The Dr Louise Newson Podcast - 030 - Early Menopause and POI - Dr Sarah Ball and Dr Louise Newson

Episode Date: January 14, 2020

In this week's podcast, Dr Louise Newson is joined by Dr Sarah Ball, a GP with a special interest in the menopause. Together, they talk all about early menopause and Premature Ovarian Insufficiency (POI) which affects women under 45 years. In the UK, around one in 100 women under 40 experience an early menopause yet many of these women are not diagnosed nor do they receive evidence-based advice and treatment. It is essential that these women receive replacement hormones at least until the age of 51 (the average age of the menopause) unless there are medical contra-indications to taking hormones. Dr Newson and Dr Ball discuss the health risks of untreated early menopause and POI and also the different ways in which women can receive individualised help and treatment.  Dr Sarah Ball's Three Take Home Tips: Early menopause is a different experience - it is essential to replace your hormones Your fertility still does need to be considered Don't feel isolated! Find some support, there are others out there experiencing the same thing. Click here to watch Dr Louise Newson discuss early menopause and POI.

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newson, a GP and menopause specialist, and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. So today I have Sarah Ball, who's one of the doctors who works with me very closely in my Menopause and Well-Being Centre. So thanks for coming today, Sarah. It's a pleasure. Some of you might know we recorded a...

podcast a few months ago now talking about migraines and the menopause. So today we thought we would focus on younger women because when people think about the menopause, often people think about women in their 50s with hot flushes and that's what most people, don't they, think about the menopause. But actually, I was quite surprised to learn really quite recently because, as many of you know, I didn't have any formal menopause training as an undergraduate or postgraduate, but that one in 100 women under the age of 40 in the UK experience in early menopause and one in a thousand women under the age of 30. So that's really common, isn't it?

It is. Did you ever get taught that at medical school? No, no, not all, no. And it is far commoner than you think it is. Yes. I was taught as well at medical school that if a woman doesn't have periods, then you need to make sure they're not pregnant. That's really important because we've all seen people who sit there and say,

know I'm not pregnant and you do a pregnancy test and they've found that they are. And we did touch on eating disorders because people who have anorexia and sometimes athletes, don't they, their periods stop. And actually we were taught that if periods stop, you need to think about their hormones because of their bone health because if they don't have hormones, there's an increased risk of osteoporosis. But that was all I was taught. So I have, for quite a few years now, I'm really embarrassed to say that I must have seen a lot

I know I've seen a lot of women who have come telling me their periods have stopped, and I've done pregnancy tests, I've talked about their diet, and that's it. Yeah, I think I would have, I remember seeing some years ago in general practice and thinking, oh gosh, the main focus in my mind was the fact that they maybe hadn't yet thought or had their families yet, and thinking, oh gosh, that's not very good, but actually not really recognizing it as actually like a chronic disease, really, which is essentially what it is. Isn't it? So let's just talk about what the definition is because there's early menopause and there's premature ovarian insufficiency, isn't there? So can you just explain the difference? Yeah. So early menopause applies to those women who are between 40 and 45 who reach the end of their periods. And then premature ovarian insufficiency applies to those women who are younger than 40, who typically they stop having periods and they have.

have low levels of estrogen and other hormones in their body then rise up, which is how we can tell that the ovaries are no longer responding to the normal sort of pathways in our body. So they are technically two distinct groups of women, the early menopause women and those with POI, premature ovarian insufficiency, but actually for the sake of practicalities, for a lot of considerations, particularly treatment, we can almost think of them in the same group of women. But those two groups of women added together are quite a distinct group of women from those that reach a natural menopause at the average age,

which is usually between 50 and 51. And it's really important, I think, like you say, the menopause isn't a disease as such, but even women who go through the menopause at the average age of 51 have an increased risk of future. disease such as heart disease and osteoposis, but this is even more relevant, isn't it, when we're under the age of 45. So before we talk about that, why do people have an early menopause? So if we're talking early menopause, then it's, I mean, there is a variation in all of us.

