- 16 hours ago
- #thefutureisfemale
To mark World Menopause Day on October 18th, this episode of #TheFutureIsFemale highlights the importance of menopause awareness, because every woman deserves an open conversation about this crucial life stage. Melisa Idris speaks with Dr Premitha Damodaran, Consultant Gynaecologist and expert on menopause and women’s health. In 2022, she led the development of Malaysia’s Clinical Practice Guidelines for the Management of Menopause, followed by an ongoing nationwide educational initiative for healthcare professionals. She was recently awarded the Wulf Utian Award at the International Menopause Society’s World Congress on Menopause in Brazil, for her “outstanding contributions towards advancing menopause education and women’s health”.
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00:10hello and good evening i'm melissa idris welcome to the future is female this is the show where we
00:16find the extraordinary in every woman and to mark well menopause day on october 18th today on the
00:22show we'll highlight the importance of menopause awareness because every woman deserves an open
00:28conversation about this crucial life stage which is why i'm delighted to introduce my guest today
00:34dr premita damodaran who is a consultant gynecologist and expert on menopause and women's health
00:40in 2022 she led the development of malaysia's clinical practice guidelines for the management
00:46of menopause and that's been followed by an ongoing nationwide educational initiative for healthcare
00:53professionals and i'm also delighted to announce that recently she was awarded the wolf utian award
01:00at the international menopause society's world congress on menopause in brazil and this is for
01:07if i may quote the award for her outstanding contributions towards advancing menopause
01:12education and women's health so dr premita welcome to the show thank you so much for joining me
01:17so you have spent your whole career being a gynecologist but now this but menopause has in
01:24particular become a focus of your work and i was wondering was there a point um in your clinical
01:30practice where you realize that actually women really were struggling with this period of their
01:37lives that there were um there's such little space to talk about menopause at what point was that
01:44where you decided to really focus in on menopause health well i think i i actually was very lucky to
01:51be very honest when i finished my specialization in 1995 um i had a very forward-thinking boss
02:00who actually pointed me in the direction of menopause and he said i was in university malaya at that time
02:07university hospital where it was called at that time and he said pramita go and start the
02:13menopause clinic there and so i think that was my first foray into learning more about menopause and um
02:22so yes i did i started the menopause clinic there uh in 1996 and um and that went on till
02:29i left you
02:30know in 2000 so when i actually started the menopause clinic and i think that's when i got to know
02:37that
02:37there were so many women actually needing help and i was learning menopause alongside them so you
02:45were a young doctor at the time and menopause far from the horizon what did you learn in medical school
02:50but nothing okay absolutely nothing except that it was the end of reproduction isn't that so sad that
02:58is you know and then you know we we talk about it so negatively because you know you don't have
03:04babies
03:04anymore that's the end of reproduction and then we equate that to the fact that you can get hot flushes
03:11on night sweats and and then came the era of okay you're going to get osteoporosis after that or your
03:18chances of getting bone loss and you know fractures increase after that and full stop you know and so
03:26when you get into it more and more you realize that there is this whole interplay that actually
03:33works on the woman completely every part of her body actually changes when she loses that estrogen
03:44during the menopause and that's really um you know very um in many ways that woman needs to know
03:51definitely so 2026 today but in 1996 take me back there what did you know in what do you know
04:00now in
04:002026 that you did not know in 1996 that was it's really crucial development for menopausal health i
04:07think one thing that or rather you know let me let me look at 30 years of menopause education for
04:15me
04:15all right um one thing that i have learned is that it is not all about the hot flushes and
04:23night sweats
04:24because if you look at malaysian women we it's they are complaining about generalized joint pains and
04:31that's the leading symptom that our women are experiencing um and is it only malaysia and i can
04:39tell you that's asian data we are getting similar data in singapore indonesia thailand our women don't
04:46experience hot flushes or night sweats or my theory is the fact that they do have it but our weather
04:53is
