GP & Women's Health Expert: How Menopause Affects The Whole Body. Why Women Are Ignored In Medicine! Dr Nighat Arif.

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0:27if you want to find a toxic workplace that's misogynistic and I hate saying this because it's my own community. It is medicine. Still now. I became a doctor and I was like, I never want to do women's health. But three o 'clock in the morning, I had a patient who came in who now I know was perimenopausal. The doctor said to me, it's flipping nothing, just get her out. And I was just like, sorry, it's really sad that women put up with that. It was then for me, the penny dropped that I am dealing with women's health issues, which are going in and out of A &E and this could be prevented at the door.

1:05Women need to understand what's happening. My grandmother went through this, my mother went through this, I'm going through it and I'll be damned if my daughter goes through this. If nothing changes, nothing changes and that's so sad and we're stood still. You have to think of menopause as being a head-to-toe disease, physical symptoms and then psychological symptoms. The best way I can say it is I just don't feel myself anymore. It's very lonely when you're in that space by yourself and you're thinking, I'm the only one going through this. There's one person saying, absolutely, don't do that.

1:34And there's another person saying, do do that. Where do people go to find the truth? Menopause sells and I'm afraid snake oil always sells. We have so much work to do, but anybody listening to this podcast and talking, I would say three things to you, please, if you do anything.

1:52Nigga, I'm so happy to have you sat opposite me today because, well, firstly, I want to say we've been friends for a very long time now, haven't we? And I really, really admire you. And I think the work that you've done around women's health for so many different communities and for so many different people, the difference that you've made to their lives going forward. I mean, even personally speaking, my daughter, realising that she had adenomyosis. and it was thanks to you and I had somewhere to go, so thank you. So it's an honour to have you on here today. I wanted to start by asking you kind of what is your mission in life?

2:40In terms of work, who do you want to reach? Where do you want to go? I think firstly, my imposter syndrome just won't let me hear all the nice stuff that you just said. So that's my first mission, to flippin' get over that. I just be like, I struggle with compliments, but thank you so much. And I think my main mission is just to have accessible women's health, because I fundamentally believe that if the woman is well within any household, any workspace, and she's happy in her skin, she's happy physically, she's not in pain, she's able to carry on and look after her babies and look after her family, look after herself, you know, even if she doesn't have extended family or those around her, and she's just comfortable with herself, then she thrives.

3:28But not only that, society thrives, community thrives, economy thrives. And so if you put women and girls at the heart of any of your work plan, I always think that when we were building a house, you put foundations in. And in your foundations, you're thinking about women and girls. Then whatever structure you put on top, it's going to be flipping so strong. And we haven't done that for decades and decades. look at the research, look at everything. We always sort of think of women as an afterthought and they are secondary to men. They are secondary to men's achievements. They are secondary to what is capable of, as a society, of even when it comes to basic things like respect or accountability and making sure that women are looked after well.

4:19And we're not little men. so my mission little men we're not little men and so I my mission really is to change the narrative or change the dial in the most smallest way possible but in the biggest way where it's not just then when it comes to women and girls it's not just for the the majority are always seen so women like me are seen as South Asian women black and Asian communities marginalized communities whatever you identify, you come and bring your full self and not hide who you are. So I'm really proud to say I'm a Pakistani, British, Muslim woman who wears a hijab and I'm really comfortable and it's taken a journey to get to this point, whether it's my journey with the hijab, but I am the most comfortable I've ever been.

5:10But it's taken me to my 40s to really understand that. I want to talk to you a little bit about growing up in Pakistan I know you left when you were nine but what was life like for you before that as a young I have really clear memories of being in Pakistan so we as a family there are two families and we grew up in a village and it's known 38 so 38 fateh within Bahawalpur Bahawal Nagar and it's on the river Indus so in Punjab and we're in the thick of it because we were subsidy farmers so we grew up on a farm and I remember having very vivid memories about sort of the age of four or five uh going to the cotton fields with my mum to pick cotton and I was expected to pick cotton and I don't it wasn't a bad memory because I was always with my cousins but that was it was just survival remembering you know if the monsoon rains didn't come there was famine and remembering the fact that my first drowning experience happened when I was about seven because there would be makeshift little canals of river to try and get all the water into the fields and I thought I could swim so that put me off swimming for a very long time but fast forward now I'm now a really good swimmer so I go swimming regularly and then the first experience of being held back because of my gender the nearest closest school was about a mile away which was a walk in really blistering heat.

