The Dr Louise Newson Podcast - 003 - Menopause & Depression - GP & Menopause Expert Dr Rebecca Lewis & Dr Louise Newson

Episode Date: June 27, 2019

Symptoms of depression commonly occur during the perimenopause/menopause. Here, Dr Newson is joined by Dr Rebecca Lewis and together they discuss why symptoms can occur & ways of managing them with the right treatment. For many menopausal women, these symptoms are incorrectly diagnosed as depression; research shows around 70% of perimenopausal/menopausal women are inappropriately offered/given antidepressants. There is no evidence that antidepressants are beneficial for the low mood associated with changing hormone levels. Dr Rebecca Lewis' Thee Take Home Tips about Menopause and Depression: Low mood is a very common symptom during the menopause - you are not alone! There is a great treatment available and the right type and dose of oestrogen can really help these symptoms. HRT is safe and can be so beneficial for our mental health, as well as cardiovascular health and bone health. Find out more about Dr Rebecca Lewis

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsome, a GP and menopause specialist, and I run the Newston Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. Today I'm going to be talking with Dr Rebecca Lewis, who's one of the doctors who works very closely with me here at my clinic. I've known Rebecca for a long time as a friend and also a colleague, So it's really exciting that she's working so closely with me. So today we thought we'd talk about depression, a bit about anxiety,

how it can happen and occur in the perimenopause and menopause. So, huge problem really, isn't it? Totally. It floors so many women, I think. I think most women have experienced it to greater or less than you. But yes, it sort of comes along. It's kind of insidious and honest, like many of the menopausal symptoms. but the fluctuations I think in eastern levels which we see in the perimen of course

really does affect the neurotransmitters that are important for our mood of 5HT and they act on the limbic systems you know in the area of the brain it's important with mood and that's affected by fluctuating levels of estrogen so women often then feel one day they could feel okay and a couple of of weeks later can feel absolutely flawed by their symptoms of low mood, increasing anxiety. That's very common. Feeling a little, sometimes paranoid sometimes, actually. Some poor women really are affected quite considerably by that. Sleep as well is also bad. And so they're not getting good night's sleep. They're feeling exhausted, low, anxious. Tend to overthink. Yes.

Do you find that? Totally. And lots of people get this irrational anxiety. I saw someone this afternoon and she was saying to me, I've stopped going on a tube, I don't like closed bases. It won't fly. That's very common. Yeah, and driving. Driving, of course. Yeah, great, no problem with driving and suddenly, not able to drive on a motorway.

It's, you know, never had these symptoms before. No. And often, I'm sure you see the same women don't associate these symptoms with their hormones because why would you? No, really. Yeah, absolutely. You know, I don't know about you, but certainly my children at school just get talk the menoples winning period stop.

Yeah. We talked about estrogen, how important estrogen and progesterone are for our cycle, a reproductive cycle. But we don't... No. People don't always realise, do they? No, I just think it's... Your periods change and you get a few hot flushes. But estrogen gets all over around our body, doesn't it? It's so... completely. The eastern receptors in the brain

is so hugely important. We have receptors all over the body, don't we? Collagen and the heart and the vagina and the bladder, but the brain is so important. And we don't realise until we haven't got it, do you know. And I'm constantly amazed by ladies who come into the clinic, how they really are desperate. I mean, their mood has really dropped.

I mean, sadly, some poor people do feel so low that they feel almost suicidal. And it's no surprise, sadly, that the commonest rate of suicide is between the age of 45 and 55. And what's the average age of the menopause? Yeah, 45 and 55. It has to be a connection, man. Yeah, obviously.

Yeah. Yeah. But, I mean, the good news is with Eastern Replacement, it's so rewarding being here. I see women come back and they're so, their anxiety is gone. They're not overthinking. They used to be catastrophizing about small things. Even, you know, capable women, the high, high demanding jobs, found it really difficult than that.

Anything made them anxious. But now they come back, they're coping with their jobs. they're able to do easy everyday tasks while I'm feeling overwhelmed so you know it really is important that hormone eastern I'm always fascinated how how much it plays in part of our

personality because it's if we just go back a little bit and think about depression so many of us have bad days don't me and we say I'm really depressed and that's not clinical depression no no it's a situation so how do you

distinguishing things sad and having a low mood it doesn't mean it's necessarily clinical depression which is a sustained low mood again with low poor sleep often loss of appetite unable to interact dark all the time not sometime it's not a fluctuating mood it's persistent

and it is a difference and women often realise that they say I'm not depressed, but I'm low and flat. Yes. In combination of this fatigue, it's sort of this sort of, ah, grayed out. Everything's enormous effort. So with clinical depression, you tick all those boxes, but women tend to not have much of an insight, do they?

