Health Expert REVEALS The #1 Thing Women Over 40 NEED TO KNOW | Dr. Annice Mukherjee

Dr. Rangan Chatterjee 0:00 You are, I think, regarded as one of the most experienced, one of the most respected medical menopause experts in the country. Right at the start of this conversation, what is it that you would like most women to know?

Dr. Annice Mukherjee 0:17 Well, both in relation to all aspects of women's health, but particularly menopause, women have so much more control and agency over their wellbeing, their health, their hormone and menopause-related symptoms than they think.

Dr. Rangan Chatterjee 0:33 It's really interesting to hear you say that, because one thing I've observed in the social media space, the public conversation around female hormones, is that on one hand it's been really good that there's more and more awareness, but I really feel there's been a lot of negativity as well, a lot of fear, a lot of confusion. Why do you think that is?

Dr. Annice Mukherjee 0:56 Absolutely. W- and I agree with you that raising awareness is crucial because women's health, menopause has been shrouded in secrecy until, you know, very recently. So raising awareness is really important, but with that comes problems because misinformation can spread, particularly on social media.

Dr. Rangan Chatterjee 1:17 Yeah.

Dr. Annice Mukherjee 1:17 Not deliberate, but it... you know, things can be taken out of context. And also, the big issue around social media is that it, it tends to facilitate extremes of view, and it's also sound bites, and negativity bias is very prevalent. So if, if you've got-- if you're saying bold statements, if you're, you know, talking about all the negatives, and more people talk about the negatives on social media-

Dr. Rangan Chatterjee 1:45 Yeah

Dr. Annice Mukherjee 1:45 ... than they do positive. You don't hear people saying, "I'm having a wonderful menopause experience." You know, you hear people saying, "I'm really struggling, I've really struggled." Um, and unfortunately, that paints a very negative picture. Women who are doing well don't tend to take to social media to say, "I'm doing great." So it just, it just makes the whole picture m- more unbalanced.

Dr. Rangan Chatterjee 2:10 In your book, I think you say something to the effect of this, "There has never been a better time in history to be a midlife woman." What do you mean by that?

Dr. Annice Mukherjee 2:26 There's so many opportunities for women now. You know, the equality is better than it's ever been. It's not perfect, but, but things should be much better for women today. But it doesn't seem to be at all, that there are actually more women struggling with quality of life and wellbeing today through the menopause transition. But also younger women, I see lots of younger women with different hormone health issues, and it's... Y- you know, I, I'm seeing more women struggling today than I saw day in, day out in my clinics when I started out, which is more than 30 years ago. So it, it is a real paradox. We should be so much better. There are more treatments available if you have problems.

Dr. Rangan Chatterjee 3:08 Mm-hmm.

Dr. Annice Mukherjee 3:08 More people can access treatments. Why are we struggling so much more?

Dr. Rangan Chatterjee 3:13 That's really interesting. You've been practicing for over 30 years, so you will have seen tens of thousands of patients, but you're saying women are struggling more today than they were 20, 30 years ago. Why do you think that is?

Dr. Annice Mukherjee 3:28 The world's changed hugely. The world has changed for women. Women going through menopause are the fastest growing demographic in the workplace in, in modern societies. Um, there are more demands. Everyone's living longer, so more midlife women are looking after elderly parents with all sorts of health issues. They have other care roles. Many women have their kids later, or they've had to have, you know, fertility treatment. There's all sorts of things going on in women's lives. Um, they're looking after, you know, teenagers when they're going through menopause, which was less common 30 years ago. So there's lots of challenges. You know, teenagers, young people are having lots of health issues, mental health issues today. A lot of the burden of care and, you know, as well as work roles are falling on women. And so midlife is an incredibly busy time of life for women. It's a, you know, I call it sort of a rollercoaster total wipe out course. And of course, the menopause hormone transition comes during that phase, so it can sometimes be difficult to know if you're not feeling well, you know, what symptoms that you're suffering from are due to hormone changes, and what symptoms are due to, you know, the general stresses of modern life. You know, multi-morbidities are more common today than they were 30 years ago in terms of, you know, health issues. There are so many different things-

Dr. Rangan Chatterjee 4:49 Yeah

Dr. Annice Mukherjee 4:49 ... and social media makes everything out to be simple, but people's lives and people's health are not simple.

Dr. Rangan Chatterjee 4:55 We're definitely going to get into what kind of lifestyle changes women can make to feel better at all aspects of their life, how it can help them with hormonal symptoms, peri-menopausal, post-menopausal, whatever it might be. Before we get there though, I think you really raised some fascinating points for me. Societally, culturally, if we look at this, one thing you mentioned there was maybe 20, 30 years ago, women at that phase in life, let's say in their 40s, may have been through raising their kids. And, and obviously now with people, families, women having children later, it does shift when are you going to have those teenage children, when are you going to have those elderly parents at the same time when your body is going through all kinds of changes. But culturally as well, like I really think about this, we live much more individualistic lives these days, don't we? You know, many of us have moved away from our family, from our tribe, and so many families, many mothers are trying to raise kids by themselves. There's a lot of pressure- ... on everyone these days. I do agree with you. I think in many families, women take on an extra burden, and for all the kind of evolution that we've had, and of course it's great that women have so much opportunity, I don't think everything has changed enough. So what ends up happening, and I'd appreciate your perspective on this, what ends up happening is that women are probably under more pressure now than ever before.

Dr. Annice Mukherjee 6:40 I agree. I totally agree, and, and everything that you've said is absolutely spot on. Um, and also, you know, if you've got elderly parents, they might not be together. They might be in different parts of the world. There's a lot more traveling going on.

Dr. Rangan Chatterjee 6:52 Mm.

Dr. Annice Mukherjee 6:52 You're not near your elderly relatives. If you haven't got children, many of the women today have got incredibly challenging work roles as well, and ta- and taking on other responsibilities. So it, it... I do think women have, midlife women in particular, have more challenges today than ever before.

Dr. Rangan Chatterjee 7:10 So I wonder if a good place to go would be to talk about some of these terms, peri-menopause, post-menopause, menopause. I wonder if we could just go back to basics right at the start, and I read a pretty alarming statistic, uh, Annice, the other day. It was well over 50% of women, cert- certainly in this survey that I read, said that when they first experienced their very first periods, they were petrified. They're getting scared when they're experiencing their first period, and from the women I've spoken to, presumably that's around education, whether your mother, your school, your community discussed it or not. So I wonder if you could just speak to that initially, and then broaden it out as to what happens. What are these different phases? What are they called, and why do we need to know about them?

Dr. Annice Mukherjee 8:00 Yeah, I mean, it's absolutely right. Teenage girls, you know, going through adolescence often still don't really know what's going on, and it can be frightening, the changes that are occurring to their body if they don't know, if no one's talking about it. And it's similar during the menopause transition, and that's why it're really important for us to raise awareness because if a woman notices changes in her, you know, symptoms, wellbeing, her periods, and she knows what's going on, she's ahead of the game. She can s- you know, start to think about things that, that are causing her symptoms. She knows what's happening. She can work out strategies that might help with symptoms. She'll know when to seek help. So, so the raising awareness bit is really important, as long as it just doesn't focus totally on the negatives, which is what we, we mentioned before. Um, so I mean, in terms of the terminology, if you want to talk about-

Dr. Rangan Chatterjee 8:52 Yeah

Dr. Annice Mukherjee 8:53 ... the terminology, um, so puberty, I think most people know that puberty in boys and girls is, um, when they go from very low hormones, a little bit like in post-menopause, through to secondary sexual characteristics and fertility.

Dr. Rangan Chatterjee 9:07 Right.

Dr. Annice Mukherjee 9:07 So prepubertal children are not fertile. They go through puberty. They develop longitudinal growth, secondary sexual characteristics, and then they become fertile. So then you've got all your pre-menopausal years, which are your fertile years, so we call that pre-menopause, and that, in women, is depicted by usually a regular cyclical, uh, cycle of, of periods. So we usually say monthly periods, but every woman will have a slightly different, um, timing of their menstrual cycle, and we call that the infradian rhythm. Um, it's a body clock, so every woman's body clock will be different. Interestingly, women who are fertile who live together align their body clocks, which is fascinating. We don't understand why that happens, but they tend to align. And it, it's, it's all, um, related to a field of medicine that's growing, actually, called chronobiology, uh, 'cause there's a number of body clocks. Most people know about circadian rhythms, which is the day-night rhythm, but, but the infradian rhythm is, is the female cycle bo- body clock.

Dr. Rangan Chatterjee 10:10 Ah.

Dr. Annice Mukherjee 10:10 And so that happens obviously through, uh, younger adult life, and then at some stage, the eggs start to run out, and essentially menopause occurs when a woman's finite resource of eggs, which she's actually born with in her ovaries, runs out. But it's not a sudden... It's not a s- an on-off switch. As she has less eggs in her ovaries, the, the, the periods can start to become less regular because the changes in hormones which occur every single day of the month through a woman's monthly cycle are related to changes in estrogen, progesterone, testosterone through that month, and i- it's all based around release of the egg.

Dr. Rangan Chatterjee 10:51 Right.

Dr. Annice Mukherjee 10:51 So it's quite a big deal. The, the, the energy required to produce a monthly cycle is like a little miracle every month for women.

Dr. Rangan Chatterjee 10:58 Okay, so a woman at birth is born with all the eggs that she's going to have. So the woman's got all of that potential within her already. What is it that happens at puberty? What's the stimulus to the female body to start changing and developing and start having a period, basically?

Dr. Annice Mukherjee 11:21 Well, that is, is quite complex, and that's been studied quite a lot recently. It all comes from the hypothalamus and pituitary within the brain, so the master hormone glands of the brain. And we recently discovered a, uh, a sort of a neurochemical, neurohormone called kisspeptin, which is brand new, and all, all the incredible neuroscientists-

Dr. Rangan Chatterjee 11:41 Yeah

Dr. Annice Mukherjee 11:41 ... neuroendocrinologists, um, talk, are talking about this at the moment because we didn't really understand why that occurred.

Dr. Rangan Chatterjee 11:48 Wow.

Dr. Annice Mukherjee 11:48 Why at the end of puberty did s- the egg release start to happen? And so it's complicated, and, you know, I'd love to make it all simple, [laughs] but it isn't. Um, but we, we now understand that much better, and that's actually helping a lot of current really state-of-the-art research looking into infertility, um, because, y- you know, it is precarious. You know, not everybody... [laughs] It, it doesn't work nice and smoothly and synchronously for every single woman.

Dr. Rangan Chatterjee 12:14 So there's a message from the brain essentially-

Dr. Annice Mukherjee 12:15 Yeah

Dr. Rangan Chatterjee 12:16 ... of some sort that sends a signal to the body, "Okay, time now for puberty. Time now for things to start changing."

Dr. Annice Mukherjee 12:23 Yes.

Dr. Rangan Chatterjee 12:24 A friend I, I spoke to literally this weekend said she can still remember having her first period at school- ... in the toilet and she was literally petrified. She didn't know what was happening. She thought she was going to die. And she actually told me that actually one of her friends at school was the one who told her, "No, no, I've been through this. This is okay." And she said she went home and spoke to her mum, and her mum still didn't say anything. She just pointed her to the bathroom where these sanitary towels were sort of there on the shelf, but no one had ever spoken about them. So if there is, you know, a mum or a dad who wanted to talk to their children about this, what, what would, what's important for them to know?

Dr. Annice Mukherjee 13:06 Well, it is im- important to talk about it and to talk to their daughters. You know, it's very, very important. It's actually taught in schools now, so at school, girls and boys will be taught about this, and they'll often, there'll be communications with parents about the, you know, talking about, that they're gonna be talking about the topic and it, and it would be good to expand on that at home.

Dr. Rangan Chatterjee 13:27 So this is a good thing in your view?

Dr. Annice Mukherjee 13:29 To raise awareness, absolutely.

Dr. Rangan Chatterjee 13:31 Yeah.

Dr. Annice Mukherjee 13:31 To raise awareness of all aspects of women's health is really important. It has not been talked about enough, and it is starting to be talked about. And, you know, I think working in my field, I think everybody knows now, but they don't.

Dr. Rangan Chatterjee 13:43 Yeah.

Dr. Annice Mukherjee 13:43 They really don't. Um, and the story that you described is, was really, really common 20, 30 years ago. I'd like to think it wasn't common nowadays, because actually girls get a lot of information from social media as they're getting older. Um, and they get information from school, and I hope parents are talking more openly to their daughters and sons.

Dr. Rangan Chatterjee 14:02 You, you've seen so many patients over 30 years, and have you noticed between different ethnicities or cultures, have you noticed, um, a difference in the tendency or the desire to talk about these things? Because of course, every culture's different and in some cultures it's pretty open to talk about female hormones and periods and things like that.

Dr. Annice Mukherjee 14:27 Mm.

Dr. Rangan Chatterjee 14:27 But in other cultures, it's probably a bit more taboo. What, what's your experience been of that?

Dr. Annice Mukherjee 14:33 Well, I think 30 years ago it was taboo in pretty much all cultures. [laughs] I mean, even i- in Western cultures, which are, te- tend to be more vocal in talking about things, all women's health aspects were, were very little talked about.

Dr. Rangan Chatterjee 14:46 Mm-hmm.

