The Dr Louise Newson Podcast - 034 - Menopause Taboo in Women from Different Ethnic Groups - Dr Nighat Arif & Dr Louise Newson

Episode Date: February 11, 2020

Dr Nighat Arif is a GP with a specialist interest in women’s health, based in Buckinghamshire. In this week's podcast, Dr Nighat Arif talks openly with Dr Newson about her work educating and empowering women from different ethnic groups about the menopause. Many women from ethnic minorities think the menopause is a condition that only affects Caucasian women or it is a western phenomenon. However, it is well known that many women are experiencing symptoms such as pains in their bodies, “head to toe pain”, low mood and anxiety which are being misdiagnosed and inappropriately managed as these symptoms are not being linked to the menopause. Although language is often a barrier to consultations with a healthcare professional, there are also many cultural differences that need to be explored. Many women’s health issues, including the menopause, are kept “under the veil” and not spoken about. In this episode, Dr Newson and Dr Arif also talk about other taboo subjects such as vaginal dryness, painful intercourse and how that affects marital relationships in a conservative community.  Dr Nighat Arif offers three take home tips in Punjabi to help break down barriers and empower women from South Asian Communities to not accept their menopausal symptoms and suffer in silence.   Dr Nighat Arif's Three Top Tips: For all women, please keep a symptom diary. No symptom is silly and this is useful to your doctor during the 10-minute consultation. Never deny yourself treatment, there are always risks and benefits to every treatment and only your health and wellbeing will suffer if you don't seek help. Don't suffer in silence!  

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsom, a GP and menopause specialist, and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. Today I have Dr Nigat Arif with me, who's a GP in Buckingham. She has a special interest in women's health, and I'm absolutely thrilled, honoured and delighted that she's agreed to come onto a podcast with me And we've only recently connected, although I have known about her for a while through the joys of social media and media. So welcome. Thank you so much for having me. Honestly, it is genuinely the honour's all mine. I'm so privileged.

So just tell me a bit about what you do and what you've done in the past and how your life is changing, because I sense yours is changing, like mine's changing every day, is a bit different. So just talk me through your journey up to now, if you don't mind. Yeah, of course. So I came to the UK when I was nine years old and I did. speak much English and my father worked very closely with the Asian and Pakistani community in Buckinghamshire in Cheshem. So I grew up, went off to do medicine and then came back and I worked mainly as all junior doctors do through all the rotations. And it was when I was in Slough, I used to see a lot of Asian women come in with head to toe pain. And it was always, oh, this is a classical symptoms that Asian women go through. So went in my general practice and I was lucky enough to get

women's health in my rotations when I was training as a GP. And I had an amazing trainer, Dr. Vivian Carter, who was very proactive about the menopause, very proactive about HRT and championed it in her surgery. So she was the forerunner back in the day, and I was lucky enough to learn from her. However, we used to then, and Louise, you'll back me up on this. I'm hopefully. We'd get a lot of information through our emails on EMIS saying, are you sure you want to prescribe HRT? HART has breast cancer risk. Yes. HRT has clot risks.

And as a junior doctor, that used to scare me so much. And so I stopped prescribing and I realized. So when was that? Well, what year was that roughly? So this is back in 2009, 2010. Okay. So the WHO study that some of my listeners might know about which was the real nail in the coffin for HRT had come out.

Yeah. Because as some people might know before that time, people were very proactive. we would give HRT a lot. And then this study that was done in America showed that there was an increased risk of breast cancer, heart disease, in some women, but the media got hold of it. And it was a real, wasn't it?

Nairn in the coffin, people were very scared. And it was such a flawed study. It was, absolutely. And what happened was, because people were enjoying HRT and realizing there were health benefits, they did a big study, but they were giving the wrong type of HRT

to the wrong women. So the design was not good. So they were giving older times, of progestogens, which women need if they have their womb, with tablete estrogen, which has a clot risk, like you know, often in women who were in their 60s, who were obese and had heart disease and had really come through the menopause. So they were the wrong demographic. And when the results have been analysed and reanalyzed, they've actually shown all the benefits that we know about HRT. So sorry to interrupt there, but it really changed the

perceptions of HRT. So that's really interesting because you're younger than me. I was sort of older and brashier and more confident when the DEHI study came out, but it unnerved a lot of people. And I can see for you, it would have been even more. As a junior doctor, it really scared me. And actually, I have to be honest, I hold my hand up to this. I proactively used to, when I did a medication review, discuss all these risks with them. Because this is what I was sent down from the powers that be. And as a junior doctor, to kick back at that, it's really a scary ground to stand on.

