Sleep disturbance affects between 40 and 60 per cent of women during the menopause transition. Hormones account for some of it. Age, mood and undiagnosed sleep disorders account for much of the rest.

In this episode, consultant neurologist and sleep physician Dr Oliver Bernath explains what oestrogen and progesterone actually do to sleep, what HRT can realistically improve, and why waking in the night becomes more noticeable with age in both sexes. We discuss CBT for insomnia, morning light and melatonin timing, which supplements have evidence behind them, and the conditions frequently missed in women, including obstructive sleep apnoea, restless legs and low ferritin. We also look at what sleep trackers can and cannot tell you.

00:00:00 Introduction

00:02:29 Midlife sleep, hormones and HRT

00:06:05 Night waking and how much sleep you need

00:15:18 How night waking becomes chronic insomnia

00:18:31 Light, body clocks and melatonin

00:22:56 Supplements

00:27:27 When optimised hormones are not enough

00:29:07 Sleep apnoea and restless legs in women

00:34:50 Sleep trackers 00:47:20

Full show notes and support resources: https://www.thewomanshandbook.com/

Dr Oliver Bernath: https://www.drbernath.com/

Find me on Instagram and Substack: https://substack.com/@drnataliehutchins https://www.instagram.com/thewomanshandbook/

This episode is for general information only and is not a substitute for individual medical advice.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit thewomanshandbook.substack.com

Episode Introduction

Cardiovascular disease is the leading cause of death in women worldwide, and yet for decades it has been studied and treated as though women are simply smaller men. The symptoms we are most likely to experience are still labelled atypical, despite the fact that women are half of the population. We tend to get disease within the smallest vessels of the heart, where a standard angiogram shows nothing at all. And the risk calculators used to decide who gets treated do not account for female specific or predominant disease like preeclampsia, gestational diabetes, preterm birth, autoimmune disease or menopause.

In this episode I sit down with cardiologist Dr Sara Moscatelli to separate what is really important to know how about to look after your heart. We cover how heart disease actually presents in women, which tests find it and which miss it, what statins do and do not do, where hormone therapy currently sits, and how much exercise your heart really needs. Most importantly, we talk about what you can start doing straight away because for too many women, the biggest risk factor is that we put ourselves last.

Guest Bio

Dr Sara Moscatelli is a cardiologist with specialist expertise in paediatric cardiology, women’s health and cardiovascular imaging. Originally from Italy, she moved to London to train in cardiovascular magnetic resonance at the Royal Brompton Hospital. She is now undertaking a PhD at University College London and Great Ormond Street Hospital, investigating arrhythmogenic cardiomyopathies in children. Alongside her clinical and translational research, she writes and speaks internationally on sex differences in cardiovascular medicine, including diagnostic bias in cardiovascular imaging in women.

What We Cover

[00:02:50] The awareness gap, and what it costs women

• Why so few women know that cardiovascular disease is their leading cause of death

• The measurable consequences: longer delays, fewer cardiology referrals, worse outcomes

[00:05:30] The risk factors standard calculators leave out

• Pregnancy complications, autoimmune disease and menopause as cardiovascular risk factors

• Why the risk scores your doctor uses still cannot account for any of them

[00:07:32] What a heart attack actually feels like in a woman

• Breathlessness, profound fatigue and upper abdominal pain, and why calling these symptoms atypical is part of the problem

• The case from a colleague that changed how Sara listens

[00:10:32] Small vessels, invisible disease, and the tests that find it

• Why men’s disease sits in the large arteries and ours in vessels too small to stent

• What a clear angiogram really means, and how cardiac MRI has changed the picture

[00:19:34] Statins: the evidence versus the algorithm

• A viral social media clip on statins, taken apart claim by claim

• Whether the dementia claim survives scrutiny, and what actually drives cognitive risk

[00:25:14] Blood pressure, the silent killer

• When to start measuring, how often, and what to do with a high reading

• Where home monitors and wearables genuinely help, and where they do not

[00:27:43] How much exercise your heart actually needs

• Walking, running, HIIT, VO2 max and lifting: what to prioritise and in what order

• Why the three month mark matters more than finding the perfect programme

[00:32:20] Heart attacks in younger women

• Coronary artery dissection, and why chest pain in your thirties should never be dismissed

• The other cause of heart attacks in young people that rarely gets discussed

[00:34:56] Menopause, hormone therapy and the heart

• Why losing oestrogen changes cardiovascular risk, and what HRT may or may not do about it

• Where the evidence currently sits, and what Sara is waiting for

[00:38:08] Why heart failure looks different in women

• Diastolic dysfunction, and how a heart that pumps normally can still be failing

• What decades of sex bias in clinical trials has meant for the way women are treated

What You Will Learn

• What are the symptoms of a heart attack in women?

• Why are women’s heart attack symptoms described as atypical?

• What is coronary microvascular disease?

• Why is my angiogram normal when I still have chest pain?

