#63: Eating for The Menopause with Dr Hannah Short

Dr Hannah Short: 45% of women in the UK or in the Western world die of heart disease and yet it doesn't really remain on people's radar that much.

Dr Rupy: Yeah.

Dr Hannah Short: Everyone's still very fearful of of cancer and I'm not downplaying the cancer but it's the other even women with who've unfortunately had breast cancer are more likely to die of heart disease.

Dr Rupy: Dr Hannah, thank you so much for coming in.

Dr Hannah Short: Thank you.

Dr Rupy: Really appreciate you coming down. Um, and I appreciate the list of foods that you said you like as well. So even though it's the morning, I'm going to be cooking you a Thai style tempeh salad. So it's sort of like a play on Thai beef salad, but obviously you're plant-based, so we're going to go with tempeh. And I'm so glad you like tempeh because I've been wanting to use this for so long. I'm a big fan of this stuff. I think it's got a great texture. You just need to hit it with loads of flavour. So I'm going to make a quick marinade that actually goes in after I've cooked the tempeh on a griddle pan with a little bit of coconut sugar, some chilli, black pepper, grated lemongrass, garlic, ginger, quite a few ingredients, I know.

Dr Hannah Short: Sounds good.

Dr Rupy: Some spring onion, and then put it all together with some other beautiful salad ingredients that we'll talk about in a sec.

Dr Hannah Short: Okay, sounds excellent.

Dr Rupy: Good, good. I'm glad. So, you came really highly recommended from a friend of mine called Dr Anita Mitra. I don't know if you've come across her.

Dr Hannah Short: I know her work, but I don't know her.

Dr Rupy: She's a big fan of yours. Because I was in the gym with her and I was like, look, I really want to do an episode on the menopause and eating for the menopause and just trying to talk through what the misinformation is out there and how we can actually give people some reliable information. And she said, you definitely need to speak to Dr Hannah Short because she's got some great stuff and personal experience as well. So tell me, tell us a bit about yourself.

Dr Hannah Short: So I'm a GP, but I'm also a menopause specialist and a specialist in premenstrual disorders as well. And so that interest kind of comes about really from a personal experience. And I guess it isn't really where I thought I would end up or thought what I'd end up doing at all. I went back to do medicine later. I was 27 when I went to med school. And at that point, I actually was really interested in psychiatry, just because I've always found it really fascinating from an academic point of view, always been interested in psychology and things like that. And I was also interested in how your mental health is affected by the menstrual cycle. At that point, I wasn't really thinking about menopause, but I guess hormonal change generally. Really interested in postnatal depression. And when I was a medical student, did some, did a training bit with a liaison psychiatrist at Addenbrooke's in Cambridge. And then I came down to Tower Hamlets and was shadowing the perinatal mental health team. So that's where I was kind of heading. That's what I was really interested in doing. But ultimately, things kind of changed because I became kind of unwell myself. I'd been quite, I'd struggled, I think, throughout my whole teenage years and 20s with pain as a result of endometriosis. And I just felt that that was kind of my life. I think, you know, basically two weeks a month, I was just crippled with pain. I'd had several surgeries. I'd had various medical treatments, you know, including the pill and other hormonal treatments. I'd tried every kind of complementary therapy out there that I, you know, I felt things had helped for short times, but nothing had ever completely kind of got rid of the pain and the sickness and the fatigue and everything else that I suffered. And I did go through periods when actually stuff was a bit more stable. And that was around the time that I applied to medical school. I was probably in a better place. But I think probably the stress of medical school and actually the stress of being a junior doctor kind of set me back a bit. And then that's also when I, I did always have a little bit of PMS, so I'd kind of tend to feel a bit low and irrational, I guess, just before periods. But I would always like, well, okay, that was kind of manageable. And I used to think, well, I'm probably feeling slightly anxious because I know that my period's going to be awful. I'm going to be in so much pain and I might have to miss work or anything again, you know, because sometimes I, you know, was incapacitated completely. But then the PMS kind of took off as well in my 30s, in my early 30s. And I suspect now it would probably be diagnosed as premenstrual dysphoric disorder. So, you know, PMDD, because my anxiety was through the roof.

Dr Rupy: Which I must admit, I don't think I've come across PMDD before. Certainly nothing that I've come across in medical school.

Dr Hannah Short: I don't think we're taught about it really.

Dr Rupy: Yeah, yeah. Would you mind telling us exactly what what PMDD is?

Dr Hannah Short: So it stands for premenstrual dysphoric disorder. And there's a little bit of a contentious diagnosis because actually it was, it was labelled as a psychiatric diagnosis in the states. So it's in the DSM-5 as a depressive disorder, but actually it's got neuroendocrine roots. It is essentially a severe form of of PMS or premenstrual syndrome. And I think they are on a spectrum. Some people will say, oh no, it's nothing like PMS, but they are connected. But there's lots of different things or root causes. So we think there's a genetic susceptibility to it. So it's basically an acute hormone sensitivity. So an abnormal reaction to normal hormonal fluctuations. A lot of women and girls will be familiar with like premenstrual changes. So they might be aware that maybe their breasts get a bit tender, they might have headaches, they might feel a little bit irritable, a little bit tearful, perhaps a little bit irrational, a bit low. But for most people, although it's not particularly pleasant, it's not necessarily going to have a really negative impact on their quality of life. It's not going to stop them going to school or college or work. It shouldn't be causing relationship problems, that kind of stuff. PMDD is is kind of like the most extreme end. Some people, I suppose it is responsible for people, some people not being able to work at all because they can't be reliable employees. So some people would shut themselves away completely or they can't contain their anger. Sometimes people become incredibly irritable and angry during the premenstrual phase, the two weeks before a period. Other people will become suicidal or, you know, and then they'll kind of lock themselves away, will cancel social engagements, are completely unable to kind of function. I mean, I luckily for me, I wasn't quite as severe as some patients I've seen and some cases I know about, but I did have suicidal thoughts quite intense intrusive thoughts at times. And I did think I don't know how I can go on feeling like this. And you have to, it's very important for people to track their their symptoms because obviously there are other other syndromes or other illnesses that can kind of mimic that. So women are often misdiagnosed with things like bipolar disorder because of the cyclical nature. So to get a true diagnosis of severe premenstrual disorder or PMDD, you need to kind of show that it clearly happens in the luteal phase of the menstrual cycle and it should then start to resolve or get better when your period comes. And a lot of women will say that it actually feels like a relief when their period comes.

Dr Rupy: Before people start thinking, oh, that sounds like me, I'm irritable, I'm irrational, I, you know, I don't want to go to work. This is super severe. So this is right at the end of the spectrum where people are thinking that they're suicidal. I mean, that's super extreme.

Dr Hannah Short: Yeah, I think 30% of people with it attempt suicide. So it is a big, it is an issue, but it's not recognized enough. I mean, we still don't fully understand the root causes. They have found a gene that seems to be linked and twin studies show that there's a heritability there. There's also that we think it's an abnormal kind of reaction to the metabolites of progesterone. So allopregnanolone, which normally would affect the GABA receptors and normally has more of a calming response, has the opposite response in people with PMDD or most people with PMDD. There's, they've shown on imaging studies that there's changes in the brain of structure and function, but whether that's a cause or a result, we don't know. There seem to be low, increased levels of inflammatory markers at baseline with some women with PMDD. So there's like, there's like five main pieces really that kind of seem to link and stress and trauma are quite heavily linked, but it doesn't necessarily mean you have a background in that, but that could be kind of a trigger. I suppose it's the whole epigenetic side of things really. So yeah, but it affects 5 to 8% of menstruating women or and it can affect trans trans men as well. So obviously if they were assigned, you know, female at birth and they still have their ovaries, then it could affect trans men as well. So the key thing is tracking. But there's, there are guidelines which a lot of doctors aren't aware about.

Dr Rupy: Yeah, because I was going to say, like I don't remember getting much training on this at all.

Dr Hannah Short: I don't think we get, well, I didn't get any.

Dr Rupy: Yeah, and I didn't do, sounds crazy, but I didn't do an O&G placement during my GP training, which I think is so necessary. I did paediatrics, I did GUM, so genitourinary medicine, I did a whole bunch of other things, like acute med, but the one thing I really wish I did was O&G, obstetrics and gynaecology.

Dr Hannah Short: Well, no, well, it's the same where I trained in West Suffolk. You either did O&G or paediatrics. And I've done, I'd done an O&G job when I was a foundation year doctor. But I, yeah, I didn't do it in my actual general practice training. So I did, I've did loads of, I've done so many peeds jobs. I haven't, I've done three peeds jobs, but, yeah.

Dr Rupy: I mean, it's very important.

Dr Hannah Short: Yes, obviously, it's important, but I think they're both really fundamental, really, aren't they? So.

Dr Rupy: Yeah.

Dr Hannah Short: Yeah, so we don't get much training. And when I, I started off as a psychiatric, you know, trainee, for various reasons, I chose to leave that and then went into general practice. But at the time, I, I was bringing papers showing about the relationship between estrogen and depression and premenstrual mood disorder changes and, but there wasn't very much interest and it's not a routine thing to ask about menstrual cycle and mental health. So even, I mean, that was like 2011 when I was doing the psychiatry training and people generally weren't interested and it's like, well, that's, that's what we should leave to the, you know, to the gynaecologist, endocrinologist. Yeah, yeah. But I even saw a young man who was a psychiatric inpatient who had depression that was only responsive to testosterone. So I think we're probably missing a subset of men who struggle and he'd been suicidal until he had adequate testosterone. So.

Dr Rupy: Wow. I think that's such a huge area. Like you were saying, you know, the neuroendocrinology basis of psychiatric issues, you know, which can be a symptom or, you know, a cause in some cases.

Dr Hannah Short: So I mean, there are, there are guidelines out there for the for the PMS and actually the whole spectrum of disorders. So there's like a mild premenstrual disorder, then there's the PMDD or core premenstrual disorder. There's premenstrual exacerbation, which is, which you often need to differentiate from the PMDD. So you can have an underlying mental health condition or an underlying physical health condition. So epilepsy, asthma, migraine that's worsened in the luteal phase. And actually then treatment should be targeted towards the underlying condition rather than treating the premenstrual exacerbation. But obviously the two can coexist. Yeah, yeah. And then there's progestogen-induced premenstrual disorder.

Dr Rupy: Uh-huh, which is the synthetic form of progesterone.

Dr Hannah Short: Yeah, so, um, so it doesn't even, so it could even be natural progesterone. So utrogestan can sometimes induce it, but um, women who are particularly sensitive to progesterone, and that does include a huge subset of the people who are diagnosed with PMDD. Um, also can react really negatively to exogenous progestogens in the pill, um, or, you know, in HRT. And then there's, there's no link with cycles. So there's, that's where it's important. So if there's no obvious link to exogenous hormones or cycles, then you would think actually you're looking at an underlying psychiatric diagnosis. It is quite complex and that's probably why a lot of people avoid it. And I spoke at the RCGP a couple of weeks ago and I think the feedback generally is, well, actually it's, it's helpful, but it's just in 10 minutes, it's really hard to differentiate. So.

