Balancing Body and Mind in Menopause

In this episode of The Choice Space, Dr Lee David speaks with GP and menopause specialist Dr Carys Sonnenberg about the complex ways menopause can affect emotional wellbeing, physical health and everyday life.

Menopause is often described in terms of hormones alone, yet the experience is rarely that simple. In this conversation, Lee and Carys explore how hormonal changes interact with sleep, stress, lifestyle habits and wider life pressures. Many women find themselves navigating fluctuating moods, disrupted sleep and changes in concentration at the same time as managing work, family responsibilities and other demands.

The discussion highlights how menopause is highly individual. Some women experience few symptoms, while others notice significant changes in mood, anxiety or energy. Understanding these differences can help create a more compassionate and personalised approach to care.

They also explore practical ways of supporting wellbeing during this time – including the role of lifestyle medicine, cognitive behavioural strategies, nutrition and hormone treatment where appropriate. Rather than focusing on a single solution, the conversation reflects on how multiple approaches can work together to support women through the menopause transition.

This is a thoughtful conversation about complexity, choice and self-understanding during a significant stage of life.

Key moments

00:00 Emotional symptoms in menopause
02:22 Mood changes and mental health
04:01 The six pillars of lifestyle
09:10 Habits, coping and awareness
12:21 Hormones and brain chemistry
20:27 CBT approaches for menopause
28:35 Hot flushes and thoughts
32:28 Breathing and stress regulation
37:37 Nutrition and neurotransmitters
41:01 A small wellbeing choice

About the guest

Dr Carys Sonnenberg is an NHS GP and British Menopause Society menopause specialist. She founded Rowena Health, an online service providing holistic menopause care for women. She is trained in CBT and nutrigenomics and is co-author of Women’s Health Made Easy, due to be published in 2026. Carys is also a member of the Primary Care Women’s Health Society wider committee and contributes to education through national conferences and webinars.

You can contact her via her website, or on LinkedIn, Facebook and Instagram: @drcaryssonnenberg

About the host

Dr Lee David is a GP, CBT therapist and author specialising in mental health and wellbeing. Lee has written many books on CBT, mindfulness and teen wellbeing, and speaks regularly at conferences and in the media. Away from work she enjoys running, hiking, singing in a choir and spending time outdoors with her family. You can find Lee through her website and on Instagram, TikTok (@dr.lee.david), Facebook and LinkedIn.  You can find more about her books, wellbeing courses and therapy here:  https://linktr.ee/dr.lee.david 

Transcript

Dr Carys Sonnenberg (00:00)
most commonly, the symptoms that women experience that can affect their quality of life are anxiety, the low mood, the mood swings, and often in perimenopause because the ovaries and the hormones can fluctuate so much,
women can end up not really knowing what they're waking up to that day. They can't control their moods. They find it quite frightening and it can affect them, their family, their workplace, their friends. I think it can be a really difficult time for some people.

Lee (00:36)
welcome to the Choice Space podcast. I'm Dr. Lee David, GP, CBT therapist and author. Today, we're exploring how supporting body and mind can create better balance menopause.

In this conversation, we're going to explore biological change, life context and personal responses all come together during menopause and how different forms of support can work alongside each other to navigate this period of life.

 I'm delighted to be joined by Dr Carys Sonnenberg, a GP and menopause specialist with extensive clinical experience in supporting women through the menopause transition. Carys, welcome. Could you introduce yourself and tell us a little about your work in menopause care?

Dr Carys Sonnenberg (01:22)
Thank you so much for having me today. I'm delighted to join you. I'm Carys Sonnenberg. I've been an NHS GP since and I run a women's health clinic in my NHS GP practice in Hampshire where I work. So women's health has been a part of my role for over 20 years. I love the menopause. I did my advanced certificate with the British menopause society.

I now run a small online private ⁓ menopause myself, which I enjoy. And ⁓ aside from that, I'm also interested in cardiometabolic health. And am a co-author of a book, Women's Health Made Easy to be ⁓ published hopefully this month.

Lee (02:03)
Wow, so loads of relevant to the topic we're going to be talking about today, Carys. So let's start with some of the basics. So the menopause transition is quite a long period of life. It affects people in different ways. In what ways in your experience, does it affect some of the emotional side? So maybe mood or sleep.

Dr Carys Sonnenberg (02:22)
That's a really good question. i think emotional and mental health symptoms can affect women at AT midlife. and also through their lives for many women who are suffering from hormonal mood changes caused by menstruation, cyclical mood changes. But at midlife, we see anxiety, low mood, irritability and anger outbursts, 
difficulty concentrating and focusing. 

We might see symptoms of ADHD getting worse. We also might see people who have diagnosed mental health conditions finding that the symptoms get worse at that time or even new presentations of mental health conditions can come out of the blue.

