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Ep. 430 Breaking Menopause Taboos: Redefining Women’s Health at 40+ with Dr. Nicky Keay


I am delighted to connect with Dr. Nicky Keay today. She is a medical doctor specializing in exercise endocrinology and the author of The Myths of Menopause. 


In our conversation, we explore the taboos surrounding menopause, menstruation, and periods, looking at the narratives, trends, and language that shape our understanding of those phases in a woman's life. We dive into the perimenopause and menopause symptoms Dr. Keay refers to as Pandora's box, the neuro-endocrine regulation of eating behaviors, and the relative energy deficiency associated with restriction, over-fasting, and over-exercising. We also discuss how lab testing during these transitions can lead to uncertainty, the impact of smoking on ovarian senescence, and menopausal hormone therapy. 


This conversation is invaluable, and I look forward to inviting Dr. Keay back for a follow-up discussion later this year.


IN THIS EPISODE YOU WILL LEARN:

  • The discomfort that exists around menopause 

  • The negative connotations associated with aging and the importance of changing the narrative

  • How oral contraceptives have led to a disconnection from natural hormone rhythms 

  • The positive changes in body composition and the potential for wisdom and knowledge gained during menopause

  • What are the initial signs of perimenopause?

  • The role estrogen and growth hormones play in body composition and appetite

  • The challenges of over-restricting and why balanced nutrition is essential to support hormonal changes

  • The benefits of blood tests in cases of uncertainty or relative energy deficiency

  • What is the impact of smoking and excessive alcohol intake?

  • Dr. Keay shares her preferred methods of HRT

  • Why we need more informed discussions about HRT and testosterone replacement 


Bio: Dr Nicky Keay BA, MA, MB, BChir (Cantab), MRCP 

Nicky is a medical doctor with specialist expertise in exercise endocrinology. Her research into the impacts of lifestyle, nutrition, and exercise on hormone networks has been published in peer-reviewed journals. She is the author of “Hormones, Health and Human Potential” and editor of "Myths of Menopause". Nicky holds the position of Honorary Clinical Lecturer in the Division of Medicine, at University College London. Nicky’s clinical endocrine work is particularly done with women experiencing perimenopause and menopause and all ages of exercisers, dancers, and athletes, focusing on relative energy deficiency in sports (REDs). Nicky’s passion and objective are to provide a more personalized approach to female hormone health to optimize the overall health and performance of the individual. Nicky is the medical advisor to Scottish Ballet and a keen ballet dancer.

 

“When your ovaries are winding down, the cycle length will shorten as you're not ovulating or producing progesterone.”


-Dr. Nicky Keay

 

Connect with Cynthia Thurlow  


Connect with Cynthia Thurlow  


Connect with Dr. Nicky Keay


Transcript:

Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.


[00:00:29] Today, I had the honor of connecting with Dr. Nicky Keay. She's a medical doctor with a specialist expertise in the field of exercise endocrinology. And her research impacts lifestyle, nutrition, exercise on hormones. She's the recent author of the Myths of Menopause. 


[00:00:47] And today, we had an amazing conversation starting around, exploring taboos around menopause, menstruation and periods, and how we need to change the narrative around these timelines in a woman's life, trends around oral contraceptives, messaging and language, the impact of puberty and perimenopause, the symptoms of perimenopause and menopause that she refers to as Pandora's box, the impact of the neuroendocrine control of eating behaviors, what the relative energy deficiency is that I think of as over fasting, over restriction and over exercising, why labs in menopause and perimenopause can lead to uncertainty, what determines when a woman transitions into menopause and why smoking is one of the worst things that you can do for ovarian senescence. 


[00:01:39] And lastly, looking at menopausal replacement therapy, the ideologies and quality of life metrics that Dr. Keay likes to look at, as well as helping to change the narrative around the aging process in general. I know you will find this to be an invaluable conversation, and I will absolutely be bringing Dr. Keay back later this year to reinterview.


[00:02:04] Dr. Keay, such a pleasure to have you on the podcast. I'm really excited to share your work and your latest book, the Myths of Menopause, with my community. 


Dr. Nicky Keay: [00:02:12] Well, listen, thank you so much for having me on. And I'm looking forward to having a good discussion. 


Cynthia Thurlow: [00:02:17] Yeah. One of the things we started discussing prior to the initiation of the podcast conversation formally was there's a lot of taboos, discomfort, shame around, not just the topic of menopause but the aging process. And then I would even loop into that around menstruation and our bodies and understanding the physiology. 


[00:02:41] Even as a nurse practitioner, I think I know more now than I ever did in my training, even after my training, because I think that there's not enough information or maybe we're in the process of changing that. But I feel like perhaps, our generation is going to ensure that subsequent generations are much more informed about their bodies. But where do you think a lot of that taboo stigma really stems from? 


Dr. Nicky Keay: [00:03:08] Well, I think you make a really important point. Although, we're focusing on the perimenopause, menopause, actually, we should turn the clock back. If as a young girl already a little bit about, well, you don't talk about that, and you secretly have to go around furtively with your tampons and things like this, then actually, we're not starting off on a good foot. So, rather than making it a positive discussion, number one, saying that hormones are amazing. I mean, obviously, I'm super biased because I'm an endocrinologist, but nevertheless, let's talk about hormones are amazing, powerful things that we can harness to our benefit. 


