Menopause myths debunked: HRT, collagen, hormones and more

Erica McKoy: There are so many trends online that are just so confusing. Sometimes I feel like we're being thrown from pillar to post with the amount of new trends we're seeing. So I thought I'd invite some of the best of the best in the health and wellbeing space to answer some of the questions we're all dying to know.

Shefalee Loth is our principal researcher and nutritionist. She has been working in the industry for over 20 years. She's worked for the NHS, the London School of Hygiene & Tropical Medicine, and the World Cancer Research Fund. At Which?, Shefalee is the research lead for health and wellbeing.

We've also got Dr Amir Khan. He is an NHS GP, a TV presenter, the author of several best-selling books, and a podcast host.

And we've got Dr Emma Wedgeworth, a consultant dermatologist. She has a clinic based on Harley Street and her focus is menopausal skin, acne, rosacea, eczema, sun damage, as well as a whole range of conditions including psoriasis, hair, and scalp disorders.

Midlife, mid-age, my favourite, middlescence, can be such a wonderful time. We've learned so much, and we get to that stage of our life where – I don't know, hopefully by now taking the time to look after ourselves, to prioritise ourselves. But the one thing that often happens in this time is that our bodies start changing in ways that we probably didn't expect. So you might be finding that there's a shift in your weight, or that you can't sleep properly, or your skin is feeling a little bit dry. Shefalee, can you tell us why we're focusing on midlife and the menopause?

Shefalee Loth: At Which?, we've seen over the last few years there's a huge amount of misinformation, especially on social media, and a lot of it does centre around this kind of midlife period, this menopausal period for women. It's a time where a lot of people are already feeling confused and vulnerable, and then they're being bombarded with lots of messages by people who aren't necessarily qualified. So we thought, let's try and spend some time and some research trying to separate the fact from fiction.

Erica McKoy: It's also such a busy time, because often, especially for women, they might be looking after people of different ages, like a sandwich.

Shefalee Loth: Yeah, absolutely.

Erica McKoy: Dr Amir, can we talk about what the menopause or menopause is, because I think there's lots of confusion. It's just one day, right?

Dr Amir Khan: It is essentially one day. It's when you've gone 12 months without a period. So it's a moment in time. Before that, you're perimenopausal, and after that, you're postmenopausal. Perimenopause itself can last – it will vary from person to person, but it can last years, sometimes even 10 years.
What people have in their minds when it comes to perimenopause is this kind of steady decline of oestrogen and progesterone, but that is far from what happens. Lots of women will tell you they don't have a smooth transition into that menopause. We see this erratic up and down with the hormones through that period. So one moment a woman will feel herself and how she was prior to going through the perimenopause, and then other times she'll feel very, very different, which can be a very negative thing for her. Periods can become heavier, they can become lighter, they become more spaced out. Eventually you go through that 12-month period without having a period, and that's when the menopause is, and after that, you're postmenopausal.

Erica McKoy: And then there are so many symptoms of the menopause that feel quite similar to other things. You might be having a go at the kids or having a go at certain people, or you might have stomach issues. At what point do you go to the doctor and say, "I think I might be menopausal here"?

Dr Amir Khan: The key thing to know – and we're really discovering this in real time – is that there are oestrogen receptors almost everywhere in the female body, and it governs so many things: right down from the top of your head, your hair, right down to the nerves in your feet, your brain, your heart health, as you say, your gut health as well, lots and lots of different things.
Lots of us will know the hallmark features of the menopause, things like hot flushes, mood swings, weight gain, as you say. But really common symptoms that people might not put down to the menopause, because, as you say, it presents at a time where women have a huge mental load already: they often have teenage children going through exams, they've got older parents who they may need to be looking after, they're usually at the peak of their career as well because they've got that wealth of experience, and that puts pressure on them there. At the same time, they've got to get the kids ready for school, they've got to do the shopping. That mental workload that women carry – at the risk of sounding like a man – men don't often carry the same thing or carry it with the same responsibility.
All of those things combined can lead to lots of other symptoms, and that depletion of oestrogen followed by progesterone. Anxiety is a huge one. Women may not think that is due to the perimenopause or menopause, but there's so much happening in the brain.
In terms of answering your question, "When should you go?": everybody's perimenopause will be different. The age at which you feel like you're perimenopausal will be different to someone else. Someone may breeze through that period; others really struggle with it.
I think the key thing is: don't think there's this magical age where that's when I should go. People can be as young as in their thirties and be perimenopausal. If you're feeling it there, go then. Talk to them. Explain to your doctor what you're worried about and why. You hear all these stories of younger women going and thinking, "Well, I'm in my thirties," and they might get dismissed, or they may get investigated for other things, which is appropriate because we've got to make sure it isn't anything else. But we've got to be open to the idea that it is perimenopause as well.

Erica McKoy: HRT: we really listened, we saw all the questions. HRT came up a lot. There's a little bit of confusion about HRT. Obviously in the past there's been lots of stuff about breast cancer that people, rightly so, were a bit fearful of at the time, but there's been some research since.

Dr Amir Khan: There has. It's worth running through the preparations of HRT and how you can take it. We'll start with oestrogen. Oestrogen can be given as a tablet, but more often it's given through the skin transdermally, either as a patch or a gel. You can also take it vaginally as well, as oestrogen cream.
Progesterone itself we normally give as a tablet. We've got something called micronised or body-identical progesterone now, which is progesterone that is different to the older progestogens that we used to use. It's better absorbed from the body, and we think it's probably got less side effects than the older ones as well, and people do better on it. That's usually given as a tablet at night.
The reason why we've moved away from oestrogen tablets – it's not that we've completely moved away; if that's the best option for you and you've had a discussion with your healthcare professional, that's fine. But what we know about transdermal, or through-the-skin, oestrogen is that because it goes directly into the bloodstream, it bypasses the liver. The previous worries that we had with oestrogen affecting the clotting factors in the liver and increasing your risk of a blood clot very, very slightly doesn't apply when you're giving it through the skin. People who might not have been able to have oestrogen prior because of risk of clots don't need to worry about that now because of it getting through the skin.
Then the other way people can get their progesterone as well, or progestogen, is through the Mirena coil. If you've got the Mirena coil, then that could be your source of progesterone.
We've got to always say with HRT: it is not contraception. If you are perimenopausal, there is still a chance you could get pregnant, so we've got to bear that in mind and have that conversation too.
In terms of the breast cancer risk, that is still there, so it is a lot less than we thought it was. The NHS quotes that it's there for people on combined HRT, so that's oestrogen and progesterone. When it comes to HRT, if you've still got a womb and you haven't had a hysterectomy, you need combined HRT: the oestrogen to replace the oestrogen, progesterone which protects the lining of the womb that oestrogen can sometimes increase your risk of womb cancer, so progesterone protects against that. It also has a role in your symptom management of the menopause as well.
Combined HRT, the oestrogen and progesterone, the statistic we generally quote is for every 1,000 women who are on combined HRT for five years or more, there's going to be five extra cases of breast cancer. The risk is very, very small, and whenever we prescribe any medication, it's always about weighing up the risks versus the benefits and making sure the patients fully understand that and then they're happy to go with that.
Every woman should be checking their boobs once a month anyway, but this is just a reminder that we should be doing that too. That risk is there, but it's much, much smaller, and it's not there for people who are just on oestrogen alone. If you've had a hysterectomy or your womb removed, you might just be on oestrogen because you don't need that protective progesterone, and that risk isn't thought to be there with just oestrogen alone.

