The Dr Louise Newson Podcast - 009 - Gynaecologial Cancers & Eve Appeal - Athena Lamnisos & Dr Louise Newson

Episode Date: August 6, 2019

Athena Lamnisos is the Chief Executive of the Eve Appeal which the only UK national charity raising awareness and funding research into the five gynaecological cancers – womb, ovarian, cervical, vulval and vaginal. In this episode Dr Louise Newson and Athena talk about the importance of diagnosing these cancers early which leads to better outcomes for women. Many women are ignoring signs of potential cancer such as vaginal bleeding due to fear or denial which needs to change. Athena talks about ways the charity is working to improve early detection of cancers and also with the research they are involved in and the discussion also includes managing menopause in women who have had treatment for their cancer and how important it is for them to receive the right treatment and advice. Athena's Three Take Home Tips for Understanding your Gynae Health: You need to know your menstrual health and cycle and know what's normal for you. If you no longer have periods, you need to know when your last one was. We need to break down the stigma and taboo around gynaecological health. Learn and use the correct terminology for your body parts so you can describe any symptoms properly. Know your body! Have a look at your vulva and know what is normal for you. This will help so much should you have to explain anything to a medical professional. https://eveappeal.org.uk/

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsome, a GP and menopause specialist, and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. So hi, today I'm very excited. I've managed to get someone up from London into Stratford-upon-Avon, who is the CEO of the amazing charity called Eve Appeal. Amthina Lamniosos and we've worked together on a few events, a few things and every time I see patients who have had cancer of their cervix or their ovary, I'm always overwhelmed and

shocked by how a lot of them haven't had the right to help certainly since their diagnosis with their menopause. So welcome. Thanks for coming. Thank you. So before we really get started into menopause, which clearly is all I talk about, I thought we'd take a step back. And just ask a bit about the charity, what it is, and also your involvement. How did you become to be involved with it? Yeah, well, thanks very much. And you've just used a really interesting phrase there, take a step back. And that's very much what we do as a cancer charity.

So we're really very different as a cancer charity. We are trying to stop cancer before it starts. So, you know, there are many, many cancer charities out there an amazing hospice movement that's out there as well. But we're trying to stop cancer, as I say. So we're focused on prevention and awareness raising of the signs, symptoms and the fact that these cancers even exist. So what do we do? We do three things. We fund medical research, and that's medical research focused across the five gyne cancers. So they are womb, sometimes known as endometrial or uterine cancer. And it doesn't help that we kind of

of use three words interchangeably for that part of the female reproductive organs. Ovarian cancer, cervical cancer, which is the one that most people have heard of, but is not the one that a lot of women are diagnosed with each year, and there are lots of reasons for that that I'll come on to talk about. Vaginal and vulval cancer, and no one talks about those cancers. So we fund medical research across those five cancers, and that medical research is focused. on prevention, risk prediction and early diagnosis. So trying to find new screening methods

to refine current screening methods where they exist. So for example, it's great. We've got an effective cervical screening program. It would be even more amazing if we could detect HPV and cell changes in other ways apart from a smear test which a lot of people find unacceptable. Yeah. And just to remind them on HPV, so that is... So HPV is one of the risk factors for two of the gynecological cancers. It's human papillomavirus. Yeah, it's a very, very smart, clever virus that we will all come across at some point in our lifetime. There are lots of myths around HPV. It's seen as a sexually transmitted disease by some, which in many ways, I suppose it is, in that you come across it through sexual contact or touching.

So it doesn't need to be penetrative sex. You know, so unless you're a nun and a very well-behaved nun, you are going to come across HPV. If you've just had sex once, you know, you could be at risk of HPV. Most of us just flush it out. It's not a virus that will, you know, cause an illness. Cause an illness. It's an infection that needs treating.

