The Dr Louise Newson Podcast - 053 - The costs of the menopause - Professor Philip Sarrel & Dr Louise Newson

Episode Date: June 23, 2020

In this podcast, Dr Louise Newson talks to Professor Philip Sarrel, Professor of Gynaecology, Obstetrics and Reproductive Sciences and also Professor of Psychiatry at Yale University.  Dr Newson and Prof Sarrel discuss the importance of hormone replacement, not only to improve symptoms but also for disease prevention as Prof Sarrel talks about the increased risk of heart disease in women who have had an early menopause. He is the Founder and President of the Advancing Health After Hysterectomy (AHAH) Foundation, an organisation that focuses on educating women who have had a hysterectomy by age 60, a total of 15 million women in the USA! In the 1990s, around 80% of women received HRT following a hysterectomy and now the figure is around 15%. Yet women who have had a hysterectomy in the past and take HRT actually have a lower future risk of developing breast cancer. Professor Sarrel talks to Dr Newson about how many studies, including WHI (Women's Health Initiative), have found that taking HRT can control debilitating symptoms including hot flushes, sleep disturbance and fatigue, and reduces the risk of developing conditions such as osteoporosis, atherosclerosis and heart attacks, and vaginal atrophy and sexual dysfunction.   Professor Sarrel talks about menopausal symptoms being the “canary in the coal mine” as ignoring symptoms leads to an increased risk of many diseases including heart disease and osteoporosis. The financial costs of these diseases is huge and a new article in the Menopause Journal has reported consequent medical expenditures for five of the diseases which reduced when women age 50 to 59 take HRT - coronary heart disease (CHD), breast cancer, bowel cancer, hip fracture, and stroke. When the costs for all of these conditions have been added together the expenditure consequences for untreated vasomotor symptoms in the USA in a single year is estimated in billions of dollars. In addition, around 20% of Medicare dollars in the USA is spent on Alzheimer’s disease – which is more common in menopausal women.  Find out more about Professor Sarrel's research here. Professor Philip Sarrel's Three Take Home Tips: Take charge of your menopause! Improve your knowledge and learn from reliable sources. Ask yourself about any symptoms you are experiencing – make a diary and record any symptoms. Find a healthcare professional who is knowledgeable who can really help you. It's okay to get a second or even third opinion. 

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'm really excited to be able to remotely podcast a very inspiring and clever gentleman called Dr Philip Sorrell, who I first engaged with probably around a year ago because I read an editorial that resonated really strongly with me. He was a professor of obstetrics, gynaecology and reproductive sciences and psychiatry at Yale University. And he is also the founder and president of the Advancing Health After Historectomy Foundation, which we will talk about in a bit. So welcome,

Philip. Thank you very much for inviting me to your podcast. I hope the audience will find it of interest. Oh, so I'm sure they will. I'm very excited about doing it with you. So So when I read this editorial that you wrote for Menopause Journal, it was last year, the beginning, so almost a year ago actually. And it was talking about giving hormone replacement therapy to prevent disease in women. And as you know, and a lot of you who are listening know, I'm not a gynecologist, I'm a physician, and I have done a lot of hospital medicine. So I'm very interested in anything that can prevent disease because we all want to try and avoid going to adopt.

and diseases such as heart disease, diabetes, osteoporosis, dementia are really important and very significant in women as well as men. And any way we can reduce this risk is really key. And so one of the reasons I'm so interested in the menopause is looking at ways of reducing risks. So when I read this paper, I just smiled and thought, gosh, this is so many things that I'm trying to do over in the UK to empower women to educate doctors and nurses. healthcare professionals. So I sent you an email and you were very kind and replied and since then we've had this lovely long distance relationship. So tell me a bit about your background if you don't mind and then a bit about the foundation. Well, my background has been almost entirely. My training

and experience as a professor has been almost entirely at Yale, although I have spent almost four years working in the UK. At Yale, I was trained initially in obstetric. in gynecology. And then I became a professor also in the Department of Psychiatry. I found that the effects of women's hormones on the circulatory system was of particular interest to me. And so starting, actually in research done when I was in Oxford for a year, I was able to look at the effects of hormones on blood flow. And that led into a secondary career in the field of cardiology research. I did spend a year at the National Heart and Lung Institute at the Brompton Hospital,

and that was a tailored fellowship for me in which I had for research assistance. And we pursued the actions of a particular estrogen, the one that women naturally make. It's called esterdyol, where you would say Easterdial. but we pursued the effects of it in arteries. And out of that came 20 years of basic cardiology research, in particular with the problem that women develop at menopause or related to menopause of chest pain that looks like and really is a kind of angina suggesting arterial disease.