Erica McKoy: Okay. We've had a question from Diane, who said, "For women who don't take HRT during and after the menopause, what are the long-term effects of having lower oestrogen levels on the body?"

Dr Amir Khan: It's a good question. The main thing, I suppose, is bone protection. What we know with people going through the perimenopause and menopause, as oestrogen levels decline, oestrogen has a huge protective effect on your bone health, reducing your risk of osteopenia, which is the beginning of thinning of the bones, and osteoporosis, which is thinning of the bones, because oestrogen supports the cells that make new bone cells, so they encourage that process. We all lose bone at a certain rate, but we also make it, and after the menopause that bone loss accelerates.
HRT can be used as a form of bone protection and protection against osteoporosis. If you don't need HRT, you shouldn't just have it because you feel, "Oh my god, I should have it." It's there to treat the symptoms of the menopause.
There are other ways to protect your bones as well. You don't need to have HRT as long as your diet is rich in calcium and magnesium and protein, and you're taking a vitamin D supplement, and you're doing weight-bearing exercise and strength training, which is such a buzz thing at the moment, isn't it? Everybody should be doing strength training two or three times a week, particularly women going through the perimenopause and menopause. Muscle is medicine, I always say this, and my other favourite phrase is, "Thick thighs save lives." We love it. We're over the thigh gap, aren't we, ladies? We want thick, muscular thighs, because we don't want frail women getting older that way and increasing the risk of lots of different things.
Osteoporosis is the big one. It depends on your symptoms. If you don't have any symptoms of the menopause – you're not anxious, you haven't got mood swings, you haven't got hot flushes – you don't need HRT. If you've sailed through that, and lots of women are lucky enough to do that, then that's fine. I think that's the key message when it comes to HRT.

Erica McKoy: And you mentioned calcium and vitamin D. We'll talk about that later with Shefalee. I've got a quick question. Arlette has asked, "Can you have hot flushes after the menopause?"

Dr Amir Khan: Hot flushes are a symptom of the menopause, but they can be a symptom of other things as well. If you have gone through the menopause – and it depends on what you mean after the menopause, because that could just mean you've had 12 months without a period and you're postmenopausal, but you could still be having symptoms of the menopause.
I think anyone having hot flushes that you think might be caused by something else needs investigating, because it could be something as common as a thyroid problem, a hormonal issue. But it could also be something really serious: if you're having drenching night sweats, let's say, which could be mistaken for hot flushes, that could be a sign of a blood cancer like lymphoma or leukaemia. We would like to investigate you for all of those things. If you think that it's not the menopause, but "I'm having hot flushes," that certainly needs investigating.

Erica McKoy: Head to your doctor's. Shefalee, we spoke about supplements. I want to talk about supplements, but can we talk about the menopause investigation first? Because we've all heard of pink tax, which is where you might buy a razor that's pink or some sort of girly colour, and there's a higher price tag on it. Can we talk about meno-tax?

Shefalee Loth: A couple of months ago, we looked at a range of menopause supplements on the market. We looked at around 26 in total, and then we looked at the active ingredients that were in them. There were a total of 80 different active ingredients across those 26 supplements.
What we actually found was the evidence to support a lot of those nutrients for the menopause isn't really there. You need vitamin D, sure, but so does everyone else. You need magnesium, but so does everyone else. There's a slight change in calcium needs post-menopause for women to reduce that risk of osteoporosis.
Actually, what we found is a lot of the time the supplements were very similar to a standard multivitamin, but they cost up to 20 times as much. There's that menopause tax, then, and it felt a bit like people are just preying on people's vulnerabilities.

Erica McKoy: I think I said this to you, maybe it was episode two of the podcast, I saw something that had a menopause bath salt, and I was like, that doesn't feel necessary. Why would we need that?

Shefalee Loth: Since we released our findings, people have been sending me stuff with a menopause tick or something on them, and there's this little stamp that's on products. But that doesn't mean that they're only for the menopause. There are a lot of things that are menopause-friendly, because essentially you're just going through life. You don't need to be spending a premium on these products.

Erica McKoy: Can we talk about some of the nutrients that we need during this midlife, menopause transition? What sort of nutrients should we be looking out for, if we need it?

Shefalee Loth: The biggest two that have evidence are calcium and vitamin D, and as I said, everyone needs those. You don't need to be taking calcium supplements if you eat dairy or you eat fortified – like you have fortified milks, for example, if you're vegan. If you're having two to three portions of dairy a day, that should be enough to meet your calcium needs.
The exception is vitamin D, where it's hard in the UK to get enough, especially during those winter months from October to March. Everybody should be taking a vitamin D supplement of 10 micrograms a day to prevent deficiency.
Beyond that, there's some evidence for magnesium, but it's not like your needs increase necessarily. We've talked about some of the symptoms of menopause being sleeplessness or insomnia, and there is research that shows that magnesium can help with that: it can help calm your nervous system, it can help with the production of melatonin, which is the sleep hormone. Some people find that taking magnesium supplements at night can help them with their sleep.
Beyond that, the evidence isn't super strong for a lot of other nutrients. A lot of the ingredients that we found in our menopause supplements were botanicals and plant extracts. Actually, what we found is there is some research that supports their use, but then when you compared it to what was in a lot of these supplements, the doses didn't match. Even though they were in the supplements, they weren't at the right dose that's been shown in clinical trials to be beneficial, and we call that fairy dusting.
They can put a little bit in, and even of vitamins and minerals, so it enables them to put a health claim on a product, but actually there's not enough of that product in there for you to feel the benefits.

Erica McKoy: I don't think people know this at all, that this is something that can be done.

Shefalee Loth: What's telling is at the end of the research, we looked at those 26 supplements and said, "Would we, in all consciousness, be happy to recommend any of these to people that we knew, our friends?" And the answer was no.

Dr Amir Khan: Shefalee, can I ask a question? Whenever I talk about supplements, I say exactly what you've said, and then the argument back is, "Well, it's not that we don't have the research to say all of this, it's that there's a lack of research." But I don't think that's true. The research is there to support the fact that a lot of these things, there is no evidence for.

Shefalee Loth: Yeah, and also, especially with things like botanicals, the research is weak. Study sizes are small, they're for short periods. With botanicals, there's the added complications – like if you want to test the effects of calcium, that's quite easy because you can have a consistent dose, whereas with botanicals, you're extracting something from a plant. It depends on the species of the plant, whether you've used the root. There's just so many variables that it's really hard.
A lot of people say, "Well, they're natural, so they're harmless." But actually, that is really not the case, and a lot of these botanicals are quite powerful ingredients, especially at the doses you might find, so they can interact with other medication.