[00:03:48] Actually, out of all the hormone systems, the beautiful female hormone choreography of the hormones occurs during the menstrual cycle. That should be celebrated and amazing. We're talking about all the positive aspects of these hormone fluctuations, from a young age, saying, “Look, estrogen is vitally important, for example, for your bone, for your mental health. Let's talk about all the positive stuff about hormones, female hormones, the menstrual cycle.” I know Lara, one of our colleague’s friends, talks about the right to ovulate and the joy of ovulation. Let's start the conversation with young girls about the positive side, and then things will slip into place and it will come and then okay, we understand it's a journey. I describe it as a female hormone odyssey. 


[00:04:36] So, your period start. The beautiful choreography starts. Let's accept and be honest, there might be some challenges along the way, for sure. Painful periods, heavy periods, especially when you're young, by the way, we're coming back to that, the perimenopause anyway, so we accept there might be some challenges along this odyssey, what odyssey doesn't or journey doesn't have some challenges along the way. But then, ultimately, you will come to the point where your ovaries will want to retire, okay? 


[00:05:02] By the way, bound up with menopause for most women, the majority of women, I know there are some who have earlier than expected menopause for a variety of reasons. But for the majority of women, this will occur, menopause, when the ovaries retire, will occur average age 51. So middle age. And so, actually, if you come to that point and already you have all this negative baggage about the menstrual cycle, about hormones, we don't talk about it. It's awful. It's dreadful. 


[00:05:33] By the way, the only point of having menstrual cycle is to get pregnant. Suddenly, you come to menopause and it's like, “Oh, hold on a minute. I'm old.” What's our attitude to being a slightly older, wiser woman, by the way, but unfortunately, it comes with a lot of negative connotations. So, you can't reproduce anymore, so you're on the scrap heap sort of thing. I think you're absolutely right, saying, we have to unpack it and look back to the very start of the girl's female hormone odyssey, portraying it in an honest but positive manner. 


[00:06:06] And again, there are positive things about the menopause one can argue. You've been through life to this point and you've gained a lot of wisdom and knowledge, and maybe we should be more like the Japanese who respect and revere the older generation. And to say, “Oh, they've got lots of wisdom.” We're not just egg incubators. Thank you very much. [laughs] So, I think, yeah, coming back to your initial question, I think there are many reasons why it's got this negative stigma, taboo around it, which stems back to the very start of the female hormone odyssey. But they're on the positive side. Things are changing. People are talking about it more. 


[00:06:46] For example, the book bringing together lots of excellent experts, friends, colleagues to-- Let's talk about it. Let's unpack it. Let's talk about it. Let's, of course, admit and be honest that there are some challenges, of course, but also always looking for the positive side of things. It's like, “Okay, so you don't have to have periods anymore.” It's like, “Yeah, that's positive.” Let's see what this looking forward for the positives. I think people are too ready to jump on oh negative things. Yeah, I think there's still a lot of work to be done, but hopefully, we're getting there. 


Cynthia Thurlow: [00:07:18] Yeah. And it's so interesting to me that when I reflect back on when I was a teenager and young adult, I recall my GYN offering me oral contraceptives, because I was one of those people at very irregular cycles. I either had no cycle for three months or just very heavy, debilitating periods. And so, I think the message for so many young women is, we shouldn't have to experience symptoms, so let's negate the communication between our hypothalamus and our ovaries, so that hypothalamus, pituitary, ovarian axis. And so, we are so disconnected. 


[00:07:54] I can't think of a girlfriend of mine, a close friend, that was not on oral contraceptives for a variety of reasons for 10, 15 plus years. And so, we were so disconnected with the natural rhythms as you're alluding to of these cyclical nature of hormones. And so, many of those hormones were blunted. It's not until we're a little bit older that we realize, “Oh my gosh, I missed out on peak bone and muscle mass. I didn't have horrible PMS. It was really a byproduct of being on these oral contraceptives.” And so, I think for many people, what I'm starting to see is many women, in the throes of perimenopause, they're finally experiencing these high-high of hormones and the low-low of hormones to navigate the trajectory of perimenopause, which we know can be 5 to 10 years, depending on the individual, until they get to their final menstrual cycle, which around early 50s. 


[00:08:46] I would argue that I'm starting to see younger women going into menopause, 47, 48, 49, but then just as many in their mid-50s. And so, helping build awareness and then the reframe, finding positive messaging that we can provide ourselves with-- Because when I look across social media on a given day, I would say the people I follow tend to be have a very positive message around aging, perimenopause, menopause. But I will occasionally see people who will describe themselves as a hot mess. 


[00:09:20] It's the terminology and the language that we utilize to describe our experiences that are profoundly impactful. It's not to suggest I'm going to sit back and say, during the course of my perimenopausal journey, there weren't times where I didn't feel great. But overwhelmingly, I feel like so much of my journey was a fairly positive one. And so, I don't want people to fear that transitional period, because it makes it so much worse if we go into it being frightened and scared and terrified. 


[00:09:52] I have girlfriends who are 40 years old who will say, “Oh, my gosh, I've listened to your podcast and you come at it from a very positive angle. But I listen to other people who talk about all the negative things that happen.” I said, listen. To me, it is a wonderful thing not to have to worry about wearing white pants in the middle of summer and having a spontaneous period starting. It's one less thing to worry about. 


[00:10:14] I think that one of the things that has really stood out for me personally is that women, for many, many years, they punish themselves. They don't get enough sleep. They over exercise. They're trying to squeeze into a certain size. They feel objectified and then they get to perimenopause. And that word, pause, again, language is so important, encouraging women to internalize the dialogue and start looking at what is working for you or not working for you at this stage of life.