Exactly. Or that we'd even be aware of. For some of us, we don't flush it out and our body undergoes cell changes which lead to cancer. Now, that's not just cervical cancer. It's one of the high risk factors for many of the throat cancers, which are more prevalent in men. I think it's about 90% men who are diagnosed with throat cancers. It's a risk factor for anal cancer, so both men and women, and it's a risk factor in vulval cancer. So it's a really, really important virus, one to understand, and there's woeful, woeful, woeful knowledge around HPV as a virus and what you're at risk for, but a really important virus just to destigmatise and myth bust around because, you know, there is just no shame in it.

There really isn't. So that's the kind of research end of thing. So we're looking at prevention and risk prediction and new screening programs. The second thing that we do, and really important, is to raise awareness of the signs, symptoms, risk factors, and just the fact the cancers even exist. Yes. Because what we so often hear, and is so depressing, is that the first time a woman has even heard of one of these cancers is when they're sitting in a small white room being told by someone in a white coat that they've got one. And that really needs to change. The other thing that is really important about awareness raising is that.

taking that step back. So it's not just taking that step back in terms of the research and looking at how cancer develops and so how we can intervene and stop it. But it's also taking that step back and thinking about what are the issues that sit around these cancers in terms of risk factors and signs and symptoms that we need to address. So the fact that there's such a lack of knowledge around the parts of the reproductive anatomy, but often people don't know what those words are what those parts of the body are called, that people struggle to even name when their last period was due. Lechloan asked, answer detailed questions like, when's your next period due, when did you start your periods, how long is your average cycle? You're literally kind of met

with a, look, which your menstrual, knowing your menstrual health is an important indicator for other aspects of your health. It's a really, really important thing for you to be able to talk through with your GP. Being able to talk to the GP about where you've specifically found a lump or an itch or you've got a pain is really important not just saying, I've got a problem with my waterworks. Or the all famous, I've got a problem down there or with my bits. You know, that really doesn't help your GP and you have a very short amount of time with your GP and you need to maximize that opportunity. You know, there's a clue in the G word. general. They can't be experts on absolutely everything. I mean, I've certainly seen a lot of women who

you have a consultation about their sore throat or their cough or something. And as they're going out the door, they say, oh, I just want to say I found a lump down there. And they've got their clothes on, their gloves. It's winter. You're thinking, oh my gosh, I'm already running 20 minutes late, but you have to examine them. So I think the education that you do to make it acceptable, it's a lot easy. If I had a rash on my arm, I would show my GP, look, this, and this doesn't right but somehow when it's your genitals, we're so British, we don't talk about it, and it's delaying that diagnosis. Absolutely, and it really does. And being able, you know, feeling able to say to the doctor, I'm happy to be examined if you think it would help. And it doesn't matter.

I think so many women, if I say to someone, well, can I just examine it? Oh, I haven't had a wash. Can I go and have a shower? Do you know what? I look at smelly feet. It does it. As a doctor, we are not emotional when we examine patients. And the same men have got eyes, male doctors can still examine. Even if they're not sure what it is they see, they know if it's an abnormality or not. And if you think about, you know, opening your mouth for the dentist or etc. It's exactly the same. So raising awareness and education around all of the issues that sit around the gynecological cancers and gynecological health is really important.

So that's everything from periods through to menopause and everything in between. It's also answering questions around hereditary risk. People are beginning to understand that cancer development is more complicated than just your lifestyle or just your diet or just your genetics or just bad luck. You know, there's a whole confluence of factors and they're really complicated factors. All of the issues around inherited mutations. and there are a few that make you very at risk and at high risk of gynecological cancer development is really important. Then the third thing that we do and the only direct service that we run is called Ask Eve. It's a gynecological cancer nurse service. So the whole mantra of that

services, it's taboo free zone. We're the only charity that employ a Guine-onk specialist nurse, so a gyneecology specialist nurse. And that's for any. questions. Nothing is too small, too embarrassing. It's by telephone, it's by email, and we do a lot of workplace talks around the issues. And that can be really helpful to women who are putting off going to the doctor because they're too embarrassed or they think it's something that they should be pushing aside because it's just one of those things. We often get that. So, for example, one of the red flag symptoms for womb cancer is postmenopausal bleeding. No amount of postmenopausal bleeding should be considered normal. It may not be cancer and quite often these signs and symptoms

