By Dr Radhika Vohra - NHS & Private General Practitioner in Surrey, Educator & Medical Trustee to The Menopause Charity Thankfully, everyone is talking about menopause! If you know you are suffering with symptoms such as hot flushes, sweats, brain fog, tiredness or anxiety, you may be wondering where to start when trying to get some help. Many women suffer for years with perimenopause and believe they just have to put up with the 40-odd symptoms of menopause. NO, NO, NO! Please don’t wait until you are desperate and at breaking point as it usually makes the process more frustrating. I work as an NHS and Private GP, so I very much understand the challenges GP surgeries are facing and the struggles that patients are having. So, I’m going to share some advice and tips that will allow you to get the most from your consultation with your health professional. Who to speak to? It’s not essential that you always speak to a GP about perimenopause or menopause. GP surgeries are changing, so practice teams are made up of multiple health professionals including: nurses, paramedic practitioners, nurse practitioners and junior doctors.  Non-GPs are dealing with all sorts of problems, so it’s important to try and speak to the right person… I hear you sigh in exasperation… please wait! There are lots of ways to find this right person: have a look at the practice website – does anyone have a special interest in women’s health? look at the practice social media and pop a query there if you feel comfortable most practices are offering e-consults (usually called Footfall), where you can fill out an online query form in detail and this is passed onto the appropriate health professional – this will save you and the reception A LOT of time speak to the receptionist – it’s a good idea to avoid the busy times such as morning and early afternoon consider seeing a doctor who is training; most training practices will have GP trainees. This will be a qualified doctor who is on a 3-year training programme to become a GP. Menopause education is a HOT TOPIC so quite often they will be interested in learning more through patients and will have longer appointment times. Making an appointment? So now that you know who to see, bear these tips in mind when making an appointment: try to get a ROUTINE appointment rather than urgent, either on-line or by phone. try to book a double appointment as this will give the health professional more time to spend with you. be prepared to try a few times as most surgeries release staggered appointments every few weeks to cope with demand. do your research before making a private appointment with a menopause specialist. Taking a look at testimonials, motivations and professional credentials will be reassuring for you and will often work out better in the long run. Homework before an appointment? If you have not already done so, download the FREE Balance App (balance-app.com). It will provide you with a symptom tracker, information and group chats that provide immense support. You can download the Health Report from the app which will be a summary of your symptoms and also your periods (if relevant). Many women find this alone is hugely empowering and gives them control. Preparation in the run-up to your appointment is ESSENTIAL. No one will know your history or health like you. Periods: What are your periods doing? Have you missed any? Are they getting longer or shorter? Do you regularly feel unwell at certain days of the month? Contraception: What contraception are you currently using? Is it making you feel worse? For example, many women on the progesterone-only pill find that vaginal dryness or mood maybe worse. Past medical history: Have you had any fertility care? What hormones have you had in the past either as treatment or contraception? Family history: What is your family history? If you don’t know, ask! It is important as it clears up the unknown. Pay particular attention to any history of heart disease, clots, breast cancer, ovarian cancer or dementia. If you have anyone with a family history of breast cancer, find out three things: the age they were diagnosed, type of breast cancer and their oestrogen receptor status (they can find all of this at the top of a hospital letter, usually in bold) Look at your lifestyle? Your lifestyle has an impact on your entire health – from your mind to your body! Take this opportunity to have a CLEAN UP! do you smoke? do you drink above the recommended amount of 14 units/week (1.5 bottles of wine)? do you exercise regularly? how much caffeine per day? Decaffeinated and green tea still contain caffeine!  Going to the appointment? Go in calmly and, if you have done all the above, you should be brilliantly prepared and the time should be used to focus on YOUR NEEDS. It is not supposed to be a battle but a shared conversation of risk and benefits for your health. For example, if you don’t exercise, drink 3+ coffees and 7 units of alcohol a day, then expect lifestyle changes to be a crucial part of your consultation. However, if you’ve learnt all of this from the Balance App and made changes beforehand, the conversation should be much more comfortably focused on treatment options, including hormone replacement therapy (HRT). Being self-aware about your own health and lifestyle is CRUCIAL and if you make healthy lifestyle changes, they will benefit you in all areas. If you start HRT, don’t forget/be forgotten – make sure you follow up? Once you start to take HRT, it is important to: not miss doses – ensure you have plenty prescribed and ask for a 3-month supply keep a bleeding or side-effect log stick with it! It usually takes around 3 months to get a good idea of how it suits you. have a REVIEW at 3-6 months. Menopause and perimenopause are the consequences of HORMONE DEFICIENCY. We have plenty of evidence that replacing the hormones using body identical HRT (available on the NHS) is SAFE and BENEFITS most women. I hope this information helps you to find and consult the best health professional for you.

