Perimenopause and breastfeeding

Breastfeeding and perimenopause both suffer from a lack of research and investment. When you put the two together, mothers in their 40s and 50s are often met with a lack of understanding and no clear path to follow. So this week, I’ve got together two women who know as much as anyone can do about these tricky subjects, Dr Claire Phipps, the Menopause GP, and Tamzin West IBCLC, to help me untangle the truth and the rumours.

We talk about the symptoms of perimenopause and why blood testing doesn’t always help, how HRT and other treatments interact with lactation, and we answer your questions about sleep, bone health, rage and fertility while breastfeeding during perimenopause.

You can follow Tamzin on Instagram @‌seedsofloveibclc and @‌breastfeedingandmenopause

and Claire @‌themenopauseGP

My new book, ‘Supporting the Transition from Breastfeeding: a Guide to Weaning for Professionals, Supporters and Parents’, is out now.

You can get 10% off the book at the Jessica Kingsley press website, that's uk.jkp.com using the code MMPE10 at checkout.

Follow me on Twitter @MakesMilk and on Instagram  @emmapickettibclc or find out more on my website www.emmapickettbreastfeedingsupport.com

Resources mentioned -

British Menopause Society https://thebms.org.uk/

Understanding Menopause Booklet from Diane Danzebrink https://menopausesupport.co.uk/?page_id=17128

This podcast is presented by Emma Pickett IBCLC, and produced by Emily Crosby Media.

Transcript

Hi. I'm Emma Pickett, and I'm a lactation consultant from London. When I first started calling myself Makes Milk, that was my superpower at the time, because I was breastfeeding my own two children. And now I'm helping families on their journey. I want your feeding journey to work for you from the very beginning to the very end. And I'm big on making sure parents get support at the end to join me for conversations on how breastfeeding is amazing. And also, sometimes really, really hard. We'll look honestly and openly about that process of making milk. And of course, breastfeeding and chest feeding are a lot more than just making milk. 

Emma Pickett  00:46

Thank you very much for joining me for today's episode. Today. I'm not alone, because I'm joined by two people. I've got Tamzin West, who you will find on Instagram, as @Seedsofloveibclc. She's an holistic sleep educator, as well as an infant feeding specialist. And you can also find her second Instagram account, breastfeeding and menopause, which overlaps with today's topic. And I'm also here with Dr. Claire Phipps, who's a GP and an advanced menopause specialist. And you'll find her on Instagram as @themenopauseGP. And we're going to put our heads together as a group of three to talk about breastfeeding, and perimenopause several generations ago, it probably wouldn't have been so common for these two stages of our life to to overlap. But now a lot of people are starting their families a bit later in life, and are still breastfeeding when they enter perimenopause. And we need to address some of the questions that women have because there's a lot of confusion online and some people are really not sure where to get the right information. We may not have all the answers today. But as a group of three, we're going to put our heads together and see what we can come up with. Thank you very much for joining me today, Claire and Tamzin.

Tamzin West  01:55

Thank you for having me.

Dr Claire Phipps  01:57

Yeah, likewise, thanks for having me.

Emma Pickett  01:59

So Tamzin, can I start by asking you? Why did you start the account breastfeeding and menopause?

Tamzin West  02:07

I started it towards the end of 2023, around Christmas/New Year period. And I have a personal interest in the area because of family history. My mom had an early menopause. So it's always been on my radar is something that I might experience. And I'm probably 39 In a few months, so potentially not too far away. And at the same time, I noticed in breastfeeding support spaces that there were more questions coming up, like you covered in my introduction there. That just doesn't seem to be very good information out there. I think Women's Health is generally poorly kind of understood. And then when we start putting things together like perimenopause and lactation, there just isn't good stuff out there. And I thought if I can try and bring some things together and throw one starfish back in the sea, then you know, it's a valuable thing to do I find that you know, menopause based information tends not to mention lactation and lactation based information is either about medications, which is important, but then it tends to say, oh, you know, perimenopause shouldn't affect your breastfeeding, or the symptoms you're experiencing are probably due to breastfeeding. And it just doesn't meet the needs of people looking for the information. 

Emma Pickett  03:35

Yeah, yeah. No, I think that's that's definitely a good summary of where we are. One of the things that kind of brought this subject to my mind was a conversation with a friend Rachel, who said, lots of people are experiencing Parenting Toddlers and feeling rage and struggling with sleep and having to work on you know, regulating the emotions of little people and thinking Hang on what's wrong with me? I can't do this without realising that maybe perimenopause is an extra complication on top of that, and I think, you know, it'd be really good today, hopefully to try and sort of separate some of these these different symptoms that we're talking about. There. There is a lot of confusion about what are symptoms of perimenopause and what we might attribute to lactation and what we might attribute to pre menopause. Claire, can we just ask you for this just start with a really simple definition. If that's possible, what do we mean by perimenopause? 

Dr Claire Phipps  04:25

Yeah, so the perimenopause is the transition phase up to when our periods stopped. So when we think of the perimenopause, we're thinking about possibly from our early 40s up to when our periods stop and remember, period stopping is one day in time when we can look back and retrospectively say, we've not had a period for 12 consecutive months and that's the definition of the menopause. And after that we're postmenopausal to perimenopause is that this transition up to when our periods stop? For many women, this early signs can start as young as 40, we know maybe one in 100 women will have an early menopause or when their parents stopped below that age. But if we're thinking about the majority of women, from the age of probably 14 up, we're starting to see symptoms, certainly from the age of 45. And up, we're starting to see symptoms that are wide, you know, they are top to toe symptoms, their psychological, their physical, their genital, and those are the symptoms we often find in that perimenopausal phase.

Emma Pickett  05:28

So when you say let's let's unpick some of the top to toe stuff. So I mentioned kind of issues around rage and anger and struggling dealing with emotions. Is that Is that something you see regularly? 

Dr Claire Phipps  05:41

Yeah, so I sort of divide the symptoms up in order to sort of really capture how symptoms are affecting someone, and also the effect on their quality of life. So the severity and their quality of life. So when we think about symptoms, we think about first of all psychological symptoms. So they are some of the symptoms that start to appear first, they're sort of slightly insidious in onset, you're kind of not quite sure what's going on, but they typically can be anxiety, low mood, worsening of your depression. If you've suffered from depression in the past, women who've had a history of postnatal depression, often they can feel that that sort of low mood that deep low moods come on again, but also rage, irritability, that loss of motivation, all of those symptoms can be very, very typical of the early stages of perimenopause. And don't forget, you know, sometimes when we experience those symptoms, you may have them initially and they may not return. So there may be some months when we have symptoms that are better, and some months where we have symptoms that are worse, some months where we have an anxiety or low mood or rage or symptom, and they might not come back. So it's very variable, and it's very individual. But those, those psychological symptoms are really common. 

Emma Pickett  06:56

Okay, and then physical symptoms that we're talking about maybe issues with sleep, what other sort of physical body symptoms might might someone see?

Dr Claire Phipps  07:05

Yeah, so again, this is top to toe and no two women in the same so we commonly hear about hot flushes and night sweats, but approximately 20% of women won't experience a hot flush or lights wet. So we have to be careful with if we're just looking out for those we're looking at for irregular periods. But also women can still have very, very regular cycles and be Peri menopausal, and some women don't get might have a cord inserted. And if they're not bleeding with a coil, we can't rely on the periods becoming irregular or tracking those. Then this thing is like top to toe. So I think dry hair, hair shedding dry skin, itchy skin, palpitations, joint pain, muscle aches, you know, insomnia being a really a really common one sleep disturbances, feeling like you've got things crawling on you that that sense that you know something's on you, and itchiness. Those tend to be the main ones. Some of the sort of more weird and wonderful ones tend to be new tinnitus. Tinnitus can be really common in the perimenopause. And often it's, it's it's a symptom, we sort of brush off or we just don't quite attribute to perimenopause. But if it's a new symptom, often that can be quite quite debilitating. You can imagine that's going to affect your sleep. And then we think about those genital symptoms supergiant or dryness, pain during intercourse, bleeding after intercourse, recurrent urine infections or that sense you've got a urine infection. But vaginal dryness is probably one of the really, really, really common symptoms. 80% of women might suffer from it to varying degrees, of course, and that can be absolutely debilitating. 

