Podcast Episode 3: The role of hormones in the treatment of Long Covid with Dr Sarah Glynne and Dr Paul Glynne

In comparing notes between patients, married practitioners Dr Sarah Glynne and Dr Paul Glynne became intrigued as they noticed cross over between reports of certain symptoms in their patients. NHS GP and Menopause specialist Sarah was coming into contact with perimenopausal patients concerned that they may be suffering with Long Covid. In tandem, husband Paul – a general practitioner based at University College Hospital, was progressively seeing more patients suffering with Long Covid.

Whilst Sarah and Paul may be found guilty of ‘taking their work home with them’, their findings in doing so, were arguably worth the offence. In comparing notes on patients, the couple came to the realisation that Long Covid symptoms and perimenopausal symptoms, were often indistinguishable.

In this third episode of the Newson Health Menopause Society podcast, our host Lauren is joined by Sarah and Paul who discuss their observations and share insight into the work that they are both independently undertaking. This includes fascinating insights into Dr Paul Glynne’s current work that is exploring possible interventions and treatments for Long Covid sufferers. Paul highlights his observation that HRT is currently, one of the most effective interventions in alleviating symptoms in the right patients that he has observed. 

Podcast Transcript:

Lauren Redfern [00:00:06] Welcome to the podcast for the Newson Health Menopause Society, a multidisciplinary 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] While breathlessness and chest pain may not immediately make us think of perimenopause or menopause. Some of the following symptoms may sound more familiar: brain fog, difficulty sleeping, anxiety, palpitations. These are all symptoms that have been reported in association to Long Covid. And arguably it begs the question, ‘Is it Long Covid or is it menopause?’

Lauren Redfern [00:01:26] I wanted to start today by sharing a story from a patient who’s been struggling with Long Covid. Presenting her experiences in her own words, her account describes how her untreated, perimenopausal symptoms significantly worsened after contracting COVID-19. She says, ‘I’m 48 now and had already been experiencing worsening perimenopausal symptoms since my mid-40s. I’ve been turned away by various GPs in the last few years regarding these symptoms, stating I was too young and had regular periods so couldn’t be perimenopausal. I eventually started taking HRT in January 2021, and after a nine-month battle with Long Covid symptoms following my COVID-19 experience in March 2020. Almost instantly my symptoms of anxiety and depression went away. I started sleeping better with no night-time waking, my regular hormonal migraines stopped, I didn’t need to go to the loo all the time, and my mood is more stable throughout the month. My memory has improved along with my ability to multitask, and my desire for sex has come back and the pre-period skin itching I would have has stopped. My aching hips and knees no longer ache, and relationships with my family have greatly improved. Basically, I can cope with life again’.

Lauren Redfern [00:02:39] I wanted to share this story because I think it demonstrates the interplay and intersection that can be observed between some Long Covid symptoms and our hormonal health. And I think it encourages us to think about and appreciate the relationships that exist and should be encouraged between arenas of medicine. I’d like to introduce Dr. Sarah Glynne and Dr. Paul Glynne – yes, they are married, and whilst I would love to know more about those dynamics, I promise I will keep it Covid related – who are here to help me shed light on the complex interplay between Long Covid symptoms and our hormonal health. Hi Sarah and Paul, would you please be able to introduce yourselves and tell us a little bit more about your background in medicine and your interest in this particular topic?

Dr Sarah Glynne [00:03:20] Hi, I’m a GP, but expressed an interest in the menopause. I work in the NHS and I’m due to start working privately from January. My advice, especially special interests, are Long COvid, as well as menopausal treatment of women with breast cancer. I also have a master’s degree in allergy and immunology, which overlaps nicely with some of the other things I’m interested in. That’s where I’m coming from.

