Peri-menopause and menopause are significant stages in a woman's life. In this first of two episodes on this subject, I speak with Dr Ghazala Aziz-Scott, Clinical Director of the Marion Gluck Clinic. As an expert in a Functional Medicine approach to HRT and Bio-Identical HRT she expertly outlines what is currently available and possible for women during this time.
If you are confused about HRT then this is an accurate and up to date explanation on the subject.
Links mentioned in this episode:
Marion Gluck Clinic
Oestrogen Matters by Avrum Bluming MD
DUTCH Test
Thanks for listening to our podcast and please feel free to get in touch:
We would love to hear from you!
Peri-menopause and menopause are significant stages in a woman's life. In this first of two episodes on this subject, I speak with Dr Ghazala Aziz-Scott, Clinical Director of the Marion Gluck Clinic. As an expert in a Functional Medicine approach to HRT and Bio-Identical HRT she expertly outlines what is currently available and possible for women during this time.
If you are confused about HRT then this is an accurate and up to date explanation on the subject.
Links mentioned in this episode:
Marion Gluck Clinic
Oestrogen Matters by Avrum Bluming MD
DUTCH Test
Thanks for listening to our podcast and please feel free to get in touch:
We would love to hear from you!
Okay. Welcome, everybody. Welcome to our new functional medicine bite size podcast. And really today is just starting the introduction, which is going to be a pretty deep dive not just today, but in later episodes, really around HRT, a really around women of that age, and really getting a deeper understanding of this whole subject, which is pretty huge, to say the least. So I'm going to introduce one of the clinicians that we work with on this side, this is Dr. Ghazala Aziz-Scott, and I'm going to give her a brief introduction before we let her give you an understanding of where she's come from, and how she has ended up being the clinical lead Medical Director for a real sort of world famous Marian Gluck clinic. And this is, as I say, a clinic that provides integrative women's health. And again, there's a big change from 10 or 15 years ago, but they're using a fully integrated functional medicine systems biology approach, with an expertise really in sort of balancing hormones, but using sort of bioidentical hormones to do that. Ghazala, morning, how are we doing?
Dr Ghazala Aziz-Scott:Good morning, lovely to be with you Pete sure. So my medical education started at Cambridge, where I did neuroscience, medical ethics and law. So I've always been sort of interested in the bigger picture. I'm very interested in science and research. And then I did clinical medicine at Oxford. I trained as a GP, and I was a GP partner in Ealing, West London for 23 years. So I've got a huge amounts of sort of conventional medical experience. But I was always interested in the mind body connection. And you know, my consultations in general practice always over ran massively, because I was always interested in the patient's narrative. Then in 2019, I thought, well, I need to do something different. I need to explore what other things I can do. So I joined, I decided to train with the Marion Gluck training academy, and I was completely intrigued by bioidentical hormones. I've seen a lot of women patients. You know, throughout the years, I've seen women you know, in my 23 year history as a general practitioner, I saw women through the whole lifecycle and you know, now they're all middle aged and menopausal, like myself. So I was thinking, oh, you know, there's going to be some things, some golden nuggets here that I could take back to my general practice, but I was actually totally amazed by this world of bioidentical hormones. We had a very inspiring teacher who was also a GP. And she said that the world of bioidentical hormones, and what she'd been able to do for our patients was one of the most rewarding parts of her career. So after that two day training, you know, I think I was very enthusiastic was always in the front row of the lecture theatre. So they said, All you seem to be really interested in this, would you like to come and meet our CEO and see whether you can come and do some work with us? So I then met up with the CEO decided to start working at the Marion Gluck clinic one day a week. And that's where my, you know, my interest in bioidentical hormones started. At the same time that year, I went to Seattle to do the introductory course in functional medicine. And that was another aha moment. Because I just, you know, a few months before being on this GP update course, where we had every single speciality known to man, and the end point for each of those specialities as to what treatment can we give people you know, when when we don't know what else to do, well there were all these powerful, you know, immune drugs and TNF blockers and stuff like that. So it was like, Well, why aren't we looking at what the root cause is? So I was already beginning to think inflammation, inflammation, then I went to, you know, the introductory course in Seattle, and I was really blown away by that whole approach. And suddenly, I felt, well I've come home, I've actually found a system of practising medicine that actually resonates with how I've tried to practice for the last 20 or 30 years. So I then, then we then had lock down. So I live streamed all of the advanced practice modules over that period of time, got trained up in functional medicine. And then I realised there was such a synergy between bioidentical hormones and the communication node of the functional medicine model and how important it was, you know, to have personalization of hormone treatments and to use hormone balancing in so many different female health conditions. So, at the Marion Gluck clinic, you know, it used to be very much perimenopause and menopause. But now we are using that functional medicine approach to integrate across lots of different women's health problems. So that's where it all began. And then, you know, what I realised as well is that, you know, we're in our functional medicine training, we're given a lot of scientific knowledge in the advanced practice module, but we don't we don't know how then to access further bioidentical hormone training and how to actually put that in practice in the UK. So I then did a guest lecture for the IFM Advanced Practice module to help delegates understand how they can get further training in bioidentical hormones and how we can then you know, access them in the UK. So what I'm really pleased to say is that in our Marion Gluck training academy two day course, which I now run at the Royal Society of medicine twice a year, we now have perinatal psychiatrists come in who are really interested in the role of hormones in mood disorders, you know, it's not just about drugging people up with SSRIs. And we're having a lot of people from the functional medicine space, who are also now learning how to use those bioidentical hormones, because it is a real field in itself. And I think you have to get quite a bit of experience in how to use them, you know, you can have the practical theoretical knowledge, but the actual practice of it does take, you know, some there's an art to it. So it takes some expertise. So then then I trained in functional medicine, I worked for really a leading functional medicine clinic for about six months, took a sabbatical from the NHS. And then I thought, right, I've got to throw myself into this wholeheartedly. So then I became the clinical leader of the Marion Gluck Clinic and brought functional medicine to the Marion Gluck clinic. And I think it's it sort of all came at an opportune time because when Marian Gluck first started bioidentical hormones, she was a pioneer in her field, and no one else was doing it. You know, we were still using synthetic hormones in the mainstream, but really in the last few years, mainstream medicine also recognises that bioidentical hormones are the gold standard. So now in the mainstream, you can get regulated bioidentical hormones, and a lot of the regulated menopause clinics, or a lot of private menopause clinics have mushrooms now. So there's a lot of people who are doing regulated bioidentical hormones, but really, we have such a unique approach because we are doing personalised bioidentical hormones. And we are integrating that into understanding how does the body then process those hormones. So we were looking at how oestrogen is metabolised and cleared, we're looking at gut health, and all of these things are so important, because you can't just view your hormones as one aspect of your health, you've got to view your hormones as a function of your entire health. So that's where, you know, I think, really, this is good, this has got to be the gold standard, you know, and I've worked in the conventional space for decades. So I've done, you know, work with women in the NHS, and now I'm doing the Marion Gluck sort of personalised work. And I really do think that, you know, we need to be collaborating, I think being in two camps is not healthy. I think we have, you know, the conventional space have so much to learn from how we do things. And unfortunately, you know, that time lag between scientific evidence and research and actually putting it into practice is about 17 years, throw in economics and the failing health system. And, you know, the fact that there aren't the resources, you know, we're we've got this real mismatch between with the patient's falling in the middle, you know, because the patient is has their needs, right, this moment in time. And, you know, I really feel that, you know, we really need to be doing our best to get the best outcomes for our patients.