Dr Rupy: But that's our excuse, I think, for a lot of things, if I'm, if I'm honest, Hannah, like, you know, even talking about the basis of diet and nutrition, 10 minutes is, isn't long enough for anything. It's literally nothing, you know, let alone, you know, a sexual history, even that, it's, it's not long enough for anything. So I think there's a fundamental issue with just the consultation time rather than the fact that we shouldn't be learning about it because it's someone else's or a different specialty's realm. But sorry, we went down a bit of a, I know. You're talking about your experience of PMDD. So were you diagnosed with that or is it on reflection that?

Dr Hannah Short: I was diagnosed with a severe premenstrual disorder, so not technically PMDD, because at that stage, I think it was still very much a term used in the US. So this is like 2012, 2013. But I, and luckily, I, I, I was referred to a very good gynaecologist who's a specialist in that area, and he made sure that I tracked my symptoms. And it was very clear that there was a cyclical pattern, although one of the issues on my, my particular case was that I'd never had regular periods, so it wasn't like I could say every two weeks this is going to happen. They were semi-regular, but it wasn't like, okay, you always know on this date this is going to happen. But it was very clear that my mood dipped. I mean, I never got, I'm grateful, I never got the anger side of stuff, but I would get very, very low. And I do remember driving home from the hospital once and thinking there's no, what's the point in any of this, but I was never at the point that I would have actually done anything, but those thoughts were becoming quite regular. And it wasn't like I got much let up when a period came because I was in severe pain from the endometriosis, which obviously has a negative impact on your mood anyway. So.

Dr Rupy: And you're doing training, like, I mean, it sounds like a dire situation.

Dr Hannah Short: And I think it's the life of a junior doctor, as all of us are aware, is, is not exactly stress-free. One, the job is inherently stressful, but two, the shift patterns. I mean, I didn't eat properly when I was training. You know, you do night shifts and I'd go in and I'd take what something healthy, but then I might end up leaving it in the doctor's mess and not have time to go back and get it. And then I'd go to a vending machine and there's only Snickers and Coke or something, you know. Yeah, yeah, exactly. So that probably didn't help. The lack of sleep didn't help. But eventually, yeah, so having had all the recommended treatments in terms of the endometriosis and PMDD, they, I was given something to try and switch off ovarian activity. But I had a negative reaction to that. I got one of the rare side effects.

Dr Rupy: Gonadotropin releasing hormone antagonist.

Dr Hannah Short: Yeah. So, but I, I experienced one of the negative side effects of that and so I had to stop. I had just very, very severe thirst.

Dr Rupy: Oh, really?

Dr Hannah Short: Yeah, unquenchable thirst. So I said that meant I couldn't, I couldn't have any more of that. But and eventually referred me for a hysterectomy and removal of both ovaries, which is obviously a pretty major decision.

Dr Rupy: Yeah, and that's like literally last resort, last chance saloon.

Dr Hannah Short: Yeah, but I, I remember I begged him for that because I was so desperate and I wrote, I, in some ways I feel slightly embarrassed about it now, but then I think about how I felt then because I felt I had no quality of life. And.

Dr Rupy: You know, it's interesting, because I wanted to talk about this a bit later about how some people, and this is, this is true of both men and women, would feel a failure if they've done all the lifestyle things, they take care of their health, they eat well, they meditate, they do all this stuff, and they still have to, quote unquote, resort to pharmaceuticals or interventions. And I think that's like, it's quite a negative way of thinking about it because in many cases, they're really necessary and we should be grateful for that we do have these interventions.

Dr Hannah Short: Oh, definitely.

Dr Rupy: Because I feel sometimes like, you know, especially with this podcast and everything I do, it's centered around self-care and looking after yourself and making sure you don't have to use medications. But when they're there, they're there and we should be entertaining that and using that appropriately, right?

Dr Hannah Short: Definitely. No, I, I think that's, and I think as I'm a huge, you know, fan and advocate of lifestyle medicine and dietary interventions for things, but they're not a miracle cure for everybody and they're not, they're part of the picture. Absolutely. Um, it's the same with pharmaceuticals. I don't think pharmaceuticals are a miracle answer for most things. It's a combination of everything. And I see it time and again in clinic, um, which I guess we'll come on to, but I, um, people who are doing everything they feel they can and they're still struggling. And I think one of the problems with, um, you know, conditions that are dependent on the menstrual cycle and hormonal fluctuations is that your motivation and your ability to make certain changes waxes and wanes throughout the month. So with endometriosis, there's quite a lot of evidence that you can, that exercise can help. But if you're crippled in pain for two, for two weeks a month, and I remember forcing myself out about a week before my period was due to go for a run and I just, I collapsed halfway around this run in the village and I just couldn't, I couldn't move. I was in so much pain. And I just, but I felt like a failure because I was like, I can't, I can't do what I need to do. When my mood was very low, I probably didn't make the best health choices in terms of food because I just wanted comfort food or, um, I'd have, I'd have a glass of wine because I felt really sad. I don't know, and that obviously made it worse. Yeah. Um, and then, then you beat yourself up and then the next, then the cloud lifts a bit and you're like, okay, I'll do it again this time. But I see this again with my patients and sometimes you do need the either pharmaceutical or worst case scenario, surgical intervention, and then you're better able to put those lifestyle things in place. So.

Dr Rupy: Well, I think almost like being a physician and being a patient or having had that patient experience makes you a lot more empathic as a doctor. I mean, my personal experience with ill health has never left me and I'll always remember that sort of embarrassment feeling of being on, you know, a hospital bed being wheeled through a hospital in front of loads of people who weren't paying attention to me, but still that really does stick with you. And I think, you know, your personal experience, particularly as this is now your specialty, will makes you a much more empathic doctor and someone that's actually a lot more understanding because, yeah, sometimes you do crave those crap foods and there's nothing else you can do about it, but you need to forgive yourself for that too.

Dr Hannah Short: Yeah. And I think it, it, it does, I definitely makes you more empathic, I think, because, and nothing's ever black and white. I mean, I gave a lecture on nutrition and kind of menopausal health a couple of years ago at King's College and somebody came up to me and she said, well, I, she changed her diet and she said, oh, it made, it's made the biggest difference. So she'd gone completely plant-based. And I was like, and I'm a big advocate for that. And I said, well, that's amazing and I'm so pleased that's helped. And then she said, that's all women need to do. And I said, but it, it's not that black and white for everybody and it's not, and I said, I wish it were. But I said it's disingenuous to say that if, if you just change your diet or your lifestyle, that everything else is going to sort itself out. It's a huge part of the answer and it can help, but it's not the only answer and not for everyone.

Dr Rupy: Absolutely.

Dr Hannah Short: So.

Dr Rupy: Yeah. So that's basically why I, I mean, I ended up further down the line doing, it's a long-winded answer to your question, but.

Dr Rupy: No, no, no, that was great. I mean, so, so after you had your procedure, that wasn't the end of the road though, right?

Dr Hannah Short: No. No. So obviously, had the surgery when I was 35, and that's when I was, um, that was in 2013. And it was a massive decision. We don't have children, my husband and I. Um, and I don't think I was ever somebody massively maternal, but I guess I'd spent so much of my 20s and early 30s feeling unwell, it wasn't really on my radar. And I was asked before the surgery, you know, do you want to freeze your eggs? Do you want to do anything like that? And I just couldn't, wasn't in the right head space and I was like, no, I just want to get, get on with the surgery. And I naively thought surgery is, you know, this is it. I, I stupidly, I don't know how I had this thought, but I thought if everything's taken out and you, you know, the your ovaries are removed, there's no more fluctuations. You have some add back HRT and everything will be hunky dory. Obviously, it's not quite as simple as that. And I think, you know, so I'll deal with everything then. And, um, I think it was a massive wake up call, you know, having a surgical menopause at a young age is a whole different ball game to a natural menopause 15 years later, which in itself can be difficult enough for a number of women. Um, because you're removing part of your endocrine system. Um, and that's obviously everything's interconnected. So, you know, our thyroid function is connected, just our, our adrenal function, everything is, everything is connected really. Um, and I don't think I'd, I'd appreciated that and I don't think I was fully prepared for what early surgical menopause would be like. Um, and that you can't replicate healthy functioning ovaries or at least a healthy response to changing hormone levels and stuff with, with HRT if you've got, you know, if your ovaries have gone and you've got a hormone sensitivity condition. Yeah, yeah. Um, so the, I mean, I always knew I was going to go on HRT because it's, it's so important if you're able to at that age to protect your heart and your, your, um, your bones and your brain health and just quality of life. Um, but I didn't absorb the first lot of HRT. So I was having an estrogen gel and, um, and my levels were basically just at the bottom, bottomed out. Yeah, yeah. And I felt dreadful. Um, and it's, it took me a long time to find something that has suited me and I can't say I've ever found something that's 100%. I think with the underlying hormone sensitivity you get with a severe premenstrual disorder, it's never going to be as simple as it would be for somebody without that. Um.

Dr Rupy: Were your symptoms essentially the typical menopause symptoms that you, that women experience or?

Dr Hannah Short: Um, a lot of them were, but I've never had hot flushes. So the one, the number one thing that I think a lot of people think about is hot flushes and night sweats. I do occasionally get night sweats, but that was what I was waiting for, but I got everything else. So severe kind of pain. Pains are a really common menopausal symptom that a lot of people don't talk about, whether it's natural menopause or not. So muscle pain and bone pain. Um, affects 30% of women. Actually probably affects more, but it can be a significant symptom in about 30% of women. And especially with surgical menopause, it seems to be more severe. So my everything really hurt. And that's when I kind of knew that things really weren't right. I felt like I was about 90 getting out of bed. Um, and, um, yeah, really bad headaches, which I'd never really had before. Um, and it just persistent chronic headache, not a migraine, but just head a frontal headache that just never went away. Um, I would get waves of anxiety and heart palpitations. Um, and that's really common anyway with natural menopause, but and I knew that's when my levels were very low. Just extreme fatigue. Um, and a lot of people talk about crashing fatigue. So you'll be sailing along okay and then one minute it's like someone's pulled the plug. Right. Um, yeah, I mean, but dry skin, um, just, yeah, the feeling of needing to go to, you know, pass urine all the time, like almost like a UTI type feeling, but there was no UTI because the lack of estrogen affects the tissues around there. Um, I mean, I guess it wasn't so much an issue for me personally, but obviously vaginal dryness is a big issue for lots of women and for some people it's their main, their main issue to the point that some people can't sit down comfortably, can't ride a bike, can't, you know, people who horse ride or something like that, they're no longer able to do those things because they might tear or bleed. And that's to do with the lack of estrogen, lack of lubrication. So, I mean, I think I've had a fair few of the, you know, the main symptoms, but there's just a whole, there's so many out there that people aren't aware about. Um.

Dr Rupy: And everyone's different depending on their sensitivities to lack of estrogen post menopause, whether it be surgical or otherwise. And it sounds to me like what you expected your journey to sort of come to an end to was really just the beginning of another one.

