My guest this week is Dr Hannah Short, a GP Specialist in Menopause, P.O.I. (Premature Ovarian Insufficiency) and Premenstrual Disorders. In this fascinating episode, Hannah educates me on P.O.I., P.M.D.D. (Pre Menstrual Dysphoric Disorder), Endometriosis and P.M.E. (Premenstrual Exacerbation). She also talks about her own experience of premature surgical menopause at the age of 35.

*TRIGGER WARNING: *Very brief mention of some women feeling suicidal feelings*

IN THIS EPISODE WE DISCUSS:

[00:00] Teaser quote.

[02:15 ] Introduction to Dr Hannah Short.

[03:23] Premature Ovarian Insufficiency (P.O.I.) - early menopause below the age of 40.

[06:52] Treatments available for P.O.I.

[07:56] H.R.T. or Hormone Replacement Therapy.

[11:17] Hannah's interest in this area - personal experience of premature surgical menopause.

[16:11] The impact of not having children - the way society treats women without children.

[20:25] The symptoms of premature surgical menopause.

[22:41] Feeling a sense of loss at missing out on her youth due to illness.

[26:23] The power of podcasts and talking openly, especially as a G.P. (General Practitioner)

[27:37] Pre-menstrual disorders - P.M.D.D. (Pre-menstrual Dysphoric Disorder).

[38:48] Endometriosis - what it is and what help is available.

[43:22] Feelings of rage.

[46:33] The effects of calming the autonomic nervous system - exercise, anti-inflammatory diets and meditation.

[51:05] The lack of recognition for these issues - stigma and taboo.

[54:05] Advice for women badly affected by hormones - tracking your symptoms.

[56:01] Pre-Menstrual Exacerbation (P.M.E.)

[57:33] The importance of psychological support.

KEY TAKEAWAYS:

1. Follow this link to access Dr Hannah Short's website – Hannah is a G.P. specialist in Menopause, P.O.I. and Premenstrual Disorders. 
2. You can order Hannah’s book The Complete Guide to P.O.I. and Early Menopause via this link.
3. Click this link for NHS information on Early Menopause and P.O.I. (Primary Ovarian Insufficiency). POI is classed as menopause before the age of 40. Latest statistics suggest 3-4% of women across the globe or affected.
4. You can read NHS information on  HRT (Hormone Replacement Therapy) here.
5. Click here to read a patient leaflet on Pre-Menstrual Syndrome (P.M.S.) from the Royal College of Obstetricians and Gynaecologists.
6. P.M.D.D. or Pre-Menstrual Dysphoric Disorder is a hormone insensitivity affects around 5-8% of women as well as trans men, anyone who was born with ovaries. You can access Mind information on PMDD by clicking on this link.
7. International Association for Premenstrual Disorders (IAPMD) follow this link for a lifeline of support, information and resources for women and AFAB individuals with P.M.D.D. and Pre-Menstrual Exacerbation (P.M.E.).
8. Endometriosis is a condition where cells similar to the lining of the womb are found outside the womb or uterus. It's a condition that affects 1.5 million women in the UK. Support can be found here at Endemetriosis UK.
9. Meditation has been found to be very effective in calming the autonomic nervous system. You can access a 15 minute 'Loving Kindness Meditation' from Season 1 of Blue MumDays on the link here, which has been created specially for us by Poonam Dhuffer of YSM8.
10. You can access the Primary Care Women's Health Forum on this link.
11. PME (Pre Menstrual Exacerbation) occurs when hormone changes during menstruation worsen the experience of a pre-existing disorder – like depressive disorder or generalised anxiety disorder. Click on the link to read a Women's Health article on the subject.
12. Click this link to read more about Cognitive Behavioural Therapy (C.B.T.)
13. NAPS Guidelines on P.M.S. from the National Association for Pre-Menstrual Syndrome.
14. NICE guidelines for P.M.S.

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NEXT EPISODE:

For a Blue MumDays special celebrating Down Syndrome Awareness Day, I'm joined by the beautiful Jannah Hayah. Jannah talks to me about life with her gorgeous son Musa, who is 5. Musa has Down Syndrome, hearing loss and is fed via a feeding tube. Jannah is passionate about wanting the world to know that while a life living with disability can have its challenges, the struggle comes with incredible rewards. It's a wonderfully life-affirming conversation.

SUPPORT:

If you are struggling right now, please know that it’s okay to talk and reach out for help. 

YOU ARE NOT ALONE AND WILL NOT FEEL THIS WAY FOR EVER. 

*** For support specific to this episode, see Key Takeaways ***

We hope these support services are helpful (please note we do not check or monitor them individually).

Action on Postpartum Psychosis (APP)

Moderated Forum, click here to find out more.

Email: app@app-network.org

Tel: 020 3322 9900

The ADHD Foundation - the neurodiversity charity

Call us - 0151 541 9020

Email - info@adhdfoundation.org.uk

AIMS for better birthing.

Email: helpline@aims.org.uk

This email will go to a group of AIMS volunteers and someone will respond as soon as possible.

Telephone: +44 (0) 300 365 0663

You will be able to leave a voicemail message which will be sent to all our Helpline Volunteers. Please include your name, phone number and brief details of your enquiry. A Volunteer will try to call you back as soon as possible.

Andy's Man Club

A non-judgemental talking group for men

https://andysmanclub.co.uk/club-information/clubs/

Email: info@andysmanclub.co.uk

Association of Postnatal Illness

Helpline: 10am – 2pm – 0207 386 0868

Email: info@apni.org

Live chat online facility

Beat Eating Disorders,

The UK's eating disorder charity.

Help for England

Helpline: 0808 801 0677

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Help for Scotland

Helpline: 0808 801 0432

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Best Beginnings

Free NHS-accredited Baby Buddy app offering

evidence-based information and self-care tools to help parents during pregnancy

and early stages of parenting.

App users also have access to a confidential, text-based Crisis Messenger which provides

24/7 support for new and expectant parents who are feeling extremely anxious or overwhelmed.

Bi-Polar UK

email: info@bipolaruk.org

Birth Trauma Association

Email: support@birthtraumaassociation.org.uk

CALM

Contact CALM

on their national helpline: 0800 58 58 58 (5pm-midnight)

Cedar House Support Group

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Mobile: 07773 283556

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Support, advice and information for parents with disabled children.

• helpline: 0808 808 3555
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Contact a Family

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Contact a Family offer support for all childhood conditions, are also able to put families in touch. Featuring a directory of conditions and rare disorders online.

Helpline: 0808 808 3555 (lines open Monday – Friday 9.30am – 5pm)

CLAPA – Cleft Lip and Palate Association

www.clapa.com

Information and support on cleft lip and palate treatment.

Dad Matters

Support dads to have successful relationships with their families, with mental health and accessing services through peer support and signposting.

kierananders@homestarthost.org.uk

0161 344 0669

DadsNet 

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Dope Black Dads

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hello@dopeblack.org

Family Lives

An organisation providing immediate help from volunteer parent support workers 24 hours a day, 7 days a week.

• helpline: 0808 800 2222
• website: www.familylives.org.uk

Family Rights Group

Support for parents and other family members whose children are involved with or need social care services.

• helpline: 0808 801 0366
• website: www.frg.org.uk

Fathers Reaching Out

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Run by Mark Williams, campaigner, speaker and writer, offering support to dads.

FiveXMore

A grassroots organisation committed to changing Black women and birthing people’s maternal health outcomes in the UK.

Email: fivexmore@gmail.com

Gingerbread

Single parents, equal families. Help and advice on the issues that matter to lone parents.

• helpline: 0808 802 0925
• website: www.gingerbread.org.uk

The Hub of Hope

A directory of mental health support around the UK.