Dr Paul Glynne [00:03:43] I’m Paul Glynne. I’m a consultant physician at University College Hospital in central London and have developed a Long Covid clinical practice through our independent practice at the physicians clinic, where we have several physicians across different specialties working on Long Covid and have developed alongside our clinical practice a research programme trying to understand the mechanisms underlying Long Covid and the recently published work related to some of the aberrant immune responses to Long Covid and some interesting observations around novel repurposed treatment approaches to Long Covid.

Lauren Redfern [00:04:24] So obviously, I shared that story to start with from a patient’s own experience, and I think it is nice to hear from patients in their own words. And I think what I draw out from that and want to get your insight on is the overlap that can be observed between some Long Covid symptoms and perimenopausal and menopausal symptoms. And I wondered if you could talk us through that a little bit because particularly from my perspective, I think what I notice is there’s overlap. So how would one distinguish between which is one, which is the other? And how do these two intersect and interplay? And I’ll leave it to the two of you to decide who responds in that.

Dr Sarah Glynne [00:05:08] There’s lots of emerging evidence that hormones have a role to play in COVID, both in acute COVID infection, as well as in non-COVID. We’ve known from early on in the pandemic that men are more likely to get severely ill with COVID and they’re more likely to be admitted to ITU, and they’re more likely to die. And then there’s some interesting observational evidence with acute COVID that also shows that HRT has a protective effect. There was one large UK based study done in Oxford that looked at 5500 cases of women with COVID and found that HRT significantly reduced the risk of mortality in postmenopausal women who were taking HRT compared to postmenopausal women who were not taking HRT. And similarly, there was a large multinational study that retrospectively looked at the electronic health records of about seventy thousand women in different countries. And again, they found that HRT reduced the risk of death in postmenopausal women by 50%, compared with postmenopausal women that weren’t taking HRT. So from quite early on, we’ve known that there may be an influence of hormones. Many women after and during the acute COVID infection, and afterwards noted that their periods were changing. And for most women, that seemed to be a transient change, and for lots of women their periods did return to normal, but not always.

Dr Sarah Glynne [00:06:25] And then when we come onto Long Covid, there’s really not much evidence out there at all at the moment about Long Covi. We know that women are more likely to get Long Covid than men. One study found that women between the ages of 40 to 50 are the group most likely to get Long Covid and twice as likely to get it compared to men of the same age. And one of the issues that you allude to is that the symptoms of Long Covid and the symptoms of perimenopause and menopause, and in fact similar muscle activation syndrome, they all overlap. They affect multiple organ systems and fatigue, brain fog, post-exertional malaise, headaches, aches and pains, palpitations. There are lots and lots of symptoms that could be attributable to either Long Covid or to perimenopause and the menopause or possibly to muscle activation syndrome. And it raises the question as to how on earth do we start teasing out who’s got Long Covid? Who’s got menopause? et cetera. We know that menstrual changes are common as well in Long Covid. There was one large study published in The Lancet that looked at about 200 odd different symptoms in Long Covid sufferers. And in that study was one of the few studies that I’ve seen that’s asked women about their periods. About 36% of women reported that their periods had changed. Interestingly, 3% of women reported an early menopause [their periods] stopped altogether. And other than that study, the only other data really that’s out there is the data that Louise Newson has gathered. She’s surveyed the people that are using her balance app, and she’s done two surveys that I know of and one of the survey’s 73% of women with Long Covid recorded a change in their periods. Whereas in the other survey, I think 50% of women reported changing their periods and only 84% of these returned to normal. So, most of the evidence at the moment is observational. There certainly seems to be an association with periods and estrogen deficiency, but really, we have no randomised controlled trials. Then we have no good quality evidence that’s delved into that any deeper to try to work out whether this is just an association or whether it’s a cause, and it’s obviously very complicated.

Lauren Redfern [00:08:30] Absolutely. And to follow up from that, you mentioned the survey that was conducted by Newson Health that included responses, I think it’s from 460 women.

Dr Sarah Glynne [00:08:40] That’s right.

