The Dr Louise Newson Podcast - 059 - PMS and the Menopause - Dr Hannah Short and Dr Louise Newson

Episode Date: August 4, 2020

In this episode, Dr Louise Newson is joined by Dr Hannah Short, who is a GP and menopause specialist. She also has a particular interest in premenstrual syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD) which is very common yet not well managed.  Many women need individualised advice and treatment which is often a combination of lifestyle changes and taking hormones.  Hannah openly talks about her own experience of having a surgical menopause when she was younger. She talks to Dr Newson about ways of improving awareness of this condition so women do not have to suffer both physically and mentally as a result of inadequate support and treatment.   Dr Hannah Short's Three Take Home Tips: Track your symptoms by using apps or online downloadable trackers.  Use the internet to find useful resources. Firstly https://iapmd.org/ which is a US based site and http://www.pms.org.uk/ to read the UK guidelines.   You do not need to solve this alone, look for support. Be kind to yourself.  https://drhannahshort.co.uk/ Find Hannah on Instagram: @dr.hannah.short   Read this booklet from Dr Newson for more information about PMS and menopause.

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsome, a GP and menopause specialist, and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. Today I'm very excited and delighted to introduce to you Dr Hannah Short, who is a GP and menopause specialist who works near Cambridge. And I first met Hannah a few years ago on a International Menopause Society. meeting and we've been closely associated since that time. So welcome, Hannah. Thank you. Today, obviously, I spend a lot of time talking about the menopause and a significant amount of time talking about the perimenopause, which a lot of you know is the time before the menopause, so before periods stop when menopause or symptoms start. But actually, a lot of women have hormone

imbalances before the perimenopause that worsen during the perimenopause, which is called a or premenced or syndrome, or some people know it as PMT, and there's also PMDD. So there's lots of initials. And lots of women actually experience it, but have never heard or spoken about it or even received any treatment. So I thought this podcast would be really useful to dig into Hannah's brain and access her knowledge about PMS, which is something that she knows a lot about, but there's still plenty more that we are discovering all the time. So before we get started on that, Hala, could you just say a little bit about you and why, how you've come into being a menopause specialist and with a special interest of PMS? I mean, I've always been interested in women's health

and hormonal health and also mental health. And before I trained as a GP, I was actually training in psychiatry and then switched my training to go back to do general practice training. I've also also I had personal experience of female hormonal health issues, including severe PMS, and I also had endometriosis, and together that resulted in an early menopause because I had my hysterectomy and my ovaries removed when I was 35, having gone through various different treatments over the years, and sadly, none of them had kind of given me the quality of life that I really needed. So that was the driver for kind of doing a bit more training in menopause. I mean, one thing I realised when I became surgically menopause at the age of 35 is that we don't

look after menopausal women well as a general rule in the medical community. And if it's bad for women of natural menopausal age, it's particularly bad for those of us who have been plunged into surgical menopause and for those of us who have a premature menopause below the age of 40. And so that's kind of, I suppose, where my passion comes from. So menopause is obviously a whole huge subject, as we all know. And again, surgical menopause and menopause in those with a history of PMS or premenstrual dysphoric disorder, which is the severe form.

Again, it's a whole, we could spend an hour, two out, three hours probably talking about that. But yeah, premenstrual disorders, it's a whole spectrum of different disorders, ranging from quite mild symptoms to quite severe symptoms. And it's something I suppose that fascinates me, the more I learn about it. I think even before my surgery, I didn't really know much about it. I just knew that I felt particularly awful. I was first bit saying things a bit mildly, really, but I felt horrendous before my periods and I knew it was cyclical and that I would tend to feel slightly better when my periods arrived. But I didn't really have much understanding about

why that was happening or why I wasn't responding to treatment. And over the years, I suppose I've been learning more and more just through research and through seeing patients in clinic. So clearly as women we have hormones that are in our bodies and they work to regulate our periods and for our monthly cycles but also help during pregnancy. But can you just explain what the hormones are and how they change throughout the month? Okay, yeah. So as with the two primary hormones in the menstrual cycle are estrogen and progesterone. Estrogen starts to rise just after your kind of period and peaks around two weeks in most women after the their period and that's around ovulation. And then it starts to drop off and is very low just before

