Thank you so much to Patricia and now we’re actually going to go on to our next speaker, Dr Quinn, who’s going to do a talk on “Menopause: rewriting the narrative”. Thank you so much. Thank you, God I’m depressed I think I need a gin and tonic, you should have wine for sale here.

Well if you think you’re depressed now, you’re going to get a whole lot worse because, I’ve been asked to speak about menopause. You may be thinking “what would he know about menopause?” He’s a man. And that’s true but Shauna and Patricia are both women. My wife’s a woman. My kids are all women. My puppy’s a woman. All the patients are women. You know so and when I told my mother, I said, you know, I’m giving a talk about menopause and she said “sure what would you know about menopause?” And then my father went on to tell me that he watched a TV show where he seen this man called an obstetrician doing a thing called a caesarean section, and he said it was the most amazing thing I’ve ever seen.

I said, “that’s what I do for a living” and he says, “you don’t be doing that kind of crack do you?” I says, “I lost count at like 1500 sections” and he, he says, “boys a dear, that’s what you do for a living?” and I was like, you were there when I graduated, you know, and you’re it was okay for you to have all the prosecco that day

I graduated, but he still doesn’t have a clue what I do for a living. This talk should be called “It’s a man’s world” because let’s face it, it is a man’s world. I hear that ten times a day, every day. And I try and give some stats about men’s health but the women tend not to care. But I’m going to talk about menopause today, and, I will never be menopausal but unfortunately in my line of work I have made a lot of women menopausal, and I’ve seen firsthand the impact that has had on their quality of life. And, sometimes the menopausal symptoms that they have are actually worse than the cancer, you know. And it’s a it’s a big thing. It’s a thing we need to talk about.

It’s a thing that it’s a very intimate, very personal thing. It’s a very embarrassing thing for a lot of women. And I certainly have worked with a lot of nurses who are in the depths of menopause. And I’ve seen the impact that has on their work life, their home life, their quality of life. I’ve seen my mother going through menopause.

She blames me because I was 10 pound and after her birth of me, she had to have a hysterectomy. And every time she looks at me, I think she kind of grits her teeth. But she’s, she’s happy enough now. This is how we normally talk about menopause. It’s often lighthearted in conversation because nature decided that pregnancy, labour delivery, breastfeeding, stretchmarks, saggy boobs and cellulite just wasn’t punishment enough.

But there is light at the end of the tunnel, because now we’re talking more openly about menopause. It’s a very, very popular thing. Long before Davina McCall made menopause very topical again. I was at courses learning about menopause, trying to make things better for my patients because I was so sick of making people menopausal and, and not being able to look after them properly, and that’s not right. You know, it’s not right that at these courses, I’m the only man. It’s not right. I’m often the only gynaecologist. I’m often the only person from Northern Ireland, you know, so somebody has to fight for it for our patients. Really what we need to do is improve the consistency of the information and support we give our women with menopause, and to talk about the long term benefits and risks of it in a very open and and frank way, because there’s a lot of myths around menopause.

There’s a lot of myths around HRT and 2002 was when the big study came out that basically stopped a whole generation of GP’s from prescribing HRT because of safety concerns around breast cancer. Again, that’s all kind of been debunked lately and especially for gynae cancers and we’ll have a chat about that later on. So, you know, I’m sure you’re sick seeing pictures like this but basically, you know, 4 out of 5 Americans can’t identify all these organs, you know, because we don’t talk about these things, especially in Northern Ireland.

We don’t talk about these things to our children. They’re very intimate, very, very personal things. But basically when women are younger, the ovaries help make oestrogen ok. And oestrogen, of course, is that female hormone oestrogen and progesterone. In men it’s testosterone is the number one sex hormone. But it’s the oestrogen that comes from the ovaries. So if you have any kind of surgery that removes any part of these organs, even if you have a hysterectomy and you keep your ovaries, there is still a risk you can go into premature menopause because of some of the blood supplies to these, ok.

So why is this important that we talk about this? Because we’ve we’ve done all the studies now we know that nearly half of women feel that their menopausal symptoms have a negative impact on their work. We know that if you’re we’ve done studies on nurses, we know that if you leave nursing because the impact of menopause, you’re very, very unlikely to reenter the workplace again.

You know, we know that a third of women no longer feel that they’re good company because of social anxiety and they don’t like leaving the house because they’re embarrassed because of hot flushes and sweats. We know that a lot of men feel helpless when it comes to supporting their partner through menopause. This is well recognised. A quarter of women feel more isolated, and over half of women feel that the menopause has affected their relationship also in an intimate way.