Lauren Redfern [00:08:41] And one of the measures I saw in that was that out of those 460 women, 84% reported not being asked about perimenopause or menopause when discussing Long Covid, and that there was no advice or support provided on or around hormonal health. And I wanted to really ask you both what your thoughts were on this. And I suppose coming a bit to what you’ve alluded to, Sarah, that there perhaps is a lack of interest or support around research that is exploring these correlations and connections.

Dr Sarah Glynne [00:09:18] Yes, absolutely. So as I said, when I was looking for evidence about the role of estrogen in Long Covid, as I said, there’s very little out there. There’s been some really big reviews of symptoms published in places like The Lancet and The BMJ and Nature. And as I said, the only one I found was the one that was published in The Lancet, which included questions about periods in their findings. There’s definitely a lack of awareness.

Dr Paul Glynne [00:09:41] I think, in terms of the existing Long Covid services. It is true to say that up until recently, there was a lack of awareness across the board in terms of Long Covid clinic provision. We know because UCL has been so prominent in the field and have been an early adopter, if you like, in terms of Long Covid clinic services that they are the only group to have published high quality observational data. So we know from the data, which is now clearly to some extent historic, because of the timeline to publication, that there was clearly a lack of awareness about the relationship between perimenopause and Long Covid symptoms. So I don’t think that had been included at the time, but I think there certainly is now. So I think the emerging observations in the work that’s done by Louise Newson, Sarah, other colleagues who are interested in the area is raising interest in that. And I certainly know I have other contacts in the NHS who are running Long Covid clinics, for example, in the community who are definitely including that in their questioning. So it’s changing. But to put into context, you know, this is an emerging field. It’s very much in its infancy. And so we’re still at a very early stage in understanding the nature of the condition. And to date, most of the work is narrative and its observations around clinical presentations. And that’s all we’ve got. And in terms of observations, I can identify from our work, which again, is observational. What we’ve seen would certainly be consistent with what Sarah said, is that approximately 75% of the patients who are referred to the physicians clinic, Long Covid service, are women and about 70% of those women are between the ages of 40 and 60. So perimenopausal age women are disproportionately affected by long COVID.

Lauren Redfern [00:11:43] And I wonder whether you could tell us a little bit more about the possible links between estrogen deficiency and Long Covid symptoms. And I suppose if I can ask you to explain this in a little bit more in detail for those who may be unfamiliar about how those conditions may be related, how that may relate to Long Covid, or why we think there may be an association. And obviously, as you said Paul, at the moment, the data is observational. But nevertheless, it is a very interesting observation to see such a high majority of women in that age group and category being referred for Long Covid symptoms.

Dr Paul Glynne [00:12:19] Definitely, that group are disproportionately affected by Long Covid. They are poly-symptomatic. And what I’ve seen in the clinic is that in terms of symptoms, patients often present with a relapsing and remitting fluctuating course, which is punctuated by repeated symptom flares, which are triggered by certain consistent factors across the board, and in women particularly, hormonal factors play an important part. So in fact, in premenopausal women, it is extremely common for women to report very significant fluctuations in Long Covid symptoms which are cyclical, and in perimenopausal women we know that not only is that group predominant, but in fact the observations that when you treat patients with HRT, many patients report an improvement in some of their symptoms. I mean, there are a number of other factors and from work that we’ve done, we have this consistent approach that all patients have a number of barriers to their recovery. So we see that these barriers to Long Covid recovery are the same factors that cause repeated flares. And they’re factors like sleep deprivation, stress, overworking, overexertion, poor gut health and particularly in this group of women, their hormonal health. So I do think that the observations would support a very important link in that group in terms of the mechanism. I think that’s more Sarah’s field, so I will defer to her on that, although we’ve had some interesting conversations about it. But I think Sarah’s got a much more in-depth knowledge about the putative mechanisms. And what I can add is some of the benefits of the observations of treating, you know, quite a significant number of Long Covid cases.

