The Dr Louise Newson Podcast - 054 - The Basics About HRT - Dr Rebecca Lewis & Dr Louise Newson

Episode Date: June 30, 2020

In this podcast, Dr Louise Newson chats to friend and colleague, Dr Rebecca Lewis and together they talk all about hormone replacement therapy (HRT). They discuss the different types and ways of taking HRT, as well as the advantages of various preparations and different types of progestogens. Dr Newson and Dr Lewis also detail the numerous benefits of taking HRT and the possible risks. It is very important that women receive individualised care and treatment regarding their perimenopause and menopause and that they receive the right dose and type of HRT for them. Many women often find they have to try several different doses before they optimise how they are feeling.  Dr Rebecca Lewis' Three Take Home Tips: HRT will help your systemic symptoms. HRT will help improve your future health. There is no time limit on how long you can take HRT. Find Dr Rebecca Lewis on Instagram: @dr.rebecca.lewis Get more information about Menopause & HRT in this booklet from Newson Health. Click here to learn the facts about HRT and uncover common myths.

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 in this week's podcast, I decided to bring back into my clinic, Dr Rebecca Lewis, who is a great friend, mentor to me, and also she's a GP with a special interest in the menopause. She's also one of the clinical directors here with me at my clinic in Stratford-Parnayvon. So we thought we would actually go back to the basics a bit in this podcast and talk very openly about HRT hormone replacement therapy, what it is, the different types, the different doses, and just really start with some very simple messages about HRT. So welcome, Rebecca.

Well, thank you very much for having me. It's lovely to be here. So we both coming here on a Saturday morning because we both work so much during the week we never really get to talk to each other. So we decided to have a little oasis of time away from the stress of clinic. Very nice it is too. So HRT is three letters. Just talk us through. So HRT hormone replacement therapy can come in various guises, pills, patches, gels.

And so it can be quite confusing for women really, where to start. with HRT. I mean, traditionally, the old-fashioned HRT really was an oral tablet, which combined, usually estrogen and progesterone. But we've moved on since then and are now using transdermal estrogen because of the benefits. So that's through the skin, which means through the skin, exactly. So estrogen, that's one of the most important hormones, isn't it, in our Yes. I mean, when we enter the menopause, what happens basically is we become estrogen deficient. So it's like a blood problem. There's not enough estrogen within the blood getting all around the body. So we have numerous symptoms in different parts of the body because of the lack of

estrogen in the main. So estrogen is produced by our ovaries mainly, isn't it? Yeah, exactly. So the ovaries fails, which is normal and natural. And when it stops working, you know, we become menopausal. And as a result, the eastern levels fluctuate to start and then decline. But also, So testosterone levels will fall because, funnily enough, the estrogen is not the only hormone the ovary produces, but it produces testosterone and produces more testosterone than estrogen. Which is very interesting, isn't it? So testosterone, everyone thinks it's a male hormone and estrogen, the female hormone. Yeah.

Men do produce some estrogen. Yes. And women produce more testosterone than estrogen. From the ovary, yeah. From the ovary. So I never knew that until a few years ago. Nor did I? That was a completely new fact.

We would never learn that in biology lessons at school. And I certainly didn't learn it in any classes or lectures. No, it's a new thing for me as well. Yeah. So testosterone and so they get produced by the ovaries, but it's not just about our reproductive tracks, is it, that these hormones are important for? Like you say, they go in our bloodstream. That's right.

And is there anywhere in our body that they don't affect? I can't think of it anywhere. It doesn't affect. I think that's a better way of saying it. Where don't they get? to and I can't think of anywhere. So the brain, the skin, the heart, the bowel, the vagina, the joints, the bones, everywhere. A hair, skin, nails, eyes. Quite something. I can't think of many other hormones that affect us in so many ways. Absolutely. And affect every cell because we've

got cells that respond. So essential for us to function. That's right. And it's a bit like other hormones that we know or a lot of people would have heard of things like hormones such as insulin or thyroxin or adrenaline, our fight and flight hormone. These are all hormones. They're just messengers, aren't they, that find the cells that they respond to. And then there's certain processes that take place. Functions, in the cells that have important bodily functions, don't they? That's right.

