The Dr Louise Newson Podcast - 046 - Menopause Education for Nurses - Mandy Garland, Sharon Hartmann & Dr Louise Newson

Episode Date: May 5, 2020

In this episode, Dr Louise Newson is joined by Advanced Nurse Practitioner, Mandy Garland and Specialist Nurse, Sharon Hartmann - together they discuss nurse education for menopause and HRT in primary care.  Both Mandy and Sharon chose to develop their own skills and knowledge in menopause by completing the accredited training through the British Menopause Society. They are currently waiting to submit their final log book; following an intensive 2 years of study, specialist visits and practical assessments.  In this podcast, Dr Newson chats to Mandy and Sharon about how they have used evidence based practice to develop a pathway of care, offering patients at their busy NHS surgery a holistic service founded on NICE guidance; such as initiating and reviewing a patient’s use of HRT. This has been particularly challenging due to the lack of funding their surgery receives for management of the menopause. Mandy and Sharon hope that the long term benefits will be evident, with the improved quality of life women experience when on appropriately prescribed HRT, and that nurses all over the UK will receive the same opportunity to study at a higher level. Mandy Garland, Advanced Nurse Practitioner, Menopause Specialist and Nurse Prescriber - @garland_mandy Sharon Hartmann, Specialist Nurse: Integrated Sexual Health, Menopause Specialist and Nurse Prescriber - @hartmann_sharon Mandy and Sharon's Three Take Home Tips for nurses who want to gain a better menopause education: Menopause is a complex, in-depth subject and should be seen as a Holistic Medicine. During your training, find a like-minded nurse or professional that you can work with and study alongside. Attend as many clinics as you can within the local area and work with your local pharmacy.

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. So today I have a real first. I not only have one, but I have two people to interview today, which I've never done before. So it's a bit scary, I feel outnumbered. So I have two lovely ladies with me today.

Mandy Garland and Sharon Hartman, who are both specialist nurses in the menopause. And I've met them a few times on various conferences. And I've always been struck by their happiness, their enthusiasm and determination to really make a difference in menopause care. So welcome both of you. Thank you. Nice to meet you. So it's the first time they've been to my clinic. So I'm always really excited when I show people around because obviously what we offer here is quite unusual in that we give really holistic care. to women, which is really important. So tell me about your journey, because you've not, both of you haven't always been specialist, menopause, nurses, have you? No. So for me, Sharon, I started when I decided to change from a very long-term job, I was working in young people's sexual health. Okay. And I've done that for probably about 16 years through the journey of my own girls growing up. And I decided because I wanted to expand the specialism that I was doing within sexual health, and I wanted to start doing coil-fitting. I felt that I'd outgrown my job and wanted to change.

And I just had a really great opportunity to start working at a GP practice as their lead nurse. But it was very clear from the onset that I would specialize in women's health. However, I'd had no experience in the order ladies' journey through contraception in sexual health, really. And so it was very quick for me to recognise that I needed to gain some more experience. but also I was in the age range myself. There's a bit of hidden agenda going on. Yeah. So, and what's about you, Mandy?

What did you do before? Well, I've been in primary care now for 20 years, working as a nurse, then moved on for chronic disease, prescribing, and then as practitioner. We joined the practice. This practice we're working at now about three years ago within about a few weeks of each other. So we decided that we do this journey together, just to each other. and it's been a godsend.

Because I think doing this on your own is very challenging. And the lack of trainers as well was an issue. There weren't many. It is a big problem. And some of you that are listening, menopause education for, especially in primary care, it's really difficult. And the menopause isn't a disease. We know it's not a disease.

But if it's not managed properly, it increases risk of so many diseases, such as heart disease, diabetes, dementia, osteoporosis. or osteoarthritis and mental health depression as well so it is important to get right isn't it and i had hardly any training nothing really formalised as an undergraduate or a postgraduate or as a GP training either and it's the same for nurses isn't it often yeah did you have any when you were none whatsoever no they focused on contraception yes and family planning but nothing at all past that stage which is quite amazing isn't it because i think you know i mean i've been pregnant three times and I had fantastic care by midwives and really quite intense care.