We hear so much about how the menopause is catastrophic for skin - on a number of levels, but rather than accepting that it’s all doom and gloom, we thought we’d take a bit of a dive into what’s happening on a hormonal level, why it has such an impact on skin, and — crucially — what you can do about it... THE HORMONE FACTOR “You have hormonal shifts and fluctuations throughout your life,” explains consultant dermatologist Dr Alexis Granite. “Puberty is one of them; perimenopause is another.” The hormone that we tend to talk about in relation to the menopause is oestrogen. Known as one of the female sex hormones and produced largely by the ovaries, it’s the one that starts to rise when you hit puberty to give you breasts, mature the internal sexual organs and start menstruation. While it does fluctuate across the course of your cycle, it stays relatively constant until we get to the perimenopause. Exactly when that happens will vary from woman to woman, and there are several factors that can have an effect — some forms of chemotherapy, being a heavy smoker and having surgery on your ovaries can predispose you to an earlier menopause — but the most significant factor seems to be the age your mum was when she experienced the menopause. Although we talk about “hitting the menopause” or about “hormone levels falling off a cliff”, this isn’t something that happens overnight, as Alice Smellie, co-author of “Cracking the Menopause: While Keeping Yourself Together”, a new book on the subject due to be published this September, explains. “It’s a really gradual process. The official age of perimenopause is 45, but in fact symptoms may begin in your late 30s or early 40s and last for a few years, as the number of eggs declines, and oestrogen levels start to fluctuate. These can go up as well as down, but the general trend is downwards.” And that, as you’ve probably heard, is not good news for your skin. “Oestrogen and oestrogen receptors are found in all types of skin cell, so it’s likely that oestrogen influences most structures of the skin,” explains Dr Sajjad Rajpar, a dermatologist with a special interest in perimenopausal and menopausal skin. “And the skin is the body’s biggest organ — the skin of an average woman weighs around 15kg! So that’s a lot of oestrogen that’s required to keep it functioning properly.” Depressingly, he points out that, from a purely biological perspective, we weren’t meant to live much beyond our child-bearing years and that it’s only as life expectancy has increased that we’ve started to appreciate the importance of oestrogen. AGE IS MORE THAN JUST A NUMBER We can argue about whether it’s OK to use the term “anti-ageing” or not, but can we agree that using the term “ageing” when it comes to talking about skin is just a convenient shorthand that covers a lot of the ways in which skin changes with the passage of time? It just means that we don’t have to say “wrinkles, changes in skin colouration, sagging skin, loss of volume etc” every time. So, with that in mind, it’s time to break the bad news that the menopause is really ageing. “Essentially you have a few things going on when it comes to skin ageing,” says Dr Rajpar. “There’s chronological ageing that happens in men as well as in women. That happens because, as we age, our cells don’t live as long, so there are fewer cells, and they also function less efficiently. When it comes to skin, you can speed up that process with external lifestyle factors, such as the sun, smoking, stress, and bad diet. But, in addition, there’s the skin ageing that is caused by oestrogen deficiency and, in women, that’s actually more important than the chronological age of the patient.” Research suggests that the number of years women are post-menopause is a better indicator of how aged their skin is likely to appear than their actual chronological age. This doesn’t necessarily apply in women who are taking HRT (see below). But, while the menopause really does stick the boot in on a number of aspects of skin ageing, there are things you can do. TURNING DOWN THE VOLUME Collagen is one of the proteins that give skin that firm, bouncy, juicy, plump appearance and, as one of the roles of oestrogen is to stimulate collagen production, a loss of oestrogen means a loss of collagen. There are some studies that suggest that you can lose around 30 per cent of the collagen in your skin in the first five years after the menopause. And the thickness of the skin also reduces by around two per cent each year. Some of that is down to collagen loss, but other skin structures will also diminish with age. So, not only are you likely to lack volume, but your skin will also be thinner and so may bruise more easily. From a skincare point of view, to tackle issues like this, you want ingredients such as retinoids and peptides, which will stimulate collagen growth. But that’s only part of the issue because, as Dr Rajpar explains, the collagen in your skin seems to be less well organised so the same mass won’t give you the same sort of volume-boosting as it might have done ten years before. “Topical products can help, but they have their limit,” says Dr Alexis Granite. “That’s when clinic treatments can come in. Fillers can help replace lost volume, while radio frequency treatments, such as the Morpheus 8 and Ultherapy, can help boost sagging skin.” HUNG OUT TO DRY “The number one complaint I get from my menopausal patients is about skin dryness,” says