So that's why without them, it can be really hard to function. Not just mentally, but physically and physiologically as well. Yes, yeah. I mean, women will know that, that their concentration decreases, their memory, they can't get the right word, they get stuck in the middle of the sentence, they can't remember what they were talking about. You know, it's very difficult to work with that sort of problem. You know, on the physical symptoms, the bus aches and the fatigue. And we've all been tired. We're used to being feeling tired.

but it's deeper than that is it's sort of bone tired if you like so walking up a flight of stairs exhausted at the top your muscles your thighs are aching because you're aching everywhere can't exercise yeah without these hormones is what happens so so HRT's been around for a long time hasn't it for decades yeah and when it was

first came out really the most popular type a lot of people have heard of premarin or prempaxi and that contains conjugated equine estrogens they're called. So explain where are they from? So it's a bit of a mouthful, isn't it? But that's equine is from the horse. So it's from mares, pregnant mares urine contained estrogen. So it's made from that.

So that's where they're... Which is quite bizarre in some ways. But there are lots of estrogens in that urine that gets conversed into tablets. And some of them, obviously we don't need. Some of them have been shown to be very beneficial. and some of the early research really showed a benefit, didn't it, for women and women's health as well. So not just for improving symptoms, but for reducing future risk of really important diseases, such as heart disease and osteoporosis.

So most women who are perimenopausal benefit from having some estrogen, don't they? Oh, completely. Eastergium returns their function and all the cells all throughout the body. So most people will feel much better on some estrogen. But there's different doses and there's different types, aren't there? And that's important. Yes. So you say, well, obviously, you say initially the tablets,

but we tend not to prescribe much estrogen as tablets anymore, don't we? We don't really, because there are side effects that are unwanted with oral estrogen. It's metabolised, goes into the gut, and it's metabolised by the liver. And as a result of that metabolism, it increases clotting factors, which increases our risk slightly of blood clot thrombosis in the calves or stroke, things like that. So it's much better if we can avoid that to use the estrogen through the skin, the transdermal approach as it's called. It really is just giving estrogen as a patch or a gel,

which is rubbed onto the skin, it's absorbed through the skin, straight into the blood vessels on the skin, it's taken around the body, straight into the bloodstream. And it's not changed. It's so clever. It's not changed. the estrogen orally is changed. Yes, because it has to be digested and metabolized and broken down. That's right. So what comes out at the end is nowhere near what goes in in the mouth.

Yes. So there's a couple of different manufacturers we use, aren't there, of gels. Yes. So there's just different consistencies. Yes. Some women find that sometimes the gel floats on their skin and doesn't get rubbed in very well. And some women tell me they walk around naked from their bedroom for an hour and waiting for it to dry. What if they're doing that? It's not really working. something else, shouldn't they? Yeah, they should. So there's two different makes, mainly of gels in the UK that is. And then the patches, there's different patches, some last, well, they change twice a week,

don't they? There are some that are a week, but we tend to use the twice a week ones, don't we? We tend to use twice a week because that contains just estrogen. And we can then, if the dose isn't right, we can increase the dose, it gives us a lovely flexibility. Yes. Because there's not one dose for all. No.

And I think that's very important. isn't it? Oh, completely. I have people who come to the clinic and they're on HRT, but they don't feel well. No, and they say it doesn't work. It doesn't work. And thank goodness they have come because a lot of women will just give up on it. It doesn't work.

It's no point taking it. But actually, the reason it's not working is because they're not on the right dose for them. Yes, and that's really key. I was listening to a podcast recently and someone was talking about side effects of HRT and someone said, well, one of the side effects, of course, is hot fleshes. And I thought this isn't a side effect. This is not having enough dose. Exactly.

And younger women often need higher doses, don't they? Yeah, totally. And that can throw some people and some doctors would be cautious and concerned about that. But not at all. Our requirements, we have more Eastern receptor cells as a younger age. We need more estrogen to maintain function. Yes. Because all we're trying to do is replace, aren't we?

That's all it is. Certainly in younger women, we're just replacing what their body should otherwise be. producing. Yeah, it's restoring back to the natural normal state in fact. Yeah. And we do, often in the clinic, do estrogen blood tests to make sure that they are being absorbed and that they're an adequate level to improve symptoms. So if someone is still struggling, then it is worth talking to your doctor or nurse about possibly changing the dose or sometimes changing the type. There's some people feel okayish on a gel, but still having symptoms, then we give them a patch and they obviously absorb it more efficiently through the skin.

Wow, I feel so much better. Or vice versa, then. Correct. Yes, exactly. And some people, we use combination, don't we, of patches and gels? Because some people like to have the steady level of the estrogen from the patches. And then when they, especially when they're perimenopause or if they have a dip before their period. Yes.

