Setting New Standards in Menopause Health: Empowering Insights from Alex Ruani

Read as you listen or read on the go: Here’s the full interview for you

Maurice Castelijn

Welcome back, everyone. Today is our next interview about Menopause Health. And I’m sitting here with UCL Doctoral Researcher and The Health Sciences Academy Chief Science Educator, Alex Ruani. Hello Alex.

Alex Ruani

Hello. What a topic we have today, Maurice.

Maurice 

Yes, absolutely. And for those of you watching or listening, I mentioned in other interviews that Menopause Health is not discussed widely, and many women are suffering in silence from this life-changing transition. So today, in anticipation of the Menopause Health webinar on the 26th of January, I wanted to speak with Alex Ruani herself and get some early insights from her. It’s to inspire you to take this topic seriously and to invite you to join our in-depth webinar this Friday, where you’ve got the option to join, engage with everyone else, and ask questions to Alex and me inside the webinar. Or you can watch the replay afterwards. 

Now, Alex Ruani doesn’t need an introduction for students and alumni of THSA, of course. But for those of you who’ve not had the pleasure of meeting her, Alex Ruani co-founded The Health Sciences Academy in 2012 to train health, wellness, and nutrition professionals, debunking myths and creating science and evidence-based trainings to help specialise and raise the quality of patient and client advice. She has led the development of over 20 advanced certifications and over 60 short courses, and has written thousands of science commentaries over the years. Alex has also been featured in the news, such as The Times, and has published research around COVID misinformation. Moreover, Alex herself is accredited as a National Board Health and Wellness Coach, and she’s actually been in your shoes as a professional working with clients in her earlier days. So that’s a quick overview. I’ll leave it at this, and now let’s get started with the interview. 

So Alex, from your perspective, why did we create the new Menopause Health certification?

Alex

Well, that’s an interesting question, Maurice, because I will say we founded The Health Sciences Academy 11 years ago, right? And perhaps we’ve been a little bit negligent in this respect because we have received so many comments and inquiries asking us to help with Menopause Health education. So we’ve prioritised so many other topics – fertility nutrition, for example. Women want to extend their fertile years as much as possible, right? Because we are in the workforce and at the peak of our careers in the middle of our lives. So, Menopause Health is one of those topics that has been pretty much ignored, not just by us – I’m admitting that mistake – but in general, by research. And one of the things that was quite shocking is when we say, okay, now we have to listen, right? We have to look into menopause nutrition. I, myself, I’m getting older, right? Getting closer to my menopause transition, and I want to be prepared, but also the women in my life, right? Mothers, sisters, and friends are going through these changes and one of the things that shocked me the most is knowing that that menopause shift lasts about two decades of our lives! So it’s not that all of a sudden, overnight, you are menopausal. So for many of us women, the menopause transition can last many years – an entire shift of hormones, metabolic processes, epigenetic changes, you name it, that is a transition that takes about two decades of our life. It’s way too long to ignore. So it starts from maybe our late 30s, early 40s, well into our early 60s. And women spend around 40 years of their life in peri- and post-menopause. Now, we’re talking about half of our life in menopause, peri and post.

So my team and I, including Dr. Michelle de la Vega and others, looked into the research. 

We wanted to understand what research is available out there on this important topic, right? Currently, 1 billion women around the world are either entering perimenopause or postmenopause. It’s projected that in 2030 or by 2030, 1.2 billion women will be experiencing perimenopause or postmenopause. So we’re not a minority. This is not a problem of a minority. We’re talking about a large proportion of the world population and a significant chunk of our female life. So when we looked into the research, I thought, for granted, there’s going to be so much research, right? I’m sure there’s going to be a lot of interesting literature on nutritional influences, on perimenopause, on menopause, on postmenopause, and we were shocked to discover that research is lacking. What is going on? I was expecting so much more research on all of these topics that we were interested in. I didn’t encounter that problem when we were researching fertility nutrition, for example, or dermatological nutrition. But with menopause, we were quite shocked. 