04:53so great that they you know sometimes minimize it until it gets to that threshold that they can't
04:59actually manage it but they are suffering from generalized joint pain sleep disturbances mood changes
05:06digestive issues so this is what they're actually coming in with but what do women do they they don't
05:13they don't think about joint pains as being an estrogen deficiency problem or a menopause problem
05:20they think it's i'm aging i'm getting older you know and and then they deal with it very very
05:26differently so that's one thing that i've learned okay the other thing i've learned is the fact that
05:31the mental health issues oh my god you know how much the whole transition zone when the hormones are
05:39actually changing the estrogen levels are going up and down during the perimenopause how that can
05:45actually work on mental health and how that can bring about the mood disorders the feeling low um this
05:53and then compounded by the sleep issues that come in and when you don't sleep you feel irritable moody
06:00the next day and then you when you go to sleep the next night you think oh can i go
06:04to sleep tonight
06:05will i be able to sleep because i may have to deal with children going to school or you know
06:10bosses
06:11who are going to ask you for certain assignments or any other issue you know so that compounds that
06:17overthinking in the brain and then that makes you know the that particular person even more irritable
06:25lose her self-worth because she feels that she cannot cope with things wow it's um really affects the
06:31woman's ability to function on a daily basis at home or at work i love that you brought out all
06:36the
06:36different symptoms and i absolutely agree with you that a lot of the conversation around menopause has
06:40always centered around hot flashes or night sweats talk to me about the cumulative effect of symptoms
06:48on a person and how do we make that distinction um especially as a medical professional but also as someone
06:55who may be a woman who may be thinking that she's experiencing some of the symptoms how do you
07:01um differentiate what can be a menopausal transition versus the effects of aging versus say risks that can
07:09be modified through treatment or prevention so let's take a woman who is transitioning i know so she's getting
07:16her periods normally now she is going to what we call the menopause transition where her periods may be on
07:23and off um sometimes earlier sometimes later her period flow changes sometimes lighter sometimes more
07:32towards the fact that she now goes into menopause and menopause means no periods for one year
07:38so that's this transition time can be in some women three years in some women can be seven years
07:44okay so we different for everyone everyone woman is different so during this time a lot of these women
07:51are actually having symptoms now i'll be the first to admit that there are women that breeze through
07:57menopause without any symptoms good for them but most actually have some sort of symptoms and so let's
08:04look at someone who as i said having joint pains today pain here tomorrow knee pains pelvic pains that
08:12just don't go off with just two tablets of panadol it comes back and it comes back and what do
08:19women then
08:19think about they think they start worrying about those things then you compound it with what i said just
08:25now you have sleep issues you get headaches you get bloating in the tummy you feel hot sometimes you
08:33get sweats at night your you know your irritability level changes now women are fantastic at multitasking
08:42and i'll be the first thing that you know first person to tell you that
08:44we can manage 10 things at one go but when we get tired and we get fatigued with all the
08:52other
08:52changes that are happening to us we cannot multitask and that's when we really think oh my god
09:00something's really happening to me and they feel very worried about how they are going to cope so now
09:08you take this particular woman who is now say mid 40s children maybe you know in their teens maybe
09:16teenage problems children who are going off to the university um you know and and handling all that
09:23parents who or parents-in-law who may not be actually very well yeah getting older financial issues in
09:31the family this lady might be working may actually have reached a certain position
09:35um and now finding that she's not being able to cope so life stresses are now coming in to that
09:43particular woman who's trying to handle all these hormonal issues before she could handle it but now when
09:52that estrogen is swinging she finds it more difficult to handle it so then that causes that domino effect
09:59the spiral effect that just keeps becoming worse and worse so that's what the menopausal symptoms are
10:06all about now again as i said some handle it very well but many actually don't and we i always
10:14use this
10:14figure of one third handle it well you know um or rather one third don't have any symptoms one third