They can use some gel then. I find that really useful. A lot of ladies feel that bit worse the few days before, we don't know, period. And topping up with a couple of extra pumps of gel really does help stop those symptoms. So it's really important. And we know from research that women who still have some vasamotor symptoms, so flushes, sweats, despite being on estrogen, have an increased risk of heart disease and osteoporosis, don't they?

So some women say to me, well, I've reduced from having 20 flushes a day to eight. So I'm doing really well. Yes. And I'm saying, no, but we've got to. We want zero. Zero. Because of your future health. Yes.

Yes. So it's a bit, I always say to them, it's a bit like if you were diabetic, it's not good enough for your sugars to be lower, but still on the high side. we won't be completely normal. Yeah, that's right. It's the same analogy, isn't it? It's a good analogy that. It's being completely optimised, if you like, I suppose.

Yes. And sometimes people find with time they need slightly more. And then sometimes as they get older, they need slightly less, don't they? Yes, usually the requirements, say after the age of 60, on average, women can often decrease their amount of eastern they're using because they don't need as much. No, that's right. And the guidelines certainly a few years ago used to be, use the lowest dose for the shortest length of time.

And we know that's wrong, don't we? It's important to have enough. It really is important. And also the guidelines are very clear we can continue in the long term. That's right. It is important to have enough because we're not only taking it for our quality of life. We're taking it to protect our future health and to ensure we've got adequate levels to maximise the benefits on the heart and the bones.

Yes, which is really important. And we've spoken at length over the past few months. really about letting women think about the menopause as a hormone deficiency status. So it's a female hormone deficiency that we will never get those hormones back unless we take them. So even if our symptoms had completely gone, once we stop HRT, then we're exposing ourselves to an increased risk of really important conditions that increase as we get older, such as we've already said, heart disease, diabetes, dementia, osteoporosis, even depression. women who are untreated, have an increased risk of depression.

So it's important to think about why you possibly aren't taking it really. Yes. And then there's other hormones up there. So you've mentioned about progesterone. So when would a woman need to take a progesterone? So yes, the reason we give progesterone is if a woman has a womb, Eastern on its own would solve a lot of their menopausal symptoms and help their future health. But it would cause thickening of the lining of the womb,

which if left could go on to something called a hyperplasia, which have left a bit longer and, you know, could, a small percentage could go on to something more sinister, like an endometrial cancer. So that's if they have estrogen only on their own with a womb, so we don't do that, do we? So we don't want that, of course.

So we give a progesterone to keep the lining of the womb thin. Yes, and that stops the risk of cancer, so there's no risk of womb cancer if someone has progesterone as well. As long as they take the progesterone, if they have a womb. And how's that given then? So, well, we tend to give it as a tablet, because we want a body identical type of progesterone for several reasons.

Number one, as it sounds, it's exactly the same as our progesterone we produce in our own bodies. So the body likes it. It sees it as self. It doesn't look at it as a foreign hormone coming into the body. It works on the receptors beautifully. And it replicates a woman's physiology, which is what hormone replacement therapy is all about. The closer you can mimic the natural, normal state of a woman's physiology. the better.

And they're less likely to have side effects. Much less likely to have side effects. Because some people that old-fashioned progesterones, particularly in the tablets, they can cause a lot of side effects, such as bloating, low, flat mood, irritability. Women can feel really quite dreadful. Yes.

And a few can feel phenomenally unwell with these type of progesterone. So it's really important to get a progesterone that's going to be much less likely to cause these problems. So the micronized progesterone is, body identical one. And we give it usually as a capsule. It's a little oral capsule.

Yes. It takes orally at night time. Yes. Because it can cause some sedation, which is quite a nice side effect. Which is good because a lot of people can't sleep. It's one of the effects of menopause. And there's different ways of taking it.

So if a woman's perimenopausal still having some periods, we often give it in a cyclical way. So they have it for two out of four weeks to help really regulate their periods. That's right. And doing that pattern, they should have a nice regular light period going forward. And the other important thing to say about the, micronized progesterone just because it's oral, it is still perfectly safe in terms of blood clot.

Yes. And it's not metabolized to anything that will harm the body. Which is very important to know because some of the older progestogens that are like you say in some of the combination tablets, there's a small risk, but there is still a risk of clot and heart disease and stroke with taking those as well. And this whole breast cancer risk that everyone is concerned understandably about seems to be associated with the older types of progesterones more than the newer micronised progesterone, doesn't it?