Dr Rajpar. And, he explains, there are several mechanisms at play here. “Oestrogen is required for the quality and quantity of ceramide production — ceramides are your skin’s in-built moisturising system. But they’re not the only ones — there’s also sebum, another form of oil or moisturiser that is also stimulated by oestrogen.” Add in the fact that hyaluronic acid, an ingredient found naturally in the skin that helps the skin hold onto water, is also stimulated by oestrogen and you can see why, if you diminish the supply of oestrogen, you're choking the pipeline of all these essential skin moisturisers. The solution? Look for good moisturisers, that might feel slightly heavier than what those you’ve used in the past, to help replenish levels of oils and ceramides, and layer these on top of a good hyaluronic acid serum. In a clinic, skin boosters, such as Profhilo, that inject lots of hyaluronic acid at a superficial level, can help increase moisture levels and give you back your glow. FEELING IRRITATED? We’re not just talking about your mood. “In healthy skin, ceramides and other fatty acids, coat the skin cells and help to form the skin barrier, but when skin is lacking in those moisturising factors, the barrier is compromised and you’ll find that skin is more sensitive or reactive as a result,” says Dr Rajpar. “Many women might find that products that they’ve happily used in the past suddenly start irritating the skin as. its threshold for injury is much lower.” If this is happening to you, he advocates simplifying your routine and avoiding anything that could be an irritant. “Use gentle cleansers, avoid over exfoliating and scale back the number of products you’re using. More products mean more ingredients, which means more potential for problems.” IT’S IN YOUR BONES You might think that even if your skin is giving up the ghost, at least your bones are underneath it all as a strong foundation. Sadly, that’s not true. You might have worried about post-menopausal bone density and being more prone to breaking a leg or a hip, but it seems you also need to worry about your jaw. “If we look at men and women, the facial skeleton ages at a similar rate until you hit around 50 when we see an accelerated rate of ageing in women in the lower face due to a loss of bone mass,” says Dr Rajpar. “There is more bone loss with low oestrogen after the menopause and some bones — including those in the lower face — seem more prone than others to density loss.” The result can be jowliness and heaviness in the lower face. Judiciously placed filler can help to counteract this, as can other skin-tightening treatments, or procedures such as thread lifts. SPOT THE DIFFERENCE Just as not all teenagers will get acne at puberty, so not all perimenopausal or menopausal women will suffer this condition. But if you do, you’re not alone. The mechanism behind why it happens is not clearly understood, although there is one theory that the drop in oestrogen means that testosterone, one of the hormones associated with acne, is relatively higher. There are several dedicated ranges on the market designed to treat acne (which is normally associated with oily skin) without drying out already dry menopausal skin. But if you’re really struggling, speak to a dermatologist as acne can be very distressing. IS HRT THE SOLUTION? Taking HRT (aka Hormone Replacement Therapy) where, using patches, pills, or gels, to increase your levels of oestrogen to offset the natural drop, could help with pretty much all the above. As yet, there’s not enough research to know, (as I’d like to), whether sticking a 40-year-old woman on HRT and maintaining “youthful” levels of oestrogen for the rest of her life will mean that she will never show any of the symptoms of ageing that are associated with a lack of oestrogen. But, as Dr Rajpar explains, “we know that women who take HRT have better skin than women who aren’t taking it.” Of course, improving — or preserving — your skin quality isn’t the only benefit you’ll get from HRT. It’s also been associated with a reduced risk of dementia, heart disease and fractures. But a lot of people are worried about it because, says Dr Rajpar, “we’ve been subjected to two decades of misinformation, much of which was based on old studies done on synthetic oral oestrogen. “But now, the application of HRT is increasingly likely to be topical (delivered through the skin rather than as a pill) and body-identical (meaning it’s in exactly the same form as the hormones women produce naturally in their bodies) so it’s much safer.” Let’s get things straight, HRT isn’t going to be for everyone. However, according to Dr Rajpar, there are actually very few women who can’t take HRT. “Only one in eight people who are eligible for HRT are on it,” he says. “That’s a lot of women who are missing out.” And, interestingly, he advises it’s never too late to start. “Some women think that if they’re more than ten years post-menopause, there’s no point taking HRT, but actually even at that point, you will get some benefits — for example studies show that you’ll get some bounce back in your levels of collagen.” Ultimately, only a medical professional can help you decide whether HRT is right for you personally and, if you’re not getting the answers that you need from your GP, ask to be referred to a specialist. It’s not a silver bullet for every woman, but it could make a significant difference to the appearance of your skin.