Their life is very down and dark and bleak, and it is overwhelming. But somehow with menopause and perimenopause, they have these tincts, but they want to get better. didn't they? And they almost sit there and say, I know I'm not depressed. That's right. They can detach from that. They do have an insight to their mood because again, the mood can improve. Yes. And that's one way of part of the problem really because people put this low mood down to circumstances. And of course, three weeks later, when their Eastern levels have peaked up a little bit, they feel a bit better. And they put it down to X, Y and Z in their life,

which is stressful. And don't put the connection. Actually, it's the perimenopause causing us, I find. So it almost is worth then trying to have a mood diary and working out with their periods. That might be quite revealing for a lot of women. I think it would be, actually, yeah, definitely. Because there is an association,

we sometimes talk about this reproductive depression, don't we? Do you want to just talk through that thing? So some women are much more prone to having these symptoms especially if they've had really bad PMT the week before their period and during the first few days of the period feeling very low. And that's classfully when estrogen levels got,

that ties in exactly, low eastern levels. And then some women also get this after birth of the child, postnatal depression, which we're well aware of. Again, plummeting low levels of estrogen. And it really can affect some women incredibly severely. So these ladies are more at risk of suffering with these low moods in the menopause and very menopause. So it's a bit of a warning sign. If you've suffered those things before, it could be tricky.

Yeah, yeah. And so when periods start changing, that's often when hormone levels start changing. Exactly, yeah. So those low levels, often are lower for longer, aren't they? Yeah, and it's maybe more severe as well. Yes, yes. And it is important because the treatment changes, doesn't it? I mean, you've been a GP for years, I've been a GP for years.

We've seen between us probably thousands of women and men who have been clinically depressed who have responded very appropriately and well with antidepressants. Yes, they're very useful. And they work pretty well, don't they? Yeah, definitely. But we've also seen thousands of perimenopals of menopals or women who have had low moods but not being clinically. That's right. It's different.

and they often realise it's different, but they're so desperate to feel better. Perhaps they're offered perhaps inappropriately anti-depressants by their GPs, and they may take it. And they may feel perhaps the anxiety's blunted as a little, but really they don't improve very much. So let's just talk about antidepressant use, because clearly I'm not here, or we're not here to be rude about antidepressants, because they work very well in proper clinical depression,

and I think we need to make that really... Oh, gosh. Yes, yes. But is there any evidence that antidepressants help for women whose low mood is related to the perimenopause or menopause? No, there's not. No, there's nothing at all. So we, and the guidelines are quite clear.

The nice guidelines are very clear that actually should not be used for low mood and the menopause, but in fact, HRT should be used. Yes. Yeah. So then a lot of women that we see and talk to have sadly been inappropriately offered or given antidepressants, haven't they? and I think it's often misunderstanding, isn't it? Because we do sometimes use a low dose of antidepressants for menopause or women, don't we?

Yeah, but that's different. It's a different sort of cases for people who perhaps can't take HIV. For example, people have had breast cancer. Yes. And I think antidepressants do have a good role there. And we use it for the prevention of hot flushes. And that's the key, isn't it? That's the different from the mood.

So when they're used or given fancy, depressants women should be questioning why their doctors giving them shouldn't they? Yeah, that's right. That's right. Because it's a missed opportunity really. Yes. Really to start someone on HRT. Because that's part of her symptoms. And actually then if we stop and pause, there probably have other symptoms such as muscle pains and the hot flushes and the change in periods and the poor sleep pattern. Yes. Which together makes the diagnosis of the perimenopause and menopause. Because with the diagnosis of perimenopause and menopause, most women are over 45, aren't they?