Peter Williams:And isn't this the thing? I mean, this is how we met, wasn't it? Because, you know, I've been in practice 25 years, with our group. And, you know, we approached many endocrinologists. So as I look at what we do, it's a question of, we're pretty good at understanding, I like to say you're almost like the conductor of the orchestra. So you've got a really good idea of how everything needs to meet and fit together so that you play really nice music. But that doesn't mean to say that in every stage of that, there is going to be a component where you need someone else who has a specialisation and a certain specialist ear to allow you to play the music. And I can remember, as I said, when we went out for dinner we had that conversation is that you know, the reason why I hadn't come for years to come and see your group again is because we've just been let down not been let down the wrong word. But we'd gone to send some of our patients to endocrinologists who were very traditional, conventional endocrinologists doing the right job, but completely missing the bigger picture. And so we ended up in situation where quite a few of our patients just really didn't get good results, because the clinicians weren't thinking about the bigger picture. And I think that's so refreshing about how quick, certainly the endocrine space has moved from a point of view of, we can't just keep on tweaking your end stage oestrogen or progesterone without thinking about the bigger picture, because we'll just go pillar to post pillar to post every three months. And that's been the great thing about sort of, I think where not gonna say the industry, but where endocrinology has gone, particularly with women's HRT. And that, as I say, it just makes us feel very comfortable about if we send the patient over to you, you guys know what you guys have got to do. And then we can we can bash it straight back. So that's what again, I think, what has been really great for us, because that's changed massively. So I think we've sort of opened up on that. Can we just start with some fundamental basics, because most of the people who are going to listen to this will be female, of an age. And you know, as I said to you, my 51 year old wife is currently just started underneath your, on your care, because she's perimenopausal on now. And so it's, she's not going to listen to me not that I know it. And again, passing it on on that side would be great. But what are the sort of just basic things there's sort of basics about what is happening to a woman as they go through perimenopause and into menopause? And can we talk about where just the basics with regards to risks are and then if we can, can we go to the rewards of HRT, and then we can move on to how a conventional approach maybe doesn't match what a bio identical systems biology approach would? Would what would work?
Dr Ghazala Aziz-Scott:Sure. So um, so the average age of menopause in the UK is 51. So menopause is is defined as a cessation of periods for 12 months. So it's a technical diagnosis really, because we don't just fall off the cliff at the age of 51. And our periods just stop. So now, we have much more recognition of this phase before menopause, which is the peri menopausal period, and the peri menopausal period can go on for a decade. And really, I think women's hormone patterns start changing when they're in their early 40s. And the peri menopausal phase is where the cycles are changing. And specifically the luteal phase, the luteal phase is the second half of the cycle. So from day from ovulation to when the period starts in during that phase, we should have a really good level of progesterone production. And progesterone is our natural calming hormone. So when you've got a good healthy menstrual cycle with good levels of progesterone, progesterone is soothing and calming. And in general, people have, you know, a good experience of their menstrual cycle. When you've got perimenopause and you are starting to have anovulatory cycles, so you're not ovulating every month or the amount of progesterone you're producing, goes down. That's when you start getting symptoms of the perimenopause. So the classic symptoms of the perimenopause are symptoms of progesterone deficiency, which are anxiety, you know, women are saying, oh, you know, I feel really anxious when I'm driving on the motorway because I feel I'm gonna crash, you know, kind of more anxiety, overthinking about things feeling that they're not coping as well, and insomnia. So, you know, people find that their sleep pattern is really, really disrupted. They also can sometimes get physical symptoms of anxiety. So you get a lot of women who are suddenly start palpitating think they've got some chest pain, they end up in a&e, and actually they're Peri menopausal, and it's a progesterone deficiency and the number of women I saw when I was in general practice, you had a full cardiology workup when they were peri menopausal. So I think this is the thing to look out for. Now. A lot of women when they're going through that Peri menopausal phase, they're actually pretty stressed out. You know, they've got jobs, they've got teenagers, they've got you know, long term relationships. So sometimes it can be quite difficult to tweak out what what is causing my symptoms. Is it the perimenopause, or is it my life in general? And actually, there's this big overlap, and we know that when you are more stressed, and so this is where you know the beauty of the functional medicine system where we're looking at people's cortisol patterns. We're looking at how stressed people are. When people are in high stress, their experience of the perimenopause is much worse, because progesterone is really impacted by cortisol. So when our stress hormones are high, cortisol can also compete with progesterone receptors. So you might produce a level of progesterone in your second half of your cycle, but the cortisol is taking over, the cortisol is becoming dominant. So you feel very stressed and you've got less progesterone on board. So this is where the symptoms can become much worse. Also, you know, I think it's really important to think about, you know, people's previous history. So when we do a very comprehensive history, people who've had a lot of trauma, childhood stress, they also experience the perimenopause in a more heightened manner, because they have adrenal dysregulation so their adrenal glands are not functioning in an optimum way. So this is another thing that we layer into when we're when we're assessing people. So that these are the symptoms of the perimenopause. Now, in that phase, oestrogen levels can be very fluctuant. So in conventional medicine, when someone presents with any kind of perimenopause, or middle age symptoms, people are immediately put on oestrogen and progesterone as HRT, because in the conventional model, the NICE guidelines state that if a woman is over 45, do not do any blood tests. You don't do any testing, just put them straight onto HRT. Now, the progesterone bit of it is okay. But the problem is with oestrogen. So we also know now that in the perimenopause, women have different patterns of oestrogen production. So we know that in that perimenopause period, a lot of women can become very oestrogen dominant, so they have levels of oestrogen that are