The Menopause Awareness Advent Calendar 2023

This wonderful initiative was conjured up by fellow GP’s Dr Ceri Cashell and Dr Emma Harvey as a campaign to shed some light on some of the MANY symptoms of peri/menopause in December 2023.

Written by Co -Founder Dr Sunita Chelva, this was Hera’s take on each of the multitude of symptoms experienced during this time (which by no means is a complete list!) In reality, discussing these entities only just scratches the surface of the conversation we need to continue with our friends, families, work colleagues and community at large.

Remember, not everything about the menopause transition is bad- there is great liberation, wisdom and strength with the next phase of your life!

✨THANK YOU Array Studios for providing the beautiful artwork for this series✨

DECEMBER 1ST: HEAVY PERIODS

🩸 Periods are viewed with mixed feelings but let’s face it they are what make us quintessentially female! They can be the bane of one’s existence, or they can be a sign of life, growth and fertility.

🩸 Often the first sign of Perimenopause can be a changing period - shortening/lengthening of cycles, missed periods or increasing heaviness, pain and clots.

🩸 As women, we are conditioned to just ‘suck it up and keep going’ but heavy periods can ruin your your day as well as your dignity! Moreover, losing significant amounts of blood lead to iron deficiency or even anaemia (as if we need another reason to be fatigued!)

🩸 Treatments for heavy menstrual bleeding in peri/menopause include :

• Anti inflammatory medications like Ponstan or Naprogesic

• Tranexamic acid

• Certain progesterone only pills eg Slinda

• The Mirena IUD

• Endometrial ablation and sometimes hysterectomy if all else fails.

🩸 These options can also be part of or used along side your HRT.

🩸Heavy periods are treatable so please speak to your GP about the options that best suit you 🧡

  DECEMBER 2nd PALPITATIONS:

🧡 Though not widely known, palpitations are an extremely common symptom particularly in Perimenopause. (Up to 50% of women report this symptom)

🧡 Perimenopause is a time when Estrogen levels can start to swing up and down wildly. Interestingly, dropping estrogen levels can overstimulate the heart ­­– it can beat 8-16 times more per minute. Palpitations, or the perception of one’s heart beating, can be rather distressing, but often there is no major cardiac issue causing it. 

🧡 Palpitations can occur in isolation, or be related to stress, anxiety or hot flushes. 

It is a very confronting and scary symptom, and whilst most likely has a benign cause, it is a good time to assess cardiovascular risk and start preventative measures.

🧡A few lifestyle changes might reduce the occurrence of menopausal palpitations. These include:

• Reducing caffeine (a known stimulant ) in coffee, tea and such drinks

• Cutting back on or avoiding cigarettes and alcohol

• Practicing relaxation techniques, such as yoga, mindfulness, and breathing exercises (it’s amazing how we all forget to simply BREATHE)

🧡 It is important to seek help if palpitations do not abate or if you experience chest pain or breathlessness or dizziness. 

Remember, our risk for cardiovascular disease escalates as estrogen declines through the menopause transition.

🧡 We cannot forget that cardiovascular disease is the major cause of death in women, far more than breast or any other cancer, so midlife is an excellent time to get checked, start to improve our diet and ramp up the exercise!

DECEMBER 3RD: POOR SLEEP

🥱All living organisms with a brain need sleep.

🥱Sleep allows the brain to not only rest, but to process thoughts, lay down memory, recharge and reboot!

🥱 There is a reason why sleep deprivation was a form of torture used by many cultures in the past. We all know it leads to mental fogginess, poor concentration, reduced reaction times and declining mood. 

🥱 Chronic sleep deprivation can have a significantly negative impact on the brain, metabolic and immune health. According to the AMS, ‘Sleep duration of less than seven hours a night has been associated with increased mortality as well as linked to cardiovascular disease, obesity, mood disorders and diabetes’.

🥱It’s also been suggested that people can develop a tolerance to chronic sleep deprivation. Even though their brains and bodies struggle due to lack of sleep, they may not be aware of their own deficiencies because less sleep feels normal to them (sound familiar?!)

🥱 Peri/menopausal women often wonder why they have declining cognitive function, are irritable and perpetually exhausted. They feel they lack the energy to exercise or optimize their nutrition perhaps even ‘self medicating’ with alcohol (which has a negative effect on sleep contrary to what is intended!)

🥱Estrogen and even possibly Progesterone & Testosterone have important roles in the science of sleep and hence losing these will make sleep worse. Hot flushes, restless legs, sleep apnoea & partner interference can all be contributing factors as well. For many women it is a long continuum of insomnia from child rearing years onwards!

🥱 Replacing lost hormones with HRT, Cognitive Behavioral Therapy specifically for sleep, good sleep hygiene, optimizing diet (reducing caffeine and alcohol) and exercise are all key to a good nights sleep. 

🥱Improving sleep is a top priority during menopause !

DECEMBER 4TH : ITCHY DRY SKIN

🐜 Women do not often make the connection between Estrogen and the skin as they notice that their skin becomes noticeably dry and itchy in menopause. 

🐜 Estrogen affects every system of the body including the skin. Estrogen receptors are most abundant around the genital area, face and lower limbs.