• What are MINOCA and INOCA?

• Does preeclampsia increase your risk of heart disease later in life?

• Do cardiovascular risk calculators work for women?

• Do statins cause dementia or memory loss?

• Do statins work as well in women as they do in men?

• At what age should women start checking their blood pressure?

• How much exercise do I need for heart health?

• Is walking enough exercise for your heart?

• Do I need to know my VO2 max?

• Does HRT protect the heart?

• Can you have a heart attack in your thirties?

• What is spontaneous coronary artery dissection (SCAD)?

• What is heart failure with preserved ejection fraction?

Key Takeaways

• Your symptoms may not look like the ones in the textbook. Unusual exhaustion, breathlessness and pain around your stomach can all be cardiac.

• A clear angiogram does not always mean a healthy heart. If you have ongoing symptoms and no explanation, ask whether microvascular disease has been considered.

• Your obstetric history is cardiac history. Preeclampsia, gestational diabetes and preterm birth belong on the list every time your risk is assessed. Mention these risk factors yourself if you have not been asked directly.

• Start small and start now. Walking counts. Three months of a habit you actually keep will do more for your heart than a programme you abandon in a fortnight.

Further Resources and Support

Heart health information and support

• World Heart Federation. Global alliance of heart foundations, with campaigns and links to national member organisations

• Go Red for Women. The American Heart Association’s women’s heart health initiative, including symptom guidance and survivor stories

• British Heart Foundation. Patient information, risk checkers and a cardiac nurse helpline

Microvascular disease, SCAD and less common presentations

• Beat SCAD. Support, information and community for people affected by spontaneous coronary artery dissection

• SCAD Alliance. International patient-centred organisation advancing SCAD research and awareness

• Cardiomyopathy UK. Support line and information for people living with inherited heart muscle conditions

Heart failure

• Pumping Marvellous Foundation. Patient-led heart failure charity offering peer support and practical day to day information

• Global Heart Hub. International alliance of heart patient organisations, including heart failure advocacy

Cholesterol and blood pressure

• HEART UK. Cholesterol charity with a helpline and clear information on statins and inherited high cholesterol

• Blood Pressure UK. Practical guidance on measuring your blood pressure accurately at home

• World Hypertension League. International blood pressure awareness resources and links to national societies

Pregnancy-related cardiovascular risk

• Preeclampsia Foundation. Information on preeclampsia and the long-term cardiovascular follow-up that should follow it

• Action on Pre-eclampsia. Support and information for women who have had a hypertensive pregnancy

Physical activity

• World Health Organization physical activity guidance. Global recommendations on how much activity is needed at each stage of life

Disclaimer

The content of this episode and these show notes is provided for general information and education. It does not constitute medical advice and is not a substitute for an individual assessment by your own doctor or healthcare professional. If you are experiencing chest pain, breathlessness, or any symptom that concerns you, seek urgent medical attention. Always discuss changes to medication, hormone therapy, diet or exercise with a qualified clinician who knows your medical history.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit thewomanshandbook.substack.com

For some women, what happens during pregnancy is so much more than just a chapter in their journey to motherhood. It’s a preview of what their physiology is capable of under stress, and a map of where the fault lines lie. The data we need to understand a woman’s long-term risk of cardiovascular disease, insulin resistance, endothelial dysfunction, metabolic ill health, and hormone sensitivity can appear decades before menopause, during pregnancy. We’ve known this for some time, and yet conversations about women’s specific longevity keep starting at the menopause, despite many women carrying important information about their future health from a much earlier point in their lives.

Pregnancy is one of the most extreme physiological events a human body can undergo. Cardiac output rises by 30%, the kidneys filter up to 50% more blood per minute, and metabolic rate reaches levels comparable to elite endurance sport. As well as having a significant impact in the perinatal period itself, complications such as pre-eclampsia, gestational diabetes, preterm birth, and perinatal mood disorders are markers. Women with gestational diabetes are up to 70% more likely to be diagnosed with type 2 diabetes within ten years. Women who have had pre-eclampsia have a 2 to 4 times increased lifetime risk of heart disease. And women who deliver preterm carry a 1.5 times increased lifetime risk of cardiovascular and cerebrovascular disease. This points to subclinical endothelial dysfunction and metabolic susceptibility that existed before the pregnancy began, and that may endure long after the baby arrives.

This information isn’t new. The issue is whether a care structure exists that allows that knowledge to be held by someone able to offer continuity across a woman’s life course. A woman who’s just had a baby is, of course, focused on surviving those early days: feeding, sleeping, healing, and keeping a new human alive. The last thing she’ll be thinking about at six weeks postpartum is her lifetime cardiovascular risk. But that moment passes and if the healthcare system hasn’t built in a mechanism to follow her over the long term, those signals go unread.

