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Podcast Episode 13: Treating the Perimenopause and Menopause in Western Australia with Women’s Health GP, Dr Sunita Chelva

Podcast Episode 13: Treating the Perimenopause and Menopause in Western Australia with Women’s Health GP, Dr Sunita Chelva

Around the world approaches to treating the perimenopause and menopause differ. Despite these differences however, the stories of women desperately seeking support for their symptoms resonates globally. Joining host Lauren Redfern to discuss the treatment of the perimenopause and menopause in Western Australia is women’s health GP Dr Sunita Chelva. Dr Chelva highlights how geographic distance can prove a major barrier in Western Australia when it comes to accessing care for the perimenopause and menopause. Drawing upon her own work at holistic women’s health practice Woom in Perth, Dr Chelva recalls how it is not uncommon for her to see patients that have driven over 5 hours just to attend an appointment with her. Lauren and Sunita also spend time discussing the current evidence surrounding HRT efficacy and safety, the emerging research exploring the benefits of testosterone use and the importance of adopting a holistic approach when consulting with patients.

Dr Sunita Chelva is a women’s health specialist currently consulting at Woom – a multidisciplinary gynaecology and fertility practice in West Perth. You can find out more about the holistic approach adopted at Woom by visiting their website www.thewoom.com.au and can follow them on Instagram @woom.womenshealth.

Podcast Transcript

Lauren Redfern [00:00:06] Welcome to the podcast for the Newson Health Menopause Society, a multi-disciplinary collective of interested professionals passionate about improving hormone health across the world. The society exists to educate and inspire others to raise the standard of menopause care and access to treatment, to facilitate research, collaborations across specialities and countries, and to provide expert advice and guidance to our associates. The ultimate aim of the Newson Health Menopause Society is to improve the lives and future health of women and all who experience the perimenopause and menopause. I’m Lauren Redfern. I’m a medical anthropologist and I’ve been exploring the experiences of those using testosterone as part of their HRT treatment. In this podcast series, I’m going to be talking to guests from a variety of different disciplines in order to share knowledge and ultimately improve our understanding of the perimenopause and menopause.

Lauren Redfern [00:01:05] Monica has lived in Perth, Australia for 27 years, a clinical nurse specialist in the emergency and intensive care department. Monica was well aware of what was happening to her when in her mid-forties she started to experience the telltale signs of perimenopause. What she was unaware of, however, was the long battle she would be facing in order to get the help that she needed. Monica first suspected the perimenopause when her periods started to, in her words, go haywire. She describes experiencing terrible fatigue and hot flushes, feeling more tearful in the run up to her periods and feeling like her memory was getting worse. Having recently separated from her husband, Monica explains how she put down some of her symptoms to life changes – being a single mum and the stress of having a busy job. However, as Monica’s symptoms worsened, she became so unwell with her once well-managed anxiety, she could barely leave the house and was signed off work for eight weeks. Monica was referred to a psychiatrist who advised that Monica start HRT as her symptoms were likely related to the menopause. Unfortunately, however, Monica’s GP disagreed with the psychiatrist’s opinion and refused to prescribe HRT to Monica. Monica describes feeling desperate. She outlines how she continued to return to her GP when experiencing yet more symptoms but was simply referred. Monica explains that she collected an array of diagnoses that included after she was admitted to hospital for heavy bleeding but was transferred to a psychiatric unit for anxiety bipolar disorder. Unable to work for years because of her crushing fatigue and uncontrolled anxiety, Monica persisted to seek treatment, spending thousands of dollars on specialists. She quoted the UK’s NICE guidelines on treating the perimenopause and menopause, but was told that Australia’s guidelines were not concurrent with advice in the UK. Eventually, Monica was prescribed HRT, but at a very low dose. She was certain that she needed a higher dose or a different type of oestrogen to feel better. Yet she was repeatedly told that nobody ever needs that much HRT. It’s been six years and counting since Monica started to experience symptoms. While Monica has now managed to obtain a prescription for oestrogen gel and uses this in combination with testosterone, she’s still not quite back to feeling like herself again. Monica explains that whilst the majority of her physical symptoms have mostly improved, she still gets sudden bouts of extreme fatigue, making it impossible for her to return to work. The financial toll upon Monica has been huge and she recently lost her house. Despite this, Monica describes the psychological impact of her journey as the worst part. The effect it’s had on her children who just want to see a return of their old mum. She describes losing all independence and her life being placed on hold. I wanted to share Monica’s story because it illuminates not only the variety of ways in which a person’s life can be greatly impacted by the effects of the perimenopause and menopause, but also because it highlights how in different contexts, access to care and treatment can be very different. Indeed, in Monica’s case, she explains how the guidance in Australia when it comes to treating the perimenopause and menopause differs. Here to discuss with me today some of these differences in approach to care and treatment is Australian based GP, Dr Sunita Chelva. Sunita has extensive experience in working in women’s health and is a practitioner based at WOME, a specialist women’s health hub in West Perth. Hi Sunita, thank you so much for joining me today. I’m really excited to welcome you to the podcast. I wondered if we could just start off with you introducing yourself to those listening and telling us a little bit more about the work that you do.

