Menopause and multiple sclerosis with Dr Fatima Kahn

Andrea: This is the MS podcast series. I'm Andrea Salmon.

Today I'm talking with Dr. Fatima Khan, who's a menopause specialist who has a holistic approach to women's physical, emotional, and mental wellbeing. And I'm also joined by Jacqui Perry. Jacqui is a physiotherapist who works at MS as one of our employment support consultants. So, it's wonderful to have these two wonderful ladies with me today.

Dr. Khan, we're going to start off with just a really overall question. Can you just take us back to basics and tell us what is menopause?

Fatima: Hello everyone and all the lovely followers. Thank you for having me on your platform to talk about something I'm very passionate about.

So, yes, I think that's correct. Let's get all the basic definitions in. Menopause, in theory, is defined as your last menstrual period. More specifically, 12 months of no periods is when we'll say you're going through the menopause and a period after 12 months is defined as post menopause. And the period where you're getting irregular periods or any kind of four or five years prior to the menopause, we would say you're perimenopause.

And it's essentially marking the end of our ovarian function. So, we're born with a defined number of eggs in our ovaries and their lifespan comes to end on average about age 51 and that's pretty standard globally. It hasn't really changed over the years. Saying that, lots of women do experience menopause under the age of 45 and that would be classified as an early menopause.

But the majority of women will experience symptoms starting in their mid 40s, taking them up to mid 50s. But I think that's where we get a bit confused thinking, oh well I've got a few years before I get there, but actually it's really important that we're prepared in our early 40s because it can happen to us at any time.

Jacqui: Thanks for that clarification, Dr. Khan. I guess another important question for us to ask is what are some of the main symptoms and signs that women should look out for? At what point should they reach out to their doctor for these signs or symptoms?

Fatima: Yes, so this is this is where the trouble lies with patients living with multiple sclerosis because I was just looking at a recent study paper that was done in Frontier Neurology Journal and they were saying 50 percent of Multiple Sclerosis patients report worsening of their MS symptoms during menopause.

But the problem is a lot of the menopause symptoms overlap with their multiple sclerosis symptoms, such as poor sleep, fatigue, changes in their mood, so depression, anxiety, they can get a worsening of their bladder function. So, menopause itself can cause urinary urgency, bladder incontinence, recurrent UTIs, which we can see in general MS patients as well.

Other symptoms that are more commonly recognised, as what we call vasomotor symptoms, are hot flushes, night sweats, and of course, when you get themyou think, menopause.

But the less talked about symptoms of menopause are the mental health symptoms. 50 percent of women who, in the general population, will report five to six years before the onset of their first hot flush, changes in their mood. So, depression, anxiety, feeling overwhelmed. Up to 40 percent notice a decline in their ability to learn, memory, they become more forgetful. And they literally say to you that I feel like I'm suffering, have I got dementia, because there's changes with the hormonal fluctuations can be quite profound.

Of course, if you're someone who is living with multiple sclerosis, you might think oh, this is just a worsening of my multiple sclerosis, or my bladder function is getting worse, my memory and learning is getting worse, my sleep is disturbed, is this just a relapse? And so, this is where the problem is and if you might go and see a neurologist and they might have not put two and two together that you're going through the menopause, because not everyone's going to go in and say “These are all my symptoms.”

They might just say, oh, my mood's changed and I'm generally not feeling that great. And you're not going to think of mentioning your hot flush and night sweats, and I said they come quite later. So first of all, if you've noticed a change in your menopause, in your multiple sclerosis symptoms, and they happen to coincide with additional features that might differentiate with them, would be things like night sweats, hot flushes, but more importantly changes in your reproductive cycle, in particular your menstrual cycle.

So, if your period has become heavier, if it's lighter, if it's shorter or longer duration. If you came to see me, I'm getting seven, eight days of really heavy periods, then that is a sign of perimenopause, and you will notice an exacerbation of your MS symptoms. Other things you can get is starting to skip your periods, or you might have six months of no periods, then you'll definitely be getting hot flushes and more pronounced symptoms.