🐜 We all know that age shows visibly on our skin. Consequently we spend vast amounts of 💰pampering/plumping/pinching/prodding and poking our skin (or some do at least!).As Estrogen drops at menopause rather rapidly, so do collagen levels- resulting in drier, less elastic skin.(No wonder pregnant women are told they have such an amazing ‘glow!’)

🐜 Some women suffer with a horrible sensation of ants crawling under their skin in the menopausal transition -‘formication.’ This is related to increased circulating histamines in the skin around this time, sometimes triggered by certain large spikes in Estrogen levels particularly in perimenopause. Others might get recurrent hives or simply be more prone to rashes in general. 

🐜 As we lose our Estrogen, and androgens (testosterone) become comparatively high, acne and rosacea can also make a return through perimenopause (no one wants to be a teenager again!)

🐜 A good moisturiser, soap free cleanser and a non- comedogenic sunscreen is vital 

🐜 Hyaluronic acid, Vitamin C and Retinoids are great too 😁

🐜 Replacing the lost Estrogen via HRT/MHT can also help - talk to your GP!

DECEMBER 5TH: ANXIETY

😬 At the galloping pace of the post Covid modern world, anxiety abounds…
😬 Anxiety affects around 1 in 3 women in their lifetime. Times of hormonal flux in particular can induce anxiety- evident with PMS, Postnatal anxiety and Perimenopause.
😬 Plummeting Estrogen & Progesterone can trigger a flare of anxiety and in turn a surge of adrenaline & cortisol (which can then drop testosterone)
😬 Of course peri/menopause also coincides with times of high STRESS in life: work/relationships/children/ageing parents etc Our brains are overflowing 🤯
😬 High functioning, superbly capable women, previously masters of ‘the juggle’ can find themselves shrouded in anxiety around Perimenopause. (We see this every day!)
😬 Symptoms can be subtle or intense and can include
* Feeling nervous, irritable, or restless
* Difficulty relaxing
* Constant worry & rumination
* Having trouble concentrating and remembering things
* Tensing muscles throughout the body (even pelvic floor muscles!)
* Urinary urgency
* Sweating
* Trouble falling asleep or staying asleep
😬 What helps? Reducing caffeine & alcohol, increasing exercise, social connection, getting out in nature, breathing, counseling, CBT and of course replacing those depleted hormones with HRT! 😁

DECEMBER 6TH: WEIGHT GAIN

🏋🏽‍♀️ Through menopause,women gain an average of 0.5 kg a year
🏋🏽‍♀️ Body composition itself changes with a decrease in muscle to fat ratio.
🏋🏽‍♀️ Fat deposits around the lower abdomen, thighs & hips.This might be because peripheral fat stores are trying to ‘generate more estrogen,’but studies have not shown a direct link between menopause & weight gain.Weight gain has a multifactorial cause- it’s not so simple.
🏋🏽‍♀️ We all know that increased abdominal fat is associated with a higher risk of cardiovascular disease, diabetes & even potentially dementia.
🏋🏽‍♀️ Chronic stress leads to increased cortisol & adrenaline which in turn can lead to insulin resistance. Insulin resistance means you cannot metabolize glucose effectively. This fluctuation can lead to the typical sugar cravings that women get in the evenings.
🏋🏽‍♀️ Poor sleep depletes energy and increases the hungry Ghrelin hormones.Aches and pains are magnified and exercise becomes a CHORE. The couch tends to be more inviting as does a sneaky glass of wine and thus-the vicious cycle begins!
🏋🏽‍♀️ Estrogen has positive effects on glucose & lipid metabolism, so raised total cholesterol and impaired fasting glucose are common findings.
🏋🏽‍♀️ Nutrition (not fad diets!) - pack in the rainbows, protein, legumes & whole grains. Add in some probiotics, prebiotics & lots of water. Keep the🍷to a minimum.
🏋🏽‍♀️ Move your body even if you are not a ‘natural exerciser!’ Do what you love and are likely to keep doing. Weight loss requires building muscle not just cardio!
🏋🏽‍♀️ Some women do require medical weight loss adjuncts (when available) if their stubborn metabolism just won’t shift!
🏋🏽‍♀️ Women are worried that HRT will make them ‘put on weight,’ but often it can result in a normalization of metabolism 😅
🏋🏽‍♀️ Eating disorders can resurface around this time. Part of the menopause transition is owning and accepting that our bodies change. Do the best you can for it as you only get one !

DECEMBER 7TH : POOR MEMORY
🧠 Science tells us that women’s brains are different to men’s. We are better at multi-tasking, word memory and social cognition, with superior verbal abilities. Until, that is, our hormones start to decline.
🧠 Memory loss and brain fog are one of the MOST debilitating symptoms experienced during peri/menopause.
“I feel like I am losing my mind!”
“I can’t remember the name for..”
“People at work look at me like I’m stupid!”
“I walk into another room and forget why I am there!”
“My husband gets so frustrated that I don’t finish my sentences..”
““My mum has Alzheimer’s, could this be dementia????!”
🧠 Women’s brains age differently to men because the female hormones Estrogen & testosterone play major roles in cognitive function. Decline of these hormones beginning in Perimenopause results in reduced processing speed and verbal memory. Concentration lapses and confusion leads to anxiety. The brain fog is REAL people!!!😶‍🌫️
🧠 Hot flushes/vasomotor symptoms do cause transient vascular changes in the brain and in turn cognitive changes.
🧠 Rest assured memory and cognitive issues associated with menopause do not lead to dementia and are reversible.
🧠 Back to the basics: quality sleep, exercise, a Mediterranean diet with lots of omega 3’s 🐟 and olive oil, social contact, and learning new things will help brain function.
🧠 HRT/MHT started in a timely manner can help restore hormone levels in the brain, and no doubt the flow on effects of sleeping better and less hot flushes helps too.