Emma Pickett  08:40

Gosh, one of the things that's really striking me and I'm guessing it is for you Tamzin as well. Lots of the things you just listed, Claire are things that people attribute to lactation. If you are dealing with vaginal dryness and you're breastfeeding 99% of the time someone's going to tell you that's about the fat. You're breastfeeding and your low oestrogen levels are about your foot, you're breastfeeding. And if someone's dealing with sleep issues or irritability or aversion and they're still breastfeeding, maybe a toddler, someone's going to say, oh, maybe you've got breastfeeding aversion. Maybe this is your body telling you it's time to wean. It's really hard to unpick some of this stuff, isn't it and work out exactly what's going on. One of the things that I'm often finding is that people are thinking maybe perimenopause is an issue. They're going to talk to their doctor and someone saying, oh, we can't really do any testing on you because you're lactating. Is that true? Is that Is there anything that we can do to investigate perimenopause while someone's breastfeeding? 

Dr Claire Phipps  09:33

Yeah, I think this is this is a really tricky subject and probably why there's not a lot of information out there for women experiencing sort of, is this perimenopause, or is this as a result of breastfeeding? And essentially, that's because breastfeeding reduces our oestrogen levels, which in the same way is what perimenopause is doing? So it's sort of almost chicken and egg what's going on when we think of breastfeed? When we think of the hormones that are involved in breastfeeding, they're coming from our brain. When we think of perimenopause, and we think about what are the hormones involved, they're coming from our ovaries. So there's two separate areas that these these hormonal imbalances, if you like, are coming from. Unfortunately, when we breastfeed or fortunately, depending on how you look at it, are used to die all levels out the main oestrogen kind of component of us in our reproductive years our estradiol levels plummet, and that's so that we can continue to breastfeed. In the same way as perimenopause, menopause and post menopause. Those oestrogen levels are dropping based on the number of eggs that you've got available in your ovaries and our ovaries and our eggs drive the amount of oestrogen we've got. And as we reduce that oestrogen level, we start to experience symptoms. So when we look at blood tests, then you know the symptoms mimic each other. What's what's perimenopause, what's breastfeeding, the symptoms are very, very, very similar. When it comes to blood tests in a woman that's breastfeeding, if we were to do your estradiol levels and you're fully exclusively breastfeeding is very like you're always to dial levels are going to be through the floor. We then look at the hormones that are tried to trigger ovulation. Because that's one of the things that we can test for. And again, early lactation, or women as sort of a year after birth. And if you're still breastfeeding, those hormones can be low, and then back into the normal range. So actually testing for them isn't likely to give us a diagnosis. If we remove breastfeeding for a moment, or we think about a Peri menopausal woman, who is over the age of 45. Again, we rarely do blood tests, because we know that women over the age of 45 are very, very likely to be Peri menopausal. And the reason we don't do blood tests is because those levels of hormones fluctuate minute to minute, day to day, and we often capture a normal level doesn't tell us anything. So we have to go on symptoms alone. So actually, when it comes to blood tests in a breastfeeding woman as to whether or not she's perimenopause, or they're not that helpful, unfortunately, so we have to think about age, we have to think about how long you've been breastfeeding for. We have to look at that used to die or level which will vary but which will be low. And we have to think, Well, if we suspect that perimenopause is part of this process, then do we think about treatments? Do we think that we should hold off on any treatment before we sort of come to that weaning stage and beyond? Because for some women, and this is probably sort of, I'm on the fence here a little bit. But for some women who start to wean, who stopped breastfeeding, and their estradiol levels pick up they feel very much better. They just do because their oestrogen, their master regulator over their entire body is coming up again. And some women do feel better. Now obviously, it depends on what age you are when you start to do that process. Because if you're approaching your mid 40s, it's very likely that those levels are going to start changing naturally anyway.

Emma Pickett  13:09

So when a doctor saying sorry, love can't do a blood test on you, that's not the patriarchy that is actually coming from somewhere sensible. And actually, often in lactation, people are saying, Oh, well, you know, let me do a blood test for prolactin. It is your only capturing a tiny snapshot and doesn't often do much value to to do blood testing on on hormones that are to do with lactation. Something you said just then about the the Easter dials. I think that's important just to drill down that for a moment. So when somebody is suckling, they're going to not produce the follicles that we need to make the oestrogen so oestrogen doesn't come necessarily magically, just because you've not breastfed for x, you know, you breastfed for X number of months or not breastfed for X number of months. It's all about what your follicles are doing. And if your hormones because you're lactating and suppressing your follicle development, and you're not producing those mature eggs, they're not going to produce the oestrogen. So somebody that's breastfeeding a 12 month old or a 13 month old, if they're breastfeeding very frequently, all through the 24 hour period, may still be quite low and oestrogen similar to somebody who's breastfeeding a much younger baby because of the amount of suckling and the amount of suppression, we're going to get on those on those follicles. So we're not going to get the gonadotropin releasing hormone. We're not going to get the luteinizing hormones, we're not going to have the oestrogen happening. And that's about somebody's breastfeeding. So if they were going to the doctor and saying, you know, test my oestrogen levels, that's just gonna give them a lactation story, not necessarily a perimenopause or menopause story. Yeah, exactly that. Yeah. So it's very hard for people to come up with answers and they're going to be talking to doctors who, you know, also don't have answers and that can be very difficult for people to hear at times and what kind of symptoms are you hearing people talking about when they're talking about struggling during lactation? 

Tamzin West  14:58

A lot of the things that Claire I mentioned with regards to the sort of mental health things coming up a lot. I've heard a lot of people mentioned things like irritability and rage and feeling touched out. And it's so difficult because, you know, we've, we've all been there with toddlers, you know, wanting to breastfeed every time you sit down and twiddling and swapping sides every two seconds. And how much of that is the breastfeeding behaviour? And how much of that is actually something else going on in yourself? Really, really difficult. So that that's a big one. Sleep, of course, you know, most of us are going to have disturbed sleep with young children again. So it's really difficult to say how much you know, what's been caused by what, but we know that breastfeeding hormones can help with sleep. So, you know, if sleep is really disturbed, and not necessarily anything to do with your child, then perhaps we can say there's something else going on there. So I definitely think the sleep and the the mental health are probably the biggest things that I'm coming across that people are asking about. I have had people asking me about vaginal atrophy due to low oestrogen and they were told that it was because of breastfeeding, which, you know, we do know that that there's a link there. But probably Yeah, rage rage is a big one. And people don't like to. It's uncomfortable to admit that you suffer from rage. I've had it is this big symptom for me when I had postnatal depression twice. Rage was a big, big symptom and I completely empathise because it's, it's horrible. And it's really uncomfortable to talk about, as well. So, yeah, really difficult, difficult things to talk about for a lot of people. 

Emma Pickett  16:44

You know, I think often when we have the idealised image of what a mother is, you know, good mothers in inverted commas don't have rage, good mothers are regulated, especially when we've got so much information now about how we emotionally support little people and how we help them with their emotional regulation. And, you know, we're all reading the fabulous Seroquel, Smith, etc. You know, the, if you've got rage, and you're struggling, it's not something that you necessarily feel you can talk about openly. And some sometimes I think, parents and mums will want an answer. So actually to say maybe I'm Peri menopausal, actually is easier potentially than saying, maybe I'm doing a job that society is not supporting me to do maybe I'm, you know, trying to work full time and breastfeed through the night and CO sleep with my toddler. And that's where I'm being failed by the lack of support by the lack of support in society. But maybe it's easier to say, am I Peri menopausal than it is to say, I'm not able to do all this. And I wonder whether sometimes people are looking to put that pre menopausal label on things, because that's that feels more comfortable to sort of externalise some of their symptoms. Does that sound right? I'm just sort of thinking out loud here. 