But it turns out it's part of the phenomenon that are occurring when women have hot flashes. And it's due to the release of a chemical in the bloodstream during the hot flashes, which makes the arteries constrict. In the United States, the women will often have a coronary angiogram. They're always normal. And in the studies we did at the Brompton, we did show in a set of 20 women, all we had to do was replace the estrogen that had declined with their.

menopause, and that was the end of their quotes angina. They didn't have significant disease. This led to an important publication that came out of St. George's Hospital, and Dr. Koski was the editor of that whole journal on the condition called Syndrome X in Women, which is, it looks like the real thing, and patients will tell you, gee, it feels like there's an elephant sitting on my chest, And it's very frightening, but in fact, it's easy to bring under control. And it's just one of a myriad of symptoms that women develop when their estrogen levels decline naturally with menopause or with surgical menopause. But it's not just a symptom.

It's reflecting pathology in the functioning of different systems of the body. For example, in one of the studies that was done, and this was done at Chelsea Hospital for Women back in the early 1980s, and I participated in that study, one of the most frightening of the symptoms that women had developed at the time of their menopause was a change in short-term memory. And we would say to the women, well, do you have any problem starting a sentence and not remembering the second part of the sentence? Oh, yes.

What about coming in a room? get something and you can't remember what you came to get. Yes, well, has that been true all of your life? No, it's something that's only occurred within the last year or six months or so. How do you feel about that symptom? That's the scariest of anything I've been experiencing. Does it mean I have early dementia? And the answer to the question is very simple and straightforward. No, no. It just has to do with the role of your estrogen and nerve transmission. and how the signal is going along a nerve fiber. There is hardly a cell in your brain

that doesn't have the mechanism for using estrogen over every single cell. I'm going to pause you there because that's so interesting, isn't it? Because when people think about female hormones, they think about periods, they think about menopause is when periods stop. And if your periods have stopped,

your menopause happens and then it's over. And you can get through the other side, and your post-menopausal. But actually, just you saying that how estrogen is so important in every cell in our brain is really key, isn't it? So when we don't have estrogen, once we've gone through the menopause, we won't have estrogen ever again, will we, unless we take estrogen. So the effects on our brain, less alone the rest of our body, are huge.

Well, there are some cultural differences. There are some places in the world where dietary estrogens do, do play some role in continuing to have brain benefits, cardiovascular benefits, but in certainly Western cultures in the United States and in Europe, our diets really don't provide very much in the way. There were about 600 plant estrogens. So in fact, you can trace them all out, but our diets really don't provide that very much. So you are absolutely correct.

Once the menopause occurs, the blood level of the estrogen drops to about a 20th of what it was during most of the woman's reproductive life. I think it might be worth mentioning that all menopause is is a transition from the reproductive phase of a woman's life to the post-reproductive phase. Her ovaries don't dry up like prunes and die. In fact, new cells grow into the ovaries, and they produce hormones, but not estrogen. So what women experience is this change in their blood estrogen levels, and that's very easily correctable with today's science and the availability of a wide variety of very reliable estrogen replacements that can be monitored, can be tailored to the industry. individual women. Unfortunately, all of this takes a little bit of time, but not a lot of time.

