Am I going through the change now? A menopause GP explains, with Dr Nirmala Daya

Lightly edited for readability.

Dr Daya: I have to admit, I’ve learned more about menopause from my patients than I learned from medical textbooks.

Sharryn: I want to welcome Dr Nirmala Daya. She’s a GP in Pymble, in Sydney, and I’ve invited her here to talk about what she does for women in the menopause space. Can you explain how you came to focus on women’s health, and for women looking for help with menopause, what the difference is?

Dr Daya: I’ve worked in general practice for well over 25 years, and as a surgical assistant I worked alongside a lot of obstetricians and gynaecologists. I pursued my interest in women’s health and gynaecology, and a few of the specialists said to me, you should just do gynae in general practice. That was the impetus for me to start North Shore Women’s Health, and to keep my focus purely on women’s gynaecological and breast issues. With that, menopause has become a major part of what I manage.

I also have to admit that, as a solo practitioner, it’s very hard to take a normal general practice, with paediatrics and geriatrics and everybody in between, and make it entirely focused on women’s health. So I had to give my general practice away and start this from scratch.

Sharryn: You were the one who said something that really stuck with me: for a lot of GPs, menopause isn’t a sickness, so they don’t focus on it in the same way. I think that’s why some women are having difficulty. They go to their GP hoping for all the answers, and the GP isn’t always prepared for that.

Dr Daya: I agree. Menopause is a physiological process. Every woman is going to go through that change of life at some stage. It’s not a disease or illness, and medicine is built around managing disease and illness. That’s why there’s so little about it in our textbooks, and very little in our training about how to manage it. We were given certain tools, like the old HRT, and we knew it helped women with their symptoms. But when I trained, we weren’t even made aware of the long-term consequences of menopause. Short term, everybody knew about hot flushes and periods stopping.

Sharryn: And it’s a tricky space, because someone might come in thinking it’s one thing. They say, I’ve got this symptom and this symptom, and as a GP you have to say, I hear you, but it may not be menopause. It might be an underlying health issue. So you have to be able to pull it apart.

Dr Daya: Yes. That comes down to the foundations of medical training. You start with the history, which is when the patient shares what they’re going through. Then examination, then the investigations that are needed. You can’t jump backwards. That’s how patients are well managed. The other part is asking whether we’re missing something important that’s quite treatable, because some medical conditions overlap with similar symptoms, and it takes time to work that out.

Sharryn: I guess part of the challenge is the woman’s expectation of coming to the GP hoping for an instant solution. For some people it’s, I’ve got menopause, I need HRT, and that’s the only solution I’ll consider. They’ve got ten minutes with the GP and they pour everything out. Women tend to do that, because our minds are full and we’re dealing with everything. And the GP might not respond the way she hoped, maybe because they’re not trained in it, or because they’re not really understanding the patient. I think the government funding for longer appointments now gives a little more scope.

On the website, I created a workshop with a video to help women prepare for that appointment. So instead of walking in with no preparation, it helps them collect their thoughts and write down their symptoms and how they’re affecting them. By the time you sit in front of the GP, you’re more collected.

Dr Daya: Yes, it’s a starting point. There’s information on the internet and from friends, and there’s a whole group of symptoms women go through, physical, emotional and others. It’s really lovely if a patient has written down, even with pen and paper, the symptoms they’re experiencing and want to discuss. Quite often, if they’re anxious or scared about what’s happening, they forget a fair bit of that information. So writing things down helps the doctor as well. We need to look at whether those symptoms are all related to menopause or could be another underlying condition. For us medical people, the first thing is to make sure it’s nothing sinister, and nothing that gets overlooked because we’ve just said it’s all menopause.

Sharryn: As a general practitioner, they’ve got to have knowledge across everything, so expecting the solution the instant you walk in is a lot. Sometimes it takes a bit of grace, knowing you’re on a journey to get your health back. One of the real pleasures for me has been speaking to different health disciplines and hearing them talk about the woman as a whole person, going through a life experience over a number of years, with different people becoming a team around her, rather than, I got HRT and it did everything for me. Do you find women are bringing other kinds of support into that experience?