[00:10:45] Was that your own experience that you felt like or you feel like with your own patients? In many ways, we are forced to mirror image ourselves to look at what is not serving us. That could be psychologically. It could be spiritually. It could be emotionally. It could be that maybe you're forced to take care of yourself. You can't get away with eating ultra processed foods and not sleeping and not exercising. Like, suddenly, that lifestyle really becomes critically important as we're making this transitional time in our lives. 


Dr. Nicky Keay: [00:11:14] Amazing point you make there. So, going back to what you said originally about the tendency to dole out the contraceptive pill, almost like smarties to young teenagers, that's a real concern for me. And also, the messaging is incorrect, “Oh, this will regulate your periods.” 


[00:11:32] Let's be clear. As you said, the oral contraceptive pill, it severs the connection. It makes all the hormones flat. It doesn't regulate periods. It stops them. So, then already, as you say, then you're disconnected from your own hormones, you don't know what it does feel like. And yeah, it can be a little bit awkward as a teenager when they will be irregular. You will get spotty skin. You're a teenager. Stuff happens. By the way, lots of these things are what you will experience in perimenopause. So, they're mirror images. So, that's another point. 


[00:12:01] If you arrive at perimenopause and you never really truly experienced the highs and lows, as you put it, of the teenage years, then actually it's like, “My goodness, what's this?” But it's actually, guess what? Things don't always have a clear full stop. There could be a few dots or a little comma. It's not that clear cut. But if you've never experienced the beginning bit of it, then it does seem really scary and you can't understand what's going on if you're going to experience these hormone fluxes during the perimenopause. 


[00:12:31] So, I think we're depriving women of an experience of the teenage years, not least from a health point of view as you point out, jeopardizing potentially peak bone mass and all sorts of things like this and neural development. I know Lara talks about this with the synthetic progestogens. So, I think that's one point, that the woman is really scared, because it's like I've never had any experience anything like this before. No, you probably haven't, because it was masked by what was happening before. Maybe through no fault of your own. And I think that is a responsibility of doctors. 


[00:13:05] I always explain what exactly happens in whatever terms the person can understand. Obviously, a 17-year-old girl, 16-year-old, she probably doesn't want to know every single little detail about the HP axis. But in general terms, this is what your hormones look like by themselves. This is what they will look like if you do take the pill. And lots of them at that point say, “Oh, I didn't realize that, and actually I'm going to choose a different way,” you see? So, getting in tune with your hormones is quite important. 


[00:13:32] So, then, as you say now you reach perimenopause and it is. It is terrifying. It can be challenging. Anyway, I have to be honest. I knew, of course, as a medical doctor, this is what's probably going to happen. The hormones are going to change, and people talk about anxiety and this, that and the other. But until you've actually experienced it, I was thinking, gosh, if I didn't know what was happening, I would think I was losing my mind, which is, by the way, actually one of the chapters in the book written by my friend who's professor indeed at University College on the cognition of aging and the effects of menopause. 


[00:14:11] She tells a lovely story in her book how as this professor of this department. She said, “Now, there are three important points. One. Two, and three. Blank. Gone, you see? And so, it is. Let's be honest, it can be challenging and it can be actually quite scary, even if you understand theory behind It. But even more so if you don't understand what's going on and if you haven't experienced some similar thing as a teenager or whatever. 


[00:14:35] So, I think just being honest and open and saying probably will be some challenges like this, forgetting what number three is or whatever it is. Hot flushes and disturbed sleep and yeah, there probably will be some ups and downs for the majority of women. Thankfully, it is a natural physiological process. But how you experience that, we can't dictate that. But already starting off on a negative thing is not a good starting point. 


[00:15:02] By the way, in Japanese, they don't have a word for menopause. Well, they do. They call it the second spring. Because like you say, they look on the positive side, because they're positive about aging in general, and also, they're positive about accepting this is nature's way and not talking about own-- even talking about symptoms.


[00:15:22] As I say in my book, symptoms, we usually connect with a medical condition. But to be clear, for the majority of women, there will be some poor women who for whatever reason, medical interventions, medication, surgery, yeah, it's not a natural physiological process, but thankfully, it’s the majority it is. It's not therefore an illness or a condition or something, symptoms. But nevertheless. So, you see, all the wording is, like you said, got this negative spin about it, but that's what it is. But I think our job, as you've described, is to be honest and say, “Yeah, there are some challenges, but also look at the positive things” and also suggest some positive solutions to feel like you're taking control of the situation. That's really what's going to make the difference. 


[00:16:10] After all, women, because we're living longer, we're probably going to live a third of our life in the menopausal state. So, I don't know about everyone else, but I want that third of the life. I don't want to throw in the towel. I want to get the most of that bit of my life out of it that I can. 


Cynthia Thurlow: [00:16:27] No, I think it's such an important point to amplify what you're suggesting is helping women understand this is a normal process. If you live long enough, you will go into menopause at some point. What I find and it has been my clinical experience is and having interviewed hundreds and hundreds of researchers and physicians, the realization that a woman's perimenopausal menopausal journey is as unique as she is. 


[00:16:55] So, I wish that you and I could say to listeners, you're going to have these 10 symptoms. But we know that there are over 100 symptoms just based on looking at data that is ported. But in your clinical experience as an endocrinologist, so you are a hormone expert, what are the most common symptoms that you see clinically within your patients? The most bothersome symptoms? Because I think most of us expect, we're going to have menstrual irregularities. We might not sleep as well. But I think that on top of that are what are the most problematic symptoms that women will experience that you've seen clinically? 