And the prevention of disease is more than worth the investment of time to get it right at the time of the menopause. Which is so important because sadly, a lot of women, a lot of healthcare professionals are really negative and scared about HRT. And there are various groups of women where it is really imperative that they consider HRT and the guidelines are very clear. they're the group of women that I'd really like to focus on. And so mainly young women who've had an early menopause in the UK around one in a hundred women under the age of 40 have an early menopause. And also women that have had a hysterectomy. And when women have a hysterectomy, often their ovaries are also removed, which plunges them into a surgical menopause, but also some women

keep their ovaries, but then they have a higher risk of then having a menopause, which can be sometimes difficult to know because obviously the woman's not having periods. So I was reading some really interesting statistics that in 2002, around 90% of women were given estrogen replacement after they had a hysterectomy, mainly for their hot flushes, but nearly half, around 40% were given it to prevent heart disease and osteoporosis. Now, that's not the same now, is it? No, it's not the same. and what was being done back in the 1980s and through the 1990s was extremely important. And number one, the clear evidence from a disease prevention point of view, that the loss of bone was a silent disease.

There was no symptom of that. And yet, by the time women reached their menopause, about 40% were identified to be rapid bone losers, and they had already lost 10% of their bone mass. Now, those are women having a natural menopause. Women having a surgical menopause are at an even earlier age. The natural menopause, the women are age 51 plus or minus four years. But the women who are having a surgical menopause, half of the women are under the age of 45. the most common age in the United States, the most common age to have a hysterectomy, is age 40 to 44.

The second most common age is age 35 to 39, which it means by age 45, all of those women were taking their estrogen. We already knew by the mid-1960s and early 1970s that by taking the estrogen starting at the time of their surgery, they would prevent the bone loss. That was made very clear. So that was the first of the diseases to come into widespread recognition. But you know, even earlier than that, in the 1940s, it was seen that removing the ovaries, even in a very young woman, could result in severe arteriosclerosis, atherosclerosis. In the early cases reported from the male clinical,

in 1948, the first two patients. One is 28 years old, the other is 24 years old, and they've both died of heart attacks following within four to five years of having their ovaries removed and showing severe atherosclerosis. That began 60 years of research of how does the estrogen act in the artery to prevent atherosclerosis? And there's a vast literature about that. There was A meeting in the 1990s in San Diego, at which all the major researchers from all over the world came together, and a book was published by the American Heart Association, and over a thousand papers are cited in that one volume

on how estrogen protects arteries from acerosis. Now, all of that knowledge, all of that understanding was lost in what turned out to be a misrepresentation of data. It was lost starting in 2002, as you said, and it began with the publication of a study called the Women's Health Initiative, in which the first part of the study was a study not of women who'd had a hysterectomy,

but of women who'd had a natural menopause, and who were given both replacement estrogen, but also a counter-hosterone. hormone, a progesterone-like hormone, which balanced the effects of the estrogen in the lining of the uterus, but it also compromised the effects of the estrogen throughout the body. That study got reported as an estrogen study, which was not a proper representation. Two years later, from the same major study, they did report the effects of estrogen alone after hysterectomy, and they were quite different.

There was no increase in breast cancer. There was no increase in stroke in the younger women. All of these things that people were worried about from the 201 study was not shown with estrogen alone. Fast forward 18 years later, the same women have been followed up by that women's health initiative, and they show quite conclusively that following hysterectomy, If the women had their estrogen replaced, just as you said back in the 90s, 92% in the California teacher's study, 141,000 women, 97% of the women took estrogen after hysterectomy.

They showed no evidence of any increase in heart disease whatsoever. It was prevented. But the long-term follow-up study of the women who had a hysterectomy who had their estrogen replaced, who took the hormone starting between ages 50 and 59, which would be the typical time to take it. Those women show a decrease in risk for major diseases, at least six different major diseases, and we can say more about that in a moment, but they also show long-term decreased risk of dying, dying of breast cancer is reduced, dying of dementia, of Alzheimer's disease is reduced significantly in these women. So we had to wait 18 years to see clear data

that it wasn't just preventing osteoporosis, but protecting the brain, protecting the heart, preventing colon cancer, all sorts of important issues in women's health. Which is very interesting because there are so many diseases, which makes sense when we realize that estrogen affects so many parts of our bodies. So even diseases that, such as diabetes, Parkinson's disease, depression. I've read some research showing that even asthma or renal disease, kidney disease can reduce. But I really want to pick up on you saying about the reduction in breast cancer because lots of people think that estrogen causes breast cancer because we talk about estrogen receptor positive breast cancers. So a lot of women who I speak to who

have had breast cancer say, oh well, I was on HRT and it fueled my breast cancer. It promotes It started, it initiated my breast cancer. But you're saying quite clearly from the research that women who only have estrogen have a slightly lower risk of breast cancer. So how can that be? Because I know there'll be lots of people listening thinking that doesn't make sense. Well, it has to do with understanding how hormones work in the cells of our bodies. You have to recognize that the hormone is released from the ovaries, circulates in the bloodstream and enters cells throughout the body.

