Dr Louise Newson: [00:00:03] So today on my podcast, I've got two lovely ladies. They both work in mental health, and they've personally had experience, but they've also witnessed a lot. And once you see hormonal changes, you can't unsee them. And, once you have knowledge, you want to share it, because you want other people to learn from other people's experiences. And actually, that's what we do as women, isn't it? We just share, and then we make decisions ourselves. So Jayne and Diane. I just welcome you to the podcast studio and thanks for both of you giving up your time to come today.

Jayne Kendall: [00:00:38] Thank you, Louise. Thanks so much for having us. I'm a mental health nurse and I'm also 49 and experiencing this wonderful time of life and I've had my own struggles with that. But more importantly, I think it's made me recognise the hormonal impact on mental health for women when women come into our service. It's something that I'm struggling with, it's something I struggle to advocate for because that just isn't enough knowledge and it's just not spoken about.

Dr Louise Newson: [00:01:10] Yeah, what about you Diane?

Diane Glancy: [00:01:12] So I'm also a mental health nurse, I'm a CBT therapist and I've just recently finished my master's degree in mental health, specialising in the menopause and the efficacy of CBT for vasomotor symptoms. And like yourself and Jayne, I've experienced so many women coming into mental health services being with diagnostic overshadowing, been misdiagnosed, being put on anti-psychotics, anti-anxiety medications. And so, yeah, we see it all the time. So my kind of hope is that I can bring a standard menopause questionnaire into mental health services at the point of referral for any women over 45. I think it's really...

Dr Louise Newson: [00:02:04] I think it should be any woman though actually because you know one in 30 women under the age of 40 have an early menopause and a lot of women who are young have PMDD, premenstrual dysphoric disorder. So I often think there are sort of three questions that I think every woman but especially at mental health services should be asked and one of them is, do you think any of your symptoms could be due to your hormones? Because actually, once you ask the question, people start to think. But also, do you have changes in your mental health throughout your menstrual cycle when you were having periods? And then the other thing is, have you ever had postnatal depression? Because that would unmask a lot that's going on in mental health at the minute because I see a lot of women who have been under psychiatrists, they've been under mental health teams. I do see quite extreme cases. But I think back to my psychiatry training, and a lot of the inpatients were women. A lot of them were, you know, 40, 50, 60s. But I wasn't taught to ask those questions. And then, like you say, if you have a symptom questionnaire that you give to people, and you don't have to give it to them when they're in crisis the first day they come in. But giving it just focuses people to think more about the role of hormones in the brain, doesn't it?

Diane Glancy: [00:03:28] Absolutely.

Jayne Kendall: [00:03:30] And I think it, Diane and I have worked together, so we both worked on the same service. So I know, well, I don't think anything has changed. But the questions are just never asked. There's never been any consideration. We used to suggest, didn't we Diane, in the MDT if somebody came in and they were kind of mid to late 30s, early 40s and they'd never presented before, we'd then start asking the questions around their menstrual cycles. I don't think it was ever really taken seriously. Most of the women were diagnosed with bipolar type 2, which I have to say I'd never heard of until I worked in Scotland. And then when you actually worked with these women, because that was our role as the nurses, as the kind of community mental health nurse, and asked the questions and dug a little bit deeper into their life, you started to see the pattern.

Dr Louise Newson: [00:04:21] So why do you think people aren't asking the questions because they're not, it doesn't cost any money, doesn't take much time to ask those questions.

Diane Glancy: [00:04:29] There's a lot of reasons but I think fundamentally a lot of the psychiatry traits are misogynistic in nature and unfortunately it gets poo-pooed at that level unless you have people who feel really strongly. There's no education on hormones even from childhood up. You know, as children, we don't get taught about hormones. Women don't know what's happening to their bodies. And so if women were perhaps educated in mental health services about it, I mean, any kind of education on this has been self-education for myself and I think for Jayne as well, because, you know, in the NHS you're not taught about the impact of hormones in your body.

