Dr Louise Newson: There are many benefits of taking hormones, as many of you know. But one of the questions that comes up a lot is, can I take HRT if I'm over the age of 60? So I want to unpick this because it causes so much confusion and I don't think it should.

So let's think about hormones first. And when I talk about hormones, I'm only talking about three of dozens of hormones we have in our body. So we've got progesterone, we've got estradiol and testosterone, and they're made in our ovaries. They're made in our adrenal glands, they're made in our brains, and they're made in other organs and tissues. And as you know, they're chemical messengers, so they go into our bloodstream and they affect every single cell in our body.

They have really important biological actions in cells to keep us healthy like our other hormones do. But when we become menopausal, the levels of these hormones reduce and decline, and then they stay low forever.

Now, because we still produce hormones in other tissues, we are still getting some hormones. And because our other hormones are biologically active, they can often take some of the jobs of our other hormones, but not all of them. So we have receptors on us, on our each cell that are specific for each hormone. So we have a progesterone receptor. We have an estradiol receptor. In fact, we have two of them and we have testosterone receptors.

And as you know, I'm sure as well is that our cells are constantly being remade. Like if you think about just our skin, we're constantly shredding skin cells from our, outside of our skin and our body's making new ones all the time. Our bone is dynamically active. We're building new bone and breaking down bone all the time and repairing. Our blood vessels are regenerating in our brains as well we get, we are forming new brain cells all the time, and all of these cells have receptors for these hormones in them.

And so our bodies work a lot better when we have the right amount and and type of hormones in our body. But as I've said, when women become menopausal, the hormone levels reduce and stay low. The average age of menopause in the UK is 51, but we know in many countries. The average age of menopause is younger, in the 40s, and you also know that our hormone levels fluctuate and start reducing often 10 years before we are menopausal. So women in their 40s will have hormonal changes that often affect them.

Now, traditionally, menopause has been thought of as something that doesn't cause periods that indeed you have to be a year since your last period to officially be menopausal. But also once they discovered hormones many years ago, they associated low estrogen with hot flushes. So a lot of people think menopause is lack of periods, hot flushes and night sweats, the so-called vasomotor symptoms. And indeed, many doctors still think that's how we define menopause. But we need to be thinking beyond that because we know the symptoms can be a lot more than flushes and sweats, and there are a lot more severe symptoms than flushes and sweats as well. When we've looked at our data of hundreds of thousands of women who are reporting their symptoms often daily on our free Balance app, then we notice that the most frequent symptoms are those affecting our brains. So symptoms such as memory problems, fatigue, brain fog, poor sleep, reduced concentration, irritability, but also symptoms such as muscle and joint pains, urinary symptoms, reduced libido. And in fact, flushes and sweats aren't even in the top 20 of common symptoms.

Now, symptoms are often worse and more severe during the perimenopause when hormone levels fluctuate. But when women are menopausal, many of us still experience symptoms. Symptoms of vaginal dryness, soreness, irritation, urinary symptoms, so cystitis, urinary incontinence, increased frequency of urinary tract infections. Those symptoms often persist and continue sometimes forever, but for many years.

There's been lots of studies looking at how long the symptoms last for, and it depends what you read and it depends on the study. And some studies say seven years, some take say 10 years. So let's think about it. Most women who are menopausal will have their symptoms in their 50s, but I've seen women who have had symptoms for decades. I've seen women in their 70s and 80s who are still struggling with symptoms, and this is where we have to be thinking beyond symptoms actually, because as I've already said, our hormones work in a biologically active way throughout every cell in our body.

So whether we have symptoms or not, the low hormones can have negative effects on the way that our cells function. And we've known this for many years. When we look at the inflammatory cells, when we look at the risk of diseases in menopausal women. We've known for decades that the longer a woman is menopausal, the greater the risk of inflammatory conditions. And we need to wake up and think about this because the commonest cause of death in women is cardiovascular disease and also dementia. So any way that we can reduce our risk of diseases is really important, but it's not just those two diseases.

I'm sure you've heard me talk about the list of diseases associated with menopause, but just to recap, other inflammatory diseases include type two diabetes, osteoporosis, clinical depression, schizophrenia are thought of to be inflammatory diseases. Non-alcoholic fatty liver disease, and of course, autoimmune diseases, inflammatory bowel disease, cancers are related to inflammation, Parkinson's disease, motor neurone disease, multiple sclerosis. These are associated with increased inflammation in the brain.

So once we think about these myriad of conditions that we have an increased risk of when we don't have our hormones, then it exposes us as menopausal women to a higher risk of diseases.

Now, I'm not here saying that everyone will get those diseases, but it is fact that without those protective hormones, progesterone, estradiol, and testosterone, our risk during menopause will increase of these diseases regardless of whether we have symptoms or not.

