The M word women don't want to talk about

Every woman needs to listen to this podcast episode about menopause. We're all going to experience it eventually, and being informed is what I'm all about!

We finally have an episode with a gynaecologist! Dr Kaushi is a fertility specialist, OB and GYNE with over 10 years of experience in her field. She practices in the Sydney CBD, helping women with fertility concerns, endo, adenomyosis, menopause, and a whole lot more! 

You can find her on Instagram and via her website for services @Drkaushi

This episode is all about menopause! We answer questions like:

- What is perimenopause and the typical symptoms

- What are the major health concerns for women going through menopause

- What are the treatments available for women going through menopause

- Debunking myths and misconceptions about gynaecology

Check out my website and follow me on socials:

Website: https://ascendwomenshealthau.com/

Instagram: https://www.instagram.com/ascendwomenshealthau/

Tiktok: https://www.tiktok.com/@ascendwomenshealthau

Transcript

SPEAKER_01 0:00

Welcome to the Dietitian Dispatch, hosted by Alia Gaselby, registered dietitian specializing in women's health, bringing you clarity with nutrition and evidence-based science. I'm loving to finally bring you a special episode about menopause with gynecologist Dr. Kirchy. You can find her on Instagram and her website. So Dr. Kirchy is a kidney-based gynecologist with over 10 years' experience in obstetrics and gynecology. She helps women with fertility concerns, endo, anomiosis, menopause, and a whole lot more. So definitely go check out her website for all of her services. So thank you so much for joining me today.

SPEAKER_00 0:44

Thank you, Alia, for having me. It's really nice to collaborate with, you know, someone from your background of experience, your wealth of knowledge. And I'm very excited for this podcast and this topic.

SPEAKER_01 0:58

And I think a lot of women also really want to know about this. A lot of my patients across my like different jobs as well, experiencing women coming in, sometimes not even just for menopause, but then I tell them, hey, actually, I think this would be good to focus on because it's linked in with all of the other things they're mentioning. So it's so important. But first I want to to give our audience a bit of a bio about yourself and your experience. So how did you actually get into this field?

SPEAKER_00 1:27

So I actually always, I think it was second year of medical school, and I always knew I wanted to do on Sangalini. So I did everything throughout medical school geared towards that. And I just did not think of any other speciality. And I think I had a really good um sort of lecturer that inspired me to um sort of continuing this pathway. And um I have not looked back. There's not been one moment where I've looked back and said, oh, would I ever consider an alternative specialty? And no, it's been of Saint Granio through and through. Yeah.

SPEAKER_01 2:04

Amazing. And you also get to see, I guess, women across their lifespan as well. So I love that too. But what are some of your areas of expertise or your favorite clinical areas that you love to work in?

SPEAKER_00 2:18

Yeah, so definitely I have undertaken a sub-specialty training on top of often guinea in fertility. So my primary sort of mode of work is around being a fertility specialist, and I really enjoy that. But I also do gynecology as well. So I look after women all the way from this sort of pediatric adolescent all the way through to gynecology. So I really enjoyed the breadth of experience that comes with that. And they kind of go hand in hand as well.

SPEAKER_01 2:57

100%. And I love that because then you get so so much diversity. And what is one misconception people have about your field?

SPEAKER_00 3:07

That's an interesting one. So I think in the context of guiding fertility, one of the things that a lot of people are reluctant or fearful of is being on any form of hormonal medication. Yes. And I think the commonest misconception is that people think it may impact their fertility if they will for many years. And the reality is that it actually not, it has zero impact on your fertility.

SPEAKER_01 3:35

That's good to know.

SPEAKER_00 3:36

Delay your period coming back maybe by a you know a couple of weeks to months, but normally it doesn't impact your fertility. So I think one of the commonest misconceptions people have when they um sort of come to see me for whatever reason. Yeah.

SPEAKER_01 3:52

100%. And I'm always telling people, I see it online um in the endospace, women not wanting to go on birth control. You know that it is a tool for people because their period symptoms are so bad that they can't bear to be with it as it is. So I tell people it's it's an option. It's 100% an option. So they don't need to be afraid of it. But then again, some medications do have side effects and it doesn't match well with people. But I guess that's the reality of pharmacy. You've got to find something that actually works for you as well.

SPEAKER_00 4:24

Yeah.

SPEAKER_01 4:25

Yeah.