And people who have significant serious mental health illnesses, example, schizophrenia, bipolar can also worsen at this time. most commonly, the symptoms that women experience that can affect their quality of life significantly are the anxiety, the low mood, the mood swings, and often in perimenopause because the ovaries and the hormones can fluctuate so much,

women can end up not really knowing what they're waking up to that day. They can't control their moods. They find it quite frightening and it can affect them, their family, their workplace, their friends. And I think it can be a really difficult time for some people.

Lee (03:42)
So what I'm hearing there is that there's a real mix and quite a wide range of different symptoms and that these can be new symptoms or there may be worsening of existing issues. it might then trigger maybe a relapse in an existing problem like significant serious mental illness.

And so it feels like there's a whole lot of complexity there. And that can sometimes be quite difficult for women to unpick. What is it? Is it the menopause? Is it something I've had before? Is it that I'm stressed at work? And so it feels quite like there's a lot to try to work out, doesn't it?

Dr Carys Sonnenberg (04:01)
Yeah, absolutely. And I it takes really good, thorough consultation to start from scratch here. really focusing on how that woman is living her life and what stressors she has at her every day.

what I find helpful now is to say, look, these are the six pillars of lifestyle medicine. Please could you briefly summarize in a minute or two how your life is in relation to these things? Because that gives me such an enormous amount of information to start with. and you also want to be is she doing? Where is she turning for support at the moment? Is she turning to alcohol because she wants that lovely calming GABA effect?

Is that affecting her sleep? Is she finding it difficult to get to sleep? Is she waking in the night multiple times? Is she talking about family or elderly relatives? Or has she immediately leapt into history of trauma or mental health? Just listening to that person for two minutes can almost change the entire conversation that you have afterwards, ⁓ and really, those two minutes can be invaluable.

Lee (05:23)
So it sounds like that would be a useful thing for people to do for themselves as well, what are the areas of my life, what are the pillars of living that I might be affected by at the moment. And that brings a really lovely, broad, holistic approach that doesn't then just focus on one solution, but looks at these interconnected, we talked about the complexity already, and there often are, multiple reasons that people are under pressure in midlife, including pressures at work, family pressures, caring for elderly relatives. 

There's a whole lot of issues that women are often holding at that stage in life. So what you're describing there is a way to start to sit down and think, okay, let's try and be a bit more systematic and think about what's affecting me. So could you talk us through what those areas might be if somebody then wanted to do a bit of a check-in about the different areas of life?

Dr Carys Sonnenberg (06:15)
Yeah, definitely. so the things I'm interested in hearing about are sleep and your exercise, your movement, what sort of exercise you do in the day. I'd like to know about your stress levels, your alcohol intake. I'd like to know whether you're smoking or any toxins that are going into the body. 

And I'd like to know about your nutrition, your food. and you can get a really good idea then how people are living their lives and what symptoms may be affecting them most because a lot of people will struggle along with lots of symptoms but the minute they stop sleeping then they really feel shattered and they don't know where to go from there. and then the next question I would ask maybe, do you think there's one or two things that you could change in your lifestyle that might improve your symptoms and if that's the case what do you think would be a good thing to start with?

because we all know Rome wasn't built in a day and we can't sort of state to people, well, is the way a perfect life should be led. this isn't the case for us life, is it? maybe it could be a case of having a regular getting up time, not drinking caffeine in the evening. So to help with sleep or if sleep is a real issue, I might then start to take more of a history about sleep and think, well, are you snoring? Could it be obstructive sleep apnea?

Are you getting up every ⁓ night to go to the toilet a lot? Okay, well maybe your bladder's really struggling. Have you got genitourinary syndrome with the menopause? So things that would help guide me into symptoms are affecting the quality of her life and her wellbeing at that time. Is she turning to alcohol? And I might say, well, why are you drinking that amount? Did you know, actually that alcohol can affect your sleep? Do you know units are in a bottle of And actually for them getting to the end of the day, having that glass of wine, gin and tonic makes them relax. So is that why they're drinking? Could there be other things that we could give you that are healthier choices to relax. 

A lot of empathy going, I completely understand why you're doing that. So shall we think about some ways that give you that calm that isn't going to be alcohol, but a more healthy choice, something ⁓ which can relax you a little more and getting them to reflect on their choices. 

Because sometimes when you're in the middle of it all, you're overwhelmed, you don't know where to turn, you probably haven't really thought about anything clearly, and you make choices because you haven't thought about them, you just do them. And actually taking time to reflect. get my patients to write in my private clinic their lifestyle in detail, some of them complain bitterly, this is just too detailed, it's taking me too long. But I was like, this is the core of the whole consultation. If I can't understand you, how you are, then ⁓ I'm not going to give you the best care because I will be missing a big chunk of what might be really helpful for you to try and work And I find it really, really helpful.

