Ep 54: Menopause in the rheumatology clinic

In this must listen to podcast, Dr Stephanie Gall talks with Dr Zoe McLaren & Dr Mel Sloan about all things menopause. Ranging from of a review of the physiology to how we correctly attribute symptoms related to menopause or underlying rheumatic diseases or both! 

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Transcript

You're listening to the Talking Rheumatology Spotlight podcast brought to you by the British Society for Rheumatology.  Hello and welcome to this Talking Rheumatology Spotlight podcast on menopause and rheumatic diseases. I'm Stephanie Gall, a rheumatology registrar in Merseyside, and I'm joined today by two guests who both have a professional and personal experience of menopause. I'm joined by Dr Zoe McLaren, a consultant rheumatologist with a specialist interest in lupus and is Associate Medical Director in Liverpool. She was one of the leads for the upcoming BSR reproductive health guidelines. I'm also joined by Dr Mel Sloan, who is head of Long Term Conditions Research Group at the Department of Public Health at Cambridge University and the University of East Anglia School of Medicine and lead of the Menopause Matters Research Group. Welcome and thank you both for being here. 

Hi, Steph. Thank you. Thank you for inviting us. Thank you.  So, I wondered if we could start with you, Zoe, and if we could start with the definition of menopause and perimenopause. 

OK, great. So it's good to start with some definitions because I don't think we've been taught this or talked about it much since med school.  So, menopause is a retrospective clinical definition that marks the end of reproductive life for a woman.  It's 12 chronological months without a period that is not explained by other physiological or pathological explanations, and it's caused by ovarian hormones declining and the cessation and the release of eggs.  And the average age of menopause in the UK is 51. About 10 % of women can have an early menopause. So that's defined as menopause below the age of 45. And 1 % can have premature ovarian insufficiency, which is below 40. Perimenopause is that long hormonal transition that leads up to menopause. And it is long, can be up to 10 years for many.  And that's influenced by various factors, including socioeconomic status, ethnicity, smoking, BMI, but also disease and treatment. And hormones don't decline smoothly, they fluctuate.  So, the perimenopause is a bit of a hormonal roller coaster.  It's important also to recognise that women still may be having periods during that perimenopause period and they aren't all an ovulatory, so they can still get pregnant.  

Okay, I didn't realise that it could last up to 10 years. I didn't realise it could last that long. Would you be able to chat about the signs and the symptoms if that's okay? 