Dr Claire Phipps  17:55

Yeah, I mean, I certainly think it does and is from a from a menopause practitioner perspective. I'm very, very keen that we don't label women as perimenopausal or postmenopausal. If we think there's other things going on, everyone really, really is keen to go why is this my perimenopause? Or is this my thyroid issue? Or is this x, y and Zed? And I've always really clear that whatever is on your plate is on your plate. And potentially if you wrap the perimenopause around that or the post menopause around, that it will infiltrate everything, but it's not just going to be one thing, particularly at this time of life when we're experiencing symptoms that could be attributed to perimenopause. It's probably not just your perimenopause is it it's going to be other things and we just need to be mindful that, like you said, No, you know, there's a lot going on for mums these days. And for dads, but certainly, because we're having children later, there's a lot more to juggle the sandwich generation is is is it's obvious it's there. You know, managing work managing life managing older parents, younger children, that is just the reality of many, many people's lives. And the perimenopause will add an extra layer of complexity to that certainly.

Emma Pickett  19:09

Yeah, yeah. And I think sometimes to talk to a GP and say, blood test to me blood test me, you know, if I take a medication is that going to make these problems go away? can be very tempting, because the bigger conversation is harder,

Tamzin West  19:23

from our point of view as breastfeeding supporters. We're so used to breastfeeding being a scapegoat for everything. And I'm really conscious of not now saying or at least probably perimenopause, not it's not because you're breastfeeding. It's probably because you're perimenopause or because he is a subject that I'm interested in and I'm reading about but actually, we still need to take that step back. And so we don't, as Claire said, We don't want to be blaming perimenopause for everything is in the same way that we don't want to be blaming breastfeeding for everything as well. There are so many factors

Emma Pickett  20:00

Just trying to unpick for a moment. We know that when someone's immediately postpartum, they have that very low oestrogen level, we're gonna get vaginal dryness, we, you know, we may get symptoms associated with low oestrogen is it would it be fair then to say, if those symptoms may be improved at the end of the first year, but then come back again, you know, maybe 18 months? Could that be a red flag that maybe suggests there is something hormonal going on? 

Dr Claire Phipps  20:27

Yeah, I think I think it also depends on Yeah, what the symptoms are, what age that woman is, and also family history, and medical history, because obviously, we're not just about hormones, you know, the genetic aspect of things as well. So taking a really holistic approach to it, and thinking about what else could be happening, but certainly, if you start to feel better, and then you start to feel symptoms, or you start to feel worse again, yeah, I mean, that is definitely something that needs to be flagged, and we need to think about what else is happening there? Is this hormonal? Is this a combination of hormones and something else too. And that holistic approach, I think, and individualising, that approach is really key. 

Emma Pickett  21:08

And then similarly, with, with sleep, if somebody as Tamzin suggested, we've got research that suggests that if somebody's exclusive breastfeed exclusively breastfeeding, they're actually going to have better quality sleep in the in the first six months and potentially beyond. If they feel rested, and then it gets worse again, there are other things that cause problems with sleep, you know, whether it's iron levels, or you know, vitamin D, or, you know, your lifestyle, or what else is happening, I guess we just need to, as Tamzin said, we've just got to be really careful. We don't go into the breastfeeding scapegoat problem. But also, we don't necessarily go into the peri menopausal scapegoat problem, either. We we want to meet someone who's going to help us have that holistic conversation, which I guess it's not always easy when a GP is only got a 10 minute window to talk to somebody. I mean, if someone's listening to this, and they're thinking, you know, who can I sit down with and talk about my symptoms? What would you recommend?

Dr Claire Phipps  22:02

If there's any concern about could this be breastfeeding? Could this be Peri menopausal symptoms, I think your first port of call is is your GP, it could even be your practice nurse. But I think also giving them the heads up about what you're coming in to talk about maybe even asking for a double appointment. I know that's hard, harder these days, but But trying to see if there's somebody within your practice that could support you and support those questions that you're asking. Unfortunately, as as you're both be aware, there isn't a referral pathway necessarily for these women within the NHS. So if we're comparing breastfeeding or perimenopause, we want you to be treated very holistically. But there's a referral pathway for breastfeeding women, there's a referral pathway for Peri menopausal but they don't combine. So if we're thinking about perimenopause, and we're wondering whether or not you you need treatment, your GP offices, your first port of call, but then thinking about menopause clinics within the NHS as a referral pathway. But really, it is, you know, as a GP, our responsibility to be able to take you under your wings and go right, what is happening. Let's think about this really, logistically. Let's also perhaps bring you back for a few appointments so that we can really start to dig deep, and really think about all your symptoms and start to kind of formulate a plan about what could what could be happening and how we could help. 

Emma Pickett  23:33

Let's talk a minute about menstrual cycles. So when someone is obviously in the early days of breastfeeding, it's for although there are people who do have a cycle returning at sort of six weeks postpartum, it's more common to, you know, have several months, I think the average return is about 14 months. Is that right terms? And if I remember that correctly, yeah. And when someone does have their period return, it might become regular. And then perhaps if breastfeeding patterns change, it might, it might disappear again, and it will go backwards and forwards. Taking breastfeeding out of the equation for a moment. If someone is in their early 40s. Or starting perimenopause, what tends to happen to our menstrual cycles?

Dr Claire Phipps  24:11

It can really variable so for some women, they have regular bleeds, until they're in the mid 50s. And suddenly they stop. But other women can the early 40s, they might have some irregular bleeding. So they might have some months where they bleed some months where they don't, they may have heavier blades, shorter blades, longer blades, lighter blades, and those blades can change month to month. And that's what's so confusing as you go from perhaps having a regular ish cycle with a normal flow for you to having months where you're not bleeding and then a month where you bleed really heavily and flood it this is not this is not my norm, what's happening there must be something wrong and often those are the symptoms that we see in women who have Peri menopausal symptoms and are having irregular cycles. So Hey, what's changed? The periods just change. And there's no, there's no sort of kind of classic way they change. And each, each woman will be different. But it's, it's tracking those changes that are really important. So you can really kind of pin down what's happening month to month. And there's lots of tracking apps you can use to do that, but but tracking the changes is really vital.

Emma Pickett  25:25

Okay, so coming back again to that idea of things settling and then things changing and during lactation. So, you know, let's imagine someone's period does restart at 14 months, they start to be quite regular. They've got a fairly decently long cycle. They've measuring their luteal phase. And, you know, they can see it's kind of 14 days or whatever they are sensing ovulation, they might be doing ovulation testing all that, you know, let's say they have another year and a half of that. And then breastfeeding patterns haven't changed. But their cycle starts to get shorter, or they start to flood or they they start to see something obviously going going a bit askew compared to what they would normally expect. Would it be fair to say that that is somebody who's experiencing Peri menopausal symptoms, even if they're lactating? If they were fairly stable, and then it changed despite breastfeeding, not changing? Would that point to it probably being more to do with perimenopause, would you say?

Dr Claire Phipps  26:19

it's one of the differential diagnoses. Yeah, absolutely. But then we're also thinking about other things. We're thinking about what are your levels like? What's your thyroid doing? Are you over exercising? So are you losing weight are the calories changing so that we can't actually make our reproductive hormones effectively and that drives that cycle? So perimenopause is yes one of the things but also we're thinking about, you know, other things as well. Typically, thyroid, typically blood count, typically, weight loss, typically stress, cortisol levels, all of those, those things that can be can be really directly influencing our cycles.

Emma Pickett  26:56

Okay, so thyroid is a hormone that you can be tested for while you're lactating. So I know we mentioned before about how you know prolactin oestrogen, these hormones are not going to be so reliable to reliably tested, but you can absolutely test that test for thyroid just just to remind us what some of the symptoms particularly of low thyroid,

Dr Claire Phipps  27:13

thyroid tend to, again, mimic some of the symptoms of perimenopause. So we're thinking that you can feel hot or cold actually, with low thyroid, typically people feel cold, but you can also gain weight, you can feel very lethargic, you can just feel your mood can dip you can also feel quite irritable as well. So you can see the symptoms are very, very similar to perimenopause. And then if we think about kind of, if you've got a low a low blood count, obviously we know that can predispose you to having fatigue and tiredness, insomnia, again, iron levels, low fatigue and tire tiredness, insomnia, really, really common and we and we know lots of women in the UK, or have low iron levels and they just might not be realising it. So thinking about all of those things, and yes, third is one of those those hormones that you can test and the blood counts. And you know, magnesium levels, for example, can be really helpful if we're not eating well and not nourishing our bodies. Well, all these trace minerals and vitamins can have have implications for our long term health.