Lee (09:10)
Yeah, and I think it's interesting because it sort of reflects how we do a lot on autopilot. I think that we fall into patterns of coping with stressors, pressures, symptoms, could be well be a combination of all of those things and mood symptoms as well. And have a default set of coping strategies and it is very understandable that we turn to ways to try and cope in the short term.

sometimes we get into that habit where we just turn to it automatically when it is perhaps got some long-term challenges or problems. And so that level of detail, it kind of encourages us to be more present, be a bit more mindful about the choices we're making on a day-to-day basis. 

And this is the Choice Space podcast. And I think unless we've got that awareness of what choices I'm actually making, in real time so I'm a bit more present, I'm a bit more aware. I've got home from work, I'm feeling really tired, I'm feeling very stressed and I was quite embarrassed perhaps had a hot flush at work today my urge is I just want to reach for the bottle of wine and it's kind of just pausing with that rather than just doing it and just taking some time to reflect on

Dr Carys Sonnenberg (10:17)
Mm-hmm.

Lee (10:25)
what's going on for me here. sometimes think it's like an iceberg where that urge to reach out is the tip that you can see above the surface, but actually underneath it there's a whole load of other stuff. And if we can just take a moment to pause and notice what is actually the issue here and what am I experiencing and what am I trying to deal with? I just wonder if it helps us to make more healthy choices.

Dr Carys Sonnenberg (10:49)
Yeah, I completely agree with you. There's always so much more to the choice in the end, isn't there? portion of women feel guilty, they feel that they're to blame for making those choices, but they can't help it and they don't know where to turn. They don't really know what else could be and sometimes stopping something seems enormous, it's like a mountain to climb, doesn't it? So a huge thing. I'll never be able to do it. You know, I've been doing this for a long time, but maybe even just trying to reduce or stopping just for two or three days and then reflecting, how do I feel now? 

So I might think, well, I'd really enjoy a glass of wine, but actually for me, I'm not going to sleep well, I might have palpitations in the night, then I'll feel really tired tomorrow, and I really want to have a great day tomorrow. So actually, that glass of wine has got consequences to it for me. So I am going to choose something else, and something like, there are so many lovely non-alcoholic drinks, there? Aren't there gingery spicy ones that are a treat, you can have them in a lovely glass with an umbrella in it, or something if you want to feel calm. It's making an active choice because you know that some of the choices you might be making have consequences that you don't like.

Lee (11:57)
And can we go back a little bit to think about, Carys what are some of the biological changes during the menopause that might underpin some of the emotional symptoms and physical symptoms and how they all join up to have that impact that can be quite significant AND really have an effect on people's lives and wellbeing?

Dr Carys Sonnenberg (12:21)
Yes, definitely. So I say to my patients, you know, we're born with say two to three million eggs, When we get to puberty, we have 200 to 300,000 eggs. We've lost a lot. And then during our lifetime, we harvest some eggs each month. One of them or more will be ovulated. Some of them will make estrogen and some of them will and some of them, one of them will after ovulation make your progesterone each month and that the hormone levels vary through the month. 

And then you get to late 30s, and there seems to be an acceleration of egg loss at that time towards the menopause where you have very few eggs left. And then there's not enough eggs to make estrogen, therefore there's no ovulation and everything stops and hormone levels remain low. But during the perimenopause, that time running up to the menopause, the fluctuations of estrogen can be extreme. So really high, really low. Some people have a level of estrogen that remains high and then they fall off a cliff and it goes very, very low suddenly. Other people have a gradual decline. Some people are high and low like a yo-yo. 

Some people's ovarian function is okay some months and then they don't ovulate and then they may have that very long anovulatory bleed or have a pause in their bleeding. So everyone is a little bit different, but because estrogen has an effect in the body as does progesterone, in testosterone we see a gradual decline from the age of 20 to the age of 60 being its lowest, then it might increase slightly. So there's not a huge change in level of testosterone at menopause, but estrogen can be all over the place and we're all a little bit different with how it happens. 

And now we're now, the Royal College of Psychiatry's recent statement stated, that we're seeing that the neuro steroid effects of sex hormones are actually poorly understood and we need more information about it, but we do know that estrogen, can affect serotonin levels, which then ongoing affects melatonin levels  and then it can affect dopamine levels. So we can see our brain neurotransmitters can be significantly affected by the changing fluctuation, high, low levels of estrogen and also the progesterone not being produced each month. Progesterone can be for some women a lovely calming, reducing anxiety, helping aid sleep type of hormone. Whereas we definitely know for others, it is the opposite. We have those 150 symptoms of premenstrual syndrome, PMDD, premenstrual exacerbation, where women find that hormone just intolerable it affects their quality of So we know that these hormones do have effects on the brain, the neurotransmitters.