Yes, yeah. There's no blood tests. We don't need a blood test for that. It's a clinical diagnosis based on someone's symptoms. Yes. And that's all that's needed. Yeah, no blood tests. And I think it's really important that women know because a lot of women that we speak to

are told, well, it can't be on menopause because it appears not stopped. Yeah. Yes, or they may even do a blood level of estrogen and say it's normal. You don't need. Well, of course, sometimes. in the perimenopause, your eastern levels can be normal, but the next two in two weeks time

they can be absolutely very low. That's right. And the problem is with antidepressants given inappropriately, it causes side effects, often blunting of mood and detached feelings. And also it can upset

libido. Yes. And libido is not anywhere. So it really can have an effect on that. And some side effects. Yes. Yeah. I mean, a lot of people say to me, I just feel blunted.

Yeah. In fact, the lady said to me a few months ago that she had crashed her car, she just reversed into a wall at home. She said, I didn't, wasn't bothered. No. She said, I realise that's not me. Yes. Yes.

I think there's a side effect from the antidepressants, which wouldn't happen with HRT, which is the appropriate treatment for the correct diagnosis. So let's talk about HRT. It's only three letters, isn't it? Yes, yes, exactly. Formin replacement therapy. Yeah. What is it and what are the different types then?

So really it's replacing what the woman's lost. And here at clinic, you know, we use exactly the same body identical hormones. So it matches exactly what the woman used to produce. But with the failing ovary, the levels are falling. So we simply replace what they've lost. We don't give higher levels than their body's required. We just replace the missing amount. similarly, when someone comes to seeing with a low thyroid problem, I replace it with

thyroxin. And different women need different amounts. And different women need different amounts because we all absorb things differently to control their symptoms. And the most important hormone, of course, is... The most important is estrogen, exactly, because these eastern receptors that we were saying are all over the body, which gives rise to all our symptoms in the brain, in the muscles, the vagina, the heart, heart palpitations, and in the bone, which is really important.

And that's one of the very important messages about HRC, about improving the quality of life. Yes. The here and now, but also the future, isn't it? Yeah, totally. And that's so important to get that message across. Yes, because actually we live longer after the menopause than we do in our reproductive years or any other stage of our life, really. Yes, it is, exactly. potentially 40 years ahead of good quality life that's to be enjoyed.

You know, because as we know, it prevents, helps prevent osteoporosis. And there's actually a treatment for osteoporosis and helps prevent osteopenia the stage before. It's progressing. So it's vitally important for our bones. And of course our heart as well. It can have the risk of heart disease. which is huge.

As you know, heart disease kills more women than any other condition. Yeah, including breast cancer. That's right. So the estrogen, we often give it, don't we, through the skin as a patch or gel? Yes, yes. We'd like to do that because if it's given through the skin, there's no increased risk of blood clot because it's not metabolized with the liver. It's very safe.

Yes. It's a nice clean way of giving it and actually you get a better absorption through the skin than through the stomach. Yes. through a tablet form. And then let's spend a little bit of time, if we may, talking about progesterones. So women who still got their womb need to have a progestogen.

That's right. Who have had a hysterectomy often don't need one. But there are different types of progestogens, aren't there? Yes, exactly. The old-fashioned type of progesterones were much less well-tolerated, really, and often given rise to sort of bloating, low-mood, P-MT-type symptoms. really. They're in the pill, aren't they?

They're in the pill and more in the oral preparations. And their job really is to thin the lining of the womb for women who haven't had a hysterectomy and they do that job, but they're side effects because it doesn't actually match the progesterone we produce in our body. So it gives rise to many more side effects than perhaps the body identical type of progesterone, which has many advantages because it is exactly the same structure. as the progesterone we produce, the body likes it and has less side effects. And that comes as a capsule, doesn't it? There's only one type in the UK. It's only one type that we can describe.

It's a capsule and you can take that orally or so it's quite versatile how it's used. And it's taken a night time, isn't it? It is. It helps sleep which is really a nice side effect. Very good side effect because most women have poor sleep patterns with it with perimenopause. cause. So you're just to take and helps smooth that very nicely and women are suddenly sleeping and feeling better. And it can help some of them feel calmer on it, don't they? I think there's a calming effect definitely I've seen, yeah, yeah. But then around 20% of women have some side effects with any type of. That's right. Still, there's no, you know, that's perfection isn't it? Some ladies do, but we can get around that quite often by perhaps giving it vaginally

because less is absorbed into the bloodstream. So this is the same capsule that you take orally. Yeah, yeah. You insert very simply into the vagina every night. And that's enough to protect the lining of the wound from being thickened. But yet much less gets into the bloodstream. So a lot of women have much less side effects taking it that way. So it's often worth, isn't it?