Dr Sarah Glynne [00:14:08] So I mean, I think the first thing to say is that obviously as yet, the underlying aetiology pathogenesis of Long Covid has not been established and there are lots of possibilities being floated about and we don’t actually know what’s causing it. And the other complicating factor is that Long Covid is probably an umbrella term that includes several different phenotypes or symptoms of patients. So, for some patients, estrogen deficiency and hormonal factors are probably quite important. Other patients, there might be problems with their clotting or autoimmunity or infection, or perhaps intensive care type syndrome. There are lots of factors coming on and probably these overlap in many patients. So, we don’t know what’s causing Long Covid in terms of estrogen deficiency, how that might be having effects, we’re certainly observing as Paul was saying, but it seems to be implicated in the aetiology, and HRT seems to be benefiting a group of women with Long Covid. We don’t know how that might be affecting the immune system, ultimately causing Long Covid. We know that estrogen has lots of effects on the immune system. We know that there are estrogen receptors on many cells in the immune system. We know that immunomodulatory properties. We know, for example, that the ACE2 protein, which is the protein that the SARS-CoV-2 virus binds to get into the cell, is highly expressed in the ovary as it is elsewhere in the body. And so it’s obviously quite plausible that in the same way that the virus is getting into the lungs, getting into the heart and getting into the brain, if you’ve got the receptors on your ovary then it’s presumably getting into your ovary as well, and in premenopausal women, as I say, often their symptoms generally seem to recover. We are wondering whether in perimenopausal women who are coming to the end of their reproductive life, perhaps the ovaries are more vulnerable to an assault, which they might not recover from. So I think from what I am seeing in several groups of patients in the menopause clinic, and one is where obviously the ovaries are affected the same the same way that other organs in the body are affected. And so, they’re getting lots of different symptoms because some of those will be attached to estrogen deficiency. But then I think what I’m seeing sort of several months down the line is perhaps that when those other Long Covid symptoms have recovered or improved, their ovaries haven’t recovered. And so they’re coming to me with predominantly perimenopause and menopausal symptoms that they are attributing to Long Covid because that’s what caused it in the first place, it’s possible that if they hadn’t had the virus, they might have not become menopausal quite so early or it might have been more gradual or their symptoms might not have been quite so bad because they’ve had this acute insult to their ovaries to develop very quickly. And that’s why, as I say, that a lot of their other symptoms are breathlessness, headaches, palpitations. Some of those symptoms are settling down by the time they see me in a menopause clinic, but we are left with perimenopausal and menopausal symptoms.

Lauren Redfern [00:17:15] I mean, I think what’s interesting about this as well, and part of the reason I wanted to provide the patient example to start with is I think you mentioned earlier, Sarah, that the majority of those diagnosed with Long Covid are somewhere between 40 and 60. So it is a proportionate group that would fall into that category. And the patient in that example explains that she wasn’t able to use HRT that her GP had said, ‘You’re too young to be perimenopausal at this stage’, but that when she started using HRT, what she terms ‘perimenopausal symptoms’ went away or drastically improved and demonstrates the benefits that were made possible to her quality of life by using HRT. But I think in relation to management strategies, and I think you’ve both alluded to this and talked a little bit about it is I’m trying to think of a better way to describe it, but it almost seems a bit chicken and egg. Which do you go about treating first and how do these interplay? So, from a clinical perspective, if you are coming into contact, let’s say with a woman that falls into that 40 to 50 demographic that very well may be perimenopausal, how would you know that point to say, ‘What do we treat first?’ When so in the case of someone that is struggling with breathlessness, but also some of these symptoms that you mentioned, Paul, as well sort of disturbances to sleep, disturbances to gut. Is it a case of drawing them apart and thinking we take an approach one way to the Long Covid breathlessness and perimenopause or the other way? Or how would you advise from a clinical perspective going around that?