So the classical symptoms again, I don’t need to tell you all these, but the biggest ones of all. I break them down into physical, psychological and either sexual or urogenital, that means it affects in and around the front passage. The big one are the hot flushes and the sweats. These can be incredibly debilitating. I’ve worked with people before who have had towels wrapped around their necks, starting a 12 hour shift on a on a busy ward.

The sleep deprivation can be really bad, the insomnia. Going to bed at 10 o’clock and waking up at 2 o’clock and that’s you for the day. How can you function if you’re in your 50s and you’re going to work and you have you’ve only slept for 3 or 4 hours. How can you function in life? You can’t function in work.

How can you not be grumpy if somebody is annoying you and you’ve only been asleep for three hours? How can you rear children properly? How can you look after elderly relatives? And then at night time if your husband rolls over and gives you a tickle, you’re going to say “would you catch yourself on? I’m only going to get three hours sleep”.

So these are things that you hear all the time, but we don’t talk about. The joint pains, the joint aches. People say to me “I just don’t feel strong anymore. I feel like I’ve lost my oomph”. The headaches, the skin problems, the itchy skin, the dry skin, the hair loss. I mean, everything can be put down to menopause.

There’s a huge impact on somebody’s quality of life. Let’s talk about the hot flush. 85% of women get them and why do women get a hot flush? They get them because, the temperature control part of your brain is very, very sensitive to oestrogen and if you haven’t got a lot of oestrogen, then you can’t control your temperature properly.

So you always get daily fluctuations in heat. For example, if you if you walk into a warm room or a cold room, your body can adapt, but that disappears after menopause. So you can get a really bad hot flush if you walk into a hot room, a cold room, if you have a glass of red wine, if you eat spicy food, the body thinks it’s overheating.

And if the body thinks it’s overheating, then it acts to flush the skin to lose that heat. Ok and that’s why people get them.

The psychological symptoms. People say to me, I always say to my patients “how would your partner describe you at home? How would your kids describe you?” and they say “oh they say you have a short fuse or, you know, I flew off the handle”, I had one woman recently threw a pack of sausages at the back of her husband’s head.

The problem was she was actually frying them at the same time, and she threw a frying pan and the sausages at her husband. I thought to myself, my gosh, that relationship’s not going to last too long. But she says then I was okay again and it’s amazing how you can just fly off the handle. But the anxiety people can feel can really affect their quality of life at work.

We know that if you leave work through anxiety of menopause, most people tend not to reenter the workplace. Difficulty coping and brain fog. People think that they’re developing Alzheimer’s because they forget words, they forget the friends of their’s names. People, I have one woman who is the CEO of a huge, big company and she went home one night and made herself beans and toast for tea and had the toast and then found the beans two days later in the microwave.

That’s classical brain fog. But then the more serious side of that is that people have difficulty coping. They lose confidence and that can all be related to hormonal changes. Hormonal changes that come from that dreadful word that begins with C, you know that if you if you have surgery for a cancer and we remove the ovaries to reduce your risk of recurrence, then your quality of life afterwards can be very, very bad.

The sexual symptoms, again vaginal dryness can be terrible. Even the even up to a third of women who are on HRT can still get vaginal dryness and loss of libido. Now libido changes for men and women. For men, it’s we’re very simple beasts, if somebody says “do you fancy going to bed early?” you say “of course I do” do you know what I mean, but women, it’s a bit more complicated.

Libido is multifactorial. It’s how you feel that day, it’s how you get on work, it’s how your family are, if you’re stressed out. That’s libido is, is essential to all those things. And there’s no quick fix. People often think that testosterone therapy can help. Certainly does help libido in some cases but it can’t make you feel close to your husband if he’s not very nice to you.

Do you know what I mean, there’s no cure for that. Let’s talk about HRT. There’s loads of different types of HRT and over the last kind of generation it’s got a real bad press, but now it’s come back into vogue again as a very, very safe treatment. And it is a very safe treatment and I give out a lot of HRT and I’ve seen first hand the improvement in one’s quality of life.

So if you had hypothyroidism, if you’d no thyroid you’d think nothing about taking thyroxine. If you had diabetes you’d think nothing about taking insulin or metformin. But yet if you’re a menopausal woman, you know HRT has a stigma to it that, you know, you shouldn’t be taking that, because why? What’s the number one reason people don’t take HRT?