LGBT Mummies

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Email: contact@lgbtmummies.com

Make Birth Better (Birth Trauma Support)

Email: hello@makebirthbetter.org

Maternal OCD

Peer support available, email info@maternalocd.org to arrange

Mayah's Legacy

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Email: info@bigoutreach.org

0300 102 1596

The Motherhood Group

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Motivational Mums Club

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Music Football Fatherhood

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Muslim Women’s Network

Helpline: 0800 999 5786, open Mon-Fri 10am –

4pm with support offered in English, Urdu, Punjabi, Mirpuri, Putwari, Hindko,

and Bengali.

Email: info@mwnhelpline.co.uk

Online chat: www.mwnhelpline.co.uk

Text: 07415 206 936

National Autistic Society

www.autism.org.uk

Support and advice for parents and carers of autistic children, including support to develop a greater understanding of their child’s needs and accessing services that meet the family's needs.

Netmums

Netmums offer peer support via their Maternal Mental Health Drop-In

Clinic.

NHS

Contact your local GP surgery.

Call the NHS on 111

or contact a local NHS urgent mental health...

One of the most debilitating things about

it is that it's cyclical.

So it comes around month in month out.

A lot of women will say, "My period arrives and I feel myself again".

Or maybe a couple of days afterwards they feel themselves again, and then they

kind of think, "Did it really happen?

Was it really that bad?"

And then you start doubting yourself and you go to a medical

practitioner and some doctors haven't heard of P.M.D.D., for example.

And they'll say "Well, not really sure, I think you might have mild P.M.S."

or, you know, things like that.

And so there's a bit of - not intentional I think- but medical

gaslighting that can go on with severe forms of premenstrual disorder.

And also to have a diagnosis of P.M.D.D., there shouldn't really be any other

underlying mental health or psychological diagnosis, but often they come hand in

hand because if you struggle with severe premenstrual symptoms month in, month out,

you are gonna become depressed because it feels quite hopeless because you feel

whatever you do, you feel horrendous.

And so even if you do feel okay for two weeks, three weeks, a month,

you know this and it is exhausting.

I've had women say they just can't face going through it every month.

And so it's not uncommon to have kind of concurrent depression or

anxiety alongside those changes.

So when I see women, I often say, well, "look at their notes."

So sometimes there's a referral letter or they sometimes refer themselves

in, but they will have on their notes that they have depression or anxiety.

But it's always important to say, "Okay, what came first?"

Because often it's the depression and anxiety have arisen after their mood

changes have just been going on for several years and it's like a feeling of

hopelessness because whatever they do, they find themselves in this situation.

But there's definitely help and advice out there.

Having a baby is meant to be the most joyful time of your life.

But for many mums and dads, it can be the hardest and at

times the darkest of places.

Welcome to Season 2 of Blue MumDays, the podcast for anyone

struggling with parenting.

All the stories shared here are from the heart.

These are real conversations and may be triggering, so

please listen with discretion.

Today's episode covers feelings of suicide.

We will also signpost you to help in the show notes.

Thank you.

Today's guest is Dr.

Hannah Short.

Hannah is a G.P.

specialist in menopause, Premature Ovarian Insufficiency (or P.O.I.)

and premenstrual disorders.

She is recognised by the British Menopause Society, the International Association for

Premenstrual Disorders, and the National Association for Premenstrual Syndromes.

Hannah has a particular interest in induced menopause, Premature

Ovarian Insufficiency and hormone sensitivity disorders.

She is a member of the I.A.P.M.D.

Clinical Advisory Board and the Surgical Menopause Advisory Committee,

and has previously worked as a volunteer doctor for the DAISY Network.

They are a charity dedicated to girls and women diagnosed with P.O.I.

Hannah has personal experience of premature surgical menopause, which

drives her passion and informs her work.

She is co-author of 'The Complete Guide to P.O.I.

And Early Menopause'.

Hi Hannah.

Thank you so much for joining us today.

Welcome to Blue MumDays.

Thank you, Vikki.

Nice to be here.

First of all, can you explain to us what P.O.I.

is, for those of us who aren't familiar with it?

So Premature Ovarian Insufficiency or P.O.I.

is now the preferred name for early menopause below the age of 40.

But it's not quite as straightforward as that.

So menopause normally indicates like a permanent state, whereas,

you know, over your ovaries are no longer going to function,

you're not capable of conceiving.

In actual P.O.I., there's fluctuating ovarian activity, but there is

reduced fertility in these girls and women who are affected.

And you can have menopausal symptoms and issues relating to oestrogen deficiency.

It's also related to early menopause, which means your periods

are much more likely to stop.

But generally it's used as an umbrella term for anybody who falls into

that category or their periods have stopped or they've had their

ovaries removed below the age of 40.

Sorry, there's not a very succinct answer to it because it's, it's not a

very really straightforward explanation, but I hope that explains it a bit!

Thank you.

And how common is this would you say in the UK?

So we used to think it was, um, one in a hundred women,

below the age of 40, but recent estimates suggest it may be up to

3- 4% of women on a global level.

I mean, the percentages are greater in the 30-40 age group than they

would be in the 20-30 or under 20.

But there are some teenagers and even kind of tweens who can be affected.

Their periods may not start, they may never have normal ovarian function.

Oh my goodness.

So actually that's a lot more common than I thought it would be.

Yeah.

And yet it's, it's not talked about or very understood what it is.

It isn't at all.

And I think, you know, women are constantly told they can be too

young for menopause or, I mean, the words premature menopause and P.O.I.

used intermittently even though they're not always the same thing.

But essentially the, the health risks and the concerns are very similar

and it often means that if it's not recognised, girls and women don't get

the treatment and the support they need.

So yeah, we need to rate, raise awareness basically.

It's It's amazing you say that because I know so many of my peers and

friends who are feeling like they're going through perimenopause and you

know, in their mid forties, they're being told, "Oh no, you're still

too young for that" and yet you kind of know when things are different.

But that's, it's crazy really that we're telling women

they're too young in the mid forties because any age after the age of 45,

if you actually stop your period, so you're fully menopausal- is considered

within the normal age range, and you can, your perimenopause can start

10 years before your final period.

So it's not unusual to have perimenopausal symptoms in your late thirties.

That's not to say women will always need treatment or medical

support, but it's not unusual.

And perimenopause is different to P.O.I.

and this is where it can get a little bit complicated.

But yeah, we shouldn't be telling women that.

I mean, we've got guidelines -if women have or they're concerned they're

having menopausal or perimenopausal symptoms over 45, we don't worry

about doing things like blood tests.

Um, we just treat them clinically.

But under 45, we, we normally would do blood tests to rule out other conditions

and certainly under the age of 40.

So everyone should be taken seriously really.

Thank you for that.

And obviously, gosh, we could do a whole, a whole episode on its own, on

perimenopause and, and the menopause.

But one of the reasons that I wanted to speak to you today for this is,

is because there is so much about women's hormones and we're so affected

by hormone fluctuations and that can really affect things like mood.

If we stay with P.O.I.

for a moment, what sort of treatments are available for anybody going through that?

So in P.O.I., if you've got loss or reduced ovarian function,

you're not producing normal amounts of oestrogen which is really important for

things like your bone health and your heart health and your brain health,

and also your general wellbeing.

So first line treatment is Hormone Replacement Therapy (H.R.T.) to bring

the levels back up to where they should be at the premenopausal age.

And there are guidelines for this.

So that's really what we should be doing, whether or not a

girl or woman has symptoms.

So not everybody will struggle with oestrogen deficiency or menopausal

symptoms, but then maybe their periods have stopped and if other

courses have been ruled out, then that's something we need to look at.

I mean, there will be some women who have a P.O.I.

or entered a premature menopause because of cancer or something like that,

which means that sometimes that's not really what we'd be offering, if it's

an oestrogen appended cancer, but each case has to be viewed on its own merits

and we look at risks and benefits, and there are other treatments we can use

to support women who can't take H.R.T.