Yeah, so perhaps the first thing is to start with what's happening with the hormones in the menopause. So, in early perimenopause, our oestrogen levels are beginning to fluctuate really wildly, and you get surges and crashing of that oestrogen, often even from hour to hour.  And the peaks can be higher than in the normal menstrual cycle and the troughs can be very low. And that fluctuation drives symptoms like breast tenderness, migraines, heavier or erratic periods, emotional lability, and the hot flushes.  Then later in late perimenopause, the oestrogen becomes more consistently lower overall, but it's still fluctuating. Patients often describe feeling wired but tired. They'll have joint pain, sleep disturbance, brain fog, and that's all influenced by the falling and unstable oestrogen. In the postmenopausal, oestrogen levels just fall to very low stable levels, around five to 10 % of reproductive levels. No more surges, but symptoms can persist due to the absence of oestrogen rather than those fluctuations. And then we have progesterone. So, in early perimenopause, progesterone is usually that first hormone to decline. And that's caused by increasing numbers of an ovulatory cycles, so cycles without an egg being released, and our ovulation becomes unreliable. And that low progesterone contributes to feeling anxious, sleep disturbance, PMS-type symptoms, heavier periods. And then as you move into late perimenopause, progesterone becomes consistently low or  absent  due to the lack of ovulation. And in postmenopausal, progesterone levels are very low as ovulation stopped entirely. The bits we measure in the blood aren't just and oestrogen, also look at FSH. So FSH is released from the pituitary in response to that ovarian feedback. And in early perimenopause, FSH begins to rise intermittently, reflecting impaired ovarian feedback. And it's not reliable for diagnosis because of that.  In late perimenopause, FSH becomes consistently elevated as the ovary starts to fail to respond to stimulation.  And often is over 30 international units per litre, but NICE rightly avoids using blood tests for diagnosing women if they're over 45 and post menopause FSH is going to remain persistently high. Luteinizing hormone throughout perimenopause LH fluctuates. It's less dramatic than FSH, but the surges become less effective because the ovaries begin to decline in their reserve and post menopause luteinizing hormone levels rise but plateau at a moderately elevated level. And the other bit that's important is testosterone. So testosterone will decline gradually as we age, but it's not specifically at the menopause. But because oestrogen drops sharply, that oestrogen testosterone ratio changes.  And so women may notice decreased libido, reduced strength and power, and sometimes symptoms of androgen excess.  So skin and hair early on due to that relative imbalance.  it's the rising and falls, the fluctuations in hormones, but also their relative balance to each other that gives rise to the symptoms of the menopause.  So early menopause, we've got hormonal chaos high, low, oestrogen swings, erratic progesterone, intermittent anovulation and variable cycles.  Late perimenopause, we're starting to get hormonal failure.  Oestrogen’s low, inconsistent, progesterone almost absent, and FSH and LH is constantly high, with periods becoming increasingly widely spaced.  And then post menopause, hormones are stable but low. So, oestrogen’s low, progesterone's low, FSH, LH is high, and the symptoms can persist, but the roller coaster stops. About 80 % of women are going to experience symptoms and around 20 % of them will have symptoms that are severe enough to impact on their day-to-day life.  And because those hormones act across multiple systems, the symptoms are incredibly broad.  So vasomotor symptoms like hot flushes, night sweats, but equally common are things like sleep disturbance, cognitive changes, brain fog, mood changes, musculoskeletal pain,  enthesitis, fatigue, vaginal and urinary symptoms, itching, dryness,  altered menstrual cycle, increased menorrhagia, dysmenorrhea. premenstrual dysphoria, palpitations, migraines, acne, changes in the beta. It's a bit like adolescence in terms of impacts and changes in the body. Nice to make it clear that menopause and transition to perimenopause phase, it's a clinical diagnosis in most cases. So, we don't need blood tests to diagnose.  And in fact, they can be really misleading in the perimenopause. So women can be told your blood tests don't show that you're in perimenopause, but actually it’s a clinical diagnosis. A little bit to remember for our cohorts is we see surgical and chemically induced menopause in our rheumatology population and that tends to be really very much more abrupt and often much more symptomatic. 

So Zoe, what does this look like in practice in our rheumatology patients? 

So in our clinics it can be a real diagnostic challenge and we do need to acknowledge that and not oversimplify because there's still quite a lot we don't know.  But in the general population, more than 40 to 60 % of women will experience musculoskeletal pain during the menopause transition. And for about a fifth, it's the primary symptom. And that's often diffuse, fluctuating, and quite hard to characterize. So for us in rheumatology, there's two big issues. So first is symptom overlap. So menopause can mimic early inflammatory arthritis, connective tissue disease, chagrin, fibromyalgia. or flare of established disease. And we'll often see women presenting with new arthralgia, morning stiffness, tendon pain, fatigue, cognitive dysfunction, poor sleep, which we can find difficult to diagnose or satisfactorily explain unless we think about that massive hormonal transition that's going on for that woman at that time of life.  And second, midlife is a time when a lot of our autoimmune diseases often will emerge. So in particular, thinking about rheumatoid arthritis, Sjögren's. So the hormonal transition and disease intersect. oh and the challenge is attributing symptoms correctly. Is it hormonal, inflammatory, both or neither? And a phrase I hear a lot in patients is, I just don't feel like myself. And that combination of fatigue, cognitive change and pain is very characteristic of perimenopause.  In the rheumatology population, things get even more complex. So symptoms like fatigue, joint pain, stiffness, poor sleep, cognitive dysfunction, those really heavily overlap with autoimmune disease flares.  And for new referrals, perimenopause can mimic that early inflammatory arthritis, connective tissue disease, chronic pain syndrome, and particularly fibromyalgia. When I think about fibromyalgia patients and the overlap in those symptoms, there's a huge overlap. The Venn diagram is almost on top of each other. So for patients already in neuro-care, menopause symptoms can look like increased disease activity and that risk of misattribution, assuming everything is menopause or assuming everything is a traumatic disease, can lead to delay in appropriate treatment either way. And sometimes we don't know and it's important to... to acknowledge that  and to work with our patients  so that we try and methodically go through the symptoms  and try things and look at the evidence and work with our patients,  listening to them about whether they think it is a flare or whether they think it could be to do with hormones and just acknowledging what we don't know. I think that's important.  