This episode is about changing that. I’m joined by Dr Christina Aye, consultant obstetrician and clinician scientist specialising in maternal-fetal medicine, to talk about what pregnancy can reveal about a woman’s long-term health across cardiovascular, metabolic, and mental health domains, and what a life course approach to women’s healthcare would actually look like if we took that information seriously.

Guest Bio

Dr Christina Aye is a Consultant in Obstetrics and FetalMedicine and Honorary Senior Clinical Lecturer at the Nuffield Department of Women’s and Reproductive Health, University of Oxford. She completed a DPhil in Cardiovascular Medicine at Oxford and her research focuses on the long-term cardiovascular consequences of pregnancy complications, including hypertensive disorders and preterm birth, in both mother and child.

What We Cover

[00:02:18] Pregnancy as a Physiological Stress Test

• Why pregnancy puts the body under demands comparable to running an ultramarathon, and how complications that arise in that context are often early signs of vulnerabilities that were already there.

[00:09:42] Pre-eclampsia: What It Is and Why It Matters Long-Term

• What pre-eclampsia actually is, how it is diagnosed, and why having it in pregnancy raises your lifetime risk of heart disease and stroke, even after your blood pressure returns to normal.

[00:17:51] The Placenta, Blood Vessels, and What Goes Wrong

• How a healthy placenta remodels the blood vessels that supply it, why that process fails in pre-eclampsia, and new research showing that the effects on the kidneys can still be measured months after birth.

[00:23:25] What Should Happen After a Hypertensive Pregnancy

• Why monitoring your blood pressure at home in the weeks after birth can have lasting benefits, and why so many women currently leave hospital without the follow-up plan they need.

[00:27:49] Preterm Birth and Long-Term Health

• Why giving birth early, for any reason, is an independent risk factor for heart and circulatory disease later in life, and why women who have delivered preterm are rarely told about this.

[00:30:05] Gestational Diabetes: A Metabolic Warning Sign

• Why gestational diabetes does not simply disappear after pregnancy, what the statistics on type 2 diabetes risk actually look like, and what checks you should be having in the years that follow.

[00:39:21] Perinatal Mood Disorders and Future Mental Health

• How postnatal depression can be a signal of longer-term mental health vulnerability, including at perimenopause, and the striking data linking it to cardiovascular risk decades later.

[00:45:11] What Pregnancy Can Tell Us About Our Children’s Health

• What the science of epigenetics and fetal programming actually means in practice, why the messaging around it needs to be handled carefully, and how to think about your child’s health without adding to the pressure of pregnancy.

[00:52:57] What Better Postnatal Care Would Look Like

• What a joined-up system of care after a complicated pregnancy would actually look like, including the case for using your obstetric history as part of every future cardiovascular health check.

What You Will Learn

• Why is pregnancy described as a stress test for the body?

• What is pre-eclampsia and does it increase the risk of heart disease later in life?

• Does preterm birth affect a mother’s long-term health?

• What is gestational diabetes and does it go away after pregnancy?

• How soon after gestational diabetes should you be checked for type 2 diabetes?

• Does postnatal depression increase the risk of cardiovascular disease?

• What is epigenetics and how does pregnancy affect a baby’s long-term health?

• What follow-up should women expect after a pregnancy complicated by high blood pressure or gestational diabetes?

Key Takeaways

• Complications like pre-eclampsia, gestational diabetes, and preterm birth are early signals of underlying vulnerabilities that require long-term monitoring. You may need annual checks.

• If you had postnatal depression, perinatal anxiety, or struggled with your mental health around pregnancy, that history may be relevant to your future mental health and, emerging evidence suggests, your cardiovascular health too. It’s worth telling your doctor.

• Your obstetric history is part of your health history. Whether you are navigating midlife health decisions or speaking with a new clinician, what happened in your pregnancies matters.

Further Resources and Support

Cardiovascular Health After Pregnancy

British Heart Foundation — Information on heart disease risk, prevention, and support for women.

American Heart Association — Resources on cardiovascular risk in women, including pregnancy-related risk factors.

World Heart Federation — Global resources on cardiovascular disease prevention across the lifespan.

Hypertensive Disorders of Pregnancy

Action on Pre-Eclampsia (APEC) — Education, support, and resources for women affected by pre-eclampsia.

Preeclampsia Foundation — International support organisation with resources on diagnosis, management, and long-term health.

Gestational Diabetes

Gestational Diabetes UK — Peer support, dietary guidance, and information on postnatal follow-up after gestational diabetes.

American Diabetes Association — Information on type 2 diabetes risk, prevention, and management following gestational diabetes.

Perinatal Mental Health

PANDAS Foundation — Support for women and families affected by perinatal mental illness, including postnatal depression and anxiety.

Postpartum Support International — Global network offering support, resources, and provider referrals for perinatal mood disorders.

Maternal Mental Health Alliance — Advocacy and resources focused on improving access to perinatal mental health care.

Preterm Birth

Tommy’s — Research and support for pregnancy complications including preterm birth, miscarriage, and stillbirth.

