Dr Sarah Ball is a UK-based GP and specialist in menopause and midlife women’s health, known for her compassionate and evidence-based approach to hormone care. She trained at Birmingham University (MBChB) and completed postgraduate training in General Practice, earning diplomas in Obstetrics and Gynaecology, Family Planning, and practical contraceptive techniques. Over many years in clinical practice, Dr Ball developed a deep interest in women’s health, particularly the complex changes that occur during perimenopause and menopause.

Today, she provides personalised menopause care through Health in Menopause, offering tailored HRT and hormone optimisation strategies while helping women make sense of medical evidence in a way that feels relevant to their individual lives. She has a particular passion for supporting women who have been told HRT isn’t suitable for them, helping them thrive in their health, careers, and relationships.

Dr Ball also contributes to broader awareness through media appearances and educational discussions alongside other menopause experts. Outside her clinical work, she enjoys running, including completing the London Marathon, and is a strong advocate for normalising conversations around midlife health.

> During our discussion, you’ll discover:

(00:04:45) What is menopause

(00:13:11) Is modern life causing women to start menopause earlier

(00:19:33) The Women’s Health Initiative

(00:30:11) Is there a point at which it’s too late for women to start HRT

(00:36:10) Should women try to fix lifestyle factors before starting HRT

(00:42:10) Can thyroid issues be mistaken for a need for HRT

(00:47:40) Should women do health tests immediately upon starting HRT or wait for symptoms

(00:51:52) What genes does Dr Ball look at with DNA testing

(00:53:21) The use of testosterone in HRT for women

(01:05:08) DHEA for women’s HRT

(01:08:35) How to control the conversion of testosterone into DHT in women

(01:12:31) One lab test every woman on HRT should consider getting

(01:13:06) The biggest misconception about the use of testosterone for women

(01:13:28) Does HRT need to be titrated down with age

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Research Links:

• Menopause Research and Education Fund: Mind Your Menopause Marathon
• Health in Menopause, Menopause Experts, Call or Book Today
• Dr Sarah Ball | Instagram

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Welcome to the VP Life Podcast, the show

where we bring you actionable health

advice from leading minds.

I'm your host, Rob.

My guest today is Sarah Ball, a medical

doctor specializing in menopause, HRT,

and personalized

female hormone optimization.

Expect to learn what menopause rarely is

and how it differs from perimone emples

and why the symptoms vary

so widely between women.

Why hormone replacement therapy became so

controversial after the Women's Health

Initiative and what the evidence rarely

says, and how personalized HRT can be

safely implemented using genetics and

metabolic testing to see

the best possible results.

Now, on to the conversation with Dr.

Sarah Ball.

Good afternoon, Dr.

Ball, and thank you for

joining us for the podcast today.

This is a

conversation I'm excited to have.

As I know, there's just a lot of

confusion about menopause, everything

from what it actually is to where the

hormone replacement

therapy is safe and effective.

We've got a lot to

cover for that's for sure.

Before we dive in though, would you mind

just running us through your background,

your origin story as it were, and how you

got into this space to begin with?

Yeah, sure, and thank you, Rob.

Thank you for inviting me.

So I'm Dr.

Sarah Ball, and I am a medical doctor.

So I trained at medical school and became

a GP as quick as I could.

I always wanted to do kind of general

stuff, but I always length towards the

female side of medicine and women's

health and contraception and things.

And I qualified as a GP in 2002, the

summer of 2002, which was literally, it

was three days before this big trial that

I'm sure we're going to talk about was

suddenly broadcast to the world about how

unsafe HRT was having previously been

thought to be the best

thing since sliced bread.

So it's literally, as my career started,

menopause kind of

became something that people

stopped talking about and were scared of

and were confused about.

So really just through my career as a, I

carried on being a GP, so I

was a GP for 20 something years.

And just found myself feeling, although I

was keeping as up to date as it was

possible to be with women's health,

including menopause, it almost felt like

we were living in the dark ages.

You know, we could manage all other

conditions really well with all this

evidence and trials going on and great

big conferences and all sorts of things,

but it felt like we were quite behind.

And then the NICE, the National Institute

of Clinical Excellence Guidance came out

in 2015 and kind of slightly started to

turn the corner a bit in terms of, oh,

actually, you know, there is a chink of

light that we could maybe

start to improve menopause care with.

And so in 2018, then I started to also do

private menopause work.

And I trained with the British Menopause

Society, so I'm an

advanced menopause specialist.

And so now, well, the demand for that

private menopause work

just absolutely skyrocketed.

I mean, Exponential doesn't even begin to

cover the demand for it.

And so for the last six years now, I've

done purely private menopause work.

And so you really get a chance then to

dive into it in a much more deep way and

to really focus on the extraordinary

extent that it has been neglected.

We've sort of had 20 years of neglect and

it's trying to bring everything more into

the 21st century and actually support the

half of the population that are going to

be directly affected and the other half

of the population who are going to be

indirectly affected also.

So yeah, so I now work at a clinic called

Health in Menopause.

And yeah, it's the most wonderfully

rewarding job because it feels like

finally after a drought, there is help

that we're allowed to give and that the

public are now more receptive to thanks

to lots of conversations now

happening in the public arena.

So that's me.

That's perfect, thank you for that.

I'm glad you mentioned these guidelines.

I'm sure we'll get to them later.

Yeah, so I reckon we might as well dive

straight and thank you

for that introduction.

It really sort of covered a lot of bases.

And I'll ask you this question, which I

suppose, what fundamentally is menopause

and how does that differ from sort of

period and post-menopause?

I know many clinicians will sort of refer

to menopause as a single day.

But yeah, could you break down what these

terms mean and then walk us through maybe

some of the common symptoms that one

would sort of associate with, we should

associate with menopause that are

oftentimes put down to maybe other life

circumstances that women and especially

men will often miss.