you have your, the period starts. And progesterone, it also kind of drops just toward that time as well, although it's often higher in the luteal phase, since the last two weeks of the menstrual cycle. And that's really important, isn't it? Because certainly when I was doing biology at school, and actually even in university, you learn a lot about hormones and how important they are for the lining of the womb and development of the egg that gets released during ovulation. But we don't really realise, or I certainly didn't realise as much, how important these hormones are all around our body, aren't they? So they affect probably every cell in our body, but the effect on our brains of estrogen especially, but also progesterone, are really important,

aren't they? Oh, definitely. I mean, I think obviously you spend your time, and I see it's time of seeing women who are hugely affected by the effects of hormones on our brains and the rest of our bodies. And I think, you know, we have hormone receptors, or certainly Eastern receptors throughout the body in our brain, in our lungs, in our heart, and vagina, in the bone. But progesterone is there as well and can have a huge effect, especially on kind of mental health as well as some of the physical symptoms that you obviously see around perimenopause and menopause, but there can be physical symptoms just before period as well. And I think people don't realize, do they? I think a lot of people, just maybe the day before

their period, feel very low, very flat, less energy. But increasingly when I talk to people in my clinic, they tell me for 10, 20 years maybe they've had four, five days of the month, classically before their period where they feel dreadful. And some of them have been experiencing even night sweats and hot flushes and joint pains as well. But they've never put that together with their hormones, but they can reduce so much, can't they, that they can effectively cause menopaus or symptoms. Yeah, I mean, so there will be symptoms of a temporary kind of estrogen deficiency, and so that can certainly cause those symptoms that you mentioned, so stuff like the hot flashes and the night sweats, particularly, and headaches,

that can be another one for people who have hormone-sensitive migraines. Yeah. But PMS is incredibly complex, and it's not just about the dropping off of estrogen, but that certainly does contribute to symptoms. So how do you diagnose PMS? Is there a quick blood test that people can do? Or how would you diagnose PMS in your patients? No, I mean, there's no blood test really that's going to be helpful in diagnosing PMS. And PMS or premenstrual syndrome, as I think I said briefly at the beginning is a whole spectrum of disorders. And there's quite a lot of frustration around, I suppose, in medical community and also, I suppose, in the general population about how we diagnose PMS or the severe form, so premenstrual dysphoria. disorder. I mean, essentially, the more severe end of the spectrum, premenstrual dysphoria

is an abnormal response to normal hormonal fluctuations. So checking your hormone levels is not going to be helpful because, to be honest, they're generally normal in women with PMS or premenstrual dysphoric disorder. That's not really the issue. It's normally the brain's response to those changing levels. And this is when it can kind of get quite complex. I mean, in terms of diagnosis, it's tricky because diagnostic criteria vary hugely and there isn't a big general consensus. So because PMS, PMDD kind of spans across both gynecology really and psychiatry, the different disciplines have their different ways of diagnosing. So PMDD, the most severe form of premenstrual disorder,

is actually diagnosed according to an American Psychiatric Association definition, which is really quite strict. Women have to have five out of 11 particular symptoms, one of which has to be a particular mood-related symptom. One has to be from another behaviour-related symptom. But the American Congress of Obstetricians and Gynaecologists, again, have a different criteria. The World Health Organisation diagnoses, or talks about diagnosis, something called premenstrual tension syndrome. And that, basically, about 80% of women could fall into that. But I don't think 80% of women would say that they have a clinically significant pre-menstrual disorder.

Yes. So it is quite tricky. I mean, in the UK, we have guidelines, protected by the Royal College of obstetricians and gynaecologists, called the Green Top Guidelines for premenstrual syndrome. And what they do is they diagnose or kind of define five different variants of premenstrual syndrome. So there's a mild form, which I think quite a lot of women could relate to,

because a lot of people will notice that, you know, some changes, maybe slightly uncomfortable changes in terms of breast tenderness, may be feeling a little bit low before their period. So that would be like a mild premenstrual disorder. Then there's core premenstrual disorder or premenstruic disorder where there's significant disruption to quality of life and very significant symptoms. Well, people can't function particularly, you know, well at all,

may not be able to go to work, may have rows with their partner, quit their job, you know, and some women become suicidal. I think a third of women with a diagnosis of PMDD have attempted suicide, which is really quite a shocking... I mean, that's huge, isn't it? I mean, we don't know the true incidents, do we, of PMDD, because it's probably underdiagnosed. Well, I think, yeah, this is the problem.