So just because the average age of the menopause is between 15 and 51 doesn't mean that there's variability in there. So some women will just reach an earlier menopause, say at the age of 43 or 44, just through variation alone. But when we're talking about premature ovarian insufficiency, so those women below 40, there's quite a number of reasons. So the commonest reason is what we call idiopathic, which is just a posh word for meaning we don't know. We don't know what the cause is. And that probably applies to about 85% of women. Actually, we just don't understand why their ovaries stop working sooner than they were designed to.

And then about another 10% of women, they have a genetic reason why their ovaries have stopped. not working. So it's often a chromosomal problem, which they may or may not have already been aware of. And you do sometimes find families where numerous people have the same genetic traits, and therefore they almost may have an early menopause on their radar because of other family members. Some women get to it for what we call autoimmune reasons. So autoimmune diseases are things where our body abnormally recognises something as foreign and starts to attack it. So some women, for example, that have thyroid problems or adrenal gland problems, it's because their own body is attacking those glands and the same thing can then happen to their ovaries.

So that makes up another small percentage of it. And then some women, the reason is what we call iatrogenic, which is a posh word for medicine has created their men of it. So that's often women who have had treatment for cancer, maybe as a child or as a younger women, and they've maybe had chemotherapy or radiotherapy or something which has made their ovaries not want to work properly anymore. Or we see another group of women where they've had their ovaries removed at an early age. So for example, women that carry the bracker gene, which we know is to do with an increased

future risk of breast cancer and ovarian cancer. So they will have their ovaries removed to try and prevent that. But in doing so, they then create. create a menopausal status. So that sort of covers all the causes apart from. We also know that smoking, for example, is a bit more associated with premature early and insufficiency. So for some women, smoking will actually help to switch off your ovaries earlier than they should have done. There's lots of different reasons. But for most, we just don't know. No. And I like you say, sometimes it can run in families, can't it? When we see people in the

clinic, they often say, my auntie, my mother, my granny had an early menopause. So they were expecting it. But what I don't get surprised anymore, what I did initially is what people always say that they were actually looking forward to their menopause because obviously, as you know, period, stop, that is really good. But a lot of young women have no idea about the symptoms, but also the health consequences as well. And there's a significant proportion of women who have an early menopause or P.O.I that don't actually have symptoms, don't they? They don't have the classical hot flushes sweats. About 10 or 15 percent. Which is quite a lot, isn't it? But I think they probably do have other symptoms, don't they, that they don't associate related. Yeah, and often I

tend to find it's psychological symptoms that they have, which have been put down to just anxiety or just depression, and because they haven't had any physical symptoms, no one's really put two and two together. And so they may not even notice for quite a while. I saw a lady in the clinic just last week, who actually was one of those women who had. never had symptoms. So it was about three years after. And she was suffering with anxiety, which wasn't responding to treatment. And it was only then that her blood tests were checked. And actually it was found that in her late 30s, she had actually reached an early menopause. And she was gobsmacked.

It's interesting, isn't it? Yeah. I think because the hormones estrogen and, as you know, also testosterone affects so many cells all around our body, especially in our brains, it is those symptoms of low mood, reduced energy, often anxiety, poor motivation. People just feel generally a bit flat, don't they? But there's lots of reasons why people might feel like that. And so unless they put the two and two together, they wouldn't always know, would they? And sometimes often symptoms can change as well. So people maybe have some symptoms a little bit and then they improve.

And especially if it's more of a natural menopause, often they have women still become peri menopause or before the menopause. So they have months where they're fine, other months where they're not. And so then it's really quite difficult, aren't it? So tracking symptoms with periods can be really useful. So there's the symptoms that we've alluded to already about the health risk. So talk us through. Why should people be concerned for their future health if they have an early manipause? Yeah.

