What I have learnt since falling in love with menopause care with Dr Abbie Laing
In this episode, Dr Louise Newson speaks to Dr Abbie Laing about why she now specialises in menopause care and what she has learnt through her research and writing on the subject. Together the experts discuss clinical hot topics where misinformation and misunderstandings are rife such as what the evidence shows about the risk of clots and breast cancer with HRT, and treating symptoms of genitourinary syndrome of menopause (GSM) with vaginal estrogen.
Abbie’s 3 tips for women with symptoms of GSM:
- Seek help early and use vaginal estrogen; persist with treatment options if the first one doesn’t suit you. The benefits are huge, and treatment should be long term.
- If you have recurrent UTIs, consider vaginal estrogen treatments .
- For elderly, frail, or very busy women, the vaginal estrogen ring (Estring) is a very effective and safe option.
- Vaginal estrogen treatments are very safe and do not have any associated risks, including for people who have had cancer.
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 [00:00:46] So today on my podcast, I want to welcome to you, Dr Abbie Lang, who is one of the doctors that works very closely with me in the clinic, but she also has a brain, very big, and she likes writing and researching. And she’s a bit like me in the respect that a lot of her time is now thinking about the menopause and talking about it to anyone that will listen. So thanks ever so much Abbie for joining me today.
Dr Abbie Laing [00:01:10] Thank you, Louise, for that kind introduction. I feel very grateful to be here speaking with you today.
Dr Louise Newson [00:01:15] So tell me about you first, and then we’ll talk more about clearly the menopause. But why are you interested in menopause and what was your journey from medical school to here?
Dr Abbie Laing [00:01:25] So I was always interested in women’s health. If I look back retrospectively, I can see that I always wanted to work in women’s health and I had a natural passion towards that side. My initial career started out in obstetrics and gynaecology, and I did that for a few years, initially in Perth, Australia, I moved out to Perth and did a lot of obstetrics and gynaecology. As part of my rotations out there, I never went through a menopause rotation and I know that in Perth they were available, but unfortunately I didn’t get to do one of those. My husband did do a menopause rotation in Perth, and he always talked about menopause aspects of care that I felt I didn’t fully understand. I then returned to the UK and did my GP training, and I knew that I wanted to be a GP with a specialist interest in women’s health, and I felt I’d equipped myself in most of the prongs of women’s healthcare. But HRT still felt like a grey area, and I was finding it really quite hard to learn about HRT and access good HRT information, and it became more of a mission, might be the right word, to learn about it. And I spent many hours reading journals and emailing people to try and get more information because I wanted to get really good at it, as lots of perimenopause and menopausal women were coming in, and I still felt I hadn’t quite mastered the art of it. And actually I emailed you when I was working in primary care and asked you some questions and you kindly replied to me, which I was so pleased about. And then the penny started to drop with the more questions I asked, and the more information I read which you had written, the penny started to fall into place and I started to understand menopause care. The penny dropped for me, and that was when I fell in love with the subject. And I read more and more about it, and I saw more and more perimenopausal patients and I realised how much I could help them and how much these ladies were struggling, and they could have their lives turned around. And I had completely fallen in love with menopausal care, and I have now jumped ship. And as you know, I work three days a week in your Newson Health Menopause Clinic at the moment, which I absolutely love. So it has become my main speciality.
Dr Louise Newson [00:03:47] It’s amazing isn’t it? It’s so interesting how people come from different backgrounds. Obviously, I’ve not come from obstetrics and gynaecology, and I’ve come from a background of hospital medicine and general practice. But again, menopause wasn’t in my radar at all. But once you start reading and reading the evidence as well, not just the evidence for HRT, but also the evidence of the risks of not having our hormones replaced, it’s quite astounding. And actually, I spend a lot of my time feeling cross for lots of reasons, but I’ve been very cross and disappointed that no one told me the obvious years ago. I wish in the 90s and 80s, when I was at medical school, someone sat me down literally on the first day of medicine, said, ‘Do you know estrogen, and probably testosterone, in women are the most important hormones and we have to be thinking about it all the time’, and it would have changed the shape of so much I’ve done over the last 30 years.