Yeah, absolutely.

And you're right, it's trying to pin down

the definitions of the words can be

confusing and tricky.

And I would still say that menopause is

one day in a person's life,

a person that has had ovaries

or still has ovaries but they've stopped

working or they've been removed.

So it's that one day if you're having a

natural, a naturally occurring menopause

where your follicles, the parts of the

ovaries that can produce eggs have

stopped working and you've gone a whole

year without a menstrual period.

So yes, it's that one day, but unless you

have a surgical menopause or a menopause

that's induced by some kind of medical

procedure, which can be quite sudden,

most people's naturally occurring

menopause doesn't just happen, it takes

anywhere between two and maybe 12 years

for the buildup or the decline in the

ovaries to actually then

become them not working anymore.

So the average age of menopause is 51.

So that means a woman could be starting

to experience some

issues with changing hormones

while her periods are still going on and

she may be just in her late forties, but

she might actually be in her late 30s.

And so we have this usually decade, which

for most of us is in our 40s where there

could be all sorts of shenanigans going

on with symptoms and health complaints

and life happenings.

And previously we didn't, my sixth sense

and another clinician sixth sense was,

there's gotta be some hormonal

involvement, but there wasn't a kind of

permission to call it something and to

actually then be able to

give it a label and therefore be able to

start to help to manage that.

So yeah, so we have this perimen pause,

which previously was really poorly

understood really, and it's probably what

I would say is the biggest change or the

biggest sort of light bulb moment where

you go, oh, right, okay,

yeah, that really helps.

If all medical doctors knew

that, that would be helpful.

And then you have this one day

which is your menopause, and then forever

after, you are postmenopausal.

So you could have your

menopause at the average age of 51.

And then if you live to 100, well,

actually for the next, for 49 years, you

are postmenopausal and there can still be

issues arising because of that.

So it's, I think, conventional or history

has sort of taught that menopause is, you

know, a couple of years, maybe have a few

symptoms done and dusted,

and then you can move on.

But of course it really, really isn't

because for, you know, the average age of

women in this country, anyway, at the

moment, if life span goes to sort of 83

to 84 years, then actually you're gonna

spend about 50% of that, yeah,

but more, you know, if you start from the

beginning of perimenopause, which from

maybe average is sort of early to

mid-40s, then, you know, that's a hell of

a long time to not understand what's

going on with your own body and to risk

that your health professional also

doesn't understand what's

going on with your body.

So yeah, symptom-wise, I think this is

where another big area of confusion is

that there's so many symptoms and they

can start all at different times for

different people and you might have

completely different symptoms to your

sister or your mother or

your friend or your neighbour.

And so it's trying to, it's constantly

trying to join the dots.

So there's this, maybe the slightly

better known symptoms or the more kind of

physical symptoms, the symptoms that

people find a bit more easier to talk

about, which would be

things like hot sweats, flushes,

fatigue,

maybe headaches, migraine,

joint pains.

Actually joint pain is actually,

worldwide, is the commonest symptom of

menopause, but again, not a lot.

Everyone thinks it's hot sweats and

flushes, but actually only three quarters

of people will ever have

a hot sweat or a flush.

A quarter will never have one.

Yeah, it doesn't mean,

yeah, it doesn't mean they're not

suffering in other ways.

So yeah, so there's another sort of

physical, you know, poor sleep.

So yeah, sort of physical symptoms, but

then there's the genital urinary

symptoms, which people struggle to talk

about often because it can

be slightly more embarrassing.

So-- Fertional dryness, things like that.

Dryness, the vulva dryness, the bladder

issues, the lack of libido.

So that's kind of a tricky thing to talk

about, especially if you're still in your

40s and you think, you know, things are

going a bit wrong down there, it can be a

difficult thing to talk about.

And then there's the emotional symptoms.

And actually, of all of the symptoms, I

would say it's the psychological

symptoms, which are the most troublesome

to women that would come and seek help.

And it's the unexplained anxiety that

comes in midlife for no apparent reason,

or the feeling overwhelmed with life when

previously you were able to kind

of-- That massive drop off and gather.

Yeah, absolutely, yeah, the paranoia, the

rage, you know, and that's

real and scary for some women.

It's the lack of, or the losing

self-confidence and self-esteem.

It's delightful being female, isn't it?

Delute, yes, an

absolute challenge to navigate.

I mean, there's some, I often think,

well, you know, we have this,

for many of us, luckily, this amazing

ability to reproduce,

but there's a hell of a lot of

complicated biology going

into allowing that to happen.

And then of course, when it, even if it

starts to not work in the

proper way, that's challenging.

And then, you know,

there's extremes of that.

So there are some women who sail through

the menopause, and that's wonderful, but

there are literally some women who, it is

the start of the end in terms of, you

know, physical symptoms could just be

completely overwhelming, or it could be

the start of the decline of their future

health, because menopause not only

affects you in the day-to-day sense, but

it affects your

future health and wellness.

And, you know, it changes people's lives.

It takes one in 10 women out of their

job, because they can't cope anymore.

It, you know, the highest divorce rate is

in females in their 40s, because the, you

know, relationships

become more challenging.

You know, people literally, you see some

people, not everyone, some people fall

off their perch completely at menopause,

someone that was very capable, very, you

know, managing life,

multitasking, you know,

absolutely confident and fine, and just

becomes a different person, and no one

previously really understood, you know,

they were usually just

treated as being depressed,

or their individual

symptoms were treated.

They might be sent to a cardiologist,

because they had palpitations, or they

might be sent to a neurologist, because

they had migraine, or sent to a

gastroenterologist, because their bowel

habit changed, or whatever, and what we

have to get so much better at doing, and

medical person is joining the dots,

going, actually, have we thought about

whether there could be a common cause

that's linking all these problems, rather

than seeing them all as

the individual issues.