Dr. Annice Mukherjee 14:46 So if I saw a patient in clinic, they'd be sort of surprised that I'd be talking, you know, openly about, about the topic because that's what we do as endocrinologists.

Dr. Rangan Chatterjee 14:53 Mm.

Dr. Annice Mukherjee 14:53 But, um, nowadays, there's, there's quite a discrepancy. So, um, white women [laughs] in the West tend to be more open about talking about hormones. Um, North America, UK, to some extent Europe, but it, it does vary even when you're talking about Western culture quite a lot. I gave a talk to the African and Caribbean Health Network recently, and it was really interesting, um, preparing the talk for them about menopause for International Women's Day, and it's very interesting that, um, Black women suffer probably more severe symptoms of menopause, but they don't talk about it, and they may suffer symptoms longer. But it, it's, it's still much less talked about than, than it's talked about in white women. Most of the research on menopause and lots of aspects of women's health are in white Caucasian women.

Dr. Rangan Chatterjee 15:51 Yeah. I mean, it's so, so interesting. Before we get into some of these lifestyle changes that people can make, the, the other thing I was thinking about, um, in particular in relation to this, I think, very negative view the menopause has a lot of the time on social media, and I came across some research. I don't know what, what your view on this is, uh, Annice. Um, someone called Dr. Mary Jane Minkin, professor in obs and gynae and reproductive health at Yale Medical School, she did some research where she concluded, "In societies where age is more revered and the older woman is the wiser and better woman, menopausal symptoms are significantly less bothersome. Where older is not better, i.e. Western culture, many women equate menopause with old age and symptoms can be much more devastating." So I guess my broader question is how much does our view of what it means to be old, of what the menopause actually is, how much of that view influences, do you think, our experience of it?

Dr. Annice Mukherjee 17:06 Very significantly.

Dr. Rangan Chatterjee 17:07 Really?

Dr. Annice Mukherjee 17:07 Very significantly, yes. And it's absolutely true. That, that, that is an observation that's been, you know, seen and some Asian cultures are, are more revering of menopause. In Japan, I think menopause is, is, I don't think it has a name.

Dr. Rangan Chatterjee 17:24 Yeah.

Dr. Annice Mukherjee 17:24 And certainly there was no name for hot, hot flushes or flush, the vasomotor symptoms. But it, it, it's a sort of a respected state, and I think at the moment in general society and through social media, we have this sort of anti-aging culture.

Dr. Rangan Chatterjee 17:38 Mm.

Dr. Annice Mukherjee 17:38 Anything that could be related to aging is, you know, negative. And there is a fightback because, a- and myself included, we, you know, I think we should be talking about pro-aging and healthy aging, not anti-aging.

Dr. Rangan Chatterjee 17:54 Yeah.

Dr. Annice Mukherjee 17:54 None of us can stop the aging process, although social media would make, make you think you could.

Dr. Rangan Chatterjee 17:59 Yeah.

Dr. Annice Mukherjee 17:59 And I think it's associated, it's, it's a very loaded statement, anti-aging, and I think it does make women feel that menopause is symbolic to aging, which, in a negative way, which it shouldn't be negative. It should be we've got so much life experience, knowledge.

Dr. Rangan Chatterjee 18:15 Yeah.

Dr. Annice Mukherjee 18:15 You know, um, it, it's actually your, your fertile years, I, I mentioned, you know, you're going through regular monthly cycles. It's exhausting for the body. I see so many younger women with hormone imbalances. They have to have bleeding every month. The hormone fluctuations can cause lots of symptoms. Post-menopause, you don't have to have a regular bleed. Actually, you're not deficient in hormones. The post-menopausal ovaries and the adrenal glands produce estrogen and testosterone post-menopause, but not enough to create fertility, not enough to create a menstrual cycle.

Dr. Rangan Chatterjee 18:48 So it's not a state necessarily of hormone deficiency as you write in your book?

Dr. Annice Mukherjee 18:52 Yes, it's not a state of hormone deficiency. It's a, it's a state of lower stable levels of hormones, and there are exceptions, Rangan, because if you have both your ovaries removed or if you have both your adrenal glands removed or you don't have adrenal function, that can have a significant impact on hormone production. But most women who go through menopause haven't had both their ovaries removed and haven't had their adrenal-

Dr. Rangan Chatterjee 19:15 Yeah

Dr. Annice Mukherjee 19:15 ... glands removed.

Dr. Rangan Chatterjee 19:17 That idea, a- and you really emphasize this in your book, that menopause is not a deficiency state, I think it's so important because as a medical doctor who has seen tens of thousands of women, uh, throughout my career as patients, you know, this is very, very important to me how we think about these things, how we frame these things. Um, I think your final chapter in the book is my favorite. You know, there's, there's so much practical information in the book, but it's really an empowering, uplifting, inspiring end. This is what you write. You, "I would love to make menopause into a positive word, something for younger women to aspire to and men to respect." Now, I thought that was really key because it's easy to think that what we're gonna talk about throughout this conversation is only relevant for women, but it's not. It's just as relevant for men as well and-

Dr. Annice Mukherjee 20:15 Mm

Dr. Rangan Chatterjee 20:15 ... uh, in, in the intro to your book, you say that 13 million, one three, 13 million people in the UK are peri to post-menopausal.

Dr. Annice Mukherjee 20:25 I think the latest statistic's higher than that now actually, [laughs] but yeah, it's going up.

Dr. Rangan Chatterjee 20:28 Right. So first of all, just remind us what peri to post-menopausal-

Dr. Annice Mukherjee 20:31 Yeah

Dr. Rangan Chatterjee 20:31 ... means, what it encompasses.

Dr. Annice Mukherjee 20:33 Mm.

Dr. Rangan Chatterjee 20:33 And then if it is high, even that is pretty much a quarter-

Dr. Annice Mukherjee 20:38 Mm

Dr. Rangan Chatterjee 20:38 ... of the population, right?

Dr. Annice Mukherjee 20:40 Yeah.

Dr. Rangan Chatterjee 20:41 So that quarter are of course interacting with the rest of the population, so I think we all need to know about this.

Dr. Annice Mukherjee 20:48 Definitely. So perimenopause is a h- a hormone imbalance phase as the ovaries are starting to sort of, I, I, I describe it as misbehave. They're not able to produce the nice, harmonious monthly cycles as a woman would be able to produce when, in her younger years because the eggs are running out, and actually, the egg release every month is integral to the hormone changes during-

Dr. Rangan Chatterjee 21:14 Mm

Dr. Annice Mukherjee 21:14 ... every monthly cycle. So perimenopause, you know, it can be very short, from, from a f- few months to several years, and it can be depicted by symptoms that are sim- similar to menopause symptoms, which we can talk about. Um, but particularly also period irregularity, and that can be more frequent, less frequent, more painful, less painful, um, periods. So the periods can change in perimenopause, but you can be perimenopausal and still be having regular periods. And in perimenopause, the hormones can be extremely high or extremely low. They can change very rapidly, and I often describe it as a bit of a hormone rollercoaster, and then menopause is essentially the time when your periods stop. But because, you know, y- your periods can stop for six months in perimenopause and then restart, we, we time menopause as, well, it's, it's when you've had no more periods, so we define that as a year later. 'Cause when you've had no periods for a year, we know that a year ago you went through menopause. So it's a retrospective diagnosis.

Dr. Rangan Chatterjee 22:16 So you only know after the event-

Dr. Annice Mukherjee 22:18 Yeah

Dr. Rangan Chatterjee 22:18 ... that I have now been through the menopause?

Dr. Annice Mukherjee 22:20 Yes.

Dr. Rangan Chatterjee 22:22 If we perhaps go through different ages, maybe that will be a nice way for-

Dr. Annice Mukherjee 22:29 Mm-hmm

Dr. Rangan Chatterjee 22:29 ... people to get their heads round what happens, what are common symptoms, how can they be treated, for example. So do you think that's a good way to look at this topic?

Dr. Annice Mukherjee 22:38 It is. It is. So younger women a- a- are also subjected to different hormone problems and imbalances, so there are a number of different conditions. Premenstrual disorders, premenstrual syndrome or premenstrual tension, more severe premenstrual dysphoric disorder, which is where you can get quite severe symptoms-

Dr. Rangan Chatterjee 22:57 Mm

Dr. Annice Mukherjee 22:57 ... as the hormones change through the month. Polycystic ovarian syndrome is a metabolic condition that can result in women having less often, less frequent periods, so, you know, several months of missed periods or irregular periods. So there are quite a lot of different hormone problems and imbalances that can affect younger women-

Dr. Rangan Chatterjee 23:16 Mm

Dr. Annice Mukherjee 23:17 ... during those fertile years. Obviously, different fertility problems. There are gynecological problems like endometriosis, which can affect women's health through that, those fertile-

Dr. Rangan Chatterjee 23:27 Right

Dr. Annice Mukherjee 23:27 ... years of life. Um, now in terms of sort of diagnosing menopause and, and numbers and rates, it, it varies between ethnic groups. We, we tend to say about 1% of women will go through menopause under the age of 40 years, so that's quite young, and usually there'll be some other medical problem that's, that's led to that. Um, sometimes it's just a, it's a family history of early menopause, but usually there's, there's other causes, and if it's before 40, we call it premature ovarian insufficiency. And about one in 1,000 women will go through menopause under the age of 30, so that's pretty young, and it's not on anybody's radar. When I see younger women going through an early menopause, unless it's after a cancer diagnosis when it's more predictable, it's, it's diagnosed very late, 'cause if a, if, if a woman says sh- you know, she's in her 20s and she's not having regular periods, the, the, the first thought process is not by, by who- whatever doctor or healthcare professional she sees, the first thought process is not this could be menopause.

Dr. Rangan Chatterjee 24:27 Yeah.

Dr. Annice Mukherjee 24:27 So that's often diagnosed very late.

Dr. Rangan Chatterjee 24:28 And, and why is it that a woman- um, may go through it in their 20s. Is this normal physiological, it just happens to some women, or is it secondary to something else?

Dr. Annice Mukherjee 24:38 It, it, it's obviously very rare, one in 1,000. It might, it's, it, it can be either, so it can be due to an autoimmune condition.

Dr. Rangan Chatterjee 24:44 Right.

Dr. Annice Mukherjee 24:44 So like most people have heard of things like autoimmune thyroid problems, you know, the, uh, r- arthritis type problems can be autoimmune. You can get an autoimmune disease that stops the ovaries from working-

Dr. Rangan Chatterjee 24:55 Mm-hmm

Dr. Annice Mukherjee 24:55 ... pathologically early. Um, it can be related to other treatments, so women who've had chemotherapy. So we're seeing a, a huge increase in long-term survival after cancer treatments now, thankfully, you know. Um, many, uh, younger people who have various different solid organ cancers and blood cancers and lymphomas are treated with very toxic chemotherapy-

Dr. Rangan Chatterjee 25:19 Right

Dr. Annice Mukherjee 25:19 ... and that can cause, um, an early menopause. So that's more predictable, 'cause, uh, you know, the doctors caring for that woman will, will be aware that, and they'll make her aware that she might go into an early menopause.

Dr. Rangan Chatterjee 25:31 So menopause typically happens at what age, are you saying?

Dr. Annice Mukherjee 25:38 So the average age in Caucasian women is 51, um, but it, it's quite variable. So in Black women, it's a- around 49. In Indian, Asian women, it's around 46. In the Far East, it's more like 48. So it, it actually varies, and we don't actually know why there is such a variation in average age of menopause between different ethnic groups.

Dr. Rangan Chatterjee 26:01 Okay, so a woman's in their fertile years, and at some point they start to get symptoms. Let's go through what are the common symptoms that women will experience, and then how are they meant to know if this is related to their hormones and them being perimenopausal, or whether it's completely unrelated?

Dr. Annice Mukherjee 26:26 So the most common ones would be a woman experiencing symptoms prior to her menstrual bleed. That's always when a woman will feel a little bit more vulnerable, as her estrogen is dropping at the end of the month, whether she's 18 or 45.

Dr. Rangan Chatterjee 26:38 And can we call that a normal thing?

Dr. Annice Mukherjee 26:41 It's very difficult. There's, there's not hard lines between, between these things. I mean, w- I have to emphasize that other things that are going on in your life can impact the severity of-

Dr. Rangan Chatterjee 26:52 Mm

Dr. Annice Mukherjee 26:52 ... hormone symptoms. So if you're under a lot of stress, stress hormones suppress healthy hormones. It's just a fact. You know, cortisol, if it's dysregulated, will suppress female hormones. So, so if you're very stressed, you might have a month where your symptoms are much worse, and then another month when you're, you know, you've had less stress, you might not have as severe symptoms. But if a woman's having symptoms ev- with every menstrual cycle, that is a suggestion that she's got a degree of hormone imbalance. And there is a little bit of a gray, gray area between what might be a premenstrual disorder and what might be something progressing into perimenopause. And in perimenopause, you know, the symptoms can be relatively similar to the symptoms that a younger woman would be experiencing as a-

Dr. Rangan Chatterjee 27:41 Mm-hmm

Dr. Annice Mukherjee 27:41 ... premenstrual disorder. So it, it really, it... I will say to my patients if they feel that they're losing wellbeing at certain times, and they're not sure what it is, and they might have impacts on sleep, on mood, you know, might be getting a bit hot and sweaty, I ask them to keep a diary of symptoms, 'cause that can sometimes help them understand, is this really related to my menstrual cycle, or actually, is it actually related to other things?