DECEMBER 8TH : NO INTEREST

..No interest (i.e. everything is a bit.. ‘meh’)
😒 “Then I became what I am. A menopausal woman. In the eyes of evolution, that makes me a pointless person. Why are we the only creatures to get menopause apart from two types of whales? We don’t know.” Rose George.

😒 Anhedonia (lack of interest) is defined by the DSM-V as : “lack of enjoyment from, engagement in, or energy for life's experiences; deficits in the capacity to feel pleasure and take interest in things.”
😒Through the menopause transition, women often feel they become a ‘shell’ of their former selves. Life is a bit colourless and bland…
😒 Whilst poor sleep, hot flushes, fatigue, pain, irritability and all those (not so festive) symptoms can lead to lack of enjoyment, anhedonia is actually linked to lack of dopamine in the brain caused by the drop in Estrogen during Peri/Menopause. What fun.
😒Practically, we are all stretched in every direction whilst each brain cell is consumed by a zillion to-do lists. The mundane does not leave much space for enjoyment or inspiration!
😒Lack of motivation, low self esteem and burnout are all prevalent at this time. Life’s pressures and declining hormones leave us utterly DEPLETED.
😒It’s no wonder that highly qualified, superbly capable women take a demotion, or drop out of the workforce entirely at this time. The statistics are astounding. (What a huge loss for society ?)
😒 It’s not all doom and gloom if we consciously can make a choice to step out of this hormonal rut.
Rediscovering what makes you inspired, trying new hobbies and interests and purposefully focusing on YOU will bring back the joy in life. Making time to exercise (nothing beats natural endorphins!), to meditate and to even think unhindered is not selfish.
😒Talking to your GP about this lack of interest, considering HRT/MHT, maybe antidepressants and great targeted psychological support will restore the zest for life that we all deserve. 🍋 🌈

DECEMBER 9TH : HOT FLUSHES

🔥 ..A hallmark symptom of perimenopause & menopause some women can experience hundreds a day 🥵
🔥 But… not EVERY woman will experience them, so you can still be in the menopausal transition without having hot flushes/vasomotor symptoms at all.
🔥 Some women have cold chills instead 🥶
🔥 It’s not *just* thermoregulatory dysfunction which occurs with a drop in Estrogen... Professor Pauline Maki in the USA has shown that vascular changes actually take place in the brain.
🔥 Given this vascular link, women with more hot flushes in menopause can have greater cardiovascular risk in later life
🔥Smoking and increased alcohol make the dreaded hot flush worse so best to reduce these as much as you can.
🔥Simple measures- dressing in light clothing, having a small fan handy and adequate ventilation can all help.
🔥Targeted Cognitive Behavioral Therapy has been shown to help reduce hot flushes too..
🔥Replacing Estrogen with body identical HRT is the MOST effective treatment for vasomotor symptoms and is low risk with other benefits.
🔥 ..But, what if having a hormone sensitive cancer means your treatment has suddenly rendered you menopausal and you can’t take hormones? There are some non- hormonal therapies that work well including: certain antidepressants (Venlafaxine, Desvenlafaxine, Escitalopram etc), Gabapentin (a nerve medication) and Oxybutynin
(for bladder over activity)
🔥 Recent findings have shown that the mechanism of vasomotor symptoms are more intricate that we thought. Low Estrogen in the brain results in increased increased Neurokinin B & Kisspeptin 💋and lowering these neuropeptides are the targets of novel therapies on the horizon.
🔥 Either way, don’t just put up with this awful symptom!

DECEMBER 10TH : IRRITABLITY

🤬 All too often, a (perfectly sane) woman walks into my office and declares ‘I’m going to kill my husband!’
🤬 Naturally, this would not be taken lightly, and I would typically suspect PERIMENOPAUSE as the culprit in this potential crime scene.
🤬Perimenopause is a time of wild hormonal swings up & down. There is no pattern of the menstrual cycle leading to chaos.
🤬 With normal (PRE - menopausal) cycles, Estrogen levels usually rise and fall gently within a reasonably predictable range throughout the month.
🤬 At the beginning of Perimenopause, hormones can start to drop more dramatically in the second half of the cycle and typical PMS symptoms present- drop in energy, libido, mood, teariness and irritability.
🤬 A more severe version of this is PMDD (pre menstrual dysphoric disorder) where women can be agitated, anxious and so low, they can even be suicidal. The onset of the period brings welcome relief to these symptoms. In my experience, new onset worsening PMS or PMDD often heralds Perimenopause is round the corner.
🤬 In the thick of Perimenopause however, it’s like having PMS or PMDD ALL the time.. and can persist for some years (~10yrs) BEFORE the last egg of menopause is thrown out.
🤬..Forget about irritability - many mild mannered women describe white hot RAGE as a common symptom, and it can be very distressing for their partners/families/work colleagues let alone themselves.
🤬 Reassurance that this will not last forever is key. Creating awareness and an understanding workplace helps enormously.
🤬 Educating our families & friends about this tumultuous time might give them a heads up about what’s going on.