Definitely, yeah. So it's kinder to the breast, we think. Yes. We've had some interesting research saying that actually one research showed that five years of taking this progesterone, they had no increased risk of breast cancer, which is really positive. Which is really exciting. And even after that five years, the risk was lower than with the older types of

testosterone. Yeah, that's right. But I must add, even with the older types of breast cancerin, which is right. of progestogen, the risk is still very low. A woman, for example, who's overweight or drinks moderate amounts of alcohol has a far higher future risk of breast cancer. Exactly. And taking that as well.

Exactly. So the estrogen patch or gel seems to be the best. Better absorb, no risk of clot. The natural micronized progesterone as an oral capsule. Now, they're made, not from horses urine, aren't they? No, they're from the root vegetable, the yam. The yam. Yes.

but you can't eat yams. Well, you can eat yams. Of course you can, but you can't eat enough to replace your hormones. So that makes them very natural, which I think is really important. We all want to know the source of what we have. But these are regulated licensed products. Some women, though, still can't tolerate the progesterone, can they? It can still, even the natural micronized progesterone, people sometimes find that it makes them feel very low in their mood, very withdrawn, very not themselves.

Yes. So there are other ways. Yeah, other ways we can use it. So the beauty of the oral tablet, it can be inserted into the vagina. Yeah. And much less will get into the bloodstream then. So that often helps a lot of women and they can tolerate it then. And you would need half the dose of the oral.

Which is good, isn't it? Yeah. So, well, yes, studies have shown that 45 milligrams, which the dose of the capsules is 100, so roughly half each day protects the lining of the womb. Yeah. So we often say one capsule vaginally every other evening, don't we? That's right. If this isn't licensed, then we explain to our patients, it's off licence,

but there does seem to be enough evidence to support it. And certainly, I'm sure you're the same. If a woman doesn't have any bleeding and they're using this, then that's very reassuring, isn't it? Yes, definitely. Women who start HRT often do experience some bleeding. It can be very common, can't it, to have bleeding? Oh, yes, completely.

We always warn people when you're, first start, the first three to six months, there may well be a regular bleeding. And certainly when I started my HRT a few years ago, I had a lot of bleeding initially. And I thought, my goodness, this is what I warn people about. And then it settled down. It does. And after an increase in dose, you may get a little bit of a bleed as well. Yes.

So that's important. Any time a dose is changed, which will increase, all the progesterone's changed. That's right. You might get bleeding as well. Yes. What we always worry about as doctors, if someone has bleeding that is constant and it's not associated with a recent change in HRT, then we don't want to miss any, obviously, any disease from the lining of the wound.

Yeah. Some people have polyps or fibroids. Yes. Very few do, will have cancer because, you know, cancer does occur. But it's very unlikely if someone's on HRT and they're taking it in the right way to have something serious, isn't it? Yes. In fact, I think it even decreases your risk of endometrial cancer overall because you are actually

taking a progesterone than if you weren't on HRT. Yes. Absolutely. So I think it's really important to know. We do sometimes see women who do have bleeding and they've been on HRT for a few years and they say they've had some bleeding. Sometimes it can be just, I saw someone the other day and she told me she had one episode of bleeding after having sexual intercourse. But she noticed she had quite a lot of vaginal dryness at the time. And she went to see her doctor who got very worried.

Sent her to hospital she had a very distressing investigation. and everything came back normal. But actually when someone examined her, they said, oh, you've got a lot of vaginal dryness, some vaginal atrophy. So she really needed some other treatment, some local vaginal estrogen. So it's very important to, if women do have some bleeding,

to have the right type of investigation and treatment. That's right. Endometrial cancer, so cancer of the lining of the womb, usually cause constant, often quite heavy bleeding. So a woman that has an intermittent bleed, especially a light bleed, can hopefully feel reassured it's unlikely. Very unlikely. But there are other reasons. So it's very important that they have a proper examination.

That's right. To locate the source. Yes, absolutely. So it's really important. I see a lot of women who have vaginal bleeding due to the vaginal atrophy, the thinning of the vagina walls. The vessels become very fragile because there's no lubrication or thickness to cover. To protect them. So it's very easy to bleed.

Yeah. And so I mentioned briefly vaginal estrogen. So you can have, women can have estrogen as a pezzary or there's cream, isn't there? Yeah. It can be as a little pecery you pop in with a tablet of estrogen or a cream or a ring that goes in and stays for three months. This is an HRT. This is not HRTs. It's called local estrogen.