Well, that's really interesting about it being uh mainly a clinical diagnosis.  I think that that leads quite nicely onto some of Mel's research.  You've done a lot of research on attribution and misattribution of symptoms now.  I wondered what are some of the difficulties, especially with the overlap between autoimmunity and hormonal? 

Yeah, thanks, Stephanie. So with all the systemic rheumatic diseases, but especially those that are multi-system like lupus, we all know it can be very difficult to correctly attribute symptoms. So say someone has depression, is that from living with a difficult disease? Is it from the medications?  or as our research shows, is it sometimes from the direct effects of these diseases on the brain which isn't often considered so much. Now add in hormones or lack of hormones in menopause and that's another possible cause to add into all of this attributional confusion. So what we're finding in another related study is that women with rheumatological diseases are significantly more likely than men to report being misdiagnosed with mental health or psychosomatic conditions. for their autoimmune disease symptoms. So for example, autoimmune disease symptoms were reported to have been misdiagnosed as psychosomatic in 34 % of females compared  to 22 % of males. That's a real significant difference.  And what have people said in the interviews? Yeah, so when we're interviewing these women, they're often telling us that they feel that their gender and their hormones are often blamed for physical and mental health symptoms throughout their whole lives.  But the other side of the coin is that hormones and menopause are often not even considered or discussed as impacting health of these patients and their disease for all our rheumatology patients. So it's a difficult mixture of sometimes over attributing symptoms to being a woman and their hormones, and on other occasions, under attributing symptoms and not even considering the hormonal changes when we're making those decisions. 

Yeah, I wondered if you could tell me about the Menopause Matters research project and what were some of your findings? 

Yes, we've got such a lovely research team  for this project of rheumatologists, including Zoe here, patients who are really important parts of all our research teams and treated as equal members, academics, psychiatrists, and we're doing an in-depth exploration of various aspects of hormones and menopause in particular in women with systemic rheumatic diseases. So we started with an international survey where we got over 3000 women responding. We asked many questions. It was a long survey as many of us are about what they felt about their menopausal transition care, their symptoms and really importantly any views and effects of HRT if they tried it. And we also surveyed over 300 clinicians.  We’re contributing to the work at this stage. So Cara, our amazing researcher who's coordinating the project, she's still interviewing currently. But one of our important early findings is that menopause care in this group is currently seen as reactive rather than proactive. So people are having to actively ask for support and treatment, which can obviously increase inequalities. And from the clinician side, many of them are very motivated to improve care and do their best, but they feel very under confident, particularly with the safety concerns of prescribing HRT. 

OK, it kind of shows that we need to be more proactive with this. And I think actually that that follows nicely on to discuss what is  hormone replacement therapy? 