March of Dimes — International organisation working to improve outcomes for mothers and babies, with resources on premature birth.

Women’s Health Research and Longevity

Royal College of Obstetricians and Gynaecologists (RCOG) — Clinical guidelines and patient information on pregnancy complications and women’s health across the lifespan.

Society for Women’s Health Research — Advocacy and resources promoting sex-specific research and women’s health across the lifespan.

Disclaimer

The content of this podcast is intended for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional regarding any health concerns or before making changes to your care or treatment. The views expressed are those of the individuals speaking and do not represent the position of any institution or organisation.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit thewomanshandbook.substack.com

Two thirds of people living with dementia are women.

It is the leading cause of death for women in the UK and Australia, and a significant proportion of those cases are preventable.

In this short extract from our recent episode on women’s brain health, Dr Natalie Hutchins asks Professor Cassandra Szoeke, neurologist and principal investigator of the Women’s Healthy Ageing Project, one direct question: what are the top three things women can do right now to reduce their dementia risk?

The answers are specific, evidence-based, and in some cases, not what you might expect.

She also weighs in on creatine, vitamin D, the ketogenic diet, and what the data from over 20,000 Australian women actually shows about diet and brain health.

For the complete conversation — including what happens to women’s brains at menopause, why brain fog is not the same as dementia, and what 30 years of longitudinal data tells us — watch the full episode here:

This post is for educational purposes only and does not constitute individual medical advice. Please speak to your doctor for advice tailored to you.

Thanks for reading The Woman's Handbook! Subscribe for free to receive new posts and support my work.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit thewomanshandbook.substack.com

IVF is one of the most emotionally loaded journeys a person can take. By the time most couples walk into a fertility clinic, they have already spent years trying, months grieving, and countless hours searching the internet for answers. That combination of hope and desperation is, in many ways, what makes navigating the IVF landscape so difficult. Vulnerability and high-stakes decision-making do not make easy companions.

The problem is that the IVF industry does not make it easy to choose wisely. Success rates are presented in formats that are virtually incomparable between clinics. Regulation varies dramatically from country to country, and even within regulated systems, quality of care, laboratory standards, and treatment add-ons fall largely outside the scope of oversight. A clinic can display a headline live birth rate that looks impressive and entirely fail to mention that it only accepts patients with excellent prognosis.

Then there is the question of cost, access, and geography. In many countries, publicly funded fertility treatment is limited, inconsistent, or unavailable. Waiting times can stretch to a year or more, and the eligibility criteria can be opaque until you are already deep in the process. The result is that the people most in need of support are often the least equipped to navigate a market that is, frankly, not well designed with them in mind.

In this episode, I am joined by Emma Whitney, an embryologist and chair of the fertility charity Fertility Action, and Professor Bassel Wattar, a gynaecologist and clinician researcher specialising in reproductive medicine. Together we cover everything from how to read a success rate, to what actually goes on in an IVF laboratory, to which treatment add-ons have genuine evidence behind them and which do not. If you’re thinking about IVF, already in the middle of it, or just trying to understand your options, this episode gives you the tools to ask better questions and advocate more effectively for yourself.

Guest Bios

Emma Whitney is a clinical embryologist and the chair of Fertility Action, a charity dedicated to improving access to fertility treatment and supporting those navigating the fertility landscape. She has extensive experience in clinical embryology, including embryo selection, preimplantation genetic testing, and laboratory quality.

Professor Bassel Wattar is a gynaecologist and clinician researcher with a specialist interest in reproductive medicine. He co-leads a research unit dedicated to evidence synthesis in women’s health and the Clinical Trials Unit at Anglia Ruskin University with a focus on delivering high quality applied clinical research.

What We Cover

00:03:04 Access to IVF: public funding, waiting times, and the postcode lottery

– Why 60% of IVF cycles are now done privately, and how eligibility criteria for publicly funded treatment vary enormously depending on where you live.

00:10:48 The global picture: how other countries fund fertility treatment

– International comparisons showing that some countries offer unlimited IVF cycles as a matter of public health policy, in response to declining birth rates and demographic pressures.

– Why the economic and societal case for funding fertility treatment is largely absent from political debate in many places.

00:13:10 How to choose a clinic: what to look for beyond the website

– The role of specialist matching, multidisciplinary team culture, and continuity of care in predicting a good clinic experience, none of which are visible on league tables.

– How corporate ownership models and rented laboratory arrangements can fragment the care pathway in ways that matter to outcome.

00:16:55 Understanding IVF success rates and how they can mislead

– Why live birth rate per embryo transferred systematically excludes patients who never reached a transfer, and why cumulative and per-cycle-started metrics give a more honest picture.

– How patient selection, including excluding older women or those with low ovarian reserve, can significantly inflate a clinic’s published success rates.

00:26:55 The embryology laboratory: the part patients never see

– What makes a high-quality embryology lab, including time-lapse incubation, seven-day working, and embryologist involvement in clinical decision-making.

