The Dr Louise Newson Podcast - 063 - Psychosexual Medicine and Menopause - Dr Stephanie Goodwin & Dr Louise Newson

Episode Date: September 1, 2020

In episode 63 of the Newson Health podcast series, Dr Louise Newson is joined by Dr Stephanie Goodwin, a london-based GP, menopause specialist and specialist in Psychosexual medicine. Together, Dr Newson and Dr Goodwin discuss the possible consequences of cancer treatment on women’s sex lives. Often sex isn’t discussed at the outset of treatment and it isn’t until much later that women have the opportunity to get advice.  Dr Goodwin also speaks about vaginal changes during the menopause and the importance of intimacy and keeping channels of communication open with your partner if sex becomes difficult during this time. Vaginal dryness is a very common problem that is easy to treat so don't be afraid to seek out advice.   Dr Stephanie Goodwin's Three Take Home Tips: If you are having cancer treatment, ask for advice about the possible impact on your sex life at the start.  Find someone in the team who is comfortable discussing that with you. There are lots of resources available that can be helpful - Macmillan, Cancer Research UK, The Daisy Network (for younger women under 40) and The Institute of Psychosexual Medicine.   Don’t be afraid to ask if you need help! That’s not just for cancer patients but for any women having sexual difficulties.  If you don’t get help the first time, try someone else and keep asking.  www.drstephaniegoodwin.co.uk Find Dr Goodwin on Instagram: @drstephaniegoodwin

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 for this podcast, I'm really excited to have with me, Stephanie Goodwin, who is a GP and menopause specialist. She also is a specialist in psychosexual medicine, so we thought today we'd focus more on this area of her work. So welcome, Stephanie. Hi, Louise. Thanks. An interesting way to work for a change, isn't it, both sitting at our computers. It is. So Stephanie was going to come to my clinic, but we're in the depths of COVID. So obviously, we're socially distancing, but it's lovely to be able to still see you and hear you and carry on doing this recording. Yeah, it's great. So tell me about

your background, Stephanie. Tell me about how did you become interested in psychosexual medicine and actually even what is psychosexual medicine? Okay, so I became interested in psychosexual medicine about 22 years ago. I'm a GP and I just started working in private practice when I was seeing a patient, a gentleman, and I was doing a genital examination. And I remember it so clearly and he said to me, he'd had treatment for prostate cancer, I think, I can't remember something. And he said, but of course you'll see that my penis is shrinking

before your eyes, before our eyes. And I had no idea what to say. I was completely flawed because I could see no problem at all, but it was obviously his perception of what was happening to the body. And actually my cousin, who is also a doctor, was working in psychosexual medicine with the Institute of Psychosexual Medicine. So I decided to start training, and the training is done by seminars. So we'd meet every four weeks, present cases, after two years you do a diploma, after four years you do a membership exam, and it's just been really fascinating. And what it's about is looking at the physical and psychological aspects of sexual problems, because of course sex is a physical and an emotional act. And whenever there's a

problem with one part of that, there's a problem with the other. So it's trying to help patients understand where the problem is coming from. It's really fascinating. reading. Interesting, because it's something that we don't, while I circled at medical school, we talked a little bit. Actually, I remember we had one lecture talking about issues with sex and about trying to, if people having problems, then we should try to not let them have sex so they can explore each other's bodies and be tactile in other ways, which actually was a really, really good piece of advice. But at the time, I remember being 200 medical students in a lecture of theatre, everyone bursting into hysterics, the thought of sex, talking about sex,

and never really putting this information into practice until I was probably qualified for a good 10 years when I was felt more comfortable, just more at ease talking about something that's very sensitive to people. Did you have any training as an undergraduate? I really don't think so, but I didn't have any training in the menopause either. No, it's quite amazing. And certainly, as a lot of you who are listening, know that we do the green clemiteric score, which is a scoring system for menopals or symptoms for all our patients. And on it, it says loss of libido. So women who fill out the questionnaire before they come know that there is going to be some sort of discussion about sex. And it's really

important because I'm sure you'll find the same that a lot of women who come and talk to me, their libido is reduced usually because of the perimenopause or menopause. But they've never spoken about it. They've never talked to even their partners about how they're feeling. And so when I say to them, I'm sorry to ask, but could we talk about your reduced libido? They're so pleased to be able to talk about it. Yeah, me too. I mean, my patients know that if I'm doing a general health check on them, for example, I always ask them about sex because it's a medical signpost for other conditions apart from anything.