Dr. Rangan Chatterjee 28:06 Yeah, keeping a diary's really interesting. I've had several patients throughout my career who for various religious reasons are keen not to use contraception, and so these women would be very, very particular about taking temperatures and, and diarizing what's going on so they know when they are likely to be fertile and when they're unlikely to be fertile. And one of the things that they would often say is that they started to become more in touch with various parts of the cycle. They would start to identify patterns. I mean, if we ta- talk about something else, like food diaries, for example, when people start documenting things and seeing, oh wow, when I have that food, I have tummy cramping and bloating, it, it just starts to help build that own self-awareness. So it's really about empowerment, isn't it?

Dr. Annice Mukherjee 28:59 It absolutely is, and, and I'm not saying everyone should be over-focusing on every symptom they get, because hypervigilance can be a problem with-

Dr. Rangan Chatterjee 29:06 Yeah

Dr. Annice Mukherjee 29:06 ... with, with health. But it, it can really be helpful if you're, if you're running into difficulties, and it is, it can be empowering, because you can look back, you can see patterns, and it's insightful because you can think, ah, actually, I was stressed, so maybe I can do something about that stress. Maybe I was overcommitted, you know, something else was happening. And it, it, it helps you paint a picture for yourself, and it, it also, the key point there is that every single woman is different at, at every stage in her, you know, hormone lifespan, during the perimenopause. It's not the same for everybody. So I think that also feeds into if you see f- you know, scary stories in social media about somebody having a terrible problem, or even s- scary stories somebody has a terrible problem, and then they found a miracle cure, it doesn't mean that's gonna work for everyone.

Dr. Rangan Chatterjee 29:53 Mm-hmm.

Dr. Annice Mukherjee 29:53 Because actually, the treatments for, for, for the various different hormone problems that I see, it will vary even with the same condition as to, you know, the needs of, the individual needs of that woman.

Dr. Rangan Chatterjee 30:07 Stress can worsen symptoms, so let's talk about some of the symptoms that I guess people commonly associate with perimenopause and menopause, night sweats, mood disturbances, fatigue, you know, weight gain, um, hot flushes. If we look at those symptoms through the lens of stress, in your experience, can stress management potentially help with a lot of those symptoms?

Dr. Annice Mukherjee 30:38 The short answer is absolutely yes, it can. The narrative answer is, is more complicated

Dr. Rangan Chatterjee 30:43 To make sure you're taking action after watching this video, I've created a free breathing guide that's gonna help you reduce stress, calm your mind, and boost your energy. In this guide, I share with you six really simple breathing practices that work immediately. Even just one minute a day will start to make a big difference. To receive your free guide, all you have to do is click on the link in the description box below

Dr. Annice Mukherjee 31:11 So there are some symptoms that are very tightly linked with the menopause hormone changes or the peri-menopause transition, whatever you want to call it. Um, the vasomotor symptoms, which are the hot flushes, flashes, night sweats, are very tightly linked to the drop in estrogen, and the severity of those symptoms is very variable. So about 80% of women going through the menopause transition will experience those symptoms, but that doesn't mean that they're gonna be, you know, severe. That doesn't mean it's going to be impacting on everything to do with their lives. But there are a number of women, and we don't understand why, that suffer really severely with those vasomotor symptoms. Now, those symptoms are tightly linked with hormone changes, and if you're having drenching night sweats every night so that you're having to change your bed clothes three times a night, which I've seen that happening-

Dr. Rangan Chatterjee 32:08 Mm

Dr. Annice Mukherjee 32:08 ... and then you're not sleeping because you're so disrupted at night, you will have brain fog the next day. You will be exhausted. You know, you've had no sleep. You'll be hungrier during the day because you're not sleeping. That all links very tightly into the menopause symptoms, and if you're stuck in a rut, it can be quite difficult to manage, you know, to, to use stress management to get out of that cycle. But that is not the majority of women. The majority of women will h- will say to me, "Yeah, I notice hot sweats and flushes. They're not really bothering me, but isn't that, doesn't that mean I'm going through the menopause?" And that bothers me, you know, but actually the symptoms, the heat symptoms aren't severe for most women, although most women will experience them. So then we can look at other symptoms, so the irregular periods. So in the menopause transition, if a woman's having absolute flooding and severe pain which is erratic or unpredictable a- and it's causing anemia because she's bleeding so much, she might be bleeding chronically, she might be bleeding, you know, for multiple days in a month, that's exhausting-

Dr. Rangan Chatterjee 33:14 Mm

Dr. Annice Mukherjee 33:14 ... and we need to address the cause of that, which is very linked with the h- hormone transition. So the vasomotor symptoms and the, and heavy painful periods are, can be really difficult to then just manage with lifestyle, i- i- i- y- because they can really affect everything that's going on in that woman's lives. However, there are a lot of symptoms in today's world across society that are being attributed to menopause and mid-life women, but actually may not be as tightly linked with the menopause transition, so things like overwhelm, anxiety, sleep problems. There, there are other causes of those symptoms across society. You know, it's not just hormone changes that are affecting sleep problems across society. You know that sleep problems in the pandemic were, exponentially rose. You know, there are many modern world factors that disrupt sleep, you know, blue light on devices that, you know, suppress melatonin and delay melatonin release. There's many other factors. It's a, it's like a matrix trying to work out what, what, what your symptoms are caused by.

Dr. Rangan Chatterjee 34:19 Yeah, so whilst the growing awareness of menopausal symptoms on social media across society is a good thing, one of the downsides can be that we doctors, um, women are maybe putting things down to their hormones and the menopause when it's possibly completely unrelated. I think that's a, a really, really important point. Annice, why is it if we take a 30,000-foot view on this and go, okay, by definition, all women when they transition from being fertile to being post-menopausal, when they are no longer fertile, my understanding is that every single woman will have a change in their hormones, but not every single woman will have menopausal symptoms. So when we look at that, and of course the, the human body is very, very complex, one might go, "Okay, everyone's hormones are changing, but not everyone's getting symptoms." So is it just the hormones, or of course there's individual variation, but at the same time, are there other factors going on in their life, let's say the stress load they are under, which we've obviously spoken to how much stress there is on women? What I have seen in general practice, more often than not, when a woman was suffering with severe menopausal symptoms, not, not in every case, but in a lot of cases, there was also a lot of stress. Now, could it be that the menopausal symptoms were making them feel bad and increasing the stress in their lives, or could it have been the other way around? I'm sure it was a bit of both, whereby, you know, chronic stress was potentially exacerbating their symptoms. Uh, quite a little bit there. I wonder if you could unpick some of that a- and share some of your thoughts.

Dr. Annice Mukherjee 36:17 Yeah. So as we, as we've already discussed, modern lifestyles are much more adverse than they were 20, 30 years ago. There's been a paradigm shift in women's lives, actually in all of our lives-

Dr. Rangan Chatterjee 36:29 Mm

Dr. Annice Mukherjee 36:29 ... throughout, throughout, you know, men and women of all ages. So- The stress factor and the adverse lifestyle factor is, is definitely a new factor in terms of, of the symptoms women are having to experience during the menopause transition. And the human body is complicated, and we know that even from studies done 20 years ago, about 25% of women will have severe menopausal symptoms. It's, it, it, you know, we haven't had y- a study that can tell us if that's increased or not in today's world, but I would probably say symptoms during the menopause transition are worse, but i- is something changed about menopause itself or is it from the outside? Are there things going on? And I think it's more likely that, um, there are other things going on in women's lives that are making their menopause experience more difficult to, to navigate. And, and, you know, w- we can, I mean, we can talk about this later, but you know, if you look then at the treatment that we recommend for menopause symptoms, the first line treatment if we're going down a medication route would be hormone replacement therapy or menopause hormone therapy. And what I know and what's evident from research, um, because there was a very nice report done last year, um, by the Fawcett Society, 4,000 women were surveyed who were on hormone replacement therapy. 54% said that the HRT had resolved their symptoms, and th- that was probably women who'd gone on HRT for, for hormone, for menopause symptoms. 46% said it hadn't.

Dr. Rangan Chatterjee 38:02 Mm.

Dr. Annice Mukherjee 38:02 Right? So it's not helping every single woman, even if you're targeting the actual cause, which is the low estrogen.

Dr. Rangan Chatterjee 38:13 For a woman who thinks that they may be perimenopausal or menopausal, right, and is getting symptoms and is seeing things online and they're thinking, "Wow, I think this is th- I think that's me," right? "What that lady is describing or what that doctor's describing or like that, that's me. That's my life," how are they to know if this is the menopause or not? Are there blood tests, for example, which can help, or can they be misleading?

Dr. Annice Mukherjee 38:42 Well, while a woman is still having periods, as I mentioned, the perimenopause is a hormone rollercoaster, so blood tests are not really very helpful because you might do a blood test and it looks normal, but you might repeat it a week later or a month later and it's very abnormal. So we tend to say, actually, perimenopause, it should be a clinical diagnosis. You should be excluding other potential causes for symptoms. A clinician should be looking for red flags in their patient. But if, if there's nothing else-

Dr. Rangan Chatterjee 39:07 C- can you ex- for people who don't know, can you explain what a red flag is?

Dr. Annice Mukherjee 39:10 Red flag. So, so, um, i- in a clinical consultation, you know, if, if a woman is saying, "I've got hot flushes, night sweats, brain fog, anxiety, it's all new, I've got sleep problems," then they're pretty typical. There's no red flags there. If a woman comes and says, you know, "I've lost two stone in weight. I'm not sleeping. Um, I'm having night sweats, but I've, I'm also feeling absolutely exhausted. I haven't been able to work for three months," th- th- th- it's a more extreme paradigm, and things like weight loss, um, is, is something that we don't expect, significant weight loss. Equally, you know, if a woman says, "I've got severe palpitations," it can be due to menopause changes, but that would need to be looked at separately. Um, i- you know, if a woman says she's absolutely exhausted, she's, she's, you know, was completely fine and, and over the last few months, she, she's exhausted, blood tests are gonna be needed to see if there's a thyroid problem, if there's anemia, if there's something else going on with the liver or kidneys. So a doctor will, should be able to identify if there are concerning features in that history quite easily. Um, so the, the, the key then is if a woman ha- is experiencing symptoms, she and her health professional think that perimenopause or the menopause transition is causing or contributing to those symptoms, then she should be offered a trial of treatment as long as she has no risk factors, con- contraindications to that treatment, which would usually be hormone therapy. And hormone therapy works pretty quickly. It- it's sort of somewhere b- I mean, as, as early as two weeks for treating the vasomotor symptoms which are impacting sleep, energy, mood. Um, it can take up to three months, so we would, I would normally say try, try treatment for three months. If, if after three months of taking treatment a woman says, well, her, her hot flushes, night sweats have gone, but she's still feeling exhausted, she's still gaining weight-

Dr. Rangan Chatterjee 41:07 Mm

Dr. Annice Mukherjee 41:07 ... she's still getting migraines, or she's still got brain fog, overwhelm anxiety, we need to be looking at other causes for those symptoms.

Dr. Rangan Chatterjee 41:16 Right.

Dr. Annice Mukherjee 41:17 And that goes back to modern life, stress. Many women I see in my clinics come to me and they say, "I've tried six different hormone therapies and my symptoms are more severe or exactly the same as they were," or, "in fact, my symptoms are the same and I've now got side effects from the treatment." And then I look into their lives and they've got the most unbelievable challenges, and I think women almost are a victim of their own success-

Dr. Rangan Chatterjee 41:41 Yeah

Dr. Annice Mukherjee 41:41 ... because they just think they can take on everything and do everything for everyone. And our bodies are not, are, are not invincible.

Dr. Rangan Chatterjee 41:48 Mm.

Dr. Annice Mukherjee 41:49 And that stress on the body, even if it's not psychological, if it's, it's physically stressful to do what that woman is trying to do, it doesn't matter how much hormones we give, it's not going to cure the underlying cause.

Dr. Rangan Chatterjee 42:02 So powerful, a- and it, it really makes me think about one of the other ideas that you write about and I've heard you speak about, that a woman can actually prepare for perimenopause and menopause. You really make the case that actually that time can often simply exacerbate underlying issues. So the issues were already there. Maybe women were pushing too hard, they were taking too much on, they were chronically stressed, and then the perimenopause happens. There are starts, starts to be fluctuating hormone levels- And yes, of course, it can be down to the hormones, which might require HRT in the right patient, but it can also be a reflection that this is almost like a, a warning sign to say, "Hey, listen, if you can start making some changes, not only can your perimenopausal symptoms get better, but also you can probably learn things about yourself and your life that are gonna help you, yes, now, but also for the next few decades." Would you agree with that?

Dr. Annice Mukherjee 43:10 Absolutely. Absolutely. So, you know, I sometimes say to my patients, "You know, you, you've really been building up some of, of these, you know, overcommitments, challenges, adverse lifestyle." It's... We're all guilty of it, you know?

Dr. Rangan Chatterjee 43:23 Mm-hmm.