So I think the main point here to emphasise, is for women to become more self-aware, because if you are not aware of what your body is like during your menstrual cycles, then you're not really going to be able to communicate that to a neurologist who might not connect it, because remember, they are not gynaecologists.

But we know that most women who develop multiple sclerosis, predominantly a condition that affects females more than males, affecting women between 20 and 40. We know that the multiple sclerosis symptoms are worse with every reproductive hormonal fluctuation, so we know women report worsening of their symptoms two, three days before their menstrual cycle.

And that's why there's a role of hormones and whether there is a role in using oestrogen, in particular testosterone, and managing and alleviating the symptoms. I just realised I've gone from symptoms into treatments. I'm going to stop there. I'm going to let you intervene and let me know where, what else did you want to ask before I go into management.

Jacqui: Sure, I guess another important question is, because, unfortunately there is still a bit of taboo in our society around menopause and talking about it and reaching out for help. A lot of women just assume, okay, well, everyone is going to go through this, I just have to put up with it. I guess at what point would you encourage women to reach out to their doctor for advice? Is this to every woman or is it only with certain signs and symptoms?

Fatima: So for me, it's the symptoms that impact your physical, emotional and mental health. That variation and the effect that something like a hot flush, I see women will say, oh, that doesn't bother me, it's not impacting her, compared to someone who's getting them every hour, and it has an impact on her. It's more about what is unique to that individual rather than generic advice. So for me, in my opinion, every woman should seek advice because we know menopause is a major health milestone in every woman's life. And it doesn't just have implications short term in the symptoms that you get, but it also has significant future health implications. So it's a good opportunity to optimise and look at what we can do to prevent future diseases that impact women, such as osteoporosis and osteopenia, which is weakening of the bone, heart disease and Alzheimer's dementia. We know these illnesses predominantly increase post menopause and one of the hypotheses is that, with the decline in oestrogen you get changes in your cellular system where we become predisposed to these illnesses because they do not happen before menopause.

And oestrogen is a neuroprotective, which protects the central nervous system, and it's cardioprotective, so it protects the heart from heart disease, and it's bone protective. And we've got several data on this, we've known this for about over three decades. So, women who use oestrogen and other hormones actually have a 50 percent reduction in death from heart disease, getting osteoporosis, and there's some debate about Alzheimer's.

Now, you might say, what about the other 50%? That comes from your lifestyle. Smoking, drinking, stress management and how we live our lives and physical activity. Now we know women with multiple sclerosis and men, to an extent, have a higher incidence of getting heart disease and osteoporosis, and then let's add in menopause, with the decline in oestrogen, now your risk of getting all these illnesses is increased.

We also know the post menopause, during menopause you have more relapses, and the theory is that oestrogen is anti-inflammatory, reduces demyelination, so generally, it's more neuroprotective for women in multiple sclerosis. So, when they're pregnant, we know that women have the lowest amount of relapse, especially in the third trimester because they have the highest levels of estriol in them.

And similarly in the menopause, it's shown that their relapse goes up because the oestrogen is meant to have these immunomodulatory, anti-inflammatory, protective effects in the central nervous system. So women who get given hormone replacement therapy, not only would have their symptoms reduced, off the menopause, but also their multiple sclerosis symptoms would be reduced as well.

Andrea: So, Dr Khan, that's something that we've been conscious of for a while that people run the risk when they've been diagnosed with multiple sclerosis. There's a risk that every experience they have is kind of put down to their MS. So this is another really classic example where we want people to be on the front foot and empowered to go and ask the question of their GP even, or their neurologist, so they really get a handle on what's going on. So obviously there's some treatments available. Do you want to talk to us about what those options might be?

Fatima: Yes, so going back, just before I go into treatment, you can only ask for treatment once you yourself realise that this is something else, and it's not my multiple sclerosis flaring up.

And every woman will know what her own symptoms are, and the way to do that is by journalling, in sync with your menstrual cycle. So, get a diary and do, okay, this is day one of my period, how am I feeling in my sleep, my energy, my mood and my bladder function, my sexual function, any physical symptoms like headaches, what's happening with my memory, what's my appetite like?