Dr Louise Newson: [00:05:34] But it seems so wrong because we've known for decades about the role of hormones in our brain. We've got evidence showing that all three hormones, progesterone, testosterone, and estradiol have effects on mental health. Even in men, we know that testosterone can have an effect on mental health and low testosterone can cause depression, but it's just been ignored.

Jayne Kendall: [00:06:03] I don't know if it's easier to just prescribe the medications that they're used to prescribing. If it's easier, like an easier box to tick to say that somebody has depression, as an example. I'm recently working with a woman that's been in services for a hell of a long time, and there are lots of factors that contribute to our mental health status. But I recently recognised that she came into service with postnatal depression and she's now on heavy antipsychotics, she's on clozapine, and I just wonder what that journey actually looked like for her. I can imagine nobody asked any questions around her hormonal health around her menstrual cycle, you know, recognise that she had postnatal depression and what that then meant. And as a result of that, she's now been in services for 30 years and I doubt very much that she'll ever get out. So I find that incredibly distressing, that we are literally diagnosing these people incorrectly and ruining their lives.

Dr Louise Newson: [00:07:15] So you might've heard my podcast with Jay and Hayley, Hayley was in and out of psychiatric hospitals for 30 years. And when you talk to her, which is quite nice, isn't it? Talk to the patient and ask those questions. Do you think it could be related to your hormones, she said maybe. And then I said, did you ever have changing mood symptoms with your menstrual cycle. She said, oh yeah, the days before my period were awful. That was when I was argumentative. I was irritable. I just literally was terrible. And then my period would come and I would feel so different. It was like night and day. And then she's had three children. So again, I asked the question, did you have postnatal depression? Well, she did, she had postnatal psychosis and was sectioned. And that was when she had her first ECT round. But I said to her, how did you feel when you were pregnant? And that was the first time I met her and she grinned from ear to ear. She said, I just felt amazing, the best I've ever felt. Now I think if you just asked all your inpatients who had been pregnant before, how did you feel when you were pregnant. And it's not because they were pregnant. It's not, because, you know, whatever, usually it's because they've got hormones in their body, often for the first time and it's often more related to progesterone as well. And I feel cheated as a doctor that no-one taught me for so long, but I feel sad because the psychiatrists still pushed back. I spoke to someone the other day, she was a mental health nurse, she said, I can't even talk to the psychiatrist. They won't even entertain. And my pushback is always, you know, I think, I'm sure you agree, mental health issues are multifactorial. It's not just one thing. So, I was taught quite early on as a doctor that you can't change people's homes and their circumstances as much as you'd like to, that you can't do it, but you can change the way that they think about it and the way maybe their future life's going to be. And it's the same with mental health. There's things we can help and a lot of things are associated together. But often until you balance hormones, they can't think better and then they can't then address their alcohol and their drugs and whatever else is going on. And I feel like we're just letting these poor women down more and more.

Diane Glancy: [00:09:50] Yeah, I think women are kind of double disadvantaged because if they go to the GP, often the GP is not educated on hormones and treatments that are available for them. So then they come to us. If they go straight to an outpatient psychiatrist, they often get, as Jayne said, diagnosed with, you know, late-onset bipolar, fibromyalgia, chronic fatigue syndrome, they get given a whack of medication, they're still no further forward, they're still having all these symptoms. They think they are actually losing their mind and in fact, I had a lady last week who I had had a really good session with, and she just said at the end of it, you've made me feel that I'm normal again, because I just normalised all her symptoms. And you know, we've done a really good piece of work, but unfortunately, I had to kind of educate her on what to go and say to the GP to try and get what she needs to get, but not every woman gets that opportunity.