Dr. Nicky Keay: [00:17:32] Well, in my book, I describe it as Pandora's box. As you say, there is a lot in the box. But that doesn't mean that you qualify, “Oh, I have to have everything and I have to be really awful.” But the statistics tell us that, as you said, the most initial indication that your ovaries are winding down, going part time is actually the cycle length will shorten, because you're not ovulating, as Lara will tell you, and we're not producing progesterone. So, the cycle might actually get shorter. And so, therefore estrogen, is the boss and can go actually quite high. So, shorter cycles, heavy periods. Yeah, I remember myself skiing and I was up at the mountain. It's like, I cannot believe this. So, I skied down the fastest I've ever skied down. 


[00:18:18] Anyway, [Cynthia laughs] so, I need to get some sanitary products anyway. But guess what? These are exactly the symptoms that you experience in the teenage years, by the way. So, the top one, that's the initial sign. Change in the cycle, initially shorter, probably heavier, maybe them becoming spaced out, a little bit erratic. But the top one is said that 75% of women will experience vasomotor symptoms. So, we call them hot flushes over here, you call them hot flashes. But anyway, basically, what it means is temperature regulation goes a bit awry. And so, literally, you'll be sitting or trying to sleep, minding your own business, and suddenly you come over really, really hot and sweaty. That in itself can disturb sleep. Sleep is also disturbed because the hormones are a little bit erratic. So, those are the top ones. The vasomotor symptoms of the hot flushes, disturbed sleep, which are intertwined. 


[00:19:08] And also, intertwined with that, interestingly, is the brain fog. So, the forgetfulness that I'm talking about. It's thought to be connected with the vasomotor symptoms, because when you get really hot like that. You're really red in the face, you're feeling really hot, your skin's really hot, but actually the blood supply to your brain isn't so good. So, it could be connected. If you're getting a lot of vasomotor symptoms, you're probably getting a fair bit of the brain fog issues, cognitive issues. So, those are the top ones, which, by the way, in themselves are bad enough. 


[00:19:39] And also, your mood is just up and down. Anxiety for me was a key one. I'm a busy doctor. I got a lot to do I would have, but I get it done. But I had this overwhelming anxiety. It's like, “Gosh, am I going to get all this done?” So, those are the top ones. And that in itself-- anything that inter disturbs your quality of life, whether that's your work environment or whether that's your family environment. My family were like, “Oh, gosh, what's going on here? Why are you being really angry and they're really sad?” So, whatever the context is, whether you're working or not, it will affect your relationships with others and your relationship with yourself, because you really start to panic and wonder about yourself. So, those are the top ones. 


[00:20:25] But other ones, as you said, just to mention a few on this big Pandora's box, other common ones, random aches and pains, not injury. Speaking to a physiotherapist, wrote a section in the book and said she gets a lot of masters athletes coming and thinking they're injured. But actually they're not physically injured. It's just because of, again, the hormones doing new weird things, strange things that cause these random pains. Also, digestive system, there's the gut microbiome, which is dedicated to estrogen. So, that goes a little bit awry. Headaches, because again, the blood supply to the brain is all erratic, so increased headaches, sometimes even palpitations. 


[00:21:08] But I say that one saying, always make sure there isn't an underlying cardiac condition and all of the things we're talking about. You can get very hot, because you've got an overactive thyroid, for example. So, if in doubt, if these things are all coming together and the menstrual cycle is changing like we described, you're of that age, then most likely it is that. But sometimes, I have said to someone, actually, I think we just need to check the ECG just to make sure there's nothing else going on. So, those are the main ones that I see. But it's actually the mood type things and the cognition that actually are the most bothersome. And anything that disrupts sleep, whatever it is, amplifies everything, makes you feel worse. So, it's a vicious circle in that sense. 


Cynthia Thurlow: [00:21:56] No, I couldn't agree more. It's interesting how many people take poor sleep quality as just a function of aging. And for many people-- I've met nurses that have had 10 plus years of really poor-quality sleep. It has eroded their metabolic health. 


Dr. Nicky Keay: [00:22:11] Yes, exactly


Cynthia Thurlow: [00:22:11] They become insulin resistant. They're dealing with odd food cravings. They've gained weight. They don't realize that something as simple as not getting good quality sleep is driving a lot of these other health issues. And I agree, there's nothing worse, and especially running a podcast, word finding is a byproduct of estrogen. 


[00:22:31] So, one of many reasons, I love Dr. Lisa Mosconi's work about really looking at what's going on in the brain as women are making that transitional perimenopause into menopause, and understanding the influence of estradiol predominant form of estrogen until we go into menopause, that influence is quite significant and profound. 


[00:22:50] I have some patients that have gone on estrogen solely, because they are so frustrated with the brain fog, the word finding. They were like, “I'm an attorney or I'm a surgeon. I can't not have the ability to find that word when I need it.” And so, helping people again, that bio-individuality piece. What I find really interesting, and this book is so well done because it's so many experts, amplification of their area of expertise and finding information. 


[00:23:20] One of the things I found really interesting was looking at eating behaviors around menopause. So, how many women are finding that they're more hungry, they're less satiated, having to make dietary changes in response to some of the hormonal changes that are ongoing? For you as an endocrinologist, the neuroendocrine control of eating behaviors, is that something that you see quite a bit women that are reporting like, “I don't understand why I'm not satiated. I don't understand what it is that I'm doing wrong and understanding the interrelationship between specific hormones like leptin, ghrelin, PYY as an example, how that acts on our appetite stimulating centers in the brain and how that ultimately impacts body composition?” Because let me just back things up and say that I'm someone that is known for the strategy of intermittent fasting or eating less often. 


