask for HRT? How dare you think your joint pains could be due to your hormones?’ Let’s try and learn from our patients, because I learn every day from my patients.
Dr Andrew Weber: [00:24:28] And they will tell you what their needs are. We give them a carte blanche ‘Here it is, here’s your gel. If after four weeks, there’s very little improvement up it and then we’ll see, you know, two or three months later and we’ll find out where you are and what’s working, what isn’t, and take it from there’.
Dr Louise Newson: [00:24:48] Yeah, which is great advice. I’m just pleased that we sing from the same hymn book as it were and it’s lovely that, you know, I think it’s the most transformational medicine that I’ve ever practiced. It’s very rewarding as a doctor to be able to help so many people in my clinic, but it’s also very frustrating listening to the people that are suffering. So, there’s lots more that needs to be done. But before we finish, Andrew, I’m going to put you on the spot because I always ask for three take home tips. So, I’m just going to ask you, if you don’t mind, for three things a woman could do if she was on HRT already but feeling that her dose wasn’t quite right, or that she was still getting some hormonal symptoms, what would you suggest that she could do to help?
Dr Andrew Weber: [00:25:32] Be flexible…control your medication, because, I’ve already said, you’re going to know what works for you, what balance, what amount. That’s really the first one. In terms of pump priming, we start discussions in the 30s because we’re talking about skin and we make patients aware of what potential symptoms might be, what to just keep an eye out for, that they may be hormonal, so at least they can come to us. And the third one, I was a GP in Chiswick for 33 years and I had a local pharmacy and there have been shortages of HRT. He’s twigged on to the fact that I prescribe a lot, he has everything in, so he’s actually found a little niche. We tell our patients ‘Look, he’s got everything. He will update me on what he’s got, what he hasn’t got’. So somethings out, he’s got it, you name it, he will have. And then once a month he’ll phone up and say ‘Look, I’ve got it back in’ so we’re aware and we can actually send our patients not so much to him, but to contact him because he’s happy to receive the prescription and then post out. So, yes, that would be number three, have a friendly pharmacy that has everything in stock.
Dr Louise Newson: [00:27:04] Very good advice. And the most important thing is if you’re not getting help from the first person there are always other people that you can see, people shouldn’t be suffering alone. Thank you ever so much for your time, it’s been great.
Dr Andrew Weber: [00:27:17] Thank you.
Dr Louise Newson: [00:27:20] For more information about the perimenopause and menopause, please visit my website www.balance-menopause.com or you can download the free balance app, which is available to download from the App Store or from Google Play.