I think because there is no worldwide consensus, it's hard, and this is the frustration. So the PMDD aspect, I think a lot of people with severe symptoms want to kind of latch onto in a way because they think PMS just doesn't sound serious enough because there's lots of general symptoms and they just think their symptoms won't be taken seriously enough.

But not everybody with severe premenstrual symptoms fulfills the DSM-5 criteria of PMDD. This is where I think I prefer using the Royal Colleges guidelines because I say they have these five different variants and there's also one with pre-menstrual syndromes when you have no period. So if you've had a hysterectomy, but your ovaries are in place still there.

Endometrial ablation. If you've had heavy menstrual bleeding, or if you've got the marina coyl in, for example, and you're not bleeding, but you could still have symptoms without having a period. Then there's premenstrual exacerbation, which is worsening of an underlying disorder, so depression, or it could be epilepsy or anxiety. And then there's progestogen induced premenstrual disorder, which I don't think is typically prenu actually really a premenstrual disorder, because it's more just response to progestrogens that are in hormonal therapy. I mean, as far as I'm concerned as a clinician, if something is happening in the last two weeks of your menstrual cycle

and is causing significant disruption to your life because you're having such significant symptoms, and these are primarily going to be mood-related symptoms, so anxiety, irritability, very low mood, lacking concentration, brain fog, coupled with maybe some physical symptoms like the breast tenderness and joint pain, that I think enough for me to think this is a significant pre-menstrual disorder and you need help. Absolutely. And I think that's really important, isn't it? And I think this is why it's so important, and I'm sure you do the same, is to ask women to put down their symptoms in the illness, almost in their diaries, but actually record. And it's really useful even over a three month period, isn't it? So people can assess, because we're all busy. And our days often merge into one. And sometimes you think, oh, I'm in a bad mood because I've had a bad day at work or my children have been shouting at me or I haven't had much sleep. And we always blame something else, don't we? But it's only when you look down at a history or a diary and you see, actually, Every two weeks these symptoms came. And then a lot of women tell me that after their period, they feel on top of the world.

They feel brilliant. And then it's like anything, when you're happy, you forget about how sad you are because you're so lovely to feel better again. And then you have this dip. So it's very important, isn't it? Even if people feel those symptoms are really trivial, they're still affecting them. And if they're affecting them, then they need to consider treatment. Exactly.

You agree. No, I think, yeah, I kind of went off on a bit of a ramble about the different. different types because I really want people to understand that it is a spectrum of disorders. And you don't have to necessarily have a label really even to get help. But yeah, it's really helpful. And what you do need for a diagnosis and to get the right treatment is to track your symptoms for at least two to three months. And you can do that via an app. So there's one called me versus PMDD.

Things like Clue, there's premetrics. There are lots of them out there. Or you can download a printable tracker from there's the NAP's website. PMS.org or IAPMD.org, they've got principal trackers, which personally, as a doctor, I prefer to see because you get a nice graphical representation and you can see the fluctuations in the symptoms. And it's, yeah, it's not good, like you say, to kind of necessarily look back. I mean, even though I think you don't want to patronise women and say, oh, well, you don't know that this is what's going on until you've tracked the symptoms. But actually, our memories, we can't really rely on them properly if we're

trying to sort out a diagnosis. And as you say, you feel. forget the awful times when you're feeling better and kind of vice versa. But I think, I mean, I've also seen a lot of women in my clinic who are perimenopause, because clearly my clinic's all about the menopause and perimenopause, who have had symptoms for quite a long time and they know they're their hormones. A lot of women are quite intuitive, aren't they? And we're quite tuned into our hormones. And a lot of women have said, but I know it's my hormones.

And actually, if a woman's telling me that, I completely believe her and trust her because women tend to know they have this sort of sixth sense almost sometimes with their hormones. And so there's not a blood test. There's a lot of women who, especially now you can send off and do a finger prick and have your own hormone blood test done. So a lot of women say to me, well, my blood tests are normal. My hormone levels are normal. It can't be my hormones. And clearly, you know, like you've so rightly explained, that hormone levels change all the time, don't they?