higher than when they were having normal menstrual cycles. Now that higher oestrogen coupled with lower progesterone is what produces the imbalance, the hormonal imbalance of a lot of Peri menopausal women. So the oestrogen dominance will present with breast tenderness, more PMS type symptoms, bloating, fluid retention, migraines. So if you then give those women, oestrogen, as well as progesterone in the conventional system, because we're not doing any testing, they're going to feel dreadful. And they're going to think, well, I don't actually tolerate HRT. So I'm going to give up on this. And it's very easy to kind of get people off piste, you know, if they've had a bad experience to get them back on the road can be quite difficult. So I think it's so important to be able to distinguish between the hormonal pattern someone's experiencing, and, you know, until the time at which they reach the menopause. So that's a technical definition, but we can have all sorts of patterns of hormonal imbalance leading up to that period of time. And I think stress plays a major factor. And that's where I think, you know, we sort of, you know, people say, Oh, well, our ancestors went through the menopause and perimenopause, and they didn't have any problems, where your average 50 year old 100 years ago, would, you know, may have died in childbirth would definitely be a grandmother would definitely be retired would definitely be doing their knitting by the fire. So they didn't have, you know, the same experience of what they were expected to do at the age of 45, or 50, compared to 100 years ago. So I think it's also, you know, we need to think about what are we expecting of the average woman these days, you know, and from an evolutionary point of view, we haven't, we can't have haven't evolved. I mean, you know, ideally, you know, menopause needs to go in proportion to the retirement age really, doesn't it? You know, it would be ideal if we could go into menopause when we retire. But you know, that's not happening.
Peter Williams:I think. I think there's a lot to unpack on that I'm gonna say one thing in a minute. I'm pretty sure your mic still a bit too high. So can we wak it down to a little bit less on your mind? Yeah. But But let's go back, and I'm gonna unpack a quite a few things. So it makes me chuckle that you get a lot of people saying, well, Palaeolithic man or woman didn't do that. And they were fine. And it's like, well, yeah, but Palaeolithic man and woman basically died before they were 40. Anyway, so, again, I suppose what we're trying to say is that, you know, this is a different world, we're living much longer, we're living much longer than we did from our ancestors. And therefore, we need a different approach. And I still find it so maybe you can answer this for me. I know we have NICE guidelines with regards to testing. Do you think that is still validated in the science or do you think that is partly because and look, don't get me wrong, there's a money saving aspect to this because you know, you can't be testing everyone all the time. And so you think it's a combination of both? Because obviously, the reality is we're trying to do population based medicine, which may be completely inappropriate for the patient, which is, of course, why they have not a great experience. So what would you say on that?
Dr Ghazala Aziz-Scott:I mean, I think testing is vital. I really do because it you know, yes, hormones are fluctuant. But you get so much information from doing a hormone profile, you know, you know, you know, what, what is it FSH and LH? Yes, it may fluctuate, but you get a pretty good idea from looking at everything in the hormonal picture, which is the hormones that come from the brain that go up when our ovarian hormones are fluctuating. We know we can get a luteal phase progesterone, so we know how much progesterone are you producing? We can get a ratio between the oestrogen and progesterone production in the luteal phase. So we can say, is this patient oestrogen dominant or not? Because we want a ratio of 10 to one in terms of oestrogen and progesterone. So, you know, if we get a an oestrogen of 1000, and a progesterone of 0.5, we know that they're way out of whack. So again, it gives us information. Also, we don't just look at oestrogen and progesterone in the functional, sort of functional endocrinology space, we also look at testosterone, we look at DHEA. We look at cortisol patterns. The other thing is that there are a lot of coexisting things that can happen in middle age. So we know that people can become more insulin resistant. We know that people can become hypothyroid. And all of those things are linked with the hormonal changes we're going through, you know, so with the perimenopause and menopause, we do become more insulin resistance. With the oestrogen dominance of perimenopause, we can become hypothyroid. So to be able to look at someone's baseline health, so our initial profile is looking at metabolic health, general health, it's looking at liver function, you know, you might give someone some hormones, but you want to make sure that they are going to be able to detoxify those hormones and we're looking at their that their hormonal patterns. So, you know, I, you know, I think the sort of guess don't test, I would say, no test don't guess it's really, really important. The other thing is, I think, you know, we, we have the privilege of our amazing functional testing, and I absolutely love the Dutch test. So I think the Dutch test gives us so much information. So, you know, for our listeners, the Dutch test stands for dry urne total comprehensive hormone analysis, and all of these hormones in our body produce, as they're processed in the body, they produce metabolites, which are then excreted in the urine. So by looking at these urinary metabolites, and also salivary metabolites, we can get a really good idea of what is the pattern of hormones in your system? How are you metabolising those hormones in your liver? How are you clearing them, we get a lot of clues to what's happening with a person's body, and also, the adrenal profile. I mean, I think looking at someone's adrenal health is so important when you are looking at someone's hormone overall Hormonal Health. The other thing that is amazing about functional endocrinology is we actually recognise the interactions between all of the hormone systems. So even a conventional endocrinologist, they see each endocrine system as sort of functioning in isolation. And I find this so hard to believe you know, that they can't they you know, that there's not this sort of understanding of those interactions. You know, we know that when cortisol is dysregulated, we know that it has an impact on thyroid stimulating hormone, we know that it has an impact on prolactin, we know that there are all of these hormonal interactions, and yet, there's still that penny missing when it comes to conventional endocrinology, where they're looking at pathology. So they're looking at, okay, what happens when your adrenal glands are not producing any cortisol? So you've got Addison's disease, or what happens when your adrenal glands producing too much cortisol and you're Cushingoid. No one looks at the imbalances and the nuances in the same way that we do in the functional medicine space. And I think