10:20handle it well and then you have that 30 40 percent of women who are really struggling and i think
10:26we need
10:26to listen to them we need to actually help them because it is not fair to that woman it's not
10:31her fault right and you know and it's it's more the fact that we as healthcare professionals we need
10:37to be able to understand them and then guide them through that transition zone because this is also
10:43the time as you correctly said what are the things that are happening in the body her cholesterol level
10:49starts slowly creeping up oh cardiovascular health right um the sugars might go up her blood pressure
10:57now changes but metabolically in her body she is losing muscle she is gaining more what we call
11:06the visceral fat or the midsection and that's where the mid-drift weight gain comes in and when that weight
11:14gain comes in it actually increases your cardio metabolic issues right so everything again becomes
11:22worse for her in her medical health wow and you know what the studies have actually shown is that
11:29these changes can start about six years before that last period so it's already happening sometimes
11:35in your early 40s or mid 40s even though your last period might be in your 50s so again silent
11:43changes
11:43that are already creeping in the whole body is responding to this um to the changes in in
11:50estrogen in hormone level can you talk to me a little bit about hormone therapy it is it remains a
11:56subject of considerable confusion but there has been so much um changes in the evidence over the years
12:02tell me about that so we are going through menopause means going through a hormonal change your
12:09estrogen levels are changing um so when a woman is actually suffering through the menopause we tend
12:17to then talk to her about hormonal therapy that means putting back that estrogen into her body to
12:24stabilize her right to even out those swings so that she is able to cope with whatever symptoms that she
12:32is going through so we have many types of hormones uh when we're talking about estrogen estrogen can be
12:39given as a tablet it can be given as a gel it can be given as a spray we also
12:45have the fact that a woman
12:48we there are women who have had their uterus taken up uh for some reason you know maybe fibroids or
12:55any
12:56other issues now they only need estrogen therapy but if a woman has a uterus intact we always have to
13:05add
13:05another progesterone another hormone which is called the progesterone hormone so this balances up the
13:12estrogen and the progesterone in the uterus and so these women um uh go through the menopause a little
13:19bit better sometimes this the way that we give them the progesterone they get their periods every month
13:24sometimes no period so it's that conversation that we have with them and and then we go from there
13:30so hormone replacement therapy would be actually estrogen but progesterone comes in if she still
13:38has her uterus okay and are there still concerns around safety around the use of uh hormone replacement
13:46therapy for menopause so i think we have come a long long way since that data that came out in
13:522001
13:53in 2002 let's go back to that era that era where they actually gave an estrogen that was called
14:04conjugated equine estrogen a little bit more of a synthetic estrogen and they also gave the woman a
14:14synthetic progesterone okay so then they looked at this data that came out and that data showed an
14:25increased risk of breast cancer at that time and an increased risk of blood clots and increased risk of
14:32heart issues so the study was actually prematurely shut down okay now let's look at that study again
14:40and if you really look at that study they had women between the age of 50 to 80 80 years
14:49of age on
14:50hormonal therapy so they had this huge 30 year range and they put thousands of women on hormones and
15:00these women's were not actually having hot flushes or night sweats they just randomly put them on it to
15:07study what the effect of long-term hormonal therapy would do to them wow yeah so actually the design of
15:15the study was not correct and thus when the results came out it was totally skewed but the bad news
15:22that
15:22came out to the world was the fact that oh my god if you take hormones you will get breast
15:28cancer
15:29so along the way we have actually looked at the data again and they then divided it into women
15:36in their 50s to 60s 60s to 70s and 70 to 80 and they found that risk in that 50
15:45to 60 no risk and they
15:48found even in the 60s to 70s hardly any risk and it was only the risk that was in women
15:55who were much much
15:56older in their 70s to 80s so that risk at that time skewed the whole data wow and but
16:05you know what bad news always comes out first right yeah so so now to try and convince that woman
16:11it takes us a lot more effort okay have you have you seen the damage done in your practice oh
16:17yes okay