So estrogen is massively important for lots of functions in our body. And so the ones that suffer the most when we lose them early are our bones. and our blood vessels, so especially our cardiovascular health, so to do with heart disease, but also our brains really suffer as well. So our brains need estrogen both to help with our mood, but also with our normal functions, like finding words and being able to remember things and to concentrate on things. So we know that there's increased risks of dementia and heart disease and osteoporosis for women with premature ovary inefficiency. And also sexual health really suffers as well, both from a physical point of view, because we know that about 50% of

women with premature ovane insufficiency have either vaginal or urinary symptoms, but also libido drops a lot. So there's multiple reasons why sexual health then also declines. So it's really important that women are diagnosed early. So the earlier the hormones are replaced. the better, isn't it? There's an interesting study by an American showing that women who have their ovaries removed early have an increased risk of all the conditions you said. But I'm sure you know the paper as well, but there was also there's an increased risk of diseases such as schizophrenia, even drug abuse, kidney failure, even lung problems, asthma. And I'm sure you remember the slides that's associated with the paper. And what surprised me was the array of

diseases, but also it highlights that our hormones get everywhere. You know, most people would not think that estrogen is important for our lung function or for our mucous membranes or even allergies. And it's fascinating that our hormones get everywhere, yet we're not taught about them. As women, we're not taught about them at school. But even as healthcare professionals, we're not taught about them. And they interact with so many cells and so many processes. and like you say, it's important for the sugar metabolism in our brains,

is essential to have estrogen on board. And a lot of women, even when the diagnosis is made, we know they have an increased risk of anxiety and depression because it's very hard being diagnosed as menopause anyway. It's quite socially isolating when you don't know what's going on. And I know when I was experiencing menopause and symptoms when I was in my mid-40s and I said to some of my friends that, gosh, I've realised now I'm menopause. and I'm going to start HRT and they said, gosh, that must make you feel really old and you can't

have children now. And I was thinking, well, actually, I'm very fortunate. I have children and I was sterilised. But I then thought, if I was in my 30s or 20s and everyone around me is getting pregnant or talking about contraception and you have this diagnosis, it must be really hard, wasn't it? Yeah. And we certainly see people in our clinic, don't we, who, and quite understandably, it's really hard and they have no one to talk to about it, do they? And although we take for granted having to think about contraception throughout our, you know, 20s and 30s and 40s and having periods, they might be a pain. We might wish that we didn't have to worry about them all the time. But actually, they are almost seen as a normal part of being a female.

And so actually if you take them away from, especially a younger woman, that need for contraception and periods, it sets her aside somewhat. And so you want to try and normalise her. Yes, it is. And actually I think it's important for women who do have an early menopaus or POI to realize that for a lot of women, they're not infertile, are they? Their fertility reduces. So some women actually find when they start taking HRT that their fertility improves. And it's something obviously we always talk to people about at the clinics because we have had a few, haven't we, who have been delighted that they've become pregnant because they've been on HRT by replacing the hormones. So it doesn't always mean they're infertile.

But we also, and I feel very strongly about this, I see a lot of women who have been told in infertility clinics that they have reduced ovarian function, that they're likely to have an early menopause. And often at the time, these women think, great, my periods have done me no favours. I'm really pleased they're going to stop. But sadly, none of these women are given information. And it's very frustrating, isn't it? Because we see these women later on when they've suffered for a long time. Yeah. So talk about how do we diagnose it?

So it's if someone has periods that are maybe a bit more. more scanty, a bit more irregular. They're getting a few symptoms. They've maybe filled out the questionnaire, the green clementteric questionnaire that's available if you just search questionnaire on my website. And they think it might be. How do they get a diagnosis? We tend to be more detailed in diagnosis for those less than 40 because the implications are so much greater. So typically, you're looking for a woman that hasn't had periods for sort of three months, But as you say, if the periods have just changed and become less scanty, then we should still consider testing. So we would typically test for a blood test called an FSH, your follicular stimulating hormone, which rises typically if the ovaries aren't working properly.

