Dr Louise Newson: [00:00:01] So Mary, it's great to have you on my podcast. You are in South Africa, so we're doing this remotely and you're a doctor who's as passionate as I am in helping women to feel better and to live better, healthier lives by having hormones that so many of us want. So thank you for coming today to the podcast.  [00:00:21][19.7]
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Dr Mary Atkinson: [00:00:22] Absolutely. Thanks for inviting me. It's a great opportunity.  [00:00:24][2.2]
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Dr Louise Newson: [00:00:26] Well, we've known each other a little while and you've been brilliant because you came, you've come to some of our education events, you came to the last one in March, and you know your thirst for knowledge is great because you learn from your own experience, but you also learn from patients all the time. So tell me a bit about you and what your background, if you don't mind? [00:00:48][22.9]
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Dr Mary Atkinson: [00:00:50] Yeah, thank you. So I did medicine, as in my core degree, many years ago, like 30 plus years ago. And I practised as a GP for a couple of years. And then I was really inquisitive about other sides of medicine. So, I left clinical practice for a while and joined pharmaceuticals. I worked in the pharmaceutical world for a number of years, initially in clinical research, doing research in many different areas, cardiovascular disease, osteoporosis, oncology, metabolic conditions, and then moved across to diagnostics. I worked for Roche for all of that time, and I worked on the diagnostic side focusing on diabetes care. And really understanding for the first time truly the value of diagnostics and how to use them alongside clinical practice to really empower what we need to do or how successful we are with our treatments or whatever aspect. And then I guess through my own journey with menopause towards the sort of back end of my career at that stage got very interested in functional medicine and functional health mostly to try and sort myself out to be quite honest. I was in sort of late perimenopause and I have hypothyroidism and I kind of put everything off to just having a busy career, young kids, I'm trying to do life. Completely sort of missed most of my symptoms, quite honestly, in terms of menopause. Although, I mean, I must say, obviously, I really received very little education in terms of menopause in my core degree. And so no wonder I kind of missed it because I think it's why it's missed in most women. And why most women don't recognise it is that we understand it as a word, which is so meaningless for something that carries such a huge impact on our body.  [00:02:52][122.3]
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Dr Louise Newson: [00:02:53] Well, it's an irony, isn't it? Because I'd love to get rid of that word, because it means nothing. Well, It does mean something. It just means stopping periods. That's completely irrelevant, isn't it?  [00:03:04][11.0]
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Dr Mary Atkinson: [00:03:04] No, and I didn't, I never understood it as the whole process that it is in the body and truly that's actually why, I mean I went to see colleagues at the time and together we just kind of agreed that I was just burnt out and needed a holiday and you know, I just eventually decided that there must be something deeper and so started my functional degree, which really is a systems-based approach to looking at the human body at whether it's disease or ageing or whatever. I had a mum who was this strong woman all her life, the most incredible woman actually, and was diagnosed with Alzheimer's at 80. And she had just been so well and so independent and so strong and watching her just decline in health until... honestly, she actually passed of a fracture, so she actually passed from osteoporosis. So she had this double condition of Alzheimer's and osteoprorosis. My gran lived to 103, so we really didn't think that anything was really going to get her. So it was this combination of me wanting to feel better and just wanting to make sure I did whatever possible not to end up in the same scenario as my mum. That sort of took me into sort of discovering a different part of medicine. And, I think often it's sort of the world tries to play the one side versus the other. Functional medicine is just an extension of conventional medicine. We have a broader toolbox for sure. We do use many different herbal type things or adaptogenic type medicines. But the ultimate goal is when I see somebody in front of me is how do I help this person and how do I look at the things that are affecting her, both from her history, her family history, where she's at, maybe genetically, what's going on, and how do I then frame what I'm going to do and what I am going to give her to help her? And so my understanding of hormone therapy and menopause, well, first of all, about understanding menopause and what is actually going on in menopause, from the fluctuation of hormones to the decline in hormones. And all of them, right? Decline of actually testosterone from our 40s, not actually from menopause, it doesn't have the steep dive off the cliff, it actually declines from a lot sooner. But definitely the rapid sort of decline after this wild fluctuation in perimenopause of estrogen and progesterone and the whole cascade of things that that sets off in the body. And then actually recognising that menopause is a time in our lives where we age more rapidly and it really you know the first thing I always say to somebody or a woman sitting in front of me is that before we decide what to do let's assess where we are because we need to know that it's a time where we really need to be intentional about our health. We need to understand what's going on, what the impact has been of all of these changes that we've gone through. And then we together decide what are we going to do about it.  [00:06:30][205.8]