SPEAKER_00 4:26

And I think that's the thing, it's um it's understanding what works to a patient and tailoring the treatment to each patient. It's not a copy cut sort of in a one-size-mine.

SPEAKER_01 4:37

Now we'll jump into the content. So we know that our normal period is controlled by hormonal fluctuations with the estrogen and progesterone. We know that that is disrupted when you reach perimenopause. So, can we explore what perimenopause involves and what are some symptoms that women might experience?

SPEAKER_00 4:59

So I think the term perimenopause and the way I like to look at it or explain it to my patients is that it's sort of a transition phase between your menstrual reproductive years to menopause. So it's sort of that in-between phase.

SPEAKER_01 5:15

Yeah.

SPEAKER_00 5:15

And it really varies because the there's no cutoff age at which it's absolute perimenopause to menopause. It's a bit of a blend.

SPEAKER_01 5:25

Yeah.

SPEAKER_00 5:26

But most patients go through perimetopause in their early to mid-40s.

SPEAKER_01 5:30

Yes.

SPEAKER_00 5:31

And then for some of them into their mid-40 before actual menopause. The menopause is your absolute final period, whereas in the perimetopause, patients can typically still have periods. You could still be ovulating, there's still a chance of pregnancy. So you have to think very clearly about contraception around that time frame as well, even if your periods are far into you. So that's something to bear in mind in the perimetapolis phase. Symptoms-wise, I mean, patients can get cycle irregularity, they might experience some hot flushes, some change in mood, change in sex drive. These are very common symptoms. Um, and then they kind of gradually either get worse or stay the same through the metaphoris as well. So, and that's POG as you rightly pointed out, due to that hormonal fluctuation where that estrogen is sort of declining. And there is a change in the type of estrogen your own reproduces as well. The type of estrogen we produce in our reproductive years is different to the type of estrogen you produce in your pregnancy to the type of estrogen you produce during monoclonal.

SPEAKER_01 6:41

Ah, that's very interesting. I don't think many people know that. I didn't even know that, that it's slightly different.

SPEAKER_00 6:47

Yeah, yeah.

SPEAKER_01 6:48

Is it in like the, I guess, is it the formulation of it?

SPEAKER_00 6:52

Yeah, so you see a change from estradiol is the commonest estrogen type that we see, and then you end up producing a different type of estrogen called estriol, uh, which is a different type, and that's what we see more in the menopause.

SPEAKER_01 7:08

Oh, okay.

SPEAKER_00 7:09

Like relative depth. Yeah.

SPEAKER_01 7:11

Ah, okay, cool. Yeah. Now that we've talked about perimenopause, we know menopause is when you have that, you know, your period's gone for 12 months. And then I guess it's a bit like you were saying, it blends. So how do you know when you've entered the post-menopause phase? Is it after that 12 months?

SPEAKER_00 7:29

Yeah, so it's actually almost sort of a retrospective diagnosis because remember they have not had a period for 12 months or more, then they've absolutely reached menopause at that point.

SPEAKER_01 7:43

Yes.

SPEAKER_00 7:43

There's no sudden shift in symptoms or like a one day we wake up and you know you've got all the vasomotus symptoms. It's just that absolute final period, and you're like, yep, you've definitely transitioned to full-on menopause. So most people, I think the average age in Australia is sort of 51, but different patients have around that time frame. Yeah.

SPEAKER_01 8:09

Yeah. I even uh we saw one of the ladies comment, she's 32, so that's very young. Um I did actually have a question about that later. Um, but as we know, like it differs for women of different ethnicities as well. Researching into different ethnic groups is so important as well, because I think for South Asian women it's in your 40s, so it's much earlier.

SPEAKER_00 8:34

That's right. So South Asian, East Asian women tend to have it in their mid-40s. Yeah. Or sort of, I think um African Latinas sort of probably towards the late 40s, and then proclaim patients are the ones that tend to have it in the by 51 or early 50s.

SPEAKER_01 8:50

Oh, okay.

SPEAKER_00 8:51

So it's quite interesting seeing that range varying around identities as well. Yeah.

SPEAKER_01 8:58

Yeah. What are some misconceptions about menopause you would like to debunk?

SPEAKER_00 9:05

I think one thing that um so this sort of is more to do with treatment.

SPEAKER_01 9:12

Yes.