Emma Pickett  28:16

Okay, so perhaps if somebody is thinking perimenopause symptoms, the first step is to get iron, thyroid, you know, the micronutrients tested and looked at first because they are more detectable when we're thinking about someone lactating and that's, you know, there's the first things that we can possibly test for.

Emma Pickett  28:34

A little advert just to say that you can buy my four books online. You've Got It In You, a positive guide to breastfeeding is 99p as an e book, and that's aimed at expectant and new parents. The Breast Book published by Pinter Martin is a guide for nine to 14 year olds, and it's a puberty book that puts the emphasis on breasts, which I think is very much needed. And my last two books are about supporting breastfeeding beyond six months and supporting the transition from breastfeeding. For a 10% discount on the last two, go to Jessica Kingsley Press. That's uk.jkp.com and use the code MMPE10, Makes Milk Pickett Emma 10. Thanks. 

Emma Pickett  29:21

Tamzin. What sort of conversations are you seeing around HRT and breastfeeding?

Tamzin West  29:27

I've been trying to read up about this because there isn't a huge amount of information. I mean, the main information we have is on Wendy Jones's page. Breastfeeding medication, and she has taken information from other sources like Thomas Hale. If you're listening you don't know Thomas Hale is a big name in terms of lactation pharmacology, publishes a huge book every year about medications and breast milk and it's really difficult, correct me If I'm wrong, Claire, but HRT is not just one thing, there are lots of different possible doses and combinations. So that already presents an issue because we can't say, you know, we can't give a blanket statement because it's not going to be the same for everybody. From what I read on Wendy Jones's page, there isn't any conclusive research on the passage of HRT into breast milk. There's a theoretical possibility of lowered supply due to oestrogen high oestrogen is not a good bedfellow with breast milk production. That, you know, we just don't really know and so much as an individual, it's also going to depend on where you are in your breastfeeding journey exclusively breastfeeding, a four month old it day and night is not the same as breastfeeding a four year old three times a week. So that there's that issue as well. And Hale says that absorption, vaginal absorption, so if you're using an oestrogen cream, or pessary, the absorption through the vagina is going to be higher. And there was research showing that it is measurable in milk, but we don't really know what the significance of that is. With regards to the baby risks of taking it, for some people, their symptoms are going to be so serious that any potential small risk is less important to them than getting the treatment. And that's obviously a very individual thing that you know, when I'm not here to say, what's an acceptable risk for anyone else. So, yeah, I started off thinking, Oh, I'm sure HRT is fine, because most medications are, and then I've looked into it a bit more and found that actually, the information is quite vague. We don't have a lot of stuff available. And it's gonna be really, really individual to different people in terms of the symptoms they need treating in terms of where they are in their breastfeeding journey, and how they feel about potential risks.

Emma Pickett  32:09

Can I ask a really dumb question? I think a lot of today is about we don't know. And there isn't necessarily a different answer to this. And, and, you know, let's face it, who was who was funding research in HRT and breastfeeding? Not a lot of people. But I guess one question I would have perhaps, perhaps for you, Claire, or maybe you Tamsin is that? If we're taking HRT, aren't we going back to sort of normal levels, if that makes sense? I mean, people take the combined contraceptive pill while they're breastfeeding. That's got some oestrogen happening, people are taking on progesterone. People are pregnant while they're breastfeeding, and we've got oestrogen and progesterone happening there. Isn't HRT just going back to a baseline? Why would that necessarily be harmful?

Dr Claire Phipps  32:52

Yeah, so this is a really good point. So when you look at contraception, for example, we know that the faculty of sexual and reproductive health suggests that we can start the combined oral contraceptive pill that was six weeks postpartum for breastfeeding mums, and there isn't a huge amount of evidence to say that it reduces milk supply milk, performing breastfeeding performance. Now, there are some that it will of course, do that because no two women are the same. And the reason we started at six weeks postpartum is so that we can establish breastfeeding. And if you've had, you know, in those first six weeks after birth, you're more at risk of a clot. So we don't want to give you something that could increase that any further but certainly after, after six weeks, we know that we give the combined pill and other combined pill contains ethanol estradiol, and off often a synthetic progestin. Those two in their, in their in their own right. And the studies that we've got suggested that less than sort of 1% of that oestrogen is absorbed is excreted into breast milk. So actually, we give it breastfeeding moms give it take it, and their babies are very safe. So we've got that one aspect of things. And then when we look at hormone replacement therapy, what we're thinking about it was trying to give the most body identical preparations possible these days, and certainly to breastfeeding moms. That is what we would think about giving if we were going to get that and I take a very pragmatic approach to this. It's just based on symptoms. It's based on quality of life. It's based on having that shared care discussion with somebody. But when we think about body identical forms, we're thinking about hormones both oestrogen and progesterone that exactly resemble what our ovaries have naturally produced. So when I think about that, and I think about the doses that we're using, which are very low, and don't forget, HRT is not a contraception so it's very dissimilar to that combined pill. I think how is that doing harm What is the harm that's doing? Unfortunately, we have no evidence for it. There is not the evidence there. But I think that if we're thinking about women very pragmatically, and we've got someone sitting in front of us that says, I really would like to try it, and we've done a really good thorough history, then using body a bit identical preparation seems sensible. And that's not going to be the case for everyone. We've got to think about people very holistically again, think about their past medical history, think about other medications they might be taking. But when I think about body identical preparation, like you said, Emma, we're just giving that small amounts of hormones. And there is always going to be a risk that giving oestrogen might suppress breastfeeding. Absolutely. Do we have the evidence on that? No, it just isn't there. 

Emma Pickett  35:47

Yeah,  I mean, we do see them in terms of will recognise this as well, we do see, some mums behave differently when they're taking hormonal contraception and milk supply does seem to drop even the progesterone only pill for some mums seems to have quite a knock on supply. Some people hit very hard when they take the combined contraceptive pill. And, you know, the breastfeed network is a bit nervous around that taking it from six weeks message just because of that risk. It's very hard to get a message around combined contraception. So if someone's sitting in front of you, and your professional opinion is that HRT does seem to make sense. It sounds as though as a practitioner, you possibly would prescribe it for somebody who is lactating, but that's your that's not licenced the drug is not licenced, for product lactation. That's, that means that you take personal a personal decision that, you know, you will then liable for and there are some doctors who are not doing that. Is that is a less comfortable with that. Is that what you're finding? 

Dr Claire Phipps  36:43

Yeah, I think for any woman that is breastfeeding, or for any woman that has a complicated medical history, for example, I would want that person to be seeing a medical specialist so that they can have that full shared care discussion. And we don't get we use lots of lots of medications off licence all the time. We know and we don't bat an eyelid about it. And HRT isn't really any different to that. It's just another medication that we use high dose cholesterol medications for people that are resistant to cholesterol, high dose blood pressure, high dose antidepressants, and they're all off licence. And again, we're having that shared care discussion. I'm not going to make someone use it, nor would I want to, but I'm I'm having that discussion with him about what I think would be in their best interests, providing them with the evidence, we have been clear about the evidence, we don't have a thinking about whether or not a trial of treatment would be worth it for them. 

Emma Pickett  37:38

Absolutely. Do you meet people taking HRT while they're breastfeeding terms? And is that something other people are getting access to as well?

Tamzin West  37:45

I've come across a few Not, not loads so far, but I'm sure that that is something that will increase. 

Emma Pickett  37:52

So when somebody is right, this is this is asking the dumb questions. Now, if somebody's taking HRT date, and they are very menopausal, they are still fertile. They can still get pregnant while they're taking HRT. So you might have someone that's just taking HRT gets pregnant, wants to continue HRT after their pregnancy, and they may be taking it for several years, right across their, their, you know, conception and parenting experience. Would you necessarily change somebody's dosages when they're postpartum? Have you actually had an experience of helping someone across that that whole journey? Claire,

Dr Claire Phipps  38:31

are you talking about having HRT whilst you're pregnant? Or kind of?

Emma Pickett  38:35

Well, I'm just thinking if someone had HRT before they got pregnant. Yeah. Presumably, they, they might perhaps still take progesterone during pregnancy or something? What does that sort of whole kind of arc look like?