It's medico-legally, how do you protect yourself if something goes wrong? Absolutely. And then I started seeing my patients who were decades later coming back with osteoporosis, depression-type symptoms. Actually, I would get women going, I've lost myself, Dr. Arif. And that's what triggered me to go to a women's health conference in Oxford, because you are going to be there, Louise, and we're going to talk about HRT. And a group of us, junior doctors, we were young trainee GPs.

I just thought I need to know about menopause because actually as a female doctor in my practice, who's done women's health as a rotation, I was getting a lot of them coming in through my doors. And I felt helpless, but I didn't have the confidence enough to prescribe HRC. And then I felt almost vindicated by your talk because you said all of what you've just said now, HRT is not the worst thing. It's not a horrible drug. In fact, there are all these health preventions that can come about. And that's the whole point of general practice. We try and have preventative care put in for our patients.

Absolutely. And then I realised that empowered by the nice guidance that came out and what your talk was. So we connected then an infallogy. And I thought, I need to try and get this out into my community because all of that media scare is still very impregnated within the South Asian community that I work with in Slough, Southall, Buckinghamshire, High Wickham. And that message of preventative healthcare isn't actually getting through because gynecological conditions are very shrouded. They're not talked about. And actually this is where it's led me to now trying to talk a little bit more about women's health and connecting with various people and contributing. Luckily, the lovely team at BBC Breakfast have asked me to come and contribute on various matters because I think there is a real need for diversity.

and for looking at communities within the NHS because resources are finite and how best do we try and empower communities in the UK to be able to use those resources effectively. So that's where it's led to me now really doing the work that I do. Yeah, which is brilliant. I think we're very lucky in the way that we've now got social media, the internet. You know, when I qualified in 1994 and there was no internet then. And so if we wanted to find anything, we went to the library, we read journals, we spoke to people in an old-fashioned way, we would meet people. But actually now we can access information very quickly. And when the nice guidance came out, which is the National Institute of Health and Care Excellence, it's the first, isn't it?

The only menopause guidance that have really come out in November 2015, I really thought great, because this is actually helping, give me the confidence to share. knowledge, knowing that it's been rubber-stamped by an amazing body. Because in the past, I've been prescribing HRT and my colleagues have taken women off HRT and said, no, it's going to give them breast cancer and clots and everything else. And I've said, no, but through the skin, there's no risk of clot. The newer progesterine, the micronized progesterone, we know is a lower risk of breast cancer. And actually, women are 10 times more likely to have breast cancer if they're obese than taking HRT.

So let's give women a choice. Yeah. So the nice guidelines are great, but the guidelines are only as good as people when they read them. They're no good being on a piece of paper on someone's desk. So it's about disseminating those guidelines. And when I've sat in conferences before, and there's some very inspirational, very clever people, some of them are my mentors, but they run busy research departments. And they're not quite so much in the real world.

They're not hearing the stories that we hear. And I'm thinking, how can we help? but actually through the media that have sadly got a lot of information wrong because they've been fed wrong information we can really help so what you do with the BBC radio and the other radio programs you've done has been amazing because it will reach people in a way that you couldn't have probably done before but I find that using media you're almost giving people permission yes and that is a huge thing to allow people to do that just to give them permission to talk about vagina dryness talk about difficult sex, talk about memory fog, talk about the fact that they've lost themselves

quotation marks. Because usually people do that in silence. Yeah, I think so. And I think I hadn't realized, I suppose if I'd had this conversation a few years ago, I would have thought the menopause is really more about hot flushes and sweats and there's health risks, such as, because we can never replace these hormones, we have this increased risk of heart disease, osteoporosis, diabetes, obesity, dementia, without the hormones. But I never realized all all about the other symptoms like you're discussing, the brain fog, the memory problems, this sort of social isolation because people feel worthless, they feel joyless, they feel flat. And I was never taught that at medical school, and I don't know about you, but no one really

focused on those symptoms. And I often hear stories because people come to my clinic from all over the country because they're in dire need and often their jobs have gone because they can't concentrate to work, their partners have often left them. They're really a shell of themselves and they often say their life is in black and white the colour's gone and i think gosh how many other women are we missing out on and we talk so much about diversity and about trying to be non-judgmental and help as many people as we can and even before we think about color of the skin and race i think it's such a problem because it's a women's problem it is if we said to men we would castrate you when you were 51 and you won't be able to have sex and if you do it