So, in research, females are underrepresented in scientific studies. So we’re more expensive to recruit when you want to understand female responses to food or example you have to recruit 3X as many women. So premenopausal, perimenopausal, so transitioning into menopause, and postmenopausal. On top of that, if you are recruiting premenopausal women, you have to recruit 4X as many. So, there are four phases in an average 28-day female cycle. So the menstrual phase, the luteal phase, you name it. Then, in perimenopause, the hormonal changes are just so erratic. And when you look at the research, the fluctuations of oestrogen and progesterone are so unpredictable. So you have women in perimenopause skipping a few months, then becoming regular again, and then having months with really heavy flow with a risk of becoming iron deficient. It’s just the research is just not there to understand all of this. And the technology also needs to catch up. We also need a way to continuously monitor these hormonal changes. 

Let’s give an example. I’ll go to an endocrinologist, make an appointment, ask the endocrinologist, can you please test this list of hormones in me? And the endocrinologist is likely going to laugh because when you are in perimenopause or in that transition, a one-point-in-time hormonal test is not giving you the full picture. The fluctuations are so extravagant and so like almost like a massive excursion of peaks and valleys that you need a full view of all of that. So, the limitation of research is not just the recruitment of women and funding, which funding which has not been there until recently. Now, we see more funding bodies interested in funding research for these issues. But in truth, the ideal type of research is where we can continuously monitor our hormones and their fluctuations and having, I’m not saying this is going to happen now, it will take decades to have AI and machine learning to help us understand and predict some of the potential future responses so we can better manage that. But at the moment, we don’t have any of that. We do have research, quite a bit of research, but not enough, not as much as male-oriented research. And again, males are cheaper to recruit. So if I’m running a nutrition study, either I need three times as much funding to recruit three different kinds of women undergoing three different types of phases, or I recruit men simply of a certain age group, and then age match for different effects. 

So yes, there is that question of ‘why are we just now talking about this?’. And from a societal perspective, of course, Maurice, we women entered the workforce in masses not too long ago, right? And you’re seeing now this entire crisis in the workplace of women quitting their jobs or losing their jobs because of menopausal symptoms, symptoms that affect our performance. So we’re not just talking about hot flashes in the workplace where maybe we need to change our lovely blouse for a sweater so they don’t see our sweaty armpits. I’m talking about, for example, being in a meeting with executives and all of a sudden having a memory lapse or losing your chain of thought during a speech or not being able to recall certain data, whereas you were a lot sharper five years ago. So we must start recognising these changes in memory recollection, retrieval, the speed of processing in the brain, and we start calling these things brain fog, forgetfulness, and the symptoms are, you know, nameless, like so many symptoms. Thirty-five of them have been identified as being common, but there are many more. So things like migraines, debilitating migraines. So, a migraine is not just a headache. There is a cluster of symptoms around it. Sleep issues, so when we are more sleep-deprived, and there is some research indicating that it’s not because of just technology and screen time and not having a sleep routine. a shift in our clock genes and our sleep architecture, our sleep structure, how much we spend in deep sleep versus light sleep. So, all of these changes are poorly understood. And then you add to that unexplained weight gain. Some people would say, well, you know, just to address Menopause Health, have a healthy diet, healthy eating, exercise more, sleep more, or do any kind of exercise that helps with muscle strength, very generic things. I think, well, those are the same recommendations for anyone to be healthy, right? But no, it’s different. We need to treat Menopause Health differently. So let me give you an example. You have a woman that comes to you, a client or a patient, and says, “Listen, I keep gaining weight. I’ve been eating the same food for the last five years, same calories, same amount of carbohydrates; nothing changed, but why am I putting on weight? What explains this?” And, of course, in the webinar, we’re going to go through some of these challenges, right? Other nutritionists may have a client, and you put them on a calorie-restricted diet or glycemically-controlled diet, and not much happens and you see that this person is still not addressing their weight gain or losing any weight. So there is something more at stake here. It’s not just, oh healthy eating same recommendations as everyone, there are very detailed angles that we need to tap into to manage this weight gain symptom. And the same goes for everything else, right? We can name so many symptoms like a hunched posture. So it’s not because we are just not being strong enough on our back muscles, this hunched posture can also be a consequence of decalcification. So you may have a perimenopausal woman doing all of this weightlifting and still experience a hunched posture. 