Dr. Annice Mukherjee 43:24 And the perimenopause, you can look at it one way, it's like the straw that breaks the camel's back, you know? You can't do this any longer. Your body's telling you no. But equally, it is an opportunity if you start to get symptoms, and they're not severe, but you start to think, "Oh, gosh," it's an opportunity to take back control or, or, or maintain control to stop the symptoms from progressing. And I'm not at all saying that if a woman is experiencing symptoms she shouldn't use treatments that are gonna be helpful, such as hormone therapy if, if she's, if she can take it, because, you know, it, it, it, it will help the hormone changes.

Dr. Rangan Chatterjee 44:01 Mm.

Dr. Annice Mukherjee 44:01 But if you take hormone therapy and your symptoms don't improve, you need to, you need to be looking more widely and reflecting more widely at why that is. And if they do improve, it's still helpful to apply, you know, self-care and lifestyle approaches that are going to help with your long-term health, even if, even if your symptoms do resolve with, with hormone therapy.

Dr. Rangan Chatterjee 44:23 How common is it for a woman to come and see you, and they're really struggling, they've got a lot of symptoms, and they think HRT is the answer? Do some people these days see it as a quick fix magic bullet, so that, "I, I don't want to make changes, my life is busy, I've got a lot going on"? And I'm, I'm sympathetic, I understand that. "If I could just get the HRT, my life would be okay. I could continue doing what I'm doing." Is that something you're seeing?

Dr. Annice Mukherjee 44:56 It, it is, and I d- I never, I will never say, "Here you go. Here's a prescription for HRT. You're perimenopausal." I, I start off by, "Tell me about your life. What is going on? Tell me about your health. How overcommitted are you? You know, l- tell me about your diet. Are you smoking?" Smoking makes menopause symptoms worse. "Are you drinking alcohol?" Alcohol makes, too much alcohol makes menopause symptoms worse. You know, our, it's a his- a medical history. Um, but, but I think, again, the social media algorithm with, with menopause is a catastrophe and hormone therapy is a quick fix does make women think, "Maybe I will. If, as long as I just take the hormones, everything will be fine."

Dr. Rangan Chatterjee 45:33 Mm.

Dr. Annice Mukherjee 45:33 And y- HRT, hormone therapy will help the symptoms that are specifically linked with menopause, but it won't cure all those other things.

Dr. Rangan Chatterjee 45:44 Well, let's talk about HRT.

Dr. Annice Mukherjee 45:46 Yeah.

Dr. Rangan Chatterjee 45:46 I don't think we've ever covered HRT in detail on this podcast. So I'd love to go through the basics for everyone, including how has the narrative changed over time. You know, there was all kinds of talk about risks, cancer risks, and the narrative on that. The prevailing view has started to change. As things stand now in 2023, what is the current view?

Dr. Annice Mukherjee 46:13 The current view in 2023 is that the most effective treatment to treat menopause symptoms is hormone replacement therapy, and for the majority of women experiencing symptoms that are affecting her in her life and she, she, she's seeking treatment, the, during the time she's got symptoms, which are for most women time-limited, hormone therapy, um, has much more greater benefits than, than harms. It's, it's, it's really effective and safe during the menopause transition to treat menopause symptoms.

Dr. Rangan Chatterjee 46:50 Okay, and do you know when HRT started?

Dr. Annice Mukherjee 46:53 So HRT started to become really popular in the early 1960s. They worked out that you could give estrogen to treat menopause symptoms. They didn't realize that at that time, in the 1960s, that you needed to give progesterone to protect the womb. So HRT's had so many rises and falls. So it was really popular because it, it helped with the aches and pains and the, the vasomotor symptoms and sleep. And then there was this huge rise in endometrial cancers because HRT didn't include progesterone at that point. The, the sort of logic that we need to protect the womb in women who have a womb with progesterone, because estrogen thickens the womb lining, that's the sort of side effect of estrogen, um, with, with all the benefits on it, it has on general wellbeing through the menopause transition. It thickens the womb lining. So then they worked out that you have to give progesterone to women who have a womb. You don't need progesterone if you've had a hysterectomy, if you've had your womb removed. It's just to protect the womb. And, and then, you know, different regimens were tried, different dosing was tried, and it was worked out that if you have, if you're in perimenopause, so you're still having some bleeding, we give progesterone for part of the month, but estrogen continuously, and we're tr- we're not really replicating a natural menstrual cycle, but we're trying to give you the estrogen all of the time and protect your womb lining.

Dr. Rangan Chatterjee 48:17 That, that's quite important. So HRT is not there to replicate the natural cycle. It's there to help with symptoms.

Dr. Annice Mukherjee 48:26 It's there to help with symptoms by giving you estrogen, but we have to give progesterone to protect the womb lining in women who've got a womb. So we give a higher dose of estrogen for part of the month in women who are perimenopause. That's called cyclical HRT. But if you're post-menopausal and you haven't had a natural bleed for a year, there's a different regimen. We just give a low-dose estrogen, progesterone all of the time, because- The endometrium doesn't need as much progesterone to be protected post-menopause

Dr. Rangan Chatterjee 48:52 So you mentioned that we know HRT now is very good for menopausal symptoms. Does that mean that you think most women should be taking HRT?

Dr. Annice Mukherjee 49:03 Um, I, I would take every single woman individually. We think from data we've got, uh, 25% of women experience severe menopause symptoms, but that's pretty established data, and in today's world, life is different, and it may be that more women need it. Do I think every woman needs it? Absolutely, 100% no. In fact, all the data we have suggests that most women either don't need it or only need it for the time they're experienced symptoms, and symptoms averages about seven years, range 2 to 10 years. B- but many women w- won't need it for symptoms. They'll say, "I'll get a few hot flushes, but it doesn't bother me." Um, I think the narrative at the moment is everyone should be on it. I... It might be controversial to say it's, it's almost, because of social media, a little bit fashionable. You know, "Yeah, I'm, I'm menopausal. I should be on HRT." And but it's not as straightforward as that because many women will then go on HRT and they'll say, "Oh, but I've gained weight" or, "I feel bloated," or, "I've got migraines or bleeding problems." So it's, it's not as straightforward-

Dr. Rangan Chatterjee 50:07 Yeah

Dr. Annice Mukherjee 50:08 ... as just going on HRT because a lot of women struggle with HRT regimens.

Dr. Rangan Chatterjee 50:12 Yeah, so you're saying 25% of women experience severe menopausal symptoms, and so if the prevailing view now is that HRT can help with menopausal symptoms, it seems reasonable that a good few of that 25% may well benefit.

Dr. Annice Mukherjee 50:33 Yeah.

Dr. Rangan Chatterjee 50:33 But of course, that, that means that 75% of women are not experiencing severe menopausal symptoms. So i- is, is that fair to say based upon what you've just said?

Dr. Annice Mukherjee 50:43 So what we know 80% of women will experience menopause symptoms. How many of those are going to feel they need treatment and how many of those are actually gonna benefit from the treatment isn't that clear. I think-

Dr. Rangan Chatterjee 50:57 This is complex, isn't it?

Dr. Annice Mukherjee 50:58 It's really complex, and we're seeing... we've seen, as you know, Rangan, a, a really high rise in HRT usage in the last two to three years.

Dr. Rangan Chatterjee 51:07 But are some women having it or being prescribed it when they don't need it?

Dr. Annice Mukherjee 51:10 From, from my perspective, I want my patients to feel well, be empowered, and achieve long-term health, to be able to apply lifestyle approaches to k- to keep them fit and well until they're in old age. The problem is women are going on HRT, and it's not a miracle cure. So now we're seeing women going, "I'm on HRT, but I don't feel well. I'm not on enough. I need more," or, "Maybe it's not being absorbed" or... and there's mass confusion. We know that the, the doses of HRT we have licensed are effective in treating menopause symptoms, and it... this goes back to if a woman goes onto hormone therapy and after three to six months she's got some ongoing symptoms, y- we need to be looking at what those symptoms are. Are they tightly linked with menopause, or do, does this go back to what we talked about in terms of women's complicated lives today, the commitments they have, the stress they're under, the lifestyle factors that are relevant? We need to be looking at what residual symptoms are on treatment. If that treatment works for a woman and it's a safe licensed treatment, then she can carry on that treatment, and it- that's brilliant. She should be given it.

Dr. Rangan Chatterjee 52:22 Mm-hmm.

Dr. Annice Mukherjee 52:22 And there is no ti- HRT is not time-limited. Some women say to me, "I'm never coming off. I can't... I'm, I do not ever want to stop treatment." That is the m- minority of women.

Dr. Rangan Chatterjee 52:35 Let's talk about cancer risk-

Dr. Annice Mukherjee 52:37 Yeah

Dr. Rangan Chatterjee 52:37 ... because you've touched on this already a little bit, but I think it, it would be really good to get real clarity for people because a lot of women don't want to take HRT. Now, they'll have different reasons for that. Some of the time the reason is because of what they read when there were real concerns over the long-term risks of HRT. I know you've touched on it a little bit, but to ask you a direct question then, is there an increased risk of cancer if a woman goes onto HRT?

Dr. Annice Mukherjee 53:16 I'm gonna have to give you a narrative answer there. So I'll go back to the womb cancer rates that happened in the sort of the, the 1960s, '70s, and then we worked out regimens of HRT that, that, that would prevent womb cancer, and that was fine. And then the Women's Health Initiative study was set up in the 1990s, and early publication in the early 2000s. It was actually 20- uh, 2002. And that study looked at women being commenced on, it was a randomized, double-blind con- placebo-controlled trial, and it looked at women being commenced on HRT between the ages of, I think, around 50 to 76. And, and that study showed an increased risk of new breast cancers in the hormone replacement treatment arm. The treatments that were used in that study were, it's fair to say, older-fashioned hormone regimens that included conjugated equine estrogens, which is a synthetic estrogen, and medroxyprogesterone acetate, which is a synthetic progestogen, and the overall results suggested an increased risk of breast cancer, and there were also increased risks of cardiovascular and cerebrovascular events in the women in the active treatment arm. The maj-

Dr. Rangan Chatterjee 54:25 So that means the women who were taking HRT.

Dr. Annice Mukherjee 54:28 HRT. But the majority of treatment was oral HRT. The majority of treatment was synthetic hormones. And actually, uh, you know, the, the, the main e- subsequent analysis suggested that the risks were generally in older women who'd started the HRT much later.

Dr. Rangan Chatterjee 54:44 So there was this study called the Women's Health Initiative study-

Dr. Annice Mukherjee 54:47 Yeah

Dr. Rangan Chatterjee 54:49 You know, I'm, I'm really trying to simplify it. Two groups, one group were taking HRT, one group were not taking HRT.

Dr. Annice Mukherjee 54:57 Yeah.

Dr. Rangan Chatterjee 54:57 And initially, there were concerns that in the group taking HRT, there was an increased risk of breast cancer, strokes-

Dr. Annice Mukherjee 55:06 Cardia-

Dr. Rangan Chatterjee 55:06 ... and some heart events

Dr. Annice Mukherjee 55:07 ... cardiovascular events, yeah

Dr. Rangan Chatterjee 55:08 So at that time, there was some negativity saying, "Whoa, we need to be really careful here."

Dr. Annice Mukherjee 55:12 Yeah

Dr. Rangan Chatterjee 55:12 ... because, yeah, so one hand we're helping women with symptoms, but on the other hand, we might be increasing their long-term risk.

Dr. Annice Mukherjee 55:17 Yeah.

Dr. Rangan Chatterjee 55:18 Now you're saying with a subsequent reanalysis of that data, it's more nuanced than that, isn't it?

Dr. Annice Mukherjee 55:24 It's very much more nuanced. So first of all, we know oral estrogen, the tablet forms, was used in the Women's Health Initiative study. So if you're taking HRT as tablets, it can increase the risk of blood clots and strokes, and oral estrogen, the risk is gonna go up. The risk of blood clots is higher in older people anyway.

Dr. Rangan Chatterjee 55:48 Okay

Dr. Annice Mukherjee 55:48 So if you're treating women in their 60s and 70s with oral estrogen-

Dr. Rangan Chatterjee 55:53 Mm

Dr. Annice Mukherjee 55:53 ... they're at a higher risk of blood clot-type events. So we, we, we do know, and we still know, and everybody agrees, that oral forms of HRT in the wrong women can put them at increased risk of blood clots, whether that be-

Dr. Rangan Chatterjee 56:06 Okay

Dr. Annice Mukherjee 56:06 ... deep vein thrombosis or strokes. But y- for, for younger women, that risk is very low. You know, if you're in your 40s and you're healthy, you've got a healthy lifestyle, the risk of a blood clot, you know-

Dr. Rangan Chatterjee 56:17 Is low anyway

Dr. Annice Mukherjee 56:18 ... is low anyway, unless you've got a family history or you're a smoker, you know, uh, uh, there's other risk factors. But the risks in women in their 60s and 70s is gonna be higher, and then if you give oral estrogen, that's risky. So actually, that meant that over the last 20 years, the HRT that has been utilized, we've moved more towards transdermal estrogen, so that's skin patch, spray, um, gel estrogen. Because when estrogen is given through the skin, it does not increase the risk of blood clots at all. So we've immediately taken away one of the big risk factors that was found in the Women's Health Initiative study.