When it enters the breast cells, breast cells have genes, and these genes are affected by stimulation from the estrogen. There are gene effects, we say genomic effects, which can make the cell grow, and in that sense can make the breast cancer cell grow, if it's already there. There are also actions in the cell that not only don't make it grow, but induce death of the cell. There's a medical term for that.

It's called apoptosis. It's a great word. A-P-O-P-T-O-S-I-S. It's a word for people to know and understand because medicine is complicated. you can see with what's going on now with the coronavirus, how complicated the picture is and how many issues there are to consider. Well, the same is true here. The data from all of the studies indicate that women on estrogen who do show a breast cancer,

had the breast cancer before they started the estrogen. And one of the things that I learned, remember that during the year that I was, working at the National Heart and Lung Institute, the Maudsley Hospital is next door, and that's where the National Breast Cancer Surveillance Program was carried out. What I had learned early on from the year that I spent at Chelsea Hospital on King's College Hospital was that when a woman is started on estrogen, of course it's important to do a breast examination. But then, if she is due for a mammogram, What I was taught, and it became my standard of practice at Yale, but I was taught this in London by Dr. Whitehead and his group.

What you do is examine her breasts, if they seem fine, three months after you start the estrogen, then do your mammogram. Because if she had a very early breast cancer, what the estrogen will do will be to stimulate the blood vessels going to that little breast cancer. will show up on the mammogram, a diagnosis will be made, and the cancer will be cured by simple extirpation of it. Very important to understand because that technology really or that whole protocol, which was followed in the UK, most people in the world don't understand that. That one of the things that you can do with estrogen early on is pick up the very earliest. remember the data shows that women who have been taking estrogen who do get diagnosed with the breast cancer the 10-year survival without recurrence is 96 percent these are very treatable

very curable diseases but you're right when you said the women's health initiative and many other studies show there's no study that shows women taking estrogen show an increased risk of mortality from breast cancer There is no such study in the literature. That includes women who have the BRCA genes. They, in fact, when given estrogen, show a lower risk for developing breast cancer. So the overall is not just a little decrease in the risk for developing breast cancer. It's a statistically significant decrease in the risk for breast cancer.

Which is really interesting and really reassuring. And I know obviously the work that the advancing health after hysterectomy, are doing is to try and improve awareness because a lot of women are misinformed and sadly despite the guidelines saying that women should be informed about HRT and the menopause before a hysterectomy. Certainly a lot of women I speak to haven't been told anything about HRT and then they often come to see me because they've had years of often quite disabling symptoms yet they could have easily been treated with some estrogen and there's this misconception that estrogen is bad and actually know that taking estrogen on its own can lower risk of breast cancer

and women who have a family history of breast cancer can safely take estrogen and as you say, it can lower risk in the future of breast cancer is really reassuring. And for a lot of women, this is, if they take all this on board and consider estrogen, it's going to really improve women's quality of lives, but also, like you say, reduce future diseases, isn't it, going forwards? That's absolutely true. And there's another point I think we should add. Remember, I mentioned the word apoptosis.