And, if they jot that on a daily basis, they'll know, hang on, I feel very different to two days before my period than that I do during my period, and how I do two weeks after my period. And once they can drop that and they take it to their doctor they'll clearly say, oh there's a correlation here, okay, maybe something's happening in your hormonal fluctuation which is triggering your symptoms, let's try and manage that.

In terms of the treatments, of course we know the woman who used the oral contraceptive pill, this is just talking about if they're getting a bit of premenstrual symptoms, they will notice a decrease in their overall symptoms of flare ups. In particular to the perimenopause and menopause, you've got to look at the treatments, which I normally divide into hormonal treatments, non-hormonal treatments, lifestyle, and complementary.

So we'll go straight into hormonal treatment, which essentially the gold standard is hormone replacement therapy. And what we're trying to replace is your own body's hormones that are declining. And these are oestrogen, progesterone and testosterone, which as they are fluctuating in the perimenopause, when your hormone levels are going up and down, you'll notice these symptoms might be transient and might be a bit difficult to track.

But the best way to track it is looking at your menstrual cycle. If there's a change in duration, change in flow, and if you're skipping them, that's a sign something's going on. And we'll have to replace those hormones according to the stage where you are. So, when we are 12 months of no periods, we will give you hormone replacement therapy in a form of continuous oestrogen, which can be in a form of a patch, tablet or gel.

These are easily available through your GP, gynaecologist, the majority of doctors are able to prescribe them, and then we also, if you have a uterus, we will give you progesterone to protect the lining of your womb. And if you aren't menstruating for more than 12 months, we give it to you continuously, so you won't have another bleed.

And if you're still menstruating irregularly or it hasn't been 12 months since your last period, we would give it to you, what we call sequentially or cyclical hormone replacement therapy and this would be progesterone for two weeks and then you will have a monthly bleed.

If you've had a hysterectomy for a reason, which is a removal of your uterus or your womb, then we would just give you oestrogen alone, and again that can be of any way to administer it into your body through a gel patch or tablet.

Jacqui: And Dr. Khan, there's a lot of, I suppose fear and misinformation in the community around HRT and breast cancer risk. Could you touch on the current evidence around these treatments and the risk of breast cancer?

Fatima: Yes. So let's talk about, we've talked about the wonderful benefits of HRT, not just for short term symptom control, which allows you to function in your personal life, intimate relationship, relationship with your children, your colleagues, yourself, but also allows you to function in your professional life, but also the long term prevention of heart disease, bone disease, and Alzheimer's disease, because there's no cure there, so prevention is all we can do.

Now, in terms of the risks that we normally discuss are, breast cancer, stroke, and endometrial cancer. So I'll go through them one by one. The studies that looked at HRT were, and its benefits were never really designed to treat menopausal symptoms, so as a result, we were trying to look at women who are much older in their sixties who had already been 10 years post menopause, and what they did was give them HRT, after them not taking HRT for 10 years. And when they gave them HRT, it was synthetic HRT. So, they use something called Premarin, which was from pregnant horse's urine, so it's called conjugated equine oestrogen. And they also use Provera, which is Medroxyprogesterone, which is a synthetic progestogen.

So these were synthetic molecules used in a population who were quite a few years post menopause and also had pre-existing heart disease. Some of them were at high risk of getting complications due to their high body mass index and other health problems. So that data showed when we gave women oestrogen, synthetic oestrogen combined with a synthetic progestogen, there was a slight increased risk in breast cancer.

But in the same group of women, when we gave them oestrogen alone, if you've had a hysterectomy we don't need to give you progesterone, oestrogen actually was a protective factor for developing breast cancer, there was a reduction in the woman, by taking oestrogen you were getting a reduction in your risk of getting breast cancer and overall risk for dying from all-cause mortality was decreased as well.

So we've always known that oestrogen is protective and when we found out the problem was a synthetic progestogen, because the hysterectomised woman there was no increased risk, the risk of breast cancer was only increased when we gave them the synthetic progestogen. We now recommend using a plant extracted micronised progesterone, which has been used in IVF for fertility and now is used in pregnant women to prevent miscarriage or preterm labour, or preterm birth, and so that is neutral on the breast.