Dr Daya: Certainly. In the last five or more years there’s been so much more information about menopause, and more awareness among women about how best to manage it, including using allied health services to help them through the transition and beyond. We do need allied health. One good example is bones. I’d recommend most women have a baseline bone density test, because you never know how strong or weak your bones are, and some people are at risk of osteoporosis because of family history. So using dietitians, nutritionists, exercise physiologists, physios and the gym to maintain bone health is so important, because we’re living so much longer. At 60, 65, even 70, we still call ourselves young.

We need our internal health to carry us through all those years. And HRT, or MHT I should say, has been shown to have benefits on quite a few fronts: cognitive wellbeing, heart wellbeing and bone health. I’d also add soft tissue and ligaments, and energy.

Editor’s note: The Australasian Menopause Society says MHT is the most effective treatment for menopausal symptoms and has a role in preventing osteoporosis and fracture, but current evidence and guidelines don’t support using it to prevent heart disease or dementia. Talk to your doctor about the benefits and risks for you.

Sharryn: But again, some people can’t have it.

Dr Daya: Some people can’t, but there are other treatment options to support women who can’t have HRT or who are hesitant about it. There are quite a few other options we can use. And sometimes just talking to a professional to get a better understanding of your health and wellbeing works well too.

Sharryn: Information is power.

Dr Daya: For sure. Being well informed.

Sharryn: In your time, what’s changed most in how women arrive at their first appointment? More informed, more anxious, more dismissed elsewhere?

Dr Daya: All of the above. I’ve been fortunate to be in this practice for well over 18 years, and I’ve had many women come through from the premenopausal years into menopause and postmenopause. So we were both aware of the changes they were going to go through, or I could make them aware of what was likely to come.

Sharryn: Is there a typical time frame, even in broad strokes? A lot of people think, I’ll get HRT and I’ll be better, but perimenopause and menopause can be four to ten years.

Dr Daya: Or even longer. A lot of women start noticing subtle changes in their 40s, usually around the mid-40s. Hair changes, skin changes, sleep changes, breasts more tender than normal. Period changes are a big one. They can become heavier and more frequent, or lighter and less frequent. Many women complain about gaining weight for no reason. You’re eating the same, exercising the same or even more, and you wonder what’s changed. We keep an eye on it and do some blood tests to work out whether a change is happening. Menopause means you haven’t had a period for a whole year, but that’s worked out looking back. Through that whole period, some women have a difficult journey, and others, fortunately for them, sail through with hardly any symptoms.

Sharryn: Do you think people are coming into perimenopause younger? One thing we hear is that women get to the GP and are told, you’re too young, it’s just stress, or you’re complaining about something natural. So for a woman in her mid to late 30s noticing something going on in her body, it could be menopause, it could be something else. Not every GP is going to be equipped for that, so you really want a doctor who’s focused on it. Physiologically, it’s a very different journey for women. How do you handle that when women come to you?

Dr Daya: Firstly, on menopause happening in younger women: only in a small percentage is it happening a lot younger. There are certain groups, those who’ve had chemotherapy, early surgical menopause or injury to the ovaries. Then there are women whose mothers or grandmothers went through early menopause, who are at greater risk too. So it’s a small percentage that go through early menopause. But a lot of younger women are more aware of the change now, because it’s come to the forefront of social conversations. That’s why they’re coming in to find out, am I going through the change?

We need to work out whether you’re actually going through the change, or going through the big hormonal fluctuations before your periods finish. As I explain to my patients, your hormones don’t go down a sliding scale. They go up and down, up and down, over a few years. When the levels are close to normal, you feel 100 percent. When they dip, you get symptoms and think menopause has happened. Then you feel fine again and think you’ve sailed through, until it comes back. That causes confusion about whether you’re going through menopause or not. So it’s important to come in, be examined and investigated, and establish whether it’s perimenopause or menopause. That’s sometimes why our colleagues aren’t ready to prescribe MHT at the first appointment, when the patient thinks that’s going to fix the problem.

Sharryn: Dr Daya has been a GP for many years, and that experience is worth gold. You’ve moved beyond general practice to focus on breast and gynaecological health. How does that wider view help you with your patients, compared to the more isolated journey people can have?