– How the embryologist consultation works in practice, and what questions patients can ask to understand the lab team’s role in their care.

00:38:55 IVF add-ons: what they are and how to evaluate the evidence

– How the add-on designation works, what it means in practice, and why the current regulatory framework for assessing add-ons has significant limitations.

– The distinction between add-ons offered to everyone versus those targeted at specific patient groups, and why that distinction matters for evaluating the evidence.

00:43:21 Preimplantation genetic testing (PGT-A): green, amber, or red?

– What PGT-A does and does not do, including the risk of discarding mosaic embryos that might have self-corrected, and why the evidence base is still contested.

– Why age is the key variable in deciding whether PGT-A is appropriate, and how to have an informed conversation with a clinician about whether it is right for you.

00:51:41 Endometrial scratching, embryo glue, and other add-ons reviewed

– An evidence-by-evidence review: endometrial scratching (limited and contested), embryo glue (minor benefit, no additional cost, now standard in many labs), time-lapse incubation (standard, not add-on).

– Why immune treatments for recurrent implantation failure, including intralipids, IVIGs, and steroids, currently lack robust randomised trial evidence despite being widely offered.

01:00:13 Going abroad for IVF: regulation, risk, and what to ask

– How regulatory standards for IVF clinics and laboratories differ significantly between countries, and why some popular destinations for fertility tourism have minimal oversight.

– Practical advice on accessing reliable information about overseas clinics, including the value of seeking referrals from clinicians who have direct knowledge of the labs they recommend.

What You Will Learn

• Why is publicly funded IVF so difficult to access, and does it depend on where I live?

• What happens if I am on the waiting list for IVF and I age out of eligibility before I am seen?

• How do I choose between IVF clinics when they all look similar online?

• What does an IVF success rate actually mean, and how can it be misleading?

• Why do different clinics show different types of success rate, and which is the most honest?

• Should I be asking to meet the embryologist, not just the consultant?

• What is a high-quality embryology laboratory and how would I know if a clinic has one?

• What is a treatment add-on in IVF and how do I know whether it has real evidence behind it?

• What is PGT-A (preimplantation genetic testing) and should I have it?

• What is the risk of discarding a viable embryo through genetic testing?

• Does endometrial scratching improve IVF success rates?

• What is embryo glue and is it worth having?

• Is there any evidence for immune treatments like intralipids or IVIGs in IVF?

• Is IVF abroad safe, and how do I know if a clinic in another country is properly regulated?

• What should I ask a fertility clinic before I commit to treatment?

• Where can I find free, reliable support and information about IVF?

Key Takeaways

• Success rates on clinic websites are not straightforward. Always look for live birth rate per cycle started, ask about age banding, and find out what patient groups the clinic accepts. A high headline number may reflect careful patient selection, not superior care.

• The embryology team matters as much as your consultant. Ask whether you can speak with an embryologist before treatment begins, and find out whether the lab operates seven days a week. These details are not on the regulatory website, but they are worth asking about.

• Most IVF add-ons are offered ahead of the evidence. Before agreeing to any additional treatment, ask what the current evidence shows, whether it is targeted at your specific situation, and what the additional cost is.

• Knowledge is your best protection. The IVF market, wherever you are, is not perfectly regulated. Educate yourself, seek peer support, consult more than one specialist if you can, and make use of the independent resources that exist.

Further Resources and Support

Regulatory Bodies and Official Information

• HFEA (Human Fertilisation and Embryology Authority) — UK regulator of IVF clinics; includes a clinic search tool with independently reported success rates and a guide to treatment add-ons.

• HFEA Clinic Finder — Search and compare licensed clinics in the UK, including reported success rates and available treatments.

• HFEA Treatment Add-Ons — Independent evidence ratings for common IVF add-ons, updated regularly.

Charities and Peer Support

• Fertility Action — UK fertility charity co-chaired by episode guest Emma Whitney; provides free peer-to-peer support groups monitored by qualified psychologists, plus advocacy for improved access to treatment.

• Fertility Network UK — The UK’s leading patient-facing fertility charity, offering information, emotional support, and community for people at all stages of the fertility journey.

• Resolve: The National Infertility Association (USA) — Advocacy, education, and support for people experiencing infertility in the United States.

• ESHRE (European Society of Human Reproduction and Embryology) — Professional body for reproductive medicine; publishes evidence-based patient guidance on a range of fertility topics.

Mental Health and Emotional Support

• British Infertility Counselling Association — Directory of counsellors specialising in fertility, pregnancy loss, and assisted conception, for patients in the UK and internationally.

• Mind (UK) — Mental health charity with resources on managing grief, anxiety, and the emotional impact of fertility treatment.

Miscarriage and Pregnancy Loss

• Tommy’s — Research and support charity for pregnancy complications including miscarriage, stillbirth, and premature birth; includes guidance for those experiencing recurrent pregnancy loss.