6:34And only my male cousins were sent. I wasn't sent because it was really difficult for the family to ever send girls so far away and especially really, really little. I remember talking to my grandmother when I was about 23 and I was getting married and, you know, God rest her soul, she's not with us anymore. And I spoke to her and I said, you never sent me to school. And she laughed and she said to me, it did you no harm, but had I sent you to school your father was in the UK being the imam he's a priest and she goes that if you'd got kidnapped then I wouldn't have been able to look your father in the eye and so very little I was I grew up as a tomboy my head was completely shaved me and my cousin who was also a girl and we were just brought up like little boys up until the time came when it was sort of safe.

7:29And it's because... So you mean you were kind of treated like boys so that somebody wouldn't kidnap you? Yeah, I wouldn't wear a little... I remember not having dresses. I think the first dress I wore was when we came to the UK and my mum put me in a little pink dress. And there's a photo of me in a small pink dress because my father had convinced my mother we're going to a lush green country where it's absolutely beautiful. so I think she thought we were coming to the Caribbean because he was like, we're going to an island which is right because we are an island but it's not quite the same not quite the same so we landed in April on Heathrow walking down the stairs and it was raining and it was nine and I wore a pink dress which my mother had sewn because my mother's a seamstress and absolutely in flip flops and suddenly landing in this alien country in rain and I just remember going, oh my god what is this place to be fascinated by this new journey because it's me my two other brothers and my mum and my dad and the decision was made to come over because my father who's the imam had been here for a long time and my uncle my father's older brother had said to him you know the kids are getting older and the gats now older she really is fighting to go to school because I would fight I would argue so much with my other family members going I don't want to do household chores I don't want to learn this I don't want to be doing domestic chores around the house I want to go to school your dad was something of a legend right he's still he's the longest serving imam yes so my father has been the longest serving imam in one area and in Chesham he got an MBE from the queen from the late queen herself wow just before she passed and so it was a real moment for us because he's been recognized as someone to further the Muslim faith and I suppose the significance of that is is there's so many misinterpretations in mainstream media of what Muslims are like that we're very regressive suppressed women depressed and don't integrate with the community and that's really unfair because I would definitely say I'm not a unicorn I'm not hidden.

9:42I'm everywhere, thankfully. But I'm also very much integrated in society and community with my family. And my father was at the forefront of that. He had to really battle the congregation to try and get me into university. But behind him was my mother, who's a proper Punjabi woman who's so strong. What do you mean by he had to battle with the congregation to get you into university? So when I started doing GCSEs and A-levels, I said to my dad, I want to be a doctor. And he just sort of looked at me and just thought, A, that's an impossible dream. I'd come so late into the country. And so I was catching up so much.

10:22And then secondly, it was always like, so we have a phrase which I think translates to every culture, but in Punjabi is, loog kia kahe nge, what will people say? And so the fact that I would leave home to go to university and be out of the house and living independently by myself and so I genuinely had women from the community women I have to say more than men maybe they did come to our house because our house is next door to the mosque in Chesham who would say to my father your daughter's going to go off you know she'll she'll never come home and also as the leader of our community how how dare you send your daughter off unmarried, single?

11:01She will get a boyfriend. She'll smoke. She'll run away. And I think that for my father was quite difficult. And there were congregation members who at that time, I'm not even talking long ago. When did I go to medical school? 2002. So I'm not even talking about this is like Victorian time. But there were people in the congregation who really fundamentally believed that a girl shouldn't be educated. And my father was like, I will treat all of my five children equally. And all of my children will equally go to school, university and school as far as they want to. So I became a doctor. My brother is a barrister.

11:42My other brother is a chartered accountant. My sister is a dentist. My younger brother is a pediatric nurse. And we all fully work with the mosque. And we've started a football group, computer classes through the mosque. And so we talk to the local rabbi. We go to various events at the local church, the Methodist church. We're very close with the Quaker community in Chesham. So we really I think if there's a blueprint to show how it can be done properly, then that is one way of doing it. Through the mosque, using that congregation and building that trust between communities. So prejudices and, you know, the phobias of each other's faiths or the fear that builds around.

12:25And I think that fundamental fear is so much because you just don't know and you start learning about someone and actually you realise, oh, my God, we are exactly the same. Yes. We believe exactly the same. And regardless of coming back to that conversation about labels, at the core of it, if you are just flipping human, I will respect and love you. And that's it. when did you see that there was a need to help women with their health i knew that straight away from a really young age i was the first person that spoke english so i was translating periods miscarriages fibroids um anemia not really knowing what i'm translating because i was taken in as the 12 13 year old to translate okay for the community even before you became a Even before I became a GP.

13:19So Rachel and I, you know, Dr. Firth and I were many years on now when I'm a doctor and she saw me on BBC Breakfast. We had a coffee and we were laughing about it. She goes, I remember that 13 year old girl who used to come in and translate UTIs and try and find the words. And I could never find the direct translation of words. So I'd have to use English words and try and explain to the auntie, who's not my biological auntie, but just from the community, what those words are. Is that because there isn't a word in Punjabi? Yeah, because there is no word. And then I did women's health and I was never, and then I was like, I never want to do women's health.