Dr Daya: Having had so many years in general practice as a solo practitioner, I managed things on my own. Now the focus is mainly on gynae, menopause and breast issues, and I was able to take all that experience with me. I think many people feel that women’s gynae and breast health has been neglected to a certain extent, until things get really bad. A good example is a young person with heavy periods. Every woman gets periods, so it’s normalised. Then she becomes really tired, she’s low in iron, and she’s given iron tablets. But you haven’t fixed the leaking tap. Those young women need to come in so we can improve their quality of life, make periods more bearable and prevent other things developing. It’s similar with menopause.

More and more younger women are aware of it, and they’ll come and see the GP, have the discussion and get baseline measurements, so we have a starting point to see how things change. Because hormone levels go up and down, I could do a blood test around menopause that suggests the ovaries aren’t functioning very well. Six months later, the patient says she’s had a slight bleed, we do blood tests, and the levels look normal. So is she going through menopause or not? It’s not like a patient whose blood sugar is high, we do further tests and confirm diabetes. It isn’t that simple. And many women talk about menopause with friends who aren’t having the same symptoms, and feel those friends can’t identify with their journey, so they don’t get support or understanding.

Sharryn: One thing I’ve seen in conversations is the challenge some women have in their relationships. They can’t fully communicate, or when they do, it’s very emotional, and the husband is saying, go to the doctor, get a solution, put a band-aid on it. Or, you never stop complaining. For some people it can even end in divorce, which is extreme. So I think building a team that supports your overall health matters. Someone helping you eat well, someone helping you exercise well. It’s like building a business: you’ve got a finance person, an employment person, different roles. Women’s health needs to be more holistic like that, rather than menopause being the one flag everything sits under.

Dr Daya: There’s more to it, for sure, and you’ve touched on a very important part. I have these conversations with my patients going through perimenopause and menopause, because one thing most women will experience is lower libido. Your body is making less hormones. It can have a significant impact on the relationship, and not many men have a good understanding of menopause and what women go through. Many of my patients are in a difficult position: teenage kids or empty nesters, caring for elderly parents, going through physical and emotional changes, maybe a change in their relationship, and trying to hold everything together. It either comes up in conversation, or I’m happy to ask, because it’s so important. And there are some easy treatment options for a lot of those issues, to help maintain their overall wellbeing.

Sharryn: Sometimes it could be that a change in diet is what helps you course correct, rather than a medication. But you need the understanding of what to do. If someone is starting to feel the symptoms and doesn’t know where to go, what’s the one thing you’d want them to take away?

Dr Daya: I’d say look at menopause resources and find the right practitioners: people who will listen to you, take the time to do a detailed history and examination, and offer the best possible treatment options. At the end of the day, your wellbeing is our foremost goal. Physical wellbeing, emotional wellbeing, and long term as well.

Sharryn: A lot of women are working, and we’ve got an ageing population. If a big percentage of them are confused about what to do, that’s a problem. It’s great that women are talking about it now, with more information, and people more prepared to come in. Obviously we can’t talk about specific treatments or products here, and that’s not the goal. The goal is to be aware of the options, and of the different kinds of practitioners. And if you see someone and they’ve told you something, you’re well within your rights to get a second opinion. You don’t have to stay with the first person you saw. But you also have to be prepared that menopause is a transition. It’s not a day-one fix.

Dr Daya: It’s going to take some time to work out, and we can offer a range of treatment options, or sometimes no treatment. Sometimes patients just want to talk about what they’re going through and be reassured it’s a normal physiological process. It depends on how long the symptoms last, and more so the impact on their day-to-day life. If hot flushes are causing disturbed sleep, can a woman carry on day after day, month after month, year after year? The tiredness creeps in, the irritability creeps in, the mood changes. And that same woman has so much to juggle. A home, and she’s a wife, a mother, a daughter, an aunt. She’s still working. At 50, or even 60, we’re still very active, so we need our wellbeing in every way.