Dr Paul Glynne [00:18:49] Well, I think that you have to take a holistic approach to every case. Absolutely. And it’s very difficult to dissect out, which is the predominant contributing factor to a patient’s symptom complex. There will be a small number of patients who in fact are predominantly perimenopausal and may not have Long Covid. Although my experience of the patients that are referred to my clinic, that is unusual. I think it’s more plausible, as Sarah has alluded to, that COVID infection accelerates the perimenopause and that perimenopausal hormonal perturbation is a driver for Long Covid symptoms, which are driven by inflammation, which affects many different organ systems. So as a starting point, what I’ve seen is that a consistent approach by treating these barriers to recovery allow the patient a greater chance of having an accelerated recovery rather than what we see in patients who are untreated, where they recover very slowly and often are symptomatic for, you know, 18 months and longer with debilitating complex symptoms. So from a perimenopause perspective, I see that as an integral part of management in that group without which I don’t think they will make a good recovery because I’ve seen within our observational work around treatment interventions. So, in our case, our trials of repurposed antihistamine therapy, it seems unlikely that that will be successful in women who are actively perimenopausal because the hormonal disturbances are a significant barrier to their recovery, as are significant stresses, over working, overexertion, etc. So, I think it’s an integral part of the standard of care for that group of women.

Dr Sarah Glynne [00:20:49] Obviously, I agree with Paul, my view on it is that, you know, HRT is very effective at treating symptoms of estrogen deficiency. It also has long term health benefits. We’ve talked about this all the time – it halves the risk of cardiovascular disease and osteoporosis, et cetera, et cetera. It’s a very safe treatment. It’s pretty inexpensive. It’s easy to prescribe once you’ve been taught how to prescribe. And my take on it is that I think it’s well worth at least a trial in these women to see if HRT is going to benefit their symptoms because if it does, it will improve their quality of life. It will reduce their symptoms burden and they’ll feel so much better. And then also it becomes easier to see what’s left behind. So, for example, if somebody is presenting with migraines or headache, you don’t know when you’re looking at them in your clinic whether that could be due to estrogen deficiency or whether it could be due to an effect that COVID has had directly on the brain. We don’t have an alternative treatment at the moment for Long Covid. But if you give women HRT, if their migraines get better, you know it was probably caused by estrogen deficiency and you’ve helped that person. If they’re migraines, don’t get better, then you might start looking at other management strategies, you might need consultant neurologist, etc. So I think it has so many benefits and there are no alternatives why not at least give it a go because it can really help.

Lauren Redfern [00:22:01] And I mean, I honestly could talk about this for hours with you, Sarah, because I think there is something very interesting that I would say from my own research, I have observed around a hesitancy when it comes to using hormonal treatments in a capacity, exactly as you say, simply to trial, simply to see, do we see an improvement? But there seems to be a real, maybe not unwillingness, but reservation around using hormones in that manner on a trial capacity.

Dr Sarah Glynne [00:22:30] Yeah, I think a lot of women feel that if people start talking about their hormones or their menopause, things that they feel are being dismissed, which is interesting. I don’t know why that’s the case, but I think by raising awareness, that Long Covid or COVID sorry is having an effect on women’s hormones and it’s, you know, maybe having all these other effects as well. But it’s just something really safe and easy that we can do to try and tease out what’s due to estrogen deficiency, what’s due to other effects of Long Covid. And it just obviously will reduce symptoms of estrogen deficiency anyway. And then it just makes it much easier to see what’s left behind that may require alternative management strategy, such as what Paul has been looking at with the antihistamines and other options.

Lauren Redfern [00:23:15] Absolutely. So, I will just move on that if that’s okay, Paul, to the work that you’re doing at the moment, developing a standard of care that includes antihistamines, could you just tell us a bit about that and what that standard of care looks like and the research that you’ve been developing?