If women are, if you side effects. That's what we tend to do. Because certainly women who have had PMS and low mood, those women come a bit more susceptible to Yes, yes. Very much more sensitive. Not everyone, some women are great, aren't they? So you can't predict. But it's not licensed

to use it vaginally, but there's good research, isn't there? There is. It's a lot coming out now. Yeah, and it can often be used at half the day, can't it? So you can use one, alternate nights, or depending, but it's important to obviously get the right information from your doctor, but that is an option, isn't it?

Oh yes, and very successful for many people. Yeah. Yeah. And then there's, obviously, there's the marina coil, which... That's right. Then the other thing is very good is the marina coil, because that's fantastically good at thinning the lining of the womb. Of course, once it's in, it's in for five years.

It just needs to be replaced every four to five years. So it's very low dose, isn't it? Very low dose gets into... Hardly anything really gets into the bloodstream, perhaps a little for the first couple of months, but once one's through that time, it's... hardly any gets into the bloodstream. So that's another way one we could use.

And then there are other types of progesterones, even the synthetic ones. Some people find that one type suits them. Yeah, we're all individuals, and I think it's really important to listen to the woman and see what she's saying. And sometimes they, funnily enough, prefer the more old-fashioned type of progesterone,

but that's fine. Yeah, totally. And so there are quite a lot of different options we can give women. And certainly with patients or women, in that have PMS type symptoms, we often don't we just give the estrogen bit first for sometimes two or three months and then cautiously add in the progesterone and that's the beauty of having them two separately isn't it rather than a combination? Yeah, so we can control the

dose and actually sometimes I've found that actually once the eastern levels get up to a quite good level the tolerance of the progesterone is much better don't you find so actually women maybe start the progesterine quite early on and had didn't like it but yet we reintroduce it in two or three months time and they're fine with it yeah so there's always worth to trying yeah and there has been research about using estrogen hasn't there for improving mood yes oh good research and how it has helped people recover from perhaps the low mood from before and help also prevent serious depression which is really important yeah so it's a good preventer for depression later on

Yeah, I mean, there's a good study, wasn't they, using eustrogen through the skin, showing how it reduces. And depressive symptoms are incredibly common, aren't they, doing the perimenopause and metaphors? I don't know what you've read, but I've read very different figures, but some have said as much as a third, some have said as much as a half, I think. Yes, I would say least a half, but probably unsaid and unmeasured because a lot of women may have them and then temporarily then feel better, but not actually say that they are suffering. It's quite private for some people

I don't want to discuss that. It's very hard, isn't it? It's not easy if you've got to rush on your arm you can show your friends and talk about it, but it's very hard. There's so many women who are socially isolating themselves because of the way they feel. It's not just their families that are having an impact on, it's their jobs as well.

Yeah, I mean, there's lots of women who have given up their work. Yes, we did a survey recently, and 51% had reduced their hours 52% that take long time off work because it's very difficult to cope with work feeling like this. And yes, it's a huge impact on women's lives at home and at work. And I think, I don't know right you, I've certainly seen a lot of women who have been off work and their sick note has said depression or depressive symptoms. Yes, definitely. And then they're label, don't they?

That's right, and they're not actually depressed. No. But yes, it's easier to put stress or anxiety, perhaps the menopause symptoms because... And we're going to talk about the impact on work in another podcast, but it can be very hard, can't it? It's not easier almost going into workplace to say you have depression or you have diabetes. Yes. Oh, it's the menopause.

No one's going to give people sympathy for the right? Well, they'll perhaps say, well, of course it's the menopause. It's a natural thing, which it is a natural thing. Yes, of course. But I actually think we're just uncovering how profoundly affected women can be. Totally. And this is a new phenomena in our society.

Yes, definitely. Now we're living longer, of course, and in such a high functioning society we live in now, we have to be sort of performing to cope with our jobs and the children and the elderly relatives, sandwich generation. I think it's exposed this new problem. Because if you think about, in Victorian terms,

sadly, the average age of death was about 57. So we didn't have to tolerate menopause symptoms for Terry long. But this is a new problem now. Yes. It's really important, isn't it? But if we, I know we touched on it earlier, and it is very sad when we think about the suicide rate. Yeah. We see a lot of women, don't we, who have been really thinking, really close to harming themselves.