Dr Rajpar is a Consultant Dermatologist and has an interest in skin and hair concerns around the menopause. www.midlandskin.co.uk As a dermatologist, I have been seeing and treating patients with skin problems for over 17 years. I was never taught, nor did I ever fully understand, the importance of oestrogen to the skin until later in my career. It turns out oestrogen is an extremely important hormone for healthy looking and healthy functioning skin. Skin and hair issues are incredibly common around the perimenopause and menopause. Many of the skin problems seen can be significantly improved with Hormone Replacement Therapy (HRT). Oestrogen levels first start dropping during the peri-menopause, which can last for up to 10 years before the onset of the menopause. At first, the changes are quite subtle and are often attributed to stress, ageing, pollution or a change in weather. Here are the most common problems I encounter in my clinical practice. Dry skin and dullness Skin dryness is one of the earliest problems suffered by women in the perimenopause and menopause suffer from. At first, this might only affect arms and legs in the winter months. The skin becomes more prone to itching and looks visibly drier. Eczema and psoriasis sometimes worsen. Facial skin also becomes dry and doesn’t hydrate with moisturisers as well as it used to. For some women, dry skin can be a debilitating symptom, and can even be associated with formication, which is the sensation of insects crawling on the skin. This can interfere with sleep and cause a lot of discomfort. The reason why skin becomes dry when oestrogen levels drop is because the skin’s in-built moisturising system needs oestrogen to work properly. This special system holds water in the skin and stops it from evaporating. Ceramides coat the epidermal skin cells, a bit like mortar around bricks. When ceramide levels drop due to a lack of oestrogen, this special seal around the skin, known as the ‘skin barrier’, doesn’t work as well and water evaporates. It also means that skin is more sensitive and there can be facial burning and stinging caused by soaps, foaming cleansers, acids and even fragrances. Oestrogen also pushes sebum and hyaluronic acid levels up, and without these, the skin cannot hold moisture in. Lack of skin hydration means the skin cells don’t exfoliate properly – enzymes that allow exfoliation to happen just don’t work as well in dry skin. Instead, skin cells form clumps before shedding. These clumps make the skin feel rough and look dull. The clumps can cause skin to flake and scales can be seen. Many people say the skin looks as if it has lost its glow. Fine lines and wrinkles It is common knowledge that bones become thin and brittle after the menopause, but the skin also becomes thinner. One study showed that the skin thins at a rate of 1.1% year-on-year after the menopause. The main reason for this is that oestrogen is required for collagen production in the skin. Collagen is the main protein in the skin that gives it structure and resilience. The collagen levels go down 2.1% per year after the menopause. With less collagen, fine lines and wrinkles start to appear. Later these become deeper lines and folds. Collagen levels in the skin improve with HRT. A good skin care regime that includes a sun screen, antioxidants and peptides can also help reduce ageing of the skin. Sagging and jowling The bones of the face also shrink with age, and research has shown that the jaw bone and chin shrink faster than other areas of the face with the onset of the menopause. Consequently, women become prone to sagging and jowling, with heaviness on the lower face. Delayed wound healing Menopausal skin is more fragile and wounds do not heal as well or as quickly in post-menopausal women who are not on HRT. Acne and rosacea Testosterone is not just a male hormone, as women produce testosterone too. In the early stages of perimenopause and menopause, there may be an imbalance between oestrogen and testosterone. As the oestrogen levels drop, the testosterone levels may remain normal, and stimulate the hair follicles more than they used to. This can lead to very frustrating acne break outs and redness. Rosacea can develop around the menopause as spots on the central face, or as redness on the cheeks with thread veins. Flushing can be a symptom of the menopause but can also be a symptom of rosacea. Skin that has rosacea tendencies is also usually very sensitive and reacts to strong skin care. Hair loss Hair loss can be a devastating symptom of the menopause and affect self-esteem and self-confidence. One study showed that 41% of post-menopausal women experience hair loss. About two thirds lose hair all over their scalp, while one third loses hair in the front and temples. The mechanism for hair loss with the menopause is not fully understood. For some, it may be a sensitivity to testosterone in the same way that acne develops. For others it may that they have genetic hair loss known as female pattern hair loss, which worsens with menopause. Conclusion Skin and hair changes are common with the menopause and can cause significant symptoms and distress. Many symptoms can be improved or completely treated with HRT, especially when this is started early. Others may require a good skin care regime and professional medical treatment.