13:57I became a doctor, I became a GP and I was like, why? I can't swear on this, can I? Yeah, you can do whatever you like. No, because I think swearing was, I was like, I'm never going to do like women's health. I can't stand periods. I used to think it was a sign of weakness because my gender was always held against me and I it was always like women in medicine if you want to find a toxic workplace that's misogynistic to the nth degree and I hate saying this because it's my own community but I know this will be resonated by so many it is the nhs it is that that that medical fraternity that academic fraternity because unfortunately the core of it is still very misogynistic and then now i think it's changed a lot because we've got incredible campaigners who've come out about sexual harassment you know liza ridden who's been our dear friend and colleague who's spoken about the sexual harassment as a surgeon, Roshina, who's documented quite a lot about her experience.

15:06And I think women are now calling it out and men are calling it out. So we now got allies and support and men going, actually, this is so unacceptable. But when I first went into medicine, it was almost seen as the achievements of what a woman was doing was never on par. And you don't have to look far. The current Euros that we've just had, the male team going right to the sort of semifinals and not winning it was almost like oh the hurt goes on for another 59 years it's like hang on the lionesses brought it home like what are you talking about like but the women bringing home the european cup was not a part didn't count and that and that doesn't just cut people like me as a medic but it cuts all the little girls and all women i think all women but it means that it means that those little girls playing in the field um with football and battling with the boys still are going to be like well do you know it doesn't really count because what does it mean at the end of it and so I think for me in medicine that was the thing I felt like I was always I was always the sort of second degree doctor and so I just thought I don't want to do women's health because that would just immerse me in the weaker sex and I feel awful for saying your mind there were two conversations that I had and they were in in Wexham Park Hospital and that's where I did a lot of my training and I would see a lot of the Punjabi South Asian communities.

16:32One was three o 'clock in the morning I had a patient who came in who now I know was perimenopausal, 46, holding on to the bed bars like this and she was sweating, profusely sweating, it's three o 'clock in the morning and she's going, I can't sleep. So I've got palpitations. So she's said all of this, even though she spoke good English, she said all of this in Punjabi to me. You know, I can't stop sweating. I can't remember anything. I cannot talk to my husband anymore. My husband doesn't listen to me. My kids, I need to arrange their marriage and I can't sort out their wedding, etc. And the community talks about me all the time and I just cannot keep the household.

17:15and I've always been a housewife and now I'm losing my mind and as much as she was Sikh so she was as much as I go to the temple the gudwara and I'm praying God isn't listening to me and so I'm praying harder and harder. That makes me really sad. I know and I just looked at her and I just I didn't know so we did her bloods we did all her functions she came back with a little bit of vitamin D deficiency. So the doctor said to me who was actually a South Asian doctor who I respect very much she was just like oh for goodness sake another south asian woman do you know what this is this is bb begum syndrome they come in at three o 'clock in the morning taking up our time and resources and it's flipping nothing just get her out and i was just like so that was me encountering the first bit of as a junior doctor internalized racism within the healthcare sector and i was like because my mum, her surname is actually Bibi.

18:13So she's Manira Bibi. And it's the term that we give for a lot of women. And it's a term that came over when a lot of communities from India and Pakistan under the British rule, because all women were given that term. So the colonial aspect of it runs deep. The partition runs very deeply. There's a lot of trauma that I think we still need to deal with as a community. But to have another South Asian doctor reflect that back to me was just that icing on the cake of this is what colonial impact that we still have, that we still think ourselves as second class citizens to our white British rulers that were there at one point.

18:51So and then she goes to me and also I would really rethink about how you wear hijab. I used to wear my hijab slightly differently. But she goes, you'll never get far in your career wearing a hijab because people won't take you seriously at all. And they'll always see you first and think that you can't speak English and have those assumptions about you so you'll get further in your career and I think she thought she was being really trying to be helpful really helpful to me but I took away from that going oh my god like I'm in this in the medical field and I cannot help my own and my own who I think are helping me actually can't see the wood for the trees for themselves so it has to fundamentally change because if we don't help women women need to support women but women need to understand what's happening so fast forward I went into Wexham Park out of Wexham Park into my GP surgery that same patient that I'd seen three months prior she'd accidentally booked in to see me so she came in to see me and I realized then because my trainer then did women's health and she was just like this is all perimenopausal related and it was then for me as a junior doctor when like the penny dropped that I am dealing with women's health issues which are going in and out of A &E and this could be prevented at the door and we would save resources respect for women but also their their their livelihoods and the way that they function and their families because the poor husband was like beside himself going I don't know her faith was being tested I mean And this idea that God isn't listening.