Dr Paul Glynne [00:23:29] Yeah. So, our standard protocol for treatment has really emerged over the last 18 months through the observation that I and others have made. And that includes the work and the link between hormonal changes and Long Covid sufferers. And so, the conversation I have with every patient I see with Long Covid is really very similar because in the absence of high quality, randomised clinical controlled trials, I think there’s a duty on us as clinicians to make very rigorous, carefully audited observations. And if you adopt the same approach to every single case, it means at least that the observations that you’re making are all good quality. And I think you can therefore use those observations to ask more interesting questions that involve drug treatment trials and the ability to get funding to do those. So, I think that’s why we’ve taken a very consistent approach around the standard of care. It’s really very simple, and it really involves looking at from the start about the initial natural history of Long Covi. So all patients present with multiple symptoms, men and women. And if you track those patients without any intervention at all, we know that their recovery is extremely slow, particularly in the group that were not hospitalized – so, which seems to be a distinct group compared to those who were in hospital with acute COVID pneumonia. So those with relatively, mild illnesses who are non-hospitalised if you track what happens to them over time. Unfortunately, the majority of those patients remain polsymptomatic with debilitating symptoms. They are typically of working age and often are too unwell to go back to work. And it can be devastating from both a professional socioeconomic perspective as well as the health impact. And so, if you follow them and it’s imagine that a graph and recovery of symptoms mapped out against time, we see that 6 months, 12 months, 18 months, 2 years we’re coming up to for some people, they can remain very symptomatic. So, if you imagine that that slope of that recovery curve is very shallow, and then what we’re trying to achieve is to change the shape of that curve so that we can facilitate a faster recovery.

Lauren Redfern [00:25:53] Yes.

Dr Paul Glynne [00:25:54] And there are two approaches to doing that. One involves treatment interventions, which are basically designed to push the curve down. And then there are those strategies which are designed to removing barriers to recovery, which are stopping the slope of the curve go down. And there are a number of barriers to recovery, which I’ve mentioned already. But for my observation, those are actually far more potent than actually any of the treatment strategies available. So, if you don’t address those barriers to recovery, it seems unlikely that the treatment interventions will have a major effect or at best, it will be short lived because those barriers to recovery are a potent stimulator for symptom flares, so people recover transiently. And if you don’t treat the barriers, they simply get worse again. And in course those key barriers again, I’m sorry to sound like a broken record, but it is the same from all the reports to sleep disruption, any mood changes, to severe stress, anxiety, depression, which itself actually is an integral part of Long Covid in terms of some of the autonomic dysfunction which can actually drive anxiety. Patients who overwork, so cognitive exercise, patients who overexert so physical exercise, and the number of stories I’ve heard from people who’ve had a relatively mild COVID illness who, you know, go straight back to work or straight back to the gym and within about two or three weeks have suddenly crashed with severe symptoms. It’s a very all too common story. Of course, there’s no actual public health guidance about what to do in terms of recovery. It’s all about avoiding COVID, but it’s not about what you do and try to avoid getting Long Covid. It doesn’t really figure in the guidance. And of course, I think that hormonal changes are a major barrier to recovery as well. And one of the things I found in women where you look at that graph and you look at the barriers, if you include hormonal disturbances as an integral part of this treatment strategy as part of that holistic package, I think most patients are extremely receptive to trials of HRT because they understand that estrogen deficiency or fluctuations in estrogen may well be a major driver for the underlying inflammation.

Dr Paul Glynne [00:28:14] And just on that, on the mechanistic factors in why patients have got this in the first place. The work that we’ve done is again in small numbers. But so we’ve published on this fairly recently, but we now have a significant increased number of patients and the observations are the same and we’re going to be writing those up. But we know that there’s an aberrant immune response in those patients who get Long Covid, because when we look at the immune profile of patients who have a mild illness but completely recover, it is quite distinct. So, we’ve identified a distinct and tangible difference in immune profile of Long Covid sufferers. So, what we think is that downstream of that is an apparent inflammatory response, and there are fascinating emerging observations about how that might affect people. So that could be an inflammatory response effects in this particular case, you know, ovaries and hormonal production. It may affect a tiny blood vessel, so you get endothelial small capillary blood vessel inflammation leading to abnormal coagulation. And there’s some really interesting work that’s going on at the moment, which is very topical, and there’s a lot of interest around that. So, we’re beginning to put the pieces together of how this might emerge. But the hormonal intervention is a key factor, I think, in preventing those recurrent relapses.