SPEAKER_00 9:12

And I think there's a lot of controversy around this as well. But uh women are scared about initiation of hormone management because they directly attribute it to cancer, you know, being oestrogen, uh, and they worry about that. And I think the evidence that in the very big trial which was carried out was the WHI trial, which, you know, they started seeing all sorts of side effects in patients who had menopausal hormonal treatment. But what was really important to remember is that the trial looked at women over the age of 60, women who had established cardiovascular disease, women who were obese. And so putting them on estruture was probably detrimental to them. And of course, you were going to see a whole galetic side effects and issues arising from that, but they never really looked at the right core water patients. So this boils down, we can talk about it later, the window of initiation when you start patients for treatment and figuring out is it safe for my patient, is there an absolute contraindication, is there a relative contraindication? So I think that fear of oh my gosh, I don't want to be on treatment, but then should you, by the same token, allow yourself to go through all these symptoms and impact your quality of life? So I think that sort of balance is really important. Um, and I guess the other misconception is people, the use of low-level testosterone to try and improve energy levels. And I have a lot of women coming to me saying, I want to go on this medication because I hear it improves my energy levels. And really that medication specific for women with the corrector with hypoactive sexual disorder, where it's a lower libido. Beyond that, there's no evidence for improving energy levels. So I think those are some of the misconceptions I've come across. Yeah.

SPEAKER_01 11:06

Wow. Yeah, because I haven't explored much into like the hormone replacement therapy, like yeah, because it's not relevant to dietetics, but it's really interesting to see even my mum was going through menopause, and that was the reason I decided to specialise in it, because I realized there was a need for education really early, preventing things, arthritis, high cholesterol, so important for early intervention, which we'll talk about. Um, but in regards to prevention education, what do you believe is like I guess there's not really a right age to do that? What do you think?

SPEAKER_00 11:43

Yeah, I mean, I think it should be a constant continuous education rather than a specific age by which women should be important as girls that we are aware of what our bodies are doing, the potential changes. And you know, there is a big shift in our bodies, our metabolism, the moment you hit from your 30s to your 40s, and what you're able to do in your late 20s, 30 is very different to what you can do in your 40s. And I think it's important for us to be kind to ourselves and understand and be appreciative that there are major changes going on here because we tend to be really hard on ourselves, going, oh my gosh, I'm going to tired that, you know, that I was able to do this much better, I was able to concentrate much better, I was able to, you know, be more active and it's not the same. And I think just having that knowledge and education very early on, I think even instilling that sort of thing in school is really important. I think just a one-off lesson on biology about sex education is important. I think girls must be aware and be more informed about their reproductive health. Um, so that's measures and, like you said, prevention going forward. Um, so I think we're doing a lot better in creating awareness, and obviously, you know, podcasts like yourself is you know helping that situation as well because a lot of people access social media these days to get all the information. Um, so I think you know, kudos to you for bringing on uh people with like-minded sort of thought processes to get the message across. Yeah.

SPEAKER_01 13:21

100%. And I guess when I was growing up, we didn't really have in-depth lessons on reproductive health, aside from if you're going to uni and doing a science degree. So I think it's really important in schools, even just to have it in health. Um, just for us to understand the different phases of your menstrual cycle, so important.

SPEAKER_02 13:41

Yeah, yeah.

SPEAKER_01 13:44

So I work with women going menopause in regards to preventing bone density loss, muscle loss as well, which is another really important thing to educate women about. And cholesterol levels, I guess all of those are linked to that loss of estrogen. But are there any other important health issues that I'm missing or that people should be aware of?

SPEAKER_00 14:08

So I think you mean you've um highlighted the main ones. Definitely, you know, um cardiovascular health is one of the really important ones as well. One health is important, but there's also your sexual health. So a lot of women going through menopause will have vaginal dryness, which can make intercourse very painful, they get a lot of itchiness or discomfort down below. So it's really important to understand that role as well. And then libido. Libido is another thing that can be impacted through the menopause as well, uh, or perimenopause for that matter. Um, you know, they're just not interested anymore, and that can sometimes impact relationships as well.

SPEAKER_01 14:52

That's true.

SPEAKER_00 14:52

Yeah, so it's it's a much bigger ripple effect, and there's little things that you can do to try and help navigate that. So, yes, so I talk about urogenical health with women, and I also talk about they're more likely to have even bladder issues, like more urinary frequency or urgency, and you need to go to the toilet more often, and all of that is because that estrogen, because even the neck of the bladder or the bladder has estrogen receptors, yeah. So you're depleted in your estrogen levels, it makes the bladder more sort of irritable.