Yeah. And it's not a cry for help. They've been in really dark places, haven't they? They have. They have. And, you know, it is, I'm constantly amazed how wonderful, really, having the right dose of the right type of HRT, how this can really help people. We've all got stories, haven't we? No, totally.

People have managed to sort of get out of the house and get back to exercising and enjoying with friends and their family. You can be connected again. I think it's, obviously, HRT is only one part of treatment isn't it? And exercise, we know, it releases endorphins can be very good. Eating can be really good. Got health is really important for our brain health. But so many women, almost they've got low self-esteem. They feel almost failures already.

And then they say, well, I can't exercise. I feel so tired. My muscles are sore. I can't eat properly. I've not got this interest. Yes, yes. I think sometimes we've seen women who, once their hormones are balanced, then they go, gosh, right, I'm exercising my moon, my head, my

diet, they've got the focus back, they feel confident back to themselves. So they can do something if they've put on a little bit of weight. They can perhaps, they've always wanted to lose it. They can concentrate on that's easier for them. So I think what we're trying to say to women is that if they're not getting the right, help or advice that they think is relevant for them, they really need to keep asking. because it's hard being a GP and in those few minutes of a consultation

someone comes and tells you oh I'm feeling really lower my mood I'm very tearful and I'm not sleeping very well and we all think about depression a bit of a tick box isn't it? Yes. Maybe think depression if perhaps we just pause one second and just think hang on what about the muscle pains

what about the hot flushes what your periods do and soon we can see that there's a picture of how on this could be the hormonal changes and I think certainly the green chemo-terex questionnaire we do oh it's really good yeah if any of you go on to my website manipulsdoctor.com.uk and you'll search questionnaire it's there yeah yeah and I think it's really useful for women to fill it out don't you agree before they go to their jeannies and that would show and if then a woman says to their doctor or nurse or healthcare professionalistee yeah I feel lower my mood, I'm not interested in my sleep's poor, but I'm getting headaches, muscle pains.

My libido's low, I'm getting sweats, wishes and my periods have changed. Then it changes that consultation quite quickly, doesn't it? Yeah, indeed. We're sort of in the menopause frame of mind. And yeah, I find that very much for myself, actually, to see how patients respond. Oh, it's phenomenal. And patients like doing it as well to see what those are and how it's improving. And I think in general practice, because it's so quick, I think, I'm very much, I should,

your consultations. Enormous pressure, of course. We need our patients to help us in general practice, don't we as well? And I think this is a way that women can really help. And I also think if a woman's there and their doctor looks a bit worried or maybe doesn't know about the menopause, then they should see another doctor, shouldn't they? There should be someone in the practice who is qualified to treat the menopause. And they could ask the practice manager who is the best person to see.

Yes. Yes. I think that's a really important message, isn't it? Definitely. Have some information. Get the right advice for the right person. Yes. And then there are some women who are on HRT and on antidepressants, aren't they?

And that's the right thing for them, isn't it? That's right. I mean, some people have pre-existing depression. Yes. And antidepressants are really helpful and important. Yes. And it would be unsafe to stop. But what we do see, if people who have had pre-existing mental health problems,

they often get worse with the menopause. so it can exacerbate old problems. So sometimes if people are seeing a psychiatrist, they do need treatment, serious treatments, bipolar, for example. And that needs to be taken. I would never suggest to stop those for a minute. But actually also it's important to think about their hormones in conjunction. So I think that because that can just stabilise the milieu, really, of the brain

and help stabilise mood alongside the treatment that is appropriate for their diagnosis. Yeah. Certainly, I've seen lots of women who have with time come off their antidepressants because they feel so much better. But sometimes in the first consultation, they'll say to me, can I come off there and my antidepressants? No, not at all. There's no harm and it's very safe to have both, isn't it? Yes, indeed, yes, definitely. I think there'd be more harm stopping them too quickly.

without medical advice. And then just briefly, if I may just touch on testosterone, which clearly is the male hormone, but we produce testosterone. It's female hormone too, yes, exactly. The ovary produces more testosterone than estrogen, fairly enough. I know, I know, so it's hugely important for women. But it's important in our brain. It's important for our mood as well.

So, you know, everyone thinks testosterone and libido, yes, it does have an effect there, but it also has other effects in the brain, the clarity of thought, the concentration, the fatigue and the memory. Really very important. And mood as well. I've seen a lot of women just feel better, happier. It's a positive effect on the mood and well-being. Energy levels coming back to normal, which I think helps the mood.