are not cancer but we should be rolling cancer out first rather than waiting, waiting, waiting, and then ruling it out last when things, you know, have developed. We know what late diagnosis means with many cancers. So that service is a really valuable way of being able to express concerns, it's much easier kind of emailing or talking down the telephone when you don't have to look into the whites of someone's eyes and say I'm really worried, my discharge

is smelly, this and has been for the last six months and I don't, is that normal? That must be really busy, is it? It is really busy and it has real kind of peaks and troughs around where awareness is in terms of media, which is a really interesting thing. You then begin to see

both the power of the amount of health media coverage, some stories are given, and also the anxiety that's induced through information getting out there. Totally, but it's funny a balance, isn't it? Because when they do, for example, ovarian cancer is notoriously hard to diagnose, and they do a campaign saying, if you've had any bloating, go and see your GP. And most women who have bloating do not have ovarian cancer. So it's good that people come, but then GPs go, oh my gosh, gosh, we're so busy. But I think so much more now, especially with the way the NHS is so stretched

and it is nearly broken, so anything we can do to help is good. But it's about educating the women to empower them so they know other symptoms that possibly could occur in ovarian cancer. Like you say, vulval cancer, what it is, changes that might occur. Yeah. I think the whole bleeding issue is really important because as women, we just got on with things, don't we? And the amount of women that tell me that they have to change their tampon every half an hour, they're flooding their bed, but they've always done that and it's just got slightly worse than they put up with it. Can you imagine a man putting up with that? It wouldn't happen. And the more that women can target their valuable appointment, and I, because of the way GP's working, you don't often see your

same GP or you don't know who you're going to see until you phone up in the morning. And even some women say, well, I couldn't get in because it was only an urgent appointment. Well, if they've got bleeding and it's abnormal, it's urgent, isn't it? Because it could be a cause that needs some... We're certainly to investigate. Totally. So I think we need to change our slump, but also women need to go with the right information, so to look up the right information from the right sources and really say to the GP, I am concerned and I actually, I want to be examined, like you say, or I need a

referral because that's really important, isn't it? Absolutely. As women take responsibility for us. Absolutely. The whole mantra is know your body. You have to know your body so you can spot what isn't normal for you. You've got to know your normal to spot what is abnormal. Totally.

And one of the things that we've done, which is a really well-used resource on the website, is we've produced a set of top tips for having a good, guiney conversation when you go to your GP. And it's really some things which you might think are obvious, but they really, really need to be remembered. So thinking about, you know, do you know the name of your contraceptive pill? Do you know what other kind of hormone-related medication you might have been taking? Don't worry about whether you've shaved, waxed, got the right underwear on, all of those things. They do not matter.

Do express that you don't mind being examined. And if the GP thinks that's helpful, do think about, you know, what your HRT medication is, you know, how long you've been taking it. Think about things like the questions that you might be asked about your hormone history, the number of pregnancies that you've had, whether you've taken, whether you've had IVF, all of the things that might be helpful and might be, you know, very helpful to reflect on. Do you know when your mother's menopause was? all of those things, just have a think about them so you're not put on the spot and left with giving very little information to your deep.

Because it's so important. I know myself, if I go and see my doctor, I do feel a bit nervous and I'm wasting his time. I've got to be really quick. And then you come out, I wish I'd said, whatever. So it's really important. So out of the five gynecological cancers, which is the most common womb cancer? womb cancer. And, you know, it is pretty much the one that's least known as well, which is a real irony. So womb cancer primarily in sort of the largest numbers affects postmenopausal women. Yes. It has a town crier of a symptom in most cases, which is postmenopausal bleeding. So when we say postmenopausal, if you're postmenopausal, then it's a year after your menopause. So if your periods have stopped and it's been more than you. than a year since your last period officially, your postmenopausal. So like you quite rightly say,