Dr Sunita Chelva [00:04:44] Thank you, Lauren. Thanks for this opportunity to talk to you today. Yeah, I’ve been a GP for around 15 years and of more recent times I’ve become a women’s health specialist GP. I actually went to medical school in Dublin and returned home shortly afterwards to complete my internship and residency where I grew up, in Perth, Western Australia. And I started off actually wanting to be a surgeon working in a hospital system and upon meeting my husband I redirected my path towards general practice as it was far more compatible with having a family. I started off being terrified of doing pap smears and breast exams, having been lumped with them as the rare female GP in the practice. And over time I fully embraced all things to do with women’s health. My own personal journey, I think, with premature menopause has heavily influenced my practice. As I segued from having babies and young children, suffering menorrhagia and hot flushes, and having surgical menopause at the age of 40. And I chose to have a hysterectomy as well as my ovaries removed because my mum died of ovarian cancer. So I’ve increasingly realised that women need someone who listens and empathises with their symptoms. I currently divide my time between working a day and a half in a big, busy urban practice doing general GP and the rest of the week I work at WOME doing women’s health. And just to set the scene, Lauren, a little bit about our unique situation here in Perth. We’re actually deemed to be the most geographically isolated city in the world. So we have a population, yeah, of around 2 million and it always seems like we’re a step behind the rest of the world. We are actually the last place on earth to get COVID and we’re only just experiencing the waves of the pandemic. And so you guys and the rest of the world are returning to semi-normality and we are ramping up and getting used to life with the pandemic. And it’s still a bit scary.

Lauren Redfern [00:06:47] I sort of feel like that should be on a billboard when entering though. Last place in the world to get COVID.

Dr Sunita Chelva [00:06:53] It is! Some people are proud of it I’m sure, yeah.

Lauren Redfern [00:06:57] So the work that you do at WOME is really interesting and I wondered if we could talk a bit about that because your team at WOME consists of both clinicians and allied healthcare professionals and at the practice you take a holistic approach to women’s health. And I wondered if you could tell us a bit more about that approach, at WOME, and what in your eyes makes that so special?

Dr Sunita Chelva [00:07:21] Yeah. So as you said, it’s a multi-disciplinary practice. And it was started by Tamara Hunter, who is a gynaecologist and fertility specialist, and she started it in August 2020. And her vision has been to create a real women’s health hub where we service women essentially from the cradle to the twilight years. And I know similar clinics exist on the East Coast, Lauren, but this is the first of its kind in Western Australia. We have three gynaecologists. So we have Tamara who’s a general gynaecologist and fertility specialist, and we have one paediatric and adolescent gynaecologist, and another who specialises in complex endometriosis. We have an excellent nurse who does a lot of patient education, fielding questions from patients. And we have a dietician who’s done a lot of research, specifically on PCOS, endometriosis and the gut microbiome as well as two fabulous women’s health physiotherapists and two brilliant psychologists. Often the first port of call for a patient is either myself, or the other women’s health specialist GP. And we are the ones who are able to coordinate and direct care between all the practitioners that we’ve talked about. And this means women are able to access that holistic care all under one roof and we all try to practice with those same evidence based medical ideals. We endeavour to stay up to date with our education as much as we can, and we try and share the latest information with each other with regular clinical meetings. And I just really like that ability to be able to pick the gynaecologist’s brain in a corridor chat or, you know, just learn a simple trick from one of our allied health practitioners. Our nurse might sometimes just share something new in the tea room that she’s read or relay information from a pharmaceutical rep that’s just walked in the door. In medicine, we often, you know, Lauren, talk about being holistic, but this can often be confused with alternative medical practices and that means having little scientific basis. But at WOME we tend to see it as holistic, meaning servicing the whole woman. So taking into account the biopsychosocial factors rather than just treating the symptoms of the disease. We like to joke because we sometimes get confused for a perhaps an alternative practice, but there’s definitely no ‘woo’ in womb. It’s all scientifically based nice.