And I've certainly had patients who I've known for quite a number of years before they've told me about their sexual problem. So tell me a bit about that. saying it's a marker for other even diseases, isn't it? So just talk me through what that means. Well, so in terms of looking for cardiovascular disease risk or diabetes, or even in women conditions, vulgaritis or lichen sclerosis, so some of the other medical conditions. So it's very important to ask about it. And actually, so many patients I talk to are not having a sexual relationship and they've never told anybody so many. And for them, actually, it's just a relief. I think it's the majority of menopals or women. I don't know what you think. Yes, I agree. The patients in

my clinic, I would say at least 50% have not had sexual intercourse for at least two years, which is quite shocking. And I had no idea until I started asking routinely every patient. And clearly, some women I won't ask about sex if they're single and it's not appropriate. but actually libido isn't just about prenatative sex either is it it's um you know when we talk about sex it's not you know sex means different things for different people doesn't it and also sometimes when i talk to women about it they're not having sex but actually they'd quite like to but their partner has a problem so in this sort of age group the men are starting to get sexual dysfunction yes so it's a very challenging time because everything seems to be going wrong and then you're

relationship changes completely so that you're no longer having an ultimate relationship and living alongside one another. Yes. It is very different. And certainly when you were talking about male sexual problems, we know, don't we, that the blood supply to the penis, the blood vessels are obviously very small. So a lot of men who have erectile dysfunction, it can be a marker of future heart disease or like you say, diabetes as well, can't it? Which a lot of people don't realize, do they? No, that's right. I mean, interesting. I know. were talking about women, but I actually saw in a very short period of time within about six weeks three men who were referred to me with erectile dysfunction for psychosexual counselling.

Two of them have pituitary tumours, so they had hormonal problems. And the third one had testicular atrophy because he'd had mumps when he was much younger. So, you know, I think because people are scared to ask too many questions, they just assume it's a psychological problem and then send them off to me. Yes, and I think it's very interesting, especially with the advent of Viagra being available over the counter. It's a double-oged sword. Obviously, it's good because people can access it and it

means it's hopefully spoken about more. But like you say, it can be a marker of future disease, a bit like high blood pressure. People don't think about blood pressure as a condition or a disease, but actually if it's untreated, it can lead to heart disease. And there's some work, isn't there? There's

even people, men who have erectile dysfunction. It can be a few years before that they then subsequently develop heart disease. So it's very important that if any of you listening, if your partner is suffering from erectile dysfunction, they should really see ideally a GP or a medical person to be screened for these conditions. Absolutely. Yeah. Because it's often the women that we see are the window or the way in to talk to their... Absolutely. Yeah. And it's very important. And actually for women, it can be almost a relief if their partner has some sexual problems, because a lot of women are very scared of having sex.

They feel that their bodies have changed, which they often do during the perimenopause and menopause. Often our body shape changes. And then there's symptoms such as self-esteem, loss of confidence, anxiety. So you don't feel physically the same and mentally the same. And then as you alluded to, a lot of women have vaginal atrophy or vaginal dryness.

So it can be very uncomfortable having sex. So actually, if your partner has gone off sex or can't, physically have sex. For some women, they think, great, that's good, just let me off the hook. Absolutely. I mean, I've had women who've said to me, you know, don't make it too good for me because then there's no barrier to it. I think it becomes unspoken that in some relationships people do stop having sex because both partners are having a problem. So again, you know, if you fix it, you're opening a bit of a can of worms. Yeah, absolutely. So tell me the health benefits of having sex regularly. There are some, aren't there? Oh, definitely. It's good for your heart.