So when we use a estradiol, and the terminology we use is body identical, these are licensed pharmaceutical grade HRT. And so we're now using estradiol, which is the same molecule as your own body. And when we give that, along with a micronised progesterone, which is natural progesterone, micronisation is just the pharmaceutical process of it. These two are neutral on the breast tissue, so they're not showing to increase risk of breast cancer.

So, if you're worried about breast cancer, my rule normally over 45, I don't use synthetic progestogens for women. There is another option, which is the Mirena IUD, a Mirina intrauterine device, that it's got synthetic Levonorgestrel in a very small amount, and it stays within the uterine lining to keep the lining thin.

And we would use that in breast cancer patients as well, because it's not systemically absorbed to cause any negative effect on the breast. So you can have someone in their late forties, mid-forties, it has a mirena coil and can have an estrogen patch or a gel. which is easily available from their GP and is not at increased risk of breast cancer other than other things which increase risk of breast cancer, which is body mass index more than 30, drinking two glasses of wine or any alcohol beverage a night, being a smoker, and not doing enough exercise. You need about 30 minutes of exercise daily, which is a preventative thing for breast cancer.

Jacqui: Great, thank you. And could you just quickly touch on again the forms of, or the method of administering the HRT, and why we have one over the other in combination with their doctor?

Fatima: Yes, so the second thing I was just going to talk about, and we'll talk about the formulations coming to this, is the breast safety, we know the synthetic progesterone aren't safe for breast. And we know that from the contraceptive pill as well, breast cancer risk is increased as we get older. That's why we discourage women for using it as we get older. We know that Mirena and micronised progesterone, which is a capsule form, you take that at night time and you would be taking one at night continuously if you were post menopause, and if you were still menstruating or within the 12 months of having a period, then you would only take it for 12 to 15 days of the month. There will be two tablets over 200 milligrams, and you would have a monthly bleed. So that's a regime for the micronised progesterone, again easily available from your GP and healthcare professionals and you can get it from a local pharmacy. This is not compounded; this is a licensed pharmaceutical drug with all safety around it.

The other option is the Mirina IUD, which is an intrauterine device which is inserted and can be left in for five years as a contraception. It reduces heavy menstrual flow and can be used as part of the HRT to protect the lining of your womb, and it's licensed for four years. So those are the only two options that I normally advise because they're safe for the breast.

Now let's talk about oestrogen component, which comes in a tablet gel and patch form in Australia. There's also a spray in Europe, which we don't have here. I normally recommend, and all the guidance is to recommend the gel and the patch for woman really over 45 or anyone at risk of getting a clot, because if you take oral oestrogen, this includes a contraceptive pill as well, orally it gets broken down and metabolised by the liver.

The liver is also in charge of our clotting factors so there's a tiny risk, one in a thousand, of activating your clotting factors and so you can get a stroke or a clotting episode, which we don't want. So normally that can be eliminated when we bypass the liver and give you something that goes straight into the bloodstream in a form of a patch or a gel.

In Australia you can get these patches and they're available on the PBS. There is a massive shortage at the moment, unfortunately, but typically they'll be applied once, twice a week. I normally say anywhere on your body except your torso which means your midsection. You don't want to put it around your breast and upper tummy and they're applied twice a week. They tend to be small, translucent cluster kind of band aids and they're waterproof. You can bathe with them, run with them, exercise with them. They're very easy to apply. The other option is there's a once weekly patch as well and these are oestrogen only patches.

And then you've got the gels. There are two gels, one that comes in a in a sachet, and the other one comes in a pump dispenser. These are daily applications, they tend to be odourless, colourless kind of gel, like a bit of alcohol gel, but they don't smell like that, they don't have much of a distinct odour. It's about, I wouldn't say a pea size, I would say a bit bigger than that, about 10 cents size, and you apply them anywhere on your limbs, legs and arms, and they're applied every day, in the evening before you go to bed or in the morning after your shower, they're more daily applications. They're very well tolerated.

And the final one is the tablet, which might be easier, but I don't normally prescribe that over 45, because you've got that tiny risk of clot. Now, as we age, we all tend to become sedentary. We're not moving as much and we all know when you have a long haul flight your risk of getting a clot such as a DVT is increased.