So this is a really important area for us as rheumatologists. And there's a lot of confusion among clinicians and patients about modern HRT.  Much of the safety concerns come from studies from about 20 years ago where women were given oral conjugated equine oestrogen and older synthetic progestogens.  I'm not suggesting that rheumatologists should be routinely prescribing this, but we do need to be informed and keep up to date so that we can help  our patients make decisions.  So we now talk increasingly about menopause hormone therapy  because it's hormone replacement in its truest sense.  In perimenopause, we're using this to smooth the roller coaster and in menopause and post menopause to replace what's lacking.  As well as benefits with respect to smoothing symptoms and helping quality of life, we're maintaining function. But we also know that systemic HRT helps maintain bone strength. So protecting against osteoporosis and fractures by restoring oestrogen levels, which is especially important for early menopause when periods stop before 45, but also in our patient cohorts who have higher risk of osteoporosis because of their inflammatory rheumatic diseases.  But also maintaining muscle strength, preventing frailty and in the right patients potentially supporting cardiovascular health, although that's slightly more controversial.  So modern HRT is usually transdermal estradiol, so patches, sprays or gel. And that carries a much lower safety risk profile than the older oral oestrogen.  containing pills.  Women with a uterus also need progesterone to protect the endometrium. And ideally now that's going to be micronized progesterone or a mirena IUD or equivalent to protect the endometrium from being overly thickened by oestrogen.  In perimenopause, we also need to think about contraception, which will guide some of the decisions about what HRT is right for the woman. Then in addition, there's topical oestrogen. So it's important that we highlight that's different. So topical oestrogen, vulvovaginal oestrogen, is different to transdermal systemic oestrogen.  So here we're talking about topical vulva vaginal oestrogen, topical creams, vaginal tablets, pessaries, rings.  This has low systemic absorption and it's safe for almost everyone.  It doesn't increase systemic hormone levels and blood oestrogen levels are going to remain in the normal postmenopausal range.  They don't require progesterone projection because it doesn't stimulate the endometrium. And this is a low-risk type intervention that It doesn't help systemic symptoms, but really helps the genitourinary syndrome of menopause, which is quite relevant, particularly in our Sjögren's patients.  And that reduces the risk of recurrent UTIs by restoring mucosal immunity, vaginal pH normalization, and it improves bladder symptoms, and sexual function. So the majority of post-menopausal women on a systemic HRT will still have the genitourinary symptoms of menopause unless that element is treated topically. And then also there's testosterone and that can help libido and energy in some women, though it reminds unlicensed for that indication, it's increasingly seen.  There are side effects from HRT, which we should talk about side effects that are relevant to all patients. So things like breast tenderness, unscheduled bleeding, headaches, and different individuals will absorb products differently. So patches can fall off and irritate the skin. There's a lot of trial and error with this.  So trying different products to find the right thing for the woman. And that's something we can help support our patients with navigating that with whoever it is that's providing the HRT.  In terms of safety risk from HRT, so systemic HRT by which I mean the patches, the pills, not the topical, and that's progesterone replacement. The risk of strokes, one thing we talk about, so that's a very small absolute risk under the age of 60.  Oral oestrogen increases that slightly, but transdermal does not so blood clots or leucine increases the risk, but transdermal is much safer.  Coronary disease, menopause increases cardiometabolic risk, which is already elevated in many of our autoimmune disease patients. And that risk is not increased if the HRT started before the age of 60 or within 10 years of menopause.  Endometrial cancer risk depends on adequate progesterone coverage, but with correct regime, the risk stays low. And then the other thing we worry about is breast cancer. Oestrogen-only therapy has little or no increased risk of breast cancer and combination therapy carries a small duration-dependent risk in the case of the more modern progesterone used,  the micronized progesterone that's body identical. And lifestyle factors are often m considered to outweigh HRT risks.  So in menopause clinic, this is discussed and framed in terms of reducing risk by attenuating things like smoking, exercise, alcohol. For women who've had cancer in general, the only type of cancer where HRT is not advised is where it's oestrogen-dependent cancer. But that information should come from the clinician treating or following the patient for cancer, because even in the case of non-oestrogen-dependent breast cancer, HRT can be used for most women,  and  topical vaginal oestrogen is okay. So that needs to come from the cancer teams, and we need to help support women in making those decisions.  It's not a flat no, and I think we've got to be careful in our messaging, because if we say no as a consultant rheumatologist about something based on fairly out of date 20 years ago research, then we're putting the doors down for that patient and they get different messages depending on who they speak to. It's important that we're clear and we understand. I can talk about risks specific for rheumatology patients as well. So don't know if you want me to go to that was really useful. It's useful to know from our point of view things that we need to think about and talk about.  And yeah, you mentioned some of the benefits, especially for Sjogren's patients. m It'd be useful to discuss the benefits and the risks in our patient populations. So this is really, again, an important area. And I think something that we as rheumatologists need to get used to talking about. So for RA in particular, HRT can improve pain, sleep, and overall symptom load.  During perimenopause, might even improve remission rates when used alongside DMARDs and some evidence to suggest that. We know that treating menopause symptoms improves pain, perception, sleep and function, but it's not a cure for joint inflammation.  We do worry about lupus. So  historical concerns were based largely on the older formations in lupus and evidence from the Selina trials  and more recent analysis suggests that transdermal preparations can often be used safety, but it's with careful risk assessment.  So thinking about the right timing for patients and their overall disease control and working with the patient.  and move through symptoms which we can talk about.  with APS, with antiphospholipid syndrome or high thrombosis risk, we're going to avoid systemic oral HRT but vaginal oestrogen is universally safe and then it's individualized decisions on the modern regimes of systemic HRT so the patches  and coils and pills. So depends on other risk factors and profile and the use of anti-calculation is going to be important. It's not a flat no.   There's a useful patient information leaflet from Thrombosis UK on this subject, but it's again about individualized risk assessment and decision making. And that might include consideration of what our haematology colleagues think and navigating this for that patient. But again, not just saying flatly no to somebody because we don't know.  In Sjögren's, we know that HRT won't reverse the glandular pathology, but it can really help systemic and MSK symptoms. In OA, oestrogen seems to be protective to cartilage, so there's some data showing that HRT users have greater cartilage volume. So as with everything, it comes down to that individual risk and benefit assessment, shared decision making, but for most women with rheumatic diseases, we can use HRT, HRT safely,  and it's going to be of positive benefit. There are some caveats around lupus and APLS but it's lower risk than pregnancy or combined contraception and we can stop the HRT as well. So if you find you're getting increased flares or it's not suiting somebody, can we can navigate that. 