be really painful, but your brain will go. You'll start to feel maybe achy joints. You'll start to have migraines. You'll probably give up work. We have a treatment, but we can't give it to you. And it's quite cheap for the NHS, but we're still a bit resistant. It would never happen, would it? So it's, I don't quite know. I think there's so many barriers to having good proper menopause care. And it's such a shame. So the barriers I've identified are always lack of education, lack of awareness and then also the conflicting stories. So who do you believe? So where's the evidence? And the difficulty that we have is that within ethnic minority communities, all three of them, they will tick those boxes. And then on top of that, there's cultural factors that are playing a

huge influence. For example, talking about gynecological condition is such a taboo. Because the minute you start talking about vaginal or genital related symptoms, it's sexualized. And when you get into that, that sexualized thought has to be put into a box. If you keep putting that into a box, it turns into a Pandora's box. Because women, they don't talk about it. They don't ask about it, but yet suffer in silence until it tips over. And then all these symptoms come out, but they're late stage symptoms. You know, severe vaginal atrophy, sleepless nights, depression.

And I only came across this, actually, through the women in my community, because I didn't realize that they were suffering this much. So a really close family friend of ours, she'd always come and see me at the mosque and say, I'm head to toe pain. I'm aching all the time. I've lost myself. But my periods have stopped. This is great. I'm really enjoying the fact that my periods have stopped because I can come to the mosque. Ten years later, she's outside putting her clothes on the line and she slips and she has a fractured hemorrh. She's wheelchair bound. And actually, in hindsight, she was describing bonapausal symptoms to me. I kicked myself as a doctor because this is a woman that's nurtured me. She's

helped me grow up. She's my auntie. She's not my blood relative. But she is my woman. She's me. And actually, I'm missing stuff. And as a doctor, as you know, how horrible that feels. Absolutely. And what our women go through is that, well, I've stopped my periods. This is fantastic. This is a joyous time. I can do all this religious activity, which I couldn't do before. Yes. They are then having detrimental health complications, which actually cost the NHS more. It's really interesting, isn't it? Because I think, to me, the best thing about the menopause is not having periods. and it is very liberating, even for a Western woman to not have periods, but for, like you say, for you to be able, the ability to be able to pray when you want to you

to go to a mosque, to not think about when your periods are going to restrict you. It must be the most amazing feeling for women. Yet, they're not prepared for what that means, and not just for their symptoms, because we know there are some women who don't experience any symptoms at all, but it's their risks, their bone density reduces so quickly after the menopause. and we know one in two women have osteoporosis after the menopause. And I personally am very scared of osteoporosis because it's a hidden condition, isn't it? It is.

It is. It's not until like you say your auntie slipped. You know, once the bones break, you're more likely to have another one and another break. And then especially osteoporosis of the spine, it affects mobility. It's really difficult to reverse. But we know that HRT is actually licensed for treatment of osteoporosis, and it helps prevent it. But most osteoporosis guidelines don't even mention HRT because they're scared of it. And within the ethnic minority community, we also cover up.

So like myself, I wear a headscarf. I wear the oboeia or burker. So therefore, you have even less exposure to vitamin D and sunlight. So that puts us at a higher risk. Within the ethnic minority groups, we have high risk of diabetes and increased weight, which we know in some studies that actually when you go through the middle age years, you do put on more weight because of the fluctuating hormones. which puts the women higher risk of diabetes.

So it's almost like within my community, I'm finding actually across all communities, there are these risk complications that nobody seems to be picking up related to a hormonal imbalance. Yeah, and I totally agree because as a GP, you're a GP, I've been a GP for a long time, that there's an incentive to prescribe statins

for people with high cholesterol, for blood pressure treatment if someone's got high blood pressure because this reduces risk of heart disease. But I was trying to work out recently looking at some studies. And actually, if you give HRT for primary prevention, so this is to stop heart disease in people, it's more effective at stopping a heart attack than giving a statin or a blood pressure treatment.

And for people with high risk, such as you're describing who have got an increased risk of heart disease because of their family history often, or they've got an increased risk of diabetes, or obesity, these people would benefit even more, saving the NHS even more money and also millions. Their lives. Exactly.