Erica McKoy: There's been a bit of research into black cohosh, right? What do we know about black cohosh? Because I know some people look at that and go, "This is natural, it's a botanical."

Shefalee Loth: The Cochrane database did a meta-analysis, so they looked at all the studies around black cohosh and treatment of menopause symptoms, such as hot flushes, and found actually, at the end of it, when you collate all that evidence and look at the results, there's no compelling evidence that it works for menopause treatment.

Dr Amir Khan: Both the British and American Menopause Society don't recommend black cohosh. Though it is there in the NICE guidance as a potential treatment for things like hot flushes, both the American and British Menopause Society say don't bother.

Erica McKoy: We've got a live question from Amanda. She's seen lots of stuff with ashwagandha in it, and a lot of the time it's quite expensive. She was just wondering if there's any cheaper alternatives, or what can you do if you are looking for a supplement?

Shefalee Loth: There is a lot around ashwagandha, you're right, and it's been used for a long, long time historically in Africa, in subcontinent Asia. The belief is that it can reduce the stress hormone cortisol, so it's found in a lot of menopause supplements.
Actually, there are some concerns around it as well. A lot of countries in Europe are looking at banning it because there have been some cases, some rare cases, of liver toxicity. In the UK, the Committee on Toxicity are conducting a review currently, and hopefully the results will be out later on this year to look at actually whether it's safe and the doses.

Erica McKoy: We've got a question from Samantha about collagen. I'm looking at Emma – I'm sure we'll talk about it. She said that her social feed is just full of collagen. Is it actually worth investing in? There's a bit of bones versus skin, there's a bit of a debate, I've heard.

Dr Emma Wedgeworth: Skin-wise, I would say there is no good evidence. In fact, the studies really suggest that it improves hydration, but I think there are plenty of better ways that we can improve cutaneous hydration than taking oral collagen.
We need to think beyond collagen. When you actually look at the changes that happen in your skin over the menopause, yes, collagen is part of it, but so is the whole of your extracellular matrix: your fibrillin, your elastin, the glycosaminoglycans that are in your extracellular matrix. It's not just collagen. We've latched on to collagen because it's a nice story: less collagen, more lines; more collagen, less lines. But it doesn't really work like that. I do not take oral collagen and I don't routinely recommend it to my patients.

Dr Amir Khan: I'm so glad you've said that. I have been singing that from the rooftops, and the stuff you get back – but I'm so glad. You're the expert, you see this stuff. I'm just so pleased you say that.

Erica McKoy: Shefalee, can we talk about vitamin D? Because we can all be deficient in vitamin D, because we just don't get enough sunlight in the UK. We've done a bit of a self-test kit investigation as well, right?

Shefalee Loth: That's right. As you say, vitamin D deficiency, especially over the winter, is quite a common thing. You can buy self-testing kits over the counter in Boots, in Tesco, etc., where you can apparently test your vitamin D status.
One of our researchers in the health and wellbeing team has done this. She's bought a handful of tests, and on the same day tested her vitamin D status and had a blood test. What's quite telling – our research is going to be released, I think, in the next week or so – each test pretty much gave her a different result. Based on this, we won't be recommending people to buy these over-the-counter tests.

Erica McKoy: It's something to be mindful of.

Shefalee Loth: It really is. I don't know if you have experience of self-testing kits?

Dr Amir Khan: No, most of my patients just come in and ask me to test them.

Erica McKoy: Our members can access our vitamin content over on which.co.uk. But for our new friends and listeners, we do have 50% off exclusively for our podcast listeners. You'll get access to our product reviews, our app, one-to-one personalised buying advice, and every issue of Which? magazine across the year. But you'll also be helping us to make life simpler, fairer, and safer for everyone.
Let's get back into the podcast. Dr Emma, skin dryness is a common one when it comes to menopause, and sensitivity. But something that lots of people don't realise is that you can get adult acne?

Dr Emma Wedgeworth: Yes, you can. As Amir was saying before, your hormone levels can go up and down significantly. It's not just a steady, linear decline, and it's those sorts of changes that can really impact on hormonal acne.
Some women will find that their skin is just generally much more erratic, it's much more unpredictable, and as well as getting sensitivity, brilliant, you also get spots at the same time. I see that quite a bit.
And then adding HRT into the mix: for example, some people may be taking progesterone or some people may be taking testosterone, and that can all change things as well.

Erica McKoy: I'm not the doctor in the room, I'm actually probably the least qualified person in the room. But our skin is an endocrine – it takes things in and metabolises things, and it does magical things. It's one of the biggest organs we've got on our body. How does the skin process and metabolise, or how does it help us process and metabolise our hormones?

Dr Emma Wedgeworth: You're spot on, it is an endocrine organ. Pretty much all the cell types in our skin – our keratinocytes, our fibroblasts, our melanocytes – they will all have receptors, particularly oestrogen receptors, on them. It also metabolises vitamin D. We've talked about vitamin D, and exposure to the sun is a great way of getting vitamin D. We have to balance that carefully with the damage that we can get from the sun, but we don't say to people don't go in the sun at all; we just want to be mindful that you don't want to be sun-seeking particularly, or trying to change the colour of your skin.
There's a lot of activity, and then all of the other stress hormones, cortisol, pretty much all hormones will act on the skin. That's why we do see significant changes as people are going through menopause.

Erica McKoy: I'm sure there's lots and lots of different products out there, and you don't have to give name brands, but what are the top three things you'd recommend to someone that may be experiencing a bit of dryness in midlife, menopause?

Dr Emma Wedgeworth: I think it's a really good time to change your skincare routine around. As you said, dryness and sensitivity, now that's probably the main thing that I tend to see. Everything needs to change texture a little bit.
For example, you may have been using a foaming cleanser; you may change that to something like a gel cleanser or a gentle cream cleanser. Your moisturisers are going to have to be a bit thicker. One thing that happens during menopause is that we stop producing sebum as much as we did.

Erica McKoy: That's the oil that's in our skin?

Dr Emma Wedgeworth: Exactly. It's the oil that's produced by your sebaceous gland. It's not the only oil we have in our skin, but we start to produce it in puberty and then it starts to decline around menopause, and so our skin will get a bit drier. As well as that, our skin barrier starts to become a little bit more sensitive.
Creams tend to need to be a bit thicker: shea butter-based or some other sort of occlusive, and then alongside that, barrier-boosting products like ceramides or niacinamide. Those are really basic things you can do.
And then if you've been really keen on actives – at the moment actives like retinoids and acids, those are so popular – just dial them down a little bit, because at that point your skin doesn't want to be pushed too much, and it's always a little bit of a balance.

Erica McKoy: A question from Helen, who is 50. She's developed menopausal acne. They use salicylic acid to help cleanse her skin, but then whenever she gets hot flushes, she breaks out all over again. Sometimes it feels like it's for no apparent reason. They have a healthy diet, lots of fruit and veg, rarely eat processed food, drink green tea, plenty of water, well done. They're not overweight, they exercise regularly. Her GP has prescribed antibiotics to deal with it, but Helen would like to start an effective treatment when she comes off the antibiotics to avoid going back to the previous symptoms. Can these be prescribed by the GP, or do you reckon she needs to go to a dermatologist?