Yeah, that's that's really useful to know. It's really useful to know for these patients that it's not a flat no as maybe we've been previously told um and where to find out some information in the thrombosis UK.  And Mel, I'm wondering what have your patients said about the effects of HRT in your study?  

A big caveat to specify first that our data is currently retrospective, so it's from studies,  from the surveys and self-report. So there's a significant limitation that people are going to be remembering, sometimes decades ago, what they felt the effect of the HRT was. So there's obviously going to be some recall bias there. But early findings are very reassuring in that the majority reported no effect on their rheumatic disease activity and some diseases actually had a significant percentage that reported improved disease activity from HRT as Zoe was saying, particularly in the Sjogren's community and also in rheumatoid arthritis, we had about 30 % in each of those disease groups who said actually HRT made my disease better, not just my quality of life. Again, as Zoe was saying, there were some studies around 20 years ago which used the older style HRT and found that HRT increased lupus flares. which then led to a lot of reticence in rheumatologists in then recommending that for their lupus patients. But obviously we have newer style now. um We did actually have more lupus and APS patients than those with other diseases in our study who reported the most adverse effects on their disease activity.  So it was about a quarter of lupus patients that it did worsen their disease, which we obviously need to be very aware of.  But this was still a minority and the vast majority felt that HRT improved their quality of life and was of benefit to their overall health. So, for example, 88 % of PMR patients said it improved their lives overall.  But obviously we need to do a proper randomized control trial to test for effects on disease activity and safety. 

Absolutely. And as Zoe mentioned earlier, it's individualized. And like she said that if patients are getting side effects and getting relapses, HRT can always  be stopped. I know Zoe, you've mentioned about sort of the long-term benefits of m HRT, but I wondered if we could chat about what the long-term health consequences of the menopause if left untreated. 