And then when I had my baby up until the age of five, you get a lot of visits, don't you? And then suddenly you're on your own. And actually most of us, hopefully, will be menopausal for 30, 40 years. Yet a lot of women don't get any contact, do they? No education, no help, nothing. Well, they might get a prescription through the GP, but it wouldn't necessarily be alongside an holistic approach to looking at their well-being. Yeah, and I think that's so important.

We did a survey of about 3,000 women recently and found that only 24% had been asked any information about their lifestyle. And, you know, we were joking before we started how good nurses are at sort of filling out forms and going through lists. But actually, it takes a minute to ask someone, do they drink alcohol, do they exercise, do they smoke? Got a good diet. What's a diet like. Yeah, and I find when I ask people, it often opens up then another conversation. or some women then come back to the clinic and say,

I felt so guilty. When you asked me about exercise and I hadn't done any, I thought I can't come back to the clinic and have not done any. So it's amazing the power of just a simple question can have, isn't it? Yeah. And it's also having the opportunity when you see the person in the room, when they've got an appointment with you, one, what they've actually come in for.

They won't necessarily think that you're going to even ask them about questions like that. I know for me, when I'm working in the practice environment, for all nurses, we've got an ideal chance to speak to women about their holistic health when they're coming for their smears. Absolutely. And that's an area that within our team, we've spoken to the nurses a lot about that this is a great time to talk to them about their contraception, how they're managing on it. And then also, I think nearly every woman that comes in to see me in 40 at least and above

what's your vaginal health like. Well, that's so important, isn't it? And I speak to so many women who have stopped having smears because it's uncomfortable. And they say to me, my last smear was so painful. And I said, well, did you get any help or advice? Oh, no, the nurse said it would be over quickly. Whereas we know that certainly vaginal dryness affects, some studies say 70% of women. So the majority of women.

And it's very easy to treat, isn't it? It's very quick and easy. And they find it, well, they don't want to come off of it. Yeah. And they don't have to. Absolutely. So they can stay on for the rest of their life. Yeah.

And so often we're talking about local vagina and estrogen, which is different to HRT. Yeah. It's very safe. And I think also if a woman comes in and you ask them, well, what was their last smear like or what their vaginal health is like? And if they are really struggling in that area, or they've stopped having sex or struggling with sex,

then actually you can delay giving them their smear and get them on their topical treatment. And then invite them back with the instructions on how to come back, being off it just for a short period and then get the procedure done. That can make all the difference because they still do have to come potentially every five years. And if they're going to dread it, that's horrendous. No, absolutely.

And I think it's also, even though the smears stop, don't they, at 60? Or 65. And depending worldwide, there's different ages, but usually in the 60s. But actually, women in their 70s might still have some problems with their gyne reproductive organs. So if they have bleeding, then they will need to be examined. And so it's really important. But as we know, vaginal dryness isn't just about having an unpainful smear.

It's a lot of women I see and speak to who can't sit down. They can't wear undercliens. So a lot of, even healthcare professionals think, well, vaginal dryness only matters if you're having sex. And it's not. No, I see a lot on my day-to-day being the nurse practitioner side of it, with a recurrent urinary infections. Yes.

And a lot are missed when you don't ask them about their vaginal health and whether they've got any issues. And we do start an awful lot on treatment following recurrent infections. Which is brilliant because we know, certainly with recurrent UTIs, urine utract infections, giving antibiotics is not the first-line treatment. And we know that giving localised vaginal estrogen reduces the incidence of urinary tract infections. And women love it, haven't they? because they don't have this stitis or even incontinence that they can't have.

And it usually responds to treatment very quickly as well. It does. And it stops them having to go to secondary care for quite invasive investigations when they're not actually needed. Yeah. And I think also for the women as well, sometimes they actually have a barrier about starting it. If they think this is more well, it doesn't really affect me because I'm not sexually active with my husband. Because of certain things that their relationship is, that's what they've chosen. Yeah.