So we cannot explain everything by unhealthy lifestyles. There’s a lot more at play here, and our hormones have a huge impact on this. And so does our gut microbiome. So we’ve seen in research that our gut microbiome changes, even, you know, from compared to our premenopausal years and our perimenopausal years and postmenopausal years, the bacterial composition, the colonies in our internal habitat change. And these changes may have nothing to do with the way we eat because we are eating the same, right? 

So, what explains all of these changes? That’s why Menopause Health is not just the same healthy advice for everyone. No, it’s very specific and we need more research around it. Yes, there is research that we’re seeing that is fantastic. We’re listening to this research, we’re trying these things, but we definitely need more.

Maurice

So Alex, it sounds like a lot of research is not available in order to have a full picture. 

There’s also a connection here, and we heard it in recent interviews with others, when I asked about the gap in Menopause Health. Not just in general, but even with GPs, medical doctors, and dietetic professionals – why do you think that gap is so big?

Alex

Right, so in medicine and obviously, Menopause Health is part of the curricula, in the UK at least, but perhaps not to the extent that you will see it being in future years. Women represent half of the population, if not more. One of those gaps is perhaps that the medical community has been so male-dominated for many years. And this is not to blame men, Maurice – we’re just talking about society in general. Women inserted into workplaces came a lot later than men. So, the awareness of it – yes, menopause is a natural life stage. All women will experience it. Most of us will be menopausal by the age of 51. That transition definitely starts about a decade earlier for the majority. 1 in 100 women enter menopause before their 40s. The more data we have now, the more we can address it, but that awareness was not there traditionally. So, because menopause is a normal transition in our lives as women, the medical community – and this is not to fault, this is just education, as with everything we keep evolving, the medical community has looked into these menopausal symptoms and the pain as something that needs to be normalised. Oh, it’s normal, just live with it. Now, women go through that. So, yes, 80% of women experience menopausal symptoms, about 25% of them have severe debilitating symptoms that impede normal functioning. 

But normalising menopause doesn’t mean normalising that pain. In our mid-40s and mid-50s, we are still at the peak of our productive years. For example, from a career perspective, we may be at the peak of our careers or anything we’re doing to support our families, that energy that we need, the intellectual performance. And it’s not normal to be compelled to suffer from all of these things that are impeding our usual functioning. 

So why is this decline happening, and why are medical doctors, not all of them, but why are so many medical doctors dismissing it as just living with it, you know, it’s normal, all women go through this. No, no. So you have that voice of perhaps, you know, feminists or us who are like, no, this is not normal. 

“Yes, menopause is normal, but these symptoms are not normal.”

I do not want these symptoms to continue. I want to feel like myself again. So there is this shift of identity as well, like, who am I? Am I now an old, useless person to society? No, I’m at the peak of my career, the peak of my productive years. I want to keep being a productive member of society or in my family and my workplace. I don’t want these signals to stop me from that, from realising my full potential. I still have another half a life to live, right? So, all of these questions are being asked right now, and the final voices are louder. And also, let’s not just women. So it’s a larger issue. And again, it’s not a minority issue, remember? It affects 51% of the population. So it’s a topic that we certainly need to address. So that was a great question, Maurice. And hopefully, through this certification and more research funding, we can start evolving our knowledge and understanding of this space and making sure that we are productive, happy members of our society rather than suffering these symptoms with shame and not talking about them.

Maurice

Wow. That’s so much information. Whilst you went through creating the certification together with the team, it sounds like you also came across lots of surprising things that you learned yourself, right? For instance, you mentioned HRT or Hormone Replacement Therapy a number of times to me. So what kind of things did you come across when developing the certification where you were like, “Whoa, I hadn’t realised this and actually changed my perspective or my view on it?”

Alex

Yeah, that’s very interesting because I guess menopause, again, remember, Maurice, that this shift, right, is not overnight. It takes about two decades for all of these hormones to change and then normalise again way after post-menopause, right, in the more stable years of post-menopause. So it’s quite a stormy period, right, these two decades that we have to go through. And when I was little, perhaps menopause was not talked about so much. And I do remember conversations that perhaps are culturally influenced in terms of putting hormones in your body and being viewed as something that could be harmful. So, in my mind, I’ve been very biased culturally, in terms of Hormone Replacement Therapy, like why are we tinkering with our natural hormones? Why are we poking with our hormones? And I was kind of misinformed in that respect because when we started to look into the research of all of these supposed misconceptions and myths surrounding  Hormone Replacement Therapy. 