that is so important. So we have got the hang of it in some things. So when you're looking at diabetes, for instance, there's you know real recognition in the conventional medicine space that diabetes as an endocrine condition is reversible. In terms of being hypothyroid, you know, it was really interesting. A lot of the people who come on the functional medicine training are people who have reversed their own Hashimotos. And when I was a conventional doctor, I would never have even known that you could actually, you know, reverse autoimmunity or not so much reverse it, but you could actually hold it in its tracks a lot more and there was so much you could do to support a patient. So I think that you know, the way we're taught conventional Medicine is very, very black and white. And we're not taught about the nuances that I think are so important. And we know that if we can help patients with their imbalances, then we can prevent disease. So what I really love about functional medicine and indeed doing bioidentical hormones is that there's a lot of prevention. And it's much harder to get people well, when they've got a disease compared to when they've got an imbalance. You know, it's much easier to get people into into a better space. I
Peter Williams:I think that the difficulty is with all of that is that we have been in a paradigm where we live in a paradigm where, if there's something wrong with us, we go to the doctors, and that's how we've been brought up. And so we don't really know anything different. And we don't tend to do anything until pathology and disease turns up. I think there's a massive change on that from, the problem with is I sometimes look at a lot, we've got to say, we've been, you know, everyone moving into this space is becoming more and more successful, because people are recognising I need to do something now to save me later on. And we can have a chat of certainly about brain health and perimenopause on that side, because we were doing quite a bit of work on that side. But I think it's, it's because you've lived in that paradigm of just going to the doctors, when when you're when you're ill, it's very difficult to recognise that on a daily basis, you need to be doing preventative. So you, you get into your 60s 70s and 80s and you live a pretty, pretty good good as minimal intervention from from medicine as possible. And that's a hard buy in. But more and more I look at this, and I see that people are buying in. Because I think I think more I don't think we're ever on here to dismiss conventional medicine, because it absolutely has its role was pathology and disease and emergency medicine, I mean, there's no doubt on that. But it's not the approach where I think the general public is generally needing with regards to, there are certain things that you have to do on a daily basis to try and keep yourself in shape. Can we go on to now obviously, there's two approaches, isn't it? And again, I think we've got to be careful on this. I mean, I mean, the great thing about about you, and your history is you've had 25 years in the NHS 30 years, 30 years. Well, there you go. So. So it's not as if you haven't spent the time in the trenches and understand people who may be listening to this can't afford, you know, to go to so much somewhere like the Marion Gluck clinic. And I think it would be great if we can get some tips of the trade on that one. But what I think you've done a really nice introduction, but what if when we're talking about the medications that would be given for HRT, what is the difference between just sort of the conventional medicines that would be given and the bioidentical hormones? And can we get into a little bit about and compounding pharmacies, because I know what a compounding pharmacy is, but probably most people don't. So if we could get into that, that'd be awesome. Sure.
Dr Ghazala Aziz-Scott:So I mean, you know, I completely agree, I think we're very privileged to have a public health system in the in the UK. You know, as I just said to you earlier, Pete, I was just in the in the states doing some training. And actually, although they have very advanced scientific research because they don't have a public medical system, menopause falls through the neck because you can't claim it on insurance. Yep. So actually, menopause care in the USA is really, really expensive. Now, thank goodness the NICE guidelines from the from 2019 onwards, have recognised that bioidentical hormone treatments are the way forward for women in the perimenopause and menopause. So, yeah, can
Peter Williams:you just explain to everyone what the NICE guidelines are? Because again, I think this is a really important for sure.
Dr Ghazala Aziz-Scott:So the nice guideline stand for the National Institute for Clinical Excellence. So the NHS work with NICE to produce protocols and guidelines that general practitioners can use to provide evidence based health care to their patients. So you know, as a general practitioner, you see millions and millions of different things. So having these nice guidelines can be incredibly helpful to help you manage your patients. So essentially, the NICE guidelines advocate bioidentical hormones. Now I'll explain to you what is a bioidentical hormone. So bioidentical hormone is a hormone that has the same chemical structure as our own natural hormones. They come from plant sterols, they come from Mexican yams and sweet potatoes. And it's really fascinating to think that you know, humans and plants evolved together. Because these products, these compounds are in the animal kingdom in the plant kingdom. And basically, these hormones are then extracted into powders, and then made into formulations. So the nice guidelines recognises that this is the best way, if you think of a bio identical hormone has the same structure, it's going to fit into a receptor site in your body in the same way as your own natural hormone. And that means that you're going to have a much better physiological response. Now, conventionally, you know, before sort of in the last decade, what was happening is that we were using synthetic hormones for HRT. So there was this massive study in 2002, it was called the Women's Health Initiative. And they use synthetic hormones for HRT, and obviously, there were some very negative side effects from that. And that gave HRT, a really bad name, and lots of women came off their HRT. And so we had a period of time for about a decade where people weren't being prescribed their HRT. But actually now, nice recognises that we need to give people bioidentical hormones. So the ones that we get in the NHS are what we call regulated bioidentical hormones. So they are made by pharmaceutical companies in standardised doses and formulations that have had controlled clinical trials done on them. So that means that, you know, pharmaceutical companies or educational bodies have taken a cohort of women, put them on this treatment, and then they've looked at the outcome measures. So they've looked at how many of these women had adverse outcomes, how many women had beneficial outcomes, they can look at what this regulated HRT did in these women. So the outcomes are really, really good. They're very, very positive for using regulated body identical bioidentical hormones. They're very good outcomes. And for most women, the benefits to their health in the long run in terms of their brain health, their heart health, their bone health, and there is a very minimum risk of breast cancer with five, five years use five to 10 years use of bioidentical hormone treatment. So the regulator treatments are really, really good. And for the majority of women, they will work well. Now there are,
