Menopause expert Dr Naomi Potter shares advice on common symptoms

Menopause can be a confronting time for women. Photo / New York Times

Dr Naomi Potter is a leading menopause expert and author. She answers some common questions from women.

“What I love as a menopause doctor is having the opportunity to transform someone’s life completely for the better,” says Dr Naomi Potter, a 48-year-old menopause specialist. “You take a person who feels utterly broken and you put them back together.”

After 16 years working for the NHS, Naomi is now one of the UK’s leading menopause experts. She is the founder of the Menopause Care clinic (the UK’s largest team of British Menopause Society accredited doctors and specialists) and co-authored the frank and taboo-busting book Menopausing with Davina McCall. She is also a mother of five with three boys and twin girls. Here are the 10 questions she’s usually asked – and what she advises.

Dr Naomi Potter, pictured in 2023, loves the opportunity to transform women's lives. Photo / Getty Images

1. Why is my hair getting thinner?

Oestrogen affects every system in the body, including hair quality and the way it grows. In the same way that when you’re pregnant, you have really noticeable hair changes, such as its thickness, a massive hair shed. It’s all driven by hormones and with menopause, that’s the decrease in oestrogen. Yet women are notoriously bad at judging the true extent of hair loss and it’s common to feel that it’s more dramatic than it is.

However, with everything related to the menopause, the main rule is that there are no rules. Every woman’s experience is different.

Some women find their hair gets better – becoming thicker, glossier and faster growing – at menopause, and others notice a big change during perimenopause, but post menopause things settle and then they can improve, and then they settle. Hair can also change going from being straight to curly and vice versa during this time.

Dr Potter’s solutions

If hair’s gone very dry and brittle, then moisturising shampoos might help, but anything you put on won’t really influence the speed of hair growth. And while it’s tempting, if you’re unhappy with your hair, over-treatment can make it worse, so don’t keep going to get it coloured.

Make sure there’s no other underlying cause – such as vitamin deficiencies, a thyroid imbalance or anaemia. Any significant changes, including a receding frontal pattern or totally bald spots, need to be investigated.

Very slim women or those restricting calories may notice more hair loss because as far as your body is concerned, hair isn’t a priority and it will preserve nutrients for the body instead. So, make sure you’re eating well and cut back on alcohol. Liver conditions associated with alcoholism can cause endocrine disruption and hair loss.

2. Why am I getting brain fog?

Brain fog is a common complaint and it’s a description that encompasses many symptoms – being forgetful, struggling to find words and not remembering which way you’re going, even on familiar routes. It can come and go. Not feeling as sharp or switched on can shatter confidence. Lorraine Candy, the former editor of Elle magazine, described on Dr Potter’s podcast Is It Hot In Here, having to put sticky notes all over her wall to remember the most simple facts. She feared she had a brain tumour until her friend, Trish Halpin ,admitted the same thing – and they thought it was unlikely they both had tumours at the same time.

Dr Potter’s solutions

For Lorraine, within days of her trying hormone replacement therapy (HRT), brain fog disappeared. But it’s one of those symptoms that is hard to tease out from other life things – is it hormones or the pressures of work, relationships, child rearing or elderly parents?

Ask yourself how you felt coping with challenges five years ago – when perhaps you were still sleep-deprived from toddlers? If you felt able to cope better with stress back then, it could well be menopause-related hormones.

Think about what in your life is causing sleepless nights. For many women, quite naturally, it has to do with your children and how they’re doing. We can feel the need to be in control all the time – but that’s just not possible. Sometimes we have to step back and say “Okay this isn’t brilliant, but I have to let them get on with it”. It’s the same for elderly parents, sometimes we need to let go a bit instead of fretting.

It’s important to make time every day for yourself – eating properly, getting some exercise (outside, ideally), even a walk around the block counts.

Breaking the alcohol/coffee cycle can help too, if you’re not coping. It’s common when people are stressed to drink half a bottle of wine, then not sleep properly and wake feeling anxious and tired and then drink coffee and get caught in a vicious cycle. Stopping both can help.

3. Is menopause weight gain inevitable – and will HRT stop it?

Our hormones influence not just metabolism, but how fat is deposited. In fertile years, females classically have a curvy physique, laying down fat on hips, bottoms, breasts and face. With the loss of oestrogen, you change shape, with fat depositing more centrally around the organs.

Ageing generally causes fat gain and muscle loss as metabolisms slow down. So, while HRT can offer some protection about where you’re storing fat, it won’t affect general metabolism, alas.