SPEAKER_01 15:30

Oh, does it get like loose as well? Like I was thinking, like I did we did an episode about pelvic floor and ut eyes, and I was saying women of post-menopause going through menopause, they're more likely to get UTIs. Is that yeah?

SPEAKER_00 15:45

So again, to do with um the so as you rightly said, one is to do with bladder prolapsis, a separate thing, but definitely uh, but it has some mechanically driven factors like through childbirth, that means you can have yeah, flow. But estrogen does help with nourishing that bladder health, nourishing the neck of the bladder, and helps with UTIs as well in general, because um you're more likely to you can retain, you might not empty your bladder as well as you would normally, so you might have what we not do a full void, so you might have some urinary retention, urine retent, the breed or infection mediums you get infection. So those are things to consider as well. Yeah.

SPEAKER_01 16:31

Yeah. Oh my gosh. Yeah, there's so much to do with menopause, like I tell people, it's not so it's not simple at all. Um, and there's so yeah, there's so much to it.

SPEAKER_00 16:40

Um the other thing is hobbyess. A lot of patients talk about that cognitive decline. Oh um, so brain fog is a real thing. I have a lot of patients going, my gosh, I can't focus, I can't concentrate, and that is something that is real and completely validated in the same experiencing. So, yeah. And I guess the fourth lead contributes to that.

SPEAKER_01 17:06

Yeah. Yeah. What what kind of things can you do for brain fog?

SPEAKER_00 17:11

Yeah, it's really hard. There's no simple treatment.

SPEAKER_01 17:15

Yeah.

SPEAKER_00 17:15

You know, I whenever you talk about menopause symptoms, and you know, I look at it as a holistic approach. And the first thing I do is lifestyle, lifestyle, lifestyle. Lifestyle, yeah. Good sleep, hygiene, you know, depending on your weather, like dressing layers or you know, dress appropriately. Um then um the type of diet that you have, all of that is really important because you know, uh hydration, all of that's really key, and then exercise is really important because um, so I do touch on all of that. Um, and then we kind of go down um hormonal and non-hormonal trip adoption that not all women want to go down the hormone road. Yeah, can't go down the hormone road because of their health issues, yes. Um, so and then we kind of go down different pathways tailored to the uh yeah.

SPEAKER_01 18:07

So that's like addressing the root issue, which is I guess for that, if it was whole monore replacement therapy that you were gonna go into, that'd be like, you know, the estrogen. Um, is it like a pill? How does that work?

SPEAKER_00 18:20

Yeah, so I guess the evidence for menopause hormonal treatment is essentially to tackle what we call vasomotor symptoms. So vasomotor symptoms are clustered symptoms, it's your typical night sweats, your heart flushes, more irritability, your sleep and all of that. Sort of the dominois thing from there. So when you're looking at vasomotor symptoms and tackling that estrogen, we know it's the culprit because of that decline in estrogen. So the idea is to find improved pebbles. So in terms of preparations, there are tablets that are available. Um, the commonest ones are now tropical estrogen, so they come in the form of patches or gels or creams for some patients. And um you uh so those are the commonest uh sort of preparations that we have, and then anyone with a uterus, it's really important that you don't use unopposed estrogen, they should always protect the lining of the uterus and have some form of progesterone. So that can either be in the top type of a pessary, which you insert vaginally or an oral preparation, or in some cases I have patients on the Myrena as well. Oh, yeah, unless thing for them to take, and they've got that for many years for endometrial protection for five years usually.

SPEAKER_01 19:39

Oh, okay, interesting.

SPEAKER_00 19:41

Yes, and I think it again depends on which patient you're giving it to. So you're you the topical route is actually uh considered to be the safest route, less in terms of the thrombotic risk compared to the oral route. Oral root bypasses through the liver. Um you there is a higher risk for clotting with the very cautious about um, you don't have to be through absolute metaphors to be able to access estrogen treatment. So if you're going through the perimetaphores and having past blushes, and you know, so it's then absolutely you can be on hormone treatment. Um, but for those patients, an oral root might be okay, but when you're getting after 50-51, you want to probably change them to a topical root to minimize their cardiovascular risks and things like that.

unknown 20:31

Yeah.