Dr Emma Wedgeworth: A lot of questions in there, and it's a really common one. I think often as your skin gets a bit older, it gets more sensitive, but you're breaking out.
The first thing to make sure is, is this just blemish or acne, or could this be a little bit of an overlap with rosacea? I see that a lot in menopausal women, that you've got a little bit of rosacea: you're a bit more redness-prone, that gets worse when you have a hot flush, but also you're getting a few little blocked pores as well, which is more of where the acne sits.
It sounds like Helen's doing everything right, and that's, again, really demonstrative that our skin is just at the mercy of our hormones. Sometimes we are doing everything right, but our circulating hormones and the way that they're talking to the skin is producing these sorts of changes.
I would strip out the salicylic acid. I've got to say, I'm not a fan of that at this sort of time of life, because it can be quite harsh on the skin barrier. I'm a big fan of azelaic acid, and I think that's definitely something that I would introduce alongside a nice gentle gel cleanser and a nice rich moisturiser.
Speak to your GP about that, because they can prescribe azelaic acid, and it's a great one. Antibiotics are really good at calming inflammation, but you need to have a plan B, because when you come off that, you need something that's going to maintain it, so I'm thinking azelaic.

Erica McKoy: We've had a question from Liz, who said, "What can help with very dry skin made worse by HRT? Can one avoid collagen drinks and approach it another way?"

Dr Emma Wedgeworth: I would definitely avoid collagen drinks. I think it's such an expensive way of trying to hydrate your skin. If you think it's made worse by HRT – Amir, I don't know about you, but I'd think about having a look at your HRT.

Dr Amir Khan: Yeah. HRT shouldn't be making your skin dry, and it might be that you're on the wrong preparation. I would think about trying a different – perhaps a different oestrogen or a higher dose, I would think about that if your skin is becoming particularly dry, because it should be the opposite, really.

Dr Emma Wedgeworth: Exactly. And then other things you can do: change what you're washing your skin with, that can make a big difference. Instead of using a foaming wash or a harsh shower gel, you might go for something like an oil-based wash, and then a nice rich body moisturiser. Thinking about something like shea butter, that's a really good occlusive.
Keep the temperature in your house down, don't switch the heating on too early, make sure that you're not using particularly hot water. And then – I don't know what you think about this, Shefalee – but some good fats in the diet just to try and help support that, so making sure oily fish, things like that.

Shefalee Loth: Yeah, absolutely.

Erica McKoy: We've got a live question, it's anonymous: "Any tips for peridermatitis on her lips?"

Dr Emma Wedgeworth: It sounds like that's perioral dermatitis, and this is a particular type of dermatitis that I see that happens around the lips, and it can also happen around the eyes, in the creases of the nose. It presents as redness, flaking, and then these tiny little dots which can be really tenacious. It hangs around even though it looks sometimes not too severe.
Often that's to do with the microbiome of the skin, so the balance of bacteria and yeast, and also dryness. It definitely is something that tends to happen around more in the way of dryness, and I often see it in the context of using retinoids. If you are using anything active, dial that right back. Use a nice – I keep saying the same thing, but gentle cleanser, nice rich moisturiser.
If it's not shifting, then do go and see your doctor, because there are anti-inflammatory things that we can use. I've mentioned azelaic acid, non-steroidal anti-inflammatories, and then sometimes we have to use antibiotics as well.
I think it's such a difficult phase, though, because people are starting to lose a bit of confidence. They're often desperately trying to counteract the changes that they're seeing in their skin: more lines, more sagging. They're using a million different products, and then often that ends up causing irritation, so it's a difficult time.

Erica McKoy: Shefalee, what sort of foods should we be looking out for boosting our skin health?

Shefalee Loth: Really there's no one ingredient that's going to help you, but it is about having a good, balanced diet: that's eating a variety of fruit and vegetables, your wholegrains. We know fibre affects your skin as well. Making sure you're getting enough protein. Emma mentioned those healthy fats, so fish, but also nuts and seeds, those polyunsaturated, monounsaturated fats, olive oil. It's about just getting a good, balanced and a range of foods. You shouldn't be excluding anything if you don't need to.

Erica McKoy: We've got a question from Rebecca: "Have I just got to quietly accept that my hair will no longer be full and lustrous as it used to be, rather than spend and waste money on miracle shampoos and conditioners? What's our thoughts, Emma?"

Dr Emma Wedgeworth: Every day I have someone coming in worrying about their hair loss, and it's real. It's not that people are just worrying about their hair loss, and the problem is until you lose about 50% of your hair, no one else notices. People will say to you, "What are you talking about? Your hair's fine." But you know that your hair density is starting to reduce.
It's multifactorial. In the same way as our skin ages, our hair follicles do age and our hair becomes thinner, it becomes more brittle, it grows less, and it breaks more. When we start to see our hormonal changes, that really accelerates. We also see a lot of female pattern hair loss. We don't talk as much, I think, about female pattern hair loss as we do about male pattern hair loss, but we see it an awful lot and it's actually very common.
Hair loss is one that you do need to try and tackle quite early. If you leave it right until it really shows, then it can be difficult to get it back. If you are noticing hair loss, you want to act.
The first thing is sometimes just to do some simple blood tests. Sometimes we see changes in iron levels, we see iron deficiency. We can see thyroid changes we talked about before, so we can do some blood tests just to make sure there's nothing that's going on with that.
Make sure that you are careful about how you treat your hair: for example, that you're not damaging it. It's already a bit more brittle, so make sure you're not being too harsh with it. For example, when it's wet, it can be much more fragile, and so you want to make sure you're brushing it more when it's dry.
And then if you're finding that all of these simple measures are not helping, actually that's when treatment might be helpful. Now, I don't tend to advise many shampoos and things, but I do advise a lot of minoxidil, which is over the counter. HRT can sometimes be very helpful. Sometimes we will use anti-androgens for hair loss.
There are a lot of things you can do to actually try and address it. There's nothing that we just say, "Just sit back, just accept that your hair's going to go." There's lots you can do if you want to.

Erica McKoy: I think that's also it: sometimes people feel quite powerless, don't they? What I'm learning is that oestrogen governs everything. Everything that's going on in my body has some sort of link to oestrogen, it seems.
Before we open the floor to questions, this feels like a really good time to talk about our free healthy living newsletter, where you can find our latest investigations and articles, and they will be sent directly to your inbox. Our experts and researchers do the heavy lifting for you when it comes to researching supplements and debunking those very confusing social media trends. We'll leave a link to that in the chat and in the show notes.
We've got a question from Kim. She said, "So just to confirm, it's been a little over 12 months since having a period, so am I menopausal or postmenopausal?"

Dr Amir Khan: You would be postmenopausal at that point. Menopause is a moment in time: you've gone 12 months without a period, that's your menopause, and then after that, it's postmenopausal. But people often associate postmenopausal as being no symptoms. I think that's the confusion, isn't it? "I've gone through the menopause, I'm postmenopausal, I've got no symptoms." But that isn't the case. You can be postmenopausal and still have symptoms of the menopause, and they can go on for many, many years. The terms themselves are quite confusing, but menopause is just a moment in time, really.