Yeah, it's a really good question. So, oestrogen testosterone decline, and that accelerates biological aging across multiple systems. So bone, muscle, cardiovascular, metabolic, even cognitive and brain health. And that's particularly important in women with early menopause or ovarian insufficiency who carry higher risks of osteoporosis, cardiovascular disease and chronic pain. So for rheumatology patients who've already have that elevated risk in some of these domains, the impact is additive.  And in rheumatology, we're already thinking about osteoporosis, cardiovascular disease, but menopause adds an extra layer of risk, especially for women with early or surgical menopause. And for many of our diseases, the long-term impact can be seen when we measure damage indices and disability.   So it's important we don't just treat symptoms but also recognise that long-term health trajectory for our patients and consider our messaging around lifestyle, because HRT we've talked about a lot, but it's not the only intervention.  So there's really strong evidence for exercise, physical activity is one of the most effective non-hormonal interventions for managing uh menopause transition.  And the benefits include reduced vasomotor symptoms, so those hot flushes, night sweats, improved sleep quality, reduced anxiety and depressive symptoms. improvements in joint pain, stiffness, muscle strength, reduced cardiovascular metabolic risk and maintenance of bone maths. And the best forms for that really is going to be strength training, which is crucial for bone and metabolic health, but also yoga and Pilates have evidence for sleep anxiety, strength impact, and then impact exercising. So if bone health allows things like jogging, stair walking, jumping can all be helpful.  Diet and nutrition is also really important. So for symptoms and long-term health, the Mediterranean style diet is shown to reduce cardiovascular risk and improve metabolic health. But we also need to be sure that women are taking adequate protein. So one to 1.2 grams per kilogram per day for preserving muscle mass and also making sure we're having plenty of fruit and veg eating across the rainbow, making sure we're having a really varied diet with healthy fats and whole grains. For bone health, need to ensure adequate calcium and vitamin D intake, particularly in the UK in the winter months, but for lupus patients all year round, we avoid light exposure in lupus patients because of risk of flare. And then to reduce menopausal symptoms, consideration of things like reducing alcohol, because that worsens hot flushes and has an impact on sleep, reducing caffeine, because that triggers palpitations and flushes, and lowering the intake of refined sugar. which can help support with weight management, mood, energy. There's also evidence of things like cognitive behavioural therapy. That's one of the most evidence-based non-hormonal treatments and can help with hot flushes, night sweats, anxiety, insomnia, and distress related to symptoms. NICE explicitly recommends cognitive behavioural therapy for vasomotor symptoms, particularly when HRT is unsuitable. And then sleep interventions, so simple things like the cooling of a bedroom environment, regular sleep, wake schedule, avoiding caffeine mid-afternoon avoiding heavy meals, alcohol late in the evening, mindfulness, resistance exercise, all of which helps sleep quality and improves that significantly. Insomnia often improves when the night sweats are controlled. So HRT can help with that, but the lifestyle changes still have an impact. And then thinking about weight management, mind-body interventions, smoking cessation. Smoking is associated with an earlier menopause, worse phasor motor symptoms, low bone density, increased cardiovascular. So that holistic assessment is really important.  Also thinking about pelvic floor health, vaginal health  in the round. not just the topical HRT, but thinking about vaginal moisturisers, lubricants for intercourse,  pelvic floor physiotherapy, good hydration, avoiding fragrance products, et cetera. So there's just lots of things to think about. And you can see here a really strong role for our wider rheumatology MDT in supporting our patients through this. 

Yeah, absolutely. Absolutely. As doctors, sometimes we tend to think about just the medicines, but actually the lifestyle advice and the holistic approach is really, important.  Mel, I wonder if you could chat about what some of the short-term consequences of the menopause is. 