SPEAKER_01 20:31

Now we get to our QA section. More questions. So, like you were saying before, I guess managing things like hot flashes, it's by addressing the root cause. So that would be the HRT. If someone was not wanting to do that, how would you manage things like hot flashes?

SPEAKER_00 20:49

Yeah, so there are non-hormonal options that can be used. Obviously, they are if you were to look at the evidence for them, there is some evidence, but they're nowhere nearly as effective as hormone replacement.

SPEAKER_01 21:02

Yeah.

SPEAKER_00 21:03

Oh, metaphor's hormonal treatment, which is the right term to use now. But there's things like Remifemin, which is sort of more of a herbal supplement, and some patients get some benefit from that. Okay. Then you've got things like um gallopentin, which is quite effective. Again, nowhere near as hormones, but still effective. Um, and then there's other things like cloning, which can be used. Some patients go down the pathway of SSRIs, which is similar to sort of like amitryptylin. They're used in different contexts as well, in the context of anxiety and things, but they can also be used for tackling menopausal related symptoms. So some typical um sort of treatments are effective for different patients. So, yeah.

SPEAKER_01 21:48

That's interesting.

SPEAKER_00 21:50

Yes.

SPEAKER_01 21:52

Um I guess in clinic, I'd be interested to see um, I guess, what benefits have you seen or outcomes for patients that have. Done the HRT, and how long does that treatment go for?

unknown 22:05

Yeah.

SPEAKER_00 22:06

So uh it's a really important question because as we talked about earlier, that window of initiation is really important. So most patients, if you're initiating menopausal hormonal treatment within the first five to ten years of an established menopause, it's deemed to be a safe window. Yeah. And so they can be on it essentially to tackle the symptoms. And I've seen women with great improvements in this with menopause hormonal treatment and different dosages work for different patients as well. Um, and you know the dosages vary depending. If it's the summer, absolutely they find themselves going up their dose because it's so hot. So that's it's quite interesting. Seasons also do impact their vasomolic symptoms, and then in terms of sort of weaning off, um, most patients, sort of 60 around that time, you talk about weaning them off their medication. You do it very slowly, you try and do it with the cooler winter months rather than waiting the peak of summer. You just got them weaning off their medication then. Um, and some patients do it and do it very well, like they just drop their dose very gradually, so there's a gradual sort of thing, and then they try and see how they go um without the medication, and it works well. But I have other patients who absolutely will not come off their medication. And you know, they and you know, I I have one patient who says to me, Look, I'm I've got one actually who's in her 80s, and she's actually said, I am so content, I'm leading a good quality life. I'm very well aware of the risk factors of stroke and heart disease and clots, but I'd rather live my next five or ten years with good quality life than um and I'll deal with whatever side effects that come. So she's just you know, and I totally respect her decision. She's very well aware, very well informed, but she had had such a big improvement in her quality of life that she would not come back, come off her for one and three. So then I think you know, if you come to the patient and this is what they want to do, and then we get an informed decision, then exactly.

SPEAKER_01 24:20

Yeah, but that's so interesting. She's in her 80s. Wow. Yeah, because you think I guess would you still have I guess you would still have symptoms post post-menopause, like you were saying, into your 60s and 70s. So then she's like, yeah, I just want to keep on it.

SPEAKER_00 24:41

The symptoms get better and they're more stable, you know, because it's that massive change from your 40s to your 50s, you know, big shift. And then most patients are okay, but I think some patients just find there's their you know certain aspects that, and you know, women are now, you know, they're still working well into their sixties, and they're you know they're career focused, and this is just keeps them going, you know, pulls them. So it's interesting that they just want to stay on it and you know draw it down to standing of the risk, and yeah, you know, deny them of that treatment.

SPEAKER_01 25:18

Yeah, of course.

SPEAKER_00 25:19

Um, but by the same token, most women do well with weaning as well. But one thing I do not do, and I'm very cautious about is if I have a 65-year-old woman come for the first time with me, like, I you know, I had hot flushes and I'm still having hot flushes, or I've got new hot flushes, then you need to be really cautious because you need to start thinking about is there something else that's going on here.

SPEAKER_01 25:43

Yeah.

SPEAKER_00 25:43

Or you know, is there some you know I would do what we call a flush screen, like check for some autoimmune issues or some renal issue or something else that causes their temperatures to go up. You need to think about the red flag.

SPEAKER_01 25:57

100%.