any bleeding you need to get checked. Most people who have bleeding in this stage do not have cancer. No. So we don't want people to go worrying that they have got cancer or that potentially have cancer. Most people don't. But there's usually a cause. So sometimes it can be, I saw a lady yesterday in my clinic and she had a really bad vaginal dryness. The lining of the vagina become very thin, irritated and she was a fell runner, so her running had exacerbated some bleeding, but she was examined, had some treatment. And so it's very important. There is a cause. And like you say, most people don't. A lot of people, though, do get referred as a two-week weight, which means it's a suspected cancer. And so that can be quite scary, can't it? So you go to your

GP, you know that most cases aren't cancer, and then you suddenly see this referral saying suspected cancer. I'm mentioning it is really to reassure people because it's the only way as GPs, isn't it? We can get women seen within two weeks. And I think we need to sort of shift the mindset, don't we? Where it's a really good thing to rule cancer out first. Because what we see at the moment, if we look at the National Cancer Statistics, so if we look at the National Cancer Audit and the way things that categorised in terms of diagnosis and delays in diagnosis, there's this whole.

chunk of avoidable delays which is caused by and I say caused you know really likely actually because it's called by the patient almost knowing they've got symptoms but not seeking medical help so there's this delay that's where your work is crucial

where old work comes in there's this next stage of delays and they're categorised as avoidable delays and avoidable breaks my heart to read it as a word which is caused after they've been to the GP and before being diagnosed because what you have is this repeated story of to and fro and

two and fro whilst ibs is ruled out whilst coliac disease is ruled out while all these other things that aren't cancer are ruled out and what i would prefer to move to is let's rule out cancer first and then move on to looking at what the other myriad of things that it might be And I think it's very important because, as you know, I'm sure, the earlier a cancer is diagnosed, the more treatable it is. And certainly for cancer of the womb, it's actually a good cancer to have if it's picked up early. So if a woman has bleeding early, goes on the two-week weight, has an investigation, finds cancer, there's different treatments, but they're usually treatable, isn't it? And so, which is a very different story if it's been. left and the women who have late stages often then do admit that they have had bleeding for quite

a long time which is a great shame. So you raise a really interesting point there so well not only does common sense and everything that we know tell us that an ounce of prevention is worth a pound of cure and it is across all aspects of women's health we know that for every pound we put into contraception the health service benefits nine pounds you know there's a real benefit to prevent across the board. All of the great moves in health have involved prevention, whether that's been vaccination or even before that cleaning wards and washing your hands, it's all been about disease prevention. So we know that. We also know that there are cancers with very good prognoses. So if they're caught early, you know, as you say, with just surgery, womb cancer

has got a very good prognosis. So you asked about, you know, which is the biggest cancer that affects women. Now, that's womb cancer. If you were to ask the question another way, so which is the gynecological cancer that most women die of, that's ovarian cancer. So over 50%, it's about 52% of women who die of one of the five gynecological cancers within five years of diagnosis, will die of ovarian cancer.

And that is just a horrible and brutal statistics. I mean, the average time for diagnosis, is long, isn't it? And I read somewhere that the average number of doctors a woman sees before she's diagnosed with symptoms related to ovarian cancer is seven, is it, or eight. And it's often diagnosed in the A&E department, isn't it? Which you wouldn't expect for a gynaecological cancer. No, you really wouldn't.

So we still have far too many cancers of ovarian cancer being diagnosed at A&E. We still have most cancers about three quarters being diagnosed at stage three or four, where the prognosis is poor, whereas if they were diagnosed at stage one or two, it's about 90% will survive five years, over five years. So, you know, it's a very, very different thing. One of the things is it's so hard to diagnose sometimes because you don't get the bleeding necessarily, like we've already mentioned with womb cancer. The symptoms are quite vague, like I said before, the bloating, sometimes some pain.