Sharryn: Speaking for myself, sometimes you don’t notice your vitality slipping, because you put it down to being tired and doing a lot. Family, work, everything. You reason it away rather than thinking about getting health support. So it’s helpful to understand the pathway of working with someone like you, being supported, and being directed to options.

Dr Daya: Certainly. We talk about short-term symptom control as well as long-term health, and long term that’s cognitive wellbeing, bone health and heart health, and soft tissues and ligaments. It’s not uncommon for women around menopause to say everything hurts. They’re still active and exercising, many eat very healthily, and they wonder why. Life expectancy in Australia keeps increasing, so women in their 70s expect to feel good, look good and still do the things they want to do.

Sharryn: Without the fear of declining and getting old.

Dr Daya: Absolutely. So it’s good to be aware and get started early. Not necessarily with treatment, but in terms of having yourself checked.

Sharryn: When I created Menopause Resource Hub, it was an idea I was exploring, and some people came on as founding providers who partnered with that idea. What made you decide to be part of it?

Dr Daya: What appealed to me was somebody like you, Sharryn. I thought, where have you been all this time? I’ve been quietly working here in my corner of Pymble on exactly the ideas you had. But I’m not in a position to bring a whole lot of allied health people together under one umbrella. Menopause isn’t just an age-related transition. It starts at some stage and carries on for a long time, and there are medical risks that need managing as a consequence for some women. Osteoporosis is a good example. You want to stay active, healthy and eat well, but it’s good to know how strong your bones are, because you want them to carry you when you’re 80 and keep you out of hospital with fractures.

Sharryn: Exactly. So you’ve got your GP, your physio, your gym.

Dr Daya: And your dietitian.

Sharryn: That was part of what motivated me. You’re all the stars of the show.

Dr Daya: Thank you for reaching out and making me part of Menopause Resource Hub. Having a whole resource of practitioners with a similar goal, helping women have the best health outcomes, matters. Let’s not talk about disease or illness. Menopause is a natural physiological process, but we want the best possible outcomes, short term and long term. What also appealed to me is reaching women where medical services aren’t readily available. Country patients find it hard to find doctors like this.

Sharryn: Even in their local suburb, some people can’t find a GP who’s focused on it. In developing the Hub, I’ve become a lot stricter than when I started. We initially listed a whole group of people, and I went back and removed about half of them. They’re fine in their own space, they just weren’t specifically focused on perimenopause, menopause and midlife women. And I thought, women deserve better than that.

Dr Daya: Because we wear a lot of hats, and we certainly deserve better care. I can proudly say I have patients coming from as far as Melbourne.

Sharryn: Do you do telehealth?

Dr Daya: I do, but at some stage patients need to come in for a face-to-face appointment, because the examination is really important. I’ve done a lot of work with breast surgeons and breast cancer patients, and I support quite a few women going through menopause after breast cancer. Specialists refer patients to me to help them through the menopause phase. And if someone is going to be on hormone therapy long term, I think it’s important to have breast checks. So at some stage we need a face-to-face consultation. Only ever doing telehealth isn’t necessarily good medicine.

Sharryn: It might be fine as a first connection to explore things, but there’s nothing like face to face. We’ve been speaking for a few months now, and that’s how this relationship grew. Finding GPs who really care about women is part of the goal, so when I find them, I’m thrilled. I really appreciate the time you’ve taken out of your schedule today.

Dr Daya: No problem, if this time helps thousands of women out there, or gives them a guide to finding like-minded practitioners in their own state, or helps them go better informed to their GP. Don’t hesitate to write those lists down, or the symptoms you’re concerned about. It’s a great starting point for us. And as the Hub expands, the journey to find the right practitioner is going to be that much easier for many patients. It’s reaching women in all corners of Australia, and whether or not they have access to services, at least they have access to your resource and information.

Sharryn: Together we’re going to make a difference for women in Australia, and who knows, beyond. Thank you so much for your time today.

Dr Daya: Thanks for coming all the way out.

Sharryn: Dr Daya is at North Shore Women’s Health in Pymble, New South Wales, at Suite 6, Level 1, 55 Grandview Street, Pymble. You’ll find her listing in the directory, or ring her office. Hopefully we’ve answered some of your questions, and if you have more, you can always contact us.