20:34Exactly. I really hope you're enjoying this episode. And if you can, give us a follow. Now, you were just talking about the woman that came into A &E and who you then were able to help in your clinic. And you talked through some of the symptoms. And I just thought it would be interesting to just chat about a few of the symptoms or not even chat about them, but just mention them quickly. Can you just tell us a few of them? I always say you have to think of menopause as being a head-to-toe disease so it's all encompassing so you start from the head and we always in medicine we go their vasomotor so they're the ones that are going to cause physical symptoms and then psychological symptoms they are very much part of the reduction in estrogen that happens so if you think about head so hair thinning scalp issues you might get skin changes as well brain fog memory issues lack of confidence lack of self-esteem tearfulness for no apparent reason uh lack of concentration yeah rage absolute anger that can happen without any rhyme or reason and normally you're quite a placid person changes in your hearing so tinnitus changes in your taste yeah i've started to now i'm perimenopausal i started getting this sort of a metallic taste which was very significant when i was pregnant and in also gum health i mean the number of dentists that i've told watch out for this this is perimenopause.

21:56And again, it's because of that reduction of estrogen. You might notice then around your heart, so palpitations, as my patient was saying to earlier, you might notice that actually your allergies that you never had before are suddenly flaring up again. Gut, remember a third of your immune system, which uses estrogen as an immune modulator, sits in your gut. So bloatedness, weight gain around the middle that can happen through your adipose fat tissue as well. foods that don't suit you so well so alcohol you could tolerate it before now you just cannot tolerate alcohol anymore yes we talked about pins and needles in your legs or feeling like spiders are crawling down your legs um on achy feet achy joints so there's a lot of symptoms within the south asian community that they complain of so that's translated as everything hurts from my head right down to my toe and now we know it's arthralgia it's your joints and your aches aching hands and your feet etc fatigue extreme tiredness Japanese women complain of sort of shoulder aches more so and then the fundamental one which is always given as number one is hot flushes night sweats or cold flushes and then the most taboo symptoms that we never talk about are vaginal atrophy or genitourinary syndrome of the menopause so that's soreness splitting of the skin irritation around the vulva and the vagina recurrent urinary tract infection which cause a lot of misery for so many patients a uterine prolapse increased urination so you're feeling like you need to go for a wee all the time we're not able to hold your wee as well and then just sex is so difficult or going for a smear is so difficult so it's the whole body is taken over and it's a transition it starts around the age of 40 and they don't all come at once as you know they come as hodgepodge and I think we need to start thinking of ourselves as these transitional cyclical beings so now I'm 40 I'm really comfortable in saying the fact that I'm a perimenopausal woman and everybody's like but you're 40 but as south asian women or black and asian women we start between two to five years earlier than our white counterparts and a lot of black and south asian women don't know that no they don't because in their own communities no you don't it's it's been a shameful thing or an embarrassing or a weak thing to talk about the word for periods is which is you are off the rag now what woman is going to openly say that when it's so entrenched in patriarchy and misogyny and then in urdu it's translated directly as barren banji so you're banji you're barren and they're like well no that's not really the case at all in arabic the literal translation is the age of despair so these conversations it's terrible and my granny my granny used to call it the curse I mean or the change yeah oh well the menopause is the change yeah the change has happened and because you don't want to use the anatomical words and so I you know kanonki is the word in Japanese and it's it means rebirth or you know second spring and you're just like these are lovely words that they have a completely different spin on it and we understand that women are born we go through puberty then we go through our fertility years and then we go through perimenopause menopause which is defined as one year without a period and post-menopause which is one year and one day without a period and you're post-menopausal but because we're seen as little men men go through born puberty and then that's it so we have never seen women and I always say as women we are these incredible circles made to fit into squares constantly wherever we are and so that's why nothing is set up for us and that's why I go back to where we started we were never at the thought when the foundations were put in you know the other thing that I feel that a lot of women get hit with but it's an like you said it's an emotional um symptom rather than a physical one and this was the one that I hear so many women are unable to kind of describe but the best way they can say it is I just don't feel myself anymore and that one always really breaks my heart because I can really remember that and from being a uber I mean I think you and I are so similar in personality very confident kind of happy to talk to anybody extrovert um enjoy company and suddenly I lost the ability to be myself and I when I say to somebody are you able to feel joy often they say oh I've forgotten what joy feels like I'm sort of flatlining and that's exactly how I felt where do people go to find the truth I mean I'm I find it all the time with health issues any health issue you look and there's one person saying absolutely don't do that and there's another person saying do do that where do you go what we're trying to do so I'm I know you're part of it as well but we're working with YouTube health I think YouTube health and platforms have got a huge role to play here and the who so the world health organization so i am a member of the who fridays program and the youtube health program because we're trying to get content creators like me who look at data who look at evidence who are giving a sort of down the middle view unfortunately what sells on socials is clickbait yeah so you've got to be either the extremes of the two and then where do you get the misinformation dealt with well you've got to look at verified uh follow you know doctors and then i think within that if i'm a bit selfish in saying that doctors who actually clinically practice yes because i think that makes a huge difference because my medical doctor yeah because there are lots of people that call themselves doctors that aren't actually medical yeah it's a bit of the wild west at the moment unfortunately because is that you could do now a three-week sort of online course and say, I'm a menopause expert.