Dr Paul Glynne [00:29:41] And then moving on from that in terms of treatment interventions. What we observe right at the beginning was that there are a number of patients who reported both after infection and interestingly then after vaccination. What we would consider normally to be abnormal, almost like allergic reactions – they get rashes, unexplained rashes, itching of the skin, runny noses, irritation of the eyes and many patients report food intolerances, or they become alcohol intolerant. And many of those symptoms are very reminiscent of what people who describe who have so-called Marcell activation syndrome.

Lauren Redfern [00:30:17] Yes.

Dr Paul Glynne [00:30:18] And so that’s what led to the empiric therapeutic trials of antihistamines. And what we found is that using a combination of antihistamines that block the H1 histamine receptor and then block the H2 histamine receptor, but not only did some patients report an improvement in those histamine allergic symptoms, but we had a number of patients who also reported that they had an improvement in their broader symptoms, for example, fatigue and brain fog. And over a 12-week treatment trial, we observed a 70% reduction in symptom burden in our patients, which is actually a sustained observation as we’ve continued out longer and increasing the numbers of patients treated. So that’s a really interesting observation, and that’s the one that we’ve been focused on recently and was the subject of the work that we published. Interestingly, what we didn’t see is any effect on autonomic dysfunction, which I think the mechanism of the underlying autonomic dysfunction is slightly different. It’s certainly been very helpful. But interestingly, using that strategy in perimenopausal women who are not on HRT, I think is much less effective than those who are on HRT. So, I think it’s a sort of multi-pronged strategy, but that is broadly the standard of care that we’ve adopted in our patient group.

Lauren Redfern [00:31:49] And it’s fascinating. And you can read more about Paul’s work, it has been published recently, and there will be provided links so if you’d like to read more and the published article, you can. I think that leads me really to what I’d like to finish on – a question really for you both, and apologies because there’s so much more that could be said. But I suppose it’s a broad question, a general question, really, which is what advice you may have for best practice when it comes to those coming into contact with patients presenting with Long Covid symptoms. So that may not be a GP or a clinician, maybe a nurse or a physiotherapist, or somebody coming into contact with someone that’s presenting with Long Covid symptoms. How they can think that through?

Dr Sarah Glynne [00:32:29] Yeah. I mean, I think really, obviously from my perspective, it’s in women who may be anywhere between the age of 35 to 60 to think about whether hormonal deficiency could be playing a role in their symptoms and to really encourage women to go and see a GP if they haven’t seen a GP already, and perhaps download the balance app, start thinking about it for themselves, start looking at their symptoms which may be accepting that the COVID virus is obviously having an effect on this in some way that we haven’t yet determined. But the good news is that if you’re in this category, that HRT is a really effective treatment that will probably really help your recovery. And in some way, we’re lucky because I noticed that the men who did it tend to be more refractory to treatment, and I don’t know if that’s because in women we have this tool, but we can’t at the moment for the men, which is HRT and as I say worst case scenario, if it doesn’t help and you don’t want to continue with it, then you don’t have to. It’s not irreversible, everything can be reviewed. You know, think about the testosterone, but that’s what I would think.

Lauren Redfern [00:33:34] Absolutely.