[00:24:15] And certainly, here in the United States, I would say the average American eats too frequently and eats too many of the wrong types of foods. And that in and of itself is problematic. But I find a lot of my patients, as they are navigating perimenopause and menopause, they may eat really well during the day, but then they find that they have these cravings in the evening. And it's not per se, an emotional thing. They just feel like they are not properly satiated. 


[00:24:40] So, when you're working with your patients, maybe people they're overweight, they may not qualify as being obese. When you're talking to them about some of the hormonal changes that are occurring in perimenopause and menopause, how do you approach this specifically with. 


Dr. Nicky Keay: [00:24:54] Well, basically being empathetic. Saying that it does become more challenging, because not only are your female hormones changing, and estradiol in particularly is anabolic hormone, so tends to favor building of muscles and things. So, obviously, those levels are ultimately declining as you go further towards or past menopause, then that. There is a tendency. Absolutely, I'm afraid that's the honest truth to deposit visceral fat over muscle. The other hormone that's declining in men and women, by the way, men get old as well. Just wanted to say.


[laughter]


Anyway, just throw it in there that the other anabolic hormone that declines with in men and women with increasing age is growth hormone, which is really powerful in terms of body composition, favoring the deposition of muscle over fat. So, accepting and understanding that changes in hormones will affect your body composition and also your appetite, as you mentioned, tendency to insulin resistance, all sort of things like this. 


[00:25:57] But also on the positive note, if you understand that these changes are happening, then, okay, what are you going to do in a positive way? I'm like everyone else. I would I love quick fixes. Who doesn't? If there was a quick fix, you just have eat this particular thing or this particular way, and that will solve all your problems and you will remain looking 21. That's what we're looking for, the holy grail. But the clinical dietitian who wrote in my book, is there a menopause diet, because everyone wants to clutch at things, as I say. I understand it, a quick fix. 


[00:26:35] But just to reassure people, there isn't a menopause diet. It is just the fundamentals of a healthy diet. But as you say, you have to review, revise, tweak. You can't eat like you did when you were 21, because your hormones have changed. So, you have to respect that, you see? The hormones will respond to what you do. So, if the hormones change, then you change your inputs to them. There are various approaches, but I think that people often want to do extremes, because if you feel your shape is changing and things are out of control, then you can be tempted to really restrict, restrict, restrict maybe too much. This actually has the negative effect of increasing cortisol levels and favoring the deposition of fat, which is the precisely the thing you're trying to avoid. 


[00:27:28] I think again looking on positive saying, this is an opportunity to review and revise. Your hormones are changing, so have a look at what you're eating. Maybe have you been tempted to follow some latest fat diet or are you restricting too much? Again, the distribution I think is important. Sometimes people that say get the munches late in the evening, maybe actually they haven't eaten enough in the day. Protein, for example, we should eat more protein as we get older, men and women, by the way, to give a support to the declining anabolic hormones, try and maintain muscle mass and all those sort of things. So, you should be increasing your protein anyway, especially trying to put some in throughout the day, in the morning, because then that will satiate you because this complex molecule takes more time to break down, etc. So, there are tricks. 


[00:28:20] So, coming back to your original question, I do often see that people are over restricting, thinking that that will work and then they feel really weak and feeble. It comes to the evening and they're really hungry and they're craving something. The body's saying, just give me anything. Anything will do, you see? Whereas if actually they had thought about portion size, protein proportion throughout the day, then actually you come to the evening and probably, hopefully you won't feel hungry and tempted to what you feel is over indulging, but actually, it's just responding probably you haven't eaten enough during the day. So, they're little tricks. I want to say strategies to try and respect that your hormones are changing and to support, favorable body composition, etc. 


Cynthia Thurlow: [00:29:11] You bring up so many good points. I think it is human nature that if we start seeing changes in body composition, we think that we need to exercise harder. We think that we need to push ourselves harder in the gym. We have to restrict more food, whatever that is, whether it's carbohydrates, or going keto or doing too much fasting. 


[00:29:30] In the book, there's a discussion around this relative energy deficiency, which I sometimes refer to as the triad. It's over fasting, under fueling, over exercising and how I see a lot of-- I don't per se think it's a latent eating disordered behavior, but I think for anyone who's feeling out of control, that might be the one thing they can control. I agree with you that many people are simply under fueling their bodies chronically and habitually. There's something called the protein leverage hypothesis. And so, if you aren't getting enough protein in your body out of desperation is like, “I'll eat anything. I just need food.” 


[00:30:09] And so, more often than not, it's an over consumption of the wrong types of carbohydrates and the wrong types of fats. But helping everyone understand we have to be conscientious about protein, we need more. Like, my teenagers can probably sneeze and have 10 g of protein and that's fine. They'll have plenty of muscle protein synthesis. I know my husband and I aim for 40 or 50 grams per meal of protein minimum. We know that that's really important to continue to maintain and build. 


[00:30:38] I love that you talked about growth hormone, because I think so many people are focused on testosterone. It's these changes in testosterone that are driving these body composition changes. I remind people that if you understand the way growth hormone functions in the body, that has I think a greater propensity for some of those body composition changes that we're seeing-- 


[00:30:58] Now, a common question that I'm asked on social media is testing hormones. Now, as an endocrinologist, I'm sure you are testing hormones. But when you have women that are in perimenopause and menopause, are you routinely checking IGF-1 as a proxy to growth hormone? Are you checking the sex hormones, or is that something you're going based off of symptomatology? What are patients reporting to you as opposed to looking at labs? Because this is certainly a very divided. Depending on the physician I'm speaking with, some are very pro checking hormones. Others will say, “I don't worry as much about that. I really base treatment decisions on clinical presentation and symptomatology.” 