And I say, well, actually, what we're looking at. that as well is the ability to function well in your daily life and the fact that to reduce any risks as you're aging for things like the neurodrax infection. And actually it's a change in thought for them as well. Absolutely. And that's so important. A lot of women I see who live alone, who have been elderly, tell me that they have had a lot of itching and discomfort during the nighttime. And so inadversely it's keeping them awake. And so once they have treatment, they say, gosh, I sleep so much better. And then my mood's better. my energy is better and you know it's one of those I think people expect to have some symptoms

when they're older but they shouldn't no and I think what's been interesting for me more recently in the GP practice that we both work in is that some of the GPs are are actually referring the patients to us and to do a review because they know actually that we've got a little bit more time to spend on your appointments they're very flexible we've got a system of appointment booking that we are responsible for on the whole so we can book our own patients must be such a luxury Yeah. Well, we have a certain amount per week that we need to do, but both Mandy and I have discussed it with our GPP partners and also the practice manager. And at the moment, we tend to see an initial patient, if we're seeing them for HRT, for between about 30 minutes and 40 minutes.

Wow. And then for a repeat, we tend to put aside 20 minutes. You know, it's so important because if you get menopause care right, it's a really good investment because we've done some work looking at the number of investigations, the number of appointments women often have, just to get the diagnosis of the menopause or perimenopause made. And as you both know, it's not a biochemical diagnosis for most women. You don't need a blood. No symptoms.

Just about symptoms. So we can make the diagnosis actually quite quickly. You know, have your periods change or stop. Have you got symptoms or if you've had a hysterectomy or marina coil? Just symptoms. So the diagnosis bit is the easy. bit. Yet women, I saw someone in my clinic last week who said the last six months she's been going three times a week to her GP because she's had joint pain, she's had muscle

pain, she's had urine infections, she had migraines, anxiety. No one's put it together but she knew something wasn't right. Which is why when obviously we're looking downstairs in your waiting room that you've got your symptom checker that they feel out, we do exactly the same one that they feel out before they've come to us. Yeah. And a lot of my sort of ideas with some of the work I'm doing is to try and empower women so they can direct the consultation. Because if as women, we're educated, we know what's happening to our bodies, we understand the perimenopause and menopause, it makes the consultation so much easier, doesn't it? So, the woman comes with a completed questionnaire, which can be downloaded from my website

and says to the nurse or the doctor, had these symptoms, these are all linked. Can we talk about the next stage of treatment? The first 10 minutes of your consultation is insulted, really, hasn't it? fair, we try and do a lot of our pre-appointments by email. So we have a system that we can email out our patients. Send them links to our website. So our GP practice have got information on the menopause on there. We've got the menopause questionnaire on there. And then when we send a first contact, so when we're planning to book the appointment in with them, we send them a list of things that we're going to talk to them about in the consultation. We send them the links to your website.

Oh, thank you. Thank you. To the women's health concerns. Yeah. So that we try and prime them and enable them to start thinking about it and thinking about it. What, they know, want out of their consultation. And do they know. Yeah. Yeah. We've got a recent website change, which has made it a little bit more clunky to get the questionnaire, but we can still send it as an attachment, and then they can have a look at it and set it out.

And I find that, even for me, with time pressure, is so much easier when I know that I've given. And also because the time is so precious that we want to also allow the women to take responsibility for what they want to come to speak to us about. And also open their mind up to think, oh my gosh, I didn't actually even realise that was to do with the menopause. I've been really suffering for that. Probably much longer than maybe the reason

that they've actually decided to come. I think so. And I think even just filling out the questionnaire, a lot of women say, gosh, I had no idea muscle joint pain was a symptom. I didn't know my headaches. My migraines were related.

So it's that light bulb moment, isn't it, where they sit? And I think it's so important. But it's quite unusual because you're both working for the NHS, which is fantastic. But as you both know, it's really difficult to find good NHS menopause care. As you know, I can't get a job as a menopause specialist in my area because there's no funding. So, which, when it happens to all women, it's really inexcusable, isn't it? And I'm hoping things

will change. But I have been doing some work behind the scenes with some nurses because when I educate nurses, it's lovely. They're a great audience. But, yeah. A lot of them, like you say, are menopausal age, so they have a lot of interest themselves. They've got so many questions, but what really saddens me is so many of them are leaving the job. A lot of nurses now are leaving practice nursing. They're leaving secondary care nursing. But when you look at the demographics, a lot of these women are in their 50s and they feel burnt out. Struggling to cope with.