Lauren Redfern [00:09:43] And that’s interesting in what you were saying that you will also do paediatrics. So all the way from children to postmenopause. That’s fascinating. Yeah. So we started today’s episode by sharing Monica’s story and consequently Monica is from Perth, has different needs. Right, which is interesting. Yeah, it is. And I’m yeah, I’m curious to hear your thoughts on this because obviously she had a terrible time getting access to the treatment she needed and sort of talks about how even though now most of her symptoms are well managed, she’s still not quite right and back to feeling like herself. And I wondered how her story really reflects the patient stories that you come across, the work that you do both at WOME and in your general practice.

Dr Sunita Chelva [00:10:29] Yeah. Lauren I mean, this is such a tragic story and it’s exactly the kind of patient that arrives at our doorstep at WOME or yeah, out in general GP land. My heart bleeds for these women. Often they are patients who are high functioning, very savvy, well read, and they’re acutely aware of what’s going on with their symptoms when it comes to perimenopause. And often these women only present when they really can’t function, like Monica. And it can be quite a way down the track when they secondarily develop mood disorders, they suffer fallout maybe in the form of a broken relationship, or they’re completely unable to continue in their professional capacity despite being relatively young in their career. I mean, given the average life expectancy for a non-Indigenous woman in Australia is 82.9 years, these women are only halfway through their lives when they present in their forties. So I see women like Monica who are clearly a shadow of their former selves. They’re a bundle of anxiety, you know, it’s manifest as palpitations and panic attacks and hot flushes and cognitive decline and weight gain. Completely erodes their self-confidence and desirability. And these once formidable women are just desperate, like Monica, and broken. A lot of men wouldn’t have tolerated this. And women for some reason had this badge of honour, where they feel like ‘I’ve got to keep going at all costs’, and then they just fall in a heap. Now, I mean, women, with the advent of the Internet and brilliant podcasts like yours and Louise’s, you know, patients have ready access to a wealth of information, but they can’t translate it into a robust management plan. And they keep hitting these brick walls when they perhaps present to their GP or specialist. And I’m often really shocked that our patients have been already to gynaecologists, endocrinologists, to psychiatrists, to cardiologists and a myriad of other different specialities before ending up at me. I’m just a little humble GP, so in Monica’s case it’s sad that her GP was actually actively against prescribing HRT and I don’t know if it’s because of their own insecurity or lack of knowledge in this area. And then she actually does end up in the hands of an alternative medical practitioner who is actually willing to give her time and listen. And that’s a really common outcome in Perth as it is, I imagine, around the world. And I’ve certainly noticed, as you may have Lauren, that with the advent of the pandemic, there’s a lot of these telemedicine clinics which have blossomed completely all over the internet and there are plenty of websites professing to treat the perimenopause and menopause with bioidentical hormones. And it’s just, you know, with an online consultation. And that scares me, you know, I mean, as we talked about at length, the fallout from the WHI has meant a 20-year hiatus for these women and they’ve not been adequately been treated for their menopausal symptoms. So it makes sense that they have turned towards bioidentical hormones. And the wellness movement is huge in Australia. So, you know, there’s this belief that these are natural entities so therefore much safer. Yes, but we know with the Australian Therapeutic Goods Administration they’re not, and people don’t know that we don’t know the end organ outcomes for these hormones and therefore they probably are at risk, greater risk of breast and gynaecological cancers. We also know they’re not as effective at treating perimenopause or menopause, and that in the compounding of these products themselves, the actual amount of hormone can vary widely with each troche or cream dispensed. And there was a study done by Herbert in the Climateric Journal in 2021 that actually suggested that Australian midlife women do actually have a good understanding of the immediate effects of menopause. They know what happens, but there’s a great lack of knowledge about the long-term consequences and that the overall thought about the effectiveness and safety of HRT is still very negative.