Dr Hannah Short: Definitely. Um, and I think it isn't just as simple as, okay, start some HRT and just get on with it. And it, it's, it really kind of opened my eyes to that. I think I was naive, but then I was so desperate to feel better. And to be fair, I am better than I was. And I'm, I'm now like six, seven years down the line. I'm definitely in a much better place now. Um, but it's taken me quite a long time to get there. Um, and I think there's not enough recognition that surgical menopause is, is a whole different ball game to natural menopause. And menopause at a younger age needs to be taken very seriously. I see women all the time who are told you're too young to be menopausal, but it can happen to women in their teens. This is when it's slightly different, not necessarily surgical menopause, but the premature ovarian insufficiency.

Dr Rupy: Yeah, we should probably talk about that. So we should talk about the differences between, um, uh, natural menopause, uh, POI, premature ovarian insufficiency, which is primarily what you see in your clinic, is that correct?

Dr Hannah Short: Um, I see a mixture of stuff. So I see a lot of women who are naturally menopausal, but I am seeing increasing numbers of women who have POI. So that's menopause below the age of 40. Um, and those with surgical menopause or with a history of cancer and things like that. Yeah.

Dr Rupy: And so the differences between them, so natural menopause is something that, um, generally you see over an age group of 45, if I'm correct.

Dr Hannah Short: So, yeah, so the average, so menopause in terms of the terminology can get a bit confusing. Menopause is technically one year after your final menstrual period. So the average age in the UK is 51, um, but any time from 45 is considered normal. But in the lead up to that, um, it's, that's called the perimenopause. And that's when your hormone levels start to change, there'll be fluctuations in estrogen and progesterone levels. And it's as your ovaries are kind of starting to wind down their function and you're no longer going to be as fertile, although it's important to know people can still conceive in perimenopause and it's not time to kind of abandon contraception and stuff like that. But, um, certainly your ovaries are no longer functioning as they once were and that you're going to get these this big kind of up and down swing. It's and a lot of women will notice that actually from their late 30s, early 40s onwards. Some won't because they probably those ones who don't have a genetic susceptibility to the sensitivity there, but. Um, so that perimenopause is just the changing levels. And then postmenopause is after you've had your menopause. Yeah. Um, but yeah, it's essentially when the ovarian hormones kind of dwindle down, you're no longer ovulating, producing eggs, no longer fertile. So.

Dr Rupy: And POI is a specific scenario where, or there are a number of different reasons as to why someone might go through POI, right?

Dr Hannah Short: So POI isn't technically menopause. Um, it's true premature ovarian insufficiency because some women ovarian function can fluctuate and very occasionally women can conceive. Um, whereas if you're truly menopausal, you're no longer going to be fertile. Um, but premature ovarian insufficiency is when essentially, yes, your ovaries just are not working sufficiently. Um, and the symptoms are very, very similar to, um, to to a, you know, a natural menopause, but it just occurs at a much younger age. So, um, I'll say the symptoms are similar. Interestingly though, things like hot flushes and things are not probably quite as common. It's often more things like the fatigue and mood changes and and other things that can be more common at that stage. And that's one something that's people aren't aware about in, um, perimenopause, often mood changes start before anything like hot flushes and night sweats and stuff happens. So a lot of people aren't aware of that. So the, the symptoms are similar, but it's not, it's not always as obvious. And that's why if, if somebody's having menstrual irregularities, so their periods are becoming less regular or maybe they've struggled to conceive because that's often when women might find out that that they've got POI. Um, they'll should have a number of blood tests looking at things like thyroid function as well. And there's certain criteria you have to meet to have that diagnosis. Um, and you need to have raised FSH levels, um, with the follicle stimulating hormone levels, um, at least four to six weeks apart consistently to and to have a diagnosis and a low level of estrogen. Um, but it takes a very, it takes a long time for women to get diagnosed and a lot of women are told their symptoms are signs of stress and things like that. So and it's, it's a real, it's a concern because I think if women aren't treated properly, it has a long-term impact on their quality of life, but also their chronic disease risk.

Dr Rupy: And then chronic disease, yeah, exactly. Yeah. We are going to get into that. I just want to bring you back to this recipe I'm making you. So, uh, just to recap, I've just grilled the tempeh with a little bit of sesame oil on, um, the griddle pan here. Um, and I've basically bathed that in a marinade afterwards, so it soaks up all the flavours of the lemongrass, garlic, ginger, a bit of tamari, uh, some sugar, some coconut sugar that I've used. It's got that beautiful earthiness. Um, and I'm just throwing it together with some bean sprouts that I've blanched in hot water. That's all I've done. I've just taken it out. Um, some pea shoots, uh, some finely sliced red peppers, some, uh, carrots, and I'm just tossing some cashews on the top. And I'm not going to give it to you in this bowl because it's massive. But, uh, I'll serve it to you in this small one here. And I'll let you have a taste. Thank you. Uh, and then we'll have a break and then we'll carry on. It looks delicious. I'll pop this here. So, tempeh, I'm really glad you asked for tempeh because no one asks for tempeh. Everyone thinks it tastes bland, but it's, it depends on like what you cook it, how you cook it, how you prepare it. Like, it's actually a really delicious ingredient. So.

Dr Hannah Short: Well, it's, I think it's so healthy as well, as in it's the fermented soy, it's the minimally processed soy, isn't it? And so many health benefits, but I, I think I probably would have been skeptical many years ago, but I've got a friend who's an amazing kind of vegan chef and she, she makes her own tempeh and she makes black bean tempeh and stuff as well. And so she converted me to it. Um, and, and then there's a couple of places in Cambridge where they serve amazing kind of tempeh sandwiches and I just, I was a convert and I've just started cooking at home a bit more and I don't know if you steam it for 20 minutes, that often gets rid of the bitterness. So I think sometimes people don't always, it doesn't always have to happen, but sometimes that's why people don't like it. So.

Dr Rupy: Interesting. Yeah.

Dr Hannah Short: There's a really nice recipe with tempeh piccata that I do.

Dr Rupy: Oh, nice.

Dr Hannah Short: And, um, yeah, you steam it first of all and.

Dr Rupy: Oh, you have to send that to me. I will do. It's good.

Dr Hannah Short: Uh, let me give this to you. I'll give you a fork as well. You can try it. Don't worry, I won't make you eat the whole thing on the pod. Here you go. You can give me your honest opinion of the tempeh. I've never steamed tempeh before. I've always just like thrown it together in like schwarmas with loads of like, you know, sesame and paste and all that kind of stuff. Um, some greens and, yeah, so. It's delicious. Good. I'm glad.

Dr Rupy: How was your breakfast/lunch?

Dr Hannah Short: It was, it was delicious. Thank you very much. I polished it off.

Dr Rupy: I'm glad. There's no food waste here.

Dr Hannah Short: No, there's not. No.

Dr Rupy: I will give you the recipe, don't worry. It'll be on the website as well. And I want your piccata recipe as well. Is that piccata like the Spanish piccata where you, you, you blend like, um, garlic, almonds and parsley? Is that, is that what it is?

Dr Hannah Short: It's, it doesn't have any almonds in it. It's got, um, capers and parsley. It's, it's actually, it's, um, a Chloe Coscarelli recipe. So it's in her book, but it's, it's really nice and it's managed to convert my husband to tempeh because he didn't like it until that recipe.

Dr Rupy: Nice. I do like using capers and pistachios. It's kind of like a Sicilian Italian thing.

Dr Hannah Short: Oh, that sounds nice.

Dr Rupy: Yeah. So, no, there's no nuts in it, but, um, yeah, it's, it's a really good recipe. So.

Dr Rupy: Good, good. So, we were talking earlier about, uh, your personal story, which I think is super important to highlight. Um, and thank you for that as well. We talked a little bit about symptoms, but just in the break, we were talking about how, you know, just because we don't mention certain symptoms like vaginal dryness, for example, or libido, it doesn't mean that those symptoms are less important. I think every symptom is as important as it is to that individual. And this is something that you see in clinic, right?

Dr Hannah Short: Yeah, definitely. Um, so I kind of, as I said before, hot flushes for me have never been an issue. And I'm very grateful for that, although I remember at times I've thought, well, I'd switch the anxiety and the palpitations I sometimes get for hot flushes. But having said that, for some women, hot flushes are so debilitating, affecting people throughout, you know, every 20 minutes or waking them through the night, drenching bed, you know, their bed clothes and things like that. And it's just very much individual. And so what one person would say, I'd happily swap this symptom for that. We don't, you have to be in another person's shoes to judge really. And I think the thing about menopause and about, um, premenstrual disorders and or just about hormone-related conditions anyway, that they, they can affect any part of the body. Um, we've got hormone receptors just, you know, throughout. So the estrogen receptors in obviously in the brain, in the gut, in your lungs, in your skin, in your eyes, everything. So, and I've seen one lady and her main symptom was dry eyes, but to the point that they were driving her literally to distraction. And and then inducing a kind of a panic because of that. And I think, you know, if people say, oh gosh, dry eyes, it's not a big deal. But I think if, if it's the first thing you notice when you wake up and your eyes are constantly uncomfortable, I can imagine it is very debilitating. Um, so, yeah, I think, and and some people it's the digestive upset you can get with with the change in hormones, that that can be really debilitating too. Other people, um, like the the pain, I had one, one patient with severe pain in her hands and she used to play the violin and loved to garden and knit and the three things that she loved most were being affected. She didn't have hot flushes, she didn't feel particularly anxious, but the pain was making and estrogen replacement for her was really going to get her quality of life back. So.

Dr Rupy: Yeah, to your point, you know, it's about the impact of that particular symptom to someone's daily activities of daily living, their, their quality of life, their enjoyment of life. So, yeah, whether it is something as trivial sounding as dry eye, it can actually have a huge impact on someone's mental health.

Dr Hannah Short: Definitely. Yeah.

Dr Rupy: I, I like to, so I have a little mnemonic about the symptoms of menopause. So it's all the M's. So it's, um, uh, mood, uh, muscles, so muscle pain. Um, there's vasomotor, mop hair, hair loss. Um, and a whole bunch of others. But there are a whole bunch of different symptoms like you said because of the estrogen receptors that we've found across the body. Um, it seems to me like you, uh, learned a bit more about lifestyle measures prior to your own procedure. It seems like you went into your procedure like, you know, with sort of a lot of information. You tried herbal supplements, you tried loads of different activities. Is that when you had kind of had your light bulb moment towards lifestyle medicine or did it come after the surgical intervention that you had?