And we all work on different normal hormone levels as well. So what makes me happy with my certain Easterdale level might make you feel very differently. No one knows, do they? What's the right level for them? But also because they fluctuate so much, the blood test is very unreliable. So a doctor might do a blood test to exclude other causes of tiredness, for example, to make sure a woman's not anemic or have an underactive thyroid. But they shouldn't be diagnosing on doing estrogen levels, should they?

No. And I think that's one of the frustrating things I see that people are told, well your hormone levels are normal, therefore this isn't a hormonal issue. And I think it's a fundamental lack of understanding about premencial disorders and hormonal health and mental health as well. I mean, I think PMS really and PMDD should be defined as a psychoneuroendocrine disorder because it's the interaction with, you know, the brain, the nervous system and the hormonal system and the psyche. They're so closely related, don't they?

I mean, even if you think back of just being nervous for an exam and having butterflies in your stomach and then having a increased heart rate and then feeling with a dry mouth and feeling worried, all those systems are being activated, aren't they? Absolutely. And the hormones have such a huge importance for our brains. And that's why I think it's so interesting you having done a bit of psychiatry, your general practice, and your menopause and hormone health, it all interlinks, whereas sadly in medicine, we're very much taught to be in systems, aren't we?

end, you know, it's either a gynaecological problem or it's a respiratory problem and it shouldn't be because it's the whole person that we need to look at. So if you've seen someone who you think might have PMS or PMDD, what's the treatment? Because there are different treatments, aren't there, that are available? Well, this is where it can come in quite helpful with the tracking as well, because you can then tell what kind of premenstrual disorder you may be suffering from. But as I said, I don't think having a label should be a barrier or a formal diagnosis to getting treatment. And often I see women and we don't want to wait three months to start treatment. So I think that's kind of important to say.

And again, the guidelines are quite helpful and they're there for doctors. They're there for women to look at before they go to the doctor to kind of understand what may be offered. And the treatment guidelines, again, vary from country to everything else. And I suppose what I do very much depends on the individual. if the symptoms are mild, sometimes lifestyle advice can make a big difference. So, you know, making sure you eat well, you know, having plenty of kind of whole plant foods in your diet, having a fibre-rich diet, complex carbohydrates are really important. I mean, women who kind of have quite restrictive diets or kind of doing the low-carb thing,

they tend to have more of a problem in turn around that time. That can sometimes worsen these symptoms. And that might well be to do with gut health. which is implicated in hormonal health and brain health and the health of the gut microbiota, so the microorganisms that live in our guts. And I think you've probably talked about that with some people on your podcast before.

Yeah, absolutely. We've done a podcast with Emma and just Flint about this. But it is because a lot of people have sugar cravings, don't they, when their estrogen levels are low. They do. And it's very easy when you're feeling tired and fed up and low and miserable to just reach for some junk food or something with high in sugar.

But that actually can make it worse, can't it? Definitely. So sugary food, highly processed foods can make it worse. And alcohol, caffeine, everybody's different, but these things tend not to help. I mean, alcohol can cause, you know, hormonal fluctuations anyway. And if you're already sensitive, that can make it a lot worse. The reason I think that a lot of the plant-based whole food, so, you know, lots of bright fruits and veggies and things like that, lentils, beans and stuff,

they're inherently anti-inflammatory. So that might be another way in which they can kind of help with the symptoms. because women with PMDD have been shown to have slightly raised inflammatory markers. Again, you'd need particularly sensitive tests. So this isn't something you can necessarily go and ask your GP for, but in studies they've been shown to have that. So that may be a mechanism whereby, you know, focusing your diet around a high fibre diet and, you know, vegetable-rich diet is going to be beneficial.

And also a high-fiber diet kind of helps with excretions of estrogen and metabolites, which helps hopefully minimize hormonal fluctuations. So that's another way it can be helpful. Things like yoga, stress management are really important. Because as we said earlier, everything's kind of linked. And so the more stressed you're feeling about your symptoms, the worse your symptoms are likely to be and vice versa. So things like that can be really helpful.