Struggling to cope. But they don't often realize how many of their symptoms related to the menopause. My husband is a urologist, and he said to me the day before yesterday, he had about six nurses in his room. They all came in because they knew he was married to me. And they were asking all about them. One of them was had a fan. The other one was saying how much she'd put on weight and become more tired. And he was just saying, well, you just need HRT.

And it wasn't even in their radar. And it's only because they're trying to find information out themselves. But so many nurses are leaving the NHS. The NHS is really struggling we know. And I'm sure you were. would agree that you think, gosh, if a lot of the nurses had treatment themselves, and if a lot of nurses had the education that you both have in the menopause, you could help so many women.

So it's something we'd like to do is to get out there and go into the big organiser, just like yourself with the police force, to get in there and just talk to them, just an hour in their lunchtime and just explain what we do and how we can help. Yeah. And it's really important and certainly we have a nurse practitioner working here who prescribes. And, you know, I think nurses, no disrespect to doctors, but I can be rude because I am one. We often go off on a tangent. Whereas nurses, they're just better at working through a set protocol.

You're very structured. You are structured. Absolutely. And I think actually for primary care nurses who are used to doing the smears, doing pill checks for contraception, it's the next progressive thing, isn't it? Like you say, as we get older, we tend to attract people who are more our age sometimes. And, you know, you've got this big void in nursing because people aren't getting educated. They can't direct the conversation of the treatment in the right way.

For me, because I'd already, when I was working in the GP practice, I was doing the faculty training for contraception and sexual health. I just saw it as a natural link that why wouldn't I do the faculty training for menopause? And I must admit, the thing that I was shocked about when I went on the two-day training was how vastly underskilled a lot of people were in this area. And with the enormous population, their needs aren't getting met. And I think that's why we were in such a fortunate position. Because I would say that within our practice, either they were completely ignorant of what they were stepping into with us. Or we were just really fortunate to find that. we could have the support from our GP practice and our partner at that time to go off and do

the training. And it was really a journey of the unknown for all of us included. But actually, I would hope that we'd be really good role models for other nurses. I hope so. And the fact that we are able to talk to the nurses in our local area. Yeah. Offer training and events that we're running. Which is really important. I mean, I don't know if you know, we've written a menopause education program aimed for primary care. So mainly for GPs, nurses, pharmacies, and it's going to, we're partnering with 14Fish.com and we make it more online so that it's very easy. And we videoed some actresses actually, so pretending to be patients. And we have one of our nurses involved in the videos as well.

So we want to show people how easy, even in 10 minutes, you can make a big difference if you have this targeted consultation with the right information. And we're doing questions before and after so people can assess their knowledge. and people will be able to do a certain number of hours every year to prove that they keep up to date. Because that's very important. And the current training at the moment is good, but it takes a long time. Well, it's taken us two years. It's over two years to get to this point.

And it shouldn't take that long really. And part of it is the way it's structured and we need trainers and there aren't enough trainers. But it's very much, when I talk to the British Menopause Society, they say it's more really for gynecologists. Yes. But actually for primary care, we don't need that sort of structure at all. So hopefully this will help because it's not difficult when you think about the menopause, but it is if you don't know anything about it. So it's trying to demystify it, isn't it?

There's a massive learning curve we've been on over this last. But there's a lot of misunderstanding as well, isn't there? And I think certainly a lot of work I do is to try and make it really easy and accessible because that's important, isn't it? I think though for me, because I was in such a very specific area of nursing, The training that I've received all that we have actually created for ourselves as well based on the sort of targets that we've had to meet through the faculty training, it has helped me by having to go out and meet different specialisms.

So those sort of targeted sort of appointments with the bone health team when we went to the genetics department. That was really, really helpful because actually, for one, it enables you to understand what they're doing when a woman goes to that department. And also sort of creates the, link for communication. Yeah, for a result. Absolutely, and it is really important.