Yes, thank you, Stephanie. was just thinking listening to Zoe there.  One of the things I hadn't really thought about talking about today was when she was saying about calling the bedroom. Now I'm experiencing menopause myself and my husband and I cannot sleep in the same bedroom anymore because I've had to buy an air conditioning unit that's directly focusing on  keeping me cool. So obviously the impact on relationships is one of them.  But from speaking to our patients, there's two major repercussions.  The first is obviously that people Some people have an incredibly debilitating menopausal transition, physical, mental health, cognitive symptoms, all the symptoms Zoe's talked about, the increased joint pain, fatigue, dryness, UTIs, anxiety, irritation, so many possible symptoms as we know. And many of our patients currently aren't being offered treatment and support for this. So they're having to cope with these additional symptoms on top of already very debilitating autoimmune disease. The other, perhaps more hidden consequence that we're finding is that it can further reduce trust in their clinicians and healthcare in general. So they try and get support and as often happens with these patients with multi-system symptoms and often multiple clinicians is that each of the clinicians says, oh well that part of you isn't really my problem. So the rheumatologist will say, talk to your GP. They should be the ones prescribing HRT.  And the GP will say, oh, you're too complicated and scary for me to deal with your hormones. Your rheumatologist will need to sort this out. And the patient gets passed around. We call them ping pong ball patients. And this can really reduce trust long-term if patients feel that no one wants to help, even though the clinicians do want to help that patient, they don't just feel that they've got the confidence themselves. 

Yeah. And this shows why we really need to be thinking about this as well. Zoe, oh I wondered, would you be able to tell us about the upcoming BSR reproductive health guidelines? 

Sure the reproductive health guidelines are going to take a live course approach. So we’re talking today about menopause transition,  but the reproductive health guidelines are going to take all of thinking about all of our  female rheumatology patients  from  paediatrics through  to end of life. and thinking about how female hormones impact on  the care of  women transitioning through the entirety of their life with their diagnoses.  So we're going to look to provide support around adolescence, support around menstruation and periods where there is evidence that we can use and how that impacts on rheumatological diseases.  Thinking a lot about pregnancy planning, about supporting women through pregnancy and breastfeeding.  And then also thinking about perimenopause, menopause transition, and then the longer-term impacts of that. So it's a completely new guideline. We're just at the point of starting to m think about going out for assembling our team, which is going to need to be multi-professional and also have very strong patient voices because we're hearing from the work from Mel that that's something that  unless we have  that patient experience as part of  the guideline development. going to miss because actually there's quite a lot of gaps in data and research and I think there's an enormous wealth of further research that needs to be done this but this will be a starting point and hopefully will be a practical guide to allow us to start thinking about this and how we address these issues within our rheumatology services throughout the UK. 

Oh absolutely that sounds great it's really useful that it's the whole life course as well. Mel, I wondered, would you be able to tell us what the next steps for the menopause matters research team are? 

Yes, thank you, Stephanie. And so similar to Zoe highlighting, it's having that patient voices at the very centre of all we do, but also looking at how we can help clinicians because there's that huge feeling of under confidence and being underprepared.  So looking at how they feel about menopause and HRT and how we can improve that. And we've also got through to the final round for funding to do a randomized control trial where we test the feasibility, acceptability and start looking at the safety of prescribing HRT in rheumatology clinics. So Arvind Kaul, who's a senior rheumatologist at St. George's and is part of our menopause matters team, he's set up a joint clinic prescribing HRT to his rheumatology patients.  And our plan is to scientifically test this process. to see if it's something that could be implemented on a wider scale and importantly to measure the effect on disease flares of the newer style of HRT.  And I know Zoe mentioned testosterone earlier. I would love to test testosterone. It's obviously going to be harder to get through ethics.  We think it could obviously have benefits on energy, cognitive and sexual function,  which of course many of these patients struggle with anyway as parts of their disease and even more so during the menopause. So I think that would be so valuable. 

Yeah, that does sound really valuable. I wondered if we could ask both of you, what advice do you have for clinicians and patients on the topic of menopause? 