I did some training in Neutrogenomics and it talks about how you start with your amino acid and you want that tryptophan to go down to made into serotonin and then consequently into melatonin. But if you're stressed, it steals the tryptophan away to another pathway, therefore you're maybe not getting as much of it to make your serotonin.

There are other things implicated in making serotonin other than estrogen. So things like iron, vitamin D, and B vitamins, really important that people look at food as being nutrition to their body to help support them to make those neurotransmitters, which can be part some of the healing journey and the way that you can nourish your body and support it to get better. But yeah, I think there's 
25 % of women don't have any symptoms and then 75 % of women do, 25 % of those women will have significant symptoms and often the mental health symptoms are the ones that affect their quality of life the most.

Lee (15:45)
Again, hearing there's a real range and the hormones are very impactful, but they can affect different women in very different ways. So some may be very sensitive to some hormones like progesterone, others may be less so. Some people have no symptoms during the menopause. A quarter of women will have severe symptoms, a quarter won't have any. it does really highlight that diversity and how
we need to take an individualised approach to looking at the unique person, as a unique individual, how can I maximise my wellbeing and what do I need to Because even if I'm not having physical symptoms, maybe I've got lots of life stressors, which mean that I'm still becoming very stressed and low perhaps. 

And so it's not just about the hormones, but the hormones have a big effect. And what I'm also hearing there is there's a link between the hormones that the female hormones, so estrogen and progesterone and then neurochemicals. things like serotonin, which we know is linked to mood, melatonin, which we know is linked to sleep. And so there's these complex pathways and interactions between hormones and then our mental health. So it feels like there's a lot there, doesn't it?

Dr Carys Sonnenberg (16:59)
A lot and I think it is so interesting how learning more about this now and that everybody's so individual with it. so many women who come to see me go out with a different piece of advice, about how we can help support lifestyle and they want to take hormone replacement therapy or combined hormone contraception, or even progesterone contraception to help suppress the ovarian cycle during perimenopause can be really helpful because for some people that... fluctuation of hormones leaves them all over the place. and actually a different approach at different times of menopause, perimenopause, postmenopause, with doses being different, with absorption of hormones being different for each woman through their skin or orally. the question about what level do I need to be at if I'm taking hormones? What level is going to be best for me? 

And discussion that some women have really well controlled symptoms with levels that are... low, others need higher levels. So we're just all, I think your individual approach there is just absolutely spot on. We need time to listen to women, we need to be able to hear them. And we need to also listen to what's important for them, because they have a choice into where they want to live their lives, which trajectory they want to look at when they're taking what they're able to do if they're making changes and we need to really be mindful that that's not the same for everyone.

Lee (18:22)
What I'm hearing there is that when you think about how to navigate the menopause in a positive way for an individual person, we might need to look at lots of different areas and then work out for that individual what feels most relevant. So we're perhaps looking at maybe treatments for menopause symptoms directly. So things like hormone replacement therapy, HRT, may well play a role there. And we'll perhaps just come to that in a moment.

Lee (18:52)
This is the choice pause, a short tool you'll hear in every episode drawn from my books and therapy practice.

Each time it offers a different way to pause, notice and choose your next step.

Today's pause is for moments of physical discomfort.
Take a slow breath in. and a longer breath out.
Let your shoulders soften. Unclench your jaw.
Allow your hands to rest.

Sometimes the body brings uncomfortable sensations.
Perhaps a hot flush, a racing or a wave of discomfort.
In these moments, the natural urge is to tense or try to push the feeling away.
Instead see if you can pause.
Take another slow breath and allow your attention to widen.
Notice your feet on the floor.
the support beneath you.
The feeling of the breath leaving your body with a slow sigh exhale.

quietly acknowledge - This is uncomfortable right now.  not trying to make the sensation disappear.  Just allowing a little space while it passes.

Take one more slow breath.
then gently bring your attention back to what matters in this moment. The conversation you're having, the task in front of you or the person sitting beside you. Even when the body brings difficult sensations.
You can pause, steady yourself and re-engage with what matters most.

Lee (20:27)
We've talked a bit about lifestyle. Also, there may be something around how we manage stress, how we approach sleep, how we cope when we're feeling anxious, what we do when we get a hot flush and our behaviour around that. So there's the emotion - behaviour - thought link, which I think is focused on IN menopause specific cognitive behavioral therapy, which is also got evidence and is recommended by NICE, for an approach that can be women are wanting to explore that side. So again, it feels like this very multifactorial Can we talk through some of those areas? What do you see as the role of hormones and HRT around wellbeing for women?