SPEAKER_00 25:57

Yeah, because I think cautious about initiating hormonal medication in someone well above their 60s, because that is where that risk. Because by then, because of that shift in metabolism, because estrogen changes your cholesterol profile, estrogen changes your insulin resistance profile, your established risk for cardiovascular disease starts in your 60s as well. Yeah. That's a try and estrogen. So really important to know, and that's exactly going back to that big trial. They put put women with established disease on hormonal treatment, and then they went on to have bigger issues down the track. Yeah. You're really cautious about when you initiate medication as well. So I say go have a chat with your GP or you know, get referred to see a specialist. Um, and I think it's really important to just understand and just get that level of reassurance. Um, and the other thing I, you know, I also use it as a good way to do a well-woman check because that's your opportunity to check am I up to date with my survival screening? Have I had my hamograms? Have I had my cholesterol check, my diabetes check, my bone density check? Because that's the full well-woman check that you get them to do as well. So it's a good opportunity to tap in when you're checking for their menopause and symptoms, checking all the other factors as well. So they're all interlinked, yeah.

SPEAKER_01 27:15

100%, 100%. Yeah, because yeah, like I noticed, I was like, oh, actually, all of those things are connected to the menopause. Because I was like, oh, high cholesterol, like it's probably genetic. But then you're like, oh no, it's actually for her in that case was because of menopause, and then all the other things come together as well. Um, so it's like, yeah, I'm just I'm so I guess focused on the education and prevention because I guess our generation now when we're in our 20s, 30s, 40s, you know, we should be aware of all of these things and I guess put it into our routine as like, you know, okay, these are preventative things I can do with exercise. Now we get into a really interesting topic about early menopause that I've seen in cases of hysterectomy, but there's also other cases as well with autoimmune conditions and cases of patients with cancer. I saw one online about a woman who had a hysterectomy. I think it was for either endo or adenomiosis, and she went into early menopause. Could you talk about that?

SPEAKER_00 28:24

Yeah, no, it's a really important topic. So thank you for raising that. So I guess you can address that in two ways. So you've got menopause that is induced either because they've had their ovaries removed with the hysterectomy for whatever reason, you know, cancer or whether it's for the or for endorph sometimes. Yeah. Um, and it's really important when, and I know a lot of the gynecologists who specialize with endometriosis, when patients would ever have ovaries removed, they would often almost always see a menopause specialist to talk about replacement, estrogen replacement therapy, yeah, or hormonal treatment, so that they basically as soon as they have the surgery, they're almost pretty much starting treatment straight away. Because those patients they will start flushing straight away after the treatment. It's a massive shift. So it's really important to for them pre-operatively to always see someone and have those discussions and talk about treatment. We also initiate treatment in the post-operative recovery, you know, when they're still in hospital.

SPEAKER_01 29:35

Because I guess an operation like that is a huge decision as well. So doing all of that research and seeing all those specialists is so important.

SPEAKER_00 29:45

Absolutely. So we would definitely do that, and then it's really important that they have all the necessary checks done, you know, as we talk about as if anyone going through menopause, yeah. And we would continue the treatment until the natural age of menopause, which is sort of 51 for most of those women. Yeah.

SPEAKER_01 30:01

Wow.

SPEAKER_00 30:02

And again, because you want it, we know that the treatment is cardioprotective, born protective, important for their mental health, important for their sexual health. So all of those factors can be affected.

unknown 30:14

Yeah.

SPEAKER_01 30:15

Yeah, because you want to maintain the quality of life. So yeah, that's so interesting because I did I did see that online and I was like, oh, that's a thing as well.