Yeah, I mean, you touched on a lot there.

I'd love to come back to what you

mentioned earlier about someone with a

woman sailing through menopause.

In my experience, well, not that I have

much experience in this respect, but I

find that women who do transition sort of

more easily through this period in life

are generally healthier to begin with,

and I'm sure we can discuss some of the

lifestyle factors later.

Do you find that A to be the case, and

then sort of on a similar note, what do

you make of this notion that women are

sort of entering menopause sort of at an

earlier and earlier age?

I mean, that's a whole

rabbit hole in itself.

Obviously, we could have a whole podcast

in that, but do you think that there are

any sort of environmental factors that

might be, if it is indeed the case, sort

of speeding up the sort of transition

into menopause for some woman?

I mean, we know that, for example,

smoking tends to bring on menopause on

average three years before

it would otherwise happen.

When we are not looking after ourselves

properly, and of course, in this modern

world, that's very difficult.

So, yes,

on the face of it, we're talking about

getting a good night's sleep, doing

regular exercise, eating healthy foods

that are nourishing,

but we know it's increasingly harder to

do those things these days with all the

financial strains on people and people

trying to be a million

people and have a million roles.

So, and I think we've never,

we've always underestimated the role of

stress in all conditions, haven't we?

And the cortisol and how that's gonna

affect how we make our

hormones in the first place.

And things like that.

And there's so many things we don't

understand and how other

medications that we might give.

So, contentious issue, but we give out

statins now like Smarties, but actually,

is there an argument that if you give out

statins and you decrease cholesterol,

that therefore you're gonna make less

reproductive hormones?

And so sometimes we're

robbing Peter to pay Paul.

So, yeah, and I think we have a lot more,

in a way there's a positivity in that we

have, with childhood and teenage cancers,

for example, the treatments for them and

survival rates are now much better, but

for the females that are suffering those

cancers, they will go into often a risk

of going into an early menopause.

So, we have a lot more, we used to always

quote, I always used to say, a one in 100

women under the age of 40 will be a

menopause and there's unexplained reasons

for that, but for some reasons, there is

an obvious medical treatments for other

conditions has caused that, but actually

now we've redone the figures, it's

actually four in 100.

So, one in 25 women will be in menopause

before the age of 25,

before the age of 40, sorry.

So, again, it's not a

really uncommon problem.

This is everybody.

So, it's really trying to shine a

spotlight on it and not only for women

themselves, although that is the most

important thing, but actually for society

in general and for economics, social

economics, if women become less

productive because they are suffering

around their perimenopause and beyond,

then that has a real knock on effect on

their work and their employers and the

GDP and all of that, this is a much

bigger thing than just medicine.

I love you did, you

sort of brought up stress.

I mean, I sort of, as we

all talk about or fair,

this sort of this functional medicine

approach and even within that sort of

paradigm where you sort of take a very

sort of individualistic approach to

treating these sorts of issues,

I think a lot of practitioners will sort

of overlook the stress component.

And when you sort of start to look at how

stress affects biology and how it starts

to create high levels of inflammation

that then sort of force cells into these

states of sort of

being inert essentially.

It's not surprising that we're sort of

seeing that these sort of generally,

broadly speaking, these endocrine

problems in general, I mean, the same

thing obviously applies to men too.

I think, well, I know that,

what's the easiest way to put this?

If you want to put someone through hell,

completely mess up

their endocrine system.

And one of the fastest ways to do that

short of sort of chugging plastic-laden

water is to just be under this constantly

high stressed state where your body is

fundamentally put into a state where it

can no longer, is no longer worried about

reproduction and where it is no longer

worried about these hormones.

And it's just worrying about getting

through each day as it comes.

And yeah, as you've alluded to already,

I suppose it's actually nature's sort of

cruel irony ultimately, the moment a

woman has sort of transitioned through

her child-bearing edges, she

evolutionarily quote unquote, has no

purpose, said very delicately.

And all of a sudden, as an individual,

you are just sort of left in this state

where life is untenable

and can be unbearable.

And I think, which is why I'm sort of

excited about the initiatives that are

starting to come out with regards to

endocrine health in general, specifically

for women, because for years, I think

it's been far more acceptable as a man to

go to your doctor if you have low

testosterone and they'll say, well, stick

a needle in your ass once

a week and problem solved.

But for women, it's been, yeah.

I don't know why, but the

uptake has just been much slower.

And maybe that has something to do with

the women's health initiative, which

we'll discuss in a moment.

But anyway,

Dr.

Boyle, I'd like to pivot into talking

about how you treat patients in a bit,

both in terms of HRT and whether you

think there's space for some of these

natural remedies as well, things like

black cohosh and red

clover extract, et cetera.

My feeling is that these molecules, these

supplements, they can help maybe manage

the symptoms, but because they're not

really replacing anything, they're not

gonna support an individual from a sort

of a longevity or health ban perspective.

Before we jump into all of that though,

I'd like to talk about what I've just

mentioned, which is the

women's health initiative.

As I think it really set back sort of the

HRT space, specifically within menopause

by a good 20 years or so, if not longer.

Different, longer, yeah.

Yeah, so, but yeah, I'll hand it over to

you because I'm not well-written the

space, but I have a feeling you are.

So maybe you could break down what the

WHI is, what it was about, and then maybe

why it was an issue.

Yeah, sure, yeah.

So essentially, so HRT was started to

become available in

the world in about 1960.

And so for sort of 30, 40 years, women

who were usually about 50-ish and were

going through the natural menopause

started to, if they started to have some

hot sweats and flushes, they were usually

offered some HRT, and they usually took

it for a couple of years.

And- This being oral

HRT, is that correct?

Yeah, so yeah, we used to have, most HRT

used to be what we call combined oral, so

a synthetic estrogen with a synthetic

progestogen, all in one easy capsule.