Dr. Rangan Chatterjee 56:54 Were any of the women given transdermal-

Dr. Annice Mukherjee 56:57 Some were, but most were on oral

Dr. Rangan Chatterjee 56:59 So when they've relooked at that, they think, oh, actually, the women with transdermal-

Dr. Annice Mukherjee 57:06 Yeah

Dr. Rangan Chatterjee 57:06 ... uh, hormone replacement therapy as opposed to tablets-

Dr. Annice Mukherjee 57:09 Yeah

Dr. Rangan Chatterjee 57:10 ... they seem to be okay.

Dr. Annice Mukherjee 57:11 Yeah, and there's been many other studies done demonstrating that transdermal estrogen doesn't. It's to do with m- metabolism in the liver.

Dr. Rangan Chatterjee 57:18 Yeah. Well, that, that's brilliant. I think that's really helpful for people. Um, what about those other risks, then-

Dr. Annice Mukherjee 57:23 Yeah

Dr. Rangan Chatterjee 57:23 ... of, um, increased breast cancer?

Dr. Annice Mukherjee 57:26 Yeah. So there's been multiple analyses. There's been many different, uh, uh, big sort of, uh, meta analyses looking at what's the story with breast cancer and HRT. And again, it took probably almost 20 years to kind of tease it all out. Uh, the increased risk of breast cancer with HRT seems to be more with estrogen-progesterone combinations. So actually, we know up to 20 years of data, estrogen-only HRT, and I mentioned if you've had a hysterectomy, you don't need progesterone. Estrogen-only HRT amazingly doesn't seem over 20 years-

Dr. Rangan Chatterjee 58:09 Mm

Dr. Annice Mukherjee 58:09 ... to increase breast cancer risk at all. But estrogen with progesterone does increase breast cancer risk, but it's a, it's a cumulative increased risk. So it doesn't happen overnight. You don't start taking HRT and then three months later it's caused breast cancer. That, that doesn't happen. But certainly as time goes on, the longer a woman is on HRT, the background increased risk of breast cancer goes up, and it's not a, a huge risk. Um, a study that was published around 2019 suggested probably somewhere between 1 in 50 and 1 in 70 women treated for more than five years might end up with a breast cancer that they wouldn't have got otherwise. And so then we have to look at, you know, the benefits of the HRT.

Dr. Rangan Chatterjee 59:01 Yeah

Dr. Annice Mukherjee 59:02 Because if an, uh, an individual woman knows that she might have a slight increased risk of breast cancer, but if she's in the moment and her life is not worth living because she's got severe menopausal symptoms, she needs to take a view on balancing that risk and benefit, and that has to be an informed decision.

Dr. Rangan Chatterjee 59:21 Yeah

Dr. Annice Mukherjee 59:21 She has to understand her own risks. Now, th- those are kind of data that are just looking at, you know, all the data we have. But then we also need to think about modern lifestyles and breast cancer risk-

Dr. Rangan Chatterjee 59:34 Yeah

Dr. Annice Mukherjee 59:34 ... because carrying excess weight, smoking, excess alcohol, not doing enough physical activity all increase your risk of breast cancer. One in eight women get breast cancer.

Dr. Rangan Chatterjee 59:47 Yeah. This speaks to the importance of women seeing educated healthcare professionals to have this sort of nuanced conversation. If someone comes to see you in your clinic, then you're gonna be having these nuanced discussions with them and, and say, "Look, on one hand, yes, this may increase your risk here, but, you know, your lifestyle's fantastic. You've got no family history of breast cancer. You know, your symptoms are really bad at the moment." Let's say your, your night sweats are making your life miserable. Actually, maybe a few months, maybe one year of this [laughs] might really help your quality of life, which in turn is gonna help you stay focused on your lifestyle changes, which also are gonna reduce your risk. So it's, you know, this nuance is something that's very much missing in all these conversations, particularly in one-minute Instagram reels. It's very hard to get-

Dr. Annice Mukherjee 1:00:41 Yeah

Dr. Rangan Chatterjee 1:00:41 ... this nuance across, isn't it?

Dr. Annice Mukherjee 1:00:42 Yeah. And, and then, you know, you take it for a year, and then you reevaluate. And I would say it's, it's not about going on treatment and then just staying on it and that's it, 'cause actually the treatment, HRT isn't one thing. Your treatment requirements might change over time. You might- Find it's really effective at one point in your life, and then later you're getting more side effects than benefits. And most women, for most women, menopause symptoms are time-limited, and so most women do not need hormone replacement therapy for many, many years or decades to treat their menopause symptoms. You know, so, so actually, if it's used correctly, it's really, really important

Dr. Rangan Chatterjee 1:01:18 A- and again, to put it in context, we know there's a strong association, don't we, between alcohol intake for women and breast cancer. Um, I, I, I say that not to make anyone feel bad, but we have to be honest about [laughs] what the data is showing, right?

Dr. Annice Mukherjee 1:01:36 It's higher with, with excess alcohol than it is with HRT.

Dr. Rangan Chatterjee 1:01:40 Yeah. Are you able to speak to the relationship between alcohol and breast cancer?

Dr. Annice Mukherjee 1:01:45 Well, I mean, it's a, it's a complicated one, but we, we, we know h- with everything, even with women who've had breast cancer, alcohol inc- increases recurrence risk in women who've had breast cancer. It's probably s- somehow affecting e- estrogen levels, you know, m- well, 80% of breast cancers are e- estrogen driven, and alcohol a- has an impact on estrogen levels. Women still have estrogen post-menopause, and so in women who've had breast cancer, even if they're post-menopausal, we give them, uh, adjuvant therapy, aromatase inhibitors to block any estrogen that they have around in their system. That is a real, that is a real hormone deficiency state when we give, uh, aromatase inhibitors, and, you know, alcohol is probably somehow impacting on estrogen.

Dr. Rangan Chatterjee 1:02:29 If somebody has had breast cancer, breast cancer rates are very common, so, you know, there's many people who are listening or watching this who will either currently have breast cancer or have experienced it. Given the potential risks from HRT, is a previous history of breast cancer a contraindication for HRT, or are there certain instances where on balance it's like, yeah, okay, well, we need to give you this for your symptoms?

Dr. Annice Mukherjee 1:02:59 Yeah, and that's really important because as, as you say, um, breast cancer survivors are a significant proportion-

Dr. Rangan Chatterjee 1:03:06 Yeah

Dr. Annice Mukherjee 1:03:06 ... of midlife women. Um, treatments for breast f- pr- treatments for breast cancer often induce menopause symptoms, like chemotherapy, for example. And, and I also did want, as we were talking about HRT, to include, you know, those women who can't take HRT, who take it and it doesn't work, who take it, who get side effects from it and can't, or women who choose not to take it. So this is really important, and all of the impartial international menopause governing bodies recommend that HRT is a contraindication after a breast cancer diagnosis.

Dr. Rangan Chatterjee 1:03:48 For people who don't understand contraindication, you-

Dr. Annice Mukherjee 1:03:51 It, it should not be used after breast cancer, and that's not just estrogen receptor positive breast cancer because that, that is, um, 80% of, of breast cancers. But even in women who have triple negative breast cancer, which isn't hormone driven, they, if they get a recurrent, uh, if they get recurrence of breast cancer, secondary breast cancer, or if they get a second primary breast cancer, those secondary or second primary cancers in women who've had triple negative cancer can be estrogen positive. So we recommend that HRT is not used, systemic HRT is not used in anyone after breast cancer.

Dr. Rangan Chatterjee 1:04:26 Systemic, so you mean these e- these transdermal patches?

Dr. Annice Mukherjee 1:04:30 Yeah, so wh- when I say systemic, I, I often get, uh, uh, uh, comments if I, if I mention HRT is contraindicated from women who say, "Well, I've been told that I can have vaginal estrogen," which is used to treat, you know, the genitourinary symptoms associated with menopause. Vaginal symptoms can occur pretty much at any time peri- to post-menopause. They may, they're, they're very varied. It might be itching, soreness, burning, pain-

Dr. Rangan Chatterjee 1:04:56 Hmm

Dr. Annice Mukherjee 1:04:56 ... um, recurrent water infections.

Dr. Rangan Chatterjee 1:04:59 Right.

Dr. Annice Mukherjee 1:04:59 There's lots of different symptoms that can occur, most of which are actually relieved by vaginal estrogen. And vaginal estrogen is, it, it's often described as HRT, but those of us who are sort of, you know, working in the menopause field don't really consider vaginal estrogen as HRT. We think of HRT as systemic, going through your whole body.

Dr. Rangan Chatterjee 1:05:19 Okay.

Dr. Annice Mukherjee 1:05:19 Whereas vaginal estrogen is just treating local symptoms, which can be, wh- which can be really severe-

Dr. Rangan Chatterjee 1:05:25 Mm-hmm

Dr. Annice Mukherjee 1:05:25 ... really problematic for women, and again, it's, it's an area now that's still not talked about enough. So, so even women who've had breast cancer, the majority with the, possibly the exception of the aromatase inhibitor medication that I mentioned, most of the studies that we've had, and we've got a lot of numbers now looking at women after breast cancer, vaginal estrogen, if it's needed, it's not that everyone should have it-

Dr. Rangan Chatterjee 1:05:48 Yeah

Dr. Annice Mukherjee 1:05:48 ... but if it's needed, it appears to be safe. It... I, I, I should add a caveat that ev- any woman who's considering hormone treatment after a cancer diagnosis of any type, that sh- they should run that by their cancer team-

Dr. Rangan Chatterjee 1:06:03 Yeah

Dr. Annice Mukherjee 1:06:03 ... because it, it, it's, that, their cancer team has their specific statistics.

Dr. Rangan Chatterjee 1:06:08 Yeah.

Dr. Annice Mukherjee 1:06:08 And you might ask me, is there ever an exception? And there are always exceptions to a rule, but any exceptions should really be with full informed consent.

Dr. Rangan Chatterjee 1:06:18 Yeah. Look, we put this on all the copy on YouTube and on my podcast that these conversations, these are for information only. People should not take this as, um, medical advice. If they want to talk about this stuff and they want to make these changes, they need to talk to someone about them. These are, these are really quite complex issues. I just want to highlight that. But just to summarize what I feel you said there, um, Annice, if you have had breast cancer in the past, no matter what type it is, HRT, systemic HRT, oral or a transdermal patch- Should not be taken, it's a contraindication. But if you are having specific local vaginal symptoms like itchiness, dryness, pain, whatever it might be, it seems as though the prevailing view is you can take it once you've had a proper conversation with your healthcare professionals. Is that an accurate summary?

Dr. Annice Mukherjee 1:07:16 It is, but again, and I'm conscious that there may be people listening who say th- that they're not fitting into one of those [laughs] categories.

Dr. Rangan Chatterjee 1:07:24 Okay.

Dr. Annice Mukherjee 1:07:24 And so if systemic HRT is ever going to be given to somebody who's had breast cancer, it needs to be an informed decision. It, it, it is likely to be associated with increased risk, but this has to be taken in the context-

Dr. Rangan Chatterjee 1:07:38 Yeah

Dr. Annice Mukherjee 1:07:38 ... of that woman's life, and also her individual circumstances. And there are situations, and they're rare situations, so for example, a woman who's got a, the BRCA gene who, who has, is diagnosed with a very high risk of breast cancer in her 20s or 30s, she has a double mastectomy, she's found to have an early primary breast cancer. She's got a, a full hysterectomy with her ovaries removed. She's young. She might go five years. She's clear from, from the early cancer that was a low-risk cancer. There may be situations where, particularly in younger women, the cancer team will say, "Actually, you can now take HRT safely," but it's, it's so nuanced. Equally, there will be women who, who desperately want to have HRT who may have a high risk of breast cancer recurrence, who've had estrogen receptor-positive disease, and they need to have a really detailed, nuanced discussion with their health professional about are they happy then to get a, a recurrence 10, 15, 20 years later? Because breast cancer's a notorious cancer for coming back-

Dr. Rangan Chatterjee 1:08:45 Yeah

Dr. Annice Mukherjee 1:08:45 ... m- many years later. Most cancers, if you survive five years, you're cured. With estrogen-positive breast cancer, you're not-

Dr. Rangan Chatterjee 1:08:52 Yeah

Dr. Annice Mukherjee 1:08:53 ... and it often comes back later. So a woman needs to be able to make a decision being aware that, you know, she might feel great on the HRT now, and she might be fine in five years, but something, she might increase her risk thereafter.

Dr. Rangan Chatterjee 1:09:06 Yeah, and, and there's a whole section in your book on breast cancer-

Dr. Annice Mukherjee 1:09:09 Yeah

Dr. Rangan Chatterjee 1:09:09 ... I think which will help people. O- o- one of the concerns I've seen in the media recently is that some women are being prescribed very high doses of HRT. Are you also seeing some women who are on really high doses of HRT, and what are the potential implications of that?

Dr. Annice Mukherjee 1:09:32 Yeah, I, a lot of patients are coming to me who are, have experienced difficult menopause symptoms that haven't been relieved by HRT, and they're coming to me on sometimes alarmingly high doses of HRT. And when I say alarmingly high, I don't mean just high licensed dose, I'm talking about significantly higher than what we know is licensed. And when we talk about licensing, all the efficacy and safety data on all medications that we prescribe are based on, you know, clinical trials that demonstrate the doses that are needed and the doses that are safe. So actually, I don't very often use the highest dose of HRT. There are situations when I will prescribe a woman slightly higher than the licensed dose, and I think that's, that's, you know, that is recognized that s- for some reason, and, and particularly younger women with premature ovarian insufficiency may need higher doses.