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Dr Louise Newson: [00:06:31] I think that's the really important thing, isn't it? Let's decide, let's decide together. Let the patient decide, let the patient choose. And it's very different to probably you, but certainly me when I was training as a doctor. The doctor made the decisions, the doctor made diagnosis, the doctor decided on the treatment and the doctor instructed the patient what to treat or how to treat or what medicines. Whereas things have really evolved and patient advocacy is really, really important and choices. And also when you've experienced something, it gives you more fire in the belly. I've said many times before, I know if I wasn't taking hormones, I wouldn't be working as a doctor because my brain had gone. And I had a choice. Do I carry on or do I get hormones? And I've really struggled to get the right dose and type of hormones that I need. And even now I still can't get them from my NHS GP. But it's choice. I choose to exercise. I choose to eat. I choose whether I drink alcohol or not. I choose not to drink alcohol, but that's my choice. And often people, it's really interesting because not drinking alcohol, people immediately think I have had a drinking problem in the past and I haven't. I just, ironically, I was getting palpitations in my 30s, which probably were due to my hormones. And the cardiologist said, give up caffeine and alcohol. And I did from that time. And then I had pancreatitis a few years later, so there's no way I would drink alcohol. So many times I've been out socially and people have said, oh, you sure just have a small glass of wine. Just have a quick gin and tonic. No, I don't want to drink alcohol, but no-one has ever, certainly no healthcare professionals have said oh, go on, just have some HRT, you know? It's like, HRT is the forbidden fruit and there's so much confusion out there. When I say out there, I mean, whether it's in your GP surgery, whether it is in a hospital clinic, whether it's the media, and certainly on social media, you only need to open my feed and you'll be bombarded with, this hormone is good, this hormone's bad. We agree with this, we don't agree with this, this person's great, this person isn't, and actually, how are people supposed to navigate their way through this noise. Because I think it's really hard, isn't it?  [00:08:50][139.7]
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Dr Mary Atkinson: [00:08:54] Yeah, I always... So first of all, I do think that what's really important is precision care and precision hormone care and individualised treatment. And actually, when you read through all of the menopause guidelines, I shouldn't say all because I haven't read them all, but I have read the IMS, the BMS, the North American guidelines, the South African menopause guidelines. So the guidelines very clearly say that hormone therapy is the most effective treatment for menopausal symptoms, and that at least 75% of women actually have symptoms, some of which are really debilitating. I have yet to see a woman that doesn't have menopausal symptoms, I have to be honest, and for sure. I mean, I run a menopause clinic, so I'm sure that I do see women who are specifically struggling with their symptoms. But I don't think a day goes by where a woman doesn't say to me, is it safe? Is it okay? You know, what are the different types? What should I be doing? And so usually we start with where she's at. What are her symptoms? What is her history? Potentially what are her genetics? I often do genetic studies, obviously in terms of APOE4 and other things that may be affecting her. And then together we decide. So I have an approach where I go, they're coming to me because they need to be aware of what's going on. Aware in terms of where they're at and aware in terms of what the data is showing and saying around the various forms of hormones that we can use and how they differ. And then we choose together. Because ultimately the responsibility of following care and doing the best that they can is on them, right. So I have a responsibility to make sure that I am evidence-led and evidence-based and know what's going on. And they have the responsibility to then, as you say, do the exercise, eat well, not smoke, limit alcohol in whatever form that may look like and to take whatever therapy we choose to say. And there's no doubt that, I mean, coming from the side of systems biology, there's not doubt that that estrogen, progesterone, testosterone has huge impact across the body. Genetically, in terms of switching