My mum, bless her, had breast cancer that was related to H.R.T.

23 years ago.

And obviously H.R.T.

has changed a lot since then.

But I must admit, sort of with my own experience going through menopause,

I've always been wary of taking it because of my mum's situation.

If somebody was considering taking H.R.T.

what would you say to them in terms of its efficacy and its safety these days?

Well, in terms of P.O.I.

there's no increased risks.

You know, if you haven't had an oestrogen dependent cancer, there's no increased

risk, because all you are doing is replacing the hormones that would

naturally be there if your ovaries were functioning as we'd like them to do so.

So there's no increased risk of things like breast cancer and it reduces your

risk of things like heart disease, dementia, osteoporosis, diabetes.

So it does a lot of good health prevention as well, and it's

really important for health.

In women of natural menopause age, the benefits usually

outweigh the risks as well.

And there's a lot of hype around the breast cancer risk, because it's

not as black and white as "H.R.T.

causes breast cancer."

We don't actually have good evidence that it causes breast cancer.

It may be what we call a promoter of oestrogen positive breast cancer

and it can encourage the cells growth if they're already there.

But it's not like smoking where we know that actually smoking

damages the DNA and can trigger cancer in the lungs, for example.

And there are other things that are far more likely to increase

your risk of breast cancer, such as not exercising at all.

So, you know, doing two and a half hours of exercise a week hugely

reduces your risk of breast cancer, whether or not you take H.R.T.

If you are overweight or obese, that puts you in a higher risk

category- far more risky than if you take a small dose of H.R.T.

Drinking more than two units- so a glass of wine every night- again

is more risky than taking H.R.T.

So it's looking at every person and seeing 'do their benefits outweigh the

risks?' You know, do they need H.R.T.

to help manage symptoms, to reduce long-term health risks?

I'm not saying everybody should be on it at all, but I think a lot of women

are unnecessarily scared of HRT and it can be a real game changer in terms of

how well women feel and can actually reduce the risk of harm later in life.

So when there were the big scares around 20 years ago, around H.R.T.,

A lot of women stopped H.R.T.

overnight, doctors stopped prescribing it.

And actually, if you look at the statistics, rates of heart disease

and stuff went up hugely after that.

Obviously we don't say "start H.R.T.

to reduce your risk of that" unless you fall into the P.O.I.

category.

You would normally prescribe it if there are symptoms and,

and things like that as well.

But there, there were harms associated with that mass stopping of H.R.T.

So yeah, for most women, the benefits outweigh the risks

if, if it's needed for them.

Thank you.

That's so beautifully put, and funnily enough, I'm I gotta get

straight on the blower to my G.P.

then after this- see if I can get rid of the night sweats and the hot flushes!

Um, but thank you.

That's, that's really put my mind at rest in terms of, looking into H.R.T.

I mean, I'm really looking forward to speaking to you

about things like P.M.D.D.

and P.M.E.

And I would love to speak to you about postpartum rage, postnatal rage or the

effect of hormones on feelings of, anger.

But first of all, do you mind telling us about what brought you

into this area, this specialism?

I mean I've always been interested in women's health,

and I've always been interested in like psychology and psychiatry.

And when I went to medical school, I wasn't quite sure

what I would end up doing.

Initially I did do psychiatry training and then I was slightly frustrated

with the way the services worked, and then I felt I'd have more of

an impact in General Practice.

And so I went back to do my G.P.

training and I think it was in general practice that I started noticing, I don't

know, so many symptoms that women came to see us about, especially as a female G.P.

There was an element of, of hormonal influence, even if it wasn't directly

what they were consulting me about.

And I've also always had my own issues.

So I've always struggled with periods.

I had terrible painful periods from when they started to when I was 13.

I'd miss school, I missed weeks at university, I've lost a job because of

it, because I went to medical school school late, not only when I was 27 and

prior to that I, I worked in kind of administrative and then finance roles.

I lost a job in London because I was an unreliable employee.

And because I had to call in because I was so debilitated by my symptoms.

And I was diagnosed with endometriosis when I was in my early twenties.

And then together with that, I also struggled with premenstrual mood changes,

which were quite significant and got worse as I entered medical school and my junior

doctor training, which can be quite brutal because you don't have a regular routine.

You're working crazy hours, you don't eat well, you don't sleep well.

We basically don't do anything we tell our patients to do because

the rota makes it impossible.

And I think that just made everything so much worse.

But I used to have incredible anxiety and really crashing low

mood before my period arrived.

And everything felt quite unmanageable, especially

because I had irregular periods.

I never had regular cycles, so I couldn't even predict when I was gonna feel okay.

And most of the time I didn't feel okay because premenstrually,

psychologically I struggled.

And then when my period arrived, physically I struggled.

So it was probably only a handful of days a month where I felt relatively okay.

I tried various treatments.

I mean, I had several surgeries for the endometriosis, which was

successful in the short term but ultimately didn't resolve the pain.

I tried alternative medicines and, you know, complimentary therapies including

acupuncture, reiki, homeopathy, I mean, everything -changing my diet.

And I only kind of got minimal relief at best.

And ultimately it was recommended that I have my ovaries

removed and a hysterectomy.

I'd obviously tried a lot of the medical treatments, like different

contraceptive pills and stuff well before that, and painkillers and things.

And so that's what happened at 35.

I had a premature surgical menopause, so all of my reproductive organs

were removed and then plunged straight into surgical menopause.

And it was that, that really opened my eyes, although I was well aware of issues.

But when I realised how poorly we managed women in menopause, particularly

those of us who don't have a natural menopause at the natural age of,

you know, mid forties or upwards.

I suppose it ignited my passion and I thought, well, what, what can I do?

And it's just developed from there.

I've done further training in menopause and work around in the premenstrual

disorder space and yeah, there we go!

Oh my goodness, what an experience that you went through.

I mean, it's wonderful for the women that you treat that you took such a negative

personal experience and created something so positive and compassionate out of that.

Are you happy to talk about how you felt going through something

so extreme at such an early age?

To be honest, I felt so ill before the surgery

that I was pretty desperate.

And I actually wrote a letter.

I found it the other day and then I felt slightly mortified when I read it!

But a letter I wrote to my gynaecologist basically begging him to give me the

surgery because I naively thought having the surgery would put me

in a position where I felt like a "normal" in inverted commas woman.

And I would have some add- back hormones because I'm lucky that I didn't have

any reason not to have the hormones and I'd just kind of go on my way.

I knew it would take a while to get my energy back and to feel

well, but I didn't anticipate how difficult it would be post-op.

And although I've never regretted the surgery because I'm lucky that my pain

pretty much disappeared with that.

And my premenstrual changes- you know, the mood changes, obviously I

wasn't having periods- I felt a lot better and more stable mood-wise.

I struggled with absorbing H.R.T.

for example.

I felt really quite unwell from the physical menopause symptoms that I had.

Eventually that was sorted.

You know, I worked with a good gynaecologist and my G.P.s were

supportive and eventually found a regime.

But it also forced me to look at things like diet and lifestyle and actually

do the things that I knew would help me, intellectually, but I hadn't

really been putting into practice, because that's been fundamental.

And it's only further down the line that I kind of, things like not having

children kind of really hit me because at the time I thought, well, "I'm

too"- I don't know- "I'm too unwell to even consider having a child".

And I found that's the hardest thing for me in the latter years.

And it's not so much, or at least not always, not physically having a

child, but it's also the way you're treated as a woman without children.

I think that's one of the biggest things, you know, and I think this

applies to whether you are somebody who considers themselves childless

or if you're somebody who's child free, you are treated differently.