And this is where I think that if we're looking at, on a bigger scale, looking after our NHS, it's all about preventative care because that is, we know that's far cheaper. I mean, osteopractic fractures, you can correct me, cost two billion pounds to the NHS. That's just hip fractures, actually. So it's a huge amount of money. And HRT, so if you're looking at estrogen and micronized progester and what, pounds. I think that's the prescription cost. It varies from area to area.

But if you look at that cost. It's very cheap. And yeah, I mean, we've just recently done a study of 5,000 women looking to see how long it took them to even have the menopause diagnosed. And about 18% had taken more than five years. So that's a lot of touring and throwing. And I think, you know, you're talking about, you know, women that you speak to who have this total body pain. And certainly I trained in Manchester and my general practice was near Birmingham and there'd be a lot of women who would take a lot of courage to even just come to the doctor and they're very scared and they wouldn't be able to explain properly and I think I'm totally felt I would give women a disservice because when they

work through an interpreter there's so much that's lost in translation and how do you say to interpreter yeah I have vaginal dryness sex with my husband is painful they would never mention that And if they did, the interpreter I don't think would ever tell me. I can shed light on that coming from that group where it's very conservative. You don't talk about, there's a terminology in our culture known as Pardar, which is South Asia women in Punjabi, will understand what that means. That just means under the veil. So things are kept under the veil because it's seen as more respectful and it's more appropriate just to save people's blushes. But when you start putting things under the veil, you miss preventative health care.

Yes. You miss educating others. So women will at home, not even discuss with their daughters, that they are suffering these symptoms. And when I come across it, because I speak Punjabi, when I see South Asian women who do speak Punjabi, it tends to be, not always, but mostly with the older generation. So women in their 60s and 70s, they will come with another relative, a female relative. A classic example I can give you is their daughter-in-law who lives at the home. She's pregnant. So I'm going through an antenatal discussion with her. And then it's the mother-in-law sitting in the consultation room. He'll say, look, Dr. Arif, I have another problem. Can I just ask you about this? Because we're talking about vaginal symptoms anyway. And that's when the mother-in-law, who's in her 70s, I'll realize, is suffering horrendously with vaginal atrophy. And she's getting recurrent new ti's, and she's itching all night. And she's been giving caniston every single time. She's inappropriate. Which is inappropriate. And the same thing happens with all over body pain.

it gets misdiagnosed as fibromyalgia. They get put on high-dose prednisolone. Which makes their bones even less. Exactly. And language is a huge barrier. And then the lack of awareness in order for the Western trained doctors, which I'm Western trained, and part of the problem, is that how do you interpret those cultural symptoms?

Because very rarely Pakistani women will come in and say, I have a hot flush. And I'll tell you the reason. And this is something I've picked up just colloquially listening to my community is that their context of hot flushes is so different. So I said to a group of my mum's friends, oh, do you get hot flushes? And their response was, stand in the 50 degree heat of Pakistan, you'll know what a hot flush is. So to them, having a small sweat in the UK is not a hot flush. No, no. So that is not even a symptom that they would offer up because it's not seen as a problem.

And if, as a doctor, you're trained to say, well, menopause is hot flushes and night sweats, isn't it? Yeah, it's totally true. I mean, we, you. is the green clemateric score for all our patients who come to the clinic. And if you're listening want to find it, if you just search questionnaire on my menopause doctor website, you'll find it. And people are really enlightened actually when they fill that out because it talks about the psychological symptoms, other physical symptoms, such as the joint pains, muscle aches that we've discussed and headaches. But it also, we've added two questions to it, which include vaginal dryness and urinary symptoms. And people sit down and fill it out and go, gosh, maybe I haven't got

fibromyalgia. Maybe I haven't got depression. Maybe I haven't got a brain tumour that I was thinking I had because we're not primed as women to think about what the menopause means and we're not primed as healthcare professionals to ask the right questions. So there's a real mismatch going on and there's a lot of people that are, if they do access the health service, they're being misreferred to the wrong people, they're being misdiagnosed and actually the implications for a woman who's been told they have fibromyalgia, that's quite scary. Or they've got thrush and they're trying caniston and it's not going to work. Then, you know, it's very hard, isn't it? On another scale as well, I look at it, we're missing gynecological cancers because of it. I mean, we're missing vulval cancers

because in our community, we don't always have the words available to explain that. I mean, that's why social media, again, is so brilliant because there's so much work being done already to say actually use the right terminology for gynaecological. conditions. It's not your hoo-ha or, you know, your flower there or whatever. No, I know. And I think it's very interesting because you were saying before I press record about talking about vaginal dryness on television and I was on television in Ireland a couple of years ago talking about vaginal dryness. And the broadcaster was absolutely gobsmacked. I mentioned those words. And for us as doctors, we can talk about anything and it really does

not faze us at all. But for a lot of women, certainly how I see in my clinic, They've never talked about their vagina. They've never said they can't. It is the words. But it's also, I'm very open and I will ask every woman I see whether they have symptoms. And some women say to me, but yes, but I don't have sex, doctor. I said, no, but it's not about sex. Are you having difficulties sitting down or wearing underwear or trousers?