Peter Williams:can I just break that down? Because again, it comes down to these studies have been done with a group of individuals, they do a population based, and then we do the classic sort of Gaussian curve, don't we? Well, we, we look at where the mean is. And the dosages are generally made up from a point of view of where the majority of the population that have been tested. But within that, you have people who don't sort of are on the outside of the curves where that dosage may be completely inappropriate for them. So it's definitely a step forward, isn't it? It's definitely a step forward,
Dr Ghazala Aziz-Scott:And at least you know, most women have moving forward. access to these, you've got to hope that your GP is trained up in understanding that, you know, there's a lot more education, they want to bring a lot more menopause education into the curriculum, because there was a big hole there. And even within, you know, even within sort of specialities, you know, gynaecologist and obstetricians are more interested in you know, operations and delivering babies, endocrinologist, as we've discussed, more interested in pathology. So, actually, menopause care does fall into the lap of the GP, but then most GPs don't absolutely have, you know, the specialist knowledge. So, there's a lot more education going on, there's a lot more awareness. You know, everyone, most women who are GPs know that they absolutely need to know about the menopause and what the NICE guidelines are, because the demand is there. So there's a lot of education going along, which is great. And as I said, for the majority of people, this is fantastic. Because, you know, these regulated body identical bioidentical hormones work quite well, but you only get oestrogen and progesterone. Testosterone is still a bit of a grey area in conventional medicine. And there are there is only one compounded preparation available for women. So testosterone don't sort of testosterone preparations for women have to be in a lower dose compared to men. So there isn't much availability of this in the NHS. So if they think a woman needs testosterone, they're giving her smaller amounts of a male preparation, which is not very scientific. So the other thing is the only real form of natural progesterone or bioidentical progesterone in the conventional space is oral Utragestan so it's an oral micronized progesterone capsule, which for the majority of women works really well. But a lot of women do not tolerate oral progesterone or they need a much lighter dose, you know, 100 milligrammes is too much for them, and they get side effects. So we don't have the flexibility to adjust doses according to the woman, and different people also metabolise hormones in different ways. So what, you know what one person may do very well on, another person may not or another person may get side effects at, you know, a similar dose. So, individualization is definitely very important,
Peter Williams:isn't this crazy thing about this? Because, you know, as I said to you, we're very experienced people in this and you recognise that, even with the best job that I may do at the beginning and the best job that you may do, it's the first fit of the wedding dress, isn't it? You know, we think we were sort of, we've done our due diligence with you, we've done the testing, and here's the first fit that the dress but, it might not be the perfect fit, and we might need to adjust all the time. Yeah. And so that recognization of, you know, to do this job, well, one consultation is never going to solve that that issue. I mean, it's crazy when you think about it. And I suppose that's more about the way certainly conventionally that just the, the structure of medicine is isn't it, it's very, very difficult to be able to give an individual, you know, that the great the great results that the they may be expecting for so little time, and and even just on the, you know, even on the wider aspect of just GPs in general, it's incredible what a GP can do in such little time and get such great results, given the timeframe, I find it quite incredible?
Dr Ghazala Aziz-Scott:Absolutely, I mean, you know, what, it's really, you know, when I first went into general practice, you know, 30 years ago, you know, we had time, we had time for patients, and also, because we bought, you know, we I was in a, you know, wonderful family practice, we had continuity of care, I saw my same patients, so, I might not be able to give them a one hour consultation at the start. But as I saw them repeatedly, I built up a real idea about that patient over a period of time. And also, you know, I knew what their life history was, because, you know, I was kind of following but, you know, as I said, you know, I followed women from, you know, when I joined there, I had children to when we all had children, we went through the trials and tribulations of parenthood, and then you know, we got to perimenopause, and menopause. So, you know, you sort of build up your own, you know, your own life experience, and your patients, you know, life experience kind of goes in parallel. So you do have a deeper understanding of your patient, you know, when we have that traditional family family practice model. Now, unfortunately, you know, general practice has just turned and, you know, after COVID, you know, there's so much more telephone consultation, the resources are limited, you know, really, and truly, the whole nature of general practice has changed, we were able to deliver much more personalised care, you know, and we're able to do the kind of the spiritual side of medicine a lot better, when we had that continuity of care, you know, and we're constantly seeing articles in the media, aren't we about the importance of continuity of care, but continuity of care just doesn't happen anymore. You know, and, you know, there's so much, you know, there were issues with resources, you know, there's that, it's very difficult to recruit GP partners, you know, the younger generation, are wanting to do more sort of portfolio careers. So you know, they're doing ad hoc sessions here and there. So you don't build up that rapport with the patient over, you know, that their lifespan, which is also so important for your own education, and what you learn about the human condition, which is also very important, as a doctor,
Peter Williams:there's no doubt on that. And again, I think, knowing the person behind the person behind the person is one of the key skill sets that you're gonna get great results with. So can we go back to again, when we talked about, didn't we, we talked about how bioidentical they're regulated, and there's only certain things that you can get, and maybe we might be missing the bigger picture with regards to testosterone, etc. Can you talk about how it works with you guys, from a point of view of the bioidenticals, but also from a point of view of how you can manipulate the dose and how you do that?