So, obviously if you're someone who's very active, you're very lean, you're a non-smoker, you don't have a risk of generally getting clots then if they really want a tablet you can go on a tablet and I certainly have patients on that. But normally if you want to eliminate that risk, I would normally suggest what we call a transdermal root gel or a patch, with either of those progesterone, are very well tolerated, their body identical, you're replacing like for like, and I've got women using them in their 80s, living alone. They don't really have many other medical comorbidities, ultimately you want to empower women to live independent lives and age with grace and dignity in their own homes. And the current trajectory is that we've got an aging population, but our lifespan is increased, but our health span doesn't match that.

So, I look after women between 50 and 80 and my job is to keep them out of aged care facilities, at home looking after themselves, being able to cook and self-care and you can most certainly do that if you are taking hormone replacement therapy and doing all the correct lifestyle interventions.

Jacqui: Thank you. I think that's so important, particularly with our people with MS, because their lifespan isn't necessarily reduced, but it's the quality of life, particularly as they age, that's impacted. And I think, again, with all women, we're going to live a significant part of our life post-menopausal, so it's so important to live well, and age well, as well as you can, and stay independent and happy. So I think that's a really important thing to touch on, definitely.

Fatima: Yes. And the life expectancy of a woman in Australia is about 85. And we know the main cause of death remains heart disease and Alzheimer's disease, and the main cause of disability is osteoporosis. That gets them into an aged care facility. Once you have a minor trip, which could be from a bladder infection, which is very common in populations who are post menopause and MS patients, and this is due to decline in oestrogen levels in the vaginal cavity that leads to changes in pH and microflora.

So, if you ask someone who's getting recurrent bladder infections, trialling vaginal oestrogens, which I haven't talked about, is really important. So it's not just there for vagina lubrication and sexual discomfort, but also we use it in the management of pelvic floor prolapse, because it helps to strengthen that, but also to balance the pH in the microflora, so you get reduced incidence of vaginal thrush, bladder infection, itching, burning, which can in older women lead to some confusion and having minor falls and breaks their hips and gives them an osteoporotic hip fracture. So we don't want that, it's about minimising these things that we can manage.

Jacqui: Yes, and that's another important risk for our population of people with MS, where they might have reduced balance and already an increased falls risk. It is so important that we keep them out of hospital for those preventable things as much as possible. And I think it's not often that people think of menopause and oestrogen or HRT as helping with that, but it is so important.

Fatima: It's important for women who don't want to take systemic HRT, that they should take vaginal oestrogens. There is no risk of vaginal oestrogen causing breast cancer. If you're someone who's very concerned about it or don't have many symptoms, vaginal oestrogens we give to even patients with breast cancer.

So if you ask someone who's getting bladder symptoms, you'll notice a significant improvement with it. So if you are a bit reluctant to take systemic HRT, you can use vaginal oestrogens in the form of a pessary or a cream. They insert it twice a week and, if you can help with that sexual function and also bladder function, then we're trying to improve something there that will impact your quality of life.

Andrea: Dr. Kahn, I'm interested to explore that group of women who perhaps don't see symptoms of menopause. They go through menopause with very few symptoms. I'm wondering about that long term impact of low oestrogen though, that they might not ever go to their neurologist or their GP because things are going okay.

Fatima: Yes, it's surprising a lot of women come to me and, I have a questionnaire that they fill in, and they say, oh, I don't have any symptoms. And what they really mean by that is hot flushes and night sweats, but the majority of them will have things like low energy, cognitive decline, they will have memory problems, decreased focus, decreased concentration, they will have anxiety and low mood, they'll have dry skin and hair loss and itchy skin, they'll have urogenital symptoms, so sexual difficulty with their partner, low libido, low sexual desire, so actually they might not specifically have the conventional system they think of, but the majority of the symptoms will be an overlap with the MS symptoms.