If they're feeling energized, I think that does help that sort of greyed out, exhausted feeling. So there's the general enjoyment of life. Yeah. Yeah, yeah, they're living life properly. Someone said to a recent it's a bit like putting on some glasses and I can see in colour again. Yes, exactly. It's putting colour back in.

And a lot of women say that with the low moon in the perine men, the pores. It's just flat lining, greyed out, everyone's. I just feel a greyed out version of a former cell. Yes. And I say, well, yes, even something lovely happens, you don't feel the joy. The colour, colour of life's gone. Yeah, and that's the sort of type. of depression, low mood, if you like, that we get for the maripoles.

So estrogen is key, really, isn't it? That's the first. Yeah. I always think testosterone is a bit like the icing on the cake, isn't it? Yes, it is. And it's not for everyone. Not everyone needs it, no. But some people benefit greatly from that.

Yes. But the key is to get the eating levels right first. Yes. Yeah. And obviously the big problem with testosterone is it's not licensed at the moment in the UK. That's a shame. It's licensed for men. Yeah.

which is incredibly frustrating for us as women. So we tend to use, don't we, the Australian version. It's a cream that is made in Australia and regulated. And we're allowed to prescribe it as a private prescription. That's right. And we do regulate it and monitor it very tightly so that the levels are within the normal female range. For example, we'd never ever advocate having oral testosterone or anything like that.

It's completely different from that. So it's very safe. completely and hopefully it will become licensed over the next few years because there's so much good evidence yeah yeah for its use oh yes very much so and then when people's hormones are balanced start to feel better it is really important isn't it to look at diet exercise yes once you're feeling better in your brain you've got the energy and your muscles are feeling a bit less sore then it's then it's really looking looking at lifestyle which is very very important And is there a particular exercise that you recommend?

Well, some people like yoga because that's really good for the brain and helping people feeling nice and calm. So that's really good. Or any exercise such as running or aerobic exercise is good for the natural endorphins. But I think as long as we need to get moving, it's good for our cardiovascular health. It's good for our mind. Doing something you enjoy on a regular basis is the key. isn't it? I think a lot of women feel really, and men,

but really inadequate because they're not doing the right type or the right sort of exercise, but actually sometimes it's just going for a little walk outside. Yes, it is, it is. Walking up the stairs is only if you'll feel good about yourself. Yeah, that's right. It doesn't have to be going to a gym and spending a lot of money. No, no, it doesn't. And also the diet, the right diet. And then we all know about, you know, the sugar and keeping not excessive purifies of products and...

Processes. Processes are in work. Yes, processed foods. And looking at your diet perhaps and more details, very important as well. Yes, yeah. And we'll talk about that another time about how important gut health is. If you've got good gut microbes, it can improve your serotonin in a more natural way as well. So there's a lot to be said for a sort of holistic approach, isn't it?

And not just a single, here's your prescription, go home and take it. Definitely not. No, no, it's a holistic approach. And talking about it's really important, isn't it? Yes. I think women... People can talk to each other and they know they're not alone because it's such an isolating feeling. Yes. And some women are very good, you know, now, thank goodness that Dubu is being broken down, but it's still there.

Yes, okay. And, you know, talking to girlfriends about it, it does make you feel, oh, well, it's not just me going through this. And solutions could be found by talking to each other. Yeah, it's really important. And that is. CPT can be helpful for some people. In addition. Yeah, so that's cognitive behavioural therapy.

That could be very helpful for some women. But again, it's not just one thing. It's looking at everything. But I think your eastern levels have to be a certain amount. You have to have some replacement, really, to be able to take on all the other lifestyle changes and perhaps things like cognitive behavioural therapy. So important.

So thank you. Thank you very much. We've gone through a huge amount, which I hope has been really informative and interesting. Just on our final few minutes, could you just say three take-home messages that people could, yes. Well, I think it's a hugely common symptom. I think most women will have experienced low mood at some degree with their menopause. So you're not alone. I think there's a good treatment with estrogen, the right type of estrogen, as we talked about.

can really help these symptoms. And that actually how safe hormone replacement therapy is and how beneficial it is for one's mental health, as well as cardiovascular health and bone health. So there's some good solutions there for women who are suffering. Thank you. That's been brilliant. Thank you ever so much. Pleasure.

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