Dr Potter’s solutions

You may believe that by restricting what you eat, the weight will come off like it did in your 20s and 30s, but it doesn’t always work during menopause. It is important to make sure you eat well, with plenty of protein, fibre, fruit and veg. The right kind of exercise is also very important, especially strength training that will help grow muscles and boost metabolism. However, finding an exercise that makes you sweaty but you enjoy is arguably more important to ensure you do it regularly. Be realistic about what you can fit into your life and try to get outdoors.

Humans were meant to be outside and it shouldn’t be surprising if we’re inside all day, we don’t feel good! I like running four times a week to clear my head as much as for my body and no, I’ve never worked out with Davina McCall despite co-writing our book together. She’s fiercely fit!

Ultimately, it can be helpful to be more self-accepting. Is it that bad if you gain a few pounds? It’s inevitable that happens as we age.

Hormonal changes can cause fatigue.

4. Why am I so tired?

Hormonal changes and oestrogen loss can cause fatigue. But not everybody is affected and it can get better on its own.

Are you tired because you are having menopause symptoms at night that are disrupting your sleep? Surges in anxiety, night sweats or getting up at night needing a wee (more common in the menopause) will all disrupt sleep making you more tired.

Dr Potter’s solutions

If broken sleep is down to menopause symptoms, HRT would help.

But if you’re managing nine hours and still exhausted, I’d suggest looking for other causes.

The reason multiple loo trips happen is there are oestrogen receptors all over your urinary tract, so when you lose oestrogen the function and integrity of that system is affected. Bladder irritability (feeling like you need to empty it more frequently) is common, as are UTIs, and your bladder can shrink, so there is just less capacity to hold wee.

During the day, avoid having what I call “just in case” wees because if you’re always emptying your bladder before it’s reached its full capacity, you’re unwittingly training it to be smaller and get triggered at a lower volume. Ask yourself if you really need to go – chances are if you’ve had a wee and then a cup of tea in the morning you don’t need to go an hour later because your bladder volume is much bigger than a cup of tea!

5. Why have I gone off sex?

This is a classic complaint and worth remembering that a lot of libido is multifactorial (involving several causes). Hormones – your declining oestrogen and declining testosterone – can definitely play a role. You’ll feel less interested in sex, but that’s not the only part of the picture.

Vaginal symptoms common in the menopause can include soreness, dryness, poor lubrication during sex, and difficulty with arousal. If you’ve suffered pain while attempting to have sex, your body will object to doing something it associates with a previous negative experience.

Testosterone declines from your 20s, and some women notice that affects libido more than others.

Throw into the mix the stresses of general midlife and the fact you may have been with the same partner for a long time (which naturally becomes unexciting) and it’s easy to see why libido can crash.

However, while less common, some women can suffer from a very high libido, which can cause them serious distress. One of my patients believes her high libido led to her affair, another one had to take herself out of the marital bedroom to pleasure herself, and one lady would have to do so when she was out shopping in Sainsbury’s and had to pop to the loo. So, it can seriously affect daily life despite people’s inclination to say “lucky you”.

Dr Potter’s solutions

Lots can be done! Local symptoms (dryness etc) can be very easily treated with lubricants, moisturisers, and topical oestrogen (in gel form used on the skin or inside the vagina) works really well. There’s an argument for every menopausal woman being on topical oestrogen because unlike oral oestrogen (HRT, which is absorbed into the bloodstream), topical oestrogen is absorbed mainly into the surrounding tissues where it is applied, allowing for targeted treatment of dry, itchy or uncomfortable vaginas.

Now, in terms of desire, it’s not as straightforward. Replacing oestrogen can help, as can replacing testosterone for some women.

We don’t have enough data to categorically say how many women should be on testosterone for the therapeutic benefits in the menopause, but there is data suggesting it can help low libidos. There’s anecdotal evidence that it helps with more than libido, but equally, there’s data suggesting there is a strong placebo effect. The absolute truth is, we just don’t know. I don’t believe women should be held back from trying it, if they want it.

If these things don’t help, I point my patients to a book called Mind The Gap by Dr Karen Gurney, who brilliantly explains all this.

The decline in hormones affect your muscles, ligaments and joints, leading to more aches and pains. Photo / 123rf

6. Why are my joints so achey?

Knee aches, frozen shoulders, plantar fasciitis and tennis elbow are all more likely to happen during the menopause; once again it’s the decline in hormones to blame, affecting your muscles, ligaments and joints. For our joints to function optimally (remain pain-free and supple), there needs to be lubrication, and when your reduced hormones lessen this, you can feel more discomfort as bones endure more friction.

Dr Potter’s solutions

HRT can – but not always – improve things. Finding the right exercise can help; cycling is surprisingly good for sore knee joints because strengthening the quad muscles can help stabilise the knee joints.