Dr Ghazala Aziz-Scott:Sure, sure. So you know, when when we're assessing someone for their hormones, we you know, we are also using that sort of functional approach where we look at the production of hormones, we look at the transport, we look at the sensitivity, so we look at you know, the risk, you know, how how, how much your body is going to receive those hormones. So, if you have not had, if you've been menopausal for a few years, or you've had hormonal balances for a number of years, your body has got used to that situation. So what happens to your receptors where the hormones will dock onto unto yourself is that they get downregulated it. So if you suddenly start someone on a really high dose of hormones, actually, they may not tolerate it very well, or they may get side effects. So what we tend to do is we tend to start with low doses, we start low, and we go slow. And we monitor a patient in terms of their symptoms, the side effects, what doses we're using. So, you know, we like to use the lowest dose possible to get the best outcome, so we're not dosing people up. So it's much more about balancing rather than sort of, you know, over medicating people with hormones. So what we tend to do, because so basically, we can with compounding, compounding a dose of hormones means that we can actually decide what dose of hormones to start you on. So, for instance, I'll just give you an example. In the conventional space, you might start someone on one pump of estradiol, which is about 0.75 of oestrogen, we would start people on maybe point 0.25 twice a day. So we start them on 0.25 see how they tolerate it, then go up to point 0.25 twice a day. So it we're able to kind of tailor the doses a lot more to the patient and start people on low doses. And then workup? There's a lot one of the major controversies about compounded medications is the progesterone question. So we do use transdermal progesterone. And at this moment in time, there isn't enough evidence, so that they're not enough trials that have been done to show that transdermal progesterone can adequately protect the lining of the womb. So when we give people oestrogen, it makes the lining of the womb get thicker, and progesterone causes the lining of the womb to get thinner. So we don't want the lining of the womb to get too too thick. So we know from our clinical practice at the clinic that transdermal progesterone is effective in endometrial protection because we're looking at each individual person, and we do a pelvic ultrasound every year to 18 months to monitor that. Now in the in the conventional space, there isn't the resource to do that. So people are put on so that licenced dose for endometrial protection is 100 milligrammes of progesterone orally. So that's what you would be given in the in the conventional space when you're menopausal. But with we will start people on, we can give oral progesterone in that way. And sometimes we mix and match, we might start them on low doses of oestrogen and then we might give them some progesterone as an oral preparation, or we might give them transdermal. The other thing that's really important to know is we can give people their medications as transdermal creams as sublingual tro Ks, so a lot of people do not absorb very well transdermally. So after a while, they may find that their symptoms are returning, and the absorption is not so good. So in the conventional space you can get you have to go straight to oral medication. Whereas what we can do is we can give people sublingual medication, where the hormones go into the circulation under the tongue, and then go directly into the bloodstream. We can also give people things like rapid dissolve tablets, we can make vaginal preparations. So we it's almost like a cookery we can, we can make formulations according to the individual needs of the patients. And also, the quality of the ingredients we're using is very, very high. So we're able to concentrate a lot, quite a lot of hormone into a very small wallet volume of quality base cream. And that is also very important because if you look at sometimes if someone's using, say three or four pumps of a conventional oestrogen gel, it's actually quite a large volume, and they're having to rub it all over their body. Now we then have the issues of disrupting the skin surface, we have the issues of whether this can transfer to other members of their family or pets. So you know, there was a there was an article that said that some women are finding that their dogs were getting nipples because there was transference of that oestrogen gel onto their animals. So we also need to think about what is the convenience of this preparation, if you're going to have to slap about four pumps of oestrogen gel onto your body every day for the next 10 years. It's quite a big undertaking. Whereas if you've got 0.3mls, which is the size of a pea, in a high quality cream that you need to use in one area of your body, you know, it's kind of like oh, actually there is quite a difference in convenience and then potential compliance as well. So I think that that's the joy of compounding is that we can actually, you know, work to what each individual might benefit from so there's an art to it, you know, there's an art to making a, you know, a good dish in the in the compounding world. But having said that we do stick to, you know, similar doses and guidelines to what we might use in conventional practice. So, you know, it's not that we diverge away, we're using those guidelines as guidelines. But we're also looking at the individual patient, and we're looking at, you know, what's going to suit that patient. Now, for instance, when you take oral progesterone, it goes straight into your stomach, and it's digested within 20 minutes. The metabolites you produce through digestion, they are very good to support your brain function. So those metabolites, they're called allopregnanolone, they essentially cross the blood brain barrier, and they have a very soothing, calming effect on the brain. So when you have women who've got very high levels of anxiety, and insomnia, very often an oral preparation might work better than a transdermal preparation. With a transdermal preparation, it will go into the fat layer under your skin, and then it will be gradually absorbed into the bloodstream. So there's also differences in how the hormone gets delivered to your body. And then there is a difference to how that hormone may be metabolised, depending on how it's taken. So we are looking at things in a much more detailed, nuanced way that really does, you know, can be very beneficial for the patient. And we then also can make compounded testosterone preparations. So we can also put women on very low doses of testosterone creams that are suitable for women, where they're not going to get any adverse side effects. And we can be very specific about the dose. The other hormone that I absolutely love is DHEA. And that's an adrenal hormone that is a precursor to the sex hormones. So very often, you know, when when women are Peri menopausal, and menopausal if they've got good level, good reserves of DHEA, they often have a bit of a reservoir to support them in that menopausal period. But if their DHEA levels are low, it's an adrenal hormone so it can be very impacted by long term stress. Then, by supplementing them with a little bit of DHEA, we get a much nicer sort of physiological balance for that patient, rather than just pumping them full of oestrogen. You know, and I think that's one of the criticisms I'd have of the conventional space is when it's not working they don't always have the tools to find out what's wrong. So what then happens, and we've seen this time and time again, in the clinic, is that people are given higher and higher and higher doses of oestrogen. We know that, you know, there's a lot more sort of endometrial stimulation, people are bleeding quite a lot through that. But it's not actually tackling the problem. Because what may be the issue is the way that hormones been delivered, whether there's adequate progesterone, opposition to that oestrogen whether testosterone is an issue, whether DHEA might help, whether their adrenals are, are unsupported. So there's a lot of things that we can look at to you know, we also look at, are they clearing those hormones from their body? Is their gut working properly? So when we're looking at when it's not working, we've got so many more tools at hand to actually quantify what's going on. And I think that is where it's very, very helpful. So at the clinic, we are seeing a lot of women who've been to the conventional space, and it hasn't worked out for them. And then we have to unravel what's gone wrong, what isn't working, and what can we do to make things better?