Dr Carys Sonnenberg (21:08)
question. So I think if we're looking at approaching how to help somebody feel better and improve their symptoms, we need to look at lifestyle and potentially if we are able to, if there's no contraindications and the woman wants to take hormonal treatment.

we are looking at adding that in and they can work really well together. So if we were looking at hormone replacement therapy, I'd be talking now about people who go through a time of menopause between the ages of 45 and 55, which we would call a naturally timed menopause. In this country, average age being 51, 45 to 55 being around the norm, but early menopause to 45 and premature ovarian insufficiency being under the age of 40. those with POI, premature ovarian insufficiency and early menopause are not necessarily what I'm talking about when I say these things. 

But if we're looking at women above the age of 45, you can offer hormone replacement therapy. Does every woman need to take it? If they don't have any symptoms, no, they don't need to take it. There's a great...discussion at the moment about fear of missing out. we have to take hormone replacement therapy for cardiovascular benefit? Do we have to take it in order to avoid fracturing a bone later? So there's a lot of anxiety about it. Some people really want to take it, other people just definitely don't want to take it. But you can start it in perimenopause. You don't have to have stopped your periods.

Usually I would start slow because I find that women take time to get used to the dose. And we let them settle on the hormones for six to 12 weeks before we might consider a dose change. People respond so differently. Some people could take an oral tablet. It's the best thing ever. It's easiest thing. Other people want to take it through the skin. Maybe there's risk factors for blood clot and that would be the safest way for them to take it.

So we can offer them a gel or patch or a spray. And then if necessary, we add in progesterone either cyclically or we add it in continuously depending on whether they're starting HRT in perimenopause or they're taking it a year after their last menstrual period.

we can talk about the regimes and then we can just optimize the dose. But we've also got to have the lifestyle factors in there as well. And it can take time, sometimes years, to get to the right place. I always say to women, this is like a stormy journey. can't get out of the storm, but you can calm the waters in lots of ways. It could be lifestyle changes. It could be adding hormones.

CBT, Cognitive Behavioural Therapy, is of real benefit. I've done the British Menopause Society course and I think all of us should know these skills. I think the more tools we have in our toolkit, the better.  

For some women that is really important, they want to talk about things, for others they have a history of trauma and that can come up at this time. They have had mood disorders, difficulties post-natal depression for example, premenstrual syndromes or something similar. We have people who deal with menopause in different ways, minority ethnic groups, the LGBTQ community, people with severe mental illness, people with learning difficulties, that we need to take an individual approach with everyone, bearing in mind we have very little evidence in some places and sometimes we don't have guidelines on what is best to do, but we need to still bear in mind that everybody from any different walk of life place, you know, can go through menopause at any time, not everyone is the same and need to consider that woman's life.

Lee (24:34)
Yeah, definitely. in the Royal College of Psychiatrists guidance that you mentioned earlier, is that for some women, HRT may make antidepressants more effective because they may be less effective during the perimenopausal period. And it sounds like that's interaction perhaps between the serotonin and estrogen and that impact. So it feels again very variable I always talk a two tracks approach where we think about physical health and physical health treatments alongside mental health and wellbeing and lifestyle and the broader perhaps CBT based treatments. And they don't have to, it's not either or it's really all of this.

It's not even two tracks, it's lots of tracks, isn't it? I mean, you mentioned Six Pillars. It's like a highway with multi-lanes, isn't it? towards wellbeing!

Dr Carys Sonnenberg (25:15)
Yes. It absolutely is. Yes.

And I think some people have, historically been given antidepressants instead of hormone replacement therapy to manage their mood changes and menopause. But and they have got a bit of a bad press now, aren't they? Like we shouldn't be using them at all. But actually, that's simply not the case because some people
they don't tolerate hormone replacement therapy well, or actually they need to have hormone replacement therapy and an antidepressant, or maybe they've been on, as we know a lot of our patients are, antidepressants for years, and suddenly they are deemed to be not working. doses are increased, and we need to also advise women about the possible side effects of antidepressants, including the effect on sexual desire and ability to climax.

In general practice, we're so lucky, aren't we? And that we, although we have short consultations, we do get to know people over time, we can arrange to see them again. We do listen to what they're saying. And although we see them in a snapshot of time, we actually can really start to understand them. We see their family members. we're in a really privileged place to be able to provide the care that we can provide.

Lee (26:30)
Yeah, it is such a lovely thing to be able to get to know people over a period of time as a GP. And it's definitely a privilege. And I sometimes think of it as being like a jigsaw where we have some little key pieces that we explore together and many of the rest of it, the person can fit together themselves. And actually that then creates a whole picture for them because much of our role is about helping them to understand themselves.