And I don't think people appreciate that unless they've had that experience.

So that's been my hardest thing for me in recent years I think,

and feeling quite isolated.

Yeah, I totally understand what you're saying because I know friends who

have chosen not to, to become mothers.

You know, it doesn't mean that they're callous and it doesn't

mean that they hate children.

It's just that they've decided for them, it's not how they want to go

on to, you know, to live their lives.

And they are very much treated differently and castigated because of that decision.

And I mean, it must have been incredibly hard as well.

Like, you know, I find it hard enough having gone through menopause when my

friends and I, we're all a similar age, and we're all going through it together

and going, "Oh my God, how come our mums have never talked about all of this?

It's such a ballache!"

But to go through that independently and at the age of 35.

And I'd imagine if it's a surgical menopause, is that more brutal?

Is that more extreme?

That must have been a very difficult thing to go through

when you are still so very young.

I mean, yes, it was, I suppose I had the advantage over some

women in that I understood and like, because this isn't always explained

to women, when they go through certain procedures, what's going to happen.

And I think because I am a doctor and I really researched it and

I was lucky that I had a, a very compassionate and knowledgeable

clinician kind of guiding me through it.

I was aware of certain things and I knew that it could be brutal, but because you

have your ovaries removed and you go from being premenopausal with premenopausal

hormone levels over to being surgically menopausal and having, you know, drop a

huge drop in your levels, right overnight.

But I was prepared in that I was given H.R.T.

straight away.

Often women are told whatever age they are, "Oh, just wait a few

months, you might not need it."

Which should never be the case because I think your body almost goes into

like a form of shock because you've removed part of the endocrine system.

And it can even in women who've actually been through a natural menopause, even

as somebody who's 52, whose period stopped three years ago, if some reason

they need that ovaries removed, and they go into actual surgical menopause,

they will notice a difference most of the time because the ovaries don't

become non-functional after menopause.

They're still producing small amounts of hormones and we think that they

do much more than that as well.

But there's been a lack of research -as there often has been in women's

health- so, it's a huge change and it really was kind of challenging.

And I do remember having a surge of, I suppose it was been an adrenaline surge

like a couple of days after surgery, which I think a lot of women describe.

And it, it did feel like my body was going, "What the hell has just happened?"

And I did think, I felt like I was gonna have a panic attack and then

things kind of calmed down and, um, it, it was, it was challenging, but I

knew that it was gonna be difficult.

And I do worry more for women who don't have that knowledge or understanding

because they haven't been given it and it hasn't been explained clearly to them.

Because I think women need to know it's not the same as natural menopause.

We shouldn't treat it the same.

You'll always be in surgical menopause.

You don't get through it.

It's not like with natural menopause, often things improve over months to

years and if, women are on hrt, most people won't take it lifelong.

Some may need to for various reasons, but most don't.

In surgical menopause, you nearly always need to or you may wish to.

Um, but because it is a hormone, a true hormone deficiency,

it's not a natural transition.

And I think natural menopause takes several years for your

hormones to kind of levels fall.

And yet in surgical menopause, things just literally drop off a cliff overnight.

So,

Wow.

Yeah.

So what, what sort of symptoms were you getting then through surgical menopause?

Was it, slightly better because you were on H.R.T.

straight away, so it wasn't as extreme?

Well, I didn't really absorb it straight away, so I was taking

what I thought was a decent dose of H.R.T.

and it was a gel I was applying through my skin.

And I was only absorbing minimal amounts.

So I've never really struggled with hot flushes and vasomotor symptoms,

so like night sweats and things.

Very occasionally get the odd night sweat and there's around 20% of

women who don't get those symptoms.

And I think often they're missed because people assume you have

to have those symptoms to be perimenopausal or menopausal.

It was more things that I had severe joint pain, like really severe joint pain,

terrible insomnia, heart palpitations, quite severe dryness in terms of skin.

My skin also changed.

I kind of developed rosacea, because you have a lot of autoimmune or

immune system changes with- you know, when you're thrown into menopause.

And that was really upsetting for a while because I just had an awful rash

on my face and nothing seemed to kind of calm it down, terribly kind of dry eyes.

I would have waves of anxiety, but it's something I've lived with most of my life.

Um, but they could be more extreme and I think that that may be kind of part

of the same thing that goes on when women have hot flushes, but you just

don't have that hot flush at the end.

Because hot flushes are generally associated with a surge

in adrenaline and cortisol.

And often women will say that they feel a wave of panic before a hot flush comes up.

That doesn't happen to everybody, but there's something going

on there with that as well.

So yes, I, I would get those symptoms.

Um, bladder symptoms like needing to rush to the loo, or constantly feeling like

I'm getting the beginning of a U.T.I.

(urinary tract infection), but nothing ever being there.

Oh, headaches.

Yeah.

Quite severe migraines and headaches as well.

It sounds like the whole jamboree of...

who'd be a woman?!

I know, I know It

It wasn't fun.

And thank you so much for being so open and talking so bravely

about, about your symptoms because I'd imagine there are so many listeners now

who are listening to this and going, "Wow, finally I feel seen and heard"

because of what they're going through.

Do you mind me asking you, did you go through a period of grief about not

being able to be a biological mother?

Or is it something that you felt you came to terms with quickly?

I think.

I have definitely had some feelings I suppose I would describe as grief, but

to be honest, a lot of it was more to do with feeling like I'd lost a lot

of what should have been my healthy youth to illness and to my hormones.

Because I just think back to my late teens and early twenties and I was somebody

who had to go home, you know, night out.

I'd go home cause I was in absolute agony or I was so fatigued and,

you know, I missed out on a kind of adventure sports holiday that

I planned with loads of friends.

And I had to stay at home because I just couldn't move because of

the pain with my endometriosis.

So things like that, I think I grieve more in some ways cause I didn't have,

it's not like I look back at my twenties and think, "Oh, I was young, free."

I mean, I know not everybody is, there's plenty of people who are

dealing with far worse things, but that's what I struggled with.

And also the fact that I would never have those years back.

The grief around children, I mean, I suppose I was never- I was always

slightly ambivalent about being a mum.

It was never something I thought "I have to have children."

And so it surprised me somewhat that like as time has gone on, I

felt a bit more grief around that.

But it's sporadic.

And I think some of it's to do more with having the choice taken away from me.

So people will say, "Well, you chose to have your ovaries removed", but it

didn't really feel like I had a choice.

So, um, and I'm lucky my husband didn't want children, or at least

is not upset by not having children.

And so I had, because that would've been difficult I think,

if he had been desperate for us to have biological children.

And we have two cats who we love to bits and I know they're not the

same as, you know, biological human children, but I dunno, it's just lovely

to have them around and, and things.

It's, yeah, I don't know.

It's hard to answer it really, because I think there are lots of benefits to

life without children, but I think.

I don't know.

It's hard to compare the two lives, isn't it?

Because all of us will only live one, if you see what I mean, you either have

children or you don't have children.

And I think they're just different paths and there are benefits

and disadvantages to both.

And I think I now try and frame it and think, well what's the benefit?

You know, I am more flexible.

I can make different decisions that I wouldn't have been able

to make if I hadn't had children.

But occasionally it really hits me.

And that seems to come out of nowhere, so I don't really know what that's about.

But...

I can really relate as well- you were talking about your grief and

not having those youthful years, you know, those carefree years of going

out because, certainly speaking from my own experience of postnatal depression

and also from a lot of the incredible guests that I've spoken to during the

course of this podcast, is a sense of grief and loss about the early years of

motherhood that we felt, or certainly what we perceived it should have been like,

versus the reality and how dark it was.

You know, certainly for the first year of Stanley my son's life- and my God, I love

that little boy so much- but it was the worst year of my life without a doubt.

And I still get a sort of pang sometimes on his birthdays.