So, they will benefit from vaginal oestrogen and testosterone as well. And normally, when I talk to them, I will say to them, it's not just about your short-term health, it's about long term prevention. And when we get to 70s, there is no cure for these illnesses. It's about preventing, and midlife is a great opportunity, but we need to have a shift in our mindset to look at it as, this is a great opportunity for me to optimise my physical, emotional and physical health. Now I'm not looking after my children, my role as a wife, my role as a mother, this is now about me and I'm going to invest in myself about looking after and preventing the known predictors of ill health in women as we age. We know heart disease remains a prevalent cause of death for women, yet we don't even talk about it.

Andrea: It's absolutely been great talking to you. My overwhelming sense is to encourage, or anyone listening, and we then need to get the word out to everyone who hasn't been listening, around just keeping track of your own body and your own cycles and how you are impacted by that, and then as we're heading to the age where menopause, we might be pre-menopausal, to start having those conversations with GP, with neurologist, so that people are very well placed to get the, the right treatments in place to prevent these long-term impacts. So I think it's been fabulous, this conversation today.

Interestingly, leading up to today, I had a chat with many of my friends who, we're all in the right age group, no one is on hormone replacement therapies. And so it's interesting that in the broader population there seems to be a lack of understanding of the long term benefits.

Jacqui: Yes, get the conversation going.

Fatima: You know, general practitioners are wonderful. They are not menopause specialists. So, the symptoms overlap so much with mental health and cognitive decline, for them to even spot that this is related to a perimenopause menopause is missed. And when they do recognise it, the amount of patients I see will say, my GP just said, Oh, it's just one of those life events, it's natural, just put up with it.

Now the hot flushes last an average 7. 4 years, but I see women in their 70s who stopped their HRT and their hot flushes are still there and have a predominant function on their sleep. If you are waking up every night, every hour with a hot flush, we know that sleep disturbance in itself is a single predictor in poor cardiovascular health, okay? And so, we want to reduce all things that reduce that heart disease. Menopause at the same time, what we say causes a metabolic shift in your body. So you will have more fat accumulation around your tummy and as a consequence you become more pre diabetic and your bad cholesterol goes up because the decline in oestrogen causes changes in the way we distribute our fat. But also in our lipid profile, in our blood pressure, so overall predisposes us to long term illnesses such as diabetes and heart disease. And women will notice that they're eating the right amount, they haven't changed what they're eating, they're exercising all they want but their blood pressure is creeping up and all these things accumulating in their health when they never used to have that before.

And that's all down to declining oestrogen. I think we've become so scared of oestrogen, but I always like to remind you, if you've been pregnant, you're producing 40 times the amount of oestrogen in your third, second trimester. And if you've had four pregnancies, you're not getting breast cancer, you're not getting any ill health during your pregnancies.

Hormones are not dangerous. We have them in our body for 50 years. It's about replacing them with similar plant extracted hormones which are licensed, and they're safe to use, because for the majority of women the benefits would outweigh the risk.

Jacqui: And did you want to talk a little bit more Dr. Khan, about the other treatment options, lifestyle that might help as well?

Fatima: Yes. And so before, I'm just going to talk about one more hormone briefly, which is testosterone replacement therapy, which is not heard of much, but testosterone is not just important for women's increased libido and sexual desire. Interesting enough, I was looking at a paper looking at sexual activity, and a lot of the MS patients are perceived as asexual or having reduced sexual desire.

And actually, the severity of MS is not a prediction of sexual activity. So it's really important that we support their sexual function, not just through increased libido, but also local systems by giving them vaginal oestrogen and lubricants. But commonly, the low libido will be as a result of low oestrogen and testosterone, but we're very lucky in Australia to be the only manufacturer of licensed testosterone for women in the world.

Okay, it gets exported to women all around the world, so we've got a fantastic product here which not only helps with sexual desire, but testosterone is important for our cognitive health. There's an element of confidence and memory that gets improved then. There's a sense of wellbeing when women take testosterone.

It's also important for your heart health, your bone health, your muscle health, your ligament health, and we know that obviously athletes use it as a performance enhancer. We're not using it in the same dose, but you can imagine how good it is in your overall well-being to use it. And certainly, when we give it to women in the physiological doses, meaning we, as women, we produce actually more testosterone than we do oestrogen because testosterone downstream gets converted to oestrogen.