Dr. Rangan Chatterjee 1:10:32 Mm-hmm.

Dr. Annice Mukherjee 1:10:32 But the rate at which women are going on higher doses at the moment is, is exponential. It's definitely linked with social media. But the, the biggest concern I have is that the women who are coming to see me on high doses, m- really high, excessive dosing, two, three, four plus times higher-

Dr. Rangan Chatterjee 1:10:49 Oh, wow

Dr. Annice Mukherjee 1:10:50 ... than what is licensed, which y- you really wouldn't generally see with any other, you know, medication. I wouldn't give three, four, five times the dose of thyroxine for somebody with hypothyroidism because their symptoms continued. I would be saying, "What are your ongoing symptoms? Let me just see, are there other causes for those symptoms?" And I can tell you that in every woman I see who's on really high doses who comes to see me, there are loads of other causes-

Dr. Rangan Chatterjee 1:11:16 Yeah

Dr. Annice Mukherjee 1:11:16 ... for those symptoms that are being ignored because I think that woman is being led to believe that if she takes enough estrogen, it will work. If, if, if she's, if her symptoms aren't resolved, it's because she's not on enough estrogen, and it, it's kind of the elephant in the room that we have complicated bodies.

Dr. Rangan Chatterjee 1:11:33 So Annice, I remember maybe 10 years ago or so trying to find someone local who was holistic-minded to help certain female patients of mine, and when I remember referring quite a few patients to you, you've always been, a- and your book I think really reflects this, you're very pro-empowerment. You're pro helping women make small lifestyle changes. Whether they go on HRT or not, you still want to empower them to make changes. So I wonder if we could just shift the focus slightly now to what are those lifestyle changes that you commonly recommend to your patients? I understand, and it's my, my approach as well, that no one size fits all. Every woman is going to need a slightly different, uh, I guess a lifestyle prescription, if you will. But I wonder if you could just talk us through what are some of the common things that people can do that are going to help them with their hormone symptoms? To make sure you're taking action after watching this video, I've created a free guide to help you build healthy habits. We can all make short-term change, but can those changes become a fundamental part of our life? Often they don't, and that's why in this free guide, I share with you the six crucial steps you need to take. They're really, really effective. If you want to get a hold of that free guide right now, all you have to do is click the link in the description box below.

Dr. Annice Mukherjee 1:12:58 And, uh, uh, just to give you a background, this goes back to the fact that I, I worked very much in a tertiary referral menopause service. Women who, over the last 20-odd years, who had the most severe problems, s- uh, uh, symptoms related to particularly menopause, would get referred to specialist clinics. And I worked at, at Christie Hospital, which was a cancer hospital, and I looked after many women who'd had, um, an early menopause from cancer treatment, and many women who'd gone through breast cancer and developed menopause. So I was there being asked, "How do we treat these symptoms?" You know, how do we, how do we treat the symptoms in someone who can't safely take HRT, and how do we treat the symptoms? And this was very much, um, my, m- my later experience from when I went to Salford in about 2005, was women were coming to me on HRT already and still suffering from symptoms. So then I think, "Well, look, I've got to find out, if they're already on treatment, how do I make them better? If, if they can't have that treatment, how do I help these pe- patients get better?" And so my clinical experience then went to my general medical experience and looking at a patient holistically, looking at any other medical problems that might be contributing, and that's important because, you know, I might say w- women in peri-menopause might be anemic. Y- if you treat that, you're reducing-

Dr. Rangan Chatterjee 1:14:20 Yeah

Dr. Annice Mukherjee 1:14:20 ... the burden of symptoms. Hypothyroidism is actually, although w- we can diagnose it much easier now because of thyroid function tests, hypothyroidism is, it's 10 times more common in women than men. It's really common in-

Dr. Rangan Chatterjee 1:14:33 Mm

Dr. Annice Mukherjee 1:14:33 ... the demographic 40 to 60 years. Other medical problems should be treated. So, you know, I, I address that. There are other non-hormone medications which we haven't talked about, which I'd like to cover, for those women who are told, "You can't have HRT", and they feel like they're missing out-

Dr. Rangan Chatterjee 1:14:48 Okay

Dr. Annice Mukherjee 1:14:48 ... because we're talking about HRT all the time. But then, you know, I, I would talk to my patients and they'd... You know, we'd try a few things, and we'd optimize the anemia or the thyroid or, you know, try some, uh, non-hormone medications. And they'd go, "Yeah, but I'm st- uh, you know, I'm still feeling exhausted. I've still got aches and pains." So then, you know, and this is clinical experience, this, really, is that I'd then go, right, I'd go, "Just tell me a little bit about your lifestyle." And it would invariably, themes come up of overcommitment, of women expecting too much of their bodies, not having enough downtime, not having good sleep patterns, not having good nutrition, often too much alcohol, too much smoking. This is not rocket science.

Dr. Rangan Chatterjee 1:15:29 Yeah.

Dr. Annice Mukherjee 1:15:30 This is easy, but it's not something that we tend to do in conventional medicine.

Dr. Rangan Chatterjee 1:15:33 Yeah.

Dr. Annice Mukherjee 1:15:33 We have too-short consultations and... So I, I started to look into this, and actually, funnily enough, when you, when you get good at it, it doesn't take that long to go over it.

Dr. Rangan Chatterjee 1:15:41 Yeah.

Dr. Annice Mukherjee 1:15:41 A- and the other thing is major life events because again, talking about that midlife rollercoaster, as we get older, major life events hit us more and more, you know, men and women as you [laughs] as you, as you get older. And the other thing is historic trauma is a big factor in, in the experience of symptoms with other medical conditions. So there's lots of themes, and I will ask patients about different, you know, lifestyle, historic traumas. Um, and then it's about, there are themes as, as to what, what people can do, but it's not the same for everybody. And as you say, there's not a one-size-fits-all, not with medication, not with lifestyle. Because if you're absolutely exhausted, you're s- you're sitting at your desk and then you're sitting on your sofa, you don't see daylight, you haven't got energy to go and cook fresh food, so you're eating ready meals-

Dr. Rangan Chatterjee 1:16:36 Yeah

Dr. Annice Mukherjee 1:16:36 ... maybe smoking and drinking too much as coping strategies, and again, alcohol is a cope- uh, an unhelpful coping strategy. It can, over a number of adult years as your life gets busier or more stressful, you know, it, it, it can all sort of hit you. You then got hormone symptoms, and we're expecting a miracle cure with hormone treatment, but actually we need to be sitting back. So the first thing I would say in terms of lifestyle to every woman I see regarding menopause is, "How much are you moving?" And I'm not saying go and do a marathon. I'm not saying go and, you know, be an expert at yoga or do HIIT classes because there's no one-size-fits-all, and actually, if you s- try and do too much too quick, you're back to square one. It's snakes and ladders.

Dr. Rangan Chatterjee 1:17:19 Mm.

Dr. Annice Mukherjee 1:17:19 It's about starting where you are and making small changes. I sometimes describe them as microdosing your lifestyle.

Dr. Rangan Chatterjee 1:17:26 Yeah.

Dr. Annice Mukherjee 1:17:26 And, um, just tiny moments. If you're exhausted, don't expect yourself to go for a 30-minute walk, but if you do, if you don't do any exercise, you could start off by just going around the block and getting some daylight for five minutes in the morning, and then building very, very slowly. There is an amazing woman who I follow on social made- media called Joan MacDonald. Her Instagram is trainwithjoan. She-

Dr. Rangan Chatterjee 1:17:48 Oh, is she sort of 70, 80?

Dr. Annice Mukherjee 1:17:50 She's just turned 77.

Dr. Rangan Chatterjee 1:17:52 Yeah.

Dr. Annice Mukherjee 1:17:52 Joan at 46 didn't really do much exercise, and then she decided with her daughter to, um, start doing some exercise. She didn't think, "I'm going to be, at 77, I'm going to be like, you know, an internet sensation," which she is actually.

Dr. Rangan Chatterjee 1:18:09 [laughs]

Dr. Annice Mukherjee 1:18:09 She didn't think that. She just, she just said, "I just went one day at a time, and I built up slowly." She never had, she didn't put pressure on herself. She didn't have over expectations. Joan is like a miracle. I mean, she's amazing. She's absolutely amazing.

Dr. Rangan Chatterjee 1:18:26 She's really strong, isn't she?

Dr. Annice Mukherjee 1:18:27 She's incredibly strong. She's built up gradually, and she's not saying, uh, you know, "I'm, I'm in a deficiency state and I'm a mess." If you look at Joan, she is the picture of, I think, what pretty much most women would think they want to be like when they're 77. It's, or if not every single woman [laughs] on the planet. She's amazing. She's so healthy, and she's, she's done it all through lifestyle. The, the key to that is make small changes because Rome wasn't built in a day. N- and we all want quick fixes. We all want to do a miracle diet, a c- a clever hack, a, you know, a boot camp for six weeks-

Dr. Rangan Chatterjee 1:19:02 [laughs]

Dr. Annice Mukherjee 1:19:02 ... and, and suddenly drop, you know, the, you know, four stone in weight that we've gained over three decades, you know, or suddenly be fit when we haven't done any exercise for 20 years.

Dr. Rangan Chatterjee 1:19:13 Mm.

Dr. Annice Mukherjee 1:19:13 And that isn't realistic. So it's about starting where you are and building up. So that- Exercise. Uh, nutrition, I mean, as, as you're aware, nutrition is a real trigger topic. Loads of people have different views. My mantra regarding nutrition is clean whole food. Keep your plate full of real food, not processed, ultra-processed, not packets, jars, you know-

Dr. Rangan Chatterjee 1:19:37 Yeah

Dr. Annice Mukherjee 1:19:37 ... ready meals, but actually just real food. You know, fresh fruit, veg, nuts, seeds, lentils, pulses. We eat a lot of processed foods. I think, I say to my patients, "Do you eat processed food?" They go, "No." And I said, "Oh, do you have any bread, pasta, cakes, biscuits, pizza, pastry, or noodles?" And they're going, "Oh, yeah, I have those." And I'm, "Well, well, that is processed, right?" So, and I'm not saying exclude it-

Dr. Rangan Chatterjee 1:19:59 Right

Dr. Annice Mukherjee 1:19:59 ... but that shouldn't be your staple diet. I keep it simple. And then having a social network, having laughter is really, really important, and all of those things will help your weight management because, you know, increasing weight, you know, having an excess weight as you get older is, is not good for long-term health risks. So everything ties in when it comes to lifestyle.

Dr. Rangan Chatterjee 1:20:20 Oh, yeah, I mean, first of all, I really appreciate you, you sharing Joan, sharing the advice that you give your patients. Tying it back to hormonal symptoms, are you finding that when you can help women to make these small sustainable changes to their lifestyle, and of course different women will choose different things and go at different rates, are you finding that often the symptoms that they came to see you with are also getting better?

Dr. Annice Mukherjee 1:20:49 Yes. So building up movement and exercise is a stress reliever, so you're reducing the impact, that stress burden on your body. Um, eating whole foods, you're gonna have more nourishment, proper nourishment. Um, too much alcohol and smoking worsen hot flushes, vasomotor symptoms. Alcohol is very-

Dr. Rangan Chatterjee 1:21:08 Yeah

Dr. Annice Mukherjee 1:21:08 ... disruptive to good quality sleep. If you... The other thing about food is if you're eating a lot of ultra-processed foods, people talk about sugar crashes, which, and, you know, sugar surges and crashes, which is not really a medical term, but it, it, people do get reactive hypoglycemia, which is essentially a sugar crash if they eat a lot of processed foods and, and that kind of perpetuates a craving-

Dr. Rangan Chatterjee 1:21:30 Totally

Dr. Annice Mukherjee 1:21:30 ... for sh- for high sugar carbs. And so, you know, all of these things, there's actually more science behind lifestyle than there is with any medication. The thing that I would add to that is if a woman who's going through severe symptoms is listening to, you know, us talking about how important lifestyle is, she'll go, "I, I can't. I can't do anything."

Dr. Rangan Chatterjee 1:21:50 No, I get that.

Dr. Annice Mukherjee 1:21:51 So what I would say there is that, okay, there are medications that can help to try and lessen your symptoms to give you that opportunity then-

Dr. Rangan Chatterjee 1:22:00 Yeah

Dr. Annice Mukherjee 1:22:00 ... to use lifestyle, but medication is never a substitute. It, it won't make you achieve-

Dr. Rangan Chatterjee 1:22:06 Yeah

Dr. Annice Mukherjee 1:22:06 ... im- improvement in, in, in your long-term health and wellbeing, but it can give you a platform from which to start what you need to do. One thing that's often talked about is that we're living longer now, so they probably, you probably got more, for the average woman, more adult life after menopause than you have before it. So then somebody arguing the opposite point would say, "No, no, no, but you must have hormones for longer because we're living longer." But I will stick with what I say, is that during that hormone transition, we need support to get our lifestyle optimized-

Dr. Rangan Chatterjee 1:22:39 Mm

Dr. Annice Mukherjee 1:22:39 ... because living longer should be about quality of like, life and being well, like Joan MacDonald, right?