Dr Abbie Laing [00:04:43] When I look back now and I think I was given quite a lot of misinformation as part of my training, you know, I was told things like ‘taking HRT will increase your risk of blood clots’. I remember that being a teaching session. Actually, that is factually wrong. We know that there’s different types of HRT. It’s much more complicated than that. And if you have estrogen through the skin with micronised progesterone, it doesn’t increase your risk of clot. And I think I’ve become very passionate as you know, about trying to improve access to educational resources because it feels very, very confusing when you are working in primary care, for example, or as a clinician and there is misinformation and you think, ‘Well, who do I trust? What’s right? Who’s saying the right things and who’s saying the wrong things?’ And it was only after I read endless papers, endless papers by BMS, IMS, North American Menopause Society, for example, that I’ve managed to do my own research and realise what’s right and wrong going forward, and I think that needs to be corrected so that clinicians have good access to educational resources that are evidence based because there’s so much confusion out there for people at the moment.
Dr Louise Newson [00:06:00] And it’s very difficult, isn’t it, when you’re a busy general practitioner or busy clinician it’s very hard to go back and unpick the evidence. And you know, you just read what’s face value really. And a lot of it is based on information that’s associated with drug prescribing. So it’s from the MHRA, the Medicines and Health Regulatory Authority, which unfortunately, their information is wrong. So it will say about clot risk, for example, or breast cancer risk. And although we’ve been trying to change, it hasn’t happened yet. So you can understand why people are confused and having evidence based information is absolutely crucial because when we get the right treatment for women, obviously we can improve their symptoms. But more fundamentally, we can improve their future health. And this is something that I think we haven’t been taught enough about how health can improve with HRT have we?
Dr Abbie Laing [00:06:53] Absolutely. It’s a huge part of it. There’s risks to not giving HRT, and I think that’s not talked about enough. There’s risks for your cardiovascular system a women’s cardiovascular system, her bone health, her brain health, her mental health, emotional wellbeing. It is not without risk to not give HRT. And I think that needs to be thought about more. And I think it’s really hard to be a GP at the moment out there. It’s really hard to be a generalist because menopause care is one aspect of primary care and it’s very, very hard to be good at everything. It’s probably impossible to be good at everything. And it’s for that reason that GPs and clinicians in general need really good educational resources that they can access quickly and easily. And if it’s readily available and it’s trustworthy – because GPs have a very short period of time with a patient often it’s 10 minutes. They often have complex co-morbidities. It’s a really challenging job. So I would like to try and make that 10 minute consultation easier for GPs because I think it’s really tough out there for them.
Dr Louise Newson [00:08:05] So already, it’s not that you’ve just seen patients, you’ve been working really hard on some very big projects. And so one of the first things you did is develop treatment pathways, which we have put through under Newson Health Menopause Society that we’ve opened through my not for profit, which is really helped people, we’re getting some great feedback from clinicians. So just talk me through what they are, and how they help people.
Dr Abbie Laing [00:08:28] So I’ve made about 10 treatment pathways that are a concise overview of common consultation types in menopause, in primary care. For example, there is the initial consultation and common problem-solving aspects, focussing on that. There’s a three month review and looking at what happens if there’s side effects, common side effects, what to do if there’s no symptom improvement. There’s one on POI, which is premature ovarian insufficiency, there’s one on testosterone and there’s one on GSM and there’s others as well which provide a concise, evidence-based overview of those topics.
Dr Louise Newson [00:09:07] Which is so helpful because again, for busy doctors and clinicians prescribing clinicians, they’re just really useful to be able to help, to just look at and know what to prescribe and how to prescribe safely. Because as we know, the more we see menopausal women, the more we learn from our clinics, the more we can share with other people – it just makes it easier. So, you know, we did some research not that long ago through my not for profit, and we found that 7% of women took at least 10 GP consultations just to get some advice, let alone any treatment. And many women are waiting several years actually to get treatment, which they shouldn’t be. And that’s partly, I understand if a doctor doesn’t know, then the patient might go off and then come back again and then see someone else. And it’s just not fair because also it’s draining the NHS resources, isn’t it? If we can get on and help and treat it in the first or second consultation, that would be so much better.