on and off genes, symptom-wise, brain function, heart function, protecting us in terms our immune system, and that's the kind of data that I discuss with my patients. I recently did a presentation to a group of healthcare practitioners and I spoke on the impact of estrogen on the gut microbiome, which of course we know the role of the gut and the gut microbiome is huge. And a gastroenterologist actually came up to me afterwards and he said, thank you so much for that presentation. I've never known that there's an impact from estrogen on the got microbiome. And he said, you know, I see all these women who suddenly have IBS in their late 40s and I, and I just, I'd never really thought about it being menopause. So the impact is profound and it's huge. And that's what I see every day is women with symptoms. And then we discuss what can we do about it.  [00:12:22][207.9]
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Dr Louise Newson: [00:12:23] Yeah, it's so important because once you understand the biological role of hormones in our bodies and our cells and organs and tissues, it is very easy to understand what can potentially go wrong. But somehow like the top line is, oh no, only have HRT if you have hot flushes or you feel really bad or you're a certain age or whatever. And I think talking about brain for a minute is really important because most of us, we're all scared of diseases. We know the commonest cause of death worldwide in women is heart disease and dementia, but we know dementia is increasing in incidence in women and men. Most of us are petrified or very scared of developing dementia. But we know that our hormones work in our brain. We know they help improve our cognition, our memory. It's just fact that our hormones work in this way. And many years ago, Professor John Studd wrote something about, do we need a randomised controlled study to see if HRT prevents dementia. And he said quite clearly, well, actually, no, because some things are so obvious they don't need a randomised controlled study. And actually, it will take so long to do one. We'll all either be dead or have dementia by the time the results come out. And it stuck with me. Because there's so much debate about, we haven't got a study, we haven't got a study. But we have basic physiology. We know how these hormones work. We know that when women don't have hormones, they have an increased incidence of dementia. And as you know, we know nutrition, exercise, everything has a, has a role in preventing dementia, but you've got a first degree relative who's had dementia every day. I'm sure you think about it. So if taking hormones is only a small factor, does that matter? I don't see that it does.  [00:14:22][118.7]
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Dr Mary Atkinson: [00:14:22] Exactly. And I think that because, first of all, because I watched my mum decline, and like she did, and really, you know, I've seen sort of firsthand the impact of Alzheimer's disease. And also because I know that I'm an APOE4 carrier, I make sure that I am aware of any data that is out there. And, I have tried to inform myself as much as possible, Of course. It is multifactorial in terms of what we can do in dementia prevention and exercise and not drinking alcohol and making sure my vitamin D is really great and ensuring that my thyroid is well managed. But of course, metabolically, I think that's where I'm seeing Roberta Brinton's work in terms the processes and the things that are going on in the brain, some of which for sure is basic science in terms what's happened and what we've seen in mice. But there is lots of data that she's subsequently done that is also in humans, in women, to see change in brain grey matter and all of that. So we know that there are very real changes in the brain in terms of glucose utilisation, in terms increased inflammation at the time of menopause. And there is data certainly in terms of use, when hormone therapy is used early. And how it changes the brain. And I think it's really important when we assess any of the data that's done is when is it done? Because that's really key to what Roberta Brinton was showing was that the brain changes. So if we wait and do it too late, if with anything that we're trying to prevent, we've got to get in when things are still pliable and things are fixable and things still changeable. And in actual fact, at the last international menopause meeting, there was a presentation done by, I think it was Jean-Paul Depypere. And he showed, it was an early study, he's now doing a broader study, but it was a six-month study with women with APOE4 using actually transdermal estradiol gel. And, he showed how by using directly the gel, it reduced the biomarkers associated with Alzheimer's. And so we do have this data, and we do have early signals, and the reality is we're never going to have a 30-year randomised control trial showing that we actually can, it's just not ethical to do that study.  [00:16:53][150.2]
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Dr Louise Newson: [00:16:53] Of course it's not.  [00:16:53][0.5]