So many people talk about menopause being a life stage, being a transition. But if you think about what it is, so this hormone deficiency, it will last forever. Now, testosterone levels might increase a little bit with age, sometimes in people it happens. We can still produce estradiol and progesterone from other organs and tissues in our body. But essentially once the hormone levels are low, they're pretty low and that can, that persists. So whether you are 60, 70, 80, or 90 or older, your hormone levels will be low and you'll have increased inflammation in the body.

And of course, there's lots of things we can do to reduce our risk of diseases, to reduce our instance of inflammatory diseases. And of course, we all should be looking at our life, what we eat, whether we drink alcohol, whether we exercise, whether we smoke and so forth. But without hormones, we can't eat our way out of menopause. We can't replace our hormones in other ways other than taking HRT.

So this is the big question. What do you do if you are in your 60s, 70s, 80s, or 90s, and you've never had hormone treatment before?

I see a lot of women in my clinic and speak to a lot of women who have missed out on HRT because in 2002, this big study, the Women's Health Initiative study, the WHI study. Was released and reported wrongly, actually, to not just the lay press, but also to the medical press as well, and it caused so much confusion and it's still causing a lot of confusion now.

Before the WHI study, HRT prescribing was double what it is now. So we've got a long way to go before women who want their hormones back can have them. There's all this misunderstanding. There's this unfounded fear of hormones. But I mentioned WHI, because one of the things that came out of this study was that women over the age of 60 shouldn't be started on HRT, but I want to really unpick this for you because one of the things about this study is the type of HRT given to these women was not the type of HRT we prescribe now, and this is really important for everyone to understand.

The estrogen that was given was a tablet type of estrogen, and it was derived from pregnant horses' urine. So, although lots of people tell me they want something natural for their menopause and pregnant horses', urine is of course natural, I do not want that in my body, and I'm sure many of you don't either.

Pregnant horse's urine doesn't just contain estradiol. It contains different types of estrogens, and also it contains some progesterone. It also contains some androgens, and it contains all sorts of other hormones that we don't need as humans into our body.

So it does seem a bit crazy to be given that type of estrogen. But the big problem really was the type of progestogen. Now I say progestogen because it wasn't a progesterone. Progesterone is a very specific chemical structure of the progesterone we produce ourselves. So it was chemically altered to form something called medroxyprogesterone acetate. It very confusing that it's got progesterone in the title because it doesn't contain progesterone.

It's a chemical. It's been altered, so it doesn't fit the receptors of the progesterone receptors on every cell. It doesn't have the same benefits that natural progesterone does. It comes as a tablet. It, like I say, it's synthetically made and it, we've known for many years that there are small risks with synthetic progestogens, including medroxyprogesterone acetate.

So in the WHI study, they really were giving the wrong type of hormone at the wrong dose, but also to the wrong women because the average age of the women in the study was 64, and this was women starting HRT. Now they did this because they wanted to see the long-term benefits of HRT, but it was a placebo-controlled study, which meant that half of the women in the study was given a placebo, so not the real deal. It wasn't HRT, but we know that HRT is really effective at improving menopausal symptoms. And like I said to you earlier, most symptoms occur around the menopause, and certainly in the first 10 years of being menopausal.

So you can imagine giving HRT in a randomised controlled study to a whole lot of women who have symptoms, you would very, very quickly work out who was on placebo and who was taking HRT. And so they didn't want that. They wanted to have women who were as asymptomatic as possible. So women who didn't have symptoms.

So what did they do? They chose older women hoping that most of them wouldn't have the flushes, the sweats, the more common symptoms of menopause. So the average age of the study was 64. But there was another problem in the women that they chose because a lots of those women had heart disease already. So a lot of them had had heart attacks. A lot of them were overweight. A lot of them had raised blood pressure. So they're giving a type of hormone treatment that is associated with risk of raised blood pressure, risk of heart disease, to women who already had cardiovascular disease. I

t's quite unwise and I don't know that if they wanted to do that study now, they would be allowed to get through it because it just doesn't make sense.

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So they were giving HRT, synthetic hormones to older women who'd had heart disease before. Unsurprisingly, you can guess some of the results. I'm sure some of the results showed that those women who took HRT had a higher incidence of heart disease and stroke than women who took the placebo, especially when they started HRT over the age of 60.

And so when they analysed that data, there were warnings throughout from our MHRA in the UK, our Medicines and Healthcare products Regulatory Agency, said women should not be taking HRT and starting HRT over the age of 60. They also said women should be on HRT for the shortest length of time because they were worried about this risk, especially of cardiovascular disease in older women.