So then they might come back having gained some new understanding and maybe they've tried things and this has worked or this hasn't worked. And so we can then work with them make suggestions, but really going alongside rather than us automatically thinking we know what they need to do. I think people bring a lot of expertise themselves. So we talked earlier diaries, carrying out that awareness and being able to track

Dr Carys Sonnenberg (27:00)
Mm-hmm.

Lee (27:16)
actually when I do this, this happens and when I don't do this, this happens. I think that's really, really important information that we can then support people to make positive choices for themselves.

Dr Carys Sonnenberg (27:21)
Yes.

I absolutely agree. And I I love the fact that we live in a world where there is access to information on the internet. I also don't love that, But there are some absolutely wonderful, supportive websites that you can provide people with and leave them to read more. And then they may come back going, I've read this article, I've shown this to my relative. And actually now I really understand.

because there are lots of questions that people might just want to explore themselves. They So books on female sexual desire, for example, that historically we haven't spoken about those things. But actually there's so much out there that's really helpful for women.

Lee (28:05)
Can you talk a little about some of the principles of CBT for menopause? And so that's cognitive behavioral therapy, which is specifically focused on supporting women to live life positively and also cope with the symptoms? So we've talked a bit about hormone treatment and I think that has a more of a direct impact perhaps on improving some symptoms. How might you use some of the principles of menopause Focus CBT alongside hormone treatment?

Dr Carys Sonnenberg (28:35)
Yes, so you can use that ⁓ and it has evidence that it's helpful and supports insomnia, which affects 40 to 60 % of women hormones change. So it's definitely something that I would discuss with my patients looking at the Sleepio app or Sleepful or SleepStation. And it can also help in the management of hot flushes and night sweats. And it can also help support women who have anxiety and low mood. So you're looking with CBT, happens to you? How do you feel about it? And how might that affect your behaviour? 

So for example, if you were to be having a hot flush and you are ⁓ in a meeting or presenting, suddenly you feel like your face is as red as anything, you're flushing, you feel you want to take your top off, you feel like everyone's looking at you. you can deal with that in a number of ways. So you think "well, goodness, I can't carry on. I've got to leave the room." And you might rush, go to the leave the room, maybe go to the toilet, cry, think, oh, I can't do this. Stop work because you think Nothing's helping. I'm so stressed. I can't cope with this anymore. That's it. I can't work. I'm going to stop.

CBT might change process that therefore you to look at how you're thinking and to look at how you're behaving and think, well, maybe I can behave in a different way here. I'm having this hot flush. Maybe I can think, well, okay, it's a normal thing. I'm having a hot flush. This is a normal event for a perimenopausal menopausal woman. gonna go soon. I am gonna be fine.

I don't even think anyone's really noticed or if they have, can just say, I'm so sorry, I'm just feeling a bit hot. I can stay in the consultation. I can complete it. I have confidence that actually it's fine. It's okay. and therefore your behaviour has changed. you aren't giving up work. you're looking at this in a different way. And I think it has real impact in how people can change the way they they see life the way they see themselves and how they behave into a more positive way that helps them cope. So it's not stopping the hot flush, but it might make you less stressed about the hot flush, which in essence might hot flush impactful.

Lee (30:39)
Yeah, I completely agree. And I think there's something there about firstly, being more accepting of ourselves and maybe a bit less hard on ourselves. So if we are we are having a hot flush, if haven't had the best night's sleep, then we are a little bit more compassionate and more accepting that, yes, this is happening. But perhaps we don't go to an extreme of catastrophizing. This means that I can't possibly work. This means I can't function. It means that people are going to think I'm completely incompetent in my job, or these very, very extreme negative ideas about what it means about me. 

And just being a little bit kinder and saying, it's, you know, obviously it would be easier if I'd had better sleep and, and, you know, I prefer probably not to be having hot flushes in the meeting, but it's okay. And I'm not the only, I think there's something about shared common humanity, which is another part of self-compassion, which is, there are so many women who are perimenopausal who actually have this exact same experience. So I'm not alone. I'm not weird for having it. And there's nothing shameful about having it. And so if we can be a little bit kinder and more accepting and then compassionate, then I think as you say, the anxiety goes down. We feel a bit more grounded and settled. And then I think we're more able

Dr Carys Sonnenberg (31:39)
Mm-hmm.

Lee (31:57)
to handle some of the challenges that may come up in day-to-day life. we've talked about creating pauses before perhaps we reach for a glass of wine. I think having a pause when we're having a challenging emotion is also very helpful because it just helps us regulate calm, a moment of, okay, this is difficult. Have a breath, sort of a slow exhale.

And I wondered if you use any exercises to help people create a pause when they're getting distressed how would you approach that with women?