And it's so safe. and it doesn't have any risks at all because it just works locally. So no risk of clot. No risk of blood clot. No risk of breast cancer. What else could we think of what else? And what about women who've had breast cancer? A lot of women, especially who've had estrogen receptor positive breast cancer,

wouldn't choose quite rightly first line to have systemic HRT, but they can have vaginal estrogen, can't they? Yes, they can. And that's well known that it is perfectly safe to have that. Because hardly anything, nothing gets into the bloodstream. No, if you look at it. look at the graphs of the absorption, the first four hours, there's a little bit of absorption into the body, and then it's the same as placebo. So there isn't any systemic absorption into

the body, which is really important for women to know, because vagina and dryness is so common. It causes so much misery and pain, not only from sexual intercourse, which could be so uncomfortable, that women can't have intercourse because it's too painful, the burning feeling afterwards, and it feels like daggers and sharp knives. It's very uncomfortable. Or just day-to-day, feeling so. sore and irritated, more thrush, because what happens, the pH changes as we lose estrogen, so the overgrowth of thrush or bacterial vaginosis. So poor women are having all these sort of infections due to the lack of estrogen. And it's something that can be so easily

treated. Yes. And once women start treatment, they usually need to continue it in the long term. Yeah. Yeah. So they just start taking until they feel better, they carry on, which is really important. And we know around a fifth of women who use HRT, still have some vaginal symptoms and need to use vaginal oestrogen. Yeah, that's right. So even though they're feeling well systemic, what we call systemically, meaning in their whole body, they're sleeping well, their muscle pains have got better, etc.

They can still have problems of vaginal dryness. And then we can use both. We can use the local estrogen very safely alongside the systemic HRT, and that's perfectly safe to do so. Which is good. And I must add that the insert, the patient information in products, and with their local estrogen are completely incorrect. Completely.

So when you open your packet of a vaginal, estrogen pezzary, for example, it will say risk of clock, risk of breast cancer, risk of, goodness, only knows what, but it's incorrect. Completely incorrect. It's really wrong that that should be there.

Yes. And then we mentioned testosterone, which is a really important hormone for women as well as for men. Yet in the UK, it's not license, is it, for women to have. So how do women, get testosterone? So there are several ways in the NHS we can use the male treatments for testosterone, but at 10th of the dose. It's a very low dose. It's a very low dose that we can use, but we have to use the male equivalent. Also privately, there is a cream called Androfem, which is made in Western

Australia, purely for women. And that's a cream that is applied to the outer thigh. And that's a nice way to give the testosterone. Yes. So this comes as a pink cream. Yes, it's. It's made. It's white but the tube is being. Yes. And it's a piece size of cream. It's a very small amount, isn't it? Yeah. That's given.

And the MHRA, our regulatory authority body over here, allow us to prescribe it privately because we don't have a female alternative on the NHS to prescribe. Hoping that license will come because I'm sure you agree, but I think it's absolutely outrageous that women are denied their own hormone. Yes, completely. And it's licensed for men, but it's not licensed for women. Yes. It's really wrong.

But it is important, if any of you listening, who want to use testosterone, that do you really see someone who's experienced in prescribing it? Yes, because there has to be an understanding of how to use it and how to monitor it. That's right. So we do blood tests as a baseline and then we repeat them frequently to make sure that women stay within the female range of their blood tests. And we have seen various women who have had testosterone from other clinics and they've had no monitoring. And we've done blood tests and their levels have been very high. Yeah.

So you just have to really be careful that. You have it because it is safe. If it's used in the right way and monitored, people really fine, don't they, their libido is really helpful. Not just libido, it's also their mood, their concentration, their memory, the clarity of thought, their energy. Yes, it is. I always think it's an emotional energy and physical energy. Yes, yes. Not for everyone.

So there's a lot of women who have low testosterone levels and they don't benefit from testosterone. No. Because there's clearly so many other reasons why we can be tired and apathetic. there is a significant proportion of women who do find that it benefits them. But it can take six months sometimes to have an effect. It's quite gradual, isn't it? Yes. Once you're in the therapeutic range as well, you've got to stay in there for six months, then you can assess the effects. And then you assess. Yes. And there's more information about testosterone on my website, as well as the other hormones as well. And the testosterone is made from the yam, good old yam.