It's about replacing like for like, natural testosterone for women in a woman doses. Conventionally we would use male testosterone and that's where we get issues. So women get concerned they're going to grow a beard or they’re going to be muscley, and that's not the case. I have a very good success rate with women feeling great.

It's actually they say it's that missing puzzle. So, when I give them oestrogen, progesterone, testosterone, they feel what they say. I feel more like myself. I feel the sense of vitality and vigour and that's what we really want for women. So don't be scared of trying testosterone and that's all I'm going to say there.

If you don't want to take hormone replacement therapy, then there are the non-hormonal therapy, which again is prescribed from your GP. They include things like antidepressants, so SSRIs, and they're very commonly used and prescribed in primary care. And they help with obviously the mood component, would also help some of them with your hot flushes.

There are other medications such Gabapentin and Pregabalin, which are, neuro, epileptic medications or used in neuropathic pain. They can be very effective as well, and they're used mainly in breast cancer patients who've got hormone sensitive breast cancer, we don't normally use hormone therapy for them, and other drugs as well, such as all kind of antihypertensives. I would normally reserve these for women who have a contraindication to taking HRT because really, you're not eliminating the short-term symptoms and there's no future benefit for prevention of those chronic illnesses by taking the non-hormonal treatments.

The lifestyle treatments are going to be, smoking cessation, we know that MS symptoms are worsened, and the relapses are increased if you're a smoker, so this is a great time to give up. There are some pharmaceutical drugs that you can use with your GP if you've tried yourself, and actually hypnotherapy is very effective in reducing and stopping smoking.

The other things is alcohol. So we know, especially red wine in particular, can really increase your hot flushes and night sweats. It can also have an impact in on your overall kind of mood and energy level, so eliminating alcohol, if not reducing it, would be great in your symptom management, but also in terms of your overall breast health risk because we know that alcohol in moderate to excess amount, is a breast carcinogen. So if that's something you're concerned about, it's something just to review and reduce it down, if you can to once a week rather than more frequent use.

Other things that they can do, stress management. Ok, so it's a very difficult time when we're going through midlife, you know, most women have got responsibilities; a caregiver, looking after an elderly parent, they might have Alzheimer's, there might be an aged care facility might be supporting them through ill-health and other ways. There might be going through a divorce relationship break down, you know, women in Australia go through divorce between 40 and 45 men between 45 and 50.

So unfortunately, there's so many other life stresses that we forget what's happening with our own body. So I always say it's really important to, 40 to 50 is actually a time when we need to be more in tune with our body because there's so many distractions with work, family, relationships, that we don't focus on ourself.

And it's also a time when we're exploring more maybe leadership positions at work so we might be really stressed, and stress in itself was a precursor to, not just chronic disease, but also mental health disease and also exacerbation of your symptoms. And the complementary would-be things like acupuncture is very effective in reducing symptoms of menopause, and including certain herbs.

When it comes to herbs, you just need to be very careful the ones you're taking. I really see a naturopath who will make some specific formulation to you because they can interact with some of the disease modifying drugs that patients are taking, and other pharmaceutical drugs, or you see a traditional Chinese medical professional, who will prescribe these to you.

But certainly, they can have a role in reducing your symptoms. The only problem with those is the sustainability long term, because if your symptoms are lasting 7 years to 10 years on average, the cost very soon spirals out. So, I'll get women saying, it really helped but I spent $2,000 in one year and I can't afford that.

So, when I give them their oestrogen and their progesterone, I instantly eliminate their symptoms in two months. And so, it's a very cost effective way to treat short term and long term symptoms.

The other few things that you can get is, what we call mindfulness based stress reduction therapies. They're mindfulness meditation and specific psychological intervention like cognitive behavioural therapy. So, seeing a psychologist can help and hypnotherapy is shown as well.

But all of these things, they're great short term. You just have to be mindful that they can cost, that they're not always covered by PBS and Medicare. And so it's about giving women something that's long term, but I always say it's their unique journey. So start with what you feel comfortable with. There's no harm in trying what you feel more comfortable with and when you're ready you come and see your doctor for the HRT if that's what you want to go for.