It's good for your mood. It's good to keep the intimacy going within a relationship. I think it's good generally for happiness and cardiovascular well-being. Yes. Because there are various chemicals that are released in our brains and our bodies, aren't there, during sex and also, obviously, with an orgasm as well, which can be very beneficial. Yeah, absolutely. I'm wondering what's going to happen to the amount of sex. at the moment with people being forced to spend so much time together. Yeah, I think they're expecting a bit of a baby boom, but I think also for a lot of people who are forced together in very stressful situations, it can go the other way, which can be very difficult, can't it?

Absolutely. So when we think about the menopause, let's just talk a little bit about vaginal dryness, because that can be very common, can't it? I've read studies that even around 70% of women experience it at some stage in their lifetime. So why does it happen or what is it? So estrogen deficiency causes the vaginal tissues to lose their moisture. And that makes intercourse or even not just intercourse, just walking around or wearing underwear and trousers very, very uncomfortable.

And I've certainly, and I'm sure you have Louise, that heard so many women say that attempting to have intercourse or having a cervical smear done is absolutely excruciating. So these women are screaming out in pain. So it's a very, very distressing symptom that unfortunately is still sometimes being overlooked. So when someone's having a smear, instead of stopping when somebody's saying, oh my God, that's really painful, whoever's doing the smear goes to get a smaller speculum, which is not really the answer.

So I think we're missing lots of opportunities to pick out these women in general practice and help them, which is upsetting. Yeah, so I did an internet, on Instagram actually, I did a little survey on my story one day about how many people had avoided smears because of vaginal dryness and about 60% said yes, they had. And I hear it a lot, like you say in my clinic, I saw someone earlier this week and she said to me that she was up to date with smears, but the last one was so painful. She said to herself, she's never going to have it again.

So I said, well, did the nurse give you any information, any treatment? Oh, no, she said it's quite common at my age to have soreness. Oh, right. And it is common, like you say, but actually there's really easy treatment, isn't there, for women? Absolutely, yeah, it's so easy. And now, of course, we've got some nice new treatment options. But yeah, the treatment is simple. And you can use simple lubricants or vagina moisturizers.

But we know that vagina, estrogen is the preferred treatment of choice. It works so well. It's been transformative for so many of my patients. So tell me, how do people give themselves to use the vagina leastrogen? What are the options available? So there's little peccaries, little tiny capsules that you insert with an applicator twice a week, oh sorry, every day for two weeks and then twice a week. That's commonly used. There are vaginal creams that you can use as well, but I think they're a bit messy. Personally, I wouldn't want to use that.

And then now there are some newer treatments. There's some vaginal gels that you can use, which sort of stick inside the vagina. And now we've got a new treatment, which is a precursor to estrogen and testosterone called intrarosa or prasterone. So there's choices. If people find one particular method isn't suitable, then we can switch to something else. So there is plenty of choice available now. Yes. And I think it's important to add that these treatments are not HRT. They're very different, aren't they, to having systemic HRT. Unfortunately, the warnings inside the packets talk as if it is HRT. So any of you that are having these treatments, you should ignore the inserts because they're absolutely wrong. And like you say, there is a choice. So some people like

the convenience of a pezzary, other people, you know, like having the gel, for example, the creams I often ask ladies if they're having symptoms outside more on their vulva and often they can use the cream externally, can't they? And then use the pezzary internally. And actually, the dose of these treatments is incredibly low. So some women need to use it more frequently, don't they? And it's quite safe to do that. Yeah, so we do sometimes double the dose. Yes. And in fact, in the women that I see at Guys Hospital where I do a specialist

menopause clinic, which sadly now we're not going to be able to see patients there, I would have thought for two or three months now, which we're all really upset about because there's already a long waiting list. So some of the women that I see there who have complications of their cancer treatment,

we get them to use a mixture of an external cream just to try and women who get vagina stenosis, which is a narrowing of the vagina after treatment, that's really where the psychological work starts to come in as well. Yes. So let's talk a bit about cancers. So there's obviously people can get different types of cancers and a lot of the gynecology cancers, so cancers of the womb, of the cervix, even of the vagina and the vulva. The treatments can actually cause a lot of problems locally as well as often,

leading to early menopause for younger women. Talk me through what treatments are available. Are they allowed to have vagina on estrogen, for example? It depends what sort of cancer they have had. So most of the women with gynecological cancers can actually use systemic HRT, not for all of the different types of oberian cancer. And we always speak to the consultants.