Lauren Redfern [00:14:27] And that’s interesting. You know, I was thinking about that in, you know, in Monica’s case, she’s a nurse practitioner. You know, she spotted the signs of her perimenopause and menopause. And what’s interesting in her account is I feel like what we can really get a sense of is that she does become desperate and frustrated. So you can see in these instances when you’re not feeling heard, why you may actually look to bypass the practitioner altogether and that there is this appealing marketing that connects in with, exactly, as you say, compatibility. And I suppose that brings me really to my next question. And it might come into this, which it sounds like, you know, from what you’re saying, that that may be something that is becoming quite prolific in not just Western Australia but Australia generally. Yeah, and we can talk a bit about that and I’m wondering really what else you would identify as major barriers currently facing women in Australia when it comes to accessing care and treatment for the perimenopause and menopause?

Dr Sunita Chelva [00:15:25] Yeah, well I think, Lauren, it’s quite similar to what we’ve heard with the UK and US experiences and that’s the primary care level as well as a specialist level. I’m certainly not condemning GPs as I myself work in a general setting and as we all know there’s a huge time constraint in general practice. You know, sometimes it feels like we’re just putting out fires or dealing with acute symptomatology and multiple requests rather than having time to listen and look at the patient in the wider context of their lives. Yes, often it seems like we’re just scratching the surface and we don’t look at the big picture. GPs the world over I know are not sufficiently enumerated for what they do. They’re expected increasingly to know everything about everything in an up-to-date evidence based manner. And patients, I mean, I’m sure patients are everywhere, but they’re anxious, particularly, I see, in Perth, to have their issues addressed. Now they want it acted on immediately and it’s very hard to practice what I like to call ‘slow medicine’. It’s a bit like slow food, you know, you’ve really got time to get into the nitty gritty of what’s going on. And as we talked about before in Perth, I mean, my colleagues are buried completely in COVID related illnesses, so perimenopause and menopause are often put on the backburner. And I think that’s why having a subspecialty really gives us time to tease apart what’s really going on with a woman and what’s brought about such imminent decline. And I mean, no doubt, as you’ve talked about in other podcasts, we’re going to see the interrelation between long COVID and hormones very soon. Another barrier, actually, Lauren, is cost, I think just in little Perth our main tertiary public women’s hospital is King Edward Memorial Hospital. It has one menopause clinic a week, to serve a state of 2.7 million people. So this is staffed by consultants and GPs I believe, and I would hate to think what the waiting list is like. You know, we have an amazing standard of living in Australia, and we have a rather accessible health system compared to the UK in the US. But we do have an Indigenous population whose health standards in remote areas fall into the realms of actually many third world populations. So geography can also be a significant barrier in Australia with small clusters of population spread over vast distances. And so our rural populations may not have any access to a regular GP and let alone one who feels confident in treating perimenopausal and menopausal symptoms. So often I get women driving large distances to our clinic to come for help and that’s, you know, we’re a massive state so, you know, 5 hours is quite normal that a lady would just hop in the car and drive up. Yeah, finally, it’s nothing compared to what you guys or the UK comrades are experiencing, but the barriers some time has and it has started to happen here where we get accessibility problems in actually getting certain types of HRT. And when it does happen, I see a lot of women who just give up, they get frustrated and it’s a bit sad. But I guess on a positive note the word is starting to get out there in Australia, Lauren. And as is the case in the UK, journalists and actors are actually taking up the gauntlet and starting to shine a spotlight on the perimenopause and menopause. And people listen, you know, they sit up and listen to what they’re saying. I know that Davina McCall is doing that in the UK, but a lady called Mia Freeman is a very notable journalist in Australia and she launched an online forum called the Very Peri Summit, which included a number of speakers and she – this is quite interesting what she said – she said in 30 years of working in women’s media, never have I experienced a response like the one we’ve had since the summit. So I feel like this wave is about to crash on Australian shores and women are arming and educating themselves. But I’m just not seeing clinicians following suit to meet the demand of what’s there.

Lauren Redfern [00:19:13] Well, I think and that’s interesting because I suppose in Monica’s case, what we had is quite an interesting example of a potentially informed patient. Struggling to obtain the right dose of HRT. So in her story, it’s clear for her the amount or type of oestrogen that she’s receiving she doesn’t feel is really doing the job, but that she faces reluctance from her clinician to change or increase that dosage. And I think you sort of covered that, but I wonder what your thoughts are already on that, because it’s sort of an interesting predicament she’s in where she is a well-informed patient, but that she’s struggling to have those needs met.