Dr. Nicky Keay: [00:31:39] Well, certainly in the UK. I'm a member of the British Menopause Society, and I've done their extensive training, certification course etc., for doctors, and we are told pretty categorically that women from 45 and older, if they've got all the symptoms, we've discussed the change in the cycles, the various symptoms and they're of that age, you shouldn't actually do a blood test, because not only should you do one, you can't diagnose based on the blood test, because the hormones are in flux, remember? So, if you did a blood test, if you were to do a blood test, you might get a false positive or false negative. It might be a good cycle where everything is looking fine. And so, then, what are you going to say to the woman? 


[00:32:20] It's all in your head. it's like, “No, you can't do that.” But equally, you might have it where, “Oh, gosh. Yeah, it looks like the ovaries are really struggling.” But then, lo and behold, she will come back to you, I can guarantee and say, “Oh, but the next few cycles, everything's back to normal.” So, the thing about perimenopause, is that nobody likes uncertainty. But that is the key diagnostic of perimenopause uncertainty. Hormones going up and down, symptoms coming and going. So, we are strong. Well, we're told not to do blood tests, full stop. 


[00:32:50] The only justification I would have for doing a blood test if the woman is maybe under 45 and-- I, in fact, just speaking to a woman in this age group who it could be perimenopause, but actually discussing with her, it sounded a bit more like this relative energy deficiency, really doing a lot of exercise, definitely skimping on the carbs, which you need for high intensity, good quality exercise, by the way. So, I was like, “Oh.” 


[00:33:19] So, in that case-- But I wasn't particularly so much looking for the female hormones, actually looking at the thyroid function, because T3 is a really good indicator of energy availability. So, the answer to your question, is that we don't-- certainly in the UK, we're told not to test for hormones, because of this uncertainty in perimenopause. It's based on symptoms, absolutely. 


[00:33:41] But you could justify it if there was even more uncertainty in the sense that they were maybe under 45 or having taken that clinical history, it's sounding like it could be a relative energy deficiency. And in the case of this woman, actually, we found it was more the relative energy deficiency issue. We talked about the timing of the nutrition, and lo and behold, her periods are now come back and they're regular, you see? So, I think there is potentially a place for blood testing in certain clinical situations, but not just as a general thing, “Oh, yes, we should test everybody.” 


Cynthia Thurlow: [00:34:21] Well, and it's interesting, because having the opportunity to interview so many physicians and so many researchers, I can see both sides. I agree with you that the degree of anxiety that lab testing in some instances provides for specific women. When I say the specific women, I have some patients who are just anxious by nature. And if they've heard a physician or researcher say, “Your estrogen levels need to be X in order to confer protection to brain, bone and heart. When their blood values, their estradiol values are not within that range, it produces so much anxiety.” 


[00:35:02] I say this, because patients will come to us, come into programs or working with my team. I'll have to remind them, I'm like, “Labs are just one piece of the puzzle.” And so, I agree with you that, it's really going off of really good history, as you appropriately took with that woman who had the relative energy deficiency and then, also looking at the context. 


[00:35:25] Now, one thing that I guess find really interesting, is some of what determines when we go into menopause is a byproduct of genetics, depending on when our mother went into menopause as an example. For you, as a hormone expert, what are some of the variables that you feel like are most impactful to see women going in earlier? As an example for listeners, they may or may not know this, but smoking actually ages the ovaries. And our entire biological clocks, in terms of how we age as women is driven by our ovaries. 


[00:36:02] There are more mitochondria in our ovaries than anywhere else in our bodies, which I find fascinating. [Dr. Nicky Keay laughs] Great. But smoking will actually age us faster. So, for you as an endocrinologist, what are some of the risk factors for that earlier transition, things that will stand out to you when you're taking a good history with your patients? 


Dr. Nicky Keay: [00:36:23] Well, I think you've already said the key one. Genetics, for sure. But the interesting thing for women, is that ovaries, as you say, they age at a different rate to the other organs in our body. It's a little bit out of sync. And so, for men, everything is aging at the same rate. By the way, newsflash. Men don't have andropause, right? [Cynthia laughs] Everything goes along long, gradually, the same rate. But for women, yes, exactly that's an important point. 


[00:36:50] But again, it's just to know that and accept it. That's how it is, okay, that the ovaries retires earlier than the other organs in the body. So, genetics, for sure, plays. But everything, it's genetics and environmental. And I think that is the top one about smoking really is the main one, or maybe I don't know if there's any particular proof on this, but certainly in terms of risks for other things as well, like breast cancer, excessive alcohol intake sort of thing. 


[00:37:20] I'm afraid the smoking, there's no easy way to put this. It's not good for anything, including this. If I could just also pick up one other thing about the levels of the hormones. Because if you do a blood test-- Listen, don't get me wrong. I love my hormones. I would do what-- I'm a scientist. I want to know the values of the hormone. So, I'm not saying I never do a blood test, but you have to interpret the result of that in the clinical context. And in the clinical context for the woman, because you can have two women with exactly the same level of hormones, estradiol, progesterone, I don't mind what we say. Let's say progesterone. Same level of progesterone in the luteal phase. One woman will say, “I feel fine.” The other one will say, “I've got really bad premenstrual symptoms.” 


[00:38:03] So, it's not just the level of the hormone. It's your personal biological response to these hormones. And in that context, the other interesting thing, not so much about the age of the menopause, but how you're going to experience that or perimenopause, should I say? There's this triad of things. If you are particularly sensitive to changes in hormones, then probably in your 20s and 30s, you did have quite bad PMS, maybe you got postnatal depression. I'm afraid probably you might be in for a slightly tougher ride in perimenopause, because your receptors are just very sensitive to changes. 