SPEAKER_00 30:25

It's the thing. And then obviously, going to the other sort of patients, like you said, you know, patients who had premature variant insufficiency, which is POI. Um, these are patients who go through metaphors before the age of 14. Now there's uh a whole cluster of causes as to why that can happen. So autoimmune, as you rightly pointed out, is one of the things. So uh with these sort of patients, um, and they'll come, they'll present to you saying, I used to have really regular periods, and now they're just so sporadic or very light, or I'm getting really hot, and you know, they're encountering their first flush. So it's just very subtle changes, um, or they're having issues with um getting pregnant, like had their first child, no problem, and second child an issue, and then you go investigating, you're like, wow, it's got a really low ovarian reserve for someone of your age, and then you start doing a deeper dive. So it can be for autoimmune causes like thyroid issues, yeah. Um, it could be um like addison, uh, which is to do with your adrenal gland. Um, it could be due to um if they've had previous chemotherapy or radiotherapy to the ovaries, that can bring insult to the ovary. So anything that because as women we're born with all the eggs that we'll ever have in our lifetime, it's two million at birth, 300,000 at puberty, and it's continuing to decline. So that's a natural addition. Then any insult to the ovary like chemotherapy or radiotherapy is just going to make that drop happen much quicker. So chemo and radiotherapy can do that. And then for some patients, they are born with conditions like it's called fragile X, it's an issue in low X chromosome. Um typically um affects females uh with premature menopause. Um, and then for males, it's a different issue altogether, like the more developmental issues because they only have the one X chromosome from unlike the females, we have two X chromosomes. Yeah, yeah. So we're not so impacted, but when women get it, there it's the classic is premature or variant stuff, I should say, leading to early menopause. So and then there's a cohort of there's no reason, as with all things in mention is idiopathic, and we don't have a reason.

SPEAKER_01 32:52

Um that's with a lot of things in women's health. I'm like scientists gonna get on this.

SPEAKER_00 32:59

I know. So yeah, it's interesting and it's it's a really important thing to look out for that ovarian gets such a young age. Yeah.

SPEAKER_01 33:09

Yeah, because I would say five years ago I didn't know all of these things.

SPEAKER_00 33:14

Yeah.

SPEAKER_01 33:15

No, it's only through the you know social media and actually reading about it that you find out, okay, actually, that's a thing, you know, menopause can happen actually that early as well. That that's just a fact as well, because you know, we're South Asian backgrounds, so it's probably gonna happen early for me too.

SPEAKER_00 33:33

I know, and I think we're um you know, and certainly I think especially South Asians, we tend to be very dismissive or just put up with something. And if you die and you talk to your parents or the grandparents, be like you go through this in your early, you know, 30s, or and then you realize there's some familiar component here. Yes, then just accept they've had their kids because they've had their kids young, and then it's all just you know, shovel out of the cows, and they just carry on with life because you just as you do with anything, and so I think there's no talk about it.

SPEAKER_01 34:08

Exactly. And I think people are having kids a bit older now in their 30s.

SPEAKER_00 34:14

I think that diagnosis is very hard to grapple with. Um, yeah, uh, it's really, really hard because it is huge implications, not just right now fertility, but long-term implication. So, really important to I think, and it's not to say that patients who go through POI, which is premature variant insufficiency, cannot conceive vaccine. The we talk talk about natural conception still possible. You can still support these women with um hormone, many menopause hormonal replacement treatment, but you would give it in a way that it's not having a contraceptive effect. So less than five percent can actually conceive naturally, even if they've gone through POI.

SPEAKER_02 34:54

Yeah.

SPEAKER_01 34:56

Yeah. So interesting. This is why we bring on the experts, people. That's all the information and it's really interesting as well, all of those things. Um what was the oh um this this is a really popular question I've seen online. Um, I guess because it it ties into the misconception about endo that it's only a uterine condition, which is not. Um we know it's a whole body disease, but obviously endo is driven by estrogen and high amounts of estrogen. When you go through menopause, have you seen patients with endo in their 40s and 50s have gone through menopause?

SPEAKER_00 35:36

Yes, so you're right, it is an estrogen-driven issue. And so patients with menopause, ideally their endo shouldn't be flaring down, flaring up flaring up. But you have to be really cautious because now you go, now there's a whole other issue, which is the hot flushes and the other value symptoms. So then the natural thing is to go, or let me give you some estrogen. So you need to be really cautious because this is the patient, even if they've had a hysterectomy for their endo, yeah, even if you give, you can't give just estrogen. I told you that it's important to give progesterone when you have a uterus, but for those patients, you absolutely must give them progesterone, otherwise you will flare up their endocrine by giving them hosts.

SPEAKER_01 36:17

Yeah. Yeah, because I I think I saw online as well the fact that, you know, the women with endo who get a hysterectomy, it doesn't, I guess, get rid of the endo because we know it's a whole body disease and it can grow anywhere. And I guess it can create its own estrogen, but that's a whole nother conversation about it being like cancer. Um, but yeah, it's so mind-boggling.

SPEAKER_00 36:44

When you're starting someone on hormone old treatment, you know, if they've got a bad run of endonucleosis, don't just start them with estrogen only just because they've had a dysperactive, you have to give them progesterone. Yeah.