But many of the other women can use systemic and localised estrogen. but I think what I've been finding, because I've been working in that clinic for about three years now, is that my psychosexual hat comes on quite regularly because so many of these women have been so traumatised by their treatment. I saw a lady, gosh, a few months ago who'd had treatment for, I think, ovarian cancer, I can't remember. and she was a nice lady very sort of quietly spoken and I was asking her about sex and she said I haven't even attempted it and I said oh would you like to tell me why and what's worrying you

and she described her vagina she said it's very short and it's very dry and it's all shriveled up so it's never going to work and she looked really upset so I said would you like me to examine you and when you do in psychosexual medicine, when we examine patients, when we do a vagina and examination, it's a bit different to doing a normal examination because we're taking note of what's happening and the interaction between the doctor and the patient from before you actually get somebody onto an examination count. And we kind of involve the patient more in the examination.

So I said, would you like me to examine you? And she said yes. And so I popped her up on the couch. And she looked extremely worried, but keen for me to have a look. And I did a vagina examination. And actually, her vagina was fine. Interesting. So for 18 months, she'd have this image, this sort of fantasy in her mind about what had happened to her body.

And I examined her. And I said, actually, do you know what? I was also very surprised. I said, gosh, you know, this is not what I was expecting either. and I said to her, would you like to examine yourself while I'm here, which we get patients to do in psychosexual examinations, which she did. And she was so relieved. We both were actually.

It was quite emotional. So it's about looking at those aspects with some of these women where sex, when they're having their cancer treatment, it's not really discussed. And we see them six, 12, 18 months down the line when there's a major problem. Yes. And it's so important. I saw a young lady who's in her 30s who came, she took three hours to get to my clinic. And she had a vaginal cancer in the past, which is quite an unusual cancer.

But part of the treatment, she'd had a radioactive probe inserted into her vagina. As part of the radiotherapy, she'd also had chemotherapy. And she'd had radical surgery. So everything had been removed. So she'd had early menopause. Again, when I talked to her, she said, no, my vagina is very different. My husband can't go near me. We can never have sex ever again.

and she'd had recurrent urinary tract infections as well, which were obviously affecting her. And so again, like you, I asked if she wanted to be examined, and I literally had a look. So there was no plastic speculum in the room. It was just literally looking. And everything looked completely normal, a little bit of atrophies and vaginal atrophy, which is what you expect if estrogen is low. But she'd been given these dilators from the clinic, which if any of you know about them, you'll know they're very sort of hard, rigid, quite horrible looking things that women are told just to go and insert. And more of a mechanical thing rather than a pleasurable experience.

So she obviously hadn't used those at all. And like your patient, she was absolutely relieved that it didn't look awful and also that there was a chance that she might be able to have sex. And certainly I spent some time talking to her about external stimulation and remembering my lex. from the old days when I was a medical student, it's about exploring each other's bodies and actually trying not to have penetrative sex. And once that's been taken away from you, a lot of people find actually they can relax

because they've been told they can't have that thing that might cause pain. And actually that can really make a difference, can't it? Yeah, definitely. I mean, actually, there are some new vaginal dilators called Inspire, which are made of silicone and they're not these just solid plastic rigid. They still come in different sizes.