[00:38:40] So, for sure, if we do a blood test, we want to know the numbers and that can be useful. But actually, it's not just the number. It's the clinical context. You're talking about previous clinical history, the female hormone odyssey for that individual, because we're all individuals. Newsflash, we're all individuals and we need to be treated as such. Thank you very much. I don't want to be a statistic. I'm an individual. That's why I love hormones. It's, of course, you have to have the facts, and things like this and understand the mechanisms. But then, ultimately, it's putting that in the context of that individual person, what does that look like for them. 


Cynthia Thurlow: [00:39:15] Well, I love that you brought up-- There are individuals, and this has been my clinical experience, that are just more sensitive. 


Dr. Nicky Keay: [00:39:22] Yup. 


Cynthia Thurlow: [00:39:23] Bad PMS, PMDD, the really severe form of premenstrual syndrome. If you had postpartum depression, like letting people know, you may be someone that is going to be having more symptoms and perimenopause. And that's okay, because your body is just that much more sensitive. That would also, conversely, be the type of patient that I would be super, super conservative when offering, whether it's oral progesterone, or a micronized progesterone or when it's appropriate for them to start on estrogen. 


[00:39:55] In the UK, I know that you all are far more progressive than we are in the United States. I think it's less than 10% of women that are on menopausal replacement therapies or even on hormone replacement therapies. I know that in the UK, you all are far more progressive. 


[00:40:13] Do you find that testosterone replacement, is that something that is considered to be fairly conventional in the UK, is that frowned upon? Because I know here in the United States, it is starting to run the gamut of either people are pro, if appropriate to replace it. Others are like, “Nope, women don't need testosterone.” 


Dr. Nicky Keay: [00:40:33] Well, something in between. The thing is, the whole debate, we call it more generally over here HRT, hormone replacement therapy. I know there's problems with that, because that suggests maybe replacement. Meaning, a deficiency. It's a biological event, natural physiology and all that sort of thing. But I tend to still use that. We tend to still use that, because there are some premenopausal women to whom who will need HRT, like the woman with REDs, relative energy deficiency, in sport who have poor bone health. And of course, I'm going to try and help them get their periods back like the woman I mentioned earlier. But if their bones are not in a good state, then we do need to give them HRT for temporizing help, for support for bone protection. So, that's the HRT. 


[00:41:19] Again, it's based on symptoms, quality of life. Those symptoms that wewere talking about, if those are really dragging you down and you've done your best, you've addressed, you're doing some exercise, you adjust your protein intake, you've done your darnedest. But if you're really struggling with your quality of life, then absolutely that is the main indication for HRT regardless of blood test, by the way, okay? We, in the UK, certainly we would be ready to start that at any age. You don't have to have officially reached menopause and no periods for 12 months, etc., etc. Because actually, officially in that 12 months, we don't know. You are actually still in limbo, you're still in perimenopause until we have definitive proof. So, you could argue, “Well, you could be a bit like quantum physics” or whatever. You could be or you couldn't. 


[00:42:03] Anyway, so HRT absolutely for bad symptoms, whether you've officially passed menopause or perimenopause, that's fine. It's all about helping the woman, overcome her symptoms. So, HRT specifically what we're talking about, well, ideally transdermal estradiol. So, through the skin. So, we don't have all the kerfuffle of going through the liver and causing problems with the liver clotting factors, etc., so through the skin gel or patch. And then, ideally, the top choice would be the micronized progesterone that you mentioned, because that's body identical. So, that would be the top choice. But of course, it will depend on the individual. 


[00:42:44] If one of the woman's symptoms is really heavy periods, then actually having a Mirena coil which releases continuous synthetic progesterone. Actually, if that's her main problem, her main symptom, really heavy bleeding, then actually, probably that's a good call for her. It's the only part of HRT that is licensed also as contraception, by the way. So, you mean that these are the top choices of HRT, but then tailoring it for the individual, what a mix and match, what's going to work best for them, and certainly we would-- 


[00:43:16] But you're right about these two camps. In my book, I describe it as Scylla and Charybdis, going back to my ancient Greek myths. Odysseus, in his journey-- By the way, Odysseus, a man, had to be guided, of course, by the goddess of wisdom, a woman, Athena, by the way. That's why Athena's on my front cover in case. Anyway, Odysseus had to navigate between these two equally perilous things, right, the whirlpool and a monster and whatever. So, that's sometimes how HRT seems to be described. There are camps like these people that are like, “You have to take it. You're stupid if you don't take really high doses. Take testosterone, take the whole lot.” And then, there are the other lot that say, “Oh, you mustn't even touch that stuff,” duh, duh, duh. 


[00:43:58] It's really, really confusing, but I really want to encourage women, please, you are intelligent enough, and inform yourself and make the choice that's right for you, because you are an individual. But if you are thinking, “Look, I've done everything I can. I do want to take HRT,” again, try and opt for the top ones we've mentioned, but it depends on the individual. In terms of testosterone, what's placed for that in the UK certainly, we would consider offering that to a woman, but it's specifically for reduced libido, okay? So, lack of sex drive, in other words. But this would only be after you're on the systemic HRT. We just discussed the estrogen and the progestogenic, whatever it is combined, you've got an optimal dose of that for your other symptoms. 