And certainly when I talk to other people and educationalists about the menopause, it's not a women's health problem. It's not a gynecology problem because rheumatologists need to know about it. Cardiologists need to know about it because of palpitations. Neurologists need to know because of the headaches. Urologists because of the bladder problems. Gynecologists. We also don't know an awful lot about HR.

Absolutely. Yes. And as you know, we've got a Dexter scanner here. So anyone, osteoporosis is really important. So it is trying to look at all this. And I suppose I'm more unusual in that I did a lot of hospital medicine and went into general practice. So I'm not a gynaecologist. I don't pretend to be.

But you don't need to be for a menopause specialist in that way. Gynaecologists are brilliant in their field, but predominantly their surgeons. Whereas I think in primary care nursing, there's so much you can do. where they don't need to go into hospital, which I think is really important as well, isn't it? Yeah, definitely. I think the aftercare, once you've been to secondary care and then just left.

Yes. And then we're left then to pick up the menopause symptoms that then follow on, which we find really satisfying. And you can both prescribe. Yeah, absolutely. And that's been fantastic. And I've noticed the difference in my prescribing journey with the menopause because when we first started,

there was so much to learn. and I felt like I was a complete novice again with prescribing. I was really comfortable with prescribing with contraception and sexual health. And then suddenly I felt really nervous and tentative. But we were, yeah, but then it all changed again with the shorter ditch. So that put us all as like, well, where do we go with all this now? But it's all very much formerly led and oral medication. Well, we don't tend to go down that route.

We tend to go down the transdermal route. and the natural progestergen as well. Yes. We do something that you actually talked to us about when we first met you. Yep. And you sent me all the pathways for you to Jesternd. And that was really, really helpful because we were involved in our local area of creating the pathway for Bristol an area.

But I think what I recognise is when I'm talking to my nurse colleagues who are starting on the journey and learning about menopause, that my knowledge is so fast to where I started from. So I also feel comfortable when I'm talking to women about talking to them sometimes when it's off-licensed to what is the former areas. But I can also back it up with evidence-based dentists, which is really important. And certainly all the work that we do here in the clinic is evidence-based, non-biased, because it's so important. And like you say, the whole licensing thing is a lot of drugs that are licensed, but they're licensed for, certain indications. So for example,

HRT is only licensed for menopausal symptoms. Whereas we have loads of evidence that the earlier women started, the better. So we often do start it, don't we? Perry menopause. Yes. But that is off-licensed. Yeah. But actually it's fine because we know it's safe. And it's really

important that women know that because also with HRT there's a lot of warnings in the packet inserts on there. So I'm sure you're the same thing. It's terrified a lot of time saying actually this is inaccurate information. And so even the vaginal estrogen, we'll talk about risk of clot and heart attack. Well, that's such a low, low dose.

And we have had challenges with that over the few years that we've been prescribing. Why are we prescribing vaginal and HRT? Yes. And that was from GPs. Yes, we get it a lot. Because around a fifth of women who have HRT still need to have some vaginal, localised estrogen. And it's really important that women, like you said earlier,

continuing the long term with vaginal estrogen. And it's fine because of, the doses so small. We've had discussions with women and also the pharmacist, community pharmacist about, I had it particularly with someone who's done a history of deep vein thrombosis. And I'd given her transdermal approach to her HRT. And that was then challenged. But also migraine with aura and understanding how to manage that. And there was a lot of misunderstanding even from other medical practitioners. Well, there is. And it's because it all boils down to education and training. And for those of you are listening, when we talk about,

about transdermal, we mean estrogen through the skin is a patch or gel. When it goes through the skin, it goes directly into the bloodstream, so it bypasses the liver, which produces our clotting factors. So it means women who have had a clot, like you say, women who have migraines, especially migraines with aura, can still safely have estrogen through the skin. It's very different to tablet estrogen. And there's lots of advantages of having it through the skin because it doesn't have been metabolised and digested. It doesn't interfere with other medication in the same way. So we tend to prescribe estrogen through the skin first line. And then for women who have still got their womb, then we often use the natural progesterone, like you say, the micronised

progesterone. Because there's less side effects, there's less risk of breast cancer. It's just a safer preparation to use. And it can help you sleep. Yes. There's a lot of people take it at night. It's recommended to take it on an empty stomach at night time and it has this mild sedative effect. And sleep is such a problem, isn't it? Yeah. Perimenopause and menopause. So it can be good as well for a lot of people.