Dr Claire Phipps  38:47

So we wouldn't advise anyone to continue using HRT when they're pregnant. Because you've got your natural pregnancy hormones both oestrogen and progesterone kind of going sky high, but postpartum, depending on if you're breastfeeding or not. It might be something that you want to return to. Yes, some women don't. But we do have we do see women who have started it is almost as part of an infertility journey as well and have got pregnant stopped it had their baby and then and then restarted it postpartum. Yeah. What we want is it ideally, we want to start hormone replacement therapy within within 10 years of the menopause. So 10 years of your period stopping either that's before after, because we know it gives you the best long term health protection. But stopping and stopping and starting it isn't ideal. But if a woman is is still of reproductive age, and still has her natural hormones, then actually she's getting a lot of the long term health benefits from her own hormones that perhaps postmenopausal women aren't getting. So it would be reasonable to restart it.

Emma Pickett  39:55

Okay. And if somebody thinks they might have perimenopause or so In terms but isn't going to take HRT, are there other things that they can take to give them the relief of symptoms? I mean, this is slightly embarrassing here. But I remember in the insects in the city, Samantha ate lots of yams. I mean, I'm not suggesting we will go and eat yams. But are there sort of natural remedies that are people that people are taking? What can people do apart from HRT? 

Dr Claire Phipps  40:20

It's really interesting, because the the natural progesterone that we use in hormone replacement therapy today is called each dress down. And it's made, it's made from yams. So it's a really natural, natural product. But yeah, I think as part of any pre menopausal consultation, what we want to be doing is not just talking about HRT, what we want to be talking about is the alternatives to HRT, of which there are many. Some of them which are prescribed and the prescribed ones tend to be for individual symptoms. So we have some medications, such as antidepressants that can be really helpful for hot flashes and night sweats. We have some that are really helpful for mood disorder. We have a set of medications that can be helpful for palpitations in the perimenopause, some for pain, some for joint aches, all of these, these, these medications are very, very good at controlling individual symptoms, they're less good at controlling a collective group of symptoms like hormone replacement therapy, and they are not good at giving us the long term health protection that hormone replacement therapy does give us. But they are part of a toolkit that we offer all women because it's really important that they that everyone knows there is an alternative aid for HRT if you can't take it, or if you choose not to take it. And that's fine, we mustn't leave those women out of this conversation. So the medications that we often use are things that things that help those individual symptoms. And then we also have the alternative treatments. So we know that there's some evidence that well, good evidence of that, that cognitive behavioural therapy can be really helpful for the psychological symptoms of perimenopause. And it's got a bit of a bad press recently, a cognitive behavioural therapy. And I don't know why. But it's really helpful. And for some women, it can be a real lifeline. We know that acupuncture can help some women, we know that Pilates and yoga can help some women as well. So thinking about those alternatives. And we mentioned magnesium before there is a small amount of evidence that magnesium can help with sleep, not huge amounts. And there's a small amount of evidence that some herbal remedies can help with symptoms. The one thing I would caution over herbal remedies. herbalist, is just because they're herbal doesn't doesn't necessarily make them safe. And also, if you're breastfeeding, and that's really important, some of these can be excreted in milk. So we've just got to be careful about that and the interactions between other medications that you might be on. 

Emma Pickett  42:44

Yeah, yeah. Okay. Thank you. Yes, I think it's really important to make that point about herbal stuff. We see that in lactation as well. People take herbs to increase milk supply and assume there are no side effects, whereas something like Fenugreek and can hit people hard, especially if they've got certain medical conditions. So we know that perimenopause can affect depression and, and anxiety. And one of the people I'm working with a lot at the moment are people who are ending their breastfeeding journey. Would it make sense that when somebody ends their breastfeeding journey and loses that oxytocin, they're likely to be hit harder, by those sort of post weaning blues and post wedding depression, if they are pre menopausal? 

Dr Claire Phipps  43:22

When you first start breastfeeding, as you'll know that kind of immediate hits can can feel can feel dreadful. And I think what I would do is I would give that time I would really see if that picks up. So I wouldn't, I wouldn't immediately say like this is perimenopause, until we've probably given it four to six weeks of really seeing what your natural hormone levels are doing. Do your cycles return. Are there other symptoms alongside those psychological symptoms that that might be going on? And it's that time which can be really difficult for women, because you're kind of you're, you're basically waiting, and we want to wait to see what's going on. But yes, when you if you come through that and you're still experiencing symptoms, and you're over the age of 14, particularly over the age of 45, perimenopause is almost certainly going to be part of that picture, whether or not it's the portfolio picture, we don't know, but it's certainly going to be there and rearing its head.

Emma Pickett  44:17

Yep. Thanks, Claire. So, so I posted on my Instagram to ask if anyone had any questions about perimenopause and lots of questions fired up. So if we can perhaps look at some of those questions together. Now one of them. I'm going to ask for your help with terms in here. One of them was about whether there's a link between breastfeeding duration and the timing of perimenopause or menopause, to somebody breasts, someone's breastfeeding choices seem to make a difference with the timing of them and at menopause.

Tamzin West  44:43

Yes. So there was a big study on this. By Christine Langton itself from the University of Massachusetts. They looked at just under 109,000 women aged 25 to 42. And this took place between 1989 and 2015. So it was long term. And they looked at the association between the number of pregnancies and early menopause, and the duration of breastfeeding and early menopause, and the combined effect of pregnancy and breastfeeding, and menopause. The age of menopause itself was not necessarily affected, but they were looking at the risk of early menopause happening ie before the age of 45. And what they found was that breastfeeding regardless of the number of pregnancies, breastfeeding for more than two years, gave a 26% lower risk of early menopause. Compared with women who breastfed for less than one month. The lowest risk of early menopause occurred in women who had had at least three full term live births, and who had breastfed fully for seven to 12 months. And then the risk was 32% lower compared with women who hadn't had at least three births and who hadn't breastfed for that long. So breastfeeding on its own, reduce the risk quite a lot. Breastfeeding, in combination with at least three full term pregnancies have the lowest risk of early menopause.

Emma Pickett  46:39

Okay, that's interesting. So, so early menopause is defined as before 45. Is that Is that right? Is that or how we define that? And I guess it's worth just reminding ourselves that menopause is described one day menopause is, you know, the day after you haven't had a period for 12 months. It's not a several years. It's, it's perimenopause. That's the several years. Okay, so do we know why that's happening? Do we have a sense why breastfeeding will be having that impact?

Dr Claire Phipps  47:09

I suspect it's because and this is an amazing study, like, like Tamzin said, because it just because of the number of women involved, and you know, we rarely get these large studies that give us really good evidence like this. I suspect it's because we're not ovulating. So we're holding on to the eggs. And when they hold on to the eggs, we kind of push the time back a little bit as it were. So we've got to remember perimenopause. And the time of menopause is really predicted by how many what are they bear in reserve is how many eggs we've got that develop and form into into viable follicles that are released at ovulation. So when we're breastfeeding or pregnant, we're obviously not ovulating. So we're holding on to those eggs and that oestrogen isn't, well, those eggs aren't driving oestrogen loss.

Emma Pickett  48:01

Okay, that makes sense. So one of the other questions said, Could breastfeeding increase the risk of nutritional deficiencies that might then present as perimenopause, 

Dr Claire Phipps  48:13

you're properly experts on this...

Tamzin West  48:16

We'll say So, generally, when we're lactating, we have higher requirements in terms of nutrition and various nutrients. Calcium, for example, when we're lactating, we have a much higher requirements. So in that respect, yes. Because if we're not taking in those nutrients that we need, then that could present in terms of health issues. For most people, if you're following a generally good balanced diet, most people are going to be okay. But that's not always easy when you've got young children and not a lot of time, and you're working and doing everything else. So sometimes we do need to put a bit more thought into it. If you're vegan or vegetarian, you're going to need to think about things that you'll be 12 Your ID, maybe it is really important for thyroid function. Vitamin D, is important for everybody. Protein, a lot of women particularly don't eat enough protein. And so we so it's, in some ways, not difficult to get into nutrient deficiencies, particularly, you know, postpartum and when you're breastfeeding as well. So I don't want to say it's, it's a massive risk, but it is something that we need to be conscious of, I think.