So they're not quite as mechanical looking as the others. And I actually say to women, get a vibrator. Yes. Make it not just a mechanical task of I must spend 15 minutes a day, but make it fun and make it part of a sexual experience rather than being homework. I think that's really important. And also your partner can then be involved and have pleasure.

helping. I certainly recommend a lot of people to speak to Sam Evans, who's nurse trained. We've actually done a podcast before for some of you who want to listen because she's very open and she's very knowledgeable about different vibrators because most of us don't really want to go walking into a shop and it can be quite embarrassing. But actually there are some very discrete vibrators which can really make a difference for people. And like you say, using the vaginal moisturisers and lubricants, especially the ones that don't cause. irritation. Again, there's advice that Sam can give about these products can really make a difference. And like you say, using vaginal estrogen is usually fine for nearly everyone who's had

cancer, isn't it? Yeah. And actually, interesting, you mentioned your lady who'd had her radiotherapy. I saw another woman in the clinic who, on the face of it was, you know, a very outgoing, attractive sort of quite brash lady and we were chatting and she'd had cervical cancer I think and she'd had some sort of radiotherapy given vaginally and she described it to me and it sounded so horrific I've never heard anything like it. It just sounded awful as if she'd almost been skewered. It was so traumatic for her and she hadn't actually spoken to anybody about how what that experience was like for her. And unfortunately, as a result of that, she had vaginal stonosis. And she said to me, I'll never be able to have sex again. I'll never be able to have children, of course,

because these women are often fertile as a result of their treatment. And it was so painful to share that with her. But at least we gave it time. We explored it together. And again, I examined her and I could barely even get the tip of my finger inside. So, she had to go back to the surgeons. It's very sad and frustrating for us as clinicians when we hear about women who have had cancer in the past, yet no one has spoken to them about the potential problems with sex and vaginal dryness because we know that most women who have hormone treatment. So usually those women who've had estrogen receptor cancer, often breast cancer,

but some like you say, ovarian or womb cancers, have treatment that blocks estrogen. So therefore it's going to block the estrogen in the vagina and the urinary tract as well and have symptoms such as we've alluded to the vaginal dryness and also recurrent urine infections. And I feel it's really important that women are given the right information from the outset. Because we see these people too far down the line. And a lot of women who have had cancer tell me that they feel too embarrassed and it almost seems frivolous talking about sex when they should feel privileged and lucky that they are. alive and they've got through their treatments. Exactly. Yeah. I actually a few months ago,

I had a really nice senior sister from one of the oncology, gyne oncology wards at UCL, came to sit in on the clinic with me at Guy's Hospital. So she obviously deals with patients when they're having their surgery and then the surgery's done and then off they go. And she came and spent an afternoon in our clinic. She said, oh my God. She said, I thought we were doing a really good job with all the work that they're doing, which of course they are. She said, but I had no idea what happens to these patients six to nine months down the line. And she was very keen then to do some extra training. Right. So that she can help advise women at the outset. Yeah. Because I think that you're right, it gets missed. And it's so important because it's not just managing cancer,

it's life beyond cancer. And thankfully, due to advances in medicine, most of women who have cancer will survive in the longer term and we'll have these conditions. So there is a booklet under the resources section of my website called Menopause with Cancer. And also I've got a fact sheet that we've recently written about vaginal dryness. And a lot of women find it really useful, but this information should be available more freely for people. Yeah, absolutely. And women shouldn't feel embarrassed talking about it as well. No, but I think sometimes when they ask the question, people don't know how to respond to them.

And that's the problem. Yeah, and I think a lot of healthcare professionals find it very difficult sometimes. And when I was lecturing a few years ago about vaginal dryness to a group of GPs, someone came up to me after and said, well, I will only ask a lady if she's sexually active, which horrified me because, like you rightly say, it's not just about sex. A lot of women who have vaginal dryness find it difficult to walk or to wear trousers or to even sit down. And you don't want to wait until it's too bad. And then there are other people who, for various reasons,

don't want or enjoy penetrative sex, but they still can have symptoms and I certainly have a lot of patients who are in same-sex relationships and if they're the same age and they're going through the menopause at the same time, it's a double-whamming. So it's very important that this area is discussed because we know that so many women are suffering and the vast minority actually received treatment, which as you've already said is very effective and it usually works fairly quickly as well, doesn't it, Stephanie? Yeah, definitely. And if it doesn't work, there are alternatives and there are alternative treatments, different doses, just sometimes combinations as well. So if any of you have had treatment that isn't helping, you certainly don't stop.