Erica McKoy: One day. We've got a question in for you, Amir: "How safe is HRT after having breast cancer? What do we know?"

Dr Amir Khan: This is a really tricky question, and I would always advise anyone who's had breast cancer – I always think they almost feel like they're left in limbo, this group of women, because we know there is a very slight increased risk of breast cancer, as I said before, with combined HRT. That makes GPs in particular, like myself, very reluctant to prescribe it to anyone who's had a history of breast cancer.
What I would say is you need to have an individual discussion with either a menopause specialist alongside a breast specialist as well. It's usually a combination of conversations that you need to have, and think about whether that risk, that very small risk, is still worth taking it for the management of the menopause. That is a very individual decision.
Usually the risks outweigh the benefits in these cases, particularly if you've had oestrogen-dependent breast cancers. That is where I sit personally: I think the risks outweigh the benefits.
But if your menopausal symptoms are really serious and they're affecting your day-to-day life, your sleep, and you've tried other non-hormonal things – and I think this is the key thing: there are non-hormonal managements of symptoms of the menopause. They're not all-encompassing like HRT can be; we can target specific symptoms with non-hormonal medication.
If you've had those conversations with your doctor and you've tried things, but you're still struggling, I would ask to see a menopause specialist and have that discussion. But it's a very individual, case-by-case basis on risk-benefit management.

Erica McKoy: I'm guessing you would suggest for women to feel empowered to have these conversations? Talk to your doctors.

Dr Amir Khan: Yeah, I think that's the key, because lots of women think, "Oh god, I've had breast cancer, I can't have HRT." For many women that is the case, but you may want to balance that out against your symptoms.

Dr Emma Wedgeworth: I think it's really hard, because you hear so much about HRT, and then it almost gets touted as the panacea, and it's not always. Sometimes I have patients who come to me and they can't use HRT, and I'm like, that's okay. If you can't, we just approach it from a different way. There is often a different way around it. As much as it may be absolutely the right thing for one person, if your doctor says don't have it, there are often a lot of other things – particularly I'm talking from the skin perspective – that you can actually do about it.

Dr Amir Khan: And there is for hot flushes as well, which is a major symptom. If you can't have HRT for whatever reason, and for some women it's just not worth that risk, particularly those with breast cancer, then there are options available to you. Please don't just think, "Well, I can't have it, I'm just going to have to suffer." Come and speak to us, and we will talk you through your options. It might be a bit of trial and error, but that's okay; we will work with you until we get it right.

Erica McKoy: We've got a question here from Emma that says, "I'm happy with the benefits of combined HRT, but not happy with the forced heavy monthly bleeding. What can I do?"

Dr Amir Khan: You don't have to have a bleed with HRT. There are continuous preparations and then ones that are not continuous, and then you have a bleed. If you don't want to have a bleed, talk to your prescriber, say, "I don't want to have a bleed," and they'll give you a preparation where you don't have a bleed.
Sometimes with younger people, it's just assumed that they want that bleed and the preparations that allow that to happen, but it doesn't have to be the case. Speak to them and see what your options are.

Erica McKoy: Shefalee, we've got a question for you: "Has there been any reliable, trustworthy, valid research into functional mushrooms?"

Shefalee Loth: Mushrooms go into the same box as other botanical ingredients that we talked about, and the struggles with reliable research in this field. What's really important here is that a lot of the menopause supplements we looked at had mushrooms in them, but again, the doses: you can do your research, and if you think you've got specific symptoms that you want to try a mushroom supplement to deal with, then that's fine, but make sure you're taking the right dose that's been shown to be beneficial.
What's really important here as well is to say that botanical ingredients don't have any approved health claims, so manufacturers can't say what the benefits of these are on food supplements, for example. They'll often put in other ingredients like vitamin D or vitamin C so they can make claims around immunity, or magnesium for calmness. Just be careful about the claims, and those claims don't necessarily match the mushroom.

Erica McKoy: We're training people to be so sceptical!

Shefalee Loth: You have to be!

Erica McKoy: We've got a question from Caroline: "If not collagen, what would you recommend to help with tendons and muscular issues? Just strength training or something else? I take collagen to support my tendons and muscles rather than my skin. Am I wasting my money?"

Dr Amir Khan: Collagen is a really abundant protein. When you take it orally, it is broken down by your gut into its component parts. When it's sold to you, they will say you're lacking collagen in your skin, or your bones, or your tendons, or wherever, and this collagen will magically get repurposed into those places. That is not how the body works. You cannot direct this collagen, the component parts of the collagen, to where you want it to be.
We've also got to be really clear about why collagen is now such a big thing. It is a cheap substance to make and sell, and it's been marketed so well that so many people are on it, right? Because of this clever, canny marketing behind it. But we don't have the evidence to support the claims that come with that.
I would always say, if you're getting enough protein in your diet – and that is the best way to get it, because you're not just eating a single substance then, you're eating something with lots of other nutrients in it. Oily fish, for example: everybody's talking about collagen, but nobody's talking about being deficient in omega-3 fatty acids, which is really common. Not everyone is eating two portions of oily fish or three portions of oily fish a week, right?
You can get your protein, you can get your omega-3 fatty acids, which your body can't make itself. They can't make omega-3 fatty acids; it can make collagen, it can't make omega-3 fatty acids. Or you're getting protein from my favourite source: beans, legumes, because we've got so many studies supporting the intake of legumes linked to longer, healthier lives, and you also get all the other beautiful things that come with eating legumes: all the vitamins and minerals alongside that protein.
My advice is, yeah, strength training: absolutely do it, but get protein from really good, nutrient-dense, whole foods.

Shefalee Loth: Similarly, with supplements that say joint health: there are no proven claims for glucosamine and all the other ingredients that you'll see in them. Usually it's the vitamin C or the vitamin D that's in there that's giving you those benefits, and you can get that from food or a simple vitamin D supplement that's going to be a lot cheaper than one of those targeted ones.

Erica McKoy: I love that everyone around this table is giving us just boring advice. I wish it could be as simple as we go out and we just buy this thing and it just fixes it. But actually, sometimes it's as easy as diet – having a healthy diet, doing a bit of exercise, cleaning your face. Sometimes it's as simple as that.

Dr Amir Khan: I know, that doesn't sell books, though, does it? Sadly, there's been a move over the last couple of decades or so to ultra-processed foods, which are lacking in a lot of nutrients. Then there's been a gap in that nutrient space, and that's been flooded by these supplements saying, "Look, all these problems that you're now having is because you're not eating nutrient-dense foods, you've got this ultra-processed food. Instead, have our supplement." But the answer is to go further back than the ultra-processed foods and go back to these whole-food diets, and that's the answer in all of this.

Erica McKoy: Shefalee, we do lots on ultra-processed foods. What sort of ultra-processed foods should we be avoiding, and what ultra-processed foods are actually okay?