People sometimes just feel a bit more tired. and, you know, lots of us have those symptoms, so it can be really difficult. Certainly, as a doctor, I've always told, if someone comes with the same symptom more than three times, you take them really seriously. And I think that's probably, I wouldn't want anyone listening to this thinking,

oh gosh, I've had a bit of bloating, I've had a bit of tibus, but if it's persistent, and also if things change, isn't it? I think that's the big thing with anything in medicine, if some people always have bloating, some people always have some pain. But if it's suddenly changed, and you don't feel right, then you have to go and see. And like you say, it could be they've got celiac disease or something else.

But certainly a lot of people feel that they're pestering the doctors who are already really busy. But it could be a nurse that they see. It could be even phoning up just for some advice to say, is it appropriate for me to see my doctor? And the thing is that there are quite a lot of diseases that have got vague in inverted common symptoms. But what you very rarely find is that that patient hasn't noticed something, but they've been ignoring it. And they probably didn't, you know, it's the lack of awareness. They didn't know.

They just didn't know what they don't know. And they didn't know that it could be cancer. And so we come back to the, you know, let's all cancer out first rather than waiting, waiting. So it's on average about three to six visits to the GP before. even a patient is referred for a CA125, which is the, so a CO125 is a blood test, looking at a blood marker, which, you know, isn't a diagnosis of cancer,

but it can be an indicator if it's raised that something is going on in your body. It might mean, again, it might mean a whole multitude of things. You asked at the beginning, Louise, about what brought me here. So I've worked in the charity sector and on issues-based communications forever through my career. And I've done a lot of work around public health. And through that work, I've done a lot of work on big public health campaigns with the Department of Health and the Department of Education.

So on every cheerful issue from flu immunisation to sexual health to teenage pregnancy to substance misuse, alcohol, drugs misuse, etc. Really varied. So very varied. All of these kind of big public health issues and how do we shift behaviour, what information does. do people have? How do we help them? Because that's the key thing for me. How do we help people behave differently and take on the information in a useful way? Because there's no use. You know, we all know that smoking doesn't, you know, enhance our health. That doesn't stop many people from smoking. That's not the way to impart health information. So I did a lot of, through that work,

I did a lot of work around cancer and screening uptake and did some really interesting projects, really opened my eyes to the barriers that people had around certain interventions and particularly around prevention. So I did one piece of work in Tower Hamlets where breast screening uptake was really low. And breast screening just feels like kind of common sense, doesn't it? You know, people have lived with it for years. It's, you know, breast cancer is everywhere. People know how horrible it can be. And you just think, well, why are people not doing it? Tower Hamlets was as interesting as an area of London because there are two very big populations there. There's a white indigenous population who have been there forever and have grown up in the east end of London

and they've been there for generations. And then there's a reasonably new, primarily Bangladeshi population, who are quite recently arrived, who have got very good health outcomes on other levels but have got fairly poor health outcomes, certainly around. screening uptake and around some cancers. And looking at how those two communities reacted to just receiving that letter about breast screening and understanding their barriers and why they weren't booking the appointments and weren't attending were really illuminating and entirely different for both communities. Entirely different. So we did focus groups with the white

women for a better way of describing them as a group who said, I don't want to see anything that's got the word cancer on it. In fact, they very rarely use the word cancer. They called it the C word. And we've heard stories about women going for screening. They didn't think anything was wrong. Then they end up having a mastectomy. They've been mutilated.

Their husbands don't fancy them anymore. Really negative view of if I go for screening, I'm going to get cancer. I don't want to talk about cancer. Don't know what I acknowledge that it might happen to me. I don't want to know about it. A denial, really. Real denial. And I'm going to get cancer.

You know, if I go, I'm going to find out bad news. For the Bangladeshi community, it was, the letter is inaccessible to me. I have to give it to my son or my husband to read for me, and I don't want something with the word breast in it. I don't know even where the clinic is that they're talking to, and I need to be chaperoned, and it is in a street that I haven't heard or I haven't been into. They probably wanted to go, but didn't know. And I don't want to be talked to in those, I don't want to be talked to in those terms. So we developed two very different communications campaigns for motivating those audiences. For one population, it was very much about really pushing to the fall the fact of how many women who go for screening are actually detected with cancer.