SPEAKER_01 36:55

Yeah, otherwise it's gonna be, yeah, a whole just gonna flare up the other end, yeah, symptoms as well. Um, but that's good to know. Now we have come to, I guess, the final speed round, and this has nothing to do with menopause, it's just I guess to know you a bit better. What does your self-care routine involve? What's your favorite part of your self-care routine?

SPEAKER_00 37:16

Ah um self-care routine. All right, so I mean, I look at you know, I think it's really important to have self-care routine because what you do now for me, the way I look at it is the payoff is in 10-15 years. Yes. So from a skincare perspective, I'm absolutely into my Korean skincare products.

SPEAKER_01 37:41

Yes.

SPEAKER_00 37:42

I keep it simple, you know, just a serum and regurin, that's what I use. Um but I don't know if it's made a difference enough. But I'm very um simplistic. I don't do a lot of makeup and layers and things just because I'm not very good at it. But I keep my skincare very simple, um face wash, and that's it. And then I outside of work, I try and at least get in. I'm terrible, but at least once a week I try and do some form of exercise.

SPEAKER_01 38:12

Yes, it's yeah, I'm like, what what's the saying? Do no, do as I say, not as I do. That's me as a dietitian. They're like, oh yeah, I'm sure you'll take care of yourself. I'm like, no, I don't need enough veggies either.

SPEAKER_00 38:26

I know, I'm terrible.

SPEAKER_01 38:28

Um it's hard, it's not easy.

SPEAKER_00 38:30

It's not easy, yeah. Try to have that balanced diet, but yeah, no, I absolutely try and do something once a week.

SPEAKER_01 38:36

Yes.

SPEAKER_00 38:36

Um, and then I enjoy um I'm a classically trained Indian classical dancer, so um, yeah, I used to dance fairly seriously up to a certain age and then obviously work to follow. But um I've got a performance coming up in a couple of months, so I need to get my examiner and self-endurance back on track. So I'm working towards that now. So that's my little side, you know, psychic outside of work. Yeah.

SPEAKER_01 39:06

That's so interesting. That was my fun fact question gone now. That's so cool. That's so cool, honestly. What's your favorite book right now, or just in general, I guess?

SPEAKER_00 39:18

I if you're gonna I am such a suckler for romantic novels, and I love Daniel's field book. But I really enjoy um reading those. I wish I had more time to sit down and read, but yeah, it's obviously my um go-to sort of book. Yeah.

SPEAKER_01 39:40

Love that. And I guess what do you spend most of your free time doing?

SPEAKER_00 39:47

So when I'm having my me time, I absolutely just get onto Netflix and enjoy just watching something that is completely like mind-numbing. I think the current thing I watched recently. Oh, one was a Netflix documentary on Justin Artins. That was very informative. I did realize that, you know, I was very surprised actually because she was, you know, classic, became prime minister, was pregnant at the time, and she sort of you know rose to the occasion because it was a sort of you know, kind of sprung upon her. That was really interesting. How she had all the travels with the little baby and all of that. It was all very interesting to me. And then I what did I watch? I watched Love is Blind. Watched like the UK version, the US version.

SPEAKER_01 40:36

All of the all of the different versions.

SPEAKER_00 40:38

Yeah, a lot of random things. But yeah, I didn't like watching things that just completely you know gray hair and don't think much about it. And uh honestly one hour of me time, yeah.

SPEAKER_01 40:48

Exactly, because you want to switch off from work and you know the family and everything, and just you know, do do something that's you know, don't have to think about it or anything.

SPEAKER_00 40:59

Yep, and Master Chef is my other thing.

SPEAKER_01 41:01

Oh yeah, yeah, I'm like, I haven't caught up with Master Chef. I used to watch it every single year when it first started, and now we're just like they're too good at cooking now. They're all good. I know, but they're not home cooks anymore. They're like, you know, all gone to different schools, and you know, I'm like, I can't cook like that.

SPEAKER_00 41:22

No, I just uh you know how they say eat with your eyes, and I just look at them going off very good.

SPEAKER_01 41:30

Yeah, yeah, it's so good. Um, but that is the end of the question section. Thank you so much for coming on this episode of the podcast. And make sure all of you listeners go and check out Dr. Koshi's page. She's got an Instagram and her website, which I mentioned before. And thank you again.

SPEAKER_00 41:50

Thank you for having me, Ali.

SPEAKER_01 41:53

Okay, thank you.