So it's getting the messages out there is really important, isn't it? But like we were saying at the start, it's not just about HRT. There's no point having HRT and smoking 20 a day and going to McDonald's. You need to be. Lifestyle needs to be involved. But I'm sure you agree. Certainly a lot of women we see once they're on HIV, sharty it allows them because they feel better to.

They're much more open then. I think sometimes when we have patients in or women in for their first appointment is actually quite overwhelming the amount of information we're discussing with them and the information we want to give. And what we look at is, okay, so we're going to follow up in 12 weeks. This is the perfect time then to really explore the areas of lifestyle and use that time because sometimes when they are feeling really rubbish, this isn't. all in at all. And I think it's really hard. A lot of women who are menopausal and perimenopausal,

they feel like failures. Yeah. Yeah. They feel very vulnerable. They feel very neglected, very isolated and also very scared. You know, a lot of people we see worry they've got brain tumour because of headaches or dementia. And then if they have someone saying, you should exercise, you should increase the amount of fibre that you eat or whatever. And a lot of people comfort eat because they feel so awful. So I think as doctors, Anna, or any healthcare professionals, we need to give trust to our patients, but we also want them to feel good about themselves, don't we? And so it's like you say, when your brain isn't working properly, because you haven't got the hormones, then to be bombarded with information and feel

even worse because you're not having this perfect, healthy lifestyle, you can make them feel even worse, can't be us? Yeah. And I think if we're doing it as a follow-up as well, and then exploring what they feel that they could make changes with. I think that's really positive to do it so that it is driven by them as well and then supported about what steps they can take to make small changes. Yes. Then they'll be more likely to be successful. Yes. And then they'll maintain them as well. And I think that's really important because it's so easy now with Instagram and everything else to think that everyone has a perfect life. Perfect diet. Everyone's filming their food and they're, you know, and actually you will then feel more of a face.

and it is making the right choices for you as well. I'm quite extreme with my diet in that I don't have caffeine, I don't eat processed foods, I don't eat much sugar, but I wouldn't expect everyone to be like that. I don't drink alcohol. But all individuals, so. Absolutely. And so, but it's working out.

I think the beauty of your job and my job in the way our clinics are set up is that we can see and follow up those women. And certainly in secondary care, by that I mean hospital care, often people see one doctor one time and then they'll see a different doctor or nurse. And you don't get that continuity. So to pick up the pieces and carry on from where you left off can be really rewarding for the patients. And also for us as well. It is very rewarding because you see them come back in the 12 weeks.

The last week I had, the husband came along with his wife. He literally popped in, shook my hand and said, thank you for giving my wife back. And then he went off to work. It's lovely. And that was really touching. Yeah. Yeah. It's quite something, isn't it? I think there's no other area of medicine that I feel so rewarded. You sort of know that you can make people even not fully better, as always, but you know they're going to improve.

It's very powerful. Like I say, my husband's a surgeon, and I've always been a bit jealous of his amazing ability to transform someone because of how he can correct their problem. And in medicine, it's not quite so easy, is it? No. There's so many other factors. But with the menopause. because it's all about missing hormones. So if we can replace those hormones and educate, you can make a huge difference. I think also one of the things that struck me,

I think, from something I've read or listened to on a podcast, it's about people if they have iron deficiency, they will replenish that. If they have vitamin B 12 deficiency, but for estrogen deficiency, they need estrogen. But they also will think they shouldn't have it. Yes.

I struggle with that sometimes. Well, I totally agree. and I spoke to someone the other day who was a friend of my mother's daughter who was struggling so she just, do you mind speaking to this complete stranger? It's not mother anything to have.

This lady who's mid-40s and saying, I've been told I'm very unusual because I'm going through the perimenopause. I said, well, that's average age actually. And she said, and I don't want any of those drugs. I want to do it naturally. They said, well, the most natural way is replacing the hormones with the identical HR tissue.