And, um, I know one of my other guests, Christine felt exactly the

same, that sort of grief of what, what it "should" have been like.

But again, it's that sort of perception, isn't it?

But I think it's, I think it's okay for us to grieve things.

And I think it's, probably good to have those feelings and let them

out rather than bottle them up.

It sounds like you had a very difficult

time and I think unfortunately so many women do, don't they?

And I think women are sold a lie about a lot of stuff in life.

It's only in recent years, people are starting to talk more openly.

And I think this is where there's the power of things like

podcasts and social media...

I mean, there's a lot of downsides to social media.

But I think the fact that it can connect people who have similar

experiences, whereas otherwise people would've been kept in the dark

and felt alone for so much longer.

I think that's brilliant.

So I mean, that's one of the reasons I chose to, I suppose be open about my

own experience, even as a clinician, because some doctors warned me against it.

But I just think, well, doctors are just human.

We're not special because we trained as doctors.

We all have similar experiences in terms of, you know, our emotions and

feelings and, and everything else.

So it's misinformation to think doctors are never sick, or, you

know, not affected by the same things that we treat our patients for.

Yeah, it's funny, we, sort of tend to put doctors on pedestals,

and it takes a lot of bravery for you to come forward and sort of admit to

having something like anxiety, but it's incredibly life affirming to know

that everybody gets affected and it's indiscriminate, it doesn't matter who

you are or what you do for a living, you know, and it's part of being a human.

Definitely.

Can you explain to me what some of the, the premenstrual disorders

are because one of the reasons I got in touch with you was because

I recently found out about P.M.D.D.

and P.M.E.

Maybe if we talk about P.M.D.D.

first, and I know it's certainly something that I could relate to.

And probably my mum, so if you're listening, "Hi mum,

have a listen to this bit!"

But I know that both of us felt terribly bleak and dark before our periods and

I didn't realise that that was a thing, that it could be a medical condition.

Yeah, and I think, again, a lot of women just aren't aware of it.

Again, there's been more awareness in recent years with social media

campaigns and things like that, but I mean, when I had my surgery,

it wasn't even termed P.M.D.D..

And I, I do wonder if I had P.M.E.

- which stands for Premenstrual Exacerbation- of anxiety

and things like that.

But I was told I had a severe premenstrual disorder.

And essentially, P.M.D.D.

stands for Premenstrual Dysphoric Disorder and it affects around 5-8% of women of

menstruating age and also trans men.

So anybody who's born with ovaries can be affected by this condition.

And it's a condition of hormone sensitivity.

So it's not that there's an imbalance of hormones, it's just that the

brain reacts or overreacts to changes in hormone levels and has an

abnormal response to normal hormonal changes such as the menstrual cycle.

So I think a lot of women will have heard of P.M.S.

or P.M.T.

and that's kind of, you know, a lot of jokes are made about it,

although it's not particularly funny.

And I suppose that's the kind of milder sister really of P.M.D.D.

and affects around 30-40% of women.

And that's where you kind of get mood and physical changes in the

lead up your period, because I think most women will be aware that their

body and brain changes throughout the menstrual cycle, but it wouldn't

necessarily be in a problematic way.

They might just be aware that, I don't know, their vaginal discharge is slightly

different at different points in the month, or their breasts are slightly

fuller at one point in the month, or their sex drive is higher at one point.

I mean, you know, they're aware of these changes.

They don't constitute a clinical disorder.

But because we're cyclical creatures, you start to be aware of these changes.

But the women with P.M.S.

will say maybe their mood, they will be a little bit more tearful or more

likely to cry or have an argument with their partner or have headaches

or breast pain in the lead up.

And they may go to their G.P.

and ask for some advice.

And sometimes things like diet and lifestyle changes

can make a big difference.

Sometimes the contraceptive pill, which evens out hormonal changes

and things like that can help.

But these women who have P.M.S., they're not gonna fall into the P.M.D.D.

category, which is where there's serious disruption to your personal life.

And P.M.D.D., it's where it's, it's more really a matter of degree.

And if you feel that your symptoms are so debilitating, so, you know,

profound depression, very severe anxiety, rage, mood swings, suicidal

thoughts, um, you know, feelings of hopelessness and despair.

It may be, you know, women feel they can't go to work, or if they do go

to work they're constantly worried they're gonna do something wrong

and try and put on a brave face.

But it's a real effort for them to kind of try and act normally, as it were.

And then these symptoms, you know, they are significant.

That's when you'd have this diagnosis of P.M.D.D.

And they need to arise in the luteal phase of the cycle.

So that's after ovulation, generally in the two weeks or

one week before your period.

And then they should get better when your period arrives.

But, um, we know that there are genetic links.

So you said your, you felt that your mum may have struggled with this as well.

There are at least a couple of genes that have been identified,

which seem to be more common.

These in particular variants that are common in women with P.M.D.D.

And they kind of affect the way the brain processes, you

know, oestrogen and serotonin.

And also the breakdown products of progesterone as well.

Because all of these things play a role in our kind of brain chemistry

at different points in the month.

Wow.

I can so relate to that because religiously about a week before

my period would come, I would feel very hopeless, very, very dark and

despairing and sometimes that I didn't want to be around anymore.

And even if I knew my period will probably come in a week's time, the

blackness would be so black that it, that wouldn't make a difference to me.

And it would feel like the reality was this and that, you know, "I'm a terrible

person" or "life is just terrifying".

And then within a week, bam, period would come and it would feel like

resurfacing from being underwater.

So yeah, this, wow.

I'd, I'd love to know if, if this is resonating with any of my listeners and

to know that potentially, it might be something that you could be helped with,

would be an incredible comfort to some.

One of the most debilitating things about

it is that it's cyclical.

So it comes around month in month out.

A lot of women will say, "My period arrives and I feel myself again".

Or maybe a couple of days afterwards they feel themselves again, and then they

kind of think, "Did it really happen?

Was it really that bad?"

And then you start doubting yourself and you go to a medical

practitioner and some doctors haven't heard of P.M.D.D., for example.

And they'll say "Well, not really sure, I think you might have mild P.M.S."

or, you know, things like that.

And so there's a bit of - Not intentional I think- but medical

gaslighting that can go on with severe forms of premenstrual disorder.

And also to have a diagnosis of P.M.D.D., there shouldn't really be any other

underlying mental health or psychological diagnosis, but often they come hand in

hand because if you struggle with severe premenstrual symptoms month in, month out,

you are gonna become depressed because it feels quite hopeless because you feel

whatever you do, you feel horrendous.

And so even if you do feel okay for two weeks, three weeks, a month,

you know this and it is exhausting.

I've had women say they just can't face going through it every month.

And so it's not uncommon to have kind of concurrent depression or

anxiety alongside those changes.

So when I see women, I often say, well, "look at their notes."

So sometimes there's a referral letter or they sometimes refer themselves

in, but they will have on their notes that they have depression or anxiety.

But it's always important to say, "Okay, what came first?"

Because often it's the depression and anxiety have arisen after their mood

changes have just been going on for several years and it's like a feeling of

hopelessness because whatever they do, they find themselves in this situation.

But there's definitely help and advice out there.

there's the organisation that I'm on the clinical advisory board for, I.A.P.M.D.

They have some fantastic patient information- sections on there that talks

about what this condition is, including all the treatment options and peer support

and they do awareness raising campaigns.

They've also got a section for professionals, so doctors and

psychologists and scientists and things like that.

And looking at all the latest research and evidence because I mean, unfortunately

a third of people with P.M.D.D.

do attempt to take their own life during a crisis.

I mean, so it is, it is a mental health, emergency in that sense.

Mind have got something on their website about P.M.D.D.

as well, because like you said, even if you have this awareness this is to do

with a phase of your menstrual cycle when you're in it, it doesn't feel like that.