🤬 Debriefing with a friend, smashing out some vigorous exercise, or doing some deep breathing exercises can calm the rage.
🤬 HRT can often help to ‘smooth out’ the ‘moans’ too. In fact, we now know Perimenopause is the best time to start for later life benefits.
(Mind you, trying to go Christmas shopping today I realised no amount of Estrogen will fix the irritability felt amongst the frantic crowds 😱)

DECEMBER 11th : HAIR LOSS

👩🏻‍🦲Luscious locks have always been synonymous with youth, beauty and health. Although we do not realise it, the hair on our head contributes enormously to our self esteem & identity. It’s expected for men, but for women, losing hair can be rather confronting.
👩🏻‍🦲Our hair follicles constantly go through a cycle of growing (Anagen), transitioning (Catagen) and resting/shedding (Telogen)
Some of the hairs on our head have been there for up to 7 years!
👩🏻‍🦲Hair loss is like many other things, multifactorial : stress- whether physiological or psychological, medications,nutritional deficiencies (e.g after weight loss surgery) and hormones all play a role.
👩🏻‍🦲Androgenic Alopecia is the most common cause related to menopause. It is genetically inherited and causes a gradual overall thinning of hair. Losing the balance of estrogen, there is increased androgenic (testosterone) activity. Interestingly, Androgenic alopecia also correlates with increased in cardiovascular disease in women over 50.
👩🏻‍🦲Telogen Effluvium is usually abrupt, where hair is shed after a significant illness (eg Covid) or deficiency- iron or thyroid etc
👩🏻‍🦲How to not end up looking like Gollum?
Good nutrition is the greatest source of the nutrients our hair needs: Iron, B12, Zinc, Vit C, and folic acid.
👩🏻‍🦲’Hair, Skin & Nails’ supplements with Biotin & Zinc might be useful too.
👩🏻‍🦲Minoxidil either topically or orally is useful but requires ongoing use for effect
👩🏻‍🦲Anti androgenic medication such as Spironolactone helps in certain cases and HRT might help too.
👩🏻‍🦲Talk to your GP or consider seeing a dermatologist who specialises in hair loss.

DECEMBER 12TH : TINNITUS

🔔 Jingle bells you say? Tinnitus is one of those ‘weird’ menopause symptoms that no one talks about (and many clinicians do not make the connection with)
🔔Typically described as ringing, it can also present as buzzing, clicking whooshing or even beeping in the ear.
🔔 As in all parts of the female body, there are estrogen receptors present in the auditory system. Although we don’t exactly know the mechanism, it is surmised that decreased estrogen levels may alter the blood flow to the inner ear and auditory pathways, as well neuroregulation in the brain and possibly even cause changes to the tiny bones in the ear themselves.
🔔 Tinnitus is reported with hormonal fluctuations around menstrual cycles, pregnancy and the menopause so hormones seem to play a role. Pre-menopausal women have better hearing than men in general, so Estrogen seems to be important in the auditory system.
🔔In the already sleep- deprived menopausal woman, tinnitus can be maddening.
🔔Other causes may be contributing: Ageing, medications (aspirin, antibiotics, antidepressants etc), teeth grinding/jaw issues, elevated blood pressure, wax impaction and excess noise exposure - to name a few.
🔔Triggers include all the fun stuff : Certain foods, caffeine, alcohol, nicotine, salt.
🔔It’s a hard one to treat, but avoiding the above triggers, white noise therapy (perhaps a nice breezy stand fan), distraction techniques, relaxation and HRT/MHT can help. Ask your audiologist. Ask your GP.
👂🏼.. and whilst we are on the topic of ears, peri/menopause is a good time to get your hearing checked! Hearing loss is subtle at first but its impact on cognition and function in later life are far reaching. It’s better to have hearing loss picked up and treated EARLY so the brain still has time to adapt🤓

DECEMBER 13TH: HEADACHES

🤕 Headaches very common in midlife and can certainly take the shine off daily functioning.
🤕There are multiple causes for headaches at this time - stress, declining vision, poor sleep, certain foods, alcohol, allergies, environmental changes.
🤕TENSION headaches are extremely common with steady pressure arising from the neck and occipital muscles and can last for days. They are not usually associated with visual disturbances & pain can be all around the head. like a tight band.
🤕MIGRAINES are a subtype of headache. They are the most debilitating in nature often characterized by throbbing pain on one side of the head, as well as sensitivity to light or sound, nausea & vomiting.
🤕Falling oestrogen levels are the trigger for the migraine in menstrual migraines.
🤕 For the same reason, hormonal flux in perimenopause causes migraines to get a whole lot worse. Given the chaos, migraines become unpredictable & intrusive.
🤕Some women get relief when the hormone flux settles in menopause… but some don’t.
🤕The majority of migraines related to hormones are usually those without aura. The kind we worry about as doctors is migraine with aura. (These have visual and/or neurological features and have a higher risk for stroke with the contraceptive pill)
🤕There is no data about the risk of stroke with the use of HRT in migraine however, particularly if Estrogen is delivered through the skin. Estrogen given this way delivers the hormone more evenly and does not cause increased risk of clots.
🤕When HRT is initiated in the migraine sufferer, it has to be started on a low dose and increased carefully so as not to trigger migraines. The right type and dose of HRT can help to ‘calm’ the rolling waves of hormones.
🤕 Simple pain relief (panadol, ibuprofen or aspirin) as well as relaxation techniques are always worth a try for simple headaches.
🤕 There are more migraine specific medications (Triptans) which can be taken at immediate onset as well as a vast number of migraine preventatives now also available.Therapeutic Botox injections have also shown promise in some women too.