• Miscarriage Association — UK charity providing support and information for those affected by pregnancy loss at any stage.

• Sands.org.uk — Support and information for anyone affected by the death of a baby, including a helpline, online community, and local groups.

Disclaimer

The content of this podcast episode and these show notes is intended for general informational and educational purposes only. It does not constitute medical advice and should not be used as a substitute for professional medical guidance, diagnosis, or treatment. Always consult a qualified healthcare professional about your individual circumstances before making any decisions about your fertility care. The views expressed by guests are their own and do not represent the official position of any regulatory body or institution.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit thewomanshandbook.substack.com

It is one of the most common questions women bring to the clinic.

Do I need to test my hormones?

And it is one of the questions that generates some of the most misleading answers online.

In this focused extract from our menopause controversies episode, Dr Natalie Hutchins is joined by Mr Vikram Talaulikar, consultant gynaecologist, menopause specialist and researcher, to give an honest, evidence-based answer.

The short version: for most women over 45, a random hormone blood test tells you very little.

Because perimenopause is defined by hormonal chaos. Oestrogen levels rise and fall unpredictably. Where you happen to catch a woman on that journey determines the result, which may have no correlation whatsoever to how she actually feels.

One of the clearest messages from this conversation:

Symptoms are a far more reliable guide than any number on a lab report.

We also explore:

• Why the NICE guidelines moved away from routine hormone testing and what that means in practice

• The problem with testing hormone levels while already on HRT

• When blood tests genuinely are useful, and for whom

• Whether continuous hormone monitoring devices are worth the investment yet

• What actually tells you if your HRT is working

There is a growing market for hormone testing, both in clinics and direct to consumer. Some of it is useful. Much of it is not.

Knowing the difference could save you money, confusion and a great deal of unnecessary anxiety.

This is an extract from our full episode: HOW TO MENOPAUSE: An Honest Take on the HRT, Testosterone and Dementia Debate. Listen to the full conversation wherever you get your podcasts.

Thanks for reading The Woman's Handbook! Subscribe for free to receive new posts and support my work.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit thewomanshandbook.substack.com

Episode Introduction

Dementia is a women’s health issue, but it is rarely framed in that way. Two-thirds of people living with Alzheimer’s disease are women, and yet it is not something we tend to talk about in those terms. Women’s health has long been synonymous with reproductive health, and of course reproductive conditions can affect women profoundly, but they are not what most of us will die of. In many countries, dementia is the leading cause of death in women. But when was the last time you thought consciously about what you can do for your brain health?

We know that the changes associated with dementia begin two to three decades before any symptoms appear, and that a significant proportion of the risk is modifiable through lifestyle. It is something every woman at midlife needs to be thinking about. But it is also a confusing space to navigate. There are mixed messages about brain changes at menopause, conflicting views on whether hormone therapy is protective, and no shortage of supplements claiming to do things the evidence does not support.

In this episode, I speak with Professor Cassandra Szoeke, a neurologist, author, and principal investigator on the Women’s Healthy Ageing Project, one of the longest-running longitudinal studies of women’s brain health in the world. We get into what is actually happening to our brains at midlife, the difference between cognitive symptoms at menopause and dementia, what we do and do not yet know about the relationship between menopause and brain health, and what you should be doing right now to protect your brain for the long term.

Guest Bio

Professor Cassandra Szoeke is a neurologist, clinician-scientist, author and is currently the Director of the Women’s Healthy Ageing Program and Lead of the seXXspecific education for the Academy in HealthCare at Monash Centre for Health Research & Translation. She was the principal investigator of the Women’s Healthy Ageing Project (WHAP), a landmark longitudinal study tracking women’s brain and cardiovascular health from midlife onwards, which has generated important sex-specific findings in dementia research.

Professor Szoeke is a leading voice in the field of sex differences in disease and is the author of work spanning cognitive aging, hormones, and healthy longevity. She is internationally recognised for her advocacy for women-specific research frameworks and for translating complex science into actionable clinical guidance.

What We Cover

00:03 -- Why Alzheimer’s is a women’s health issue

• Female specific risk factors for Alzheimers- what do we know

04:16 -- Alzheimer’s, vascular dementia, and mixed pathology

• The difference between Alzheimer’s disease (amyloid accumulation) and vascular dementia (blood vessel damage)

08:31 -- Why women’s brains are more vulnerable

• The microvascular versus macrovascular distinction

• How oestrogen loss at menopause accelerates both heart disease and dementia risk.

12:56 -- Does dementia presents differently in women?

16:05 -- What menopause actually does to the brain

• The difference between brain remodelling, which is adaptive, and the progressive neuronal loss that defines dementia.

21:40 -- Brain fog at menopause: dementia or not?

27:38 -- Hormone therapy and the brain: what the evidence shows

34:40 -- Professor Szoeke’s top three prevention priorities for women

40:25 -- Supplements, diet, and what the data actually supports

45:25 -- Social connection, brain stimulation, and the research frontier

• Why Sudoku does not reduce dementia risk but genuine social engagement likely does.