Dr Hannah Short: Um, I've always, always had an interest in things like nutrition and, um, kind of complementary therapies alongside traditional medical therapies. And I actually trained as an aromatherapist before I did medicine. Yeah. So when I was working in the city, which was the other thing I was doing before I did medicine, um, I, I did an aromatherapy course, so I qualified as an aromatherapist and massage therapist. And I was particularly interested, um, in that point in kind of how the oils, um, worked on the kind of our biochemical level and the evidence around that. So I wasn't so interested in the massage, although I appreciated it had its benefits, but it was more about the oils. And that stemmed from when I was around 15 or 16 and experimenting myself because of the pain I had. Um, and finding that I had some benefit with using the oil called clary sage. Um, and it really did help me for a long time, but eventually it wasn't, it wasn't enough. Um, and, um, yeah, so that's kind of where that kind of stemmed. And then people I met through that, I was kind of opened up to another world of more complementary therapies. Um, and again, and it's something I've not really talked about. I, one thing that really helped me in my 20s was, um, Reiki, which I was so skeptical about. Yeah. Um, but it was when I was feeling pretty desperate towards the, um, I suppose I was in my 20s just before I went to med school. Um, I was feeling really desperate because I, I'd lost a job. So this is when I, I'd changed jobs. I'd left in the city, which I'd intended to do. And I was just kind of, um, temping. Or was I temping at that point? Anyway, I don't know. I was, I was working somewhere else, um, doing still kind of working financial services, but I every month I was struggling with the pain and I just said, can I, can I come in with a hot water bottle? And they were like, no, it's inappropriate to have a hot water bottle at work. And I mean, I hope things like that have changed. But I was just in so much pain. I was just like, okay. Anyway, they let me go, but.

Dr Rupy: Oh, because of the hot water bottle?

Dr Hannah Short: They, because they said I was unreliable because I had, I called in sick because they wouldn't let me, I, yeah, there were a couple of days each month that I was really incapacitated with the pain, but they weren't that happy to, to bend the rules and let me take a hot water bottle to work and other things that they didn't really want me to do. Um, it sounds a bit ridiculous, doesn't it? But it was, it was essentially that's kind of what went on. Um, and I, and I remember thinking I've got, I've actually had a place at med school. I wasn't so upset about losing that particular role because it was just a stop gap. Yeah. But it did highlight to me the issues that people have generally with these kind of chronic conditions. Yeah. Um, but I was thinking if I can't do this, am I going to manage med school? A friend, um, who I met through the aromatherapy, she said, well, why don't you try Reiki? And I was like, what is Reiki? And I said, at least with the oils, I can understand there's some, you know, you can kind of see because there's the chemistry there, you can kind of work out how it might help and certain things. And she said, well, just give it a go. And I thought, well, it's not going to hurt me.

Dr Rupy: Well, it's literally not touching you.

Dr Hannah Short: You can't. But I just, um, and so she gave me a session and I remember I just, I felt, I just felt slightly energized afterwards and I was like, yeah, it's a placebo effect. Well, that was quite nice, right? Yeah. Um, and then she said, well, go and see my friend Stephen. So she said to get, she said because she was moving or something. So I went to this guy Stephen and it was incredible and I just do remember I was pain-free for probably a good part of two years following a few treatments of that. And even my, my housemates and my boyfriend at the time, they just, they both noticed, they said you seem different. And I felt like this energy moving and it sounds ridiculous because I still can't really explain it, but I definitely had a profound effect on me then. And I think that's what saw me through initially with going to med school. Yeah. And then things started to spiral down, but obviously I wasn't having Reiki. I probably wasn't looking after my diet and stuff kind of going down and I did try and find someone who practiced Reiki up in Cambridge. Um, and for some reason at that point it didn't seem to have the same effect and, um, so I kind of abandoned that. Um, so, yeah, so I'd say these are the kind of things I tried before. I'd always been a bit more open, I suppose, and interested in that stuff. Um, but the, the in terms of the lifestyle stuff post-surgery, um, I think it came from, I suppose I changed my diet, but this wasn't really for health reasons. This was more because of animal welfare, environmental concerns. I became vegan about five years ago.

Dr Rupy: Yeah, I was going to ask you about why you went plant-based vegan. Yeah.

Dr Hannah Short: Yeah, so that was about, um, yeah, five years ago now. And I'd for many years I'd been cutting down on kind of meat consumption. I grew up on a farm in Derbyshire. And my, my dad's a farm animal nutritionist by kind of trade and he's, he worked in farming for a bit and I was well aware about the importance of animal welfare, even on the small animal farm we had that there was generally good welfare around, you know, how we kept them and stuff. But I was, I was becoming increasingly uncomfortable about the slaughter side of stuff. And I even knew from what my father, you know, would say to me that that was what he dreaded the day that we took the sheep to slaughter and the pigs and things like that. And I think I remember for ages just thinking it's a, you know, it's a necessary evil, push it to the back of my mind, try and source stuff from farms where they treat their animals well. And I did that for a bit, but it was getting kind of awkward. If I go to someone's house and I feel like I can't really quiz where did you get your meat from, but I felt I couldn't say I'm vegetarian because I wasn't and eventually I took the plunge and I'd done the research and I was like, well, I know I can do this in a healthy way. Um, and did veganuary essentially and and then I didn't really kind of like look back. Um, although initially, I think I focused too much on the junk food aspect of it. And I was like, well, this is vegan, well, I'll have it, you know, or this is, this is a vegan cake, I better eat it. And I, and I remember not feeling so brilliant when I was doing that's kind of the thing. And then I just thought, do you know what, if I'm doing this, I need to do it properly. And I really noticed after that, I then became much more nutritionally aware. Um, in terms of I did a lot more research about nutrients and stuff and menopause and and so it was at that point that and I started to realize that definitely what I was eating was really having an effect. I mean, I was always peripherally aware of that.

Dr Rupy: Yeah, yeah.

Dr Hannah Short: But I when I looked at the science a bit more and that got me very interested. Definitely noticed as well that my response to treatment depended on how well I was eating and sleeping and everything else. And and then I kind of ended up doing the course that you did as well, I think the RCGP lifestyle medicine course with Rangan and I and so, yeah, so.

Dr Rupy: That's great. Yeah. I think veganuary or the whole vegan movement gets a bit of a bad rep because, um, you know, people do it and they essentially do what you did initially and they just do the junk food stuff. But I think it's a bit of a gateway drug into eating more nutritionally aware. And I like that way you described it. Um, and actually towards a more whole food plant focused diet. And whether people still choose to eat meat or not, as long as you're getting more plants in your diet, which across the board is exactly what we need to be doing. And I think that's something to be celebrated. And the other thing I'm really glad you picked up is being open-minded to different, uh, medicines, whether you call it energy medicine, whether you call it, you know, Reiki, whatever, because I'm a massive skeptic of that kind of stuff. Um, but even you with your awareness of the fact that this is likely going to be a placebo effect, the fact that you were doing medicine as well, um, or preparing for medical school, despite that, you still found some benefits of it.

Dr Hannah Short: Definitely.

Dr Rupy: And I think there's a lot that we just don't know.

Dr Hannah Short: Definitely. I know, and it's, and I still don't really understand. I mean, I've tried to do some reading about it, but it's, it's quite hard to know where to go for kind of trusted, the internet now, it's so hard to know, you know, if you Google certain things and there's some quite kind of strange, you know, odd sites can come up and you're like, well, I'm not sure I necessarily trust what this person's saying. So I can only really speak from my experience, but there was the fact it was noticeable to friends and family around me. And I've had so many other treatments before and they hadn't, and I thought, well, if it was placebo, it wouldn't really make, do you know what I mean? I don't know. But also had a big impact on a friend of mine who'd broken her back and was on painkillers and couldn't and she was struggling to stop taking so many painkillers because of, you know, she was in so much pain and she got off her painkillers after seeing Steve. I mean, he was, he was fantastic. And I think I don't know, obviously some of it's to do with the relationship with maybe the person you're seeing. Um, I think back, I mean, he was, he was quite a lot younger now than I am now. He was like in his early 30s, but he just seemed to be really full of wisdom and just a very gentle person, a very open person. So I suspect that and that's part of I think where the benefits come with a lot of complementary treatments as well. It's the time making people feel valued and really listening. And I think that's what's so important with all of this stuff. It's, um, everybody's an individual and every, you know, every story is different.

Dr Rupy: Yeah. I think there's definitely like a psychotherapy element to that. And I think the biggest issue with any of these complementary therapies or whatever people choose to call them is, um, how do you scale that across the population? Uh, how do you get that to the most vulnerable people in a, in an appropriate time scale? Um, yeah, there's definitely something I want to explore a bit more. Let's go back to the menopause. So, um, I want to talk about this idea of, uh, low-level inflammation in the body post-menopause. Where does that come from? Is that something you've come across yourself and do you see this in your clinical practice?

Dr Hannah Short: Yeah, well, we, we know that, um, the menopausal transition is, is a time where there's an increased rate of kind of, um, low-level inflammatory markers because estrogen itself is inherently anti-inflammatory and it has so many effects on the, on the immune system. Gut permeability increases at menopause. There's a paper that came out recently about that. And they're saying that that's one of the ways in which, you know, low-level inflammation seems to occur. Um, um, and it has an effect on the immune system because people can notice their immune function can kind of go down or conversely, autoimmune conditions rise around the menopause and perimenopause as well. Um, and we think that a lot of the symptoms around perimenopause are can be due to, you know, increases in inflammation, a general kind of level. But I mean, it's, it's hard, isn't it, to talk specifically about because inflammation is such a wide-ranging thing and some inflammation is of benefit depending on the context. Um, and obviously if you need an immune response to say a virus or something like that, you want there to be an inflammatory response. But I think the more there's so much research now, isn't there, about chronic inflammation and chronic disease, whether it's diabetes, depression, heart disease. And it certainly seems to play a part in, in, in menopause and interestingly in premenstrual disorders in women with PMDD, they tend to have slightly higher inflammatory markers at baseline. So, um, yeah, I mean, truly understanding the mechanisms of how it comes about, I think we still needs to be more research, but it, it's probably just the lessening of the, um, the effects of the, you know, if you've got lower levels of estrogen, you've got less anti-inflammatory hormone in the body. Um, but also like the gut permeability issue, all of that's probably important. So, and then the inherent stress that people are going to feel from, from the, from some of the changes that come about. And also, I think a lot of people don't appreciate that menopause for some people is a really difficult time because they feel that they're losing their youth and it shouldn't really be about that. But it is, and I think it says a lot about society and how you value women and also about how viewing that women are just people to have babies and procreate. And that's a whole thing that's important about POI, um, and something I've struggled with personally. Not that I, I was never desperate to have children, but I do have moments where I suddenly feel very sad that I would never have my own children. Um, because I mean, I definitely believe you can have a very worthwhile and happy, fulfilling life without children. It's just a different life. Um, but it's more the fact that society treat you differently as a woman if you don't have kids. And I think that that's really important to change the narrative. Um, whether you're someone who doesn't want kids, whether you've always wanted kids, whether you can't have kids, it's you're not just a, you know, a reproductive machine as a woman.

Dr Rupy: Yeah.

Dr Hannah Short: And I'm sure this obviously impacts men as well, but I think it's particularly important when it comes to women. And I see that time and again and women who feel that they've, they've lost their reason for being or and just the way people have spoken to me, you don't have kids and they're, it'll either be pity or surprise or I don't know, and some of the, some of the comments that people will say like, if you don't have a child, you never really know what love is. And things like that or only a parent would understand. And you can feel quite diminished.

Dr Rupy: Yeah, yeah.

Dr Hannah Short: And I think that's what I've struggled with and also some of the isolation that comes with that. So.

Dr Rupy: Are there some differences culturally where, uh, maybe it's something that's unique to Western society where it's expected that everyone should have kids and then after menopause, that's something to signify, oh, you're getting old. Whereas perhaps in other cultures, perhaps in ancestral cultures, traditional cultures, uh, have actually celebrated the menopause and something to be, to be welcomed and something to appreciate.