28:07So it's, and you know, what sells? Menopause sells. And I'm afraid snake oil always sells. And that is where we are. This YouTube health channel, is that up and running yet? It's up and running. So the program's been running for about a year. Alison Lomax, who's the first woman to head YouTube UK and Ireland, is really on it at the moment. and we've got Vishal who is heading all the doctors. So there's a lot of us doctors who are practicing clinicians. The reason that it came about was actually the brainchild from the pandemic because in the pandemic, if you remember back, the horrific time that we had as clinicians, but we learned from other clinicians around the world what was working well and trying to educate our communities around the virus, which we didn't really understand in the early days.

28:57and so we realized that actually public health messaging only works if you trust someone and so making content in different languages which is what I do on YouTube in Punjabi etc means that people are more likely to download that and share it with their friends and so what we have sort of guidelines that we need to follow as YouTube health content creators and they we're hoping to build on a lot of that but it means that but at least you feel like there's something to trust there's a place to trust there is there is and then obviously you know we would say the nhs websites i always say go back to the nhs websites but you and i know when it comes to menopause we still have a lot of work to do on that and we recently didn't have a whole page for adenomyosis until now i've been thinking about the power of community lately thanks to our favorite creative tool and sponsor adobe express you might know it as the quick and easy create anything app from adobe but it's also a really buzzing creative network so the other day i couldn't get um our begin again logo to look how i wanted in a doc so we jumped into the adobe express facebook group and within minutes the gang in there came to my rescue and there are thousands of business owners and creators in there all helping each other out and it's not just design advice and they're not frightening at all and loads of resources and stories honestly it's amazing if this podcast has taught me anything it's that starting a new chapter you know whether you're creating a logo for your new business idea or just doing a personal project you know obviously it's always going to have its ups and downs but having the right people around you can really make all the difference so if you're ready to take on your next big thing don't be afraid to reach out it's not scary as you think there are loads of helpful people out there and they want to help you along the way.

30:46So search for Adobe Express to find out more and get the app for free. I love a life hack. You know, anything that lets me work smarter, not harder. That's why Shopify is a partner of my podcast, because honestly, their whole platform is like one giant life hack. If you run your own business and you want to sell products online, I know this is going to help you. Are you building a website. I mean, where do you even start, right? It's a bit like climbing Everest. It just seems so huge, a massive project to take on. But Shopify makes it so simple. You can customise your online shop by using their easy peasy tools and create something that really reflects your business and what you're all about.

31:29And here is the best bit. Shopify lets you sell in loads of places, even on Facebook and Instagram. And get this, when you sign up, you only pay one pound per month during the trial period at shopify.co.uk slash Davina. How's that for a bargain? That's shopify.co.uk slash Davina and join the gang that's working smarter, not harder. I do want to touch on hormone replacement therapy because just like you were saying, the pill was a revolution for women and it was a freedom for women. If you have quite bad symptoms during the menopause and, you know, maybe 75, 80 % of women struggle with symptoms, some of them very badly, there is something that can help that has got such a bad reputation still, even today.

32:21And it doesn't just help, it has some health benefits, maybe not all the ones that lots of people say, but it does have some health benefits to it as well. Could you just quickly talk through HRT because it is such a hotbed of controversy. Yeah. Three words, H-R-T, hormone replacement therapy. We are literally just replacing the hormones which gradually start to decrease. And they decrease because you're genetically programmed to do that. But your brain is so amazing because when you're genetically decreasing in hormones, it produces it elsewhere. So we now know your brain produces estrogen. It also produces your cortisol.

32:59So that's your stress hormone, your melatonin, your sleep hormone. your dopamine, which is your get up and go hormone, your adrenaline, your noradrenaline. And what the brain does so cleverly is it talks to your fat cells. So in your fat cells, you also produce sex hormones as well. So your estrogen, progesterone and testosterone. Now, we do know that some women actually don't respond well because it's not the right level that you need at that time. And those dips and troughs means that actually your symptoms will flare up. So the vasomotor symptoms of hot flushes. So what we now know, because HRT has moved on so much from the synthetic version which the whi studies were done so they were the ones that the synthetics were associated with breast cancer increase clot increase we now have what known as body identical hrt so they go through your skin their patches gels and sprays and then a capsule version of the progesterone as well the data from that shows that actually the risks of breast cancer are only ever either not increased from your background risk.