What You Will Learn

• Why are women more likely than men to develop Alzheimer’s disease?

• What is the difference between Alzheimer’s dementia and vascular dementia?

• How does oestrogen protect the brain, and what happens when it is withdrawn at menopause?

• Does early menopause increase the risk of dementia?

• Is menopause brain fog the same as early dementia?

• Does the APOE gene carry a greater risk for women than for men?

• Does hormone therapy protect against dementia if started early enough?

• What type of exercise is best for protecting the brain as you age?

• Why does HDL cholesterol matter more than LDL for women’s brain health?

• What is the best diet for brain health?

Key Takeaways

• Dementia is not a gender-neutral condition and more women need to be aware of protecting their brain health.

• Brain fog at menopause is real, but it is almost always driven by the physical disruptions of the transition, not by neurodegeneration. Treating the symptoms often clears the fog.

• Your most important levers for brain protection are daily physical activity, blood pressure control, and staying socially and intellectually active.

Further Resources and Support

Research and Education

Women’s Healthy Ageing Project (WHAP) -- Professor Szoeke’s longitudinal study of women’s brain and cardiovascular health from midlife, University of Melbourne.

Lancet Commission on Dementia Prevention, Intervention, and Care -- The most comprehensive global review of modifiable dementia risk factors, updated in 2024.

Alzheimer’s Disease International -- International federation of Alzheimer associations, with resources and research spanning over 100 countries.

Support Organisations

Alzheimer’s Association (US) -- Support, information, and research funding for people affected by Alzheimer’s and other dementias.

Alzheimer’s Society (UK) -- Information, helplines, and local support services for people living with dementia and their carers.

Dementia Australia -- Australia’s peak dementia body, with resources, helplines, and advocacy.

Alzheimer’s Disease Association (Singapore) -- Support and services for people living with dementia and their families across Singapore.

Menopause and Hormone Therapy Information

The Menopause Society (formerly NAMS) -- Evidence-based information on menopause management and hormone therapy from a leading professional body.

British Menopause Society -- Clinical guidelines and patient resources on menopause, including HRT and long-term health risk.

Jean Hailes for Women’s Health (Australia) -- Accessible, evidence-based women’s health resources covering menopause and cognitive health.

The content of this podcast is for educational purposes only. It is not intended to replace the doctor-patient relationship, nor does it constitute personalised medical advice. If you are affected by any of the topics discussed, please speak to your doctor or a qualified healthcare professional.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit thewomanshandbook.substack.com

If your skin has started to feel like it belongs to someone else - drier, duller, slower to recover - you’re not imagining it.

In this In Focus episode, Dr Natalie Hutchins sits down with consultant dermatologist Dr Justine Hextall to talk through what is happening to skin in midlife, and why.

They cover the science of collagen loss around menopause, the role oestrogen plays in skin hydration, elasticity and even antioxidant protection, and why the gut microbiome may matter more to your complexion than your 10-step routine. Dr Hextall also shares what she considers truly non-negotiable for midlife skin. Unsurprisingly, the list is much shorter than the beauty industry would have you believe.

This episode is part of our In Focus series: shorter, topic-led conversations designed to give you real clinical insight.

⚠️ For medical education only. Please consult your doctor or dermatologist for personalised advice.

Thanks for reading The Woman's Handbook! Subscribe for free to receive new posts and support my work.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit thewomanshandbook.substack.com

If you’ve spent any time looking up menopause information online, you’ll know that it’s anything but a calm and coherent space.

You’ll find one clinician saying you must start HRT as soon as perimenopause begins. Another says hormones are for symptom relief only.

One influencer insists testosterone is essential for energy, cognition, and mood. Another suggests the evidence is not yet there.

Other debates rage simultaneously regarding hormone testing, brain health, longevity…. The list goes on.

I’ve had many women tell me the noise is just too loud; we’ve gone from famine to feast seemingly overnight, the divergent camps so fervent in their views. Some women tell me they end up feeling so paralysed with overwhelm, they do nothing. After a generation of women missed out on the benefits of having a hormone supported menopause transition because of the way evidence was translated back in the early 2000s, it feels particularly tragic that this is contributing to more confusion now.

“Can’t you all just sing from the same hymn sheet and agree?”, is a question I’ve been asked. But the reality is, doctors have always disagreed, especially in areas in which the evidence is less robust and opinion prevails. But now, instead of those disagreements playing out in a passive aggressive letter to a journal editor or during the Q&A session in a conference room, the arena is now social media. A platform we know rewards black and white views over nuance, acerbic take downs, and exceptionalist opinions; in full view of the women watching. Camps have formed. And women are stuck in the middle.