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Dr Mary Atkinson: [00:16:54] So what we do you have to do is do more studies where we show reduction in the biomarkers. And we already do have those signals, and we already to have that data. And certainly for me, as somebody with and as an APOE4 carrier, I am... It's those kinds of data that give me, I guess, the confidence to know that I'm doing whatever I can do.  [00:17:21][26.9]
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Dr Louise Newson: [00:17:22] Yeah, and this is where it comes down to individual choice, because even if you had a randomised control study that did show or didn't show, it's only in that study population. And so although we talk about X per cent of risk or benefit, for me as an individual, percentages actually don't mean much. I want to know, am I going to benefit? Am I going have harm am I going to? And no one can tell me that. And that's where it's personal choice. But actually, there are more harms from not taking HRT than there are from taking. And everyone would agree with that. But the other thing is I often say to patients, you know, you can try it and see. If you don't like it or you worry or there's a concern or you want to stop just stop. But also the other thing that worries me is that we have so much debate about HRT. I never see this debate about antidepressants, which are far more readily available and more widely prescribed for menopausal women with low mood than HRT. But I don't see psychiatrists going on social media to say antidepressants are good or they're harmful. Yet we know antidepressants are associated with the risk of osteoporosis, risk of dementia, risk of not having an orgasm. I don't even see patients being counselled for those potential side effects.  [00:18:51][89.0]
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Dr Mary Atkinson: [00:18:53] So, you know, I work really closely with a group of psychiatrists and it's amazing because they really believe in hormone therapy, certainly the group that I work with, which is amazing. And we really do have a, this end approach, right? So I don't see them as either or I think that we need to use what we need in patients to help them feel better. But to your point around, you know, let's try it and see, it's one of the things around the value of diagnostics for me. So when a woman comes to see me, I do use diagnostics broadly. I look at her inflammatory markers and her insulin resistance profile and her lipid profile and all the rest of it. And there isn't actually a patient that I've yet that we actually haven't tracked that and watched it go downwards. As we've started whatever therapy we started, which to be honest in my practice is usually as a foundation with hormone therapy, but obviously is functionally also in terms of nutrients and minerals and diets and exercise and all the rest of it. So it's really, I mean, again, when it's the person sitting in front of you and we get away from the population data, and we say, well, I think this is what we should do and we're going to start. I always say to the patients, the magic is in the journey because it's not a once-off event. It's not acute care. It's a not a paracetamol that you take for a headache and it goes away and we can see that immediately. It's like a ripple effect in a pond. You start something and then it has this onward impact. And I always to patients, the first three months is kind of coming out of the sort of dis-ease side of the symptoms and the treachery of it. And usually by the three months, the patient is going, wow, I'm actually, you know, cause we often say to patients, they need to... sleep is important and they need to exercise and they need eat better. But a menopausal woman who's deep into those symptoms, the last thing she feels like doing is exercise. And all she wants to do is grab a carb because it just is like, feels like a friend and she would love to sleep, but she can't, you know. And that sort of 3am club of waking up and like, you know, bright-eyed and can't get back to sleep. And it's just, so she would love to, and that's the thing. So once everything is back in place, often she then has that ability to be able to do those things. And that's what I often see, is that the months three to six, she's then, she'll come back to me, she'll say, oh, I'm exercising again, and I've started weight training, and I'm doing this and I'm doing that and when she looks back, it's just like, oh my gosh, I feel like a different person.  [00:21:40][167.0]
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Dr Louise Newson: [00:21:41] And that is it. And it's certainly transformational medicine. You know, there's very few things as a doctor that can really transform and improve people's symptoms and future health. And, you know, we all could sit here till we're blue in our faces telling people they need to exercise more, they need to sleep better. But it's really difficult. Like if someone had broken their leg, we wouldn't say to them, oh just go and run a marathon, or go and do some training. You know if someone has an underactive thyroid gland and they were putting on weight and sluggish and low in their mood. We wouldn't say, well, have an antidepressant and just, you know, maybe look at your weight. It just doesn't make sense because you're fighting with physiology that's changed in the body. But somehow hormones have been seen as a bit frivolous. Like estradiol, progesterone, testosterone. There's a big debate out there in social media about progesterone. And I feel very embarrassed about this, Mary. I don't know whether you're the same, but I was taught, like most people at school are taught, that the ovaries produce estrogen and progesterone. Of course, no one taught me about testosterone, even at medical school. But we know they've got estrogen and progesterone that they make, as other tissues in our bodies make. But we also know that progesterone is a really important hormone that's derived from cholesterol that forms our other hormones, including cortisol, cortisone, estradiol.  All forms of estrogen come from progesterone. So it's like a master hormone really.  [00:23:10][89.1]