Dr Abbie Laing [00:10:04] And it’s really powerful to use the menopause symptom questionnaire or to use the balance app for this. And I know that we use menopause symptom questionnaire for all our patients in the private sector. But you can use it in primary care as well, as a way of looking at symptoms which are often very insidious and can take a long time to tease out in the consultation that can very quickly be identified using the questionnaire. It’s also very powerful for women as well, because it’s a reminder as they look at the symptoms they think ‘actually no, I do have palpitations’ or ‘yes, I do have this symptom’, and it’s a very, very powerful tool. To use for both clinician and the patient involved to identify menopause symptoms, and that can help to reduce 10 consultations and the effect of that, which is a burden on NHS.
Dr Louise Newson [00:10:55] Yeah, absolutely. So it’s about being empowered as a patient and also being educated as a healthcare professional. And my dream is that balance will do the educating for patients and the menopause society and the educational work we’re doing will educate healthcare professionals and then we can close the clinic and get on with doing something else. So the other piece of work that we’ve just recently done together, actually, which has been really joyous to do together, is writing an article which is soon to be published in the Cancer Journal. We’re hoping all goes well and just can you explain what that’s about?
Dr Abbie Laing [00:11:33] Yes. So we’ve written a paper and it’s about the benefits of using vaginal estrogen and whether or not there’s any association or risks, particularly in view of cancer development because that’s always a hot topic that and one that can cause stress to females and clinicians who aren’t sure as well. So hopefully this will concisely present the evidence in one place for people to read.
Dr Louise Newson [00:11:58] Yeah. So let’s just go through, so vaginal estrogen for those listening who aren’t sure, it’s not HRT, actually. So when we talk about HRT or in other countries, it’s ‘MHT’, menopausal hormonal treatment, that’s systemic hormones, so that’s given as a tablet or a patch, gel, or spray. So it goes into the body and that helps with all the systemic symptoms, such as the flushes and sweats and memory problems and so forth. But it also helps reduce the future risk of diseases that we talked about. So this increased risk of disease with low hormones, those low hormones are improved by having HRT. But we know that the majority of menopausal women, some studies say as many as 80% of menopausal women have the effects of the low hormones in their vagina and the surrounding tissue. So the vagina, the vulva, the bladder, the pelvic floor, the urethra, (the tube that we wee out of) and low estrogen can cause quite debilitating symptoms. And one of the treatments as well as HRT – or people can have it without HRT actually – is vaginal estrogen and that will seep into the vagina but all those surrounding tissues, including the bladder as well. And so it’s very safe, but not many people actually use it do they? What are the percentages of women who actually use vaginal estrogen?