Well, that's a drug. I said, well, it's not actually. You have an underactive thyroid gland, you replace. And so it's trying to shift the menopause to something that causes symptoms in women to something that is a low hormone deficiency that lasts until we die. Yeah. You know, and symptoms change. So it's not just about improving symptoms. It's about replacing those hormones, which is quite hard sometimes to conceptualise, isn't it? Yes. And I think we've been really lucky where we are that we do have continuity with our patients. Yes. And that we can also

do a lot of the sorting to make sure that we have that continuity at the point of booking an appointment but we've also i mean i've been out to do some talks with the women's institute around cervical smears and we can see that we can do that with menopause and hrt and we're invited for christmas to do a talk with women at the local leisure centre great and although the turnout then was small thank goodness in a way because those women have so many questions are bombarded it's quite something i mean i find whenever i give talks to women however small or big, there's so many questions. And there's usually two, three, four, depending on the size of the audience, who burst into tears

because they said, gosh, this is me, I had no idea. And it's good, but it's sad. You know, my work is incredibly rewarding, but incredibly frustrating because for every one woman that I see, you see, there's millions out there. Yeah, but can't get the help. So for any of you that are listening and aren't getting the right help, then make sure that you see another doctor or another nurse or see if you can find a doctor. doctor who specialises in the menopause, but it's really important not to give up on your first

consultation, you don't get the right help. Totally, I think. But it can be really hard for people to feel that the information that the healthcare professional that they've seen isn't adequate for them. And I think that it's okay, I know that for me, I could challenge that and I feel confident enough to be able to do it. But my friends who've experienced it, they've really struggled or they go and they've explained, we have a lot of people that come to us to prime before they go to their healthcare professional.

But I think it's really good and certainly a lot of the downloadable booklets and fact sheets that I have on the website are exactly that to try and give people a confidence because it's quite scary when you see a doctor and you think that everything they say is right. It's correct. And the doctors often do think they're right because they haven't had enough training. So it's quite difficult for them. So I'm conscious that we've reached the end of our time really and I could talk to you. both all day. Thank you. And it might get you back to talk more about how you're doing more education because I think this is so key. But before we finish, and in your nursing style, you have made notes for your talk about. No one else has ever done that before. Pages.

No. You could give your, or read your take-home tip. So for me, when we were looking at this and discussed it in the car upwards, we thought, well, we actually recognise that this is a really in-depth subject, which actually needs to be seen as a holistic medicine. And that was really my first thing that I thought about. And then for our education, Mandy and I discussed it and said, actually, you need a like-minded nurse or professional that you can work together with. Banks off ideas again and talk through. Yeah. Learn together. And we thought that actually doing the British Menaceball Society two-day training is really beneficial. Yeah. It's packed full of information, even if you don't go on to do the accredited training at the end of it.

You've still got that foundation to go by. But you also need to be able to, when you are in that education setting, to be able to have honest discussions and reflect on your practice, what's worked well, what hasn't worked well. But you also do need to have someone that you can talk to at a higher level than yourself. Because we are trained at a certain level and we're not completely autonomous. And then we said, attend as many clinics within the local area. that you can, that's outside of your field of specialism, and work with the local pharmacy that you're working at, and also with your local pharmaceutical reps, because they're hugely

helpful for resources that you can give to women. And then it is for us been beneficial to work as a nurse prescriber and then do as much reading around the area as you can. Yes, absolutely. Brilliant, brilliant tips. I think it's really important and there's always things to learn. You know, I learn so much more patience all the time and there's always always. new evidence, so it's really important to keep up to date. And we've actually run a confidence in the menopause course, which is just a one day. We've got another one coming up and we run them every six months. So these are open for healthcare professionals to come and really have some basic knowledge and understanding supported by the evidence. So thank you both. Lovely ladies for coming

to my clinic and recording this podcast. I'm sure that we'll help lots of people. And happy Valentine's day. Thank you. Thank you. For more information about the menopause, please visit our website www.menopause doctor.com.