Dr. Rangan Chatterjee 1:22:46 Yeah.

Dr. Annice Mukherjee 1:22:46 At 77, who's s- stronger than she was, you know, probably when she was in her younger adult life. Um, you don't get that through any medication.

Dr. Rangan Chatterjee 1:22:54 Yeah.

Dr. Annice Mukherjee 1:22:55 You will only get that through empowerment and making sure that your body is working well.

Dr. Rangan Chatterjee 1:23:01 Yeah, I appreciate you clarifying those points, and I guess what I'm really trying to emphasize is I do think in medicine we can overmedicalize things sometimes. I think it's quite a big problem taking it beyond female health just into all kinds of things now. They become medical things that needs a medical diagnosis and treatment. And I, I also completely agree with what you said. Sometimes hormones or, I don't know, let's use a non-female health example. Um, migraines, for example, right? Um, if someone comes in and I diagnose them with a migraine, what I tend to say is, "Look, I think this is a migraine. There are a number of options here, okay? There are some medications that are likely to help you reduce the pain. There's also some things in your lifestyle that I feel I can help you with that may also help. What approach would you like to take?" And, you know, I always respect what a patient's gonna say. Like, a patient may go, "Look, I don't really want to take medication. Yeah, sure, help me. Let's see if we can tackle this another way." I would say the majority, a lot of people will say, "Well, look, I'm interested. Can I have the pill just at the moment to help me get through?" And, and that's why I feel it can be really useful. It's like, okay, it's gonna help you with the pain. It might help you get back to work. It might help you have more energy, so you can go to the gym, so you can cook yourself a fresh meal. And then over time, the medication actually allowed you to make those changes, and I, and, and I think we're, we're saying the same thing can sometimes happen with HRT.

Dr. Annice Mukherjee 1:24:32 Yeah.

Dr. Rangan Chatterjee 1:24:32 It can help you feel so much better that you can then put in those other changes that are gonna help you now but also beyond.

Dr. Annice Mukherjee 1:24:39 Yeah, definitely, and the other non-hormone options that women can have.

Dr. Rangan Chatterjee 1:24:43 So, so let's go into those 'cause there will be women who say, "Yeah, I can't have hormones."

Dr. Annice Mukherjee 1:24:47 Yeah.

Dr. Rangan Chatterjee 1:24:47 "What else can I do?"

Dr. Annice Mukherjee 1:24:48 There are a number of different medication options that we've had available for many years that can work to help the menopause symptoms, but it depends on the specific symptoms, so the, the, you know, the, there's a number of medications. Uh, the, the longest used one is clonidine, which is an old-fashioned central antihypertensive medication.

Dr. Rangan Chatterjee 1:25:05 What does that mean, central antihypertensive?

Dr. Annice Mukherjee 1:25:07 So it's a blood pressure lowering medication, and it works through mechanisms within the brain.

Dr. Rangan Chatterjee 1:25:11 Okay.

Dr. Annice Mukherjee 1:25:12 Lowers blood pressure, but it also reduces hot sweats and flushes and the, the heat sensitivity symptoms associated with menopause transition. So it was, it's been used for a long time. It does tend to have side effects in that it can make you a bit dizzy. It can make you a little bit drowsy, so in high doses, and it can obviously lower the blood pressure, so if you've got low blood pressure, you m- you may not tolerate it. But for a woman I see who, who has- can't have HRT who may have high blood pressure or other medical problems, clonidine can be a good fit-

Dr. Rangan Chatterjee 1:25:42 Mm

Dr. Annice Mukherjee 1:25:42 ... if her main symptom... It also can help with sleep and migraines. So it depends on the s- particular symptoms that a woman has. The- there are other medications, a lot of antidepressant medications, which are given a really bad rap today in relation to menopause because people go, "Well, you know, it's hormonal depression, it's not depression." But actually f- some of the antidepressants in very low doses, so not even antidepressant doses, can reduce vasomotor symptoms, so hot sweats, flushes, flushes. They can help with mood, and they can help with sleep.

Dr. Rangan Chatterjee 1:26:14 So let's say a woman, for whatever reason, cannot take HRT, and you're saying now that some medications that are typically colloquially called antidepressants, you're saying that in small doses potentially they can positively help some of those symptoms that you would've normally got HRT for.

Dr. Annice Mukherjee 1:26:36 Mm.

Dr. Rangan Chatterjee 1:26:36 Does the same principle apply just for a short period of time until you no longer need it?

Dr. Annice Mukherjee 1:26:41 Definitely, yes. If I start somebody on it and I'm seeing them, I would, I would review it, and, you know, I would only use it for as long as it's needed. But it's, it's, it's individual because, you know, for example, many of the women who end up going onto those treatments, um, can't have HRT because of an estrogen-receptor-positive cancer, so they've also gone through a major life event-

Dr. Rangan Chatterjee 1:27:02 Yeah

Dr. Annice Mukherjee 1:27:03 ... which has an impact on your mood. And, and so it depends on what happens to that woman later-

Dr. Rangan Chatterjee 1:27:07 Yeah

Dr. Annice Mukherjee 1:27:07 ... down the line. And there are other medications. There is one brand-new medication which is going to be licensed this year, we think. It was due to be licensed by the FDA in America in February, but it has been delayed. Um, and it's called fezolinetant, and this is a group of, of... Well, it's a, a neurokinin 3 receptor antagonist which works centrally in the brain, in the hypothalamus, directly targeting the menopause hot sweat mechanism, which was only found a few years ago. It's an amazing new treatment. It's... looks as if it's pretty much as effective as HRT for, uh, the vasomotor symptoms, sleep, uh, fatigue, and even, um, you know, s- some of the studies suggest it might help with weight management as well. So it's really exciting to have. It's the first time in my career that we've had a new alternative to HRT that actually has a, a correct mechanism of action-

Dr. Rangan Chatterjee 1:28:08 Mm

Dr. Annice Mukherjee 1:28:08 ... for women who can't take HRT because it doesn't work through estrogen.

Dr. Rangan Chatterjee 1:28:12 Wow.

Dr. Annice Mukherjee 1:28:13 So i- the studies are underway for a similar drug in women with breast cancer at the moment, so that's, that's really exciting for women who feel left out-

Dr. Rangan Chatterjee 1:28:23 Yeah

Dr. Annice Mukherjee 1:28:23 ... by the HRT conversation.

Dr. Rangan Chatterjee 1:28:26 Weight gain in midlife for women is something that commonly comes up. If we just go really specifically around the issue of weight gain in peri-menopause, does that time in a woman's life cause stroke, contribute to weight gain?

Dr. Annice Mukherjee 1:28:46 In men and women, weight goes up in midlife, metabolism goes down slightly, probably a little bit more in the menopause transition. But it's, it's, it's a few calories worth. It's not, you know, it's not the three stone that you've gained in the last 20 years that you suddenly gain another half a stone.

Dr. Rangan Chatterjee 1:29:03 Mm.

Dr. Annice Mukherjee 1:29:03 Because there's other things going on in your life. You're busy. Midlife, it goes back to that whole you're busy in midlife, you're drinking too much, you're not able to focus on enough exercise or a good nutrition, and the weight is going up for other reasons. And we cannot blame weight gain on menopause hormone change throughout society because the whole of society is gaining weight-

Dr. Rangan Chatterjee 1:29:26 Right

Dr. Annice Mukherjee 1:29:26 ... from, from, from small children because of our lifestyles. You know, HRT, I see patients who say they go on HRT and they gain weight. I see some women who say, "Oh, I've lost some weight since I started HRT," because it- it's helped them-

Dr. Rangan Chatterjee 1:29:38 Mm

Dr. Annice Mukherjee 1:29:39 ... be motivated to do-

Dr. Rangan Chatterjee 1:29:40 Yeah

Dr. Annice Mukherjee 1:29:40 ... more exercise. Overall, the impact is pretty small. But the other thing that I would say about weight is that, you know, obesity stigma is a real problem for progress, okay? And there are many people, because of the way the food industry is regulated and all sorts of other reasons that we haven't got time to go into, we have got an obesity epidemic.

Dr. Rangan Chatterjee 1:30:02 Yeah.

Dr. Annice Mukherjee 1:30:02 And having severe obesity is a problem for health longer term. Um, and it's associated with a number of other multi-morbidities. And w- there's a whole field of healthcare, m- medical and surgical weight management to help people who have problems with their weight. Because when you've gained a certain amount of weight and your body mass index might be 35, 40, 45, or 50, th- these are, you know, very high BMIs. And BMI isn't a great way to describe, you know, whether you're overweight, but it's, it's probably the, the easiest, crudest measure that we have. But y- it's very difficult to lose all of that weight and get into a normal body mass index when you're at that level because you get more insulin resistance, which is-

Dr. Rangan Chatterjee 1:30:47 Yeah

Dr. Annice Mukherjee 1:30:47 ... basically going against your metabolism. So we shouldn't be saying obesity is bad. We should be saying we need to be helping people who need to lose weight.

Dr. Rangan Chatterjee 1:30:55 Yeah.

Dr. Annice Mukherjee 1:30:55 And we also have some amazing, again, the first time in my career, new medications to help people who have gained weight through their adult life, perhaps even since childhood-

Dr. Rangan Chatterjee 1:31:05 Yeah

Dr. Annice Mukherjee 1:31:05 ... who, who really it's gonna be very difficult for them to just go on a diet and lose that weight.

Dr. Rangan Chatterjee 1:31:10 Yeah.

Dr. Annice Mukherjee 1:31:10 So we need to be looking at things differently. But if you're a little bit overweight when you're hitting menopause, y- y- you know, there are ways that you, you can, you know, in terms of exercise, movement, j- you know, adjusting your nutrition, managing your stress, managing your sleep, that help with weight management.

Dr. Rangan Chatterjee 1:31:27 We, we mentioned a lot about symptoms. There's also potential long-term health consequences after a woman has gone through the menopause because of changing hormonal levels, uh, bone loss being one of them, and there's a really nice section in your book, including a quite worrying graph, but, but an informative graph of what happens to bone density- ... um, throughout our lives, both for men and women, and we see how stark it is for women, um, compared to men, how, how the bone mass, the bone density starts to decline in midlife. So may- maybe we talk about bone loss for a minute. Do you get symptoms with that, or is it more a long-term risk, and what can women do to prevent it?

Dr. Annice Mukherjee 1:32:11 So osteopenia, thinning of the bones, osteoporosis is silent. It causes no symptoms until an event occurs, such as a fall, where the bone is brittle and can fracture much easier. So a lot of people say, "Oh, I've got aches and pains, maybe I've got osteoporosis." And it, actually, it's, osteoporosis causes no symptoms until you've fractured something. Osteoarthritis is a different condition.

Dr. Rangan Chatterjee 1:32:39 Mm-hmm.

Dr. Annice Mukherjee 1:32:39 That causes aches and pains. So, um, men and women's bones in- increase from puberty quite dramatically, and when you finish linear growth, when you reach your adult height, your bones still continue to grow and mature outward strength-wise, not, not longitudinal growth-

Dr. Rangan Chatterjee 1:32:57 Mm-hmm

Dr. Annice Mukherjee 1:32:58 ... until you're in your sort of mid to late 20s. And then it stays fairly stable, and then in midlife, from the five to seven years across the menopause transition, there's quite a steep drop in bone density for women. And there's a drop for men and women through later life that's associated with aging. Um, but there's a lot of variation. It's not like everybody's bones get thin, and it's lo- not like nobody's bones get thin. There's a variation. The a- the graph in, in my book is, is an sort of a, it's, it's a smoothed off graph-

Dr. Rangan Chatterjee 1:33:31 It's an average

Dr. Annice Mukherjee 1:33:32 ... average, yeah.

Dr. Rangan Chatterjee 1:33:33 I think that if we can communicate the message properly, it's like, okay, what can we do, and what do we need to do?

Dr. Annice Mukherjee 1:33:40 Mm.

Dr. Rangan Chatterjee 1:33:40 What do women need to do, in your view, to sort of mitigate against this bone loss?

Dr. Annice Mukherjee 1:33:47 Well, I've got a scarier graph actually that I could show you-

Dr. Rangan Chatterjee 1:33:49 [laughs]

Dr. Annice Mukherjee 1:33:49 ... which I didn't put in my book, which is from, it was from 2016. It's the World Obesity Forum, I think, who produced, um, a consensus statement about lifestyle factors in, and I'm sorry to go back to lifestyle again, but lifestyle factors in-

Dr. Rangan Chatterjee 1:34:02 Hey, you're in the right podcast for this.