But these women, it was sort of noticed

in the 90s, particularly, well, these

women that take HRT, they seem really,

you know, really healthy and lots of

vigor, and they look great, and they're

often the ones that are

still being physically active.

And, you know, HRT

was, you know, popular.

Women, you know, wanted to get some of

this if they felt they

were having symptoms.

And then, sort of medical trials started

to notice actually, that women that used

HRT actually seem to have

much less heart disease.

They seem to break less bones.

And there was also starting to be some

consideration that they

also seem to get less dementia.

They just seem to be

generally healthier for longer.

So essentially, and again, I'm very

simplistic about this, but

that's how my brain works.

The American National Institute for

Health, you know, quite, you can

understand why they thought it, thought,

well, okay, well, this is great.

So actually, if there's this relatively

cheap drug that we could give to women

and it reduced their risk of heart

disease, well, wouldn't that be amazing?

You know, we'd save, you

know, gazillions of dollars, yeah.

So yeah, you know, that kind of stands to

reason that they would

want to look at that.

But that's where things slightly started

to go wrong because what actually then

happened was that women were recruited in

America to this trial, but they weren't

around the time of menopause.

They were actually much older.

So the average age of a woman in that

study was between 63 and 64.

So they were usually at least

10 years past the menopause.

And then they were given the old

fashioned HRT that was popular at the

time, but it was quite high dose as well.

And there was one big arm of the study

was women that had still got their womb

and therefore they were having the

combined HRT, so the

oestrogen and the progestrogen.

And then there was another arm of the

trial, which was women

that had had a hysterectomy.

So they were just

given the oestrogen part.

And so they started to watch

these women and what happened.

And then, I mean, you

can't even make this up.

I'm sure there'll be a film about this

one day because it's just

so, such a travesty to women.

They started to notice some figures that

didn't look quite

what they were expecting.

Obviously they were hoping to find that

women had loads less heart disease, but

they weren't seeing that.

It was sort of, ooh, actually, was there

a bit of extra heart

disease in this woman?

Wasn't quite sure.

And then, ooh, actually there's been a

few more blood clots in these women in

their lungs and in their legs.

And ooh, was there a couple more strokes?

And then, was there a bit more breast

cancer in these women?

And then, so what actually happened

behind the scenes was that some

investigators, so quite junior

investigators, were looking at the

numbers, did some statistical number

crunching, but made some mistakes,

didn't go to the senior investigators to

talk to them first to come up with a

plan, but essentially went straight to

the media and the press.

And so in 9th of July, 2002, suddenly it

was announced on the news that HRT was

associated with a higher risk of heart

attack, strokes, blood

clots, and breast cancer.

And it was advisable

for women to come off HRT.

And literally overnight, about half of

women came off for HRT, and then over the

next five years or so, a load more did.

So it literally, it just kind of tumbled.

But the problem was

the statistics was wrong.

The conclusions were wrong.

So yes, so when you actually look back at

the data, and I'm not a statistician, I'm

not, but I've studied the WHO, I used to

study for donkey's years, and I kind of

feel like I know it inside out, that

actually when you look back at the data,

if you look at the very few women that

were around men of Paul's age when they

started their HRT in this trial, they

actually did really, really well, and

actually everything

was protected and good.

And the women, the average women in

there, 90% of women that were much older,

there wasn't actually an

increase in heart disease.

It was a neutral, it was neutral, but

they got the P values wrong for the areas

of statistical significance.

So what it did tell us was yes, there is

a higher risk of blood

clots with oral estrogen HRT.

And we can now get around that by having

different ways of having estrogen.

So it did help to show that.

But then the breast cancer, that was

always the one, that's the most emotive

issue around HRT still is.

And this gets really complicated, but

essentially HRT wasn't causing an

increase in breast cancer in these women.

It was actually, and this is kind of hard

to explain, but it was actually women,

when you broke down the numbers even

more, it was women that had been

recruited into the trial that had

previously used HRT.

They were actually

protected from breast cancer.

So it made it look like the people taking

HRT from scratch were at

risk, but in fact, they weren't.

It was the other group

were relatively protected.

So there were conflating

variables irrespective.

Okay.

So big, big, like huge mess.

And actually that fear has stuck solid in

most people's minds.

I mean, I'm one of the lucky ones that

has been able to really look into it.

And I know that it's not true, but it's

so difficult to take that fear away from

people from the health clinicians

themselves, but also from patients.

So we have got a generation out there.

So my mum's generation all believe HRT is

associated with breast cancer.

And if they were on HRT, they came off it

and probably never restarted it.

And they probably told their daughters

like me not to go on HRT.

And most daughters would just listen to

their mums because they

wouldn't know any better.

So we still are trying to reassure women

that the association between HRT and

breast cancer is still

not 100% eye and doubt.

But if there is a risk at all, we are

talking about a tiny risk.

So around about, so this

is with old fashioned HRT.

So I'd have to give a thousand women in

their fifties old fashioned HRT for five

years for one extra woman per year to get

breast cancer who

wouldn't have already done so.

But we now tend to use more modern sorts

of HRT where the risk has been proven to

be even lower and may

well be very close to zero.

And so essentially the risks

of getting breast cancer with

or without HRT are the same.

And actually it's

lifestyle we should be looking at.

And if we can actually get a woman

exercising, not drinking too much alcohol

and being a healthy weight, that has a

big statistical impact

on her breast cancer risk.

HRT has virtually zero effect.

So it's trying to condense that into a

way that a woman can understand and feel

reassured is tricky.

That's fascinating.

I always was under the assumption and it

speaks to my ignorance on the matter that

there was far more of an issue with the

oral progesterins and the oral estrogen.

Yeah, and that was the

other complete tragedy.

Thank you for reminding me.