DECEMBER 14TH: JOINT PAIN

🦵🏼Nothing screams ‘old age’ more so than the aches & pains which accompany menopause. It seemingly happens overnight, that women transition from feeling energetic & strong to creaky, shuffling old ladies! 👵🏻
💪🏼No doubt ageing has its role to play with the wear and tear of our joints (osteoarthritis), but the decline in muscle (sarcopenia) and bone strength (osteopenia or even osteoporosis) is steep when we lose our estrogen at menopause.
🦶🏼All sorts of aches & pains magically appear through the menopause transition without any injury or apparent trigger. Annoying niggles like Plantar Fasciitis, Shoulder/Hip bursitis or Achilles Tendonitis pop up with alarming regularity.
🫳🏼Estrogen receptors are present in the joints, ligaments, tendons and soft tissues of the body. It certainly does appear have some sort of anti- inflammatory effect to some degree.
🦵🏼Declining Testosterone can also contribute to muscle weakness or sarcopenia.
(I personally remember feeling like did not have the strength to even lift a pot of boiling water from the stove to the sink..)
💪🏼Diagnosis of muscle or joint pain can be confusing at this time, with many overlaps in symptoms. Furthermore, Fibromyalgia, Osteoarthritis and Inflammatory Arthritis (such as Rheumatoid Arthritis) are often unmasked around the time of menopause concurrently.
🦶🏼HRT (Replacing Estrogen, Progesterone and Testosterone) can help with muscle & joint aches and pains. It’s always worth a trial and if it doesn’t alleviate your symptoms, then it might be time to start looking for other diagnoses at play.
🤚🏼A diet low in refined sugars, carbs and alcohol is thought to reduce inflammation. There are also lots of emerging theories about the gut microbiome & inflammation too, so focusing on improving the ‘good bugs’ may help.
🦵🏼Exercise, exercise, exercise! It’s always the best medicine & natural pain relief. Letting go of the fear of injury is key. Building up the muscles around our joints with nice heavy weights are what the most recent studies are telling us all menopausal women need to be doing. Make it a priority 🧡

DECEMBER 15TH : CRAWLING SKIN

📌By now you would be starting to realize that :
A) Estrogen particularly, as well as Progesterone & Testosterone have receptors THROUGHOUT a woman’s body.
B) Lack of these hormones during peri/menopause therefore, can manifest as some of the weirdest symptoms in unsuspecting parts of the body (see- it’s not all about hot flushes!)
📌 Pins & Needles/Crawling Skin (parathesia) is one of those WEIRD symptoms that occur in some women at this unique time. Variations on the theme include : tingling, electric shock sensations, restless legs or even burning mouth 👅
📌 We don’t really know why these occur, but we know that Estrogen levels affect the nervous system and blood flow to the nerves themselves.
📌 As always, it’s important to make sure there are not other pathologies at play here like for example:
- B12 deficiency
- Nerve compression
- Vascular issues
- Shingles
- Neurological disorders such as Multiple Sclerosis etc
📌Always get checked out by your GP if you are concerned about unusual symptoms.
📌A colourful diet rich in macro & micronutrients is a great place to start to keep your nervous system healthy.
📌Magnesium and B12 are often lacking from our diets and so supplementation can sometimes help these symptoms
📌Acupuncture has been shown to help…(What?! A needle to stop the pins & needles???)
📌Exercise brings fresh blood flow to the nerves themselves too.
📌 Replacing those hormones often is the only thing that banishes the ‘weird symptoms of menopause.’

DECEMBER 16TH :BREATHING ISSUES

🫁 We largely take breathing for granted; it’s involuntary… but it keeps us alive!
🫁 Some studies have shown a significant decline in lung function with menopause.
🫁 Lots of things contribute : de-conditioning of muscles , more abdominal fat, bad habits creeping in 🚬 🍷etc
🫁Other studies have shown a worsening of pre- existing asthma around peri/menopause. There can be histamine flare with fluctuating hormones and losing the ‘anti- inflammatory’ Estrogen as we know has lots of flow on effects.
🫁 Progesterone actually influences the drive to breathe. The breathing drive varies throughout the menstrual cycle and high progesterone levels in early pregnancy cause the perceived ‘breathlessness’ that some women experience.
🫁 Conversely, studies have shown a possible link between low progesterone in menopause and Sleep Disordered Breathing and Obstruction Sleep Apnoea.
🫁 Sleep Apnoea (pauses in breathing/gasping or choking during sleep) is much more common around menopause. Other factors such as obesity, alcohol and floppier tissues around the airways (which are normally protected by progesterone influence) contribute.
🫁 We know Sleep Apnoea is a risk factor for high blood pressure and heart disease as well as mood disorders and dementia.
🫁 A sleep study can help determine whether specific treatment (CPAP)is needed.
🫁 Changing our lifestyle habits is ALWAYS the first port of call. Cardiovascular exercise is what our lungs crave.
🫁 Addressing allergies & nasal congestion with steroid nasal sprays helps.
🫁 Learn to BREATHE again! We all forget the good old yoga ‘belly breathing’ and need a conscious reminder throughout the day. 🧘🏽‍♂️