Dr. Annice Mukherjee 1:34:03 [laughs] I- in accrual of peak bone mass and through life, and the graph is quite frightening because if you have poor lifestyle from, you know, becoming an adult, so you smoke, 'cause smoking is really bad for bones. You drink too much alcohol, alcohol causes bone loss. Excess alcohol causes bone loss. If you have s- chronic stress, al- allostatic load, chronic stress causes bone loss. You know, lack of weightbearing exercise and movement is profound for, for bone loss, and then the other factors which are calcium and vitamin D, I mean, there are more, but these are the main factors that I talk about. Vitamin D is very important 'cause it helps our gut absorb the calcium from our diet, and that helps the calcium get into the bones. And vitamin D we get mainly from sunlight. We don't get a lot from our diet. And modern lifestyles, we're indoors all the time. We don't see daylight. When we do go into daylight, we don't want to get burnt, which is quite right. We don't want to get skin cancers, so we put fa- sunscreen on. And unfortunately, that combination means that certainly in the UK, the majority of people are vitamin D deficient most of the time, and there are guidance about-

Dr. Rangan Chatterjee 1:35:15 Yeah

Dr. Annice Mukherjee 1:35:15 ... taking vitamin D in winter.

Dr. Rangan Chatterjee 1:35:17 What about strength training?

Dr. Annice Mukherjee 1:35:18 It's hugely important, yeah. And, you know, there's got to be a big factor in f- you know, frailty and aging because people li- move, move much less-

Dr. Rangan Chatterjee 1:35:27 Yeah

Dr. Annice Mukherjee 1:35:27 ... as they become elderly.

Dr. Rangan Chatterjee 1:35:29 It's hard not to make the case that strength training becomes more and more important as we age, yet as a society, we, we associate it with teenagers and young men and women in their 20s trying to look buff and trying to look good, right? Going to the gym. But, you know, I'm not saying it's not important then, fantastic to do it then, but it's more [laughs] and more important as we get older, as we lose muscle mass, as our bone density starts to go down, because we don't want to be weak in old age. We don't want to be frail. We don't want to not be able to stop ourselves falling or fall and then not be able to recover from that fall, which is really, really common, isn't it?

Dr. Annice Mukherjee 1:36:05 And, and that's the problem with, with a- aging and frailty, and, and having worked on acute medical wards for 25 years and looking after people coming in with all sorts of different health issues and, and complications of illness, it, it, it's, as, as people get older, if you're weak, and you're sitting, and you're not moving, and you're not using your brain, and you're not eating very well, it's sort of just a, an ongoing decline.

Dr. Rangan Chatterjee 1:36:27 Yeah.

Dr. Annice Mukherjee 1:36:27 And I will not accept that for myself. I, I, and I will not accept that for any of my patients. A- any of my patients who say, "No, I'm just gonna sit on the sofa now. I don't want to do any exercise. I can't do any exercise", that will not take anyone anywhere good with their health. No matter what medication they're given-

Dr. Rangan Chatterjee 1:36:44 Mm-hmm

Dr. Annice Mukherjee 1:36:44 ... no matter what, if you sit on the sofa and you are not using your body, you're not using your mind, you know, that affects your gut. It's not good. It's not good for str-

Dr. Rangan Chatterjee 1:36:53 Yeah

Dr. Annice Mukherjee 1:36:53 ... it's not good for anything, sleep, anything. And so, i- then if you go, "Oh no, I'm not gonna, but I'll take medication that will beat disease," it won't, it won't work.

Dr. Rangan Chatterjee 1:37:03 Yeah. One of the other long-term risks that people worry about postmenopausally is dementia. Now there's, of course, many different factors that can increase our dementia risk, but I'm talking specifically about estrogen going down after the menopause. Uh, I had Lisa Mosconi on the podcast maybe a year and a half, two years ago. She's a, a brain researcher in New York, and she w- you know, was talking a little bit about estrogen deficiency and potential risk of Alzheimer's. Again, in 2023 now, based upon your experience and expertise, what can we say about that?

Dr. Annice Mukherjee 1:37:49 So the big interest in dementia and the possible impact of estrogen deficiency is really based on the fact that rates of Alzheimer's disease, which is the commonest dementia, is sort of double the rate in women compared to men. So women, there's something about women that is increasing the risk of dementia, uh, a- and that is the commonest time to, to, to manifest symptoms for the first time maybe in the menopause transition, and then symptoms tend to become more evident later on. So it's logical to want to do that research to see is it something to do with menopause specifically-

Dr. Rangan Chatterjee 1:38:27 Mm-hmm

Dr. Annice Mukherjee 1:38:27 ... hormone changes, and particularly, gosh, wouldn't it be amazing if we could give HRT and that would prevent dementia?

Dr. Rangan Chatterjee 1:38:34 Mm-hmm.

Dr. Annice Mukherjee 1:38:34 And there are, there, there's so much existing data actually on this, that there's data that suggests that actually younger women, uh, changes in the brain improve if women with premature ovarian insufficiency take HRT up to menopause, and if they don't take it, they tend to have problems with, with brain changes that can predispose to dementia later. Um, there have been a lot of observational studies. It's quite a difficult thing to study. Observational studies are, uh, you know, can be fraught with things like selection bias-

Dr. Rangan Chatterjee 1:39:08 Mm

Dr. Annice Mukherjee 1:39:08 ... so it's difficult to make really robust conclusions from observational studies. There was a big review of all the data in 2021, which was published in the BMJ, that looked at studies of women on different formulations of HRT, and it basically showed a null effect. So at the moment where we are is women get more dementia than men, but the data we have do not suggest, if we look at all peer-reviewed data, I'm not talking about one study that might have shown a benefit, because for every one study that might have shown a benefit, there are also studies that might suggest that HRT probably made things worse.

Dr. Rangan Chatterjee 1:39:45 Mm.

Dr. Annice Mukherjee 1:39:45 So actually, it's really conflicting, that data, and, uh, there, there appears to be a null effect, but there are some interesting studies looking at particular subgroups of people who may be more at risk of-

Dr. Rangan Chatterjee 1:39:56 Right

Dr. Annice Mukherjee 1:39:56 ... dementia, like the APOE4 gene and, you know, people with family history. Now, I'm not an expert in dementia, but the, the, there was a study published in Norfolk, um, either earlier this year or the end of '22, which was an observational study. It was a very small study, but it was, it was promising, that suggested there might be some potential benefits in, um, women, particularly with, with the, the, this gene. So they are quite rightly not making any bold statements. They, they are saying this justifies a randomized control tr-

Dr. Rangan Chatterjee 1:40:31 Right

Dr. Annice Mukherjee 1:40:31 ... study which will be definitive. Observational studies often show dramatic results. When we do the rand- randomized control trial, it's shown to be non, n- non-effective. So I think w- we all want to, a miracle cure, and social media wants to say, "Well, look, there was this one study that suggested HRT cures dementia, end of story, everybody should go on it," but it's not as straightforward as that-

Dr. Rangan Chatterjee 1:40:51 No

Dr. Annice Mukherjee 1:40:51 ... if you look at all comers. The other thing I want to say, 'cause I, I do talk about this, is that in the Western world, in, in North America and Europe over the last 30 years, there's been a 13% reduction in dementia instances.

Dr. Rangan Chatterjee 1:41:07 One three.

Dr. Annice Mukherjee 1:41:08 One three per decade. Each consecutive decade over the last 30 years, there's been a 13% reduction in dementia, and that's in the Western world where rates are, are quite high. And overall, if you take the whole world, it's 15% reduction in 30 years. But in, in North America and Europe, rates of dementia are falling at this moment. That, we don't know why. They, the, the researchers think it may be due to something to do with our lifestyles. It may be reducing smoking, 'cause smoking's awful-

Dr. Rangan Chatterjee 1:41:36 Yeah

Dr. Annice Mukherjee 1:41:36 ... for dementia risk. It may be something else in lifestyles. It may be that we're more stimulated, 'cause stimulation's a protective effect. But dementia rates are falling by 13%-

Dr. Rangan Chatterjee 1:41:46 Yeah

Dr. Annice Mukherjee 1:41:46 ... every 10 years in, in-

Dr. Rangan Chatterjee 1:41:48 That's-

Dr. Annice Mukherjee 1:41:48 ... in Europe and America. No one talks about that. It doesn't hit the news because it's a positive story.

Dr. Rangan Chatterjee 1:41:54 Yeah, and that's quite a nice uplifting thought to sort of bring our conversation to a close really. I appreciate what you said there about where we're currently at with, you know, hormone replacement post-menopausally and dementia risk, and it may be that in certain groups who are deemed to be at higher risk for whatever reason, potentially genetics, potentially something else, there may be an indication, and that's currently being studied. Again, Annice, you're talking about nuance. That's, that's not how we roll in 2023.

Dr. Annice Mukherjee 1:42:25 [laughs]

Dr. Rangan Chatterjee 1:42:26 It needs to be black and white, right? You're talking about nuance and context. Um, the other thing to say there is that, you know, we're talking about lifestyle a lot. Well, chronic unmanaged stress damages and kills nerve cells in the hippocampus and increases your risk of dementia and cognitive decline, right? So of course, your book is a very, very readable, a very practical guide. It, it's very clear that you have been practicing for over three decades now because it's, it's gonna really help people understand what they can practically do. What are some of your kind of, um, go-to tips, I guess, for stress management?

Dr. Annice Mukherjee 1:43:10 My favorite stress management recommendation, because anyone can do it, is just everyday mindfulness, which is walking outside in the fresh air without headphones, without a phone, because it's, it's a, it's an everyday mindfulness tool. Some people struggle to meditate or do more, you know, specific, uh, sort of s- stress management strategies. Um, but everyone can go outside in the fresh air and listen to the birds and look at the sky and be in the present that, that way. So I, I think that's a really great stress management tool that anyone can do immediately. There's obviously much more detailed, um, things that people can do, but I think if you're, if you're really struggling with symptoms, it's quite difficult to then start doing something that's quite, you know, detailed in terms of- Managing stress

Dr. Rangan Chatterjee 1:43:58 I love that recommendation. Annice, it's been a real joy speaking to you. Is there anything you feel that's important in this area that we've not covered yet?

Dr. Annice Mukherjee 1:44:08 Well, I, I think we've covered everything, but I think what's really important, we talked at the very beginning about empowering women, and correct facts are empowering, but misinformation is very disempowering. It, it makes women feel they need something that's gonna fix everything. And women have so much more control than they think, and that's what we've talked about today. And, you know, after menopause, you don't have to have periods anymore. I used to suffer terrible migraines before menopause. I don't get migraines anymore, you know. Um, actually, at some point, you get an empty nest. Some people get upset about that. I've got an empty nest at the moment, but the kids come back all the time, and actually it, it makes doing things for yourself easier. You've got so many more opportunities to build your own social networks because you tend to have more time. Your career is often in a great situation. We haven't covered employment, but I think everything that we've talked about-

Dr. Rangan Chatterjee 1:45:02 Mm-hmm

Dr. Annice Mukherjee 1:45:02 ... is gonna help women-

Dr. Rangan Chatterjee 1:45:03 Yeah

Dr. Annice Mukherjee 1:45:03 ... know that we have to have female leaders in our workplaces. And, you know, it, it is a-- menopause is a great opportunity for women today. It- it- it's, it's a... We're in a situation where it is the best time ever to be a woman, but this, it's just so complicated for women.

Dr. Rangan Chatterjee 1:45:20 Yeah.

Dr. Annice Mukherjee 1:45:20 But it is such an opportunity, and I am pretty determined, no matter what happens over the next few years, that I will still keep talking about women regaining control or, you know, maintaining control would be the best option if they're proactive.

Dr. Rangan Chatterjee 1:45:34 No, I love that. I mean, you mentioned empty nest there, and you say that, and I'm like, "I can't imagine my kids leaving. I don't want them to leave home." Like, I love hanging out with my kids. It's, it's such a crazy thought for me to think, well, the ki- well, the kids won't be at home. Like, I can't imagine it. Well, you know, given the age my kids are at the moment, it feels-

Dr. Annice Mukherjee 1:45:54 Yeah

Dr. Rangan Chatterjee 1:45:54 ... like it's gonna be a million-

Dr. Annice Mukherjee 1:45:56 An eternity away

Dr. Rangan Chatterjee 1:45:57 ... m- eternity away.

Dr. Annice Mukherjee 1:45:58 Yeah.

Dr. Rangan Chatterjee 1:45:58 But I'm sure it isn't. Um, Annice, this podcast is called Feel Better, Live More. When we feel better in ourselves, we get more out of our lives. There's so much we've covered today, but just to finally finish off, for, for that woman who's listening, who is currently struggling, what would you say to that woman?

Dr. Annice Mukherjee 1:46:21 Whatever she's suffering from, there are solutions. The solutions are not the same for everyone, and sometimes when you're in the most difficult phase of symptoms, of life, it's the hardest time to find solutions. So making small changes doesn't feel like it's gonna make any difference. It's like that first step of a mountain. But if you just keep that focus of the things that are within your control a little bit prescriptively, not like a medication, but like a prescription of something that you know will help eventually-

Dr. Rangan Chatterjee 1:46:57 Mm-hmm

Dr. Annice Mukherjee 1:46:57 ... you will get there, and there are better times ahead.

Dr. Rangan Chatterjee 1:47:00 Annice, thanks for coming on the show.

Dr. Annice Mukherjee 1:47:03 My pleasure.

Dr. Rangan Chatterjee 1:47:04 If you enjoyed that conversation, I think you are really going to enjoy this one about the specific ways women can use fasting to improve their health.

Speaker 1:47:12 We have to stop trying to do everything from how we eat to how we work out the same as men because we are massively different, and that is what needs to stop in order for us to thrive