Because it does turn out that the people who originally developed the aromatase inhibitors and who developed tamoxifen, let's use that as an example, back in the 1980s. The original statement about using tamoxifen, now a woman that gets diagnosed with breast cancer, let's say she has a lumpectomy, she may or may not have radiation, and then typically she's prescribed a drug like tamoxifen for five years. That whole concept developed in the 1980s, and the original papers state very clearly that tamoxifen taken for five years was, quotes, just as effective in preventing the recurrence of breast cancer as taking estrogen. It had already been shown back in the 1960s that women who had mastectomies for breast cancer who were given estrogen routinely

after the mastectomy had the lowest risk of recurrence of the cancer. So the group that developed Tamoxifen went on to study these women even further. They said, well, now what happens after the five years of the tamoxifen. They've had no recurrence. Is there anything else we can do? Well, they put two and two together and they said, you know, the women are having terrible symptoms from being on tamoxifen, terrible hot flashes, and they don't take their medication the way they should and so on. And the data with estrogen says it's preventative. Now, the recommendations, and the group at the MD Anderson Hospital in Texas have been the most vocal about it, and that's the group that developed to moxifin to begin with. They make it very clear that women who have had the five years, the aromatase inhibitor, when they take estrogen subsequently, if there are any remaining breast cancer cells, those cells are hypersensitive to the estrogen, and it kills them.

So I am one of three professors of gynecology whose wives have had breast cancer, all three of whom, including my wife, had their lumpectomies, had their aromatase inhibitor, and in my wife's case, for the next 32 years, has been on estrogen for the prevention of recurrence. Interesting. And you might say, well, why did your wife go on the estrogen to begin with? Well, because she's a perfect candidate for developing severe osteoporosis, and she did have osteopenia 30 years ago, and now she has none. She continues to wear a low-dose estrogen patch.

It prevents her bone loss. She sleeps the night. She's a very comfortable, productive, now retired Yale professor. but for her functioning and her brain functions well, and let's turn to that for a moment. Because in my wife's case, it was also true. In fact, both other professors' wives had the same history. They'd had hysterectomies. So here are three women, but very knowledgeable professors who knew the literature and knew how the hormone works.

So we can all look at ourselves as examples of applying that information. But the main thing, of course, we were concerned about not so much the recurrence of the breast cancer, because we knew it wouldn't. The odds were way in our wives' favors. But the functioning of their brains was number one on these women's list. The data shows very clearly that at the time of hysterectomy, if women have their estrogen replaced and use it for 10 years or more, 30 years later, there are four main. studies that show this now, including the Mayo Clinic study. 30 years later, these women have reduced their risk for developing dementia by over 80%. Wow. And that really is important. So once they enter, even when they enter their 80s, they are functioning, writing, reading,

teaching, still vibrant women whose brains are working the way they should. Which is really important because, you know, we now live on average 30 years or so postmenopausal and life expectancy has increased since the Victorian times no ends, which is great. But we want to remain healthy and certainly I struggled with some perimenopausal symptoms for a few months and hadn't really realised. I thought it was just because I was working too hard and stressed and pulled in lots of directions, but like you were saying at the beginning, I would often lose my car keys, I would forget really important names of drugs, I would forget the children's timetable, I would go to the wrong school at the wrong time to collect the wrong child. And it's really

scary when you're used to being in control. And I can imagine if I had these symptoms for years and decades, I would be really struggling. And so it makes sense when you look at this data, but to show that how important estrogen is. And certainly over the UK, I don't know if it's the same over for you in the USA, but I see a lot of women who've had estrogen receptor positive breast cancer, and they're now told to take 10 years of a aromatase inhibitor, which is blocking estrogen throughout the body. And these women often come for some individualized advice to my clinic

because their joints have seized up. They can't walk, they can't exercise, they can't sleep, they can't think. They're very low in their mood. they're really having a dreadful time, yet they're being told they have to have another five years of an estrogen blocking drug, and obviously they are also told they can't have any hormones whatsoever. And sometimes even just changing those women from a aromatase inhibitor to tamoxifen can make a really big difference. Absolutely. You know, one of the things, since you've now mentioned this, one of the things that the women should know about that they can do, that the North America,

and Menopause Society recommends, the international menopause society recommends, is the use of vaginal estrogen. Yes. Because their sex life is very important. And the problems of developing vaginal dryness, the shrinking of the vagina, it can become impossible to have any kind of penetrative sex. And the clitoris changes. So all of these changes become very important in the quality of life. For a woman, let's take the women who had a hysterectomy at age 42 and has had no hormone replacement. By the time she reaches early 50s, she can be in a situation where it's impossible for her to have sexual intercourse. And that's a really sad time in one's life.