For frozen shoulders, a steroid injection can do the trick, even as a one-off. Bear in mind that just because you have that symptom now, it doesn’t mean it’s going to stay throughout the entire menopause and after. These issues fluctuate.

7. What exactly are hot flushes?

Also known as “hot flashes” (a US term that’s been adopted here), this is when you experience a sudden rise in heat, often from your chest up into your neck and face. But it can also affect your whole body. This is caused by your blood vessels dilating and – as they get bigger and open up – the blood rushes to the surface of your skin in an attempt to cool you down. You may start sweating more, too.

Essentially, this happens because fluctuating oestrogen affects a part of the brain that regulates temperature, and a body lacking oestrogen is tricked into thinking you’re already hot. As your body attempts to cool itself down, you experience this flush.

In my podcast, the presenter Lisa Snowdon describes her confusion as she suffered hot flushes in her early 40s when she was still thinking she might have children and not realising what they were.

You can get them several times a day or now and then, or never at all for some women.

Women can also suffer the reverse of this, a “cold flush”, in which your body cools you down even though you’re not hot. Fewer people complain of this because it’s less well recognised as a symptom, but is also less debilitating – if you’re suddenly freezing cold you can put on a jumper. If you suddenly become red-faced during a work presentation, say.

Dr Potter’s solutions

HRT can be very good for this, but if you don’t want to take it and this is the only symptom bothering you, there are other medications available to address flushes. It’s also useful to learn what your personal triggers are, so you can avoid them. Stress, spicy food (or food that’s hot temperature-wise) alcohol and smoking are all common triggers.

8. Why do I feel so anxious?

Anxiety is often the first symptom women notice in perimenopause and this is because your hormones impact brain chemistry. Its impact is different for every woman, but, for some, progesterone causes a really nice, calming effect. So, when that drops in menopause you feel more anxiety. We don’t really understand how oestrogen or progesterone impacts serotonin and dopamine, the neurotransmitters that affect mood, learning, and behaviour, or why some women are affected more than others.

It’s all connected and while not every menopausal woman will suffer anxiety, there are many who have never suffered it before and then it creeps in towards the late 30s and early 40s and they’re not used to it and it’s overwhelming.

Dr Potter’s solutions

Lots can be done and mostly, it’s about looking at your lifestyle. Drinking coffee and alcohol increases anxiety, both are stimulants causing adrenalin surges (which feel similar to anxiety) – cut back or stop and see if it helps. Reducing stress, whether through mindfulness or meditation, will also help, and exercise is wonderful for combatting anxiety.

Some people find alternative therapies helpful – there are many herbal remedies for anxiety and some swear by things like acupuncture, massage or reiki.

I’m not against anyone trying anything they feel works for them, as long as it’s not ripping women off. It makes me annoyed when I see hugely expensive supplements marketed for menopause that contain the same ingredients you’d find cheaper at the supermarket.

There are no supplements I’d particularly recommend, some women say magnesium before bed can help calm restless legs, and I think there’s a little bit of evidence that it works and won’t do any harm.

9. I think I smell differently – and why is my skin breaking out?

Because oestrogen changes the environment of your skin and the way you smell partly depends on the bacteria that live on the surface of your skin, women can sometimes notice a slight change in their smell – in their sweat or vaginal discharge. It’s likely to be temporary, but any offensive discharge odour needs to be investigated by a doctor because it’s more likely to be an infection.

It’s not uncommon to have hormonally driven skin breakouts, whether it’s rosacea (little spots over your nose or across your cheeks) or cystic acne that can form around the chin. This is often down to the change in the balance of testosterone, so even if your testosterone level has remained relatively unchanged, dropping oestrogen will create an androgenic shift in the balance (making male hormones more dominant than before) that can lead to breakouts.

Dr Potter’s solutions

In addition to the commonsense lifestyle changes – eating well, exercising and getting enough sleep – there are topical antibacterial medications available, such a benzoyl peroxide for acne and topical metronidazole for rosacea.

10. Why can’t I sleep through the night?

Those 4am awakenings can be caused by a sudden surge of adrenalin that wakes you up and then you feel anxious and unable to get back to sleep. It’s complex why this happens and it’s about the activity or hormones in our brains, but we don’t really know why it happens, or why with depression falling asleep isn’t as much the problem as staying asleep.

Dr Potter’s solutions

Good sleep hygiene is crucial and part of that is going to bed only when you’re sleepy. If you don’t fall asleep straight away, get back up and return to your bedroom only when you feel ready to sleep. Spending two hours in your bed wide awake only sets you up for failure for the subsequent nights.

However little sleep you’ve had, set your alarm at the usual waking time and get up the next morning and keep doing this routine because it should help retrain your habits.