Dr Abbie Laing [00:13:20] Only 7% of women use vaginal estrogen. And as you’ve just mentioned, 80% of women have symptoms down below in the genitourinary system, and they can be really distressing and women don’t talk about it enough, and it’s really important to discuss it with somebody because treatments are really effective and treatments are really safe. And the simplest way to describe it is you give estrogen into their vagina and there is more than one type of estrogen you can use. So there is estradiol, which is the estrogen that is produced in most women pre-menopausally, and that’s found in things like Vagifem, Vagirux, which many of you have probably heard of, but there’s also estriol, which is another body identical estrogen that’s weaker. And that means that if you don’t get on with one type of vaginal estrogen, you may well get on with another. So if you have tried one and not had a great experience, for example, with irritation, it is worth trying another because the benefits are so huge for women and it’s also available in different formulations. For example, you can have it in a ring. A lot of people don’t know about the vaginal ring, and the ring sits in the vagina for three months and then is replaced after three months. And it’s a long acting way of giving estrogen back to the vaginal health. And that can be really, really powerful. For example, in elderly individuals in care homes who can’t remember to take treatments daily or who have recurrent urinary infections because of low estrogen. And it sits there and it can help to prevent the current urinary infections. It’s also really helpful for ladies who are busy and actually don’t want to be thinking about inserting daily or twice weekly regimes into the vagina. So it’s a brilliant one to think about. It’s really, really small. It’s really, really light and really flexible. And once it’s put in, you can’t feel it. So it’s underused, in my opinion, the vaginal ring. Other ways of having it includes a pessary, which is a small tablet, and traditionally that’s given daily for two weeks as a loading dose. And then there is a maintenance dose where you use it twice weekly. But if you’re still having symptoms twice weekly, you can increase it more than that. So it doesn’t have to be twice a week. It’s about finding the right dose to prevent symptoms long term. So that’s another way of using it. You can also use creams and creams are really good for targeted areas, so particularly sore areas on the labia or down below, putting creams on can be really helpful for that. So there’s lots of different types and there’s two types of estrogen, and there’s different ways of giving it as well. So there’s lots of options. There’s also a newer pessary which contains something called DHEA. And this gets converted to both estrogen and androgens, which is the testosterone. And that can be even more effective for some women because it has the estrogen and the testosterone working separately. And there is some evidence that testosterone is effective for genitourinary health independent to estrogen. So it is another one to consider and that pessary is used daily. So there are lots of options, and I have met some ladies who have tried one and perhaps not felt any benefit or had a little bit of irritation. And I think if that happens, it’s really worth trying another one because the benefits can be so, life changing for women.
Dr Louise Newson [00:17:01] Yeah you’re so right, and I see a lot of women who have quite deep seated urinary symptoms, so people who have chronic interstitial cystitis or really bad recurrent urinary tract infections and we give local estrogen. And like you say, sometimes it can cause irritation initially, and it’s not usually to the hormone. It will be due to the formulation. So just changing from a cream to a pessary, or from a pessary to using the gel, or the ring can be really useful. But a lot of these women I found it can take months to improve. So the vaginal dryness symptoms and the irritation can take weeks, sometimes usually weeks to improve. But some of the urinary symptoms I found can sometimes take 6-9 months to improve. And I recently saw a young lady in my clinic who’s only 38 and so she’s got an early menopause, and her only symptom actually has been vaginal and urinary symptoms. But they were so bad that she actually considered taking her life. She works as a primary school teacher, and they were just so awful, especially the urinary symptoms, you know, to have cystitis. A lot of women have had an episode of cystitis, but it was all the time and the pain and the burning. And she wasn’t sleeping, and she was contacting the clinic three or four times a week in an absolute crisis. And she’s had some localised treatment, as you explained, and she’s also had systemic hormones. And when I saw her in the clinic, I actually had to look at her name twice because she came in, just breezed into the clinic, sat down, was smiling, and I said, ‘Gosh, what’s happened?’ She said, ‘Well, it’s all just working. I haven’t felt like this for years’. And she said, ‘whenever I read about GSM’ – so genitourinary syndrome of the menopause or vaginal dryness – ‘it’s always about older people’. And she said ‘even some of the medical papers I’ve read say that it’s the last symptom that comes’, she said. ‘But that’s all I’ve had, and no one believed me’. And she’d been seeing different gynaecologists and different urologists. And, you know, the distress that she had in her voice when I first met her was really haunting. And but it has taken quite a few months and we do see that a lot. So it’s really important to persevere. So when you wrote this amazing article you’ve gone through, I think probably every paper that’s ever been written about this, but also we were writing it with respect to giving these localised hormones to women who’ve had breast cancer, especially estrogen receptor positive breast cancer. Because I’ve got a podcast that some of you might’ve listened to with Avrum Bluming talking about HRT, so systemic HRT, for women who’ve had breast cancer. But we see a lot of women who are told they can’t even have vaginal hormones because they’ve had a history of breast cancer. And my practice has always been to listen to patients, to share any uncertainty, and to give the best treatment to improve their symptoms. And a lot of women who find it so hard to sit down or wear underclothes. Actually, their breast cancer is the least of their worries actually, their worry is they can’t function. So it’s been an easy decision almost to give them the right treatment. But actually, the paper that we’ve written together is even more reassuring, isn’t it, for these people?