So all women came off HRT because nobody

told them there was a difference in the

results between the combined group and

the oestrogen only group.

So, and the oestrogen only group, they

were doing brilliantly.

They had far less heart

disease and far less dementia.

And actually even their risk of breast

cancer was reduced, but they all came off

it because no one kind of broke down the

difference in statistics

for another couple of years.

So yeah, complete travesty.

There have been apologies since from the

investigators, but no one ever publishes

good news or it's just bad news.

A list of knowledge is a dangerous thing.

And there was so much positives in that.

I mean, actually, if you look at the

data, I mean, the reduction

in fractures was impressive.

The reduction in diabetes was impressive.

All cause mortality.

So in other words, your analysis

oversimplification, but your risk of

dying from anything went down in the WHO

trial, no matter who you were.

But it just, you know, that never got any

wind behind it at all.

Yeah, never got published.

It's like you said,

nothing sells like bad news.

So trying to sort of refute that is going

to be an uphill battle.

Dr.

Bow, you mentioned this specifically,

this idea of women sort of in this, sort

of maybe earlier to mid

60s getting on to HRT.

Now, this was going to be a question I

was going to ask later, but I'm going to

ask you all to talk about it now.

Is there a point at which a woman who has

sort of transitioned into menopause or is

now perimenopausal should

not begin an HRT regimen?

Yeah, good question.

So we have a concept now called the

window of opportunity, which essentially

means that the best time to start HRT is

either during the perimenopause, if

you're having any problematic symptoms,

or within 10 years of your last period,

or before the age of 60,

whichever comes first.

So you could go through your menopause at

the age of 56, for example, and actually

your window of opportunity

then extends to being 66.

But unfortunately, sort of myth and

Chinese whisper and simplicity means that

most doctors and healthcare professionals

get very wobbly about

anybody starting at over 60.

But there are many people who just there,

menopause was sufficiently late that

they're still, their window of

opportunity is still open.

But what, if we were to use the old

fashioned HRT, what we would think was,

well, within that window of opportunity,

the benefits outweigh the risks.

If you're beyond that window of

opportunity and maybe trying to start old

fashioned HRT in a say a 68 year old who

whose menopause was at 50, then the risks

potentially outweigh the benefits.

But actually now that we've got newer

types of HRT, the more modern types, to

be fair, the risks never really start to

show up on a radar no

matter what age you get to.

So the benefits for almost everyone

continue to outweigh the risks.

They're just not, there's just not a

bigger, a difference between the risks,

the benefits and the risks when you're

still within your window of opportunity.

So even if you're much older when you

start HRT, you will still

get benefits to your bones.

We know that for definite.

And many, many women will still get

improvements in their day to day

symptoms, which that can then lead onto a

much healthier lifestyle and then much

greater future health

via indirect mechanisms.

So, you know, if I've had quite a lot of

women who may be in their late sixties or

early seventies, who are perhaps caring

for a poorly spouse and they are

struggling with hot sweats and flushes

themselves, because they've just had

that, you know, it's possible for hot

sweats and flushes to go on for 10, 20

years, even longer after your menopause.

And so they're up and

down every hour at night.

And then they're weighing a lot because

their genital urinary syndrome of

menopause hasn't been dealt with.

And so actually they're exhausted.

They're fundamentally fit and healthy,

but they're exhausted because they're

getting no sleep and

they can't stop weighing.

And the stress of their

caring role is all accumulating.

But I give her a little

bit of the best type of HRT.

The hot sweats, flushes

go away, she sleeps better.

Her bladder calms down.

Suddenly she's completely able to do her

caring role and actually

feels like she's, you know.

Human.

Human.

And I know that she's much less likely to

trip over and break a hip if she stumbles

against the toilet as well.

So we've got another win in there.

Yeah, I think I'm trying to remember the

stat particularly, but I think that

fractures in people over 60 or 70 is one

of the highest leading causes of early

death, just because

you're going to, well,

you're going to get into the sarcopenic

state, you lose a lot of muscle mass and

you're then going to have this massive

sort of metabolic

derangement that then follows.

And then as we know now, health is almost

all completely metabolic in nature.

So if you sort of lose that glucose sync

of all that muscle, then all of a sudden

you are in a pretty precarious situation.

I think that's difficult as well.

So if you're in your mid-40s and you're

starting to think about your hormones,

the last thing most people at that stage

are thinking of is what happens if I fall

over and break my hip and I'm 75 and I'm,

I don't know, maybe I don't have

dependence around who

are going to care for me.

People aren't on that wavelength.

But actually, if you start the process of

protecting your bones and your muscles

and your metabolism way

back in your perimenopause,

you've shifted the dial so much to a

healthier life when you're much older.

So it's again, trying to

focus medicine on thinking ahead.

And that's what's been one of another big

frustration of trying to get more

awareness about menopause in the public

arena is that, you know, the NHS, for

example, they will worry about their

budget for the next 12 months.

So they're not willing to spend it on

something that could make a massive

difference in 20 or 30 years time,

because it's just not, that's not how

finances kind of work, but it's a massive

public health option.

You know, if you think about all the

older people in care homes and

residential homes and all the social care

that takes up and all the heart disease,

all the strokes, all the things which

could, you know, if you have a fracture

as an older woman of your hip,

you've got a very high risk of being dead

within 12 months, more so than most

diagnoses of cancer.

And yet we don't tend to think of it as

something that's

important to try and prevent.

I think that's the term prevent.

There's no money to

be made in prevention.

You can't sell a drug

based on prevention.

So yeah, it's going to be

a complete uphill battle.

Dr.

Boyle, I think we've covered the basics

and some of the sort of the underlying

physiology sort of really nicely.

I'd like to talk about

how you work with patients.