Emma Pickett  49:44

Yeah, I mean, for me, I think it's, we mustn't forget that we're talking about parents of young people. You know, if you're a mother of a two year old, whether or not they're breastfeeding, it's very easy to get into nutritional deficiency. If you're working and you don't have time to eat and you're you know, not prioritising your own eating. and

Tamzin West  50:00

your dinner is your two year olds leftovers. Yeah, exactly

Emma Pickett  50:03

leftover fish fingers or whatever it might be, although fish fingers isn't bad for for some of these vitamins, but you know, we I mean, I often say, you know, breastfeeding is the norm. Breastfeeding is what we're expecting our bodies to do. But we're also expecting to, you know, be be parenting in a village and have other people looking after us as well. And we're not expected to work full time and all this other stuff as well. So I'm not sure we could say that nutritional deficiencies would cause every Peri menopausal symptom, I think tiredness would be an obvious one, if you're deficient in vitamin D or will be 12. You know, if you're feeling tired and rundown, you know, that's going to present itself. But, but but rage anxiety, I don't think we can necessarily attribute that to nutritional deficiencies. Claire, can you talk to us about sleep and nutritional deficiencies? How could perhaps sleep become affected if somebody does have a nutritional deficiency?

Dr Claire Phipps  50:59

I think sleep is a complicated one. Because I think, you know, if we, if we're not eating well, and we're not nourishing our bodies, and then then often what we what we know is our sleep is disturbed. We're all guilty of you know, having that extra coffee because we're exhausted and then we think about caffeine. We think about, you know, alcohol, those are also going to be depleting our system of natural nutrients like vitamin B 12, particularly so I'm in. So if we're not getting those, then yes, sleep can be disrupted. But also, if we think about perimenopause, we know that and also breastfeeding without low oestrogen levels, but ticularly, perimenopause. Really, it changes the way our bodies can sleep. So we might wake up with more hot flashes and night sweats, we might have to go to the toilet to pee more frequently. We might also suffer from restless legs and restless legs is something that's really common that can wake us up. And it's just that sense that you've just got to move. And that can also be a result of low iron, low ferritin and a low blood count as well. So we often see that both in Peri menopausal women and in postmenopausal women, and if that's related to a nutritional deficiency, that's obviously easily remedied. Sometimes we have to give a supplement for that. 

Emma Pickett  52:21

Yeah, thank you. So one question was, how does the combination of perimenopause and breastfeeding affect fertility? Now, I don't think we're going to be able to unpick that if someone's thinking about breastfeeding and fertility, I would signpost you to a conversation I had with Carol Smith ibclc, who has written some excellent articles on breastfeeding and sub fertility. And I also did a podcast interview with her about breastfeeding fertility that I would signpost you to I don't think anyone's going to be able to unpick that and tell you what's about breastfeeding and what's about perimenopause. Claire, just talk us through how your fertility changes during your prep perimenopause. There's sometimes people say that you your body kind of chucks out more eggs towards the end before you become menopausal. Is that true? Do people go through a kind of more fertile period? Well, you know, is that a myth? What's happening with our fertility? 

Dr Claire Phipps  53:14

Yeah, I'm not sure I'm not sure that's entirely true. What we what we see when we look at oestrogen levels in the first stages of perimenopause is slightly ever so slightly spike. So they go slightly higher than what we would normally have in that part of the reproductive cycle. And so there is a theory that your body is really it's really pushing itself to try and ovulate and it's really desperately trying to avoid it. I'm not sure that we ovulate more, because our cycles or our cycles, and they will they will be triggered by natural rises and falls in our hormone levels. But fertility will gradually reduce as we progress, obviously, through the perimenopause. And one way we can we can look at that is measuring blood tests. And we can do a blood test that looks at what your ovarian reserve is. And that gives us an idea of how well follicles if you like our ovaries are, but yes, our fertility will reduce and it will gradually reduce until the point of our medicals when we are no longer able to conceive. 

Emma Pickett  54:18

So next question says My gut feeling is that breastfeeding is currently holding the full force of the perimenopause at bay for me just now. I'd love to know if there's any science behind this hunch and what I can expect when I stop breastfeeding. I'm not heard that. I can't imagine how that would work. How breastfeeding would hold back perimenopause. What do you feel when you hear that? That question? Either of you?

Tamzin West  54:45

Yeah, I'd agree with you. I can't really see. The only thing I can think of is what you've sort of touched on earlier with the oxytocin effects in terms of your general feelings of well being. But in terms of There's sort of physiological changes, I can't really see how that would be the case.

Dr Claire Phipps  55:06

Yeah, I would agree. I think physiologically, I don't see how that would work. Apart from the oxytocin. 

Tamzin West  55:14

One of those things, I guess we can't really we can't really know or check. 

Emma Pickett  55:20

Yeah, that's again, going to be a hard to unpick for sure. I mean, in a way, it's kind of nice that she feels that breastfeeding is having that positive effect. I mean, that's the positive thing. So I wouldn't want to say no, lady, you're living in delusion land, because that's not a positive message. But I think it would be unlikely that it would be having that physiological effect. Let's talk a bit about bone health, and perimenopause. Tamsin, what have you found out about sort of bone health?

Tamzin West  55:46

Well, Osteoporosis is a big deal. Menopause post menopause will bear some inflammation, that bone density does reduce temporarily when you're breastfeeding during pregnancy as well, but then is restored once you've weaned. And to be honest, I found quite a lot of conflicting information about this. I'm sure Claire will will add. But I did find a study of Chinese Chinese women, which found that breastfeeding was not associated with osteoporosis after menopause, once they controlled for age and BMI and the number of pregnancies. 

Emma Pickett  56:26

Yeah, I mean, is it possible that somebody who's ending their lactation close to menopause may be at greater risk of osteoporosis? And they haven't had time to lay that calcium back down again? Do we have any information around that occur?

Dr Claire Phipps  56:41

So the information we've got it really clearly is is as we lose oestrogen, our bone density for significantly on so if our oestrogen levels are persistently low, that it would, in theory cause a reduction in bone density. So if we're breastfeeding or breastfeeding multiple times, and there's multiple time periods where we're not having cycles, and we're not having high dose oestrogen, it would make sense that perhaps your your bone density isn't as good as perhaps someone who who didn't have that, that sort of regular pregnancy and breastfeeding. What we know about bone density and what we know about oestrogen is oestrogen is the driver about have good bone health. And so really, what we need to be thinking of is like Tamsin was mentioning earlier thinking about calcium and vitamin D in our diet if we are breastfeeding. And if we're having multiple pregnancies and multiple episodes of breastfeeding, because our estradiol levels will be low. And as a result, our bone density there's there is a risk of our bone density reducing. I'm not clear on how much that reduces from a lactational perspective. But certainly from a Peri menopausal and postmenopausal perspective, there's a lot of evidence that suggests that our bone density reduces significantly as we progress through to the perimenopause, menopause and beyond.

Emma Pickett  58:05

So if somebody is older, and they're lactating, I guess calcium supplements and vitamin D do really become quite important. You don't want to be in that situation and insufficient and calcium in your diet as well. And I guess that would, hopefully it's something that people will be aware of and be able to get support around. Yeah, so much unknown. I mean, I had a look at some of the research around bone density. And it's very difficult to find information that talks about older mothers really, really hard to pin it down. One question here from somebody who's 51, she says, I'm 51. I'm breastfeeding my four year old, my F S H levels would indicate I'm menopausal. Now, I found that interesting because that so follicle stimulating hormone is going to be affected by breastfeeding. So someone's obviously done a blood test for this woman and said, Oh, you've got low FSH, you must be menopausal. But that's what we would expect if somebody was breastfeeding. So I don't know how that has that conclusion has come about. 