DECEMBER 17TH GUT PROBLEMS:

🫄🏻The Menopause Bloat- it’s a real thing! Why else would there be such a burgeoning industry of gut supplements exploding on to the market ?
🫄🏻The trillion over micro organisms in the human digestive tract play an important role in our immunity, metabolism, inflammation, mood, and cognition. It’s no surprise that the gut microbiome can be also be affected by menopause.
🫄🏻A study published in the ‘Menopause’ journal in 2021 showed how menopause actually changes the gut microbiome itself,
increasing fat deposition, lowering metabolism, and increasing insulin resistance.
🫄🏻Not only this, but the enzymes required for digestion also decline with reducing estrogen levels too.
🫄🏻This ‘dysbiosis’ and enzyme reduction leads to the familiar bloating, cramps, change in bowel habit and weight gain that is so familiar to us all 💩💨
🫄🏻The gut- brain axis is a well known phenomenon and so lower diversity of the bowel flora can also affect mood & cognition and hence are intricately linked.
🫄🏻 Experimental evidence indicates that estrogen & progesterone maintains the gut barrier and protect toxins from entering the blood stream as well as the gut itself from injury.
🫄🏻It was not widely publicized, but the original WHI study showed that HRT actually reduces the risk of bowel cancer significantly.
🫄🏻How can you make your gut happy?
- Up your plant intake - eat as many DIFFERENT types & colours of veges/legumes/roots & shoots as you can daily
- Add in some funky fermented stuff (probiotics): good plain yoghurt, kefir, Kim chi, Sauerkraut, Miso
- Pre-biotics include : slightly ripe bananas, asparagus, barley, chicory root, PHGG (partially hydrolysed guar gum)
- Cut down on sugar, synthetic sugars & refined carbs
- Avoid taking too many anti- inflammatories or antibiotics
- Exercise not only brings blood flow to the bowel and helps with intestinal movement, it helps improve the gut microbiome too

DECEMBER 18TH: FATIGUE

😩 Now, realistically, have you EVER come across a woman who is not tired? (They do exist, and they must be doing something right!)
😩 As we have discussed, a lot of women seem to be stretched at the seams leaving little time for themselves or brain space to decompress. Modern life does not prioritize rest so it’s no wonder that we are often fatigued..
😩To quote our dear friend, psychologist Kirstin Bouse : ‘I’m so tired even my tiredness is tired!’
😩 The vicious cycle of menopausal fatigue begins with declining hormones in the brain, poor sleep, anxiety & increased cortisol levels leading to reduced activities and exercise. Many women withdraw socially and retreat into themselves.
😩Fatigue associated with menopause is a special kind of exhaustion (where you want to curl up under your desk at work and have a nap). It’s both Cognitive and Physical fatigue.
😩However, many other things can contribute to fatigue which we must not ignore:
-Iron deficiency (particularly with heavy periods)
-Underactive (or over active) thyroid disorders.
-Infections: viral/bacterial disease
- Chronic allergies
- Sleep Disorders: Sleep Apnoea/Restless Legs/Narcolepsy
- Stress: Workplace/Personal
- Mental Health: Depression/Anxiety
- Underlying heart disease
- Chronic Fatigue Syndrome
😩Excess alcohol and poor diet (high in sugars) can most certainly affect energy levels too..
😩It’s always important to make sure your treating doctor rules out these things 👆🏽(We regularly marvel at what can lurk alongside menopause in our practice!)
😩 It’s amazing how HRT can power up the battery so the great lifestyle habits can flow 💪🏼
😩 Nourish yourself properly, muster up the ability to do some exercise and look at your sleep hygiene.
😩Look at what you can pare back in your life. Boundaries are so important. Full stops are a much needed BREATH - not just during this ‘holiday season.’ 🎅🏼