Dr Sunita Chelva [00:19:49] Yeah, that’s right. So perhaps it’s about the limitation of the GPs knowledge that she’s come across and the overall confidence in the area. I mean, as your previous guest pointed out, medical education from a medical student level to a postgraduate level, education fails to dispel the myths from the WHI study and fear very much still prevails. I was really amazed to hear Lauren talking to Professor Robert Langer on a previous podcast about how 20 years ago in the WHI, the fear that we’re talking about has actually stemmed from a non-statistically relevant increase in breast cancer related to an old form of progesterone. And that seems to have been drummed into this current generation of doctors which is including myself, by the media, which amazes me because we didn’t really have such widespread social media back then. I mean, in two years we’ve observed misinformation regarding COVID in the current tech age, it’s spread like wildfire. But even in 20 years, the fear around HRT has been so pervasive. Regarding the dosage in Monica’s case most doctors – and I do include a lot of specialists here too which is rather bold – but they don’t seem to know about the titration of oestradiol and testosterone according to patient’s symptoms and blood levels. And they sort of seem to toss HRT aside. If it’s not working at a low level, they tend to forget that all women are biologically different and function at very different levels of oestrogen and testosterone and progesterone. And it was actually this week, Lauren, I came across a patient, a lovely lady in her forties as well at work, and she was seeking help regarding HRT. She’d been under the care of a local, very experienced endocrinologist for osteoporosis, and she’d been on oral HRT, so she’d been on oral oestrogen and medroxyprogesterone for over six years, and that is the progesterone that the WHI had deemed to be dangerous. But we certainly don’t use it very frequently now. And she had actually already had a scare with an abnormality on her screening mammogram, and luckily the lump was biopsied to be benign. In addition, her mum had a DVT and she hadn’t been screened for any pro-coagulant disorders, so it wasn’t ideal for her to be on that type of HRT. Furthermore, she’d asked her endocrinologist to start her on testosterone because her libido had completely flatlined but was actually advised to go elsewhere for this. And so it was quite baffling and I felt really pleased and privileged really to be able to educate this patient and change it to a much safer modern form of HRT and commence on some testosterone therapy as well. I was speaking also, Lauren, to a recently fellow gynaecology colleague of mine, and she actually said to me that even as a trainee, I got zero training in menopause and I’m only getting comfortable with managing it now.

Lauren Redfern [00:22:45] Interesting.

Dr Sunita Chelva [00:22:46] So she said, look, it would be even harder for GPs because when there’s genuine fear of causing harm, she said. You can see how that comes about. There was actually a qualitative study done by Professor Susan Davis in the Climacteric Magazine last year, which actually looked at the views of GPs, gynaes, and pharmacists in Australia. And it confirmed that healthcare providers seem to be knowledgeable about menopause but are still very uncertain about its management.

Lauren Redfern [00:23:10] I mean that’s fascinating as well from the education perspective, what you’re saying of maybe there’s a slight embarrassment as well of going, well, ‘I have to catch up with this’.

Dr Sunita Chelva [00:23:19] Yes. That’s right. And I mean, the way I see it, so dosing HRT surely is the same as addressing a patient with an underactive thyroid or a depressed patient on antidepressant. I mean, our aim and our therapeutic goal is to titrate, to complete not just partial symptom alleviation. And there don’t seem to be guidelines around titrating HRT according to blood levels in Australia. And so in my practice I tend to follow the clinicians at Newson Health do in terms of titrating HRT according to the response versus side effect profile. Checking levels of oestradiol and free androgen index to ensure that we’re not getting supra physiological levels. And I mean, this gives me reassurance in my daily practice as well as the very fact that modern HRT is indeed safe. It’s safe. And that’s what people just need to get that message across.

Lauren Redfern [00:24:11] And it’s interesting as well. I mean, just to briefly touch on that, I mean, I find it sort of fascinating that we often think about hormones, I think, as sort of static things, but they really are fluid, you know, and I always find it interesting in my own research to try and talk about this, about how, you know, we assume it’s sort of a one size fits all, but we look at the difference in our size, in our biological makeup. We are not all going to, you know, respond in the same way. You know, some people have intolerances to many different things. You know, we are going to be sensitive in different ways. So perhaps one pump of oestrogel may work for one patient, but another may require, you know, 3 to 4 per day. And that to me, I suppose it can be frustrating for a patient sort of be given that minimal dose and feel this isn’t right for me, but there to be an attitude of one size fits all really.