It's such an important time to be able to keep one's sex life alive. And the use of vaginal estrogen for these women is extremely safe. It's recommended by the major societies, the endocrine society. The list goes on and on and on. And most doctors don't even raise the issue. Most doctors don't ask about sex, partly because they're afraid to be intrusive. They're afraid it's going to take too much time. But in fact, it doesn't take much time to be very, very helpful with a simple intervention.

That's very safe. Absolutely. And I did a charity event recently for a charity called Trekkstock in London pre-lockdown. And there were lots of young women who had had cancer there. And we just did a little panel and I asked the audience how many had experienced vaginal dryness and over half put their hands up and they were still experiencing it. Yet no doctor had spoken to them about it. And women often feel really guilty because they feel obviously quite rightly pleased and relieved that they've got through. with their breast cancer or their other cancer treatments, and they feel almost embarrassed to mention it to a physician, and often physicians don't mention it. But a lot of people, when I speak to, obviously, have problems with sexual intercourse, but also they find wearing underclothes difficult. They can't sit down.

I've seen patients who can't wear swimming costumes or cycle, because of the discomfort, or they have recurrent urinary tract infections. And like you quite rightly say, localized vaginal estrogen is very safe in these women. And it's very easy to treat as a doctor. It's very rewarding. But women shouldn't be allowed to get to this state. So if any of you are listening who are struggling, you should really keep seeing someone until you can get some proper advice and treatment. Let me add something to that. We have a cancer hospital at Yale. It's called the Smiloh Comprehensive Cancer Center. And in the cancer center, we have a gynecologist. She has a clinic. I think it's just once a week. But all of the psychologists refer to her. She has gained their trust. She has helped their patients. She's been there for a long time. I remember when she was a medical student, but that was back in the 1970s. The Smiloh Center brought out a special newsletter on paying attention to the sexual needs of the cancer patient and helping with vaginal estrogen. So, you know, that's an important imprimatur

that the cancer people recognize the importance of protecting a woman's because the vaginal estrogen, yes, it's protecting her sex life, but it's also protecting her bladder. It's helping to prevent vaginal and urinary infections. It's protecting the outer parts, the vulva from irritation. So there are many ways in which that very, very simple, safe intervention can make a difference in a person's life. Yeah, absolutely, and it's really important. So before we finish, what I would just like spend a few minutes talking about is another editorial that I've recently read. Moving on from the first one that I read that linked us together, there's one that you've also recently written for Menopause Journal. And this is looking at the economic considerations of the menopause. And can you just share with us some of the findings of the study that you write about in your editorial? There's a new paper that will be published in June in the journal called Menopause, and it's from the Women's Health Initiative Research Group.

And they are looking at their long-term data, and what they're showing quite clearly is that the women after hysterectomy, who were randomized to the estrogen group, show a decrease. They clarify five major diseases that were significantly reduced when the women started the estrogen between the eight, of 50 and 59. It was not true when they started at later ages, but most women who are going to use hormone replacement would be in their 40s or 50s. What they show then is that there's a reduction in breast cancer and colon cancer. The biggest reduction and most significant

is in coronary artery or coronary heart disease, but also in reducing fracture and in these younger women, a reduction in stroke. Now, the other major studies, it's also true in the women's health initiative, but they don't mention it in this paper, but they mention it in their other papers. There's a reduction in the development of Alzheimer's disease. Well, in the United States, Alzheimer's disease is the most expensive disease in our country today. And something like 60%, I believe, is the figure, but it may be higher of patients with Alzheimer's, are women. And the reduction of the development of dementia, in particular Alzheimer's disease in women, is really a goal that we should all try to seek and to work with. What this paper from the Women's Health Initiative says is, well, how much is it costing in medical expenditures to have all of this excess of disease that would have been prevented if the women had taken estrogen?