DECEMBER 19TH : URINARY PROBLEMS

🚺The loss of hormones through peri/menopause strikes again, throughout the delicate tissues of the vulva, urethra, bladder, vagina and pelvic floor. They lose important collagen & elastin with reduced blood flow to the area.
🚺Previously known by the miserable term ‘Vulovaginal Atrophy,’ it is now more accurately known as ‘Genitourinary Syndrome of the Menopause.’
🚺Though rarely spoken about: post menopause, more than 70% of women will suffer symptoms of GSM.. and only a fraction will receive treatment.
🚺Symptoms include : dryness, irritation & sometimes bleeding, reduced lubrication or pain during intercourse, decreased sensation, urinary frequency, urgency UTI’s and prolapse symptoms.
🚺These can occur whether or not you have given birth!
🚺Treatment is simple, effective and relatively cheap. Localized vaginal estrogens are just that, and can be used on their own or alongside systemic HRT.
🚺Women who have menopause after breast cancer CAN consider localized vaginal Estrogen as there is minimal absorption of it into the rest of the body.
🚺In Australia we have :
👉🏼Low dose Vagifem pessaries
👉🏼Ovestin ovules or pessaries
👉🏼Ovestin Cream (this is very useful for external use even without the scary applicator!)
🚺There are loads of non-hormonal vaginal moisturizers & lubricants on the market which can provide excellent relief (move over KY!)
🚺Vaginal laser is becoming more popular, but long term study results reporting safety & efficacy are still awaited.
🚺 Good bladder habits are worth practicing:
👉🏼Cutting down on caffeine/stimulants and alcohol.
👉🏼Relaxing whilst on the toilet with good posture or even a small step stool
👉🏼Avoiding constipation & straining
👉🏼Drinking water (as your body tells you -not litres & litres as the fashion mags tell us!)
👉🏼Not going to the toilet ‘just in case!’
🚺Enlisting a clever pelvic floor physio is one of the most useful and enlightening things you can do for your pelvic health.
🚺 As one of my beautiful older patients reminded me recently- ‘You HAVE to look after your Lady Garden!’🪷

DECEMBER 20TH : DEPRESSION

😞’Bah Humbug!’ we hear you say…
😞Menopausal Depression is QUITE different to clinical depression,defined as - ‘persistently low mood or loss of interest in activities which continue beyond 2 weeks’(DSMV). Mood disturbance at this time is UNIQUE, with less melancholy, and increased anger, irritability & fluctuation in severity of symptoms. It is rather reminiscent of PMS/PMDD. Hormonal depression is very common around midlife and suicide rates for women are highest between age 45-49 🖤
😞Women’s health psychiatrist Professor Jayashri Kulkarni has shown us that hormonal changes start FIRST in the brain in Perimenopause and predate changes to the menstrual cycle and hot flushes.
😞Women who have had a history of trauma or vasomotor symptoms have increased risk of depression. Those with who have had a hysterectomy with or without removal of ovaries are also at risk of depression, as are those with Premature Ovarian Failure.
😞So WHY are women still being offered anti- depressants as first line for menopausal depression ???
😞 International guidelines state that HRT should be offered as FIRST line for menopausal depression amongst the many menopause symptoms.
😞 Of course, some women who have a predisposition to clinical depression and some who have suffered the terrible misfortune of cancer choose to take antidepressants. In these cases they can work very well. Resistant cases, may need to take both.
😞It is coming to light however,that long term SSRI antidepressants may reduce bone density and so increase the risk for osteoporosis.
😞The link between hormonal depression and Perimenopause is often missed but starting HRT early can be life changing.
😞Trying to optimize overall health & wellbeing with gut & brain loving foods and pumping some endorphins into the brain with exercise is imperative.
😞CBT, Psychotherapy & even counselling can be the framework that is needed with an experienced psychologist
😞When it comes to menopausal depression, correct diagnosis, tailored treatment & specialised care can in fact, be life saving 💚

DECEMBER 21ST: VAGINAL DRYNESS.

🐫 ‘It’s as dry as the Sahara down there!’ is a common complaint we come across daily in the clinic.
🐫 Vaginal dryness is one of the most embarrassing, distressing and painful symptoms (that no one ever talks about 🤫)It’s also part of the ‘Genitourinary Syndrome of the Menopause.’
🐫Vaginal lubrication is produced by a number of mechanisms from Bartholin’s & Skene’s glands. It relies on adequate blood flow to the area and of course is hormonally driven.
🐫It’s not just about sex- it’s part of normal physiological functioning. The lubrication produced protects the genital area from injury or tearing, and keeps your vagina clean and moist.
🐫Through the menopause transition, levels of Estrogen, Progesterone & Testosterone drop in the area. Lack of estrogen particularly, causes those delicate tissues to become thin, friable and sometimes irritated. Arousal & sensation declines also ☹️
🐫The balance of the vaginal microbiome is out of kilter and more prone to discharge and infection. The vaginal pH returns to its pre- pubertal state.
🐫 As embarrassing as it might be- it’s REALLY important to have this area examined if you are concerned. Prolapse of the tissues can occur and be uncomfortable. A skin condition called ‘Lichen Sclerosus’ can be contributing to symptoms also and needs specific treatment given its small risk of transformation to vulval cancer.
🐫Vaginal Estrogens (Ovestin cream/pessary and Vagifem)are NOT HRT per se, minimal amounts are absorbed into the rest of the body. Use the cream externally as well as just inside the first 1/3 rd of the vagina. It’s safe, life changing and should be used FOREVER!
🐫Vaginal laser is becoming more popular, but it is 💰and yet to be validated in studies.
🐫Modern lubricants & moisturizers can be great additions too :(Yes, WetStuff, Pjur, Astroglide, Olive and Bee)to name a few.
🐫’Use it or lose it!’ 😉😉😉