Shefalee Loth: We talked about this with Laura last week, and she said, "I think everyone's lost the plot slightly on ultra-processed foods," which is kind of where we've been coming at for the last few years.
Ultra-processed foods are such a wide category that it's really hard to just give them a blanket "don't eat them." It's not realistic. The lives we lead don't allow us to cook every single thing from scratch. Whilst I would say, sure, cut down on those processed foods that are high in fat, sugar, and salt, such as your crisps, your biscuits, the things that don't have a lot of protein in them or fibre. But actually, there are other ultra-processed foods that we really don't need to be avoiding, and those may be wholegrain bread. Bread is an ultra-processed food if you buy it in the supermarket. But what's the alternative? Are we all going to be spending £5 on a loaf of sourdough, or are we all going to be baking our own bread? That's not realistic.
Similarly, baked beans, for example. We don't get enough fibre in our diets, and baked beans are a good source of fibre. I would say don't worry about the baked beans or the hummus or the fish fingers even, but actually cut out on those kinds of foods that we know we shouldn't be eating every single day.

Erica McKoy: We've got a question in from Viv: "Is there any advice for those of us who are on a vegan diet? I think they're particularly concerned about calcium."

Shefalee Loth: I would say obviously try to include those fortified plant milks in your diet. You can get calcium from green leafy veg; there are vegan sources of it. If you are relying on plant milks, don't buy organic, because they aren't fortified – they can't be by law. Make sure you buy non-organic plant milks.
Actually, if you are struggling, then you can speak to your GP, perhaps get a blood test to see what your calcium levels are like. Our needs post-menopause, after 55, men and women really do change, and we do need to have that extra bit of calcium in our diets just to mitigate against that muscle and bone loss.

Erica McKoy: We've got a question from Sarah: "I've been using sage tablets to help with hot sweats. I've noticed that they are not helping that much. Is there anything else that they can do?"

Shefalee Loth: If it works for you, then continue as long as you've checked with a health professional that there's no interactions with other medications that you're taking. But beyond that, I think go to your GP and talk about your symptoms.

Dr Amir Khan: I don't know Sarah's history, but if she can't take HRT, there are other things we can give for hot flushes. Clonidine is a good example of a tablet we might prescribe for you that can help specifically with hot flushes, so come and speak to us.

Erica McKoy: We've got a question from Lynette: "My hot flushes are worse in the summer. Is this normal?"

Dr Amir Khan: Yes, that is normal. Hot flushes are caused by hormonal fluctuations or drops in oestrogen that affect the hypothalamus, the temperature sensor in the brain, and it makes it very difficult for the brain to judge the temperature your body needs to work at. Changes in temperature can set that off and cause hot flushes.
A hot summer in particular – we've had a very hot summer. It is worth saying that women suffer in hot summers worse than men. There's a number of reasons for that: the menopause is one of them, or perimenopause, postmenopause, when things are not working as well as they should do because oestrogen helps manage the temperature control system in the brain.
The other thing is the way women regulate their temperature as a whole is slightly different to how men do it. Men rely more on sweat and sweat glands and the evaporation of sweat, whereas women rely more on something called vasodilation, where their blood vessels widen to allow heat to evaporate, and that isn't as efficient. Women do get hotter in the summer, and that can exacerbate hot flushes itself as well. All those ladies in work who are saying this summer's been really hard: you are right, girls. You are right. It's harder for you than it is for me, and I am sorry about that.

Erica McKoy: Anne has said, "How can I support dry, itchy skin? It's driving me mad." Any advice for Anne?

Dr Emma Wedgeworth: Dry skin is always itchy, but if you are really itchy, sometimes there again can be some underlying reasons for that. First of all, use a good, gentle wash in the shower. I think often people don't think about what they're using in their shower, but it can actually make a real difference. The surfactants, which are the chemicals in there which actually cleanse the skin, sometimes can be really drying, and you want to make sure that you're using something that's called a syndet, which is a synthetic detergent, because actually that's much more skin-barrier-friendly.
Then there are a number of different ingredients which can be really helpful for itch if you're looking at a moisturiser: urea can be really helpful for dryness; ceramides can be really helpful for the skin barrier, so get yourself a nice rich sort of moisturiser.
And then if you're still itchy, that's a medical thing, because actually we see a lot of people who have chronic itch. Sometimes that's an underlying cause, and sometimes it's just the nature of the nerve fibres within the skin. We were talking about every receptor in your body having some sort of oestrogen receptor, and nerve fibres do as well, and sometimes they can just start firing off much more. I see a lot of itch post-menopausally as well.

Erica McKoy: We've got a question from Rebecca: "Are dry eyes a menopause symptom, and are there any tips in particular? They really struggle with painful dry eyes and it's waking them up in the morning."

Dr Amir Khan: Yes, the answer is yes. As we've said several times throughout this, oestrogen receptors are almost everywhere. Oestrogen helps with the production of tears and tear film, so as it drops, eyes can become very dry.
It's not just your eyes: your ears can become very dry as well, and very itchy. Itchy ears, tinnitus, really common symptoms that people don't associate with the menopause, and so they come in and say they've been having a good scratch, which you shouldn't do.
It's the same with eyes. It's the same with mouths as well: it can affect your mouth, it can give you burning mouth syndrome, it can affect the gums and the way inflammation is in your gums. You can get loose teeth because oestrogen supports the bone in the jaw as well.
In terms of dry eyes, you can get artificial teardrops which can help with things, because dry eyes are miserable to live with: they're itchy, they can become very sore, they can become infected as well. A good place to start with that is just your local pharmacist, and they can give you something over the counter that can help with dry eyes.

Dr Emma Wedgeworth: You mentioned burning mouth. As a perimenopausal woman, you think everything is associated with menopause, right? About two months ago, I started to get a really burning mouth, and I was like, "That's it, I've got burning mouth of menopause. It's going to last the whole time." And then it lasted a few weeks, and I suddenly realised I'd actually changed my toothpaste and I was allergic to toothpaste. As much as there are so many things that can happen in menopause, just make sure you're not attributing everything to menopause, because there are lots of other things that can happen at the same time. You could be allergic to your toothpaste.

Dr Amir Khan: Very much so.

Erica McKoy: Elizabeth: terrible brain fog. We haven't really spoken about brain fog, but obviously that is a symptom of the menopause. They also have a lack of libido. They were tested for testosterone levels, but it came back as normal and they were denied it by the GP. What else can they do to help with both these issues?