34:02So what do I mean by that? You and I are sitting in this room, we both have boobs. Well, I definitely, I know you do. And if I, in this room, there was seven of me, so seven Dr. Nagats, unfortunately one Dr. Nagat in her lifetime would get breast cancer. And that's not because I'm on HRT, that's because my own natural estrogen is working on my boob cells. And in my boob cells, there are receptors which are receptive to estrogen because I'm genetically programmed as a woman so I will produce that estrogen and that causes inflammation and that is so key we've realized that inflammation is a huge instigator for so many problems cardiovascular problems clots but also cancers as well so we now have started to understand that cancer is far more complex than to say okay taking estrogen will definitely give you breast cancer actually that's not true at all for women who've had their womb removed and their ovaries removed and that's known as surgical menopause they only need estrogen on its own and estrogen alone actually could be protective for breast cancer and that's like incredible that we now have this data we've got to i mean i think that will blow yeah some women's minds because i constantly get back but it gives you breast cancer yeah so do I and it you know when you say that without a whim or ovaries it could actually protect you yeah it can do and also not just that there is no preliminary studies that come in that actually has cardiovascular benefits so reduce high blood pressure and because it offloads your fat cells your adipose brown fat cells from producing estrogen actually it's showing that women won't be putting on weight with it so that's the other myth I hear if I go on HRT i'll put on weight i hear that all the time oh i didn't know that the data never shows that because what it so i say in my clinics i say to my patients look by you putting on this gel on your skin it goes through the skin and talks to the fat cells and says mate i'm here i am going to give you a bit of estrogen because it's literally replacement so we are just replacing what you need and that's where the tweaking comes in and that tailor-made sort of advice but it's only one bit of the toolkit and it's not one size fits all by knowing from sort of individuals who have gone through that transition and we've had this conversation i'm trying to be better with my nutrition because even as a doctor i never get taught about nutrition so i'm now learning about nutrition i'm learning about sort of exercise and weight-bearing exercises i'm doing lots of holistic i took up swimming two years ago and professor joyce harper's data from ucl shows that swimming reduces hot flushes and really it does it does i forgot the data i think it was something like 60 percent of women it reduced hot flushes but oh not only that it's a life skill but i've started swimming and it's been a joy because i'm preparing for my next transition to when i come to my menopausal years and i'm fully already using hrt or a version of it i use topical vaginal oestrogen already so can we talk about to think about transitioning before it even happens vaginal oestrogen i mean i i um had a bit of vaginal atrophy when i went into perimenopause but actually when i started taking hormone replacement therapy it got slightly better and then when i went into full menopause so my periods had stopped um and it was quite interesting because I didn't know when my period stopped because I have the Mirena coil for my progesterone but um so I wasn't sure if my periods had stopped or not but my vagina told me and that's so good because I have exactly the same story and I was like oh I need some vaginal estrogen now what was interesting with that is that um not only did it reopen my shop so um sex wasn't painful anymore.

38:02I wasn't feeling uncomfortable down there. But really, amazingly, I started sleeping through the night. And that wasn't and it was because my urinary kind of, I don't know what I'd call it, but me going to the loo got sorted out that I could go longer in between weeing. And it meant that that meant that I could sleep through the night, which has completely changed my life and I had no idea that vaginal oestrogen could do all of those amazing things and again I have constantly women asking me can I take it and be on HRT I'll let you answer that because you're the doctor yes you can definitely and that if you're on it it doesn't mean you're going to overdose on it no you're not going to overdose on it and if you've had breast cancer and you've been treated for oestrogen receptive breast cancer can you take vaginal estrogen.

38:56Definitely you can take it and we're doing a lot of educational work around that and if you've had an astrazole so that's one of the medications that you have after your breast cancer there's a derivative of a type of vaginal estrogen that we can give you and it's called intra-rosa so even that is now becoming safe. I would say topical vaginal estrogen is the most kept secret from women and it blows my mind how not enough women of all age groups know about this and how it's not incorporated into the clinical pathways that we have so I've now started I would almost say the advocacy bit where I've started becoming so vocal and it starts by breaking down the taboo so it's really sweet when you said to me you know my vagina told me because I posted about vaginal atrophy because that was my first symptom.