16:17and how do you reverse that are you seeing changes in the way people are now um receiving the new
16:25evidence
16:25um i think we have come a little bit better and you know in terms of how women are actually
16:32accepting
16:32it um now women you know are reading more and now they understand where it's come from plus we are
16:40also
16:41moving on with the type of estrogen and the type of progesterone that we are giving so now everything
16:47is more natural so we are giving them natural estrogens we are giving them natural progesterone
16:54or what we call body identical hormones which are close to our own hormones so nothing synthetic about it
17:02so more natural hormones and because of that the safety angle is there so many women are more
17:10comfortable with that plus also last year fda actually came up with this whole they actually took away the
17:18the ban on hormones because of the fact that after the the big study that came out in 2001 and
17:262002
17:27fda actually advised all hormonal therapies in that in in the in the inserts that they have
17:35they have to put the risk of breast cancer and cardiovascular disease there yeah but last year
17:40in november that they removed it removed it so that actually that actually uh came a little you know in
17:47favor of the fact that now women are more receptive towards hormone therapy but there is a danger there
17:53this i guess double-edged sword because there is now a growing market for menopause supplements
17:59hormone related products wellness programs i want to ask you what your advice is for women to be able
18:06to distinguish evidence-based treatment versus commercial claims oh that's a big one because of the fact
18:14that um the shortcut is always easier correct yeah um you know uh okay i'm having pain let me go
18:21and try
18:21and get some vitamin b or uh some joint medication some joint supplements and see whether that would
18:27work um but why are you having pain you know and sometimes you know the shortcut to go and get
18:34something
18:34from the pharmacy is it's so much easier to go and get do that but what where we come in
18:39from is that
18:40why are you having that pain what's triggering that pain what's causing the symptoms correct okay so that's
18:46more important because otherwise you're going to uh you know minimize your pain but it's still going to
18:52linger and then that's going to become a chronic pain later on which then becomes more difficult to
18:58treat so in terms of supplements the only thing that's evidence-based um is calcium because we know
19:04that we know we need calcium in our body but even then i always tell my patients that calcium is
19:10best from
19:10diet and then we supplement what we we can't get and the vitamin d because malaysia 80 of us are
19:17vitamin d deficient so we need vitamin d so that's evidence-based but everything else you you know it's
19:23good to consult your healthcare professional and see whether you actually need it okay supplements are
19:28also expensive melissa that's true and they're more expensive than hormones but still women go on wow
19:34well well talk to me about the clinical uh practice guidelines so um when you put it we're leading
19:41the development of those guidelines for menopause management 2022 um what did the process reveal to
19:48you about how we were managing how malaysia was managing menopause at that time what were the gaps
19:53that you identified that really needed to be um addressed so i um we started the whole process in late
19:592019 and then covet took over in 2020 so actually so that's why okay so that was why the delay
20:06of
20:07everything because we had to meet online and things like that um and uh and you know we are working
20:14with
20:14the ministry of health and they are also very good at making sure that we're doing it in the right
20:18way
20:19but the gaps that we found was the fact that um the healthcare professionals did not know enough
20:25and again stemming from the fact that everyone was listening to the 20 year old data and getting
20:32scared about you know hormone replacement therapy i think it started from the fact that we did not
20:38know enough about menopause and what the consequences were we just had we just knew superficial
20:45not we had just superficial knowledge um we did not know the fact that what are the options for
20:52treatment and when i look at options for treatment i'll be i'm also very you know it's very also very
20:57important to tell the woman it's not only hormones you know your lifestyle right that is so much you
21:04know and i always start off with the lifestyle dialogue you know what you eat um you know what kind
21:10of exercises that you do your sleep hygiene cutting down the coffee you know by early afternoon um trying
21:18trying to be stress-free mixing around with friends enjoying life a little bit you know cutting down
21:25the cigarettes if you do smoke or cutting down the alcohol so all these things are actually very very