It feels like it's always gonna be like that.

And people worry that other people around them are getting fed up with them, that

they'd be better off without them.

And it's, yeah...

Treatment is out there.

I have to say, it's not always easy to find the right thing immediately,

but there are treatment guidelines that are accessible to all doctors.

They may not always be aware they're there, but the Royal College of

Obstetricians and Gynaecologists do have treatment guidelines, and you start with

quite basic, low level interventions, but they do go right up to, I suppose,

the treatment I ultimately had, which was removal of the endocrine system

or your reproductive endocrine organs.

I wouldn't recommend that unless it's absolutely needed, because there

are other repercussions with that.

Sometimes that's necessary.

And I think one thing to say though is it's not a cure because you still

have a hormone sensitive brain.

I think some women are told that if they have the surgery, that

actually your ovaries are gone.

So you should be fine.

But actually the issue is in the brain.

It's not the ovaries, it's the brain's response to the

ovaries' hormonal production.

And so women need to be told that.

It just becomes easier to manage if your ovaries have removed, because

you can then have some element of control if you have add- back H.R.T.

for example.

But before you get to that stage, there are lots of other things you can do.

And we use S.S.R.I.s, which are a form of antidepressant, but they can just be

used in the luteal phase at a low dose.

And to be honest, that that's got the most evidence for efficacy for patients.

And I've seen patients who have gone from feeling hopelessly suicidal every

month to feeling "normal" or they don't really notice their symptoms

and they're much more manageable.

But they don't have the side effects associated with long term S.S.R.I.

use.

I personally often use very low doses because it works in a different way than

when we are using it for, you know, things like clinical depression and things.

But there's also hormonal treatments like certain contraceptive pills can

be particularly helpful because that suppresses the natural ovarian cycle

and gives you add- back hormones.

But the, the only problem with P.M.D.D is women are hormone-sensitive

and sometimes don't get on well with the particular pills.

And this is why you probably, if you are at the more extreme end of this group

of women, then you probably need to see someone with expertise in that area and

might need referrals somewhere because it may be beyond the scope of your G.P.

for example.

But there is the help out there.

This does sound extremely complex and I think when we spoke

briefly before Hannah, I think, did you say 75% of women are felt to

have issues with their hormones?

No, I think I might have been saying that most women are

aware that they have changes at some point, you know, around their cycle.

But it depends.

I mean, it wouldn't surprise me if around three quarters of women

had issues in some way relating to their hormones, whether it's P.M.S.,

P.M.D.D., if it's peri-menopause, or, you know, or is it more to do with

endometriosis, which, you know, the symptoms are driven by hormonal changes.

I mean, if we look at the stats for menopause, around 75%

of women will have symptoms.

So I think the lucky quarter of women who don't really have symptoms, they

may be the ones who've been quite lucky throughout their reproductive life.

So I think, yeah, if we are looking at it like that, it probably is around

three quarters of women who will have some kind of issue relating to

reproductive lives and menstrual cycle.

What was interesting in particular when you were

talking earlier about P.M.S.

and P.M.T.

and how dismissive women are made to feel if you're going through it.

And it's the same with menopause, that it's like, "Oh, she's going

through the change" or, , "Oh, she must be on, having her monthly".

And it's always done in very dismissive terms and belittling terms

when actually it does have a huge effect on you - how you present

and how you feel about yourself and everything on a regular basis.

So you've talked about endometriosis- you know, it's a term I understand, but

I don't fully comprehend what's involved.

Okay, so it's a condition where there are cells

similar to the lining of the womb are found outside of the womb or uterus.

So they can be found on the outside on the fallopian tubes or the

ovaries, but also within the pelvis or on the bladder or on the bowel.

In some rare cases they've been found in the lung or in the brain.

And the problem is these cells act like the lining of the womb.

And so they respond to menstrual, hormonal changes and they bleed in

response to hormonal changes as well.

So you can get internal bleeding.

You know, some women have coughed up blood during their periods, if they

had endometriosis in their lungs.

That is quite extreme so most women wouldn't get that.

But some women will, for example, when they open their bowels, would pass blood.

And it's not because they've got piles or they've, you know, got a

fissure or something, it would be entirely related to their period.

You know, the internal pelvic organs can become fused together so the

bowel can get stuck to the uterus.

They can, and you get all these adhesions, which are formed, so

you can get what's called a frozen pelvis, where there's lots of kind

of like scar tissue in your pelvis.

And obviously it can lead to repercussions of things like fertility

issues, particularly if you've had big cysts or stuff on your ovaries.

So, yeah, pain is one of the most common symptoms, but it can, can cause

you know, severe, you know, other symptoms like bloating and there's

obviously an associated mood changes, but I suspect that's more to do with

the response to the physical symptoms.

Although having said that, it's got inflammatory and we think

autoimmune roots and we know that the inflammation there has effects on the

brain, which can trigger depression.

So there may be something else going on there as well.

I'm very lucky that I've never had chronic long-term pain, but

I'd imagine that if you're in that situation, that also affects your mood

because it's exhausting and it gets you down, living in pain like that.

And for anybody that's struggling with endometriosis at the moment, is

there anything that they can be doing to sort of help themselves or is it

a question of going to see the G.P.

first and foremost?

I think if you're struggling with pain that's related

to your periods or symptoms that are coming that seem to be associated

with your menstrual cycle then yes, definitely go to your doctor.

One good thing would be to track your symptoms to see if there is a pattern.

Um, I mean, endometriosis is a slightly tricky one because you

can't formally diagnose it really without having a laparoscopy,

you know, a surgical procedure.

Occasionally do MRI scans and if they've got like a big cyst on your

ovary, then that might be enough to say, "Yes, you've got this".

But often you can have microscopic disease, which means that you

wouldn't necessarily see it on a scan, but because of where it is, it

could be triggering severe symptoms.

So there's different grades of endometriosis, but weirdly, what

would look, if you were looking at it from a surgical point of view, 'mild'

could have horrendous symptoms, but you could have severe endometriosis,

but that may not be bothering you.

But for example, could be found during investigation for

fertility treatment, for example.

Again, there are guidelines for doctors to help treat women with

endometriosis and referral and, and surgery isn't always needed because

there are risks that come with surgery.

You know, the contraceptive pill, again, can sometimes be helpful.

Sometimes dietary changes- having a fiber rich diet can be helpful,

because of changes to do with a gut microbiome and the way our body

deals with the breakdown products of oestrogen and things like that.

Um, but it, it's hard.

There are, you can be put into a chemical menopause to shut down your

ovarian function and to see if that gives relief from the symptoms as well.

I mean, I think if anybody is struggling with what they think may be

endometriosis, look at Endometriosis U.K.

That's a UK charity and that's got lots of information and support there.

But I think if you're having painful periods interfering with

your life and doesn't just go away with a little bit of paracetamol

or ibuprofen, that's not normal.

Women are told it's normal, you know, "It's just period pain", but it isn't.

And yes, treatment is, kind of needed, but I suppose just don't be fobbed off

if you're not immediately referred to a gynaecologist and stuff because there

are conservative measures that can help.

And actually you don't want to have surgery unless you need it.

And if other things improve that your G.P.

can help you with, then that's really the route to go down.

That was incredibly helpful, thank you Hannah.

As ever with the podcast I'll be putting full support links in the

show notes, so to organisations like Endometriosis U.K., I.A.P.M.D.

and also Mind, in terms of P.M.D.D.

I'd love to talk to you as well about rage, because it's something that keeps

coming up time and time again with listeners who have experienced tremendous

anger, in the postnatal period.

It's not something that I can relate to myself, but it does seem

to be a 'thing', postnatal rage.