And I understand that, and as a doctor, I would not be giving synthetic HRT to women over the age of 60. But I've already said we don't prescribe those hormones. So I've been to a lot of lectures over the years, really trying to work out in my head why are we so scared of hormones over the age of 60?

And the real scaredness has come from the WHI study, from this data showing that starting HRT in women in their 60s, especially women who've got cardiovascular disease, increases their risk of a heart attack. But let's think, I've already said I don't prescribe those hormones and most of us don't. We prescribe the exact replica of progesterone, estradiol, and testosterone.

So when we give estradiol, it's derived from the soy plants. It's got the same structure as estradiol we produce when we're younger, so it fits onto the receptor of cells very nicely and helps reduce inflammation. The same with progesterone. It's the exact replica of progesterone and even testosterone, but testosterone wasn't part of the WHI study.

So there's nothing in our bodies that would suggest that giving estradiol and progesterone to older women is going to be detrimental. We haven't got studies because no one's done them, and I don't think anyone will to be fair. Firstly, because there's not big pharma behind it, and pharma usually sponsor a lot of big studies, but also it would be unethical to give people a placebo when we know there are benefits of taking hormones. I don't think women would actually sign up for the study either.

What do we do then if we are not sure as doctors, we go back to basic principles, basic physiology, and understand what's going on and what are these drugs or so-called drugs that we're prescribing. I don't really think of them as drugs because they are just replacement hormones.

So there's nothing on cells that changes when we are over the age of 60, and I've already said we get new cells forming in our body all the time. So when I reach the age of 60, my cells are not going to be different to how they were when I was 59, and that's the same with other women as well. These new cells won't have a clue what age they are, or they're not going to be acting differently in the presence of estradiol to how they would've happened or how they would've reacted a few years before when that person was in their 50s.

It just doesn't make physiological sense. So often with women who want to start hormones, at an older age, I'll talk to them and say, we don't have good quality evidence, but we have a lot of basic science to actually reassure us about this risk or perceived risk because the only risks have been with the synthetic hormones, which I don't prescribe for women.

So when we start women on HRT, we talk to them about the reasons for giving hormones. And there are two main reasons. One reason is to help with symptoms, but the other reason, which I think is more important as a physician is actually is to reduce future risk of inflammatory diseases. So that includes all those diseases I've mentioned already, so cardiovascular disease, osteoporosis, type 2 diabetes, dementia, autoimmune diseases, cancers, the list goes on.

And so whether a woman starts HRT in their 50s, 60s, or 70s or beyond, they're likely to still have reduced inflammation from those hormones, reduced future risk of all those diseases, which is really important to think about.

A lot of women say, well, I'm not sure if I've got symptoms or not, because the flushes sweats often abate after a few years. So they say, well, I don't get any flushes and sweats. I don't think I've got symptoms.

You may have seen the symptom questionnaire that we've got and we've produced, it's on the Balance app and it's on my drlouisenewson.co.uk website, and it's got dozens of questions. And often if you sit down and answer those questions, people will have symptoms. But of course a lot of those symptoms, how do we know they're related to hormones or not? It might be just you've got a bit of wear and tear arthritis maybe.

You might be feeling more tired because of your age. There might be some other conditions that are going on, so it's impossible to know, but actually what is useful is to have that questionnaire done as a baseline. Because then what we can do is see how people change with their symptoms when they're taking HRT.

So a lot of people, when we start them on hormones, so the body identical hormones, the exact replica of the hormones they produce when they were younger, people start to feel better. And it really varies how long it can take.

When people are older, lots of people think it's going to take longer for the body to accommodate and change and work out what to do with these hormones because they might not have had them for 20 or 30 years. So for example, if I start HRT on a woman in their 70s, and they became menopausal age 45, that's 25 years or so without hormones or with low doses of hormones or levels of hormones in their body. But sometimes people, I've remember seeing a lady years ago who was 78 and she'd had a hysterectomy when she was 48, so 30 years she'd been having night sweats, she'd been sleeping with a fan on. She'd been, the duvet on duvet off, really struggling. And literally within days of her having HRT, she felt better and the night sweats had melted away.

I've had other women who've taken a few months for their symptoms to settle and reduce. So it really varies and often, as you know, it might take a while to get the right dose and type if they don't absorb very well, for example, through with the, the gel or a patch, we might have to change the formulation. So there's always options and there's always things to change and improve.

But as a general rule of thumb, once people start taking hormones after about three months, we usually notice some benefit. And that's where doing the symptom questionnaire can be very useful because quite a few women have said to me, wow, I get out of bed quicker. I don't have that walking on marbles, feeling that I've always had under my feet when I get out of bed, my joints aren't as stiff and sore. My muscles don't take in the same way. I generally feel happier as a person. I don't have the urinary symptoms that I had. I just feel better in myself. But I thought a lot of those symptoms were just part of ageing.