Now, for context, as you've probably

gathered, I'm very pro-HRT and whenever I

do again, council a woman in that

respect, it's sort of just providing

guidance as to what they maybe should

start thinking about before, sort of

sending them on to someone like yourself.

I always make sure to point out that HRT

isn't, as we've just discussed about

symptom relief, it's about health, band

longevity, and that these hormones are,

as you've alluded to again,

are cardio neuroprotective.

And we always have the discussion around

lifestyle again, making sure, from that

preventative standpoint, and it's always

very much grounded in this sort of

understanding of getting your metabolic

health as good as you can get it.

Now, of course, that's

difficult for a number of reasons.

And I suppose I tend to emphasize the

lifestyle and nutrition

side of things because,

as a chemist and biochemist,

that's sort of my wheelhouse.

So, with regards to that, I'll often

point to things like making sure that

your detoxification

systems are working effectively.

Because if you are going to think about

getting onto HRT, you want to make sure

that your body can metabolize the extra

levels of these hormones effectively.

So, if there's impaired sort of phase one

or phase two detoxification, you've got

an issue with glucuronidation or

something like that,

maybe taking in using HRT at that point

in time is maybe not the best strategy

relative to sort of improving your health

and then considering getting onto HRT

when you've got those

basics sort of taken care of.

Now, I have a bunch more questions

relating to testing and of course, I'm no

expert here, but what do you think of

that sort of as a model?

Do you think that we should, I suppose,

as a community, be educating women on

their health in

general before starting HRT?

Or do you find that it's best just to get

someone who is struggling onto a protocol

and then sort of maybe dealing with these

other sort of this one you show off to

the fact, does that make sense?

Yeah, absolutely makes sense.

And again, I think that is maybe a

journey that we're going on with the more

public conversations now about menopause

is that traditionally,

we've had women make their first call to

someone like me because they're in a real

pickle in the throes of perimenopausal or

menopausal symptoms.

And they are maybe

sweating every hour, can't sleep,

anxious relationships are falling apart.

They're so achy that they can't, the

thought of going to the gym is

completely not on their radar.

They are depressed, they are rock bottom.

And we chat to them and we go

through all lifestyle issues.

I wanna know about

what is their sleep like?

Do they snore?

What is their diet like?

What is their bowel habit like?

What is their movement?

Do they have any movement

in their life at the moment?

What are their stress levels?

I wanna know, past trauma, I wanna know

all that stuff, but for each women, I

will treat her completely differently.

So there's some that I just need to put a

bit of, or invite her to put a bit of

estrogen in the system just to kind of,

if we could just get rid of the sweats to

start with so that she can sleep, and we

all know how dreadful it

is to be sleep deprived.

It's a form of torture, isn't it?

And then, sometimes just a couple of

weeks later, it's almost like they're

coming out of a fog, and then we can then

plan a more strategic way forward, which

is about the bigger jigsaw.

So I always, whenever I'm seeing anyone

not thinking about a jigsaw, yes, I have

the ability to put the HRT in place.

And for some people, that's

the big part of the jigsaw.

For some people, it's a very small part.

For some people, actually, it doesn't

need to be a part at all.

So,

there are some people where, and again, I

am so just to be absolutely, I'm a

medical doctor, conventional medical

doctor, but I have done quite a lot of

extra learning of my own volition about

diet, nutrition, functional medicine,

genetics, particularly

I'm looking at people's DNA.

And you just realize that I could see

someone and they'll come maybe and

they'll say, oh, you know, just really

depressed and achy and

maybe a bit overweight.

Maybe there's a bit of thyroid issues in

the family, for example, and then I'll

say, okay, do you take, you

know, what's your diet like?

And do you take any supplements?

And they'll say, you know, got a bit of a

rubbishy diet because at the moment

they've got no energy or

creativity to cook from scratch.

So they're having takeouts or whatever,

and they're not using any supplements

because, you know, they're a waste of

money, in quote, unquote.

And- Some of them are.

Yeah, and then, and they go, okay, do you

take any vitamin D at all?

No, and they work in full

time in an office or whatever.

And sometimes I just

give them some vitamin D

and then they come back a few weeks later

and go, oh, that was miraculous.

And then sometimes I don't actually need,

they don't actually need HRT for a while

longer because actually it wasn't, it was

they were lacking in vitamin D, but

again, the NHS doesn't really deal with

that particularly brilliantly either.

Or, you know, sometimes their thyroid's

completely up the spout.

I was going to ask about that because

obviously I have a better understanding

of male physiology when it comes to sort

of the thyroid testes access.

But oftentimes if you've got that

down-regulated thyroid activity, the

pituitary is not going to, in any way,

shape or form, send out sort of LH or FSA

signaling to the testes to then start

producing testosterone.

But the moment you flip the switch on the

thyroid side of things and you get that

thyroid signaling back,

not only does the HPTA start working

properly, but then at the mitochondrial

level, you're able to start producing

these hormones more effectively within

the testes, within the leg cells, and

then the totally cells.

I assume the same logic sort of carries

over to women as well.

If you can correct a thyroid issue, can

you sometimes maybe just offset the need

for other forms of HRT?

Absolutely, and we do sometimes see this

where people all come to me and they've

been on HRT for a few years and they've

just never really had that much

improvements from it.

And, you know, you're trying to, it's

like being a detective the whole time,

you're trying to work out where can we

change things for this person?

And then you'll look and you'll go, oh,

actually, well, there's a family history

of thyroid issues and actually, you're

maybe a bit overweight, maybe there's

been no vitamin D in the equation.

And I'm thinking, I don't think the

thyroid's working brilliantly and they

have, they usually, they will sometimes

bring to me their NHS blood results.

And you'll see that actually their TSH,

it's within the normal range, but it's

most certainly not a TSH that I'd want.

Yeah.

Nine, two.

Yeah, or even like four.