Dr Hannah Short: There's certainly cultural differences, I think, in how menopause is, is treated and how people who are getting older are treated. So we know in the West that there's, especially in, I don't know, places like Hollywood and stuff in the states, it's, it's all about youth, isn't it? And everything like that. Um, and yet in certain other cultures, like you say, your people can be celebrated for being older and having wisdom and and, um, and just being respected, which I think is, is not quite the same over here. I don't think it's exactly the same thing as the whole children issue, um, because I think in certain cultures where being older and more full of wisdom is respected, there can be a lot of judgment on women who can't have children in that culture. Um, so a lot of, a lot of women say from maybe traditional Asian families, and I've seen this kind of myself, I suppose, in people I've, you know, interacted with through the work I've done. Um, have just said that they, they have to keep the fact they can't conceive like a secret because they, they'd be banished or banished, but it's a huge taboo. Yeah, yeah. And, and I think I'm grateful that that's not the case for me and I appreciate I'm in a very lucky position and people whose partners have left them because they're never going to have children and if they can't have children, then that their partner say they would never, you know, they can't be a proper, proper man if they can't be a father. Um, so it, yeah, it kind of reverberates. I think that's across all cultures, um, that the issues there. Um, but I'm surprised actually still at the judgment you can face as a woman not having children in a Western society.

Dr Rupy: Absolutely. Yeah. I mean, the the kind of personal questions that people probably pose to you without you even asking, you know, it's, it's quite, um, it's pretty rude. Uh, you know, to, to ask those questions and and correct pity because, you know, you, it's completely your choice as to whether you choose to have children or not regardless.

Dr Hannah Short: Well, I think the thing was in my case, it was, it wasn't really a choice. And I think it, they say, well, it was a choice, you know, you chose to have the surgery. And I was like, but it felt like there was no other option. Um, and I said it's hard because now you can kind of further down the line, you're like, well, would I have done things differently? And I don't, I don't know. But it, it didn't, it didn't feel like much of a choice. And certainly a lot of younger women who have POI or they have surgical menopause, um, due to cancer treatment or endometriosis or PMDD, whatever it is. Um, it isn't a choice because it's a choice between having a life or not having a life for many people. And that feels taken away from you. And then it's a double whammy. You're trying to deal with the symptoms of a menopause at a much younger age and then the fact that society kind of might treat you differently and.

Dr Rupy: Yeah. Yeah. Well, I appreciate you sharing your story because I think that is going to be quite empowering for a lot of people who have had similar scenarios to yourself. Um, you mentioned, uh, the gut microbiota and gut permeability. Um, so for everyone who's listened to the podcast before, very well aware of the gut, uh, being the population of different microbes, largely bacteria, but including viruses, nematodes, fungi, uh, and absolutely inseparable from health. Um, what do we know about the gut microbiota, how we can nurture that microbiota, and what potential effects it can have on the common symptoms that we talked about, uh, previously to do with the menopause, so memory, migraine, um, mood, um, and, uh, pain.

Dr Hannah Short: It's really important. I think you've talked about in your podcast before and things that obviously the gut microbiome and the microbes we have there are just so important for general wellbeing and health, whether on day-to-day or chronic disease risk. Um, and obviously what, what's in our gut has, it affects our hormones and how we metabolize them. And I think, I think you've spoken before about things like the gut-brain axis and we know that serotonin can be produced in the gut and so the food we eat can affect our mental health. And the same goes for our kind of general hormonal health, which obviously is, is interlinked with mental health as well. Um, there's a paper that shows that people have more of a plant-based diet tend to suffer fewer menopausal symptoms. But I say that with a caveat that actually it's not necessarily a cure-all. But there's certainly an association with those following a healthy vegetarian or vegan diet, their symptoms tend to, tend to be less than those who don't. And the paper says that it's particularly beneficial if you have berries and leafy greens. Well, that's what they found in this particular study. Um, but again, you could be somebody who has small amounts of animal products, but if you're actually most of your food is whole, whole food, um, that's the main benefit is kind of going to be there. Yeah. So we think it's, it's for a number of reasons that that's going to affect menopausal symptoms. Um, one of it, we, we know that the more diverse the microbiome, um, and that comes from eating like a fiber-rich diet and complex carbohydrate-rich diet. Um, there tends to be more anti-inflammatory properties there. And we just spoke about inflammation. So if you can lower any levels of inflammation there, that's going to have a knock-on effect with the symptoms. Um, there's also something called the estrobolome. So it's the micro.

Dr Rupy: Estrobolome? I haven't heard of it. Wow. Do tell me.

Dr Hannah Short: So this is, uh, microbes in the gut that can affect estrogen metabolism. Okay. So they can affect the enterohepatic circulation. So the whether the excretion and just general metabolism of the estrogens in the gut. Um, and there's something called beta-glucuronidase, which is produced by certain microbes in the gut. And, um, that, that can activate certain forms of estrogen and things like that. And if there's, if there's a problem with the gut microbes or you don't have enough, um, of the right kind of microbes, then that can affect the activity of the beta-glucuronidase.

Dr Rupy: Interesting. I've never heard of that term before.

Dr Hannah Short: Yeah, so there's a bit more research coming out on that. So the, women, um, who have more of a plant-based diet or more of a fiber-rich diet, will tend to have a more diverse microbiome and that has a kind of a knock-on effect with that. It also, um, I think you, you tend to have more expression of certain genes that, that are again to kind of positively affect estrogen metabolism. Interestingly, women with, um, say a diverse microbiome, they, they seem to have lower overall circulating levels of estrogen. Okay. Which some people would think, well, that doesn't really make much sense because surely a lot of the symptoms to do with menopause are to do with low estrogen levels. But it's not just low levels, it's to do with the fluctuating levels. And actually, if anything, for most things, it is the fluctuating levels in perimenopause that are the issue. If you've got this diverse microbiome and lower overall circulating levels, you actually tend to have less fluctuation levels and you're excreting some of the, um, some of the metabolites of estrogen. If you don't have the, the right microbes, in inverted commas, you sometimes reabsorb some of those metabolites, which can increase things like acne, mood swings, fatigue, and things like that. Um, women who have a fiber-rich diet as well, you tend to have higher levels of sex hormone binding globulin, so SHBG. And that kind of regulates hormone fluctuations as well. Um, and it tends to be associated with a lower cancer risk, heart disease risk, and everything.

Dr Rupy: I was going to ask actually. So anything that would, um, uh, stabilize the levels of estrogen in your body is going to have a knock-on effect on the estrogen-related cancers as well. So breast and, uh, um, and others as well.

Dr Hannah Short: I think the whole, the whole topic of estrogen is, is quite complex and controversial because if you believe the papers, you'd think that estrogen's this like devil's hormone. Whereas it's not, it's just that with like with everything, you need a, you need the right balance. So estrogen is really important, especially in younger women for, you know, brain, bone, heart health, mental health, and everything like that. But obviously in excess, it can be problematic too. But I think it's more the way our bodies deal with the excess rather than the overall level of the estrogen. Um, so if you've got a slightly higher level of SHBG and you've got a relatively high level of estrogen, it kind of tends to balance itself out. Um, but it is very complex and this is why kind of like your gut health and everything else has an impact on whether you're taking HRT or not taking HRT and and symptoms whether or not you're on treatment. So.

Dr Rupy: Yeah, yeah. I, I learned, um, something quite interesting on a previous podcast, um, about how, uh, with the levels of fiber, yes, probably another mechanism is, is actually, uh, increasing the ability of your body to deal with estrogens using these different types of, um, microbes. But also, um, your digestive tract, pooping, is essentially one of the ways you, you remove excess estrogens as well from your body, including xenoestrogens as well. Definitely. Um, so actually going to the toilet and having different types of fiber can have an impact on that as well.

Dr Hannah Short: Yeah, definitely. And I think one of the major issues with, or that I see quite a lot in, in clinic is a lot of women are quite constipated because the, the gut, um, has quite a lot of estrogen receptors and that helps with gut motility. If, um, when, when the estrogen's kind of downregulated at menopause, obviously the gut tends to slow down. Um, obviously the slower the transit, the more water is absorbed, the more likely you are to be kind of constipated. So this is when water again and fiber become massively important as well. But yeah, the, so the excretion in, um, in, in, um, fecal matter is, is really important. So again, vegetarians and vegans will have higher levels of, um, estrogen metabolites in their, um, in their stool than than somebody who, who doesn't eat a fiber-rich diet.

Dr Rupy: Yeah. And estrogen dominance, is that something that you've heard clients come to and talk to you about and in papers as well?

Dr Hannah Short: Yeah, it's not, I think it's not really an accepted medical term, but certainly, um, people will come and say they think that, but it's normally, it's more that things aren't being regulated in the right way.

Dr Rupy: I like your terminology of it being imbalanced and rather regulated rather than, you know, excess too much of something because I think we, we like to think of things as humans in very binary terms, I.e. estrogen is bad, so I'm not going to have that much of it. But really, it's about improving your normal homeostatic mechanisms.

Dr Hannah Short: Exactly. And I think we're just learning about, you know, the part that estrogen kind of plays in that and the role of things like metabolic syndrome and stuff. So metabolic syndrome, cardiovascular risk, everything goes up post-menopause and that's for a number of reasons, but we know that estrogen is hugely important in dealing with insulin sensitivity and, um, and everything. And again, if you have a right balance of estrogen in your gut, it, it seems to have, it seems to decrease the risk of, of kind of dangerous bacteria in the gut. So you're less likely to say suffer with C. difficile or something if you have a good balance of estrogen. But.

Dr Rupy: Yeah, just for the listeners, metabolic syndrome is this triad of, uh, conditions where you have excess blood pressure, insulin resistance, and central obesity. And that's something you see correlated with menopause, post-menopausal women as well.

Dr Hannah Short: Yeah, definitely.

Dr Rupy: And one of the reasons why HRT, uh, which we'll get on to in a minute, uh, can be beneficial in terms of preventing, um, the excess risks associated with, with life post-menopause.

Dr Hannah Short: Yeah, definitely.

Dr Rupy: Yeah. Um, with the, I want to go on to different types of foods. But before I do that, um, uh, soy. Uh, so it's a really controversial subject. I'm constantly asked about the soy question whenever I post anything with tempeh or soy milk or tofu or whatever. Um, soy for menopause. And I know what you're going to say, it depends on the person, but soy for menopause, is it something that we should be encouraging or is it something that we need to be fearful of because of the, quote unquote, phytoestrogenic effects?

