Menopause support within aesthetics

Dr Trish Davis considers the implications within our clinical fields

Listening to the stories I’m told in the relaxed environment of my aesthetics clinic, I hear all day from women who say that they look and feel different, that work is a nightmare and that things are falling apart at home.

I have spent many years working as a GP with specialist women’s health training and witnessed poor perimenopause and menopause care. There are reasons behind this catastrophic retrograde step in medical care, dating back to around 2001 with regards to the safety of hormone replacement therapy (HRT) and breast cancer risk that it has now been superseded by.

There is virtually no menopause training in medical school or even in the various doctor speciality training areas unless you decide to take a proactive approach as an individual clinician. As an inner-city female GP, women’s health was the core of my job for 24 years.

Menopause symptoms are not always clinically obvious as menopause, and women can be profoundly affected both at home and in the workplace.

As well as being a GP specialising in women’s health, I have been an advanced medical aesthetics practitioner since 2017. During these longer private aesthetics appointments, women would tell me about how they were feeling in themselves as I did their injectable treatment, and it was even more apparent that the structure of the NHS GP appointments (that I then worked the very next day) did not provide these patients with a forum to be managed effectively at all.

This is due to the perfect storm of the condition (complex), limitations on the practical patient pathways provided (10 minutes) and lack of training (not an NHS priority), combined with a fear of using HRT due to out-of-date research (mentioned above).

Primary care doctors are physically unable to spend the time that is often needed to manage and support these patients in the 10 minutes allowed, and they are not supported in training to be able to adequately unpick the complexities of these presentations and then manage and direct the intricate medical management that these women so often require.

The fact that oestrogen deficiency affects the entire female body means that women experience a multitude of symptoms including effects on hair and skin. However, no two women are the same in how they experience the hormonal transition. As a result, their symptoms are then not always attributed to oestrogen deficiency and can be misdiagnosed as other conditions including mental health, or, even worse, dismissed completely, which is common. Patients often present to me feeling angry and distressed at how they have been managed previously.

I knew that I could make a difference in the care of women, and that I would find it fascinating and worthwhile. It was therefore an obvious and natural progression for me to become a menopause specialist and integrate this into my aesthetics, clinic which focuses on positive ageing.

POSITIVE AGEING

As a result of the nature of the condition, menopause care requires a comprehensive approach to the whole person. In my private clinic, I have created a service to ensure that women have the time to explain how they feel so that we can explore the cause and plan solutions that may or may not be hormone-related.

Not every symptom that a ‘middle-aged woman’ experiences is going to be due to menopause and this is where some danger lies, as these patients are vulnerable. The very nature of the way that a woman feels during perimenopause and menopause may encourage her to seek aesthetic treatments that she wouldn’t normally ask for in an attempt to feel better about herself.

The impact of not assessing and managing these symptoms in an appropriate way (and this doesn’t always mean HRT) can be catastrophic on careers and relationships, as the menopause can go on for 10-15 years or more and affect sexual function, cognition, mood, skin and hair, joints and urinary tract to name only a few of the symptoms. The menopause also puts women at increased risk of chronic illness, like cardiovascular disease.

Experiencing menopause earlier than usual is essentially lifethreatening. For example, osteoporosis is a condition that can end lives due to the fractures that happen as a result. I see many women who are sent away by their GP, who told them that they are “too young” to be menopausal. What if it could shorten this patient’s life, due to the missing key hormone, such as oestrogen, that is so vital for female bone health? This must at the very least be excluded as a possibility. It is not OK to send women away without excluding this possibility properly.

I hear patients say “The doctor said I am too young for HRT” all of the time. This may be true, but they have often not been clinically assessed which genuinely shocks me. Women with early menopause are more likely to need support from aesthetics clinics because of the loss of oestrogen at an earlier age and the consequences on their skin and soft tissue structures.

AN AWARENESS OF MENOPAUSE

I think that an awareness of menopause is useful in aesthetics clinics, but, due to the lack of UK regulation that we all worry about, one concern is that these patients are at risk of receiving advice on things like expensive supplements that don’t have any evidence to support their claims. There is potential for some clinics to capitalise here, especially in socio-economically deprived areas, selling products and treatments that are branded for menopause that simply don’t work.

Expectation management about aesthetic treatments is important as skin and hair treatments may not be as effective without HRT or a normal iron or thyroid hormone level, for example.

Hyperpigmentation can be hormonally influenced so an awareness of the physiological changes and hormones that the patient is already taking is key. Hormones may need to be swapped or stopped. For example, I have seen many women on oestrogen who then develop melasma.

All women deserve to have their symptoms evaluated and to feel validated. They do not want to feel unwell and this natural life event does exactly that. I see women who feel utterly dreadful, as their high-powered city job is at genuine risk and their family life is in turmoil. Hormones are very powerful and we must listen to what women are telling us and help to work out the various solutions available, including lifestyle changes.