Oh yes, no, I haven't worn trousers for years because it's so uncomfortable. Well, then that will be related to your lack of estrogen. And it's quite amazing that even in Western societies, we don't like talking. about sex because men like to talk about how much sex they have, but they don't talk about how much they don't have. And women feel very vulnerable. And I'm sure in your community, there's no way you can talk about it. If it's painful to have intercourse or you've got no libido, who do you talk to? I don't know. It's coming back to that analogy that everything is under the veil and so therefore they don't talk to anybody. And both of us will agree with this.

It's amazing how much women will just put up with. Yes, absolutely. I'm always flabbergasted at how women will put up with things that normally you wouldn't you wouldn't put up with chest pain. You wouldn't put up with your sugars being so high that you're having symptoms with that, diabetes related symptoms. If you had a bleed somewhere, you wouldn't put up with that. But yet when it comes to day-to-day symptoms which play on your psychological well-being, your well-being with your partner as well, people will just put up with that. Yes.

So coming back to the BBC breakfast because they did this amazing menopause awareness week. Yes, it was brilliant. Which you, Diane Dansbrick and Karen Kenney and the positivity girls, they were all involved with that. And one of the things that I came off, because I spoke a little bit of Punjabi on the show, and when I came, I was shopping around in my local supermarket, let's say. And actually, it was a Pakistani uncle who came up to me and said to me, Nagat, my wife was washing her dishes. She heard you speak Punjabi, and she quickly came out. Because firstly, no one hears Punjabi on BBC breakfast. And secondly, there was a doctor who looked like you talking about symptoms that my wife is experiencing.

And she just stood there and floods of tears watching TV because she thought, this is what I'm experiencing. And he said, I finally had a word that I could say, this is what my wife is experiencing because we're men, they feel very excluded. They love this woman. They absolutely cherish the ground that she walks on. But yeah, she's lost her what makes her. She's lost the joy. The intimacy isn't what it used to be. She's probably irritable.

She's probably having mood-related symptoms. She's not sleeping very well. And that affects their partners as well. So there's a lot of Pakistani men that I see who come into my clinic with blood pressure-type symptoms, stress-related symptoms. And when you actually go over the veil, so break the pardar away and say to him, tell me how your wife is. Tell me how things are at home. And then you realize what she's suffering from is menopausal symptoms, which is affecting his health conditions. Absolutely. Yeah, it's very interesting. I mean, I've recorded a

podcast with one of my patients' husbands, and she's a very strong woman, and she had symptoms for a long time and didn't know what was going on. And he was a brilliant story about how difficult it was, seeing someone you love change, and how helpless he felt, because he didn't know what was going on, and he didn't know how to help her. And I think it has a massive impact, and we know that, you know, the stress effect with men who are unhappily married or living with a difficult, you know, and it's all this uncertainty when we as practising physicians have an ability to make a diagnosis of the menopause very easily. It's not even a blood test that's needed for most women, certainly women over the age of 45 don't need a blood test. It's the questionnaire and have your

periods changed or stopped or have you had a hysterectomy in the past. And if we could make that diagnosis earlier, even not thinking about treatment, people, People would just feel more relieved, wouldn't they? Yeah. And feel more empowered. It's the relief that comes from it. The difficulty in general practice is that when you don't give a diagnosis for something, or I hate using the term fobbed off,

but lots of patients do feel possibly that they're fobbed off. And there are some diagnoses that take time to come forward. It comes to joining up the dots, it's almost like this eureka moment that you get with a patient and their palmer. Yeah. And I think that's what we as, professionals that are playing with the media, if you like, can really help women to understand that women need to be empowered, patients need to be empowered, because as doctors, we're not paternalistic. We're not here. I strongly believe I shouldn't be prescribing a medication and

giving it to a person without them having a full understanding of what's going on. But actually, in general practice, as you know, it's so hard. Ten minutes is not long. So if we can empower women and men to try and do their homework so they can direct the consultation, you know, wouldn't that be better? So even women like you're experiencing with their total body pain, with their symptoms of feeling very low, very flat, if they went and said, look, here's my questionnaire, I've read some information or I've listened to our podcast, for example, and I think it's the menopause, can we talk about it? Then wouldn't that consultation be very different? It'd be so different. Ten years ago, myself and Dr. Carter, so who I referenced earlier, she was my training.