Dr Hannah Short: Definitely don't need to be fearful of it. Um, in fact, generally, I encourage everybody to include soy in their diet. And a lot of people don't ever include any, either because it's just not something naturally part of their diet, or they believe the myths that are going around. And the myths that go around around soy are pretty much, it's, it's basically as bad as it is with HRT, which we'll come on to. And there's so many myths there. I mean, soy is essentially a bean. But yet, there's so much fear that's around it. Um, but it's chock full of these phytoestrogens or plant-based estrogens. The, the key thing is though that they're not the same as an exogenous estrogen, say in the pill or something else, or even the estrogen that we produce, but they do have an affinity with estrogen receptors. So you've got two main estrogen receptors, estrogen receptor alpha, estrogen receptor beta. And they have a bit of affinity really for estrogen receptor beta, but they, they can act on estrogen receptor alpha. So they can have estrogen-like effects and anti-estrogenic-like effects as well, depends on the tissues and where they're being used in the body. Um, the estrogen receptor beta is quite important in terms of minimizing kind of cell proliferation and things like that as well. So it can have a positive effect on kind of reducing breast cancer risk, for example. Whereas a lot of people will hear phytoestrogens, estrogen, breast, and they'll automatically assume that that soy therefore is very bad for that, whereas the research suggests anything but. If anything, girls and women who grow up having soy in their diet regularly tend to have a reduced risk of breast cancer and better bone health. And so this is, I suppose, more traditional kind of Asian populations, especially kind of in parts of rural China and Japan and places like that. Um, and obviously over here, we don't, we have less of that. It's not, it's not so much part of the culture, but, um, certainly that this the over there, that that's what that that's what the research shows us. Yeah. Um, research also shows that there's, interestingly, with estrogen positive, um, breast cancer, there's a reduced risk of recurrence if you include regular soy in your diet because it seems to have an anti-estrogenic effect on the breast. Yeah. Um, but conversely, it can have beneficial effects on menopausal symptoms. Um, and it can, in terms of bone health, it, the data's kind of inconclusive, but it's, it's either neutral to positive. So it's not going to be as effective at preserving bone health as say estrogen, but it's, it can, it can benefit your bone health in that sense. So.

Dr Rupy: Is that something that you recommend to post-menopausal women in your, in clinic then? So switching from dairy to soy milk and trying to include tofu portions of tofu in your, in your weekly diet?

Dr Hannah Short: I do, yeah, I do encourage trying to, you know, trying to include minimally processed soy. And I, one recommendation I tend to make is if people can tolerate soy, and they haven't got an allergy or, um, trying to switch from, from soy, from sorry, from dairy to fortified soy milk. Um, it's the same protein content as cow's milk and it's the most nutritionally dense of the, of the plant-based milks. So, but there's also the positive effects it can have not only on menopausal symptoms, but also and on the gut microbes, which I need to come back to because there's a very specific thing about that with soy. Sure, yeah. Is, um, also on heart health. So it improves the, um, the function of the endothelial lining, so the lining of the blood vessels. Um, associated with a reduced risk of, you know, blood pressure and stuff. It can lower, help lower blood pressure. Um, so there's so many more benefits to it.

Dr Rupy: And considering women are at risk of heart disease or most likely to die from heart disease, then anything that improves your heart health, like soy-based products are going to be very beneficial, particularly post-menopause.

Dr Hannah Short: Definitely. I mean, 45% of women in the UK or in the Western world die of heart disease and yet it doesn't really remain on people's radar that much.

Dr Rupy: Yeah.

Dr Hannah Short: Everyone's still very fearful of of cancer and I'm not downplaying the cancer, but it's the other even women with who've unfortunately had breast cancer are more likely to die of heart disease. So.

Dr Rupy: I, and I don't think a lot of people realize that because I think there's, um, we're really hot on the PR for, for cancers in general, female cancers and don't get me wrong, it's a horrific condition and I wouldn't wish it on anyone. Um, and it definitely deserves the importance, but I think if we're really going to be serious about trying to reduce mortality and morbidity, then heart disease really needs a lot more attention. And I think women typically think this is a disease of men, whereas actually, you know, women do need to be aware of it.

Dr Hannah Short: No, the, um, you know, the incidence rate sky rockets after menopause because of the, you know, estrogen is very important for the health of cardiovascular system and you kind of develop cardiovascular instability. So that's when you can see the blood pressure is kind of going all over the place and things and the build up of the, you know, fatty streaks in the arteries and all, you know, all of that stuff increases. Um, there is something called the window of opportunity in terms of hormone replacement therapy, which we can talk about because some of the data's been a bit conflicting on whether it's beneficial for for, um, heart health after menopause. And we now know that it's, it depends on when you start that. So, yeah, we can kind of come back to that, but it's, there's no, there's very few downsides to soy. Um, certainly not in the amounts that we're going to be eating over here. Yeah. We know that women who, who eat it traditionally as part of their diet, they might have two or three servings a day. We're not saying that people necessarily go need to go to that. But, um, you know, whether that's in soy milk or the tofu, the tempeh, the miso, miso, sorry, or the edamame beans, those kind of things. Um, they're, they're probably the best, you know, best ways to kind of get the soy. Um, but we.

Dr Rupy: And when you consume those types of foods, you're consuming more than just like the isoflavone that's potentially responsible for the improved symptoms and the phytoestrogens that you find in things like lignans and stuff. You know, you're getting good source of, um, protein, you're getting calcium as well. I think not a lot of people realize that sesame and tofu and beans are very good sources of absorbable calcium too. Um, not to say that you can't get it from other dairy items. Um, but yeah, I think you're getting this whole orchestra of different ingredients when you, when you eat whole foods and it's definitely something.

Dr Hannah Short: I think that's the key thing. It's the whole foods and the minimally processed. So not like the soy protein isolate that you're going to get in a cereal bar or the soy protein powder, which may have its place, but it's not really kind of what we're talking about. It is like with tempeh, the fermented soy that's particularly beneficial for gut health and things like that. But the protein and soy is a complete protein. I know we've kind of moved away from you have to have complete proteins at every meal, but it has got the complete array of amino acids and. Um, it's a, it's a very good kind of, um, non-animal source of, of protein and very healthy. I mean, unfortunately, some people will obviously have an allergy or an intolerance and there's other ways that you can kind of get benefits from plant-based proteins and other things that contain phytoestrogens like, you know, the lentils, certain seeds and stuff, red clover and things that are beneficial.

Dr Rupy: Yeah, milk thistle. Yeah.

Dr Hannah Short: So, um, you wanted to go back to the microbiota and I think I, I know what you're probably going to mention. Is it the equol producing bacteria in Asian women?

Dr Hannah Short: Yeah. So, um, interestingly, the health of your gut microbiome is going to influence how well you or how much benefit you get from soy, um, and those kind of foods and phytoestrogens. Um, and that's because it depends on how the soy is metabolized in the gut and how it's broken down. And there's one of the, the three main isoflavones, which are the kind of the bioactive compounds in the, in the soy phytoestrogens. Um, and one of them is converted to something called equol, which seems to have the most potent effects and stuff on the estrogen receptors. And these are the women who are what we call equol producers, so their gut microbes help produce that from the soy that's been ingested. Um, are the ones who are going to get the most benefit from eating the soy foods and stuff. In the West, unfortunately, there's only about 20 to 30% of women who are known to be equol producers on the average population. In the Asian population, it's closer to 60-70%. Okay. But interestingly, if you have more of a vegetarian or a plant-based diet, you're the numbers are closer to to the traditional Asian populations.

Dr Rupy: Ah, interesting.

Dr Hannah Short: So in the general vegetarian population, it'll be 50 to 60%. So there's something about the gut microbes with the fiber-rich diet again or the plant-based diet that that influences it.

Dr Rupy: Interesting, because I think, I think again, and I'm probably partial to this, I, I assumed that there was something unique about, um, uh, women of Asian origin that made them equol producers, but I didn't realize it was malleable by introducing different types of diet.

Dr Hannah Short: I think if you, I think some of the studies they've done, so Asian women who would then maybe have migrated to the West and had a more a Western style diet, so a higher fat, probably to fiber ratio, um, then then some of them that their ability to produce equol goes down. Um, so, yeah, so it's quite interesting from that point of view. So we're not saying that everybody necessarily will derive benefit from the soy foods in terms of the menopausal symptoms, but again, the more plants you include in the diet, the more likelihood that you will.

Dr Rupy: Yeah, you're going to get benefits from that.

Dr Hannah Short: And you'll still have the other benefits even if you're not an equol producer, it's still going to have the heart health benefits and it's still going to provide you with good protein and fiber and things. So.

Dr Rupy: Yeah. I think we've definitely established soy is a good food to have. Are there any other ingredients that you think are particularly, uh, useful? I, I imagine, so from the perspective of, you know, improving your, your gut microbiota, you want to have different types of fibers, of which there are hundreds of different types that you can get from flax and nuts and seeds and and different types of beans and lentils. Are there any other sort of foods that spring to mind when it comes to things that you should be introducing to to deal with the symptoms?

Dr Hannah Short: Beans and lentils are particularly, um, I don't know, they're my favorite food group. I always try and encourage people to include some in their diet and a lot of people don't, although sometimes people are eating stuff like hummus without really appreciating that obviously they're eating chickpeas and so it's a good kind of start. So there's a study showing that women who have at least four servings of beans or legumes every week, um, will have a lower risk of cardiovascular disease, um, which is important in terms of chronic disease risk, obviously. Um, but also it can help with the excretion of the estrogen metabolites and and everything else there. And obviously the fiber that's inherent there is going to be really beneficial. Yeah. Um, in terms of other things, we know from that paper I mentioned earlier, leafy greens and berries are particularly healthy.

Dr Rupy: Yeah, I'm really interested in that actually.

Dr Hannah Short: So, and I'm not quite sure if we fully understand the mechanisms. Um, again, I think the leafy greens because of the richness of things like the nitric oxide and stuff and the effects on the, on the cardiovascular system is going to be one, helpful for cardiovascular health point of view long term, but but may also help with the kind of some of those vasomotor symptoms, so the hot flushes and things like that. But I'm not entirely sure of the mechanism behind that. But that was their finding that that that they were particularly beneficial leafy greens and and berries, which are obviously rich in antioxidants.

Dr Rupy: Yeah, yeah.

Dr Hannah Short: I think some of it is that these, these foods are very, you know, anti-inflammatory by their very nature. So if you can lower the overall level of inflammation, that's going to help.

Dr Rupy: I think we're definitely learning a lot more about the potential mechanisms by which different foods, particularly from the dark leafy character, um, category and sort of berries as well, might have their, uh, potential benefits. Um, I know dark green leafy vegetables have been studied for their sort of, um, anti-inflammatory, uh, factors, their phytonutrients, whether it be sulforaphane or the different types of indoles that you find in brassica, um, as well as their, uh, antioxidant capacities of different berries. I think, I think it's kind of moving on as well about like, you know, the different types of metabolites post-digestion after your microbiota, because we actually produce, you know, tens of different types of metabolites after you ingest your anthocyanin and it's cleaved and then you get a sugar taken off it and then, you know, it goes through all these different digestive processes through your liver as well as your, your digestive tract. So there's a whole bunch of different peaks when you look at the spectrum of different nutrients that are absorbed, um, post, post-eating them. Um, but overall, there's a huge association with improvements to your, um, serum levels of inflammation.

Dr Hannah Short: Yeah, no, it's really fascinating, isn't it? And I think, I, it just, I, everything I kind of recommend, it's all kind of like the plant, the plant-based stuff just in, in, and not saying you have to be completely plant-based to derive the benefits. It's just, and my focus in clinic is always getting people just to increase the number of plants they eat because there's, there's no downsides really.