They’re afraid of a cancer called breast cancer, ok but if we delve into that later, we’ll see how safe it actually is. So it’s ok for me to simplify things but there are caveats. So if you have if you have a womb or if you have a uterus and you need HRT, there’s different preparations.

There’s one called oestrogen and one called oestrogen and progesterone. If you have a womb, you need oestrogen and progesterone to protect the lining of the womb because if you just take oestrogen alone, it will eventually stimulate the lining of the womb. If you’re post-menopausal it never stimulates it normally, it always stimulates it abnormally. So you need some form of progesterone that may be a bleed preparation where you take progesterone for maybe two weeks of the month or a no bleed preparation were you take progesterone all the time. And there’s loads of different ways of doing it. There’s pills, there’s patches, there’s gels, there’s inserts, there’s sprays, there’s coils, there’s loads different ways of of taking it. And the way I like to, the analogy I like to use is like finding the right pair of shoes You don’t walk into a shoe shop and look at a pair and say “I’ll take them”.

You look around the shop and try different ones before you find the right one for you. Testosterone is also a big current vogue in HRT because it can help libido. I give it for libido, I give it for energy, and I give it for what I call spark or vavavoom. Some women just feel that they’ve lost their spark after menopause and that can certainly help.

But again, it’s not without risk. Sometimes testosterone can deepen your voice if you use it in excess and that’s not a good look either. Davina McCall, the TV presenter is a menopausal woman and was very open and honest about her use of HRT and has written many books on it, and, that’s an incredibly positive thing, I think, for the women of the UK, because it means we can talk more openly and honestly about it.

And I think for far too long we’ve, we’ve over medicalised the menopause. We don’t talk about it. It’s not necessary for GP’s to have any training in it. It’s actually not even necessary for a gynaecologist to have any training in it and I think that’s an absolute disgrace. It should be central to women’s health, we don’t even have a women’s health strategy in Northern Ireland, you know.

So what does that tell you? We’re way behind the times with most other European countries.

People don’t talk about the benefits of HRT enough. There’s huge benefits for your heart health, for your bone health, for your love life. There’s evidence to suggest that if you take a vaginal oestrogen and the vagina is very dry and you need to run the toilet, a condition called urgency, when you have to go you have to go for some ladies taking a little vaginal oestrogen, up to a third of them can be completely cured by taking a vaginal estrogen.

Where is that in the textbooks? Where is that you don’t hear that on the national news. There’s a there’s a huge big study, recently in Europe and they suggest that it might actually decrease your chance of getting Alzheimer’s. There’s a Danish study that suggests, you can actually decrease your chance of colorectal cancer or bowel cancer by up to a third by taking HRT.

So there’s loads and loads of benefits that we don’t talk about. And on top of all those things one’s called quality of life would be the overall benefit. There are risks and anytime we talk about risks, we always talk about breast cancer, cancer, cancer, cancer where if you delve into the stats a little bit better, then, you can actually see that for some cases with HRT, it doesn’t increase the chance of breast cancer.

People often worry about stroke and blood pressure and clots. But again, with modern management of HRT, if you take it through the skin in a gel or a patch, there’s no evidence that it increases your chance of clots, blood pressure, stroke. So it’s very, very safe for women, especially larger ladies those who are at risk of those things anyway.

Now there’s loads of lifestyle interventions that one can do. And often I say when people come to me with menopausal symptoms, I say, “what have you done for you?” I say “so who’s look what are you doing for you?”. Ok because often women of a certain age have a syndrome called Irish mammy syndrome. They look after everybody else except themselves.

Their kids, their grandkids, often if they have elderly relatives, often they’re working full time and they’re at the top of the tree. Most women by, by by 50 are at the peak of where they’re going to get career wise. So and life is very busy these days. You know, it’s always very busy. But the question I always ask is, what are you doing for you?

Ok and the answer is often nothing. So I mean smoking, we know that smoking causes an earlier menopause and it can trigger hot flushes. Ok we know that if you exercise regularly, for more than two hours a week, you can actually decrease your chance of breast cancer significantly, but it also converts any kind of stress you have into more positive energy.

And this is a very common vogue, a lot of people go to the gym regularly you know, a couple of hours a week. I ran for a bus about 20 years ago and that’s kind of, that’s my kind of exercise. I did catch that bus but, so it was okay I was a student at the time, and that’s

I don’t believe in going to gym’s myself. I don’t think you learn personality in a gym. Although, you don’t learn it in a pub either, so there’s a kind of happy medium. Alcohol increases flushes ok and increases your chance of breast cancer. This is a huge problem in Northern Ireland because often people, when they cook, they open a bottle of white wine or red wine and have a wee glass while they’re cooking.