Dr Sunita Chelva [00:24:58] Correct. Yeah. I mean the fact that hormones change moment to moment, minute to minute. Patients often want to have numbers and what’s my, what are my numbers doing? But at the end of the day, it’s all in such an intricate balance. We cannot sometimes give them an answer and we just have to realise that, as you said, it’s a fluid, dynamic thing.

Lauren Redfern [00:25:18] Well, I just wanted to ask on that as well. In Monica’s story, she talks about being admitted to hospital for heavy bleeding and at that time being transferred to a psychiatric unit and in turn diagnosed with bipolar. And I’m interested to hear what your thoughts are on this and the potential misdiagnosis of certain conditions when symptoms may be occurring as a consequence of hormone decline.

Dr Sunita Chelva [00:25:43] Yeah, I mean, Australian statistical data, Lauren, shows that the highest age-specific suicide rate for females is in the 45 to 49 age group and the second highest rate for suicide was in women aged 50 to 54. So you could certainly conclude that this would be related to the biological changes associated with menopause. But research targeting the mental health of these women is seriously lacking. Perimenopausal depression is a very hard diagnosis to make and is often a retrospective one. And I think it’s really important to note that it tends to differ from typical depression. You know, it has hallmarks of paranoia, cognitive difficulties and irritability. It’s not necessarily that deep, constant melancholy or anhedonia of the traditional clinical depression that we see. And perhaps that’s in the case of Monica, why she was admitted to a psychiatric unit and ultimately, given the diagnosis of bipolar disorder. A woman’s neurochemistry is significantly affected by a drop in oestrogen and progesterone around the perimenopause, such that it can manifest as lack of emotional filter or disinhibition. A short fuse or rage is what patients will often say. Dr Jayashri Kulkarni is a professor at the Monash Alfred Psychiatry Research Centre in Melbourne, and she’s done a lot of work in this area and she actually states that menopause occurs in a woman’s brain before the rest of her body, and psychological symptoms can sometimes predate physical symptoms by 4 to 5 years. So Monica really, truly was at breaking point at the time she was deemed psychiatrically unstable when she was admitted for menorrhagia and then found herself in a psychiatric unit. We know that women who have either postnatal depression or severe PMS or PMDD tend to have a high risk of menopausal depression as well, Lauren. And certainly, in Australia GPs are very good at treating anxiety and mood disorders. And so a lot of patients do find that they are given antidepressants for menopausal depression and these can certainly help to some degree and sometimes both HRT and antidepressants are needed in certain cases. But most often, however, women who are treated with the correct dose of estradiol notice a marked improvement in their mood, their cognition, the overall function and enjoyment of life and addition of testosterone, whilst it’s only licensed for hypoactive sexual desire, also needs to be titrated to the correct dose as well, as it can also have a profound improvement in terms of cognition, drive and energy. It’s interesting, Lauren, to note that the only licensed testosterone cream for women, Androfeme, is actually made right here in little old Perth!

Lauren Redfern [00:28:34] Yes, yes it is!

Dr Sunita Chelva [00:28:34] Yes, it is. And sadly, I see a lot of clinicians are even more reluctant to use it with their female patients than oestrogen and progesterone, and it may even have more benefit than previously thought. So Professor Susan Davis, also from Monash University published findings from the ASPREE study, which was in the Lancet Healthy Longevity Journal, which showed that for women over the age of 70, having low testosterone actually doubles the risk of a cardiac event, which I think is fascinating. So maybe it’s…

Lauren Redfern [00:29:08] Wow that’s interesting.

Dr Sunita Chelva [00:29:08] Yeah, maybe it’s more far more, you know, far more beneficial than we previously thought. And it’s a very overlooked female hormone as well.

Lauren Redfern [00:29:15] I completely agree, as this is findings of my research.

Dr Sunita Chelva [00:29:18] That’s right this is what you do so.

Lauren Redfern [00:29:20] Well. I mean, I think what’s so interesting with testosterone is we talk about it being that it’s used, you know, primarily to help with libido. And that evidence for it being related to cognitive function is anecdotal that we don’t have any good data. But so many women I speak to, so many women that report, the addition of testosterone as being the moment they saw the biggest improvement which is fascinating.