Peter Williams:I think it brings up a few points, doesn't it? I always you're working with the nemomic that we get taught, don't we? Which is PTSD, production of the hormone? How is it transported? What is the sensitivity the receptor sites going to be like? And then importantly, how is everything detoxified? So you're dealing with all of those aspects of, of all, all hormones, which are dancing together? And it's a question as I said to you, is this a problem of menopause or is this or is this so solely you know, you're probably working on oestrogen progesterone or just menopause or is it the way I see it? It's, it's, it's the great web of all of these hormones dancing at the same time. And what are the what is the best way to make them dance based on the way they present going through perimenopause and menopause. I think also what is clear from the way you've discussed today is that the major difference I see on this is that once you take on a patient the put into a strategy, aren't they, they you give them a strategy. And that strategy also has a timeframe to it. You know, from a point of view of here's our first fit, this is what we think and again, start low and go slow. I mean, that goes, goes with everything. And then we see symptomatically, how you're doing, going quite well, there's a timeframe that we're going to have to get together again and go, Okay, so how well are we doing? What are the numbers look like? And what's the next step? And so I think what you do in that is that you put people in there in a consistent strategy, they know they are. And they know that there'll be a timeframe where they've got it, they've got to come back and go, Okay, so how well are we doing, which I think is the major, major difference for me. I mean, that's what we see, when we see all of our patients. It's like, here's what we think is going on. Here's what we think we're going to do. And here's the timeframe, we're going to do that in and then we're going to have to check in again and see see how well we're doing. I think also you also discussed was the difference between pure evidence based medicine and evidence based practice, which I think, again, is the key thing is like, Yeah, I know, that's what the EBM is telling me. But the evidence based practice suggests that this patient definitely needs a bit more. And I think that's the major difference as I look at it. I cannot believe we're nearly an hour in on this. So so what I'm gonna do is I'm just want to just finish off because, again, I'll have to have you on again, there's so much I mean, my notes here, were, you know, what are the rewards of HRT? We haven't even gone the you know, what are the risk factors, we haven't even gone there yet. And I think we'll have to do that at a different time. Because it really needs more, it needs more nuance, more detail, so that people can go away and just sort of listen to the podcast that you know, and I really appreciate that you'll come on again and deliver this for us. But I wanted to just sort of summarise again one of the things that you were talking about, because what you talked about several things where maybe things might go wrong, but what are the risks of HRT in with women in certain groups, I noticed a few risks. And also, I think, you know, maybe we sort of brief at this now. What are the risks and I know it's an individually based approach, but what is the risk with different delivery systems of the medication but um, and I'm thinking predominantly oral against transdermal or sublingual,
Dr Ghazala Aziz-Scott:you're sure. So in terms, we know that an oral oestrogen has got a two to three fold increased risk of thromboembolism. So we know that you've got an increased risk of heart attack strokes clot, if you're using oral oestrogen we with transdermal there is no increased risk of clotting. So you can use transdermal oestrogen quite safely. So that's a major difference. So I mean, we always use transdermal oestrogen, we don't use oral, but certainly in conventional practice, if the transdermal aren't working, they will use oral, again, they're weighing up, this lady needs HRT she can actually cut transdermal isn't working. So we've got to give her oral yes, we've got to balance up the risk, you know that there is an increased risk of venous venous thromboembolism, but she needs the HRT, what we can do is, if someone's not absorbing very well, transdermal is we can go sublingually. So we're not going down the oral route totally. With absorption under your tongue, you may get a little bit of oral absorption, but the majority of is going to be is going straight into the bloodstream. So you're bypassing, you know, the digestive system where you can then you know, produce metabolites that can increase your risk of getting a clot or a stroke.
Peter Williams:And I'm assuming that obviously, what you'll be doing over your due diligence is that, you know, if it's a strong family history of strokes, you would be you would obviously be looking at that, from a point of view
Dr Ghazala Aziz-Scott:are risk factors. If you've got risk factors, if you've got if you're, you know, overweight, you've got diabetes, you've got high cholesterol, we've got high blood pressure, you'd be looking at the other risk factors, too, you know, whether you can, but you see, that's where in the conventional system, you've got a woman who has risk factors for strokes, and she can't tolerate, she can't tolerate transdermal, it's not working. What do you do, because that patients still got menopausal symptoms, you know?
Peter Williams:So this is the this is the classic risk reward picture, isn't it? Yeah. I suppose with any any medication is that, you know, you're always wanting to have more reward than risk but the reward is never without some degree of risk. And it's a question of, you know, the clinician balancing that risk out and having that conversation with the patient. Is there any I mean, so where are we with, with the risk with regards to breast cancer?
Dr Ghazala Aziz-Scott:So we know that the risk so the risk of breast cancer is one in six for a woman in the in the post menopause. was a period. So it's quite a high risk anyway. So we know that for someone who you know, hasn't got like a, you know a breast cancer gene, the risk of using bioidentical hormone replacement and there are plenty of controlled clinical trials have been done to this with when you're using transdermal oestrogen with oral micronized progesterone, there is no increased risk of breast cancer after five years or even 10 years. Now, you've got to remember that the baseline risk is one in six. But what we also say is that if you are, you know, if you've got symptoms of menopause, you're not functioning. When you take HRT, your energy levels increase, you're more able to exercise so all the other risk factors for cancer go down. So the risk factor for that you're the risk factor for getting breast cancer, if you've got obesity is far higher than if you're taking HRT. If you're drinking far higher, exercise is protective. So you know, if you if you're taking HRT you're doing a bit more exercise overall, you might be protecting yourself more. So it's very important to look at the overall risk as well and the quality of life. So, so that's where we need to balance it up. Now, obviously, if someone's got a family history of breast cancer, or they've got a gene for breast cancer, then you know, we need to look at those situations individually. So if someone's got a family history, it doesn't mean they can't take HRT, but what we can do is we can really look at the safety of HRT with a functional approach in a much, you know, in a much more detailed way. So very often, if someone's got a family history of breast cancer or endometrial cancer, I'll make sure that I do that oestrogen metabolites. So we know that some oestrogen metabolites are more toxic. So it's so it's called the Four hydroxy, estrogen metabolite that's more toxic, and women who've got breast cancer are more likely to produce the more toxic metabolite. So we can look at those risks in a more nuanced way. And we can look at, you know, what we can do to support that woman with that particular situation. So I think that can be quite reassuring, if you say, Well, look, you're actually metabolising your oestrogen really well, yeah, you know, we can we can do genomics and look at how people are clearing their oestrogen. And that can be really reassuring for that person, you can say, look, you've got good, you've got good detox pathways, you know, you're probably, you know, we can probably put you on HRT quite safely. But if we've got someone who's got really bad detox pathways, we then know, we need to support those detox pathways to make the HRT safer for our patient. So I think there are so many nuances, and a lot of it is there is an element of intuition. There's an element of art to this as well, because there aren't controlled clinical trials about every single situation that we're presented with. So we have to go back to basics, we have to be scientifically informed. This is where, you know, having a good understanding of the science behind hormones is really, really important. And we have to obviously follow guidelines. But you know, we need to look at each individual patient as well. I mean, there's a very good book called oestrogen matters by Dr. Averin blooming, and he's an oncologist based in the USA, and he gives the evidence for and against the use of HRT does it increase your risk of breast cancer. And so that's a really interesting book for people to read, if they're interested in find out and with anything in medicine, there are always going to be studies that support and there are studies that are going to dispute things, because, again, the human body is not a machine. And so it's gonna, there's gonna be so much individual variation. And to actually make a study that's totally going to cover every single aspect of our body is difficult. And when you look at the biases that occur when people are doing these studies, you know, also it's quite hard to know, what's the truth and what's not the truth? You know, and let you know. So Averin Blooming has a statistician who also works with him on the book, because he has an oncologist can't understand the detailed statistics behind the, you know, the data that's producing these trials. So you know, you can make anything fit, if you want to. So it's, it's about how do we make sure the information we're presented with is unbiased and true.