39:48I was 39 years old. As crazy as this sounds, I was in a women's health conference where I was a keynote speaker in Sweden. And this was my third UTI. And as a doctor, I was just like, okay, this is not real. But I wasn't getting dryness. I'm not getting painful sex and smears haven't been painful for me, but it was my third UTI. And then I thought, maybe I didn't drink it. You gaslight yourself, don't you? yourself yeah oh my god you gaslight yourself and as women we're like pros at that we should get like a gold medal for gaslighting ourselves because even as a doctor I started doing that and I was in Sweden and you I was in a pharmacy um and that's when the penny for me dropped that actually I think it's vaginal estrogen that I need but you can buy it over the counter and you can buy it over the counter in the UK and that's also important to say because of the menopause mandate and we're part of that and we worked really hard so we looked at the mrha guidelines so you can it's called gina it's exactly the same as say vagifem or vagi rux can i just say something that did really make me laugh because i just thought what a funny name yeah firstly don't call a vaginal estrogen a lady's name exactly i know genus this is not okay and secondly vagina yeah oh my god i know okay um and so i i brought some the topical estrogen and then of course of antibiotics and I got better and I came home and I had a conversation on the phone with a very sweet locum doctor and he was just like you're 39 years old I don't think it's vaginal estrogen that you need I think it could just be a utah and I went I wrote a book it's the first time I ever sort of like a mic drop moment and he just went okay and I wrote it's called the knowledge and I've written the whole chapter on vagina atrophy and what it does and I think this is it so I then we did like an educational piece together so and then he was just like okay Dr.

41:41Arrow um I love him and he learned he learned he learned something and I and I think that's it and it's been a game changer oh my god it's been a game changer I've not had UTIs in October 2023 when the got the NHS England guidelines came out for utis they've documented that we get over six you know 64 year old women or post-menopausal women have the highest rates of utis over a hundred thousand women admitted into a and e with utis and chronic utis and nowhere in the clinical pathway did they mention topical vaginal estrogen because fundamentally we still do have i believe this misogynistic view that this is how, because it's men's medicine, it's part of the process.

42:24We have lied to women over two things. And actually, you say I don't get angry, but these are the two things I get angry about. One is, is that we've lied to women about their pelvic floors and said to them, just do pelvic floor exercises. And if you leak after having a baby or you have an oops moment, don't worry. It's okay, here's a pad and you can treat yourself. Actually, no, there are two times in our lives when we reduce estrogen. One is when we've had a baby, and that's when we are lactating so we are breastfeeding our baby and our pelvic floor is for love no money you could do as much pelvic floor exercises and I'm not discounting pelvic floor exercises I you know I do them and I and I encourage people to keep doing it but that's only 50 % of the argument estrogen is the other bit that you need to give women so if you get a woman in your surgery who says I'm breastfeeding and I'm totally getting irritation and soreness and I'm getting an itch please don't treat her for thrush because that's the other mistake that we make you need to give a topical vaginal estrogen and it's known as genitourinary syndrome of lactation so there's a lot of doctors who are sort of talking about this but still very quietly in the women's health sphere and it works wonders so now my midwife colleagues i'm teaching them in their nct classes going please talk about vaginal estrogen the safety data is phenomenally good so it's so local so it's localized it doesn't get taken up in the bloodstream therefore doesn't increase your risk of breast cancer and does not increase your risk of clots does that also mean that a woman say in her 60s late 60s 70s yeah could she start taking vaginal estrogen because i know it's maybe not so good for somebody to take hrt more than 10 years after you've had your last period systemic hrt so something that goes throughout your whole body there are there are conversations and guidelines but I never say no I always talk to individual women on that topical vaginal estrogen lifelong at any point you could start so I've started women in their 80s and it's been a game changer for them honestly it's like they come in I had a woman who saw me and who was 73 who'd had horrific vaginal atrophy we changed it we got it all better again and she came to see me and she goes to me i've had sex with my husband and it was the best sex that i'd had in over two decades oh my god and then those conversations like what's sad i'm sorry but you know what sorry that's okay i get like that in the consultations it's really sad that women put up yeah like you're denied pleasure even on your own or like anything it's like and you just think I can't I can't talk about it that's what makes me so sad sorry we've we're receptacles right yeah so you have your periods and then you're a womb yeah for a very long time your babies you know your boobs are sore then everything else is just like well you know have an heir and a spare and then and this is what I see in my culture a lot so when I shared my vaginal atrophy story for the first time oh my god the vitriol really sister please don't share this this is against islam this is haram don't share this why are you sharing things you know about your vulva and vagina my poor husband then was just like you know this is really against our cultural norm but i'm i would be so upset like this if i wasn't able to as a clinician have the information that i have and go well i'm not gonna i'm gonna keep this knowledge to myself because of what will people say i've thought that all my life yeah and now is not the time to start the other thing i really wanted to touch on because we've heard now about the benefits and in all the ways that vaginal estrogen hormone replacement therapy can help you on your journey if that is the choice that you would like to make what is this thing with the medical profession or sometimes the British Menopause Society talking about over-medicalisation.