Dr Carys Sonnenberg (32:28)
I breathing exercises. I used them myself when my hormones were changing and I found them so helpful. So we talk about, right, these are ways we can calm the body. And I talk to women about the lion on the shoulder. So I'm saying, imagine you have a lion on your shoulder. You don't know when it's going to take that chunk. So your blood pressure is up.

your breathing rate is up, your blood sugar is up, ready to fight the lion or run away. You're hypervigilant. So are you going to sleep well in that state with the lion here or not? And that lion could be your email, your argument with so-and-so, ⁓ something in life. And then they can visualize the the stress and what's actually physiologically happening to their body. we say, take the lion away. You are now, you fought it or you've run, you're back at the campfire.

you're in the savanna, you're surrounded by people, you're sitting calmly, your blood pressure's gone down, you're not worried, there are lookouts, you are not hypervigilant, your respiratory rate's come down, your blood sugars come down, you are in a state of rest. And that's how you're going to sleep well. So you can use then your breathing slowly in and out, making your breath out longer, breathing through your nose.

And if you practice it before you're in the situation of anxiety, then it sort of comes in as a natural type of behaviour that you think, okay, I'm starting to feel a little bit worried now. I've got a bit of that sort of chest tightness, my throat's feeling tight.

my breathing rate's going up, I know I've just got to carry on, there's no way out of this situation I'm in, so I'm going to use my breathing technique. And you're right with that pause thing. Okay, if I pause for a moment, I have time for my body to get itself together, and then I can carry on in a way which I would want to carry on. So I think, yeah, pausing and breathing are just so helpful.

Lee (34:16)
What exactly do you tell people to do for the breathing? Talk me through it as if I'm learning how to do it. What's the most helpful approach you would use?

Dr Carys Sonnenberg (34:24)
So I'd usually say let's breathe in and out of the nose the nose is meant for breathing, the mouth is not meant for breathing. want to take a breath in and then we want to slowly make that breath out much longer. You can close your eyes and then sometimes I have people do it and you can see the body relax, all the muscles, the shoulders, everything relax. and simpler than that, I don't want to make them count or make it confusing. I just want you to relax your shoulders and just to breathe in and out of your nose, making that breath out much longer. let's get your body to change from that lion to the campfire. And then that is how you practice it.

So just thinking, closing your eyes, calmly sitting. And sometimes I'll say to my patients, how long each day would you have yourself to do this if you were to sit and do this type of ⁓ breathing exercise? And some of them will say, I haven't got a single minute, not even one. But sometimes we might start at just sitting for a moment, just a minute, and then building that time up.

and you can bring them in when you feel anxious or you can do it as a practising session. And just feeling your body, so being in it. So when we have emotions, we can feel them, can't we? It could be we're upset, we're angry, something happens. But emotions, we know, don't last very long. And feeling them, understanding them, and understanding the ability to reduce stress by breathing, by changing your mental approach.

I think it's just really powerful and it sometimes just takes time and practice put it into place.

Lee (35:58)
Yeah, I completely agree. And you know what, I think the simpler the better because when people are stressed and anxious, then ideas are quite difficult to draw on. So I think just that idea of breathing out more slowly IS really key. I sometimes also ask people to notice other parts of the body that are perhaps less triggered if they're getting anxious.

Lee (36:18)
in a scenario at work then maybe noticing their toes or their feet because often our feet are not really involved in say for example hot flush so we can notice our feet on the ground press them down and we've got the lion about on the shoulder we're often in the fight flight freeze posture our body is hunched and ready to do one of those things and so actually maybe bringing up our shoulders and then bringing them back down as we breathe out, maybe sort of grounding ourselves, creating that strong posture where we've got a long neck and back and we're pushing our feet into the ground or our seat into the chair maybe having a sip of water and just noticing the cool of the glass as we pick it up and drinking very, very slowly and just taking a moment. And I think, as you say, it doesn't have to take a long time. I think sometimes even 10 seconds to just create a micro pause before we respond automatically might be enough to break the cycle of whatever stress cycle that we've got into. So I think it is just about pausing. So Just wanted to finish a little bit about lifestyle.

Dr Carys Sonnenberg (37:20)
Yeah, I agree.

Lee (37:26)
Could you just tell us a little bit about how nutrition might have an impact on the mental health or wellbeing of women navigating the menopause transition?

Dr Carys Sonnenberg (37:37)
Yes, So people's diets vary enormously, don't they? And sometimes I will talk to one of my colleagues at work I spoke to and I said, have you had any protein today?" And she's like, no, none, not a single thing. So I was going, well, how are you going to make your serotonin? Where's your tryptophan coming from? How are you going to make your You know, we have essential amino acids we can make some from our body, we need to eat some.

And I think realizing different we all are and how different people's lives are. you can't assume, somebody told me that they were a vegetarian. you might assume, that they're eating lots of vegetables.