And I'm thinking, well, okay, technically

it's normal, but I'd much

rather it was a lot lower.

And then you maybe check their

autoantibodies or whatever.

And so, you know, if, I think that's

maybe why being a GP is quite helpful in

this job, because you can see that, you

know, I'm no, you know, I'm not brilliant

at thyroid, but I know when to call

someone in that is,

if you see what I mean.

So I'll say, you know, with this, your

history and your symptoms and your blood

results, I think we actually might need

to treat you as if you have an

underactive thyroid.

And, you know, I might, I stay in my lane

and I do the hormones, but I will make

sure I send them to someone that I

trusted to look after that bit of them.

And equally I've having learned a bit

about the nutrigenomics.

I mean, that's a complete game changer in

terms of, you know, even just being able

to show a woman to say,

look, this is cholesterol here.

And it comes down this pathway and it

makes some progesterone.

And then it comes down this pathway and

makes some estrogen.

And look what happens

if your stress goes up.

It basically steals it from that

progesterone and your progesterone is

getting to your GABA receptors and giving

you this relaxation.

So you can really start to, you know, not

all women need that, not for women.

It's saying they do.

It's a lovely thing to have if, you know,

if people are in that situation that they

can access it, but it can really answer a

lot of questions and really help women.

You know, we have a lot of, you know, new

diagnosis of ADHD and things at this time

of life, because, you know, once the

estrogen drops, the poor old nervous

system then wobbles like never before.

And, you know, women just, you know,

don't know what to do with themselves.

And then when you can help to explain how

this is all a series of complicated cogs

and, you know, once, you know, if your

big methylation cog at the center of

everything starts to slow, which it will

with age and then a bit more with

menopause, then something else is going

to reach a critical, you know, drop below

a critical threshold for working, whether

that's your neurotransmitters or your

fire rod or whatever.

And then we get all the women with the

histamine issues who come and they've

always been fine and they get to the

forties and suddenly they can't control

their hay fever and they've got hives.

And if they have a one drink of wine at a

wedding, they like flush

and faint and fall over.

Yeah,

and so just, you know, and I am no expert

in it whatsoever, but I have a absolutely

fabulous colleague

that I send them off to.

And it's, I mean, the, they just say, my

God, this is so empowering.

This is, you know, to actually be able to

explain to a woman why she's always felt

like she has or why things have got much

worse recently or whatever is, you know,

it's a complete game changer for some of

these women, whether it's their thyroid

we uncover is the issue or their nervous

system or, you know, they've got

adrenaline receptors, which are like, you

know, on high alert or, you know, or they

caught us all, biochemistry

is all, you know, very messy.

Yeah.

And then, you know, it's amazing.

So it's made my job so much more

rewarding because you can start to, you

know, I've had a lot of, I send a lot of

women also to a lovely colleague of mine

who is a breathing practitioner.

And, you know, we, we either to stop them

snoring or we send their partner if

that's, you know, cause it's almost as

bad sleeping with a snorer as it is to be

a snorer in terms of your health.

So yeah, it's just, it's lovely to be

able to try and work out, you know, so

I've never got the same

formula for any two patients.

It's always a

different, a different journey.

I was, I was going to skip over this, but

then you mentioned genetics.

So I'm sorry, you shot yourself in the

foot a little bit there, but, but

testing, I assume going into, well,

actually this is a good question.

Are you doing a sort of a

lot of testing off the bat?

Would you just sort of go off symptoms?

Because I assume if somebody's coming in

with these perimenopausal symptoms, you

can be sure that things like FSH are

going to be through the roof and AMH is

going to be all over the place.

Do you sort of worry about

that straight off the bat?

Or are you?

Really, really individual.

So usually, again, I'm generalizing

somewhat that a lot of women come to me

for the first time if they're not already

being treated for their menopause are in

quite a state or they

can be in quite a state.

They might not be able to retain any

information because their brain deserted

them long ago with brain fog.

You know, they might be, they're usually

really anxious to actually have the, you

know, they're tearful.

They're, they're, they feel like they're,

that, you know, that

they're completely losing it.

And it must be that there's, there's a

massive problem with them.

And then I can listen to them and expect

that you are, you know, this is

absolutely classical of

your changing hormones.

And I can explain why

that's all happening.

But then if I,

you know, there'll often

be things they throw in.

And I think, oh, it's almost like you,

you can sort of see their

genes beneath their skin.

It's like, oh, I bet

you've got that gene.

But I usually, not all the time, but

usually won't throw that into a first

consultation because it's

like too much information.

But there's some where actually they've

already been to a

million different providers.

They've already researched their own

condition, you know,

upside down and inside out.

And I do feel that they've got the

capacity on that day to talk about it.

And so I will say, look, there is this

other test that I could send you for,

you know, and I have to

say, you know, it's private.

It's not cheap.

It's not cheap at all.

But you know, if money were no object,

then wouldn't it be great if we all had

our DNA mapped out the day we were born

so that we knew what

our vulnerability was?

Of course, the full

genome sequencing was amazing.

Wouldn't that be amazing?

But I know most people aren't in that

privileged position, but there's lots of

people that I might not even need to

think about it for, you know, a couple of

years where we've got

this right and that right.

I've had a woman recently who starting

HRT was quite helpful.

We then she became a lot more healthier,

was brilliant with exercise

that all got a lot better.

We just that we could not, despite she

brought her BMI down to normal, she was

generally doing really well, but we could

not get her HPA1C under control and no

family, I couldn't work out why it was,

but so eventually we got a genetics done

and she has got all the

dodgy glucose processing genes.

And so now she's on rather than the more

generic supplements that I

might talk about with them.

She's now on a very much more

individualized regime.

Did you reduce her carbohydrate intake

alongside that at all?

Oh yeah, she's so on it with, yeah.

What genes are you

looking at specifically?