Dr Amir Khan: There's a lot to unpack there. Brain fog is a common symptom, again, of menopause, because we've got oestrogen receptors in the brain that help manage some of the neurochemicals or brain chemicals in the brain and keep them at a level that works well for the brain. Because you don't want too many of them, you don't want too little, and oestrogen helps manage it at that narrow level. When oestrogen starts to drop, your thinking can slow down, particularly around memory, particularly around things like focus as well, so those kind of things can become increasingly difficult.
One of the big hidden illnesses around the menopause or hidden problems that happen is women who have lived with ADHD or who are neurodivergent, where oestrogen has been helping mask some of those symptoms. It becomes really, really difficult to mask. Both oestrogen and progesterone play a role in unmasking ADHD symptoms at this stage of life.
There's a part of your brain called the prefrontal cortex which helps deal with memory, focus, and avoiding distractions. Two big neurochemicals that work in that area are noradrenaline, which helps you focus, and then dopamine, which helps you not get distracted. Oestrogen helps manage those two. As things drop, those things fall out of their narrow range where they work well.
The other thing is progesterone. Progesterone is turned into something called allopregnanolone in the brain. That helps with another brain chemical called GABA. GABA is a really important brain chemical which I don't think we talk often about. It's like a calming cushion in the brain. As progesterone levels fall and that allopregnanolone level fluctuates and falls as well, that can make GABA levels really erratic, and that can feed into that anxiety that people get around this time. That then can cause issues if you've got brain fog and anxiety together, and you're unmasking your ADHD symptoms. What a horrible thing to happen all at once, right?
The second part of that question was libido. Whenever I talk about libido and testosterone, the British Menopause Society guidelines are very clear that you can prescribe testosterone to women with low libido where other things have failed. That's what the guidance says, so you should have tried other things.
Women feel very strongly about testosterone because there's a feeling that they're being denied it. This question here was, "I was declined it, what else can I do?" Well, actually, you should have been offered other things first, and if they haven't worked, then you should be prescribed testosterone for libido.
And then the other argument I get with libido and testosterone is, "Oh, well, we're only giving it because it's a lack of sexual desire and that affects their partner, the men in their lives." But I presume women enjoy sex as well, right? They want a good libido, they want to have enjoyable sex. They're not just doing it for their partner. Libido for women is important as well, and testosterone can be used to treat low libido, but the guidelines are clear that it's after other things have failed.
If you've tried something else, then you should go back and say, "No, this hasn't worked, I would like to try testosterone for it." Testosterone isn't the miracle thing that lots of people think it might be. We don't have the evidence to support testosterone in lots of other symptoms of the menopause. Brain fog is actually one of them. People will come at me for this, because there are other doctors online saying testosterone helps their patients with brain fog. But helping their patients with brain fog is not definitive evidence. We've got to look at the studies here, and we don't have the studies.
I know I'm going to get in trouble for saying this, because people feel very strongly about testosterone. We don't have the studies to support testosterone use in brain fog. In fact, and it isn't a lack of studies, we have studies that show that placebo often works better, if not than testosterone in these studies.
It's really difficult for me to talk about testosterone, because I know there's going to be people going, "No, he doesn't know, we haven't done the research and that's what it is." Perhaps in time that might change, but right now, testosterone use in HRT – and testosterone doesn't follow the same decline that oestrogen and progesterone does, it doesn't. There's a couple of peaks and troughs throughout life in women when it comes to testosterone. But for low libido, yes, you can use it. If you've got brain fog, then we've got to look at the oestrogen and progesterone combination in that HRT as well.

Erica McKoy: So go to your doctor.

Dr Amir Khan: Go back! Ask for it. Say, "I've tried this, it hasn't worked, I know the guidance, it says now I can have testosterone."

Erica McKoy: We've got a question about creatine supplements: "Are there any advantages to taking it?"

Shefalee Loth: Creatine is a really interesting one, actually, and the evidence to support its use does exist. There's proven evidence that it can do two things. First of all, it can help you when you're exercising to give you that extra push. If you're in the gym and you're training and your muscles are tiring, it might help you run that extra 200 metres, or it might help you do those extra couple of weight lifts, bicep curls, or whatever.
It's there, but what I would say is you've got to take it regularly. You've got to take it every day, because your body doesn't store it. It's three to five grams, but then you've also got to do the exercise. You can't just take it and think that it's going to help you; it's not. If you think you want to take it from an exercise perspective, then yes, there is evidence to support that.
There are a lot of claims online and on social media about brain health and brain fog, and what I would say is that the evidence that we have at the moment does not support its use for brain fog or cognitive health. As Amir says, that might come later, but based on the current evidence, it's not going to help you.

Dr Amir Khan: Can I ask a question about that as well? Because I'm a big fan of creatine, I use it for the gym. I also read that it can help with – if you've got a tired brain, rather than brain fog itself, tiredness, it might help with brain focus in that?

Shefalee Loth: That's the same kind of research: there's some emerging research, but the evidence is not conclusive yet.

Dr Amir Khan: Fair enough.

Erica McKoy: We've got a question from Suzanne for Shefalee and Emma: "I keep seeing recommendations for pumpkin seed oil. It's supposed to help with menopause symptoms, and especially with hair growth. I've been losing my hair steadily for some years and dread being bald one day."

Dr Amir Khan: Can I just say, my mum puts that on my head. So I'm really interested.

Shefalee Loth: I can't answer this question, because I've never heard of this.

Dr Emma Wedgeworth: A lot of oils get a lot of attention for hair growth, and I have to say, I don't think there's any evidence. If you're trying to improve the shaft of your hair, which is your dead keratin, a bit like you'd polish a table or something like that, great. But actually, oils are not going to get deep down into the follicle, which is what the problem is.
This lady has been noticing her hair that's been going on progressively for a few years, I think she says, and I would say that's much more likely to be something like female pattern hair loss. There are treatments for that out there.
This is the thing that I worry about with all sorts of things out on the internet: that actually it stops people from getting the actual care that they need. There's no problem with putting pumpkin seed oil on your hair, or taking it, or whatever it is, but it's not going to stop the progression of female pattern hair loss, and what it's going to do is stop you from getting the right treatment. If I were you, I would go and get some treatment, because we do have treatments for female pattern hair loss, and the sooner you can do it, the better.

Dr Amir Khan: Is there something to be said for the massage of a scalp with oil and the way it might improve blood flow?

Dr Emma Wedgeworth: Give me a scalp massage every night, that is going to improve the quality of my life, do not get me wrong. But it's not going to regrow my hair if I've got female pattern hair loss.
There's a lot of these ones about rosemary oil, various different ones, and there is no really good evidence. I would not take my chances with something like that if I was losing my hair significantly.

Dr Amir Khan: Was there a study – sorry – was there a study that compared rosemary oil with low-dose minoxidil and it was comparable?

Dr Emma Wedgeworth: But nobody uses 2% minoxidil. I would say 2% minoxidil doesn't work really either. For a long time, women were shortchanged with 2% minoxidil because everyone was worried about hirsutism and hypertrichosis. But actually, any dermatologist will give their patients 5% minoxidil. Again, I'm not taking my chances with 2% minoxidil. So it's almost like rosemary oil versus placebo: yep, it works the same.

Dr Amir Khan: It's good to know, because those are the studies that are often quoted, right? But it's good to hear why actually it's not a good study.

Dr Emma Wedgeworth: There is something around personal choice, right? I have a lot of patients who say, "I don't like the thought of using minoxidil or using it long-term." That is somebody's choice, and if you choose to use rosemary oil instead of minoxidil knowing what the options are, knowing what the evidence is, then that is completely fine. But what's really important is that you know that there is really no good evidence for that compared to things where there is good evidence. I'm quite passionate that people do start to get treatment early so that it doesn't end up becoming bald, essentially.