Rebecca qualified from Guy’s Medical School in London in 1991. She continues to practise as a GP and has developed an interest in the menopause. Rebecca is determined to improve the understanding of the menopause through education and access to accurate, evidence-based medical information.  All ages are affected: A natural menopause occurs when the ovary has run out of eggs and fails to produce the ovarian hormones oestrogen, progesterone and testosterone. It is defined as a year and one day after your last natural period. The average age in the UK for this to happen is 51. However, 1 in a 100 women experience menopause under the age of 40 (called Premature Ovarian Insufficiency), and 1 in a 1000 experience menopause under the age of 30. Also, many women are put into a menopause straight away by having their ovaries surgically removed or their ovaries damaged by medications such as some chemotherapy treatments.  The perimenopause is the time leading up to the menopause when the ovarian function begins to decline and the hormone levels start to drop and fluctuate, causing symptoms. This can be 10 years before the actual menopause when your periods have finally stopped. It is common for the perimenopause to start in women in their 40s. Symptoms of the Menopause: Women experience symptoms of the perimenopause and the menopause due to fluctuating and low levels of oestrogen. All cells around the body and in organs have oestrogen receptors and need oestrogen to function properly. Once the ovary starts to slow down, it does not produce the hormones oestrogen, progesterone and testosterone and symptoms can then occur due to these hormone deficiencies.  It is known that 80% of women will experience symptoms and, for 25% of women, these will be severe. The symptoms are many and varied, and can come and go and fluctuate in intensity and will vary from individual to individual; for example, 20% of women never experience a hot flush or night sweat. Symptoms can be classified as follows: Psychological and Brain Symptoms Poor sleep, increasing anxiety and a low, flat mood are very common and are the symptoms that most women find the most difficult. Some people are even housebound by their anxiety and have to give up work in severe cases. Poor memory and concentration are also very common and worrying, as many women think they are beginning to have early dementia as their memory is so poor and they struggle to find the right words in sentences. Fatigue is an incredibly common symptom as well. In addition, libido often suffers and declines for many women. Physical Symptoms  Hot flushes and night sweats are experienced by many, but not all, women. Sometimes the sweats can be drenching at night so that bed sheets and nightwear have to be changed. Migraines and headaches are common; these often get worse or increase in frequency in the perimenopause. Muscle and joint pains occur and women feel very stiff and achy all over and some can have severe joint pains. Heart palpitations and tinnitus are other common physical symptoms of the menopause. Vaginal and Bladder Symptoms Oestrogen is vital for bladder and vaginal health; without it symptoms can arise such as vaginal dryness and burning, making sex very uncomfortable and painful. Some women have severe vaginal symptoms making it painful even to sit down for prolonged periods or wear jeans or underwear due to discomfort. Bladder symptoms from low oestrogen levels cause urinary frequency, incontinence and recurrent urine infections. If these symptoms are present and are not treated with local oestrogen treatment, they get worse with time. Silent Symptoms affecting future health Losing oestrogen as a result of the menopause causes a hormone deficiency which will last for the rest of a woman’s life. Studies have shown this deficiency can be harmful for a woman’s future health, resulting in increased risk of heart disease, osteoporosis (thin, brittle bones), obesity, depression, type 2 diabetes and even dementia. How long do Symptoms last for? Studies have shown that symptoms can settle for some women after 7-8 years and others find that the symptoms become less severe, but many will continue to have symptoms for decades. The long-term hormone deficiency will last forever as the ovaries have stopped functioning, so women will never regain their hormones after the menopause, so the long-term health risks will remain unless the hormones are replaced. How can they be treated? The most effective way of treating every one of these symptoms is by replacing the lost hormones with HRT, which is a very safe treatment for the majority of women and can really make a huge improvement to women’s symptoms. HRT can also improve a woman’s future health as it reduces the risk of heart disease, osteoporosis and type 2 diabetes Alternative treatments can be used such as diet, talking therapy and exercise. Some medications such as antidepressants can improve hot flushes and night sweats, but not the other symptoms. However, alternative treatments are not as effective as HRT. More information The free Balance app has a menopause symptoms questionnaire form, which documents menopausal symptoms and tracks them over time. This can then generate a health report that can be taken to a woman’s health care professional. It also has free, evidence-based information about the menopause and perimenopause and the treatments available. The app and the information and content within it is not funded by any pharmacological company. There is an opportunity to be part of a community on the app to interact with others and read about other people’s experiences, There is also an option to take part in different experiments or challenges to improve an individual’s future health.