And how hard is it to unpick? Is it a hormonal problem or is it part of ageing? And we know that HRT is one of the most natural anti-ageing treatments that we can have in our bodies, and that's really important to think about.

Externally, people often notice that they look better, their skin looks better, their hair has a better texture, and often their nails are stronger. And a lot of people are critical of that and say, well, that's just a cosmetic thing. Women shouldn't be taking hormones if they just want to improve the way they look.

But actually the counter attack to that is really thinking about the skin as the largest organ in our body. And if our skin looks good, then our internal organs are going to be healthier as well. If we are building collagen on our faces and in our skin then it's going to help collagen internally. It's going to help keep our, musculoskeletal system really strong and able to function better. If we've got better bone structure in our faces. Then we're going to have stronger bones throughout our skeleton as well, so we can think beyond the cosmetic side of taking hormones.

The other thing to think about is testosterone, because we don't have very many studies about testosterone. The randomised control studies with testosterone who only been looking at libido and sexual function and sexual desire. And we know we've known for many years actually that testosterone can work throughout our body and it can help improve mood, energy, concentration, stamina. It can help improve muscle and joint pains, it can help reduce frequency and severity of migraines. It can help with urinary tract symptoms as well. So we mustn't be thinking about or we mustn't be forgetting rather, about testosterone in older women as well.

One of the confusions about testosterone is people have been worried about synthetic testosterone. So people often say, well, there's an increased risk of a heart attack. There's side effects with testosterone, and these are the synthetic chemical versions of testosterone. The same way that we've got the synthetic forms of estradiol and progesterone, we've got synthetic forms of testosterone, but when we've prescribed testosterone as a gel or a cream, it's the same molecular structure as our own testosterone, so therefore we can use it with confidence. A lot of people find their symptoms really improve and we're not putting their hearts and bodies at risk by having

It is often the missing hormone for a lot of people, so it doesn't feel right to not allow women to have testosterone back if they've got low testosterone levels and they're keen to try it to see if it improves their symptoms.

So women who are older than 60 often can try all three hormones at the right dose and type for them that improves their symptoms and reduces inflammation, and therefore improves future health.

We have to remember that HRT’s actually licensed for treatment to reduce incidence of osteoporosis, and when we know that osteoporosis increases with increasing age, the risk of a fracture, especially a hip fracture, which is not insignificant, really does increase with age. Thinking just about bones is enough really to persuade a lot of women to be thinking about taking hormones at an older age.

And just finally, before I end, thinking about vaginal hormones as well. So whether you take HRT, so systemic hormones or not, you should be thinking about your vagina and your urinary tract. We know the incidence of urinary symptoms really does increase as we age. We should, of course, be doing our pelvic floor exercises regularly, but we need to remember that we've got receptors on the cells of our vagina, our vulva, our perineum, our pelvic floor, our urinary tract that respond to estradiol and testosterone and progesterone as well.

So increasingly we ask a lot about people's urinary tract symptoms and vaginal symptoms. In the past, people have thought, well, if someone's not sexually active, we don't need to worry about vaginal hormones, and that's really wrong. I see and speak to a lot of women who have a lot of pain and discomfort in their vulva, their vagina. A lot of women tell me they can't wear tight fitting clothes. They can't wear underclothes. They wear loose fitting skirts because it's so painful having something next to their vulva because of all the tissues becoming quite thin, becoming very sore. The nerve endings becoming exposed to a lot of pain and discomfort.

So using vaginal hormones can really help and thinking about not just vaginal estrogen, but there's something called prasterone or DHEA, which is another hormone that converts to both estrogen and testosterone in the vulva, the vagina, the surrounding tissues, and that can be really important and really transformational as a daily pessary.

So whether you take systemic hormones or not using localised vaginal hormones can be really, really useful. And about 20% of women do need to use both.

So we shouldn't be thinking that hormones are just for younger women. If anyone's been told you can't have hormones 'cause you're too old, then I would suggest to go and speak to another doctor or clinician who understands the importance of hormones in older people.

And there's absolutely no time limit. We are allowed to take hormones as long as we want to because there are always benefits from taking hormones. Because we are taking hormones to improve our future health, to keep our mind, our body, our organs as healthy as possible, then we can continue taking hormones until the day we die. We don't have to stop them at a certain age, and that's really important, especially when we are thinking about the body identical, natural hormones. Because they don't have the risks of the older types of hormones.

So I hope that's just dispelled some myths for you, and it allowed you to think differently about the safety and effectiveness of hormones at an older age.

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