Dr Louise Newson: [00:11:01] It's very, very difficult and a lot of people can't advocate for themselves and they have no-one else to help them. And I also think once you've been labelled with a mental health condition, that label stays with you forever and it judges how people think of you. So it's, you know, this 55-year-old lady with schizoaffective disorder, this 46-year-old lady with clinical depression, and that's it, they're locked into the system. The other thing is, so as I've said, it's multifactorial. Some women absolutely need these drugs. They need CBT, they need hormones. There's lots of treatments that is really important, the same that we do in anything in medicine. You know, we have to look at nutrition and exercise and wellbeing and mental health, it all works together. That's just goes without saying, really. But one of the things about the drugs, you've mentioned about anti-psychotic medication, is that we've known for many years that people who take antipsychotics have an increased incidence of raised blood pressure, metabolic syndrome, type 2 diabetes, Alzheimer's, the way that the drugs work in the brain and body and affect the metabolism. But we've also known for many years, that they affect our hormones. So they give people often a chemical menopause. So we know they reduce progesterone, estradial and testosterone levels. I recently contacted the Royal College of Psychiatrists to ask them how they screen for this, because I know people have their cholesterol tested, and I know they have their blood pressure measured. So I said, well, I can't find any guidelines, but I'm not a psychiatrist, so I'm probably missing them. But where are the guidelines, or can you point me to some practical tips that you give to people about when people are on antipsychotics, screening for low hormones? I haven't had anything back, she said, there isn't anything.

Jayne Kendall: [00:13:02] I recently have been challenging, we have a young woman, she's 36, which is obviously a young woman, but she could also be going through perimenopause and she's around that age. And I've recently learned that lower levels of estrogen increase the metabolism of the medication that she takes, so therefore the medication is no longer effective. So we have been concerned. And again, the concerns are sporadic. It isn't like an ongoing psychosis. It just felt really odd to me. I didn't feel that she was necessarily deteriorating, it felt that something was kind of changing in her that we needed to address. And when I raised it, I was basically ignored and there's a consideration that you know perhaps we need to, you know, consider hospitalisation and all kinds of things. So I've had to respond and say, you know, I've done some, I'm going to say research. It was just Google. You just Googled it and there are some studies that just show up immediately, you know. I felt really sad that we didn't know that, that that isn't common knowledge and the medication is clozapine and there are lots of studies because lots of women when they enter between the ages of 40 and 60 they notice that the effects of clozapine changed but it didn't in men and then that's where they draw, do the link to kind of and it's lowered estrogen. But why why is that not common knowledge?

Dr Louise Newson: [00:14:41] Well this is what surprises me because sometimes in medicine if I don't understand what's going on I try and work it out in my head and I go back to first principles and so we've known for a while that some of these drugs can increase prolactin which is another hormone and often people have their prolactin levels measured and we know that prolactan will affect the FSH, follicular stimulating hormone which will then reduce, which will then switch off the ovaries, producing testosterone, estradiol, and testosterone. And a lot of these women will have lower levels anyway, probably, because that can trigger their mental health symptoms. And testosterone is just a blood test to measure. Even estradiol, you can measure with a blood test. These women are often having blood tests anyway, and even the men actually. Like, why aren't we measuring testosterone levels in men, in these people? Because we know that when hormones are replaced, we know mental health can improve, but also those metabolic changes can improve. So the type 2 diabetes, the raised blood pressure, the Alzheimer's risk and so forth. So it just doesn't really seem very joined up, does it?

Jayne Kendall: [00:15:53] No and I think from, on a personal level, Diane has a very similar story, so as we were just talking about that our patients often don't have anyone to advocate for them, as nurses I think we're a little bit more able to advocate for ourselves. And we're happy to challenge doctors, which people generally aren't, people generally take the word of their doctor as gospel, which I disagree with. But when I was, I was 45 and I'd fallen, I'd gone for a run and I had fallen over and I broke both my elbows. And that was the first time I thought, oh, you know, I'm 45, maybe I should consider. And I spoke to three different doctors, all women, and they all told me that I was far too young and they wouldn't consider, with one doctor, basically suggesting I may well have ovarian cancer due to having kind of heavy periods.

Dr Louise Newson: [00:16:47] And you were how old, 45, you said?

Jayne Kendall: [00:16:51] Yes, I was quoted NICE guidelines, I was told that I had to have all of these different referrals for things that I knew I didn't have, for them to then come back to me two years later and say, oh, yep, you're perimenopausal.

Dr Louise Newson: [00:17:09] It's such a waste of time and money, isn't it?