Dr Abbie Laing [00:20:17] It is.
Dr Louise Newson [00:20:18] So can you explain?
Dr Abbie Laing [00:20:20] So all of the evidence does not show an increased risk of breast cancer recurrence amongst women who are using normal licensed doses of vaginal estrogen, even if they’ve had estrogen receptor positive cancer. And there is not a huge amount of data, we could always have more, but the data we do have is reassuring and several organisations, including the American College of Obstetrics and Gynaecology have endorsed the use of using vaginal estrogen in women who have had estrogen receptor positive disease. So certainly it can be considered for women. It can often feel very daunting because many treatment strategies for women who have had estrogen receptor positive cancer have focused on lowering estrogen so it can feel a little bit daunting to then have a treatment that gives estrogen back. But the absorption is minimal with this and no study has ever shown an increased risk of breast cancer with transvaginal estrogen. Non-hormonal treatments are still given first line, but it can be considered if symptoms are not improving and it should be considered. It’s worth mentioning that tamoxifen and aromatase inhibitors, which are the two treatments that women are often on, so tamoxifen, binds with a very high affinity to the estrogen receptor, and there is no concern using local estrogen that it would compromise its effect. It is much more likely that tamoxifen will compromise the effect of vaginal estrogen and not the other way round. Aromatase inhibitors, these work slightly differently. They prevent production of estrogen and the use of vaginal estrogen in this setting of women, as you know, Louise has been more controversial. And for some, it can feel counterintuitive to prescribe estrogen, and it might be possible to switch an aromatase inhibitor to tamoxifen, which could be an appropriate decision for some women. But it is worth noting that the profound depletion caused by aromatase inhibitors of estrogen can cause such distress that it actually triggers discontinuation of the aromatase inhibitors. And that could be avoidable, so using vaginal estrogen in women with aromatase inhibitors should not be an absolute contraindication, in my opinion.
Dr Louise Newson [00:22:42] And that’s very reassuring. And it’s not just your opinion, it’s looking at the evidence as well, isn’t it? And also sometimes – and I’ve said this before on the podcast – looking at common sense medicine as well. And the other thing is is that when women have quite severe symptoms, the lining of the vagina can be very, very thin because without estrogen you get a thinning of the tissues, there’s less blood supply, there’s less collagen and so anything that is inserted in the vagina is more likely to get absorbed into the body because the lining is so thin. Estrogen works very quickly when used locally to thicken these tissues to improve the blood supply. So all the good nutrients go there, but also collagen deposition and everything else. So that’s why, after a few weeks, symptoms of vaginal dryness can improve, but the tissues can reverse quite quickly, actually. But as you can imagine, if the wall of the vagina is thicker because the treatments worked then anything that’s going to be absorbed, it’s less easy to be absorbed if you see what I mean, isn’t it?
Dr Abbie Laing [00:23:45] That’s why it’s really important not to stop and start a treatment, because if you do that, you’re going to have that initial peak in blood level happening over and over again. Whereas if you stay on the same dose consistently, then the vaginal skin will thicken and absorption at that peak will not occur. So it’s important to stay on it and not stop and start.
Dr Louise Newson [00:24:07] Yes, and that’s for anyone to carry on with it, because we know that some symptoms, such as hot flushes, might last a few months, they might last a few years, they might last decades. But a lot of people with time find that some symptoms do improve. But symptoms related to vaginal dryness actually worsen with time. Don’t they?
Dr Abbie Laing [00:24:28] They do.
Dr Louise Newson [00:24:29] There’s no need to stop using this treatment, and I’ve certainly spoken to a lot of women who have been advised like you say to stop the treatment, see how they feel and only restart if they have symptoms. And that doesn’t make any sense to do that, does it?