But there is also a second driver of controversy; the commercial interest. The menopause space has become a lucrative marketplace. And the evidence gaps have provided fertile ground for preliminary findings to be presented as fact in order to recoup investments; think facial oestrogen creams and menopause supplements. Non-medical, unregulated wellness products that make up 94% of the 20 billion dollars that is the current menopause market, projected to keep growing.

That’s why I wanted to make this episode with Dr Vikram Talaulikar, specialist in reproductive medicine and certified British Menopause Society Specialist, to give women an understanding of the reasons behind some of these controversies, how to navigate the various uncertainties and approach these conversations with their doctors.

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What We Cover in This Episode

We go through the major areas of controversy one by one:

Hormone testing: why blood tests are largely unhelpful for diagnosing perimenopause in women over 45, what the fluctuating hormone landscape of perimenopause actually looks like, and why continuous hormone monitoring devices are interesting technology that is not yet clinically useful.

Use of hormonal contraception in perimenopause: how the pill can actually stabilise wildly fluctuating hormones in ways that standard HRT sometimes cannot.

Use of testosterone beyond libido: what the evidence does and does not support, why a trial to well counselled patients despite the guidelines may be the answer and why the assays most commonly used to test testosterone levels in women were never designed to measure the ranges relevant to women in the first place.

Use of HRT as a longevity drug: what the cardiovascular data actually shows, why the timing window matters, what we can and cannot say about HRT and dementia prevention, and whether women without symptoms are missing out by not taking HRT.

What I Hope You to Take from This

What I loved about this episode was Vikram’s calm, knowledgeable and balanced approach to some of the most contested areas in menopause medicine, in which he champions putting women’s autonomy at the centre of decision making.

Whilst his approach is firmly evidence informed, it isn’t puritanical, allowing room for individual preferences, priorities and context. This is of course something we do everyday in medicine behind clinic doors, but this nuance and flexibility can often get lost when discussing these topics online in short form content.

If you’ve been confused about whether or not you need to add in testosterone or whether you should be taking HRT for long-term health even if you don’t have symptoms, I hope this episode gives you a good framework for how to approach these grey areas with your doctor.

Episode Timestamps

00:03:09 Why is there so much controversy in the menopause space, and how should women evaluate the information they encounter?

00:07:43 What is actually happening hormonally during perimenopause, and how does that differ from postmenopause?

00:10:55 Should women be testing their hormone levels? What the NICE guidelines say, and why blood tests are often misleading in perimenopause.

00:13:05 Continuous hormone monitoring devices: interesting technology, not yet clinically useful.

00:18:18 The pill in perimenopause: why hormonal contraception can stabilise symptoms in ways standard HRT sometimes cannot.

00:28:50 Testosterone beyond libido: what the evidence supports, what remains uncertain, and how Vikram approaches prescribing in practice.

00:37:00 HRT and cardiovascular disease: what the WHI got wrong, why modern HRT is different, and what the timing window actually means.

00:43:00 HRT and dementia prevention: why this remains a genuinely contested area, and what we can say for women with premature menopause or genetic risk.

00:48:44 The three things that are not controversial: premature and early menopause, ethnicity and menopause timing, and bone health.

00:53:01 Cancer-related menopause: a group that deserves more support, and the evidence for vaginal oestrogen even in women with hormone-sensitive tumours.

Thanks for reading The Woman's Handbook! This post is public so feel free to share it.

I’d love to hear your thoughts in the comments!

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit thewomanshandbook.substack.com

Worrying that your baby is not getting enough milk is one of the most common anxieties in early motherhood.

And often, it can become a source of guilt and self-doubt long before anyone has properly explained what is actually happening.

In this gateway episode, Dr Natalie Hutchins is joined by Dr Mythili Pandi, a family physician and International Board Certified Lactation Consultant (IBCLC), to unpack how milk production really works, and why low milk supply is often more complex than women realise.

They explain the role of oxytocin and prolactin, and how everything from birth trauma and pain to blood loss, C-sections, sleep deprivation, and lack of support can affect supply in those early days.

Just as importantly, they talk about what low supply actually looks like.

Because in many cases, what feels like “not enough” may not be low supply at all.

Simple things, such as whether your baby is producing enough wet and dirty nappies, are often more useful than tracking exact minutes or volumes.

This conversation also covers latch, milk transfer, and why night feeds matter so much for maintaining supply. While supplements are often marketed as the answer, the reality is that support, reassurance, and the right guidance are usually far more important.

KEY TAKEAWAYS

* Low milk supply is often influenced by birth experience, stress, pain, and support

* C-sections and blood loss can delay milk coming in

* Milk production relies on oxytocin and prolactin

* A good latch should not feel painful

* Wet and dirty nappies are often the best indicator your baby is getting enough

* Supplements have limited evidence

* Night feeds are key for maintaining supply

* Most women benefit more from support than quick fixes

If breastfeeding feels hard, it does not mean you are failing.

Often, understanding what is happening and getting the right support can make all the difference.

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This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit thewomanshandbook.substack.com