Dr Claire Phipps  59:08

But I wonder, I wonder if that's because she's four year old is, is obviously having regular meals, I imagine and the breastfeeding is is not exclusive, really anymore. So in that perspective, her natural hormone levels will start will start to change a little bit. So it might be that, you know, she's breastfeeding once a day, in which case perhaps doing a blood test might help. I'm not sure I would do a blood test and a 51 year old though for the same reasons, as we discussed before. Even in someone that's not breastfeeding, it's not always helpful, certainly over the age of 45. But in someone that is breastfeeding, I'm not sure it's very helpful. I think she's probably going to be at the very least Peri menopausal 

Emma Pickett  59:54

and potentially if she does want to take medications, as you say it would be that tailored approach possibly even talking about HRT if she can find a practitioner who's going to have that holistic conversation with her, and and taking HRT alongside breastfeeding isn't necessarily a complete No, no, it's just something that has to be very much personalised. Okay, next question says, I'm 39 I stopped breastfeeding my four year old daughter two years ago, since my periods returned at month 15. They've been shorter by three days and more frequent now every 25 to 26 days. Is this down to being perimenopause or postpartum? So she stopped breastfeeding two years ago. So for me that that suggests we're talking perimenopause. It's not about being postpartum at this point. Would that be a fair description? Do you think?

Dr Claire Phipps  1:00:45

Yeah, I mean, it could be perimenopause. It could be other things. So again, it's the things that we thought about earlier, it's thinking about very holistic approach. What else is going on what you know, whatever bloods doing? Because she's under the age of 45, it would be helpful to do a whole host of blood tests just to rule in and rule out things. So perimenopause is one possibility, but there are lots of other things there. So that someone I think, ought to ought to speak to that GP if they can, but then also, our periods do change, and it's quite normal for them to change like that. So normalising that little bit as well is also helpful,

Emma Pickett  1:01:21

I think. Yep. So you don't necessarily stick with the same patterns. 

Tamzin West  1:01:26

25/26 days is within the realms of normal for a menstrual cycle. Perhaps they've just changed, you know, from after she's had a baby. 

Emma Pickett  1:01:36

Yeah, and it also affected by things like body weight and, and, you know, fat proportions and proportions and all sorts of different factors as well. But But 39 is on the young side, possibly for perimenopause. So therefore, you would recommend a bit more investigation rather than assuming it was would be perimenopause. Yeah, absolutely. Next question says does perimenopause affect breast milk quality, considering hormonal changes? So I've had huge issues with my boys weight gain, and we suspect it's due to my hormones. We've checked for literally everything else over three months. So can I go with this one. So it is not going to be perimenopause that affects breast milk quality, or we can say that very confidently. But it could be hormonal, it might be a thyroid issue. So this mum absolutely needs to have some thyroid investigation. If if it you know, child is only three months old. And she's in that that postpartum period, it's postpartum thyroiditis is surprisingly common. And people often don't get it flagged up and investigated properly. So, so breast milk quality, people are sometimes told, Oh, your milk isn't as fatty or your milk is, is less rich than compared to someone else's. That is not accurate. That is not something that happens. But if there's a weight gain issue, we're going to be looking at thyroid. We're not going to be thinking about perimenopause, because it three months, you will have low oestrogen, you know you will have that that hormonal profile that might look a bit more menopausal. That's the normal hormonal profile three months postpartum. It is not being Peri menopausal, that affects breast milk quality at three months is that you're agreeing with me on that terms. And I can see you're doing and

Tamzin West  1:03:20

I, I really hope when they when she says they've investigated everything. I really hope that includes the baby, as well. I mean, obviously, there's a lot of information we're missing here. But presumably, if there's slow weight gain, there's been some supplementing going on. And if there's still slow weight gain with that, then maybe there's an issue there with the baby. And that needs looking at as well. So there are so many potential factors here, but it's not going to be anything to do with the milk quality, as you say,

Emma Pickett  1:03:50

Yeah, I'm gonna really hope whoever this person is that they are getting the right support that they need, because there's nothing more stressful than then struggling with weight gain issues. But yeah, what we don't want is someone to say, Oh, you perimenopause, or that's your problem, off you go. And breastfeeding, you know, that's not someone getting the right information and the right support they need. So they should be being referred to paediatrician looking at the whole story for the baby. And they should also be talking to someone who's a lactation specialist who's giving them the whole story for them as well. So I just want to clarify that it's your use of the term milk quality in the question, not quantity, that's the red flag for us that maybe suggests you haven't been getting the breast support you need. So milk quality is remarkably stable across populations across lactating parents. Were going to get similar fat quantities, whatever's happening with diet, whatever is happening with hormonal profile, we're going to get that that's fat content varying according to how empty the breast is and what's happening with breastfeeding patterns, but not affected by the hormonal profile of the parent. But milk. Quantity. If you'd said quantity in your question, it might be something different. So milk quantity can be affect Created by hormonal profiles so people who have polycystic ovary syndrome for example, they may have reduced milk supply about a third of people with PCOS have reduced milk production. There is a rare condition where people have high levels of testosterone produced by cysts postnatally that can reduce milk production. If you've lost a lot of blood in delivery, you may have a rare condition called Sheehan syndrome, where your pituitary gland isn't able to function properly. But that's going to be a situation that won't be revealed at three months that will be revealed way before three months. Or you might have experienced the significant blood loss perhaps enough to impact on the production of your prolactin and oxytocin hormones, but not necessarily enough to stop milk production altogether. So if you've experienced blood loss, if you've got PCOS, if you have high levels of testosterone may be milk production may be impacted. But you'll be asking us about milk quantity, if that's the case, not milk quality. So milk quality is that red flag for us in this question. So if this is your story, and you wrote this question, and you want to reach out to get more support, please feel free to send me your terms in a DM and perhaps we can talk about this further. But essentially, if someone's telling you that your milk quality is affected by your hormonal profile, that for me suggests that some pieces of the puzzle are not being properly investigated. And perhaps you need to get some extra Lactation Support. Next question says I have regular periods breastfeeding a 14 month old and I also have a five year old. I'm 45. The Rage creeps up on me. And it's hard to know where it's coming from. I think we can all relate to this, those of us who've had two children particularly. Yeah, I guess we're not going to know where it comes from. I mean, I think we're never going to know exactly what would you say to that, Claire?

Dr Claire Phipps  1:06:48

Yeah. So this is a really common, really common symptom in that women have the sudden onset rage, they can't predict it, they can almost tell whether they're in it. And then when they're out the other side, they look back and go. What was that? What happened? I know. And it's it's such a common symptom. And often what we find and studies have found is that it's those oestrogen levels going wildly fluctuating peaks and troughs. And it's really hard because it's such, as I was saying earlier, it's such a horrible symptom, isn't it? It's such a, it's a symptom that that just doesn't feel like it's talked about enough or you feel quite embarrassed to talk about it. Many women feel like it's still a bit of a taboo to be really angry. It's okay. It's really okay to feel that rage and irritability. It's normal, in fact, and again, normalising the symptoms and talking about symptoms is how we get help for these symptoms,

Emma Pickett  1:07:45

and normal to have fluctuations during the month. So is it right that you might have more severe sort of premenstrual symptoms potentially in the rage could be in that period? Because I'm, quite often when I'm talking to clients who are weaning or struggling with breastfeeding, older children, the range and the aversion is particularly bad just before their period starts. Is that something that we see more when someone's pre menopausal?

Dr Claire Phipps  1:08:07

Yeah, so those fluctuations are hard or harder for many women, but certainly that luteal phase, if you've got a history of PMS or PMDD, we can we can really feel those symptoms more and more strongly premenstrual Aliy. And also, as you know, in that kind of one or two days of ovulation so that when we get that LH spike, the luteinizing hormone spike, but also lots of women are very progesterone sensitive. So as those levels are falling towards the end of our cycle, and our periods are coming up, and we can actually feel worse, and that might be depression, often it's rage.

Emma Pickett  1:08:41

So next question was actually from somebody who has primary ovarian insufficiency. So, obviously, this topic and the symptoms we're talking about don't just relate to older mothers and women. I know we're talking about perimenopause. But we mustn't forget we have got women out there who are younger, who are dealing with primary ovarian insufficiency. What sort of differences? Will we be talking about when someone does have primary ovarian insufficiency? And is medication different? Or is the HRT going to be pretty similar? 