So I remember hearing probably five years ago, well you have this one study of hormone therapy saying that it’s very risky for the development of breast cancer, ovarian cancer, heart disease. And then more data came through and more data, more data, and now we have so much more data on Hormone Replacement Therapy, but it doesn’t mean that all of us should do it. What it means is that we have more information. I have more information. I will be able to make a better-informed decision for myself as opposed to what was culturally acceptable where I come from, right? So, the information we have on Hormone Replacement Therapy needs to be known. And there are pros, there are cons, there are short-term effects, long-term effects. We need different types of Hormone Replacement Therapy, different formats. So we need to understand all of that and ask our doctors, gynaecologists, GPs, and endocrinologists the right questions and have the right health assessments for ourselves to see, will this be helpful for me? Will the benefits outweigh the risks? Or will the risks outweigh the benefits, or the symptoms that I may experience from this outweigh the benefits? So then you can evaluate that and make a decision yourself as opposed to following misinformation from 10 years ago. I still see old research being cited in these studies, meta-analyses that are really old versus new research that can stratify populations better, where the data is analysed in a more complex manner. So we have much better quality information right now. And I’m very happy about that because then we can make a better-informed decision for ourselves. And yes, back to your question, Maurice, we should definitely have a webinar on Hormone Replacement Therapy so that we can navigate all of these pros and cons and the research and what we are seeing out there – what do women say? What do doctors say? What questions should we ask our doctors? So on and so forth.

Maurice

When it comes to other kinds of surprising things, what we picked up in earlier interviews, I think it was Dr. Michelle de la Vega mentioned to me, that over 40% of women in the workforce consider quitting their job as a result of these really severe symptoms that they suffer from as a result of the perimenopause, menopause, postmenopause. Over 10% of women have actually left their job because of it. Are there sort of any other specific things that you maybe quickly wanted to share here, again, in anticipation of the webinar we have this Friday, in terms of some shocking facts or things that you may have come across?

Alex

Well, perhaps, you know, back to the workplace, there is some data, and there was a UK government inquiry. So, this is being taken more seriously now, the impact of perimenopausal, menopausal, and postmenopausal women losing their jobs. So, there was this survey and data from Bupa published in this UK government inquiry demonstrating that nearly 900,000 women lost their jobs in the UK because of menopausal symptoms. And again, we’re not just talking about the hot flashes and things like that. We’re talking about symptoms that we don’t normally correlate to menopause, but now we do. So, like migraines, forgetfulness, these memory lapses when we are presenting or losing our chain of thoughts or sleep troubles and then we are at work completely sleep deprived, depleted, lacking energy, fatigue, you name it, right? Weight gain. So it’s very complicated. And again, we are one of the things that I think is quite, it feels a bit unfair, but it’s not, of course, depending on which side you look at it. We are one of the very few species on the planet who actually have menopause or experience menopause. So great apes are mammals who experience menopause, but the majority of mammals don’t. Orcas and dolphins and whales as well. But aside from that, no other species really go through this. 

So why is it that we are only fertile for such a short period of time? Why does our reproductive system age so quickly, at a much faster rate than men, at a much faster rate than other species? So is there an advantage or a disadvantage? 

And now, of course, back in the day, there would have been a biological advantage. There are several theories, like the Grandmothering Effect. So we need menopausal grandmothers to look after the offspring and to point hunting groups where certain foods are or from a social perspective gathering the family and uniting the family and creating tribes, all of that. But today, as society has evolved, and of course, we need sociologists to look into this, perhaps that advantage back then, where is it right now? In the workplace, we’re actually seeing a detrimental effect, and we definitely need to address it and the shame, the embarrassment if you work in a male-dominated environment unless it’s Maurice, right? So you Maurice it’s fantastic because I think this topic is not just for women. We need bosses. We need executives. We need fathers, grandfathers, brothers to become better informed about menopause. We need our young daughters, young girls in our family to be better prepared for this transition. Because, again, it’s not overnight. It’s a 20-year shift and then 40 years living in peri- and post-menopause. So, from a societal perspective, there is a huge impact. We need to address that. I found that utterly shocking. 