And you would usually try and do two of those blood tests six weeks apart. And if they're both raised, then you've sort of got your diagnosis. Yeah, you've got your diagnosis. But again, it's really important that because we know that, because we know that, especially in the first year after reaching an early menopause, actually your ovaries may switch back on again, just because a woman then has either maybe one of those two blood tests might be normal or both of them might be.

But if your clinical suspicion is that this may be on the cards in the near future, we just shouldn't dismiss that woman and tell them everything's fine. We should maybe keep them under radar and recheck or keep reviewing them. But then we would also check things like, their level of estrogen in their blood, which will usually be low. And we tend to check there are other hormones as well, things like testosterone. There's other hormones as well, like prolactin, for example, which wouldn't normally need testing in an older woman, but in a younger woman, we would check because there's lots of other slightly more complex hormonal pathways,

which can contribute to changing in periods. And because I said about the problem with chromosomal changes, again, depending on their family history, we may also suggest they have slightly more complex blood tests to look at their chromosomes and any genetic reasons why they might have had it. And also other things like their thyroid gland and adrenal gland, there may be additional blood tests that we could do. Yes. Yeah. And I think we've got really good guidelines haven't we, which help clinicians to know when to do blood tests and which blood tests to do. And often we also recommend a bone density scan, don't we, a dexas scan. And that's certainly on the guidelines. So if a woman has an early menopause, then she should be able to get

a dexas scan on the NHS. And that's, sometimes you, they have to push for it a bit harder, but it is important because of this risk of osteoporosis. So women should have a baseline dexascan, shouldn't they? Yeah. And also there's a bit of an association with celiac disease, which is really all to do with your digestion, but women with celiac disease are slightly more likely to have early menopause. So there's a blood test that can check for that. Yeah. So blood tests with hormones can vary. So it's not as easy as diagnosing diabetes, for example, is it? No. No. We really need a blood test or even thyroid. Usually it can help with a blood test. But if someone still thinks they have symptoms and their blood tests, even if they've had two are normal, then they should really be speaking to a doctor that specialises in the menopause. Because sometimes we give people treatment and then assess their response, don't we? So what is the treatment? What should women be thinking about? Yeah. So essentially, for those women that have got symptoms,

We want to try and help with those symptoms, but also crucially, we want to try and prevent the future damage from not having enough estrogen. So essentially, we want to replace hormones. So there's two common ways of doing that. We can use HRT, which is obviously the way that we would normally deal with it in a woman that reaches a natural menopause at the average age. And that has a lot of positive things going for it. We know actually overall it's better for your bones and your cardiovascular health to give H. but that's not going to suit all women and especially the really younger women because actually the whole stigma if you like of having HRT may make them feel even more different really

yeah from their peers so you can also use a combined oral contraceptive pill so both HRT and the combined oral contraceptive pill have the two hormones in they just do it in a slightly different way. So essentially, HRT is slightly lower dose, but it's usually a slightly more naturally occurring and safer and slightly more effective for the menopause. Or you've got the combined or a contraceptive pill, which is, of course, used by millions and millions of women worldwide to prevent them getting pregnant. But actually, it does give you high dose hormone replacement as well, but it's a more synthetic hormone. So stronger, but also provides the woman with contraception. So if actually fertility isn't an issue and she really doesn't want to achieve a

pregnancy, although that isn't hugely common, a woman can feel more normal with a packet of pills in her makeup bag or whatever than she would with HRT. So both have their pros and cons. And it's important to know, isn't there, it's a choice. Increasingly now, even with women who don't have only menopause if they're on the contraceptive pill, we tend to run packets of pills together rather than having three weeks on and a week break. But it is a very important. It's a is really important usually for women who have POI and early menopause because in that week break they're not producing their own hormones. So it would mean a quarter of their time. They're still increasing their risk of all these conditions. So if a woman chooses to take