Can you talk to us about that, what causes it and how it manifests

and what can be done to sort of help people going through that.

Well, I don't have much experience personally

with patients with postnatal rage.

Not because I'm saying it doesn't exist, because I understand it does.

But I see this a lot with premenstrual disorders and P.M.D.D.

And I suspect it's the same thing that is going on there because our brains

are profoundly affected by hormonal changes, and we all have differing

degrees of hormone sensitivity.

So the way our brains process the hormones or the breakdown products will

react to them is gonna be different.

So when we see this in women with P.M.D.D.- and I suspect that there is

similarity with the postnatal rage- is when there's issues with the brain

dealing with the breakdown products of progesterone and particularly, so there's

something called allopregnanolone, which is a breakdown product.

And normally this would produce a calming kind of sedative- like effect,

but that doesn't happen in women with severe hormone sensitivity.

In fact, it seems to induce kind of more anxiety and rage

and things like that as well.

So I think there's probably something going on there and the

way that the hormone changes and that withdrawal of hormones as well.

So it is quite a complex topic and I'm just trying to think how best to describe

it without kind of confusing as well!

Hormone disorders like P.M.D.D.

are often to do with steroid hormone withdrawals.

So it's that big change, that big drop off that triggers those mood

symptoms because it affects the other neurotransmitters in the brain.

And the same thing happens postnatally.

So you go from high levels of oestrogen and progesterone to kind of, they

bottom out when you deliver the baby.

And it will really depend whether you breastfeed or not, when you, menstrual

cycles commence and stuff because if you are breastfeeding, then there's

often, you know, suppression of your menstrual cycle and you don't start

having periods until you stop often.

But all of these things, if you have got a brain that's primed

to hormone sensitivity could trigger symptoms like rage.

And I mean there, there have been drug trials looking at this and I think

there's something in the states, which is looking at some of those molecules

similar to allopregnanolone in which is going to be used in treatment of

things like postnatal mood disorder.

They did do something in P.M.D.D..

Unfortunately, it wasn't as successful as they hoped it would be, but there

were some changes, but they weren't significant enough to say, "Yes, we

should all be doing this" essentially.

But I think it's a real phenomenon.

Again, I suppose it's going to be speaking with somebody who's an

expert in hormone sensitivity.

I mean, the way that I talk about managing premenstrual symptoms

that are similar to the postnatal rage, it's about one, managing

the kind of hormonal fluctuations.

And that can be done in various ways.

Whether it's it's with further suppression of hormones or is it, adding

hormones, whether it's kind of in form of contraception or hormone therapy.

And the other thing is changing the brain's response to that.

So anything we can do to calm the autonomic nervous

system down can be helpful.

So things like exercise- appreciate that could be quite hard postnatally

when you're dealing with lots of stuff, and especially if you're

feeling really, really low.

Um, maybe a psychiatric drug like S.S.R.I.s, because that stabilises

the neurotransmitters again in the postnatal period, as it

does in the premenstrual period.

Um, anti-inflammatory diet - this isn't gonna be enough in itself, but all

these things can kind of be supported.

So kind of having a diet rich in plants and micronutrients.

Things like meditation.

There was a study at University of Chicago looking at mindfulness based

cognitive therapy, and it showed levels of inflammation, in women with P.M.D.D.

significantly decreased after 16 week course of that.

So all of these things can have a...

they might feel like, "Oh, what are they going to do?"

but they can have a profound effect.

I think it's realistically how can we help women to do these things?

When you're struggling with a newborn or if you're premenstrual and your

mood are so low, how do you do the things that are gonna help you?

And I think then it's better, you know, to seek the support of someone who can

give you the medical support that then enables you to do the things you need to

do, in a self-care kind of way as well.

Yeah.

And with things like breathing exercises, would that be helpful

in terms of where you were talking about calming the nervous system?

Certainly all of that stuff is, is going to be really helpful.

I suppose sometimes the way it can be presented, "Oh, just do a few

breathing exercises and it'll help!"

But actually if we go back to, um, kind of looking at, actually what

happens , it's the feedback that your brain gets when you naturally slow your

breathing down, it gives the signal that you're kind of safe and so your

journal output kind of calms down.

And some of your physical symptoms can kind of get better as well.

And then that has a knock on effect psychologically.

So there is a reason why these things are recommended, but

it's not always explained why.

Um...

It's funny, yeah, I'd read things when I was trying to help myself

and it would be like "Go for a walk!"

Or "Breathe!"

And I've recently trained as a children's anxiety coach and when you actually

learn the rationale behind it and how it can actually calm the amygdala

response and it, makes you realize that, "Ah, there is an actual point to it.

It's not just airy fairy take a few deep breaths and you'll feel better."

I know.

Well, I think that it's like when you talk about diet and lifestyle and the

thing, well, everyone knows, "Yeah, exercise is good for you, should eat

some fruits and veg, but do we know why?

And I mean it's, when you look at the reasons why, it makes much more sense.

And in terms of dietary recommendations, there's no postnatal diet, there's

no premenstrual diet or menopausal diet, but there are dietary patterns

associated with general better health in terms of wellbeing in

the moment and long term health.

And that's generally one that is rich in fruits, vegetables, you know, beans,

pulses, whole grains, because that's an anti-inflammatory diet pattern.

So inflammation is often behind these unpleasant symptoms

at what the cellular level.

And so if we can do everything to kind of minimise that, that will help.

But there are so many challenges though aren't there in the postnatal

period or in the premenstrual period.

And it's easier said than done I think sometimes, but if people can

understand why it's recommended, I think that goes halfway to helping.

That statistic you were saying about the meditation,

that's incredible to hear.

And um, I was just gonna say for any listeners who haven't necessarily

come across it, in Season One of Blue MumDays, there is a special 15 minute

'Loving Kindness' Meditation that Poonam Dhuffer of YSM8 created for listeners.

And that is something that you can listen to at any time of the day.

If you've never meditated before, you don't need to do anything-

just close your eyes and listen.

Um, and one of the things that I really struggled very, very badly

with when I had my PND was insomnia.

so, as you were saying, you also had terrible insomnia, Hannah, and

I found that listening to something like a podcast late at night or in

the middle of the night when you're going through that panic of like,

"I've got to sleep and I can't sleep!"

Even if you can listen to it at that time, you know, it'll hopefully,

as you say, calm the nervous system and if you drop off to sleep while

listening, even better because, it's just there to sort of help you.

There's no right or wrong to meditating.

It's just listening and being in the moment and listening to the words.

And, um, I really hope that some of you out there get some sort of

solace from doing it or, you know, a bit of a reset and a recharge.

But it's incredible how.

at mercy of the hormones we are, especially as, as women.

And, and one thing I noticed about when I was looking at your website

is that you are pretty much fully booked for the next X months.

And that goes to show how much need there is for helping women

go through these experiences.

Yeah, no, I know.

And I think we're hugely underserved and at the moment, I mean, it's not

just to do with Covid because these issues were there before, but I think

it's one of the problems is it's not recognised, I think, as to how many

women are affected and how profound the symptoms can be and how debilitating

because there's a lot of silence and I think, again, there's still some stigma

and taboo out there, particularly when it's to do with, I don't know, you

know, menstrual related problems, birth, you know, basically gynaecological

issues together with mental health.

It's like a double whammy.

And I think women are very good at kind of putting up with stuff, hiding

stuff, masking stuff, and often not asking for help until it's too late.

And when they do, let's say, not necessarily getting

the right kind of support.

And I think one real crying shame is that commissioners in the NHS don't seem to

see the value in planning these services.

So if anything, they're kind of reducing access to things like menopausal health.

You know, there are no real premenstrual clinics.

They kind of sneak in under general gynaecology or menstrual clinics.

And in terms of kind of provision for perinatal psychiatry, it's

really inadequate, particularly in the area where I am.