Dr Rupy: Yeah. And overall, like, actually, I, I'm of the opinion that if you're going to choose one thing to focus on, it won't be macronutrient proportion, it wouldn't be calories, it would actually be the, the amount of fruit and vegetables in your diet because that's hugely correlated with, you know, improvements in a whole host of different chronic lifestyle related issues. So my focus now and everything I do in the doctor's kitchen is just more plants on plates. Yeah. Um, and you know, you can get three to four servings per meal as well. And so if you do that, you're way on your way to 800 grams per day, which is seen as like sort of like the gold standard now. So.

Dr Hannah Short: Yeah. I know, and I think just so many people still don't include enough in their diet and.

Dr Rupy: Yeah, the average is like three a day.

Dr Hannah Short: I know. So, I mean, I always try and tell people like, you know, eat the alphabet, eat the rainbow. It sounds a bit basic, but I just think, and obviously you do need to pay attention to make sure you are getting enough of certain things, but, but I think it's the diversity is the key for the health of the gut just generally and to get all the micronutrients, um, that that are inherent there as well. Um, I mean, nuts and seeds are really important. So healthy plant fats are, again, a lot of this is more to do with chronic disease risk, but I think the everything we've just talked about is important because all of these, these foods are, you know, rich with their anti-inflammatory properties and stuff as well. But, um, healthy plant fats are very important for, for kind of brain health and things like that. And I think the more healthy kind of plant fats you include, that that can have an impact on, on cholesterol. And you tend to have larger kind of more buoyant LDL particles, um, which are less damaging to the lining of the, of the, um, of the blood vessels. Um, because I mean, obviously you're aware and you've spoke about before, but you know, not all cholesterol is the same and.

Dr Rupy: Yeah, I think cholesterol is like a very misused term itself. Like cholesterol is cholesterol and then you have different transporters that have, in my opinion, have been inappropriately labeled good and bad. In reality, they can have both good and bad effects, whether you're talking about LDL or HDL. It's a topic that I've kind of veered away from because it's just so nuanced. And if I'm honest with myself, like the biochemistry of it evades me to the level that I'd want to talk about like openly on a podcast. Um, but it's definitely something on the radar.

Dr Hannah Short: No, I know. Well, I feel kind of similar and I think there's, I don't really have a full understanding of it. But I suppose I know from the research I've done and things like that that it's that well, I've known for a while it's not black and white. Um, not all cholesterol is bad and actually a lot of the hormones are derived with the cholesterol pathway. So, um, I think in terms of like you're saying about macronutrients and stuff earlier as well, I think the, the main thing is you don't want to, I think the low carb diets generally are not anything I would recommend, um, for a, for menopausal women or women who are struggling because obviously that inherently means often they're reducing their fiber intake. Not always, but often it means that, I mean, you can kind of do low carb vegan, but I, it's not something I generally would kind of recommend. And so I think it's, it's more about the right kinds of carbs. Yeah. Um, right kinds of fats. It's not low carb or high fat. It's kind of right carbs and right fats.

Dr Rupy: Yeah, exactly. Yeah. And I just think like, um, rather than thinking about food in a, in a way that, you know, makes you obsessed about the proportions of fiber and and carbohydrates, like, okay, well, just if you eat generally these different types of foods and the variety, you're most likely going to be getting the right amount of fiber that's going to derive benefits. Yeah. Um, I'm just realized I didn't talk about the vaginal estrogens as well, which is the other thing. So not every woman will need to take, um, HRT. Obviously, I don't, unless you've had an early menopause, it's very much then based on symptoms. Um, so people don't need to panic if they've not had HRT. It's, but I just think everybody should be aware of those options and things like that. Um, but some women will just, will might just need some local vaginal estrogen or something to help with symptoms because for some people for them, they are the worst symptoms. I've met people who have been suicidal because their symptoms have been so severe. Um, like their episiotomy scars have split open when they're sitting down. They're, they can't wear underwear. People have like left their job because of vaginal symptoms. And I don't think anyone talks about that. It can be a very severe burning type pain. Um, and yeah, so I think it that can really destroy lives. It can wreck relationships. So obviously a woman who's in that situation is not going to want to have sex or any intimacy because of the pain. But sometimes people are still so embarrassed to talk about it, they don't even talk to their partners. And people then are feeling rejected. So it can have that knock on effect and then can disrupt relationships and things as well.

Dr Rupy: Well, to your point at the start of this pod, you know, people tend to associate the menopause with the typical vasomotor symptoms, flushing, migraines, uh, pain. Um, and we forget about the seemingly trivial symptoms, but they can be just as important. To your point about the episiotomy scar and the dryness, you know, it definitely wrecks relationships. I've, I've certainly had patients who come in and said this is literally the worst thing ever. My, my marriage is in disarray, you know, I can't have sex anymore. I don't really feel like it. There's a whole bunch of other issues and that can compound the issues that are already associated with menopause, like sleep, etc.

Dr Hannah Short: Exactly. And I think there's still a taboo. I mean, there's a fantastic book out there called Me and My Menopausal Vagina.

Dr Rupy: Me and my menopausal vagina.

Dr Hannah Short: Oh, right, okay. By Jane Lewis, who, okay, so I can send you the, but it's excellent. So she's a lady who wrote, um, was it just called my menopausal vagina? Sorry, Jane, I've forgotten the exact name. Anyway, I will.

Dr Rupy: I'll put it in the show notes.

Dr Hannah Short: Yeah, but it's, um, she talks about her journey because she's somebody who's struggled hugely with this and she's on a mission now to make sure other people don't, don't go down that. And she did.

Dr Rupy: Is she a comedian by any chance?

Dr Hannah Short: No, no, she's not. Oh, I'm thinking of someone else. Yeah.

Dr Hannah Short: She, um, was so desperate that other people didn't suffer in the way she had, she spoke out even though obviously it's something that a lot of people wouldn't choose to speak out about. And her book is fantastic. I recommend it to everybody. Um, and she was very scared away from HRT again because of the myths that she'd heard. And thought it was dangerous and it was definitely going to give her breast cancer because I know we haven't even talked about that. But she was so scared about that. Um, and that was part of the answer for her. Um, but not every woman will need to, like I say, to be on systemic HRT, but sometimes just some local estrogen cream or pessary, there's an estrogen ring. There's also some new pessaries which have got DHEA, which is the precursor to estrogen and testosterone. They can be kind of life-changing for people. Um, and you can be taken either with or without having systemic HRT. And there's no increased risk there. Any of the other risks you hear associated with HRT don't apply, um, because it's not, they're not, any systemic absorption is minimal.

Dr Rupy: Yeah. I'm going to be talking about the subject with another, um, uh, doctor, Dr. Lisa Mosconi. She's written a new book which is all about, um, the X, what's it called? The XX Brain. And it's basically about, um.

Dr Hannah Short: Oh, yeah, I can't, I'm looking forward to listening to reading that.

Dr Rupy: Yeah, it should be really interesting. So I don't know if you've come across any sort of associations with, uh, dementia post-menopausally, the mechanism behind that might be and whether HRT has an impact on that as well.

Dr Hannah Short: There's a paper that was published in post-reproductive health, which is the British Menopause Society journal in the last edition, which was just about that. Um, so I was associate editor for the last one where we did like a themed issue on on menopause and and the brain. Um, and this one should have been included in that for various reasons, it ended up being put in the later one. But it's all about that research because it's been conflicting on whether estrogen is beneficial or detrimental. Yes. Yeah. Um, and what it seems to be is about your genetic risk and the and certain types of dementia or risk will respond to HRT in a beneficial way. We think it's very unlikely that HRT has any negative impact on that. But it's not going to be the answer for everybody. But we know that estrogen is neuroprotective. I mean, a lot of women will talk about their brain fog and memory issues. And that's, that's something that I, I certainly have. And I think one of the most frustrating symptoms for me because it's never really gone away. It's helped with HRT. Um, and I should say that I also do take testosterone, which is particularly important in younger women again, because it helps with cognition and things like that. Um, but if you don't have the right balance of hormones, it can affect your ability to think clearly, memorize, and, um, and there certainly does seem to be an association with increased dementia risk, which is one of those fun things about early menopause. Women who've had their ovaries removed below the 45 and don't have replacement HRT have a much higher risk of dementia. Right. But it's again, it's one of those complex relationships as everything with estrogen is and it's not as black and white as give estrogen and everything's fine.

Dr Rupy: Exactly, everything's clearer, you can think clearer and your skin will glow, etc. Um, okay, we've talked about so many different things. This is, it's honestly, I, I think this is fascinating for me as well because I definitely need to look into the subject a lot more. Um, supplements, uh, probiotics, prebiotics, omega-3, which I know that you wanted to talk about as well. Um, are there any things that you, um, uh, tend to recommend, um, or, you know, suggest to patients that they should be thinking about?

Dr Hannah Short: I mean, I'm not a fan of supplementing for supplements sake. Um, but I think I mentioned that vitamin D was really important. But I think that's just a population-wide thing, but it's particularly important in terms of estrogen metabolism and bone health. So it's particularly pertinent there. Yeah. And often women who've got a history of severe premenstrual disorder and they tend to be the ones who might struggle more around menopause as well, will, um, um, have a higher requirement of vitamin D. Um, iodine is something that I think's very important. Just obviously we know for thyroid health, which is connected again with, you know, all the other hormonal pathways. Um, but also for bone health. Um, and unlike most countries here, we don't supplement, we don't kind of iodize our salts like we do in the rest of the world. So there's some iodine found in some dairy products, but that's part of the cleaning process of the vats and it's, and it seems to be higher in probably the, the lower welfare, like the factory farm rather than the organic because it's to do with the cleaning side of stuff and what they use. And it's, I don't think it's a reliable source for getting your iodine. Um, and we have to think about everything else we've just said about the dairy. It's obviously found in some seafood sources, so certain fish and, um, like seaweeds, but again, it's, it can be hard to know if you're getting the right amount and you don't want to have too much. So a supplement containing 150 micrograms of iodine is probably recommended. Um, and I wonder if that's why iodine deficiency is probably behind the big kind of number of people we see with hypothyroidism. So.

Dr Rupy: You know what, it's so funny. So one of the, um, the lecturers on my nutrition master's course, her specialist interest is iodine. And the way in which we test for iodine deficiency is really archaic. Like it's like a 24-hour collection and it's, you can't just go and do an iodine test. It's impossible. We don't actually have the way of doing it. So, um, you know, the way the sources in which we, we get iodine, the ones that you just, um, uh, mentioned, dairy, um, is from the agricultural, uh, practices and that's how we get iodine. You've got it from sea, sort, uh, sea vegetables, but they can be super high and some low, um, or mainly high. Um, and then you've got it from seafood as well. So I think, yeah, if, if there is a, a concern, it's probably, uh, under iodine intake and probably supplementing with iodine.