Dr Claire Phipps  1:09:11

Yeah, so primary very interested insufficiency is when our cycles become irregular or stop before the age of 40. And it's really important that this is picked up. Because hormonal changes, when you're younger than 40 have very significant implications for your long term health, particularly your bones but also your heart. So the hormone replacement therapy really is the first is the first line treatment, if you can and choose to take it because it's it's really important we protect your bones and your heart and not only that, but also thinking about managing of symptoms and giving back you a good quality of life. And again, the hormone replacement therapy we're talking about here is the body identical preparation, so the hormones that resemble what our ovaries produce. So oestrogen through the skin and the progesterone Taken as a capshaw's, micronized progesterone. And that's really important it is it is a slightly different way of managing those patients who have a history of primary ovarian insufficiency, because often these women need higher doses of hormones than someone who's slightly older.

Emma Pickett  1:10:17

And the higher doses then possibly might have an impact on lactation or not necessarily. 

Dr Claire Phipps  1:10:24

Yeah, so what we know about hormone replacement therapy is if we're using very high doses, so when we say Hi, we're talking about the maximum licenced dose of oestrogen through the skin, there is a risk that it can not only reduce or stop ovulation, and then sort of by a knock on effect, I think that will that that could also have an impact on your natural circulating oestrogen levels and therefore, your ability to breastfeed? Yeah, I think that is a real possibility. I don't have the evidence to back that up. But just from a physiological perspective, I would imagine that that's how that that would would work.

Emma Pickett  1:11:00

So last question says, I'm still carrying extra weight after my pregnancy, when my weight was fairly stable for years. Could that be about perimenopause?

Dr Claire Phipps  1:11:12

The answer is yes. But then, again, sticking my very holistic hat on what else is happening for that person? You know, what is what is her nutrition like? What is what medication she's taking? What age is she? What other movement is she doing? What's her nutrition really like? What's our gut health like? So yes, perimenopause, again, could be one of the possibilities here. But, again, we don't want to stick everything down to the perimenopause. And that's, that's talking as a menopause specialist who loves talking about the perimenopause and hormone replacement therapy. But we've got to remember there are other things that happen. It's not just going to be perimenopause, necessarily. So again, thinking about holistic health, yes, perimenopause. But what else is happening?

Emma Pickett  1:12:02

Yeah, I mean, I think one thing I would add is that, we hear a lot about how breastfeeding helps you lose weight. And, you know, realistically, you are burning calories, it's likely that will happen. But I do meet some mums who hold on to some weight when they're lactating. And don't seem to be able to lose that last bit until they finally finished breastfeeding. Is that something you see? 

Tamzin West  1:12:23

Yeah, yeah. And I want to say I really feel, feel this is I mean, my youngest is just about to turn four. And it's taken me a long time to lose the weight from third baby than it, you know, compared with second baby, so I feel you there but yeah, I mean, there are so many, again, so many factors, my lifestyle is different. The time available to me is different. So, yeah, there's so many possibilities there, aren't there?

Emma Pickett  1:12:55

Yeah. So let's finish by imagining an ideal world where we're going to give women and lactating parents the care that they need. What would you like to see if you had a magic wand? Tamsin, what would you want to be available to people who are worried about questions around lactation and pre menopause?

Tamzin West  1:13:16

I would love to see better lit people with the knowledge in both areas, or teens, I suppose the wonderful thing would be teams. So somebody like Claire's that, you know, got the menopause specialism knowledge, able to sit with somebody like you, me, Emma, who's got the lactation knowledge, and we can have a conversation all together, and we can investigate all the things all together. That would be wonderful, wouldn't it? Yeah.

Emma Pickett  1:13:46

Is there any areas for research when you were looking at some of the research? Is there any areas where you think, oh, we need more research here? This is a real obvious gap. Yeah, all of them. All of the areas? 

Dr Claire Phipps  1:13:59

Yeah. For me, me, it's particularly around hormone replacement therapy, and breastfeeding, because it's so it's so vital, you know, but I mean, more more research into women's health in general, obviously. But I agree times in that collaborative approach that MDT solution, because we're all specialists in our own field. And just bringing us all together is incredible, because you've got so much knowledge that could be so helpful for so many women. It's just that it's almost like creating women's health clubs, isn't it? It's just somewhere where women can go that they can have access to everybody that they need, you know, in an MDT approach, so we can discuss everything that would be the dream. Yeah,

Emma Pickett  1:14:41

yeah. I second that. And I think watching out for the scapegoat problem. When we live in a world where people don't know a lot about menopause. And we live in a world where people don't know a lot about lactation. You're gonna rub up against somebody who will blame one thing when it actually could be thyroid could be nutritional deficient. See could be someone's just burnt out or, you know, we we just need to look at the whole story. And I think we are we are seeing conversations around menopause happening more than that you then used to be the case. But we need to be careful that we don't then latch on to that. And that becomes our entire focus without looking at other factors as well. And I'm, I'm hugely respectful of your approach, Claire, because I can see how you regularly throughout this hour said, you know, we must be careful, we're not assuming it is menopause, and perimenopause. And I think some of the people I'm hearing and these lactation conversations are jumping to thinking it's perimenopause or menopause, without necessarily looking at other issues. It can be quite hard when you go in to talk to your doctor to ask for a thyroid test. And it's you may get someone who just says, oh, no, it's probably you're breastfeeding. You know, why don't you just stop breastfeeding. But if breastfeeding matters to you, you have every right to continue breastfeeding, somebody should allow you to continue breastfeeding, and continue to investigate what's going on and look at other factors. No one has the right to say to anybody, stop breastfeeding. And we'll see what happens to your symptoms, that should not be a response to this in any way. Because you know, you're going to be losing that oxytocin, which could make other symptoms much worse. So, you know, we've need to respect people's choices and make sure people have the right information. But I'm heartened by what you're saying, Claire, that HRT is not a definite no, no, when someone is lactating it should it be possible for someone to get that tailored care if that is the right decision for them, which I think is good news. Is there anything you would add to terms and before we wrap up,

Tamzin West  1:16:38

I wanted to ask Claire, a question actually, about how I don't know if you know, but how easy is it for people to get hold of menopause specialists GPs? 

Dr Claire Phipps  1:16:50

It's a really great question. So if you're looking for a medical specialist, you can go onto the British Medical Society website. And they've got a link on their website that says Find a specialist so anyone's registered with the British Medical Society specialists will be on that link. If you're not sure about your surgery, for example, then I would speak to your receptionist and just find out who deals with then, of course, most who signs the most HRT prescriptions in that practice, and they'll be able to sign up signpost you to that person. And don't forget, if you don't feel like you're getting the advice that you want, or you feel like you're being told something that's just really, like you were saying, I mean, being told to stop breastfeeding, we feel that's the advice that just doesn't sit right with you. And asked for a second opinion, asked to see somebody else asked to be referred to a medical specialist clinic within the NHS. There are lots of them out there, the waiting list is pretty long for most of them. But get that process started. And perhaps by the time you get to that referral, you might not need it if you found someone else within the practice that can help.

Emma Pickett  1:17:57

Okay, good advice. So we'll put the British menopause Society website in the show notes. Are there any other resources that you think we should mention in the show notes either of you that you think are particularly valuable?

Dr Claire Phipps  1:18:07

I would do a big shout out for the medical support booklets that Diane Danzebrink has written because they are really great at just giving a very holistic overview of menopause and they are applicable to early menopause or menopause. The average age in the UK, so just the menopause support booklet, Make Menopause Matter.

Emma Pickett  1:18:31

Okay, brilliant. Thank you very much. Thank you very much, both of you. I think this is a conversation that will continue. And I know there's some people maybe not didn't get the answers they needed from today, but that's because they don't exist. So let's keep fighting the good fight. And we can check out your your special Instagram account Tamzin. And we'll make sure I make sure I put that in the show notes because I know you're continuing to share your findings in that in that account as well. And I'll also make sure that your account is in the show notes as well. Claire, thank you very much for your time. Both of you really appreciate it. 

Tamzin West  1:19:01

Thank you. 

Dr Claire Phipps  1:19:02

Thank you. 

Emma Pickett  1:19:07

Thank you for joining me today. You can find me on Instagram at Emma Pickett IBCLC and on Twitter @MakesMilk. It would be lovely if you subscribed because that helps other people to know I exist. And leaving a review would be great as well. Get in touch if you would like to join me to share your feeding or weaning journey, or if you have any ideas for topics to include in the podcast. This podcast is produced by the lovely Emily Crosby Media.