And in terms of the biological changes – this is the second part to your question, Maurice. When you look into the perhaps unwanted effects of the shift, the transition, and then post-menopause, we probably have two sets. So one of them is the very concrete things that we experience, so the migraines, the hot flashes, the sleep troubles. I haven’t changed anything in my sleep routine for the last five years. Why is it that all of a sudden, my sleep is so light and interrupted and short, and I wake up so unrested, right? Very concrete things like forgetfulness and cognitively not being able to process data as fast as we used to five years ago. So all of these changes that we start realising are mood swings, we become snappy, depression, anxiety, why am I so anxious, I don’t recognise myself. So these things are very concrete, we experience them, we can name them, we can age match and even link them to the menopause transition. But then you have the silent things, the other things that are more difficult to detect. So for example, the loss of muscle mass, the loss of bone mass. You may experience some joint problems and joint pain, and then you can have that addressed. And again, right, it could be connected to all of these changes in oestrogen and progesterone. But you have these silent things that are happening in our body, like the increased risk of cardiovascular disease, an increased risk of dementia, you name it, right? There are so many lifestyle diseases. We call them lifestyle diseases because we may not have inherited any genetic risk factor for them, but they are connected to our lifestyle. But what if some of these things are also exacerbated by the menopause transition? So we need more research to look into that, and we also need more awareness. How can we, in an informed way, mitigate this long-term risk? So we have the short-term symptom management, like this is appalling, why am I not myself anymore? And then we have the long-term health management, longevity, healthfulness, reducing this risk that we also need to look at.

 So, in a way, as women going through these stages, in an environment where we can more openly speak about that, where we have more support from dietitians, doctors, personal trainers, physiologists, nurses, and better understanding. It means that we can actually, instead of feeling like victims of this transition, take charge of our health and become more interested in managing those things that can promote our health, our well-being, our day-to-day functioning, but also, in the long run, right? I want to live a long life, so I can stay with my loved ones for as long as possible on this beautiful planet. How can I manage those risks in the long term as well? So more awareness, more education, that’s a starting point. So how do we get there? 

In our webinar on Friday, Maurice, one of the things that we are going to present is a framework. So these are some key areas that we need to consider in Menopause Health. Without addressing these key areas, we are probably not going to really tap into what we want to achieve during this transition. We’ll probably just talk again generically about eating healthily, exercising, trying to sleep better and so on. How can I sleep better if there is a shift in my clock genes, right? So, there are some things that are becoming a little bit more difficult, even like weight management and so forth. 

How can we tap into these areas and make sure that our menopause symptoms are better managed? What if we cannot take Hormone Replacement Therapy because we have breast cancer, we have ovarian cancer, and we have increased risk, and we are not supposed to take this Hormone Replacement Therapy approach? What else can we do? What else is available to us? And that’s where these pillars can help us navigate area by area the strategies that may help us manage this two-decade-long transition and then the 40 years of living in peri- and post-menopause.  So it’s quite a chunk of a female’s life. It’s a great starting point. And, of course, you can also stratify age by age and different stages as we progress through all of the spectrum of maturing into menopause. So it’s a complex topic, but definitely we need to simplify the perspective and then personalise our approach from each of these key points.

Maurice

It’s certainly a complex topic, as we’ve realised in the past interviews that I’ve done. And everybody listening and watching here will also have realised that there’s so much more that comes along with that understanding of perimenopause, menopause, postmenopause, and Alex, as you said, all of these intricate connections everywhere. Thank you very much for sharing your insights. And also because I sense a real opportunity here for us to collectively break the taboo, for us all to become much better informed, like what you said, Alex, and ultimately become just better at understanding and supporting women with their health and wellness challenges and the journey that they go through. 

I also can’t wait to learn more at the webinar – I hope you’re all as fired up as I am to learn more about menopausal health and dive deep into a number of these different topics. And the webinar is at 1:00 PM UK time, so that’s 8:00 AM Eastern time.