21:30important i actually spend time talking to them about how much protein that they actually take because
21:35that's really very important because if you exercise and you don't take your proteins nothing's going
21:41to work it's the muscle yeah it's a muscle mass you know so all these things and then the correct
21:45supplementation and then comes if you need it the hormone replacement therapy so hrt is not for every
21:52woman not every woman needs hormone replacement therapy but i think lifestyle is really very important
21:57to talk to them about so that's what we concentrated on awareness um knowledge about menopause how to
22:05investigate that woman who is now in their 40s and i think that's really very important because we're
22:11looking after her long-term health has she got her pap smear done has she got her um her mammogram
22:17done
22:17have you done a pelvic ultrasound does she have fibroids what's her family history like what is that that
22:22we have to look out for for her so i think that's really very important then the non-hormonal type
22:28of
22:28therapy which includes lifestyle changes and then comes a detailed section about how do we deal with
22:34hormonal therapy what's available in this country also we looked at um you know how to handle hrt the
22:41problems with hrt dealing with with um bleeding issues that might come in but our special para was
22:48about cultural differences and we actually had a section based on um you know how islam looks at
22:57menopause uh how christianity looks at menopause how hinduism looks at menopause and
23:03um you know so buddhism looks at menopause and and that was you know the the the crux of the
23:09whole
23:09thing so we had this little chapter on how women uh you know um because we we have to respect
23:17the local
23:18ethnic well the local context right so we brought that into um so that was this this our guidelines is
23:26actually very well received internationally um actually you know we have the nice guidelines
23:32from the uk uh which is like the world standard and our guidelines has actually been set to be on
23:38par with the nice oh fantastic that is brilliant yes but now we're working on part two so we are
23:42now
23:43revising the whole thing um and you know probably to come out in the next one of you and the
23:47education
23:48for um healthcare professionals that that's still ongoing as well okay may i ask you so given all the
23:54things that you said dr pramita in the last few minutes that we have left for women watching
23:58today who may suspect she's going through the transition of menopause when she meets with her
24:03doctor and it's likely to be primary care at the first contact what would be a good first consultation
24:10for her what should she how should she advocate for herself if she suspects she's experiencing perimenopause
24:17symptoms i think for every woman um uh if you do not feel like yourself anymore there are changes that
24:27you have noticed that you know you're not so sure about your periods have changed um and and you feel
24:34that you're not in control anymore i think it's worth having that conversation with your doctor it could
24:41be your general practitioner that you're used to it could be your gynecologist it could even be a normal
24:47physician but i think you need to start off the conversation saying i'm not the person that i am
24:54and i think that there's something going on and hopefully you know that message will then get through that to
25:00that doctor and then we can then advise you accordingly but i would like to go one step further
25:07um the you know world menopause day as you started off by saying it's on 18th of october which is
25:14very
25:15soon um the the theme for this year is actually chronic pain in midlife all right and i think this
25:24is very apt because um women we live with pain you know we are sort of tuned to pain which
25:33starts off
25:33with the period pains the pregnancy pains the delivery pains it goes on but during midlife our
25:41pain sensitivity changes and we get more hyper with our pains we feel pains much more it's called central
25:49sensitization women are 70 percent more likely to have chronic pain when i say chronic pain these are
25:57pains that can come and go you know over a period of three months and more 70 more pains are
26:03felt by
26:04women than men wow yeah and three you know three out of four women in the menopause will have generalized
26:14joint pains so i think pains are so important that they need to be addressed and if that woman is
26:22having
26:22pain she should get herself sorted out yeah don't put yourself last yes women out there yes your pain
26:29matters too dr pramita thank you so much for being on the show happy world menopause day and thank you
26:34for fighting for our our always thank you thank you that's all the time we have for you on this
26:40episode
26:41of the future is other future is female i'm melissa idris signing off for the evening thank you so much
26:47for
26:47watching and good night