Dr Abbie Laing [00:24:42] It’s progressive. It should be placed on the repeat prescription. It should be used long term. If you stop it, symptoms will reoccur, and they will become progressive with time. And unfortunately, that’s why we see so many little old ladies with recurrent UTIs and discomfort down below because they haven’t had vaginal estrogen long term and structures have progressed to that point. And actually, it’s really important to mention recurrent UTIs, I think I touched on it earlier. You see this a lot where people are placed on recurrent antibiotics to the point where they get placed on prophylactic antibiotics, which means they take them daily to prevent infection. And this is often because estrogen has gone down and affected the bladder health, the urethra, the pelvic floor. And actually, by giving antibiotics, you’re not treating the underlying cause. You need to give back estrogen replacement and there is a fairly prompt reversal then as long as it’s started earlier and it’s not progressed too much. There is a prompt reversal, in genitourinary health and that should prevent recurrent urine infections for most women. So if you know somebody, or you have a patient who has had recurrent urine infections, it is really important to consider estrogen as the underlying reason here and it gets missed commonly and it can lead to perennial antibiotic use, which is not without its own risks in itself.
Dr Louise Newson [00:26:11] Yeah, absolutely. And it’s so important and I feel that actually, we’ve already said 80% of women experience symptoms, so that means 80% women should be receiving treatment. So we’ve got a long way to go, but certainly when the article comes out, that’s really going to reassure people who’ve had breast cancer. And I think it’s essential that anyone who’s had certainly more than one course of antibiotics for an infection should be thinking, ‘Why am I not using vaginal estrogen?’ And even women who take HRT, about 20% of women who take HRT still need to use a vaginal preparation. Often actually, women who have had a hysterectomy find that they might be fine before on HRT. After a hysterectomy, they often find that they need vaginal estrogen as well. So really important that any symptoms are discussed with a healthcare professional who understands the importance of having the right treatment.
Dr Abbie Laing [00:27:05] There’s been a very good study on vaginal estrogen called The Women’s Health Initiative observational study undertaken in 2018, and this included forty five thousand women. So this was a prospective cohort. And the outcome and the summary was that using vaginal estrogen, there was no increased risk of coronary heart disease, no increased risk of stroke, no increased risk of blood clot, no increased risk of colorectal cancer, no increased risk of endometrial cancer and no increased risk of breast cancer. That is how safe this treatment is, and it’s extremely effective and restores quality of life for women. And we know that the emotional and physical wellbeing of the symptoms of genitourinary syndrome of the menopause cannot be underestimated. It can hugely affect women every day in many, many ways.
Dr Louise Newson [00:28:04] Yeah, I mean, that’s really reassuring way to end, actually. So thank you ever so much for highlighting that and reassuring us on how safe these treatments are. So just to finish, Abbie, are you able to give three tips to women who have maybe have been listening to this and think, ‘Yes, I might have some of these symptoms and certainly I’ve had the odd urinary tract infection’ or not even an infection, just some cystitis. What would be your three tips for those women to seek help?
Dr Abbie Laing [00:28:31] I would seek help early and use vaginal estrogen. And if you haven’t got on with the first one, persist and try a different one because the benefits are huge for ladies. And there are many different options, and they should be used regularly, and they should be placed on your repeat and not stopped, because that is the safest way to use it. If you have recurrent urinary infections. It is always important to think about estrogen as being the underlying cause, low estrogen causing these infections. And for frail ladies and elderly ladies in care homes, or for very busy women who are on night shifts or busy rotas? The Estring ring is a really powerful and underused vaginal estrogen, and these treatments are safe. They’ve not been shown to increase the risk of any disease, and that’s been in a huge study that that’s been proven, and they can be considered in women who’ve had estrogen receptor positive cancers.
Dr Louise Newson [00:29:37] Excellent. So great advice, and thank you ever so much for your time and look forward to all the other work you’re going to do for us going forwards as well. So thank you.
Dr Abbie Laing [00:29:47] Thank you Louise. Thank you for your time.
Dr Louise Newson [00:29:53] 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.