But there is something for everyone and the main thing is you don't have to suffer in silence because this is going to go on for years, so be proactive about it and you can go on to living a much better life that you might have been before, because you actually for the first time in your life might be paying more attention to your physical, emotional and psychological needs.

Jacqui: Do you have anything to add, Dr. Khan, about the importance of exercise throughout menopause and the perimenopausal period as well and postmenopausal?

Fatima: Yes. So, exercise is a tricky one in terms of, if you ask a woman, we haven't even talked about other symptoms such as joint pain. Most women will get severe joint pains. They'll be waking up every hour. They'll have low energy, low motivation, fatigue. I mean, trying to get anyone to exercise in that frame of mind with physical symptoms and mental symptoms, I think it's almost patronising. Most women know they have to exercise. You have to understand why they're not exercising.

So, the first question is, why don't they exercise? And if you ask them, they'll say, I just don't have the motivation, or I don't have the energy, or my joints ache, so let's address those first And so normally when I see them, I eliminate, try and eliminate their joint ache, get them to sleep properly. We know weight bearing exercises reduces risk of osteoporosis, along with good vitamin D and, we don't talk about sun exposure that much because we need to be mindful of skin cancer, so I’d rather you take a good vitamin D supplement.

So, there are things I think we need to change. If you were someone in your 30s and even 40s used to go to the gym and smash out a 45 minute workout, well no, you need to change and adapt as our bodies adapting to these hormonal transitions. And it's not about feeling guilty or punishing yourself, because I think the problem with women is we kind of just feel we should be doing this.

And if we're not doing this and we're scared of changing, something that worked for you in your 20s and 30s, is most likely not going to work for you in your 50s. So, changing your exercise regime is very important. Pilates, yoga, walking, weight bearing exercises and actually going away from the extensive long distance running and exercise, which most women, if you speak to them, will feel exhausted from doing.

Jacqui: And that might even be, going for a bit of a walk while you wait for the kettle to boil, something like that around the kitchen to begin with if you're feeling that exhausted.

Fatima: Yes. Brilliant. Thank you.

Andrea: It's been a fabulous conversation. I think you're right, we probably could go on talking and talking. But I think for today, we've really hit on a number of key things that people living with MS need to be aware of around heading into menopause or being in menopause or even being past menopause. That we need to have those conversations with our neurologist, have those conversations with our GP, and make sure that we are absolutely addressing the symptoms that are menopause, as distinct from the symptoms that are MS, but there's many of the symptoms that do actually overlap and interplay with each other.

Thank you so much, Jacqui, for being with us, and Jacqui had done some work around menopause.

Jacqui: Thank you for having me along.

Andrea: Dr. Khan, thank you so much for being willing to have the conversation with us and for obviously being so passionate about the long-term term health benefits for women and, physically, emotionally and mentally, and for the work that you're doing and the passion that you bring to that.

Thank you so much for being with us today.

Fatima: Thank you so much for having me. It's been an absolute pleasure. And you know, just for other resources to point to patients, the Australian Menopause Society has got a wonderful session. Not only for healthcare professionals, if you think your GP needs to refer to it, signpost them there, but for yourself as well.

They've got great literature with infographics, so that's a great one. And also on my Instagram page, it's really an educational platform. Everything I've talked about is on there for you to read and just educate yourself. It's your life, it's your choice, but you can make the right choice and decision only when you have the knowledge.

Andrea: Absolutely, yes.

Jacqui: Definitely agree with your page being very informative on Instagram. Great information on there.

Fatima: Thank you.

Jacqui: Thank you for putting that out as a resource as well. I think it's a good way for women to go and get it without feeling like they're really making a commitment to anything and just get a bit of an understanding themselves of what they want.

So yes, thank you for putting that out, to everyone.

Fatima: Thank you. Well, I hope everyone enjoyed it because I've certainly enjoyed talking about it.

Jacqui: It's been brilliant. Thank you.

Andrea: For more information on anything that we have covered today, please get in touch with MS Connect on free call 1800 042 138 or email [email protected].

And don't forget to find the MS Podcasts on your favourite podcast player, such as Apple, Google Play, Spotify, Overcast, or you can access the podcast directly from our website ms.org.au.