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Dr Mary Atkinson: [00:23:12] Yeah. Yeah,.  [00:23:12][0.2]
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Dr Louise Newson: [00:23:12] Yet, if people have the womb removed, we're told they don't need progesterone because it's only to protect the lining of the womb. And that's what I did for many years. So I'm as bad, as guilty as lots of other doctors here. But over the last few years my clinical practise has really changed because I'm like, well why am I denying these women like one hormone and I'm giving them the other? I either do it all or nothing. I can't just do half or a third if I'm only, not even thinking about testosterone. So we do prescribe progesterone because we know it has really important effects on the brain, on the bones, on the cardiovascular system. Yet people are really cross about it and I don't understand it.  [00:23:51][38.9]
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Dr Mary Atkinson: [00:23:52] Yeah, I must say from a, again, having trained in terms of that from a functional perspective and then coming into the sort of menopausal world as such the menosphere, as a functional practitioner, the training is to, in terms of the profound nature of progesterone and what it does in the brain and everywhere else. And so we always use progesterone, irrespective and then I kind of learned about, oh, well, you only need it actually if you have a uterus. But I use it actually in every patient anyway, obviously, unless it's a woman with progesterone intolerance or, you know, then we avoid it, But unless she has a uterus, then we use it vaginally. But... I always use progesterone because I see huge benefits to it in terms of brain and sleep and mood and yeah, so I think it is a debate and unfortunately with progesterone, it's really hard to study on its own because now, you know, with everything that's happened before and now what we know in terms the importance of estrogen, I mean, would you ever do a study where you only give somebody...  [00:25:11][78.7]
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Dr Louise Newson: [00:25:10] You wouldn't, but it doesn't really matter because it's a physiological hormone, isn't it?  [00:25:15][5.0]
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Dr Mary Atkinson: [00:25:15] Exactly.  [00:25:15][0.0]
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Dr Louise Newson: [00:25:15] So we've got to move this debate forwards because I do feel we're slipping back in time actually. I feel it's really damaging for women because the majority of women globally, the majority of women in the UK and South Africa are not receiving hormones who are menopausal. So there's a lot of suffering, there's lot of unnecessary health risks. So before we end, I'd just like to ask you three ways that you think us as healthcare professionals can quickly change the dial, move the dial, move the needle, change things for women going forward so they can access hormones if they want to, but they can access them easier.  [00:25:54][38.8]
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Dr Mary Atkinson: [00:25:56] I always say to my patients and what I say to people in general is the first thing is to be intentional. Be intentional about your health. Know where you are, understand what it is you're making a decision about and really be informed so that you can really make a well-informed choice. And then instead of, the flip side to being so fearful of hormones, I usually say to my patients, hormones are life-giving. And I try and get them to see them in a completely different way. And the power of them is profound. Obviously, we use them responsibly. I follow up my patients. It's a journey that we walk together. And that's the last one for me is that the magic is in the journey. So we will make changes along the way. We will change things as to how things are working or not working or add things. And that intentionality that we start off with must, as we do this journey together, you must end in a place where you are feeling better, doing better, and physiologically looking better. And so, yeah, it's a good journey. And for me, the magic is in the journey.  [00:27:02][65.8]
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Dr Louise Newson: [00:27:03] So good. Love it. Journey. Life is a journey and we're learning every day. So let's just take more women with us on this journey. So thank you so much, Mary. It's been great.  [00:27:13][9.9]
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Dr Mary Atkinson: [00:27:13] Absolutely, thank you.  [00:27:13][0.0]