the combined oral contraceptive pill, they should be encouraged, shouldn't they, to try and not have that pill free week the same way. And there's slightly less evidence, isn't there, that the contraceptive pill is as protective for bones and heart. But often women might start the contraceptive pill and then decide to go onto the HRT when they're in their 40s, which is important. Graduate through the choices, don't they? Yeah. And if one type doesn't help or doesn't work, then often we try something else, don't we? So it's very fluid, it's not fixed. Yeah, yeah. Which I think we see a lot of women in the clinic and I speak to a lot of women who say, well, HRT doesn't work. It doesn't work for me. I've been on it and it doesn't work. And what would you say to those people?

Usually that means they have not yet got enough in their system. So in general, the younger you are, the more hormones you need to get back up to the level at which you should have been. And so we have a generalised problem with HRT that the doses that are licensed are really quite conservative for many women and especially younger women. And we often have to go up above the licensed doses, which can feel nerve-wracking for women to feel like they're on a dose higher. what the leaflet says, but actually we seek to reassure them that actually it's not about a set dose. It's about what the individual woman needs. And, you know, we often go quite high and it's fine because it's very safe and we can measure both her clinically and her symptoms, but also if a woman is getting the estrogen, which is the main part of HRT through her skin, we can also

do blood tests, which are really, give us a really reassuring idea of where she is. Because essentially when you give a woman HRT, you're essentially getting on a ladder really and you're trying to find the rung at which the woman feels better but doesn't feel so high that she's a bit, you know. No, and we all respond to different levels, don't we? So we've all seen women and I know personally my level of estrogen obviously fluctuates because it can do, but there is a certain level where I know I feel better. And we know that if women still experience symptoms such as flushes and sweats, despite being on HRT, they have an increased risk of heart. disease and osteophrosis, so it's not good enough to have suboptimal treatment. But people are worried

I had a message this morning from someone, she's not one of my patients, and she said she's had an early menopause, she's on some gel, a GP had done her blood test, and it was high, and he said it's too dangerous, it's going to give you breast cancer, you need to come off it straight away. And obviously I don't know her, but I can give some general advice, which was absolutely do not need to stop your HRT. And people really worry about the estrogen, don't they? So there's a couple of things I want to just ask, really. Everyone worries about breast cancer with HRT. So when we're talking about giving HRT to women who are young, who have got early menopause and POI, should they worry about the breast cancer risk? No. If you lose your hormones early because you've reached an early

menopause, then actually you lower your risk of breast cancer because you're not making the hormones, which possibly contributes to your risk of breast cancer. So by replacing a woman's hormones, you're only putting her back to the level at which she should have been anyway. So we know there is no increased risk of breast cancer for women that start HRT before the age of 45. That's really important, isn't it? Because every time there's a scare about HRT, which we've talked about in other podcasts, it's the young women who often get denied HRT. And as you know, there's a Lancet paper that came out in September looking at older types of HRT, saying there was an increased risk of breast cancer, which we know there is a small increased risk with some types. But it was fueled by the media.

There's a warning going to all GPs. But actually the week after, I don't know if you're aware, there was an article in the Lancet, so the same publication. and saying that women who have an early menopause and POI, who are given HRT, have a dramatically reduced risk of heart disease. And the take-home message from that paper was, all women should be encouraged to have hormones unless they have contraindication. But there was no press release with that, and it didn't come out through the MHRA.

There was no reminder to us as GPs to say, these women really need hormones. So it's confusing for doctors. It's confusing for healthcare professionals. and it's hard for women, isn't it? Because they constantly thinking they're increasing their risk of breast cancer, but they're not realising all the benefits, which are so well documented. This isn't new fancy data we're talking about.