But I mean, it varies hugely in different parts of the U.K.

I mean, most of the women I see, they come to see me because they

just cannot get access elsewhere.

And they're desperate, but they often want to be referred back into the N.H.S.

I was doing an NHS menopause and premenstrual clinic, alongside

a gynaecologist for a year, but then they decommissioned the post.

They said it wasn't needed, even though me and the gynecologist like, well, there is,

there's, there was a huge waiting list.

But I think it's just shortsighted because the interest, they want to

see kind of immediate outcomes and obviously these things don't, things

don't change overnight, and I don't think they recognize the repercussion

for re referrals everywhere else.

So a lot of premenstrual stuff ends up in psychiatry, whereas it.

You know, really should be.

We, a lot of it we should be able to manage within the community and stuff.

But psychiatry don't get that training most of the time in the U.K.

as well.

In menopause women are inappropriately referred to cardiology, to rheumatology,

to, you know, muscular skeletal services.

And actually if everybody could kind of take a holistic viewpoint and think,

"Okay, what's actually going on here?"

We don't need to do all of this stuff.

And actually we could manage this stuff better.

But yeah, , I don't think that if they could realise ultimately in the long run

they'd save money and time and lives and, you know, women would do a lot better.

So yeah, unfortunately there is a big demand and I wish I could see more women.

And I know my colleagues who do similar clinics are the same.

Um, so yeah.

Do you have any advice for women who are listening and just suddenly for

the first time feeling, "Wow, I think this might be something that's affecting me."

What advice would you give to them?

I think look at the I.A.P.M.D.

website and also the Primary Care Women's Health Forum.

You go onto the website and there's either a link for healthcare

professional or for patients.

We've got like a patient information leaflet on there that talks about things

that you can do to help yourself and maybe how to go approach your G.P.

But really what you need to do is start tracking symptoms.

So you can do that via an app, you can do it by a paper diary, but have some

clear things showing that your, your symptoms change or your wellbeing changes

because that we didn't really touch on P.M.E., which is the premenstrual

exacerbation, which is slightly different.

That would need slightly different management, and that's where underlying

disorders- so you may have a chronic depression or anxiety- but it could

be something like migraine or asthma or something, or epilepsy, that

gets worse in the luteal phase.

Then if you can see that things get worse, but, and then improve with

your period again, that needs to be picked up and managed appropriately.

But the key thing is tracking your symptoms.

I suppose arming yourself with the knowledge and having a little bit

more understanding, knowing about the guidelines that are out there.

I know it's hard because I find it hard as a doctor myself to go to a professional

and say, "I know there are guidelines", but you know, if there's ways you can do

that without kind of, you're not gonna cause offence or anything like that,

but just say, you know, even if you say something like, "I understand there are

guidelines" and if they have the name of those guidelines, their G.P.- If they're

not familiar with it- can look it up.

I know some patients get really disheartened when G.P.s look things up,

but to be . Honest, there are so many guidelines you're supposed to know, and

we just can't keep them all in our head.

So if you have a G.P.

who wants to help, even if they're not that knowledgeable at that

point, I think stick with that G.P.

because they will help their learning and then they

can help support you as well.

Brilliant.

And if we could just touch on PME for a moment before we wrap up.

So that is premenstrual exacerbation and I'm I right in thinking that is

where you have an existing symptom that worsens during your menstrual cycle.

Mm-hmm.

Yeah.

So when we are looking at P.M.D.D.

I know we talked a bit about the overlap with things like depression and things

like that, which can occur, but if you're looking at it classically, you would be

symptom free for the first two weeks of your cycle, so when your period's there.

And then symptoms will start at some point after ovulation.

So either immediately, or sometimes it's a bit later, and then they get better.

So for half the month, essentially you're symptom free, but up to two weeks a

month, you're debilitated by the symptoms.

With P.M.E., you're probably never a hundred percent symptom three.

So you could have, I don't know, O.C.D., you could have I don't

know, a bad depression or anxiety.

And I said there can be physical symptoms, so things like migraine as well.

But you notice that these markedly change in the lead up to your period.

Then the issue is, you know, actually this is what we call premenstrual

exacerbation of an underlying disorder.

And although things never can entirely improve, most of the time

it may be much more manageable, when you're not in that luteal phase.

So the way that that is treated is slightly differently to P.M.D.D.

is that you first look at the underlying condition and make sure that your

treatment is optimised for that.

If it is and there's nothing else that can be done or added,

actually, that's when you'd kind of probably go more down the P.M.D.D.

pathway and look at that and things like suppressing the

menstrual cycle and looking at the other things we've discussed.

One of the things I don't think we did talk about was

psychological support, so C.B.T.

and things are recommended in the guidelines.

I think again, one of the issues is access and there aren't that many women or

psychologists who specialise in this area.

But it can be incredibly helpful to get support from somebody who does have

knowledge in this area, because if you can kind of help to train your brain to

have, you know, or to respond in different ways to, to the negative messages you're

given at certain points during the month, that can be hugely instrumental in

recovery and managing symptoms long term.

Thank you.

I just feel so educated on the subject now and my heart goes out to anybody

that's been affected by these things.

And when you were talking about the P.M.D.D.

symptoms, I, I just wanted to weep because for so many years after the PND, I would

still go to work and just feel desperate for so much of the time and realising that

that might have been to do with my cycle.

Because you question yourself, don't you?

And you think, "Am I going absolutely mad?

And why can't I just cope with life in a way that everybody

else seems to be able to cope?"

Yeah.

No, it's tragic, isn't it?

And I think unfortunately, you're not alone in that because.

I mean, I struggled for so long.

I think one of my, the issues was with me that I never had the regular

periods and I couldn't sometimes disentangle what was the endo and what

was the more premenstrual symptoms.

But I do remember feeling utterly hopeless and we see that.

And, and like you said, you didn't have that experience of rage,

And I thankfully didn't, but I felt like I had everything else.

Some women, you know, that the rage is the worst thing for them.

And I, I'm, so I wish I could kind of give you more certainty in terms of the

postnatal side, but I can only think that it is driven in the same way that

you know, the same kind of underlying mechanism because it's certainly something

we see and it is to do with things like that steroid hormone withdrawal and the

brain's response to hormonal changes.

But yeah, we need there to be more awareness and amongst clinicians,

but, but there is help out there.

I so I hope people kind of get that message, even though I, I know

it can be quite, quite a complex and there is no easy answer, but

generally things can improve, so

And it's, it's worth sort of unpicking to try and

find out what, what's going on.

And I'm sure this has been a very reassuring listen, so thank you.

And if you are in particular sort of affected by postnatal rage, please do

get in touch with me because I'll do my best to find an expert in that area.

So we could do like proper Q+A with them, because I can imagine it's a

very, very hard thing to, to go through.

And also, you know, even more taboo because people don't speak about those

things and women are never expected to be, or allowed to show rage.

No,

Or anger, let alone when you are a parent.

So, um, please don't feel that you are alone and it's not you.

It's, it's something that's happening to you to cause that rage.

So you mustn't feel guilt about it.

But, I will do my best to find somebody who can advise on that subject.

But for now, thank you so much Hannah.

That's been, it's such an incredible, conversation with you and I really

appreciate you taking out time out of your incredibly busy schedule.

And, um, I'll obviously put links to your, your website as well if somebody needed

to get in, in touch with you direct.

But,

there are some links on there as well.

I mean the process of updating the website, so in the next, by the end

of the year it should be the new shiny updated one cause it's quite

old at the moment and putting more links in so people can link directly

to things like the P.M.S., P.M.D.D.

guidelines, things like the DAISY network, which is for P.O.I.

And everything like that.

could help a bit more.

Thank you so much!

You're welcome- thank

you for having me,

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