But actually what that meant was they were eating bagels and jam and no meat. So people's food and nutrition intake is just so different and they can lack the ability to make the neurotransmitters because they're just not giving themselves the It really taught me the importance of that.

Lee (38:28)
It feels like there are some principles there the idea that our nutrition has a direct impact on creating the building blocks for hormones and for other neurotransmitters like serotonin, which are actually fundamental for our wellbeing. And so we can start to understand more about the fact that actually not just how many calories am I eating,

Dr Carys Sonnenberg (38:42)
Mm-hmm.  Yes.

Lee (38:53)
is my diet involving can have a genuine impact on my mood, anxiety levels, how I respond to stress, how I sleep. And so that feels really important So could you just give us some ideas about what kind of nutrition is likely to be helpful for well-being through the menopause.

Dr Carys Sonnenberg (39:12)
Yes, I mean, think as we know, there's not one diet that suits everybody and we all eat in different ways. And we have historically eaten in different ways. We've been shown different things by our parents. But I think looking at your diet and thinking about what is my plate like? where are my macronutrients? So, you my carbohydrates giving me energy. Have I got enough protein? Have I got enough healthy fats? And then looking at your wide range of fruits and vegetables that give you the vitamins and minerals you need, and also the fibre, the hydration. So we're looking at so many different types of things, but I think many people aren't knowledgeable about the balance of how to eat well.

Lots of people, I'm sure they will tell you they don't like to eat vegetables or fruit, they won't touch them. So I show them a flow chart of making tryptophan, down to serotonin, down to melatonin, I say look, see these things that are involved in this journey, you it's the B vitamins, your vitamin D, your iron, your estrogen, these are supporting that amino acid that you've eaten into being made into these hormones. It's not all just about the estrogen in this journey. It's about the nutrition and your food that you're eating isn't just to stretch your tummy and make it full. It is to nourish your body with all the little things that you need.

nutrition is really important and if we're not eating enough of the things that we really need, B vitamins, folate, vitamin B12 or not even absorbing that, then that's going to significantly affect our bodies I would love to being done in this area to help support people as a whole, because ⁓ I think that this is really important. What we put into our bodies is vitally important. We've touched on gut health, but again, that's another huge area.

Lee (41:01)
So it's been such a wide ranging and interesting conversation. And I think what I'm going to take from it is that complexity and how we can't simplify the discussion and how it's really important to pause and look at these wide ranging factors that can affect our physical and our emotional health, our wellbeing and our ability to cope with the stresses that life might throw at us at a complex period of life. So thank you so much. Just to finish, we always do a choice space takeaway.

So what might be one small choice that someone listening could make over the next few weeks that might support their wellbeing during menopause?

Dr Carys Sonnenberg (41:35)
Well, my own personal choice is walking and walking in nature. So getting out, if you can, at some point through the day to have that time next to something green. even just they've shown looking at a picture of a beautiful field or something like that has benefit effect. And spending time with nature and spending time with animals, that would be, those are calming. people who've got... pets, animals, know how lovely it is just to spend time with them and spending that time every day enjoying just a few moments doing something outside.

Lee (42:13)
I love that. And we haven't really had a chance to talk a lot about or physical activity today. I know that it's really important and I know that it's something that you promote a lot. So I would absolutely agree that finding ways to move our bodies in healthy ways, it's likely to lift our mood. It can help us cope with symptoms. It has so many positive benefits and it can connect socially with people. It can help us manage stress, so there's so many good reasons. 

I think I'd build on that and say maybe keep track of what we've talked about, start just noticing a little bit about some of the habits that we might have fallen into that are coping with difficult symptoms that might not be working so well for us. then just look at making tiny swapping them out. So maybe it's scrolling on our phones or maybe it's we're avoiding doing something which really is quite important. And then it's just putting in place little micro changes that start to help build confidence with a focus on moving life back towards being meaningful and purposeful. Even if that means we need to put our symptoms in the backpack for a little while until they're fully resolved. But actually what we don't want is to put life on hold for that whole period because I think we really lose out on lots of really important aspects of life if we get cut off from it.

Dr Carys Sonnenberg (43:34)
Yeah, I agree. I completely agree. There's so much that we can do to help. And also thinking Rome wasn't built in a day. we have time and we can make some choices and try things out and think, did that work? Was that helpful? it was, we can carry on and then we can start to add the next little thing in.

Lee (43:51)
Lovely, thank you.

Thanks for listening to the Choice Space podcast. I hope this conversation has offered a little more room to pause, and find your own way forward.

We've linked all the ways you can connect with Carys in the show notes. If today's episode has been helpful, please download and share with someone else who might find this space helpful as well. 

This episode was edited by Elle Dixon.