So from my side, I think one of the big messages for clinicians is that it's not just all about hormones. There's cognitive dysfunction, mood disturbance, pain amplification, sexual health issues, work pressures for these women as they're transitioning through.  not to forget that perimenopause and menopause tends to come at the sort of sandwich years of life  where women have got caring responsibilities and it all intersects with chronic disease management in our patient cohort. So the rheumatology MDT is important in this.  And so our occupational therapists are brilliant for sleep and cognitive strategies, pacing, work adjustments, physios for sort of help, support with strength, pain and  activity confidence and we know that patients are more likely to seek advice about reproductive health from our specialist nurses. That's an important group and that they are very skilled in the holistic assessment of our patients and key in providing health promotional advice and that assessment as part of our annual review.  Psychology is enormously valuable, but I know from this not formally commissioned as part of our services despite the overwhelming need, but my advice for clinicians is really to ask about menopause symptoms proactively. It can mimic new presentations of rheumatological conditions and flare and that new presentations are more likely. So flares can and do happen as part of the menopause transition. And we need to avoid assuming either way, listen to our women, be methodical in the assessment, but consider the musculoskeletal syndrome of the menopause before we reach for a fibro diagnosis. And for our inflammatory disease patients, think about the impact of fluctuating hormones alongside consider escalating that disease modifying therapy. We know that HRT is appropriate and safe for many women with rheumatic diseases and especially with these modern regimes and that we as rheumatologists have a really important role in supporting primary care and menopause providers and other clinicians  involved in a patient's healthcare and helping women make informed and shared decisions.  We've got the up and coming BSR reproductive health guidelines that are going to bring together that contraception pregnancy postpartum and menopause guidance, but it's crucially going to set expectations for routine conversations. So just as we've normalized discussing pregnancy planning in our clinics, menopause should be part of our routine rheumatological care. should be part of what we ask in the clinic. So my interest in menopause began through my own perimenopause experience whilst I was setting up the lupus service in Liverpool.  And I went on a menopause course to understand my own symptoms. And it was like a light bulb had switched on, reframing how I understood the women I was seeing in my clinic.  And suddenly symptoms I've been seeing in the midlife women for years now made sense in a new way.  So rheumatology and in particular the field of lupus is so female predominant and menopause and the impact of female hormones isn't a peripheral matter.  It's really important we consider and recognise menopause transition. It's crucial when thinking about symptom attribution, patient wellbeing, reproductive planning and long-term health. 

And Mel? 

For patients, I would say don't feel that you have to suffer on your own with these symptoms and be confident in telling your doctors all your symptoms and asking what treatment and support you can have.  We find in general that patients often don't want to raise their mental health symptoms. And this is partly because many, particularly women, as we discussed earlier, would have been previously misdiagnosed with psychosomatic or mental health problems.  We have many women who are given sort of lifestyle diagnosis like, oh, you're just a busy mum. As Zoe said, they're often in those sandwich years where things can be blamed upon all the stresses. And sometimes it is those stresses do exacerbate the symptoms.  And even more sort of offensive diagnosis, we had one lady who was told by her GP she was just a bored housewife and therefore imagining symptoms. So this can make women very reticent to report new mental health symptoms, even though many will be from hormones or from the direct effects of the disease and need treatment. So for patients, it's sharing their symptoms with their doctors. And for clinicians, it's a conclusion we draw from all our various studies.  As Zoe said, it's asking, but it's also listening and valuing their input. They're the ones with the symptoms. They may well have insight into and the answers as to the probable cause, or at least be able to provide a large part of that attribution jigsaw puzzle if their input is valued  and if clinicians have already built a strong, trusting relationship. where patients can feel comfortable talking about all their symptoms.  But of course, there's the massive caveat that we all know clinicians in all the health services are so time constrained and adding in hormonal discussions to an already busy clinic can just feel overwhelming and unachievable to some. So we need to support clinicians and patients.  

Thank you. Thank you both very much for the really useful discussion. It's got lots of useful information for the whole of the rheumatology team. So thank you. 

Thank you very much for having us.

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