Dr Paul Glynne [00:33:35] And my thing is to everybody who comes across it – the first thing is that this is really a major problem for our society. You know, there are a million plus sufferers. It’s an ongoing, relapsing, remitting, debilitating illness with many complex presentations. And I think it’s reasonable and it’s OK to say we don’t really understand what’s going on. We don’t know enough yet, but I think the key is to acknowledge the symptom presentation, to listen to patients. And I think too many people are reporting that they’re being dismissed by healthcare professionals, and they’re not being taken seriously. And it’s one of those conditions, which is because we don’t understand it and because at the moment, the resolution of many of the tests that we do is just simply insufficient to identify the problem. But we know if you look in the right places, there clearly is a major problem that doesn’t mean that this isn’t a major illness. And I think that’s the first thing. And what I found is that if you listen to people and you provide them with a framework on which to manage their problem, that is actually the first step it can be hugely helpful because one of the issues is, imagine if you or I suffered with an illness that presented with multiple debilitating symptoms, you couldn’t go to work. Nobody seems to understand what the cause is, nobody knows what the outcome is going to be. I mean, that is pretty alarming for an individual and that in itself is very distressing. And I think just by having a strategy, a consistent strategy to help people manage their illness is a hugely important step. And within that, it’s taking that holistic approach and also being open to exploring other new treatments, other new avenues and having an open mind. And I think that’s really important. And I look at colleagues across the globe in the US, South Africa and what’s going on in Germany. There is definitely where you see that clinicians are just a bit more lateral thinking, a bit more open minded and willing to explore with their patients other potential treatment options. The patients are very keen to get involved, even if there’s a big patient lobby who’s done more actually to advance Long Covid work and research than probably the medical profession. And so, I think that it’s incumbent on all of the sort of healthcare practitioners to make sure that they have an empathetic, sympathetic and open minded approach to managing this really significant problem. And that’s the key.

Lauren Redfern [00:36:12] Yeah. And I think, as Sarah has emphasised in what she’s said as well, is that there are actually health benefits linked to HRT. You know, we know that there are improvements that can be seen with cardiovascular health. We know that HRT has health benefits. So in that sense, whilst I’m sure there is still remaining stigma regarding use of HRT, as you say, it’s not like you can’t try it and stop it if it doesn’t work for you. So, I think it brings into that creative thinking around and holistic thinking, as you say, Paul around how to approach your patients care.

Dr Paul Glynne [00:36:46] And actually some of the patients Sarah and I’ve looked after, you know, we really have to say if all the interventions that had the most dramatic effect in terms of improving symptoms and quality of life, I have to say, but I think the hormonal interventions are certainly, you know, the most significant in that group.

Lauren Redfern [00:37:04] I’m really sorry. I’d love to keep talking, but we have to leave it there, I’m afraid. But I want to thank you so much for both spending this time with me. It’s been fascinating to hear about your experiences and the work that you’re doing, and the take home for me, I think, is clearly that more research is needed to understand these links between Long Covid symptoms and the possible interplay with our hormonal health. Were there any takeaways that you both wanted to emphasise to those that are listening?

Dr Paul Glynne [00:37:32] I think we probably have made a few points, but I think for patients, you know, they should never feel that they don’t have access to information, help and advice. And I really think that again, it’s really about the approach to the healthcare community acknowledging the severity of the problem.

Lauren Redfern [00:37:49] Absolutely.

Dr Paul Glynne [00:37:49] But I think podcasts like these and the work that other colleagues are doing, just raising information awareness of and providing useful information like this allows patients to then also are empowered to go to their own doctors and say, ‘You know, this is really interesting. I’ve seen this, you know, these are the reports’. And I think good doctors and good nurses you know, who are open minded will look at the literature themselves, will listen to the stuff themselves and learn about what’s going on. And I think those that do that tend to have the best results, but I think that would be my key message.

Dr Sarah Glynne [00:38:22] Yeah.

Lauren Redfern [00:38:26] Well, thank you both so much, and I’m sure we will speak again soon. Thank you.

Lauren Redfern [00:38:33] We would love for you to join our collective of professionals passionate about the menopause visit NHMenopauseSociety.org to become an associate, you will 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 @NHMenoSociety. And don’t forget to tell your colleagues about the Newson Health Menopause Society.

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