[00:44:44] Probably, you've also taken vaginal estrogen as well, because that will help with the vaginal tissues. Because part of lack of sex drive could be-- well, if it's painful. [laughs] You’re not going to really feel like it. So, if you've done everything you can to overcome that, if it's still problematic after a year, for example, of the systemic HRT and everything you've worked on, everything with the woman, but she's still coming back and saying, “Look, this is really not good.” And then, again, a blood test just as a baseline to confirm yes, the testosterone is low, sure, then testosterone might be considered. But to be aware, if you are a competing athlete, it is on the wider banned list. 


[00:45:25] So, I've had some masters athletes. It's really sorry, but you can't if you're competing, because you will be banned for four years. So, I think the attitude to testosterone is absolutely, again, driven by the patient's need and what she wants to do, making it clear that, we have to do everything else first and then we have this. So, I think it's all about that informed discussion, giving all the information openly, honestly. And then, the woman can weigh up the pros and cons. Women are intelligent, they can come up-- If they understand what's being proposed, then it's more likely to work anyway, you see, because you know the psychology of it, “Okay, I've made this decision, I want to do this and I understand why.” You go into it with all that knowledge and positivity we talked about. 


Cynthia Thurlow: [00:46:20] Well, and I think it's so important to make sure you're working with a clinician that is in alignment with what your purpose and your intention is. I love that you're really honoring your patients and really taking into consideration all the variables. I did not realize that if a woman is middle aged and is still competing at a high level of sports that even if they have low testosterone levels, if they were to supplement with it, that can be part of that banned substance, which seems almost a little bit criminal if you have documented low testosterone-- [crosstalk] 


Dr. Nicky Keay: [00:46:54] Well, exactly. That's a whole other argument. [Cynthia laughs] But it's like, yeah, one which something me as an individual. But you could argue, well, hold on a minute. If this is not for performance, it's just for their health. But that's a philosophical argument. Whether we like it or not, those are the rules. I did have this discussion with an athlete. It's like, “Yeah, I agree with.” You could see it's a bit unfair, because if you do the testing, you prove that it's not elevated to a level above the expected range for a woman. But anyway, that's the way it is. That's probably a smaller group of women where that applies, but I have come across it. 


Cynthia Thurlow: [00:47:37] Yeah. And I think that, again, the informed consent piece is certainly very helpful. I would love to end the conversation today. There are multiple, many, many myths of menopause that are discussed throughout the book, which I found really beautiful. And again, typifying the experiences of different clinicians, and researchers and experts, is there a particular myth for you that you feel like really is what drove you to write this book, one that you as a clinician find more problematic than others? 


Dr. Nicky Keay: [00:48:12] I think just the going back to where our conversation originally started, that this negative feel around hormones, female hormones, menstrual cycles, which then feeds into menopause. So, I think it's just that's the thing that really propelled me to want to put this book together, because yeah, I felt annoyed as a woman. [laughs] It's like, “Hold on a minute. I feel I've still got a lot to give, and I have to be honest and fair.” Actually, I didn't personally experience a negative thing. As a female doctor, I have to say, I've never experienced sexism or ageism particularly. And in fact, people do respect that I've got all its experience. So, age is on my side in that sense. 


[00:49:05] But I know that that I'm lucky for me, but I know that lots of women don't feel the same. And so, that's really what propelled me to drive it to try and put right, these myths, and proclaiming the beauty and elegance of the female hormone odyssey throughout. We can't just pick out one bit of it and say, “Oh, it's that bit. I'd only want that bit.” That's not an odyssey. That's not a story. That's not a journey. It is a journey. And so, looking on it in that way, that's what I will really propel me to write the book, to change the narrative about the female hormone odyssey. 


Cynthia Thurlow: [00:49:42] Well, I'm so very grateful for the opportunity to connect with you. Please let listeners know how to connect with you outside the podcast, how to purchase your books, the Myths of Menopause. Or, if they live in the UK, because we do have a lot of listeners over in the UK and the EU, how to work with you personally? 


Dr. Nicky Keay: [00:49:59] Sure. Well, the book, there's Myth of Menopause. My first book was called Hormones, Health and Human Potential. So, the books that are available on Amazon worldwide. I understand. So, go and have a look there. I do work with people in a clinical setting, this individual approach I'm talking about. I do offer hormone health advice. It’s throughout the world. It's advice, obviously, if it's outside the UK, not strictly medical, medical. 


[00:50:24] In any case, for example, in terms of prescribing various types of HRT, I will discuss all the options and the recommendations. But ultimately, even in the UK, I will always say, “Go and get your, now we call them, GPs here, general practitioners to prescribe it, because here we've got a very good deal. [chuckles] You can get your HRT prepaid prescription on the NHS for very reasonable £19 a year. Amazing. Anyway--


Cynthia Thurlow: [00:50:48] I wish that we had the same in the United States We have to fight-- 


Dr. Nicky Keay: [00:50:52] Yeah, I know. So, if people want to get in touch, yeah, have a look at the books and get in contact with me. I have a website, Nikki K Fitness, so you can have a look there and click and say, yes, I would like to explore an appointment. I also give lots of talks. And so, if people think, “Oh, gosh, yeah, we would like.” I do lots of talks to sports clubs, dance companies, other things like this. So, if you think, “Gosh, this could be really helpful for my group,” whatever it is, I also do that. 


[00:51:21] So, yeah, my website-- I'm on social media, @drnikkik. I'll be honest, I'm not the best at social media. So, go and have a look. I do post some things there, but I haven't got time for everything. You’re right. 


[laughter]


Cynthia Thurlow: [00:51:39] No, I totally understand that. Thank you again for your time today. 


Dr. Nicky Keay: [00:51:42] My pleasure. 


[music]


Cynthia Thurlow: [00:51:45] If you love this podcast episode, please leave a rating and review. Subscribe and tell a friend. 



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