This is long-term established. No one's going to contest it, are they? How important it is to replace our hormones. And we know that heart disease and the effects of osteoporosis and dementia are the biggest threats to our health. as a woman. And yes, breast cancer is an important thing that, you know, none of us wants breast cancer, but actually if you look at it statistically,

we're going to gain far more from our health. Yeah. Replacing our hormones than we are going to lose. And the other thing which is so rarely ever mentioned in any of the headlines that we see is that even those women that go through the menopoles at the more average age and take combined HR, when we talk about an increased risk of breast cancer,

we're only actually talking about an increased risk, which is small, of being diagnosed with breast cancer. It actually doesn't affect death rates from breast cancer at all. Yet we are going to improve death rates from the things we can prevent, like heart disease and dementia and osteoporosis. Which is really important, yeah. So certainly for young women, they should be taking a type of hormone,

unless there is a contraindication, until the age of 51, the average menopause. and then they have a different discussion, don't they with their doctor? But people should start then counting the time they're on HRT from the age of 51, don't they? Like you reset the clock. Which is really important because I've spoken to, and I'm sure you have a lot of women who have maybe started HRT in their 30s have been on it for 10, 15 years and they've maybe changed GP

or someone's reviewed their notes and says, gosh, you've been on it for far too long, you need to come off. And they're still only in their 40s, which is a minor length of time that they're on it. So because all you're doing is replacing and because women are living longer, it's really important that we can look. And I think it's really important that women are educated because hormones are vitally important for a lot of women, but it's also looking at their lifestyle, isn't it? It's looking at what they can do to improve their cardiovascular health, their bone health. So looking at taking vitamin D, exercising regularly, looking at their diet, the nutrition, their smoking, alcohol, all those things.

And I think as doctors, we should be giving people the right information so they can choose about their lifestyle. Again, like you're saying, it's about preventative medicine. So these women don't become patients. They can carry on having a healthy life, isn't it? Yeah, it's just restoring her back to the normal. Yes. Yeah. It's almost wrong when we think of it as medicine.

Yes, absolutely. And I think that's the problem. People do think that HRT is. And when we look at what we tend to prescribe, it's derived from the yam, the root vegetable, it's body identical. So we normally give estrogen through the skin as a patchal gel. And like you say, you can safely have higher amounts. And if a woman has had a hysterectomy, then she only needs estrogen and sometimes testosterone.

And then if they've got their womb, then we usually give the natural progesterone, don't mean, the micronized progesterone, or quite often a marina coil that works as a contraception as well. So there's always options, aren't there? Testosterone, sadly, isn't license, is it, for women? And there used to be a patch, didn't there? And the specific license for this testosterone patch was women who'd had a surgical menopause who were young. Because younger women often really miss testosterone, don't they? Yeah.

What does testosterone or lack of testosterone effect? Yeah, so when we talk about testosterone, women will tend to, if they've heard of it, One, they either think, gosh, that's a male hormone. And actually, yes, of course, men make lots of testosterone, but actually women make three times as much testosterone as they do. Estrogen. It's just we make less than a man. Yeah.

So, you know, a lot of women know that testosterone is something to do with their sex drive. And it is really important for sex drive. But actually, that isn't the only association with it. And we know we also, as we have estrogen receptors throughout our body, we also have testosterone receptors throughout our body. So they're also really important for our brains to function properly. And certainly our sort of cognitive function tends to improve and our mental focus. And we know that our muscles and bones also have testosterone receptors.

So physical strength and stamina also improve. Eustrogen is the most important hormone for bones, but testosterone also contributes. And mood also can be really helped. So, you know, it's very much a kind of a layering effect that you make sure you've got your estrogen. up to good levels and doing as much as it possibly can, but then often testosterone can fill in any gaps or even enhance things. Yes. So it's really important.