And are you doing

things like a Dutch test?

Are you doing more of

a generalized DNA test?

Yeah, I don't.

So again, I send, I don't, we don't do

them within health and menopause, but we

send them to somebody that we've worked

with for a long time and that is a

menopause specialist themselves and

therefore understands the intricacies of

what we're trying to achieve.

And so we really individual, so we might

do nutrient core and methylation are

often really helpful, but a lot of our

patients, we do their hormone, the

estrogen pathways as well.

They might want their metabolic doing,

especially if weight is an issue or

cholesterol issues or we think there is

sugar processing issues.

Histamine, although often you do find

that the histamine is only the tip of the

iceberg and it's usually a methylation

issue at the heart of

the problem as for my,

unexpert, my--

No, you're right on the money.

When you've got impaired histamine

processing throughout the body, it's

quite often the case that that individual

is potentially estrogen dominant and that

individual is

potentially estrogen dominant.

You've got to start looking at, well, why

aren't they clearing

estrogen effectively?

Which is why I think these tests are so

interesting because they can also then

govern, I think, the way that you

potentially would treat somebody with an

estrogen, because if they aren't

effectively very effective at clearing

estrogen from their system, then maybe

you won't sort of bias and the therapy

towards being

completely estrogen dominant.

Yeah, let's shift

your constipation first.

There's absolutely no point putting a

load of estrogen in the top if it can't

get at the bottom because

that's going to be toxic.

Yeah, definitely.

That's my very simplistic look at it.

And it's helpful, we also at Health and

Mentals, we actually also specialize in

helping women that have a history of

cancer, any type, but

particularly breast cancer.

And so, again, sometimes if you can look

at how someone is clearing their estrogen

through, you know, their four hydroxy

pathway or whatever, it just gives you a

little bit more information to be able to

more accurately direct an individual

rather than a population of

women, if you see what I mean.

It's very much an individual level.

Dr.

Baugh, I'd love to talk about the history

of management all day, but for the sake

of time, I'd like to talk about the

elephant in the room and that being the

use of testosterone in HRT.

Now, I don't know of any medical

governing body in the UK or abroad that

advocates for the use of testosterone

replacement therapy in women or TRT,

which I think is a little absurd because

it's a hormone that is, well, naturally

produced, woman number one, and B is

crucial to well, life.

Just being sort of happy, functional, I

mean, if you look at the sort of the

Adams questionnaire for men for low

testosterone, I mean, the same things

apply to women as well,

sort of low libido, low mood.

Yeah, dysregulated insulin sensitivity,

poor metabolic health and inability to

maintain and hold them to muscle, et

cetera, et cetera, et cetera.

Now, as I mentioned, there are of course

no governing bodies approving this, so

there are no guidelines on the use of

testosterone in women's HRT,

which again, I think is daft.

I'd love to get your take on this though.

What do you see in clinical practice when

a woman gets onto testosterone or some

sort of TRT therapy as

part of a world sign protocol?

Is it generally a needle mover, maybe

when they haven't had that much success

with just manipulating estrogen and

progesterone levels, or is it just

another cognitive machine?

Yeah, it can be a

complete and utter game changer.

I mean, it's literally like flipping a

switch between night and day.

For some people, for some people it's,

yeah, definitely have some benefits.

You know, it's not a game changer, but

it's definitely been helpful.

Some people doesn't actually help much at

all, and very occasionally, some people

find they feel worse with it.

But in general, the positives are so much

more numerous than any negatives.

And so the nice guidance says that if a

woman is, well, they're supposed to be

postmenopausal, if a postmenopausal woman

is settled on HRT and the HRT is

essentially sorting out all of her

menopausal symptoms, except that she

still has a low libido, which she finds

distressing, and for which there is no

other obvious cause, then we're allowed

to consider a trial of testosterone

transdermally, so through the skin.

But only for low libido.

Yeah, only for low libido.

The joke about that is that you go, oh,

okay, well, this woman actually fits all

those criteria, so let's go, and they go,

well, what are we gonna use?

Oh, we don't have a licensed female

product in the UK for this.

Oh, well, so what are

we supposed to do then?

So then the woman then either has to go

privately to be able to access,

yeah, so we have Androfem, which is a

testosterone cream that

comes from Perth, Australia.

So we've been using that in the UK under

MHRA guidance because we're allowed to

import it because we didn't have our own

product for, I don't know, probably a

good, maybe up to nearly 10 years now.

Now, it actually got its license a week

ago, which is brilliant, amazing.

Although, of course, in practice, all

that means is that now NICE will maybe

look at it as a possibility, but of

course, it's really expensive, so I'm

afraid I'm not holding my breath thinking

that it's actually gonna be available on

the NHS anytime soon.

Maybe a couple of years, but the other

option that women have is to have one of

the male testosterone products, but it

needs to be prescribed at a female dose,

which is

approximately 10% of a male dose.

Now, of course, I can do it in my sleep

because that's all I do day after day,

but most healthcare professionals aren't

used to doing it, and that's when we see

mistakes happening in women

being given the wrong doses.

Enginealized.

Yeah, but it is,

when you explain to women and say, look,

when you're in your 20s, your late

adolescence in your 20s and early 30s,

you had loads of testosterone, far more

testosterone actually

than you had estrogen,

and then from your kind of mid,

early to mid 30s onwards, it just

gradually started to decline, and it was

nothing, it was maybe one, 2% a year, not

that much, so maybe by the end of your

30s, you're thinking, well, okay, my

libido's not as good as it was, but maybe

I've been with my partner for 10, 15

years, we're not swinging from the

chandeliers anymore, we've now got kids

and jobs and stress, and people, we're

more worried about who's emptying the

dishwasher than what sexual position

we're gonna do tonight,

and so it's subtle, and most people don't

notice, but I also think there are some