We were having this discussion because we had a Qaddafi-Fakistani women who speak and read Urdu. And she said to me, like, is there anything that you know about in Urdu that I can give to my patients on the menopause? Fast forward 10 years. And we've done a poster with the positivity girls in Urdu, which lists the symptoms. And Jane Lewis, God bless her. She's amazing. It's fantastic. The author of My Menopause or Vagina and translated her leaflet. And that has almost taken the veil away because it's giving women permission a leaflet to say, go and look at the anatomy.

This is your anatomy. This is normal. This is nothing to be scared of. And look at the symptoms in your own language at home because you don't even have to get somebody to translate it for you. No. And I think that's really important. We're looking, as you know, to try and translate some of the fact sheets on my website.

And the book that I've written, we've found out recently, is being translated into Turkish and Russian. It's being available in other countries, about six different countries at the moment they're looking in. But this is what women need the information, but they don't know where to go. And so to have information, but for me, it has to be evidence-based and non-biased information. And then women can make the right choices. But we haven't even got to the choices stage yet. It's about knowing what's going on first. and that we have to try and help women and healthcare professionals.

And, you know, we do a lot of training and education so that people get better education because obviously we lacked it as we were growing up. It all comes down to confidence. So the doctor having the confidence to prescribe things and not worry about medical legal complications. And the patient having the confidence to know these are my symptoms and I can speak to the doctor about it and not be embarrassed. Because there's nothing worse than the doctor getting embarrassed and the patient then getting embarrassed. you have this stalemate where you can't go forward. And usually it comes from a place where the doctor's underconfident with their medical

knowledge around that area, that then the embarrassment comes into the consultation. And so if we can take that away in all ways possible, so translating material into various languages, which Louise, I'm so amazed, your book is amazing. So I can't wait for that to come out in different languages. But also, women empowering women, the minute you do that, women feel stronger. because actually it's not them and us, it's just us. We can do it. Yeah, totally.

Absolutely. I think that's really key. Yeah, brilliant. Come on. Power of women is great. So we've talked about loads and I think I could talk to you all day. So I think I'm going to get you to come and do another podcast. But we've run out of time, sadly.

Before we finish, I would like, two things actually. I would like you to give three take-home messages for women, especially in your community, that could really. benefit from, but I'd also like you to give those three take-home messages in Pinchelby as well, if that's possible. Of course. So to all women from the South Asian community and any women that's listening to this podcast is that firstly, please keep a symptom diary. It's really important that you do that. No symptom is silly. Every symptom is really important because that helps the doctor in their 10-minute consultation to understand what is going on. Please never deny yourself

treatment. There are always risks and benefits to every treatment. And, And actually if you deny yourself straight away, I'm not going to have this. That shuts down quite a lot of barriers straight away. And thirdly, please do not suffer in silence. Because the minute you suffer in silence, the doctor can't help you and actually just makes your health and well-being worse at home. So, so, the other than we, we're going to be, very, very sure. Menopause is a disease that's a period.

When period of the period, they're going to, they come to symptoms. If you have estrogen in the system in the then it's a lot flushes, get a grimace would, you know,

you can't get rid of your mind to get hurt, you know, and you know, that's, you know,

that's, if you know, if you're if you're to recognize, you know, please, you'll see,

this, you know, to see, this, you know, the doctor's to know, know, the doctor's not,

the second, me, never, any, any, any, you know, if you're,

if you're, if you're, if you're, say, not that you'll not, then you can't then the doctor

can't do the doctor to never deny yourself of anything. But thirdly, please, just chup chaps car,

be able to sit and this thing, this is a diagnosis that there's a large even to please

our doctor to meet and then so they can't suffer in silence. Fantastic. Absolutely brilliant.

So thank you ever so much and I look forward to future work that we're going to do together.

So thanks for coming today. I'm so excited. I'm so great. Thank you so much for having you. Thank you. For more information about the menopause, please visit our website www.