Peter Williams:But I think it's also a question of how do we take a full systems approach with regards to HRT, and as I said to you, if there is someone with more slightly more risk factors, what are they contributing to increasing those risk factors, by the way, they're currently living their life and again, that's where you can say Okay, well there's slightly more risk here, but you are overweight, your diet's poor, there's lack of fibre, you're not exercising, you're not sleeping, you're drinking a load. If we got rid of all of those or made some changes to them, we're probably really significantly probably reducing your risk. Exactly. And that's where the confidence is. But I think the confidence is it's a little bit like you were saying about looking at the oestrogen metabolites. You know, if you're at the capacity to test occasionally and have a look at that, you're getting a really good indication about how the how the oestrogen is are being metabolised? And how toxic are the metabolites? Are some really good? Or some not so good? And how do we change that dietary wise is that, you know, we've been in the Crucifer range to try and help that or is there additional supplementation that can help? And that's the beauty, I think of what certainly you guys are doing with regards to I suppose, we're calling it functional, endo endocrinology these days?
Dr Ghazala Aziz-Scott:Yeah, absolutely. Absolutely. And also working in a multidisciplinary team. So you know, I can see a client in my, you know, for functional medicine, I'll do a 75 minute consultation for BHRT, 45 minutes to an hour. And I can do a lot of analysis. But then very often, that patient needs to have their hand held, as they are walking, as they are making those changes and being supported through those, those lifestyle changes. So I work very, very closely with nutritional therapists as well, because they can then provide that ongoing support for a few months that can make the world of difference to patients. And that's where Yeah, I, you know, working in that multidisciplinary team, I mean, I'm, I never knew what a nutritional therapist did, until I started doing functional medicine, and I'm quite blown away by, you know, their knowledge and their expertise. You know, it's amazing, it's not like, you know, conventional dietician, they, they have a, you know, they have to train for three years do a degree, their training is amazing, and what what they're able to do in terms of supporting a patient's general health and their, their pathway back to wellness is, is amazing. So, you know, I do also believe in working in a team. We know, with nutritional therapists, health coaches, you know,and conventional doctors. Yeah, totally, totally, because I'm a conventional GP, GP trained, you know, I will see a patient and I'll say, no, but we need to refer you to this specialist, because we need to check this out. And I will work with their specialist. You know, and a lot of specialists are now beginning to get more interested in the, in the, in the functional space, you know, there's now professors of sort of neuro-gastroenterology. So like, they're finally beginning to recognise the link between, you know, the nervous system and gut health. So, yeah, so I think, you know, we're moving in the right direction, for sure. You know, and hopefully, I, you know, really, really hope that in even in conventional medical training, you know, the system's approach is going to be taught because, you know, having been in the system for decades, I just think it's a no brainer, the system's approach is the most akin to the human body approach that we can get. And, you know, actually, you know, we look at traditional systems medicine, like Aryurveda, TCM, you know, they all looked at the whole body and as a form of systems, didn't they really, and those traditional approaches work for lots of people. And, you know, there was that element of the healing, you know, where, when that when the practitioner is really invested in helping their patient get better. Now that energy is transmitted into the consultation, and all of those things make a huge difference, you know, because people feel validated and they feel heard, and that automatically makes them feel better. No
Peter Williams:No doubt, you're gonna get better results with patients who feel as though they've been heard and are ready to make the steps but then have some degree of hand holding as you go down the steps. Ghazala listen I really, really appreciate. I mean, I think if it's okay with you, we'll arrange for you to come on pretty quickly. Because again, if you can, if you can find some space, because there was so much that we go into, again, talk a little bit more about risk reward, particularly rewards, but then getting to stuff like you know, brain health and certainly that change, perimenopause, menopause, with brain health. I mean, that's obviously something that we've already worked with on a on a patient already, and, and linking with that, but listen, it's just just, there's so much gold dust here, that I think if we can squeeze as much as possible out of you, that would be awesome. So no,
Dr Ghazala Aziz-Scott:I'm really, I'm really happy to share the knowledge. You know, and it's great to be working with you, Pete, you know, because there is such an overlap between these 2 fields. So, you know, I'm really happy to get the knowledge out there. So you know, people can be empowered to try and find the best solution for themselves.
Peter Williams:Yeah, and there's definitely a solution for them. That's the thing. It's not like you're gonna get left alone yep you know what you might have to invest a little bit into it but it's definitely there
Dr Ghazala Aziz-Scott:yeah, absolutely
Peter Williams:all right thank you so much welcome I look forward to having you on very quickly hopefully if you can find some time for us
Dr Ghazala Aziz-Scott:definitely