It's really frustrating that it's not licensed. You know, there are positive moves towards trying to change that for the future, which hopefully will happen. Because it's very safe, isn't it? Yes. Because all we do when we give it is just replace. So we measure levels. And if a woman has normal female levels,

then the chances of having any side effects are practically zero, won't they? Yeah, exactly. And some of who might know, we often prescribe a testosterone cream called Andropham, which is made in Australia, but it's a regulated product. But it can be given on the NHS at the male version, which frustratingly is licensed, but it can be given as smaller doses. And the British Menopause Society have some great information for healthcare professionals,

and there's information on my website for women as well. So if someone's still struggling with symptoms, especially the low mood, low energy, reduced stamina, low libido, despite being on good doses of estrogen, then they should really talk to someone about testosterone, shouldn't they? Sadly, a lot of GPs still aren't trained in testosterone and hopefully that will improve with time. But they should try and seek a doctor who with a special interest in the menopause, shouldn't they? Yeah, it can make a big difference to women, and especially younger women and especially those that have had their ovaries removed. Yes. So you mentioned briefly about women who have a brachy gene or an increased risk of breast cancer often have their ovaries removed to try and reduce the risk of ovarian cancer

and obviously they're flawed into a surgical menopause. A lot of women are still denied HRT because they've got a family history of breast cancer so they don't have a personal history but they have a family history. What do you say to these women? Again, if we know there's been ample evidence now that if you've got a bracky gene and you have your over is removed to try and protect your future risks, then it's absolutely fine to take HRT. In fact, it's recommended to take HRT up until the age of 50 or 51

because the risks of not doing so far outweigh the risks of having it. And we also know that, you know, the family history of breast cancer is extremely common because actually we know now that of those of us women born after 1960, one in seven, women actually will get breast cancer at some point in their lives. So if you think about your family and how many female relatives you've got, most women have got seven female relatives. So therefore, statistically, one of them is going to get breast cancer at some point. So we really do, unfortunately, take family history a bit too much at face value and we don't actually

examine the details of that. So yes, there are some women if they have a family history, for example, a first degree relative. So your first degree relatives are your mom, your sister or a daughter. And if they have breast cancer, and especially if they've had breast cancer at an earlier age, so younger than 40 or 50, then it may actually be that they do need a discussion with a geneticist if they're not already known to have a bracketeen in their family. But actually, most people will often see women in the clinic and say, oh, you know, I've got a cousin that had breast cancer. And actually, that is absolutely just part of bad luck and statistics, unfortunately. and it doesn't affect your own risk. Their own individual risk, which is very important. And most cases of breast cancer are not related to a genetic cause or BRAC or anything.

But I think it's important that women who do have a family history, however strong, know that they usually can still test HRT. So it's really important that women are given the right advice, really. So I hope that's helped people because the more you talk about the menopause, the more that you will realise that there are a lot of young women out there who are needlessly suffering. and often not receiving the right treatment. So if you have any friends or relatives or you personally are suffering in any way,

then it's really important to get the right information to hopefully be empowered to then receive the right treatment. So thank you ever so much for talking this through because it's a really important subject. But before we finish, can I just have your three take-home messages for women who think maybe they've had an early menopause or they do have one? What would you recommend? I think the three most important points are, one, this is a different kettle of fish. All menopause is important and needs a discussion, but this is even more important. And it's not really a choice as to whether you have treatment. I mean, obviously we have a choice in everything, but it would be the reasons to consider replacing your hormones are so much stronger.

And it really should be seen as a given that that should be done. and that fertility does need to be considered and, you know, fertility clinics need to be heavily involved if a woman hasn't already had her children because things like IVF and egg donation can be, you know, life-changing. Those women's, that's really important to be done. And I think really finding some support as well, because although we've said it's actually commoner than we think to have an early menopause, if it's happening to you, it's unethical. it's unlikely that you're going to know another person with the same thing and you can feel very isolated. So I think finding support, there's online forums now so that you can chat through the psychological issues, the physical issues

and sort of everything that goes along with it and actually get the proper information so that you can take this through for the rest of your life and not let it define you. Absolutely. I think not feeling alone is really, really important. So thank you ever so much for giving up your time and doing this today.

Thank you. For more information about the menopause, please visit our website www. www.menopause doctor.com.uker.