But obviously if you're very symptomatic and you're, and as you say, you're having cravings and you're struggling, a lot of women actually struggle to make the lifestyle changes they need. And that's probably pretty similar to menopause. If you're feeling really low, unmotivated, anxious. It's really hard to think, oh gosh, do you know what I'm going to do half an hour of yoga today? And then I'm going to make myself a green smoothie and sometimes you're just not able to do that. And I don't think people should judge

themselves for that. So there are, going down the treatment guidelines and stuff, there are certain supplements that can help. There's some evidence for magnesium, some for vitamin B6. So I do often recommend a B vitamin complex for women. There's some evidence that magnesium and B6 can affect the way that your receptors respond to the hormone changes in the brain. There's some evidence for vitamin D and calcium, particularly if menstrual migraine is accompanying those symptoms as well. Agnes Custis is a herbal remedy. In trials, that's the only one really of the complementary therapist that really shows any kind of evidence. But again, we don't really have a good standardised dose preparation in this country and you can't take it alongside

hormonal treatments. But sometimes women would like to try that and that can help. Counseling, CBT can help, but I think that's more, from my point of view, that's probably more just to do with recognising that you're going to have this response and kind of moderating your stress response rather than actually changing underlying things there. And then you kind of get into the treatments for moderate to severe pre-mencial disorders and you either look at the psychological therapy support or hormonal support. Interestingly, there's evidence that certain types of antidepressants, SSRIs, can positively affect women. with the severe form of premenstrual disorder.

So things like certulisnors, so things that we often give for depression, they seem to work in a different way for premenstrual disorders. They seem to affect the way that your brain responds to those hormonal changes again. And particularly there's a receptor in the brain called gabberet receptor,

which responds to the breakdown products of progesterone. In women who don't have PMDD, the breakdown products, particularly allopragnalone, often makes women feel kind of maybe calmer, less anxious and can have a kind of anaesthetic effect. So, you know, it can reduce kind of pain reducing chemicals and stuff there. In women with PMDD, it seems to have the opposite response as well. But the interesting thing is that the SSRI seem to affect the way GABA responds to the breakdown products of that. And that might be how it works. We're not sure. We know it works in a different way

to the way antidepressants work in depression because results can be seen often within hours to days. And you sometimes only need to take it for the two weeks before you're. period, which is interesting, because you certainly wouldn't take it like that for depression. And I think some women think they're being fobs off if they're told to try SSRIs for PMS or PMDD, but there is a good scientific basis for that, although we don't fully understand how it works. We also think it obviously affects the serotonin. There are interactions between estrogen, serotonin, other neurotransmitters. So that's one thing.

So you can either trade those SSRIs all the way through the month or just in the Luteal face the two weeks before. And then there's the attempting to suppress ovulation, which then hopefully calms down your hormonal fluctuations, and that's the hormonal route. So there's either some contraceptive pills in women who still need contraception, and they generally are ones that contain a progesterone called drospirinone. They can be very effective for women. And the other form, especially good in perimenopause, is essentially a similar treatment regime to ones you will using perimenopause, so a natural progesterone or the marina coil with high doses of transdermal estrogen, so jails or patches. Unfortunately, the trials for that aren't as encouraging as you'd like

is only if you can switch off ovulation. So often the levels have to be quite high of the estrogen. But in some women, especially if their symptoms are worse during perimenopause, that can make a big difference. Yeah, absolutely. I mean, I as a GP, when I was trained to give women antidepressants just in the second half of the cycle. And some women do report, like you say, very quickly a good response, but others find that it doesn't affect them in the same way. And increasingly, because as you know, people who have PMS often have worse PMS during the perimenopause, I often do give them some gel, usually the estrogen gel that they just rub onto their skin. And I often start with quite a low dose to almost top up the deficit. And they often find that it really improves

because it's just replacing the hormones that are there. Women who are still having very regular periods, there's a debate whether they still need to have a progesterone when their periods are regular because they're still producing their own progesterone. But the guidance say that we should be giving a progesterone, but some women do have side effects to the progesterone. And I think this is why it's very important

that women receive individualised help and guidance because everyone's different, aren't they? And, you know, I think some women need a lot of treatments. And like you say, sometimes very high doses or a combination of treatments as well. And some women even have drugs, don't they, to block their hormones and consider having their ovaries removed, often with ad back hormones. But everyone's different. And, you know, I think, like you saying, giving a holistic approach is very important as well. because at doctors we can be very quick to just prescribe something and it's not just a prescription, is it?