And if you tot up that alcohol over the week, it’s well in excess of of of where it should be. My mother went to the GP recently and the GP said to her “do you drink alcohol?” and she said, “I have a glass of wine on a Friday night watching the Late Late show and then I’d maybe finish the bottle on the Saturday night watching like a film or something”.

00:15:48:06 – 00:16:09:23
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And the GP said “a whole bottle?” and I was like oh gosh. We’ve started going to the bottle bank in the middle of the night just so people don’t see us, so you don’t want to get caught. So there’s a happy medium, and there’s loads of other things that people know these days. You know that a diet low in saturated fat and salt reduces blood pressure, and it should be rich in calcium and vitamin D to help strengthen the bones.

We’re working longer. We’re working more hours than we did before and there’s loads of links between workplace stress and depression and effects on menopause. So this is a kind of a new infographic from the British Menopause Society. And basically for women between 50 and 60, their background risk of breast cancer is 23 per thousand.

So if there was a thousand of you in a room, 23 women in that room would get a breast cancer in the next ten years and that can’t be helped. That’s just because you’re a female, ok. So if you add in a little bit of HRT, that actually increases by four, up to 27 per thousand.

And that’s the same as if you have a glass of wine every day, you know? So it’s, it is deemed very safe. If your if your BMI is over 30 or if you’re heavier, then that risk goes from 23 to 44 per thousand. So it almost doubles the risk. So you can see then if there’s an extra 24 cases who are who are overweight going to get a breast cancer and there’s only an extra four through the HRT, then it’s an awful lot safer HRT than being overweight. If you’re a smoker, it goes up by three. If you’re on the combined pill, it’s the exact same as the HRT. But look at this here, if you exercise more than 2.5 hours a week, it drops by seven. So that is the benefit of staying active.

You know, it’s and it’s a very simple thing to do. So we know that, we know we think it’s, it’s the combined HRT that does the problem. It’s the progesterone that does the problem. There’s, there’s actually evidence to suggest if you’re on an oestrogen only preparation if you’ve had a hysterectomy, in some cases, it can decrease your chance of breast cancer, or certainly it doesn’t increase your chance of getting it.

So it’s very, very safe, depends on the type of of the of HRT. Osteoporosis is something we don’t talk about because it’s a hidden disease. Ok. But if you’re over 75 and you fall and break a hip, you know, there’s the mortality in the next six months is really, really high. So those people will die because of it’s a really bad prognostic thing breaking your hip if you’re over 75.

So anything you can do to keep your bone strong is a very, very good thing, and this is something we don’t talk about, HRT’s really good for your bones and it helps reduce fractures and it’s good for your muscles and keeping you supple. As regards gynae cancers, historically anytime somebody had a gynae cancer then we didn’t give out HRT.

Ok because we know that endometrial cancer is fueled by oestrogen. Unfortunately, we’re having a lot more younger ladies who are coming in with endometrial cancer. We had one recently who was 31, we’ve had a 32 year old recently and they’ve opted for surgery and a hysterectomy. And that’s terrible diagnosis for them because it it limits their fertility of course, if you haven’t got a womb then you can’t have a baby. But we tend not to take out their ovaries because of the benefits that their own oestrogen has for their heart and their bones and their skin, and keeping away menopause. So there are new ways of dealing with these things. Having a hysterectomy only without taking out the ovaries.

But if it is very early stage cancer and a low grade cancer, I mean, if it’s not a very aggressive one we can consider HRT in some endometrial cancers. Likewise for ovarian cancer, for the vast majority of ovarian cancer, because it happens usually in older ladies over the age of 60, they’ve already been through the menopause. So we tend not to consider HRT, but there are a lot of women out there who’ve had cysts on their ovaries and cysts that are bilateral cysts.

Unfortunately, there’s some girls I have who’ve had a big cyst at age maybe 18 or 19 and only have one ovary, and then they hit 26, 27 and they have another big cyst and they might end up losing that ovary as well. So they may they may not even have any children and we’ve had to remove their ovaries and then they’re instantly menopausal.

And that’s a very, very deep surgical menopause, you wake up and you’re menopausal. It’s not a gradual entry into menopause like a lot of ladies have. Likewise for women who have any kind of, extra treatments like chemotherapy or radiotherapy that can that can nobble their ovaries and that means they end that they go into a very deep chemotherapy menopause and that has a huge impact on one’s quality of life. Yes, you may have survived cancer, but what’s your quality of life like after that cancer? You know, and that’s why we strive, Patricia and Shauna and I are the rest of the men in our team. We strive to have an open door access if women are getting it tight, to let us know, and we’ll try our best to help you.