the excess breast cancers, colon cancers, hip fractures, strokes, heart attacks, and it airs up to many billions of dollars. So they're looking at it from an economic point of view. I guess the connection between medical conditions and economics has become very clear with the coronavirus. I mean, we only have to pause for a moment to recognize that medical conditions and the economy are close. into it. And so this paper points that out. What I say in my editorial is it really is important to clarify in people's minds. There's an expression that we use in the United States. I think you do in the UK. We probably got it from you called the canary in the coal mine. I have learned that they

don't use that expression in South America. You don't talk to Hispanic populations about canaries in coal mines because they don't know what you're talking about. But we know what you're talking about. And that is that something like the hot flash is the canary in the coal mine. It's a signal that something is happening that you need to pay attention to and you need to correct or there will be a disaster. And so it's not only an issue of the symptoms affecting quality of life, affecting work productivity, a subject I've been very interested in and worked with,

but it's also preventing major disease and remaining a vibrant, functional woman. That's really the important issue. Yeah, it's so important. And economic cost is one thing, but the personal cost to women and women's lives is huge. And I really hope that people who have been listening for the last half an hour feel really empowered

and inspired by your wonderful words to find the right help, to seek the right information. And certainly there's lots of information on my website and in my book that's evidence-based and unbiased. So women can feel that they can receive the right help and advice to help them forward in future years. So I'm really very grateful for you giving up your time today. Before we finish, can I just ask you, I always do this,

and I'm putting you on the spot here. I ask for three take-home tips for women. So I was wondering if you could give me three. three take-home tips for women who have had a hysterectomy or not taking HRT and are struggling with some symptoms. What are the three main messages you would like them to take home from the podcast today? I think number one is for a woman to recognize that in order to get the help she needs, she needs to put herself in a take-charge position. She needs to make herself knowledgeable about the menopause. I can promote your book.

which I have enjoyed reading, and I think everyone should read. Very kind. But it is an issue. There's a lot of information on the Internet, which is confusing. You've got to turn to reliable resources. But step number one is do read about what menopause is, what to expect, what to know, and then when to recognize you need help. The second thing I would recommend is if you think,

that you are having symptoms related to the menopause, create a diary, make a record, record, record when you had your last menstrual flow, or if you've had a hysterectomy, when that occurred. If you've used any kind of hormone, that's important. Include in your diary what you notice in the course of a day. What we found was most worthwhile is use a system in which you you recognize a symptom if it affects your ability to function. For example, let's say you're having problems with sleep. Well, then record how many times did you wake in the night and in the day that followed did it affect your ability where you tired all the time, where you sleep

you all the time? Something like what we were mentioning earlier, short-term memory, record that. In other words, bring data with you when you seek professional attention. That is really going to help guide the health care provider, whether it's a physician or a nurse or a physician's assistant. So making yourself knowledgeable, understanding what rich symptoms, many of which, like the chest pain we were talking about, you might not think are related to menopause, but you'll learn from reading that they are. Here, one, since I am a professor of psychiatry, I have to at least mention that the mood effects are very important.

10% of women who have severe hot flashes have suicidal thoughts. Now, that's very frightening. But once you learn, oh, that's part of what happens during a hot flash. It's important to know and understand that. So your own understanding, your own knowledge, and then finding a health practitioner who is knowledgeable herself for himself. That's a challenge. One reason that it's a challenge is because we have a whole generation of doctors who haven't had very much exposure to men and causal women because for the last 15 or 18 years, no one has sought help because everyone was so frightened of using hormones. Well, that's changed.

There has a real rethinking about menopause going on in doctors' minds, in health care providers' minds. It's throughout the nursing world. At Yale today, our nursing students are required to write a term paper about menopause, otherwise they can't graduate. So there's an increasing awareness and a change in understanding, and it will make a huge difference in not only the quality of your life, but also from a quality like preventing disease and all the complications of having a disease.

So those would be my suggestions. They're brilliant. Absolutely brilliant. So take charge. Think about your symptoms and put them in a diary to really help the healthcare professional and find a healthcare professional that can really help. And for a lot of women, that can be the most difficult one. But certainly if you don't get the right help, don't give up, just keep trying. And eventually there will be someone somewhere that can help you.

you. So I'm really so grateful. Thank you so much for your time today. It's been brilliant. For more information about the menopause, please visit our website www.combeautau.com.