Let us avoid providing the wrong help by not offering women expensive unrealistic aesthetic treatments or products and sending them to the wrong medical specialist and clogging up systems already under pressure, overusing mental health medications and almost encouraging women to be out of work or physically harmed due to apathy of the NHS to direct resources towards this inevitable consequence of ageing. This would surely save money elsewhere.

We need more education for patients who don’t know what is happening to their bodies and lives.

Aesthetics clinics run by medically trained professionals are perfectly placed to educate, support and signpost women to the right lifestyle interventions or treatments for them. However, we need education, support and training for the staff and employers.

Structuring the initial questionnaire in an aesthetics clinic is one key way to understanding why women are presenting at that time, what direction should be taken, and in what order. Patients love honesty. Sending them to a doctor before administering soft tissue filler is good practice and good for business as we build trust.

Aesthetics doctors can indeed support the NHS clinicians who want to help but who feel overwhelmed with the other demands placed upon them. In our clinics, we have more time to simply listen. Unfortunately, the GP appointment is still only going to be 10 minutes long and, for many of these patients, time is the key. The price will continue to be paid by society as a whole if we don’t get this right, so we can do our bit.

HRT is not the answer to everything. We are here to advise and ensure informed consent with all of the options on the table. Let’s keep our women healthy and happy. This will keep workplaces, families and the person in the middle of it all happier, living longer and taking fewer resources from NHS services by getting our women the right help, which is not necessarily a bill for something that says “meno” on the label.

CASE EXAMPLE

A 57-year-old lady came for a menopause consultation appointment.

She had a past medical history of ischaemic heart disease and gastric bypass surgery and a BMI of 28.2.

Presenting symptoms

Cold intolerance, feeling hot at night, insomnia, aching joints, low libido, recurrent urinary tract infections, thinning hair, and low mood. All of these symptoms were apparently getting worse and her selfesteem was low.

Hormone management

Continuous combined HRT was prescribed transdermally with micro-ionised progestogen and vaginal oestrogen with dose adjustment review at three, six and nine months.

Lifestyle

This was addressed and changes were made with the elimination of alcohol which was previously over recommended limits as she was drinking to feel better. She felt able to exercise once stabilised on HRT and began weight training and walking.

Blood tests

Low ferritin and folate were corrected and hair quality began to improve in the following months.

BMI 

This was then addressed with the injectable weekly Semaglutide. BMI reduced from 28.2 to 23.1 with a weight loss of 14kg. This was then stopped as the patient was happy with her weight.

Aesthetic assessment 

After correction of hormone balance, ferritin correction, cardiovascular risk reduction and lifestyle adjustment, on examination, she had significant volume loss, fine lines, mild hyperpigmentation and sagging. She was using high-street skincare products that contained no active ingredients and SPF was in her foundation.

An OBSERV scan showed hyperpigmentation, blocked pores and an impaired skin barrier.

Skincare 

Initially, a new medical-grade skincare plan was made including Obagi vitamin C, SPF 50 and 1% retinol along with lighter moisturiser and exfoliating/cleansing products.

Volume loss and skin quality

 A plan was also made for facial rejuvenation. Because of the severity of volume loss and poor structure, I initially used Juvederm Vycross soft tissue fillers for the face. In addition, she had a nonsurgical rhinoplasty and lip rejuvenation. HarmonyCa was then used for lack of skin firmness and loss of collagen on two occasions to the sub and deep dermis for skin bioregeneration.

Botulinum toxin was also injected into the upper face.

In total, I treated her with 12ml of Juvederm soft tissue filler plus two sessions of HarmonyCa.

I hope that this case clearly portrays my belief that we can achieve great outcomes in medical aesthetics clinics, but to truly manage a patient in mid-life we need to think about so much more.

The order in which patients present to us is to be respected but, with a thorough initial assessment, the direction and order of management can be negotiated.

One thing to think about is the fact that this lady’s ferritin was low and, if this had been missed, then she could have been asked to try scalp treatments that were unnecessary and expensive. In my experience, correction of factors like ferritin is required alongside HRT to optimise it and so this is why medical knowledge is so important.

In the end, I had a lady who felt better systemically and who was pleased with her aesthetic treatments and told me that her confidence had been boosted. This is why I do what I do!

DR TRISH DAVIS

Dr Trish Davis is the founder of Rebalance Your Life, a private specialist clinic in Newcastle upon Tyne, combining hormone and aesthetic approaches to positive ageing. Dr Davis is an expert in complex menopause care and has the Certif icate in Menopause Care from the British Menopause Society. In addition, she offers treatment to men for testosterone level assessment and replacement with follow-up and monitoring. She can address aesthetic requirements for her patients with the use of advanced medical regenerative aesthetic procedures.