Most of those women will find really good news. They will get good news about their health. And so, you know, you're not, you know, don't look upon screening as a reassurance, not upon something that's going to. to give you some horrible diagnosis. For the Bangladeshi women, it was about giving them a letter, which was in, you know, an accessible form for them, that came from a female GP,

that they could recognize and that came from their, you know, their demographic. It was about telling them, giving them messages about protecting their health for their families, so not talking about breasts, you know, which they just didn't want to, you know, receive information like that,

talking about how they could get to the clinic and how accessible it was and how transport could be organised around it. But really talking about the health benefits for them and their families and pushing that to the fore as the message. So that led me to think about health prevention, led me to think about what the barriers were. And I started, I'd always felt that there was a real inequality in terms of women's health. You know, we as women, we spend a lot of time. We spend a lot of time in touch with health services, not because we're ill, just because we're female. So from periods through to contraception, trying to get pregnant, trying to not get pregnant, being pregnant, having terminations, going through IVF, going through pen and perimenopause, going through

menopause, you know, there's this whole kind of reason why we have to have and access good health care, and yet we're not ill, we're just being female, which I felt really need to needed to come to the fall. So I looked long and hard for a charity that I could lead, which had that prevention focus that was focused around women's health, and that's when I alighted upon Eve. And I felt that it had that kind of, you know, there's a lot, there's a lot of communications that's needed around these issues. And I felt that was a kind of good match. So how long have you been with them? So I've been here for five years, and it feels like a blink on one level. and then I just feel like there's so much to do still.

Yes. I mean, I think it's a bit like the menopause, isn't it? Any stone you lift up so much, you don't know whether to keep it out or to put it down and open another one. And it's, it is overwhelming. And I think the more stories that you hear from women, they're more, I'm sure it certainly drives me, but I'm sure it drives you as well, that you know, there's so much that prevention is key. I've already mentioned how the NHS is struggling, but we can really help the NHS if we can help prevent a lot of conditions and diseases. And we can't ever, I don't think, prevent cancer, but we can change the shift so women are having an earlier diagnosis, which means they're more

successful treatment often. And that's what's really important, isn't it? It's the only thing that will help the NHS shifting towards a preventative healthcare model and people. taking charge of their health and working more in partnership with the health services that we have. And there are some cancers, early detection is obviously key. There are some cancers that we know we can prevent. Well, cervical cancer, I mean, it's so different. It's a great success story. Yeah.

Really different. And now with the boys being vaccinated, it's a real step, isn't it? So that might be a disease. That is something we look back at in history. And with the cancer. where we know that there's a hereditary risk. We know that there are interventions that we can make. They're not easy interventions.

So having surgery being plunged into an early menopause, changing your fertility outcomes, etc. That's not easy. There's not a walk in the park in terms of a preventative option. But it keeps you alive for your family. It keeps you alive and thriving. And it certainly does prevent cancer. Yes.

And there are all sorts of other interventions. that we're looking at that are not kind of within sites as in they're not going to change things tomorrow. It's not like food colouring into water. But over the course of our lifetime, I think what we're finding out about geonomics and what we're finding out about our own genes and what we can switch off and switch on, we're not a million miles away. And I don't think we're a million miles away from our grandchildren. I hesitate. say our children in our case, Louise, but our grandchildren, possibly being genetically tested at birth. And so knowing what kinds of diseases they're at risk out of and knowing what

prevention they should be taking from birth. Yes, which is really key. It is all about risk. And that's not easy either. Lots of people don't want that information, you know. They don't want to know what their risks are. You've alluded to about the brachene and the risk reducing surgery. some women choose to have a bilateral mastectomy, but also some women choose to have their ovaries removed. But then there will be some women will have this surgery and they'll have never had cancer. And we don't know which those are. And I think this gets me back to all the work that I do. It's about individualised choice.