So again, it's natural and it is body identical, so it's the same structure. So just before, we finish, I just want to clarify for people that are listening the difference between body identical and bioidentical. Oh yes. Because this is hugely important. So this is huge and important. Yes. So body identical is exactly how, as it sounds, it matches the same hormones that we have

in our body, exactly the same chemical structure. And the body identical hormones are regulated and approved by nice guidance and international menopause societies. However, bioidentical are. are not approved, not regulated. They're a mixture of hormones. They may be natural to a certain extent, but they're mixed up. So you might have five hormones in a pill.

And I don't know. The concentration's not known of these hormones. The interactions aren't known about these hormones once within the body. And there's been no research done on any of these substances. So they're compounded, don't they? They're made it. Some of the marketing sounds very nice, doesn't it? Because they say they're individualized.

Can be attractive. Yes. do your saliva or your blood test or match and it, you know, it does sound very good on paper, but actually because there's no regulation, they're sold as a food supplement, aren't they? Yes, they are. So you could buy two lots a few weeks apart and they might be completely different contents, right, and they? That's right. The regulation, the standardisation is not robust at all.

Yes. And there's no, I'm not aware of any evidence that shows they're more beneficial for women than the regulated. I'd be worried about what the effects are. because we just simply don't know. Yeah, and we certainly have seen quite a few women in our clinic who have come from various other clinics offering these products, and we've had quite awful results, actually, and we do their blood tests and their estrogen levels are often very low.

Yes. Sometimes the testosterone is very high, or sometimes I've seen quite a few women who've never even been given estrogen. Yeah. They've been only given testosterone or progesterone, which, and they give progesterone as a cream. Yeah. And if it's as a cream, it doesn't get absorbed properly, does it?

It doesn't. and it won't be enough to protect the womb if you have estrogen as well. So that's quite dangerous. It is. So again, there's a leafless about this on my website. If you just put in the search body identical, you'll see it. But if you are going to a private clinic, it's really important to ask the source of the hormones. Are they regulated?

Are they licensed? Obviously, testosterone is never going to be licensed if you get it at the moment in the UK for women. But it needs to be a regulated product. Yeah. It's really important. And if they're not, you need to question. the source and also question yourself why you're spending probably a lot of money on these products, because they are expensive, aren't they?

Very expensive, yeah, the price of the blood tests. Yes. It can be thousands. Yeah. And HRT is actually very cheap, isn't it? Testosterone is more expensive at the moment. But the actual estrogen progesterone is less than 20 pounds a month, isn't it? That's right.

So if you are spending more than that, you really should be questioning while you're doing it. And then we take HRT to. to help our symptoms. We've already said that once you stop taking HRT, there's an increased risk of various diseases. So when should we stop taking HRT? Well, there's no time limit, is that? This is the thing. So people have been brought up with us for five years and you have to come off it. That's not the case at all. You can carry on as long as the woman wants to carry on. It's the woman's choice. I think we should always have an annual review. And it's something you can discuss with your doctor every year because your health changes and things can change.

So there may need to be modifications or different advice given. But in essence, if a woman wants to continue until she dies, that's her choice. And there's no time limit at all. Which is really important. I mean, the NICE guidelines are very clear that as long as the benefits, that way the risks, we can continue taking it. And for most women, the benefits such as reduced risk of all these diseases, outweigh any risk. And not everyone who takes HRT has a risk of breast cancer. We've already spoken about the different types of progesterones.

Women who have had a hysterectomy and only have estrogen, actually some studies have shown they have a lower risk of breast cancer. That's right. That's right. So it's really important if someone is saying because you're a certain age or you've been on it a certain length of time that you need to stop, I think it's really important that women challenge that. Yes. And really question their healthcare professional why they're being stopped.

something that has really important health benefits going forward. It has, you know, it looks after our bones and that's huge. You know, when you think one and two women over the age of 50 have osteoporosis and how the frequency of a fractured hip, how common that is, and the results of a fractured hip in your 80s, a high risk of death, or if you do recover, 80% are dependent on others and lose their independence. So it is planning. It's huge.

You know, a lot of the work we do is about disease prevention. and about sort of planning ahead, pre-empting what might happen. And anything we can do to reduce that risk is going to be good. So thank you so much for giving up your Saturday morning. No, it's an absolute pleasure. Absolutely pleasure. So just before we finish, three take-home tips about HRT. So HRT will help your systemic symptoms.

HRT will help your future health. And there's no time limit for how long you can take HRT. Brilliant. Great advice, as always. Thanks ever so much, Rebecca. Thanks, Louise. For more information about the menopause, please visit our website www.menopausedoctor.com.