46:32Not that many people take hormone replacement therapy. So are we over-medicalising? What is that? It comes back to the transition. We try not to over-medicalise lots of the bits. So for example, puberty, I mean, that's emotionally all the physical symptoms and the psychological symptoms, but we don't have treatments for that and we don't have medicalisation treatments for that. pregnancy you could say we do we have a whole field of pregnancy obstetrics but if you look at it it's mostly because we want the baby to survive right and also because mortality of mothers dying is not a good thing to have and so then we come into this bit of life and women are pushing back and going I've done my dues I've done my pressures now give me the functionality please don't use my biology to make me walk out of a workplace one in ten women leave the workplace promotions aren't given to women so the glass ceiling i would say is still there so there's that sort of battle because actually biologically we are programmed to survive the menopause but i think the conversation has shifted where women don't want to survive they want to thrive yes and that is well we're expected to we're expected to we've got to work till we're 65 like what and we are living longer yeah and so why not as well i mean if we're living longer we want to thrive and we want to be happier.

47:51But the medical bit is why we don't want to medicalise this. And I think that also comes back to how these colleges are usually run, I would say, come back to that whole conversation piece we had earlier about misogyny in medicine. And I think still it's seen as, well, that's not the most important bit in medicine to focus on because the funding and the research needs to go on cardiothoracic surgery because cardiothoracic surgery is a proper man's job or neurosurgery. I remember being a medical student and I'll just really quickly tell you a quick story. We went on a ward and it was in the old days where the consultant would take all his medical students.

48:31So I must have been about a fourth year medical student on a neurocardiothoracic ward round. And the professor of cardiothoracic, I won't name him, cardiothoracic surgery, the patient said to them, will I be OK from the surgery? Like, well, I don't want anything awful to happen. Will I pull through? and he just went there are two people who can save you from you know your medical condition god and me frankly god's not here and i just was like we were just i was looking at him and i was like that level of cockiness you would never get in women's health no or obstetrics or gynecology but there is that sort of and so when you've got individuals like that who are just so like we this is a field that is so important so unfortunately when the research isn't there and because the funding and this is where i really think is awful the funding for say testosterone therapy in women beyond libido is it great for our cognitive function and our muscle the the research for hrt beyond the fact that it's just for hot flushes but is it safe for women who've had breast cancer being treated it for it could they 10 years down the line think about body identical it's easier to say we're over medicalizing it don't give it too much because there are going to be more things that will come out of that so greater risks of endometrial hyperplasia so womb cancers so or women bleeding on hrt where are we going because there's no real i mean the guidelines have been updated but what are we going to look at that and then also what about the risk of breast cancer in relation to the fact that we're getting fatter and fatter as a nation as we're getting older so how does the nhs cope with that um and i think you know if i'm cynical and i hate being cynical in women's health if i'm cynical it is that whole well let's control women a bit more and if you look at the data and marginalized communities so black and asian communities actually there's only about 10 uptake in hrt there's very little yeah and overall it's only about 25 percent of women who even consider hrt which is tiny over medicalizing that's for sure in my nhs surgery i would say i it's really i would have less patients on hrt but if you think about it historically we were dishing out antidepressants like smarties it was crazy but and that's not seen as an over medicalization that's what's so strange the other thing i think is interesting is um you know that that leads us to just suck it up yeah well then just suck it up what you know that rather than medicalizing yourself well you did it in your pregnancy and you did it in your period exactly you're sucking it up now but i mean the amount that we suffer it's like can't we just not suffer for a bit you know yeah yeah um so i think that's an interesting conversation that's where the people like clinicians like myself we have to put our head above the parapet but then we're really easy targets because then i'm seen as a radical gp or a radical clinician why can't i just sit in my surgery put my head down and see patient after patient treat them as a number as a number as a number and there comes a point where you think hang on i'm working in the system i am an nhs trained doctor and this is happening to me and there's a great sort of quote that says you know my mother went through this my sorry my grandmother went through this my mother went through this I'm going through it and I'll be damned if my daughter goes through this and there came a point in my journey where I just had to lift my head up and go I'll be damned if the next generation of negats who have to translate are translating the same thing when they're 40 if nothing changes nothing changes and that's so sad and we're stood still so where do individuals go when they're still stuck in this hole and like you say it took a lot like you weren't the first person to talk about the menopause but yet it became the divina effect and it then became well now doctors are just joining divina and i was like no it wasn't just joy you know we're not just joining that we've been there because it's a collaboration and we've got to start making this collaboration and get out of our surgeries and really pay attention to what's going on because it's going to happen to me in my I do a private clinic in my private clinic I would say half of my clinic now are clinicians and I'm not happy about that it breaks my heart when I get a surgeon a fellow GP who trained me somebody else along the line nurses physiotherapists I get dietitians