For cervical cancer, there’s no real contraindication for it because cervical cancer, 99.7% of them are caused by that virus called human papillomavirus. So it’s a virus we all have on our skin but our, we get rid of it. Ok you can get it from shaking somebody’s hand, but we tend to get it through close contact, with intimacy.

The good thing about cervical cancer is that a lot of countries now in the world are trying to eradicate it completely. Australia, Canada, they’re well enroute to eradicating cervical cancer through good screening ok. So the biggest, the biggest protective thing to do against cervical cancer is actually going for your smear. So we had 22 cancers last year in our trust, cervical cancers and 11 of them had no smear ever. You know. So it’s about encouraging women to go and get their smear done and and to make it as quick and as gentle as possible. I don’t worry about the women who come and see me with an abnormal smear. That’s easy. You know, I can fix them. No problem. 96, 97% of my patients are fixed within six months.

But it’s a very intimate, very personal thing, I get it. If you have a bad experience or if you’ve been embarrassed by your smear, you’re not wanting to go and go back, you know? And that’s the biggest problem we have. Under we have 40% of our under 30 year old girls don’t go for their smear. They’ll go to a beautician and get all their pubic hair wax off, but they won’t go for a smear.

You know times are changing it’s mad and this is a free test that’s available on the NHS. The other big thing is vaccination. After Covid, there’s a lot of vaccine hesitancy where people don’t get the HPV vaccine or they don’t want that for their daughters or sons.

I can’t wait for my daughters to get it, because it’ll give them about a 70 or 80% chance they’ll never have to come and see somebody like me and get a procedure done. So there is no real reason you can’t give somebody HRT because it’s not hormone dependent and it goes the same for vulval, vaginal or anal cancers. There’s no kind of contraindication to use HRT, but these are very intimate, very personal cancers. They’re not one that you know, that are very public.

The vast majority of women will opt for an alternative before they come and see me. We know this from all the evidence, about 95% of people try something over the counter before they’ll consider HRT and there’s loads of different things. There are herbal remedies, black cohosh, which is like an American herb that’s really good at decreasing hot flushes.

St John’s wort again, doesn’t interact with oestrogen. It’s it was useful for, like, it has, like, an antidepressant, anti-anxiety kind of effect. But it can if you take it in excess, it can make your skin very sensitive. It can also, interfere with some other medication so you need to be very careful with its use.

There’s a current kind of vogue for a thing called isoflavones, that’s like natural oestrogens, like in red clover or soy. But there’s a lot of you have to take a lot of that to try and get, you know a big increase in your in your hormone levels. Other people try things like acupuncture, homeopathy, reflexology, cognitive behavioral therapy.

I mean, I’d love to be able to prescribe those things, but the NHS deems them as effective as a placebo. But if they work for you, then I’m a huge fan. Huge fan. If you can avoid taking HRT for whatever reason, if these things work for you. But all the studies show that they’re no better than a placebo, which the placebo effect that means you get an improvement, without actually getting an improvement, is around 30%.

But if I was in that cohort, I’d probably try some of these things as well, because if I was in that lucky 30% that that got a big improvement. It means that it has worked for me. So statistics are only statistics when they don’t apply to you, you know. And then the other things we use like non-hormonal alternatives to HRT we use things like antidepressants, not for depression, but they have, they can improve your quality of life.

And some of them they can improve it between 20 and 66%, that’s hot flushes, feelings of wellbeing, you know, again, quality of life. Other things like gabapentin, they’re like nerve pain agents, they’re not great because they can improve your quality of life but they have big side effects and you can get addicted them very quickly.

And clonidine was always one we’d use for hot flushes, I’d never use clonidine anymore. I think it’s a horrible drug it has an awful side effect profile. So now you’re really depressed. It’s just one thing, if there’s my take home message, if you’re in any way worried about any menopausal issue, then check out this website. It’s called the British Menopause Society. Ok and their patient information wing is the Women’s Health Concern ok. And that’s real excellent, they have questions for absolutely everything. And it’s the patient information wing of the British Menopause Society. So it’s very up to date and a very safe website. Thank you for talking, thank you for listening to me.

I’ve done all the talking. I’m here for questions. If anybody wants to speak to me or if anybody wants to ask me anything personal that you don’t want anyone else to know, I’ll be here until lunchtime. So thank you very much.