It's very important that women have time to understand their symptoms and also understand how their lifestyle can have a big impact as well. Definitely. I think their individuality is the key. I mean, there are lots of people who over the years have said they found the cure for PMS or PMDD. On POP's not so much PMDD because it's a relatively new kind of term over the last few years. but certainly there was a lady called Katerina Dalton who swore that progesterone was the answer for PMS, including severe PMS. And in her experience, she had quite good results with that. And certainly there are some women who used to be given natural progesterone up to postnatal depression, and that would help. And I do occasionally see that in practice. And sometimes those women respond positively to the progesterone.

But a lot of women, as you've kind of alluded to with PMS, really have almost an intolerance to their own progesterone that they produce. and giving it back to them in the hormone therapy can be problematic. So these are the women where it isn't going to be so helpful giving them the contraceptive pill or HRT with the progesterone component. And we have to then consider if they're another route, they can have the progesterone. Maybe having vaginal progesterine can sometimes minimize side effects or the marina coil because it's an overall lower dose of hormone. But even that is too much for some people.

And as you say, sometimes you resort to going down the route of trying to switch off the ovaries with what we call G and RH analogs and that's really with a view to having surgery to remove the uterus and the ovaries but that's really only reserved for severe cases and obviously I unfortunately ended up in that group but it's not something I would advocate for unless it's absolutely necessary because ultimately it's not a problem with your ovaries or your uterus it's a problem with our brain's response to the hormone changes and so I'm hoping in years to come we're not going to remove part of the endocrine system of young women, which is what we still do. But sometimes it is necessary for certain people if they're unable to get on top of their symptoms.

And this is obviously the very severe and most women won't need to have that. Most women will manage, you know, to find something that suits them with a combination of lifestyle treatment, possibly hormonal treatments, maybe sometimes with a low-dose SSRI, which again can sometimes help the HRT work a little bit better. but it's so individual. Absolutely. And I think that's so important in everything we do, not just with menopause or hormones,

but if a person has any illness, it's very important. But I think it's also important that if anyone's listening and is struggling and perhaps not receiving the right care that they expect, then they should seek a second opinion because, you know, the training that we have as doctors in conditions such as PMS and PMDD is very limited. And so it's important to try and work towards the best evidence and get the right help. Because a lot of women are very scared, aren't they? They feel that they think they are depressed or they've got dementia because they can't think properly

or they've got arthritis because they keep getting joint pains or they have urinary symptoms. And it's not until someone sits down and works out that they happen in a cyclical way and that they probably are related to their hormones. A lot of women are just relieved knowing that they're not. there's a reason for them to feel like that. Exactly. So it's very important. So we could talk about this all day and it's still so much more to know and understand,

but I hope that's given people some basic understanding about the reasons behind this complicated condition and treatment choices. So thank you ever so much for your time. But before we finish, Hannah, do you mind just giving three take-home tips? So for women who think they might be having. some symptoms related to PMS and what are the three main things that you would suggest that they could do to help themselves? I think the first thing to do is kind of track your symptoms. And so as I mentioned, there are certain apps you can download for that or kind of going to

one of the websites I mentioned to downloadable printable tracker. And looking at good resources, so there's IAPMD.org, which is actually a US-based site, but there's a lot of, there's a lot of good information on this. Primary their focus is on in the severe form, so PMDD and suicidal behaviour related to hormone fluctuations. Have a look on there because they've got a question and answer section. They've got all the evidence and stuff on there. Or there's NAPs over here, the National Association of Preventual Syndrome. So there's some information and the UK guidelines on there. The other thing is kind of to be kind to yourself. I think there's a lot of judgment that people feel that they should just be able to solve this by themselves as though it's their fault. And although

there is some talk that stress and trauma is related to PM, the S and PMDD. Even if that's the case, it's not as though it's your fault or your choice. Trying to think of the way to kind of describe that properly, but it's, I think, because it's such a complex disorder and it's so poorly understood. There's just a lot of self-blame. And that doesn't help anybody. There is help out there. We're learning more and more about it all of the time.

I think, yes, be kind to yourself. Know that there is help, but tracking your symptoms is key and just getting the right places for support. Yeah, no, that's really important, really invaluable advice. So thank you ever so much for spending some time to explain that, Hannah. It's been really good. Thank you. Thank you. For more information about the menopause, please visit our website, www.mennepause doctor.com.uker.