Diane Glancy: [00:17:14] You know, similar to Jayne, I'd done my homework and approached the GP myself and I had a really good experience and through doing the kind of research that I've been doing, I've kind of had a bit of a specialist role in my own private practice, but in my NHS post and I've actually been met with quite a lot of resistance from some GPs when all we're trying to do is empower women to live a better life and it can be disheartening at times because, you know, you're trying to work collaboratively with GP practices to help, you know, the shared care of our patients but often we're met with resistance of what do they know, you know they're just a nurse.

Jayne Kendall: [00:18:08] 'Just' a nurse.

Diane Glancy: [00:18:08] And that can be disheartening, but...

Dr Louise Newson: [00:18:10] You see, I find this really sad. So for two, well, lots of reasons, but two main reasons. Firstly, as a doctor, I love challenge. I love people say, why are you doing this? What's this? Where's the evidence? I think it's great. I loved working with nurses. I love other healthcare professionals to have a debate because you see different things. You're trained in a different way. And I find it really disrespectful. It really triggers me when I hear that you're only a nurse, how dare you talk to a doctor, because that is just wrong in so many levels. The other thing is, like it feels that it's, like even if hormones only made you feel a little bit happier, and we know they do a lot more than that, why are people so worried about people feeling happier? Someone was interviewing me this morning about testosterone and it was a journalist and he said something about, well I hear you prescribe a lot of testosterone and hear that you'll saying it can help people feel better. And I said, well, yes, but I also do symptom questionnaire, we ask about libido. They have reduced libido, so we prescribe it for that. But hang on, I said to him, does it matter if women are feeling a bit better on testosterone because actually lots of people are prescribed antidepressants to feel a bit better and there's far more risks of antidepresants than there is with testosterone. So again, it goes back to my thing that it's just allowing people a choice. You know, if you both had low testosterone and you had symptoms of testosterone deficiency and low mood, reduced motivation, poor energy, muscle joint pains, reduced libido, sure, you could be depressed with all those symptoms, but most women say, I know I'm not depressed. And then if you say but I really want to try citalopram and I really don't want testosterone, despite my testosterone level being zero point nothing or whatever, I would say, well, let's talk it through. But somehow if you came and said, allmy, you know, everything's low and my testosterone is low and I've got these symptoms, I'd like to try testosterone. You're treated like an imposter as a woman. That's really weird.

Jayne Kendall: [00:20:33] And that's another side to it is that because not every avenue is being explored because women are not being taken seriously when they're discussing their hormones or their menstrual cycle, young girls especially, young girls have it have it really tough when they you know just just starting on their cycle and and growing into young women and dealing with life and going through schooling and you know wondering what the future holds and then they're just labelled with a personality disorder if they decide to act in a way that doesn't fit, you know, the normal criteria of young girls. But having a conversation with someone who is listening to what you're saying, who's trying to look at what might be impacting your presentation. Then you get to choose. It's informed consent. It is exactly that. Do I want to try the hormone? Do I not want to try the antidepressants? Do i want to change my diet? Do I what to reduce my stress? Do want to do them all? It's informed consent, which is what we should be working on.

Dr Louise Newson: [00:21:36] Absolutely and as a healthcare professional, I feel our job is to help advocate for our patients in the way that they want. You know, I'm never going to judge someone because they smoke. I still treat them exactly the same way if they smoke or didn't smoke, I might add into the conversation, It's probably not the healthiest habit, but I'm not going to judge them. And it's the same if they didn't want hormones. I'm not judging them. It's a choice thing, but that choice has been taken away and somebody reached out to me last week on social media and their daughter has gone to a psychiatric hospital. She's in her 40s and they're convinced it's related to her hormones, the family are, and she's got psychosis. She is having heavy duty drugs and she is going to have some ECT. And I said, could I speak to the psychiatrist? They said, no, I can't talk to them about hormones. They're not interested at all. So she's being transferred to another hospital in London. She must be quite severe, I'm not sure. And they said, we're really hoping that the new psychiatrist might entertain a conversation. And it's really harrowing in my mind because like it's not the Victorian times. We don't have to give people chemical straitjackets for everything. Of course, I am not saying that these drugs aren't important. But I am saying, why are we so resistant to thinking about hormones as well?