And I think choice is a really important word. But I really feel you can only make the choice when you've got the right information. Absolutely. And that's really key because I feel the. There's a lot of women that I speak to, and I've had this conversation with you earlier today, who have had a type of gynecological cancer, and they have been, because of the treatment, usually flawed into the menopause. And a lot of women are incorrectly told they can't have HRT.

And these women's lives have been difficult because of the cancer, difficult because of the cancer treatment, but even worse because of the menopause. And I saw a lady yesterday who came from Essex, so she'd traveled quite a few hours with her daughter. She'd had cancer of the cervix diagnosed about four years ago. She'd had chemotherapy, radiotherapy. And then she became housebound because she was so dizzy. And no one knew what it was. And then a doctor said, well, I think it might be your menopause, gave her some HRT. And within days, she felt better. And then she moved to a different surgery. And they said, no, you've been on HRT for two years now. You have to stop. And her oncologist said, you have to stop. And she'd become

house found again and her daughter was so worried about her, she'd not stop going out with her friends, completely withdrawn. And women that have had cancer as a service can have HRT and there's benefits for their long term health, their bone health, their heart health, as well as their symptoms. And, you know, for every one woman like that I see in my clinic, there must be thousands, if not millions of women who are suffering in the same way. And as you know, I get incredibly frustrated when people don't have the right information and if they have the right information, they can then usually speak to a healthcare professional to make the right decision for them. And so I think the work that you're doing is phenomenal, overwhelming, I'm sure at times.

So just finally, I would just like to ask you three take-home tips, just for women to maybe reflect on and think on and share with their female friends and relatives as well to help. Yeah, and I just want to, I don't know if this is a very, a tip, it's going to be an extra tip, it might be number four, but just to pick up on what you've said there about choice, because I have a fierce attachment to every healthcare decision being a woman's choice. You can choose whether you have chemotherapy or not. There might be lifestyle factors, personal factors that mean that you don't want to do certain things. And that's fine, is that? Absolutely fine. Every decision, vaccination needs to be a

decision for you, whether to go for your screening needs to be a decision for you. Personal choice is very, very important. I have an equally fierce attachment to facts and evidence. And there is a horrible proliferation of questionable information out there and a horrible dearth of information out there in accessible formats for many women on these issues. So it's the facts and evidence, I really am very attached to them. And that is, that's really close to our heart at Eve, making sure that women have that information and therefore are able to make that informed choice and are able to give informed consent to whatever procedure it is. So that's, that's sort of number one, but it's kind of number one point one. So three things.

You need to know your menstrual health. You really do need to know your periods or your periods what's normal for you. And if you're not having period, you need to be able to remember when your last period was. Excellent. When you were postmenopause, I'm sure you must come across this all the time.

This slightly quizzical look when you say so when was your last period. Make a note of it. The second thing I would say is we really need to break the culture of stigma and taboo around Guine Health. So use proper language, learn the proper language. It's absolutely fun. using silly euphemisms if you know what things are and what bits you're describing indeed is there's no problem in calling your stomach your tummy or your toes your tutzies everyone knows

what they are it really doesn't help when you start talking about your waterworks and your bits you do need to know what's going on inside your pelvis and what's going on between your legs and then that's number three look at your vulva really do know your body so really, you know, do have a look, look at what's normal for you. Do really understand your body and know your normal so you can begin to describe that to a medical professional. Great. Thank you ever so much. And just finding your website, Eve Appeal. Yeah. So do contact the Ask Eve Service. That's the Nurse service I was talking about. So that's called Ask Eve and you can email Nurse at Eve Appeal, one word, EVEE Appeal.

and our website is evaple.org.org.uk. And on social media, so Instagram, Facebook, Twitter, we are at Eve Appeal. So follow us, share. Excellent. Carry on the dialogue. Thank you. Thank you so much for coming. That's been wonderful. Thank you very much. For more information about the menopause, please visit our website www.w.mendaport doctor.com.ukuk