DECEMBER 22ND: DRY EYES

👁️.. ‘and there was not a dry eye in the room!’
👁️ Estrogen, progesterone & Testosterone receptors are present throughout the eye and surrounding tissues.
👁️ It makes sense then, that eyes are affected by our hormones through age,menstrual cycles, pregnancy and of course menopause.
👁️ ‘Dry eye’ is not the feature of a callous heart 😜but is in fact one of those ‘weird symptoms of menopause’ that doctors frequently attribute to other causes. It’s darn irritating, given we sit goggled eyed in front of screens all day long 🤓
👁️ Sex hormones affect all of the complex moisture apparatus of the eye- the tear film production and lubrication from the surrounding Meibomian & Lacrimal glands.
👁️This leads to burning, itchy, gritty, red, blurry eyes which can occur in up to 60% of menopausal women.
👁️ Whilst it’s common, it’s worth considering other possible causes too: environmental, allergies, medications, autoimmune conditions etc
👁️ The jury is still out as to whether hormone replacement therapy actually improves dry eye - studies are conflicting.
👁️ Other conditions such as glaucoma are more common with menopause and weirdly eye shape can change, making contact lenses not fit as well. 👀
👁️ Treatments for dry eye involve a really good lubricant eye drop that stays around -go for the preservative free ones usually.
👁️Warm compresses, lid wipes, and reducing excess makeup can also help
👁️ Fish oil supplements can help too 🐠 🐟🐡
👁️ Severe cases might respond to punctual plugs placed by ophthalmologists, which help tears hang around for longer.
👁️Cut down on screen time. (Post over!!!)

DECEMBER 23RD : OVERWHELM

🤯 ..2 days ‘til Christmas- are you feeling the ‘overwhelm’ creeping in, or is it crashing over you, drowning you like a wave?? 🌊
🤯Overwhelm is a sensation felt particularly by women during the emotional rollercoaster that is Perimenopause.
🤯 Life has taken on such a rollicking pace for us as women since our ‘emancipation’ where we are expected to ‘do it all’ and ‘do it perfectly’. What was it Barbie said recently- ‘it’s literally impossible to be a woman!’ 💖
🤯 Stress & Anxiety are part of the human condition, appropriate for sprinting away from the pouncing tiger or necessary for us to execute certain tasks under pressure, but for many women it seems to be a constant state. Post pandemic figures state that women particularly are affected increasingly.
🤯 Wildly swinging hormones through Perimenopause can cause women to feel overwhelmed, particularly as they no longer have control of their emotions. 🤯This is when many women start to drop the many balls suspended in the air and simply feel they cannot cope.
🤯 ADHD/ADD can become apparent at this time-or, worsen if you have a pre- existing diagnosis and often presents with overwhelm.
🤯Declining Estrogen causes lower Dopamine & Serotonin in the brain which can in turn produce worsening ADHD symptoms (like concentrating, staying on task, memory, planning ahead etc)
🤯 How can you manage overwhelm?
- Lower your standards ! It is impossible to be a perfect partner/mother/colleague/friend/boss/daughter..
- Carve out time for yourself as a matter of priority - doing what soothes your brain (not wine!)
- Exercise, breathe some fresh air outdoors and escape if possible. Nature does have a proven calming effect on our brains.
- Seek out positive social interactions (not toxic ones)
- Talk to a psychologist to help re- frame your thoughts with CBT/counseling etc
- Talk to your GP - it’s important to know you have support
If you are not coping at all : tell someone, call LIFELINE 13 11 44
😌 Deep breath.. you got this!

DECEMBER 24TH: LOW LIBIDO

💋Renowned GP and sexologist, Dr Margaret Redelman OAM famously said : ‘after menopause, sex is more about RECREATION than PROCREATION.’ One might choose to fill their spare time knitting, horseriding, or….connecting deeply on a sexual level with a partner.
💋Social media & society tell us there is something wrong if we’re not doing it ALL the time or if we do it a different way. But this is not the case at all.
💋Libido or arousal, is a very delicately balanced entity.
💋 It can actually increase at times in Perimenopause with those occasional spikes of hormones 😁
💋 More often however, women report their libido as ‘zilch’ as they near menopause.
💋Many things contribute (as we have discovered in the last 23 days!) and libido does not boil down to a single hormone level. It is the unique combination of individual biopsychosocial factors.
💋All of our favourite hormones contribute, but the star of the show seems to be testosterone.
💋Testosterone can help with increasing sexual desire, specifically ’hypoactive sexual desire disorder (HSDD)’ which is low libido associated with distress. (Occurring in up to 1 in 3 women)
💋Androfeme 1% is the only TGA approved FEMALE formulated testosterone in the world, and it’s made right here in WA 😌
💋Used as a specific measure of cream this can help with lack of libido when it’s causing significant impact on a woman’s life.
💋Many women also find that testosterone helps with cognitive function, energy & sarcopenia (muscle loss) although there is no indication to prescribe it for these reasons given current lacking evidence.
💋Androfeme use needs to be closely monitored to avoid unwanted side effects (unwanted hair growth, acne, irritability etc)
💋 Stress reduction, addressing vaginal dryness or pain perhaps with a good physio, localized vaginal estrogens, good lubes and clear open communication with your partner can help..
💋Addressing lifestyle issues: Decreasing alcohol, increasing exercise and doing the things which help your own self confidence will in turn improve libido.
💋 When things are really tough a good psychologist or sex therapist can help.
💋Be brave and ask your GP! Libido is actually a big part of quality of life for many women so persist with finding support whatever your age or stage.