Diane Glancy: [00:23:11] I think, from my experience, that whole, you know, talking about it is the only place to start because like Jayne said, when we run the MDTs or when we have been, it's been kind of dismissed. But we won't stop challenging, we'll continue to challenge. And the more we speak about it and the more we put it out there, the more women will feel empowered. I just think it's about that, it's about sharing and building and continuing to challenge.

Dr Louise Newson: [00:23:42] It's so wonderful that you said that because it's so true and it's sharing so that actually relatives and partners, like with Jay and Hayley, it was Jay, who's the 25-year-old son of Hayley. He's her biggest advocate and he reached out to me. But that's what we need to do. We need to recognise it and not be ashamed that we've missed it in the past because I wonder, you know, I think when I see the behaviours of some people and I think it's because they feel embarrassed. And then when you, you know, I know that when my children were younger, if they do something wrong, they get cross because they're cross with themselves that they've been found out, but that's just life. Like, we change and we should be saying as mental health nurses, doctors, psychiatrists, you know, we should we saying, look guys, we've not thought about this before, let's embrace it, let's think about it. We're not saying it's replacing all these other drugs, but we just need to think in the same way, you know, we used to think that the world was flat and it's not.

Jayne Kendall: [00:24:50] Yeah and I really feel for, because I've worked on a team before and this was many years before, before I really started to think about hormones and we had a woman and she was 60 and you know I do admit to thinking that she was like kind of older and maybe it wasn't necessary to consider it but then as I started working with her, she had a really good job, really happy family life. And then it was kind of around the time she retired, she kind of went in, sunk into some deep depression and she just wouldn't get out of her bed. And that was her life. And so she was tried on all different sorts of medications that didn't work. And when I mentioned that, you know, could we consider it might be hormonal? Again, it was ignored. And the saddest thing for me was that people were willing to just let this woman lay in her bed every single day at 60 years old. I did actually, again do some of my own research and spoke to her husband and said you know I've tried to get this through our team but it's not working and I referred him to a kind of a menopause specialist, which he said that he went and spoke with them and they did start on HRT and I don't know what happened because I left that role but I was just so angry really that somebody was happy to say well there's nothing more we can do and that's that rather than you know I'd given other other areas that we could explore and it just just didn't want to happen.

Dr Louise Newson: [00:26:23] I always find as a clinician that I'm always giving choices to my patients. So, you know, I don't give up very easily. So if this doesn't work, we can try this. If this works, we might carry on with it. If it doesn't, then there's this or this, or I can ask someone else I can, you know, because there's a reason why something happens and just because I don't know the reason, other people might, and I'm always keen to learn and explore. And, you know, it's just, we've got so much more to go. But I think the momentum is changing. I think people are learning in different ways. And I think us just doing this podcast is going to help a lot of people. So I'm very grateful that you both came and reached out to me. And so before we end this, I always ask for three take-home tips, but I can't divide, so I'm going to have to ask for two each. So two things each that you think we should do to make these changes, as in thinking about mental health and hormones more. What three things, or four things, sorry, do you think should happen quickly to reduce the suffering for some of these women? So I'll go with you first Diane.

Diane Glancy: [00:27:45] For for me standardised questionnaires as part of the referral process. We do a generic screening for people, have the questionnaire. It doesn't take any more time and you're going to get so much more information. Education for GPs, that's my two things.

Dr Louise Newson: [00:28:06] Very good. Thank you. What about you, Jayne?

Jayne Kendall: [00:28:10] I think education for nurses, to be able to challenge doctors, and I think that's it. Just to continue to challenge if you are a nurse or a patient and you don't feel that what is being said or the treatment that's being given isn't correct, just challenge. Just continue, don't accept if you're not happy with the response.

Dr Louise Newson: [00:28:36] Yeah, I think it's so important. It's a difficult thing to challenge healthcare professionals, but sometimes we have to, or get a second opinion. It is not always easy, especially if you're in a psychiatric hospital, you can't just go to another place. But just ask, keep asking and feel listened to and valued. So thank you again so much for your time. This has been a really interesting podcast.