Dr Hannah Short: Well, I do, I do worry that sometimes people go, especially people who are, you know, again, very health conscious, sometimes go and get the kelp supplements, which can be far too high in iodine. That's way too high. Yeah. And so I try and advise people to get away from that. And to be honest, the supplement I tend to recommend is the vegan society supplement because it has vitamin D, it has, um, B12, which everybody needs to supplement over the age of 50, that's the general recommendation. And if you're on a plant-based diet, obviously very important. Um, um, and it also contains iodine. Um, it also contains B6, which can actually help with the, you know, hormones as well and things.

Dr Rupy: Yeah, I was going to ask about B6 because I think that was one of the recommendations on the nice guidelines as well.

Dr Hannah Short: Yeah. So that we know that there's some evidence that can help with premenstrual disorders. Sometimes at higher levels than would be in a standard supplement. And again, that's one of those things that I would, I would speak to patients about on an individual basis. So that wouldn't be like a blanket supplement. But there's a small amount in the, in the veg one, which is the vegan society one, which, and I think it's just cheap and cheerful and it's designed by a dietitian, so I'm quite happy to recommend it because it's just, it, it doesn't over supplement, it doesn't contain everything, but it's got those basics and we know that B12 is important for heart health and brain health and we don't tend to absorb it so well from food the older we get. So. Yeah, and then omega-3s, the more research that comes out saying that actually supplements aren't that helpful.

Dr Rupy: I know, right? It's really, it's so, I mean, it flips back and forth. I mean, I personally take an omega-3 supplement.

Dr Hannah Short: I do too.

Dr Rupy: I don't, I don't have enough oily fish in my weekly diet. Um, I think on balance from what I've read, it's probably, it's not going to do harm and it's potentially going to be, uh, beneficial. I take a, I actually take a vegan version, so it's from an algae source. Um, and, yeah, and I have tons of like different nuts and seeds and walnuts for the ALA, short chain omega-3 benefits. So that's for me, not menopause or anything, but.

Dr Hannah Short: But that's what I tend to recommend, like, you know, so you say six walnut halves or, you know, having some freshly ground flaxseed or flaxseed oil, that kind of thing, other nuts and seeds. Um, I think the problem with because again, a lot of people will eat fish thinking that that's going to be helpful. But again, I think the way things are, depending on where you get your fish from, there's no guarantee you're getting a good omega-3 source. So they did a study recently looking at omega-3 levels in supermarket salmon and some of them were absolutely negligible because they're not feeding them their natural diet. Yeah. Um, and, and also there's other issues, obviously there's a whole sustainability issues about this kind of stuff as well. And I, and I, so I don't necessarily recommend people are going to eat fish for that because I think even there's not even a good evidence that you're going to be getting enough from that and there's the other concerns. Um, but with, um, yeah, so I mean, I take an algae-based omega-3 supplement because that's where the fish derive their, their omega-3 from. And so you're kind of going direct to source, but you just need to make sure it's a good one with a good EPA, DHA ratio. So.

Dr Rupy: Yeah, I'm not sure of any brands, but I'm sure there's, there's loads on the internet, but yeah, you're going to be looking at ones that have adequate.

Dr Hannah Short: But I think like you, it's kind of erring on the side of caution. Um, and we, you know, omega-3s, we know have, do seem to have their benefits, but it just the evidence in terms of supplements is is difficult, isn't it?

Dr Rupy: It's really difficult. Yeah. And I think a lot of them come from associations as well, uh, rather than actually something that demonstrates a mechanism as to why it might be worse for prostate cancer, the latest thing I heard about. Um, but yeah.

Dr Rupy: Pre and post, uh, probiotics, do you, do you think there's a role for them or do you think from a diet and from things like sauerkraut, kimchi?

Dr Hannah Short: Um, well, the prebiotics, obviously, if you're eating a fiber-rich diet and you're feeding the bacteria the healthy foods, that's going to be a benefit. And I think that's the most important thing. But again, there's, there's some more research coming out about the importance of probiotics in certain things, particularly whether it's mental health or there was a particularly interesting paper about bone health and reducing bone health, um, bone density loss in early post-menopause. Um, so a particular strain of, it was three types of lactobacilli. I can't remember the exact names of them, but again, I can send you the paper on that. Um, and it showed that it, it minimized loss, um, and stabilized, um, bone density in, in women who are in the early stages of menopause, which is really fascinating.

Dr Rupy: That is, yeah, absolutely.

Dr Hannah Short: So, and it was a, it was a particular strain, I think it might not even be available in the UK, but, um, there's more research needed and I've had some fascinating conversations with a pharmacist in Canada who I, who I connected with on social media, um, who's this is her area of research and so we've been chatting about that. So.

Dr Rupy: Brilliant, brilliant. I mean, from everything that I, I'm, I'm hearing, it's, it's about looking after your gut, having tons of different types of fiber, a plant-focused diet, um, and supplementing on an individual basis. Um.

Dr Hannah Short: Well, the sea buckthorn oil was the other thing. Oh, not on probiotics. There is, there is some, sometimes there's some evidence for vaginal, um, vaginal health because the vaginal pH changes post-menopause. So women sometimes become more, um, likely to develop, you know, things like bacterial vaginosis and things like that because of the overgrowth of the less, you know, favorable, um, kind of bacteria and things like that. Um, so there is some supplements out there, some probiotics that can be helpful in restoring that. Um, but equally the estrogen, if you have local estrogen, that can help restore that natural balance. Yes. It comes again down to estrogen changes, right? And it's the, and it's, and it's just on an individual recommendation. Sea buckthorn oil, there's some evidence that that's helpful for mucous membrane health.

Dr Rupy: Interesting.

Dr Hannah Short: So something that you take orally?

Dr Hannah Short: Yeah, so you can get capsules a bit like kind of omega-3 capsules, but you can also get an oil. Um, that, that can be helpful in, in terms of either vaginal health, but also just skin health generally and eye health. And I first came across that when I was doing an ophthalmology job. Oh, really? Um, yeah, and it was being recommended to a lot of women who I think now were perimenopausal were coming in with dry eyes and difficult symptoms. And it seemed to really help them. So.

Dr Rupy: I'm definitely going to look into that because I have a sea buckthorn, uh, drink that I got from a food festival recently. I read a little bit about sea buckthorn and how it's like super, super high in, um, vitamin C, I think. Uh, and a couple of other phytonutrients. So I just tried to put it in my, um, it's really popular in Brazil, I think.

Dr Hannah Short: Is it? Okay.

Dr Rupy: Yeah, it's really randomly. Um, so I just put it in, um, water almost like a cordial, but it doesn't have any added sugar in. And it gives like a, a, uh, an exotic sort of citrus note to your water. And it's a taste delicious. I really like it. But it's, it's not to everyone's liking. It can be a little bit bitter.

Dr Hannah Short: So you can get the capsules, yeah.

Dr Rupy: You can get the capsules. Yeah. So. Um, Hannah, that was amazing. Uh, I'm, I'm really enjoying this conversation. You're doing a lot of stuff with the RCGP, improving, uh, other GPs' knowledge of of menopausal health and POI in general. Um, and you, you do work with the Daisy, is it the Daisy Network?

Dr Hannah Short: Daisy Network. Yeah. So the Daisy Network's a charity for women with premature ovarian insufficiency. So that can be whether it's naturally just occurred. Um, so some, some girls in their teenage years will will be diagnosed. So somebody as young as 13, 12, sometimes, um, they never maybe fully have their periods and they're found to be almost post-menopausal in their teenage years, which obviously is a very difficult thing. But they would support people through that or girls and women who've had cancer treatment. So the chemotherapy or radiotherapy has has affected their ovarian function or people like me who've had treatment for, you know, endometriosis and PMDD. But anybody essentially under the age of 40, um, it is there to provide information and support. So, um, there's a few of us who are kind of volunteer doctors, so we kind of do online chats for Daisy Network members. And we do that twice a month. So if you're a member, you can just log on to this chat and ask questions. It's probably not the perfect format, but it's the kind of what we can offer at the moment. But I think it can be helpful for people. And every year there's a, there's a Daisy Network conference where people meet generally at Chelsea and Westminster. Oh, yeah. Um, and there's a day of discussion and then support and workshops and they have talks on nutrition and mindfulness and dealing with infertility and and all of that kind of stuff.

Dr Rupy: That's amazing. I had no idea.

Dr Hannah Short: Yeah, so.

Dr Rupy: That's a quarter from us. Yeah.

Dr Hannah Short: No, I think it's the 6th of June this year. I think that's when it is. So, yeah, so we do that.

Dr Rupy: Perfect. Well, I'll definitely link to that in the show notes as well.

Dr Hannah Short: Please do. I'm mindful, I know we've spoken for ages, just we haven't really mentioned the breast cancer thing with HRT. I just wanted to say very quickly that this is the one thing that puts most women off taking HRT. Um, there is a small risk associated with HRT use. Again, it depends on which form of HRT, how big or small that risk is. But in the grand scheme of things, the risk of developing breast cancer as a result of HRT use is so small compared to kind of the benefits we've talked about, but also it's, it's just, it's minimal compared to people who are, you know, the other risk factors like being overweight, if you drink alcohol every night, a small glass of wine is a bigger risk factor than taking HRT and if you don't exercise. So it's, there's a brilliant infographic that I generally talk about with people. Um, and it's about putting everything in context. It's not something I want to just say, oh, don't worry about it at all because it's something that needs to be talked about. Yeah. Um, but it's, it's, it's not as black and white as if you get this, you definitely have this increased risk or, um, and but I think that's what sometimes clouds people. The stuff that came out last year in the Lancet, um, when they were talking about, oh, that it showed that, you know, it showed yes that there's a small increased risk with ongoing use. But we have to put it into perspective. And I've even got patients who've had a history of breast cancer who choose to be on HRT because of the other quality of life issues and.

Dr Rupy: But obviously not everyone would want to take it or they may be a strong family history and they're, I think the lifestyle stuff then is particularly important. There are other things that can help, acupuncture, there's slight evidence base there, CBT. Um, it's just accessing these things sometimes. The SSRIs, so some of the antidepressants can be helpful in terms of reducing the vasomotor symptoms, the hot flushes and things. So I don't want anybody to think there's not an option if you've had a hormone-dependent cancer, but if that's the case, you need to see a menopause specialist because it requires a specialist knowledge really. So.

Dr Rupy: Brilliant. So. I think that would be super useful for a lot of people.

Dr Hannah Short: Well, I hope so. And I just, I want people to think even if they're in a desperate situation, know that they're not alone and that there's, there's always something that you can do, whether it's a combination of pharmaceutical things or HRT or alternatives to HRT or lifestyle or supplements, um, that there's, there's always something that can be done and you're not kind of alone. And the other thing is is alcohol briefly, that a lot of people do not realize how much of an impact that can have on menopausal symptoms, not only disrupting the gut microbiome because it can cause gut dysbiosis if you have a lot of that. But, um, it really is can be a trigger for things like hot flushes and the mood-related symptoms. And often I find if people aren't, they've maybe making other lifestyle changes, they might be on an appropriate HRT, but things still aren't settling. Quite often it's the, it's the alcohol and it may not even be that much or they might not consider it that much. It may be one small glass of wine every other day. It's enough to disrupt things for them. So.

Dr Rupy: Absolutely. Yeah. Yeah.