Erica McKoy: Amir, you mentioned a menopause specialist. Do they exist, and how do I access them?

Dr Amir Khan: Yes. Your GP surgery may have a women's health specialist – we certainly do, often it's me or it can be someone else – who should be trained and have done some postgraduate training in the menopause. If that person doesn't exist at your surgery, which might be the case, then you can ask to be referred to the hospital to see a menopause specialist as well.
Most GPs can manage HRT. We should all be able to do that; I train GPs, I train them to manage symptoms of the menopause using HRT. But if you have been back and forth and your preparations have been changed and your symptoms are still ongoing, or you're not happy with the answers that you're getting, it's perfectly reasonable to ask for a referral.

Erica McKoy: Do it. We've had another question: "Are there any alternatives to HRT, especially if you're already taking the necessary vitamins like vitamin D and iron? Are there sort of any alternatives that you can try and take to help with the symptoms?"

Dr Amir Khan: It depends on your specific symptoms. When people come in and HRT is not an option for them, what we do is talk to them about their very specific symptoms and target each one in turn. There isn't anything like HRT which can cover multiple symptoms at the same time, but we do have individual medication that can help with things like your mood, or the hot sweats, or whatever you have, as you say, hair loss or skin issues.
One thing we haven't talked about, and I just want to say because I know we're close to finishing, is topical vaginal oestrogen. Girls, get yourself on topical vaginal oestrogen! The evidence is so, so strong for it. This is not the same as HRT or oestrogen through your skin. Topical vaginal oestrogen is generally thought to be safe for everyone, because it's not absorbed systemically; it doesn't go everywhere else in the body, it just stays in that same area.
Vaginal dryness is the principal thing that it's treated for. You get something called vaginal atrophy when oestrogen, which keeps the vulval area plump and moist – as things drop, it becomes thin and it can become dry and it can become itchy. Vaginal oestrogen is your best friend.
The other thing that it can really, really help with – and you don't have to wait for vaginal dryness for this, ladies – is recurrent urinary tract infections or symptoms of urinary tract infections, something called genitourinary syndrome of the menopause, where you get the burning, the frequency, symptoms that feel like a urinary tract infection. We have really strong evidence that it reduces that significantly.
Actually, don't wait. If you are mid-thirties, I would say start it, because we have quite good evidence to suggest not only can it reduce all of those things, but there was a huge study done earlier this year that looked at topical vaginal oestrogen and it reduced all causes of death in women as well. There was a – so it's an association, but sepsis was a big thing that it had a significant impact on. I'm a huge fan of it, and I think more women should be on it.

Dr Emma Wedgeworth: It's such a good point, and it goes back to the thing we were talking about, libido. If you are sore every time you're having sex, or you get a UTI every time you're having sex, of course you don't want to have sex, and no amount of testosterone is necessarily going to help that. Teasing out the individual things, for example with libido, about why it might be – vaginal oestrogen is such a good point.

Erica McKoy: We've got our final question from Sharon here: "During the perimenopause, postmenopause transition, which three actions or interventions do you think are the most important to focus on?"

Dr Amir Khan: If we're talking about lifestyle changes, then I think strength training is a big one. I would also say look at your protein and fibre intake as well, because you get something called sarcopenia around this time, particularly the first five years of postmenopause, where you get a significant drop in your muscle mass.
Remember, muscle isn't just there to support your movement; muscle does so much more than that. It is a storage organ for sugar, so it can help manage your risk of type 2 diabetes. Muscle sends off chemicals called myokines up to your brain, and it's thought to help reduce your risk of Alzheimer's, dementia, and heart attacks and stroke. The leaner you are in terms of skeletal muscle, the healthier you're going to be in the long term, and of course it protects you against frailty and fractures as well, so all of that is key. Certainly the strength training combined with the fibre and the protein.
We can talk about lifestyle measures and look at your home environment and your work environment. The other thing I would say – and I would make this point number three – a lot of the focus is in what the women can do for the menopause, right? We haven't talked about what the men can do to support their partners through the menopause! There is a long list of things:
First of all, try and understand what the menopause is, and do some reading, boys. Do some reading around it, don't wait to be told what it is. Try and understand how tricky this situation can be for a lot of women: what's going on in their brains, what's going on in their mood. Don't argue back with them! Just take it and accept it, because it's a difficult time, isn't it? Just keep shtum, keep quiet.
And don't wait for her to tell you what to do to help: offer the help, do the help. Don't wait for her to say do the washing-up or do this with the kids, just do it, because her telling you that is adding to her mental workload. Do it. That's my point number three, for the boys.

Shefalee Loth: Absolutely. I love that.

Erica McKoy: What do you think, as well?

Dr Emma Wedgeworth: I can't add too much to that from a medical perspective. Skin I'll definitely say, but I would say delegate, because frankly, middle-aged women take on far too much. Say no, because we say yes to everybody, and be kind to yourself. I would say those are the three things from a sort of personal perspective.
With my dermatologist hat on: skin. I'm going to say go gentle. Again, be kind to your skin. Your skin does not want 25 different actives, okay? Don't worry that your skin is going to drop tomorrow; you're going to be fine, but just be kind to it.
Sun protect. As much as going in the sun is important, if you go and try and tan your face, by the time you've got to menopause, your skin is getting a bit more inefficient: it's going to produce pigmentation, it cannot protect itself as much. It's a risk of skin cancers, various different things. Facial skin: do not tan it, just be gentle with it, do wear sun protection.
And then change the things that you can change. If you're not feeling confident about something, go out and try and change that, because there are so many different things you can be. Be it hair, be it, if you've got a bit of lines and you decide you want to go and have a procedure, don't be apologetic about that, go and do it. Have the confidence to change the things that you can change, and accept the things that you can't.

Erica McKoy: Shefalee, from a nutritional point of view, what can we suggest?

Shefalee Loth: Really quickly, Amir already said it, I'd say protein: up your protein intake. Your fibre, because we know there's a real link between your gut health and your hormones.

Erica McKoy: Was it 70 to 80% in the gut?

Shefalee Loth: That's your immune system, but lots of people talk about how their digestive system changes during the menopause. Your gut microbiome diversity decreases. Really try and get your protein, and then my final thing would be get that vitamin D supplement.

Erica McKoy: Yes, absolutely. This has been a real science lesson, it's been a lifestyle lesson, it's been all of the lessons. I hope everyone at home has been taking notes. I hope also people walk away feeling like actually they can do something about this. You don't need to be uncomfortable and going through this quietly.
I hope everyone's been taking their notes. That's all we've got time for. We've got loads more advice on the website: which.co.uk/health. We have a free fortnightly health newsletter that rounds up everything our brilliant health team have been up to. Sign up to that at which.co.uk/joinhealth. And don't forget that the membership offer is there for all new podcast listeners: you get 50% off our annual Which? subscription at which.co.uk/podcastoffer.
Thanks to all our guests that joined me today. Thank you for joining me.

Dr Amir Khan: Thank you.

Erica McKoy: And we'll see you next time.