Dr Sunita Chelva [00:29:42] And I like to say that it is another piece of the puzzle. You know, it’s just, as we talked about hormones being so intricate and such a delicate balance. And this is just another part of it. And again, not every woman needs it. Not every person may benefit from it, but it is something to think about and not forget.

Lauren Redfern [00:29:58] Yeah, definitely. I wondered if you have any best practice advice. I mean, the work that you do at WOME and beyond is interesting and I love that the practice takes this holistic approach. And I wonder you know, you yourself if you have any best practice advice for GPs coming into contact with patients, presenting with perimenopausal, menopausal symptoms.

Dr Sunita Chelva [00:30:19] Yes, I would say Lauren my best practice advice to GP’s, particularly coming into contact with perimenopausal or menopausal people would be to listen! It’s just really a matter about stopping, trying to listen to the patient’s agenda. The first step for a perimenopausal or menopause a woman is to be validated I think, you know, it’s not women are not these hysterical creatures of yesteryear. They’re not suffering from climateric insanity with their heads in their wombs.

Lauren Redfern [00:30:51] Yes.

Dr Sunita Chelva [00:30:51] You know, the other thing to do is to consider perimenopause or menopause as underpinning any possible ailment presenting to you. I mean, as Dr Sarah Ball encouraged us in one of your other recent podcasts, modern HRT is safe with robust scientific backing. And, you know, we need to think about the fact that there’s no harm in giving it a try. There’s no harm in seeing if it does make a difference to a woman’s life, whatever she might be presenting with, once you’ve obviously ruled out the obvious. And, you know, modern HRT might be looked at in the future as a necessary preventative for many major conditions, such as cardiovascular disease, osteoporosis and dementia. I mean, these are the reasons that women certainly in Australia and over the world are dying and so we need to think of it in that light as well. Education is really important and as we said, perhaps the universities are falling behind. I think they’re starting to teach this as part of, I think GP training. We know in some of the universities as well as at a medical student level, but postgraduately, you can certainly educate yourself as a GP by completing courses like the Newson Health’s Confidence in the Menopause course. In Australia there’s lots of e-health courses on the Jean Hailes website or the Australian Menopause Society and sometimes just coming across one of these well-informed and well-read patients like Monica, can actually trigger your own drive for knowledge. I often I learn so much from my patients and there’s nothing wrong in saying that. I think if you can’t stomach menopause medicine for some reason, that’s okay. You just need to seek out a good women’s health GP for your patient and direct her there. One of my favourite quotes I just wanted to share with you, but it’s actually by Jane Hales, who was actually the first women’s health GP in Australia, and she said that if a woman is in good health, her family, community and the society around her also benefit. So we owe it you know as clinicians, not just in Australia, we owe this to our female patients in Australia but across the globe really, you know, to have that point of view.

Lauren Redfern [00:32:58] Well, absolutely. And it’s lovely as well to be able to join by somebody, by yourself all the way from Perth, which is demonstrating how we are really sort of globally learning and connecting from one another. I like to end these podcasts really by asking our guests if they have any particular take home messages they’d like to emphasise or stress to those listening really from our chat today.

Dr Sunita Chelva [00:33:18] Well, mine are very simple take home messages Lauren. It’s really to have an open mind as a clinician. Medicine is constantly changing. We have to change with it. Always beware a woman presenting with depressive symptoms, particularly in that perimenopausal and menopausal age bracket, which can be wider than we have previously thought, because they may in fact have oestrogen deficiency. So it’s just really worth keeping that in the back of your mind. I think a lot of what Monica suffered can be prevented. And even if you don’t know what to do, if you can just as I said, validate people and be able to direct them on the right path. It would save a lot of heartache and a lot of trauma.

Lauren Redfern [00:33:59] Absolutely. Thank you so much for joining me today. I think it’s been such an illuminating conversation and it’s so lovely to have you on the podcast. I hope that you’ll come back and join us again soon.

Dr Sunita Chelva [00:34:08] Oh, I’d love to. Thank you, Lauren, for this opportunity. Thanks a lot.

Lauren Redfern [00:34:14] We would love for you to join our collective of professionals passionate about the menopause visit and each menopause society.org to become an associate. You’ll receive regular webinars and advice from our experts as well as opportunities to network and connect with the latest research from around the world. You can follow us on twitter at @NHMenoSociety. And don’t forget to tell your colleagues about the Newson Health Menopause Society.

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