You should really seek the right help and advice. Yeah, definitely. I couldn't agree more. So are there any other tips or information that you would give to people who haven't got vaginal dryness, who maybe their libido is coming back, maybe after treatment for a cancer? what other sort of psychosexual tips would you give them? Well, I think it's important to keep sex or intimacy going because it's very difficult, you know, just to, if things are waning, it's very difficult just to suddenly reignite everything again.

So it's really, really important to keep the conversations going with your partner. And I encourage women to read erotic literature, as I say, to get a vibrator, anything to, you. explore their own sexual fantasies and allow themselves a bit of freedom. But I think, you know, it's the old use it or lose it, I think it's very important with sex. And as I say keeping the channels of communication open is very, very important. Because so often it's just the conversation stops in relationships. And then how do you start it again?

That's the difficulty. And I think that's so important. It's talking certainly, I've been with my husband. I'm very fortunate for a long time. and we have three children and after each child, it was almost like being a teenager again because, you know, you've got to wait for the time's right and there's always reasons. And I can see if you're not close to your partner, then there's a real wedge, isn't there? And then a lot of women say to me, well, there's no point bothering.

It's too late. I've not had sex for a decade. I'm not going to. And someone recently came back to my clinic and they hadn't had sex for 15 years. Right. She had such bad vaginal dryness when I saw her. She was one of these ladies who, sadly, couldn't wear underclothes because it was so painful.

She'd seen various doctors and no one had really helped her. And it's taken about 18 months to get the right combination of treatments. But the last time I saw her and her husband, they both had this cheeky grin on their faces. Oh, really. I knew what was going on. And, you know, it's lovely. And they thought they hadn't missed it because they'd spent so long without having a

sexual relationship. Yeah. Okay. But it gave a whole new dimension to their lives. and they're both in their late 16s. And it's just lovely. That's a great story, Louise. I wish I had more of those.

I think often for me with people with psychosexual problems, if they're coming for a purely psychosexual reason, often they've had problems for many, many years. And it can be very difficult to disentangle. And sometimes it's just a question of helping people to live with their situation as it is. But certainly, from the point of view, the cancer women that I meet, I think just in allowing them to talk about what's happened and how

they feel and examining them in a way that enables them to try and connect with that part of their body again is so powerful. Yes. But even just doing that can bring a lot of relief and comfort to these patients. Absolutely. And I think the power of examination shouldn't be misinterpreted or sort of dismissed really for us as clinicians, we're so used to examining people in intimate ways. And like you say, a lot of time we examine people, but we don't actually have to insert anything internally.

It can just be a visual examination. And that can be really reassuring for a lot of women. So none of you should feel embarrassed by even asking your doctor. You know, I always say to women, do you mind if I examine you? And there's so many in and say, oh, my gosh, are you sure? Are you really sure? Gosh, that was so good. No one has examined me for years.

And, you know, we don't get embarrassed. You know, I actually hate examining feet more than I hate examining people intimately. So it's, but, you know, we're trained and all doctors, you know, male and female doctors should be able to examine. So if you are embarrassed, then you shouldn't be. And also, I think sometimes things get missed. So I've seen women in the past and recently as well who nobody's examined them. And actually, they have a vulvaal skin condition, some of which are pretty. cancerous. And I honestly, I've seen some women and I think, how can nobody have seen that

because they haven't looked? They just say, oh, it's have this, or it's thrush, it's this. So, you know, we're missing a lot of pathology by not taking what can sometimes just be a few minutes to have a quick look. Absolutely. So I think if any, and I know it's hard because doctors are very busy and pressure for time, but if any of you feel that you should be examined, then I would certainly, it changes the consultation quite often if a woman says, do you mind examining me? And no doctor would mind. And if they didn't have time in that consultation, they can make another consultation to actually examine.

Yeah, sure. Or sometimes it can be a nurse or someone else that will examine. But it's important to ask as a patient if you feel you need examining. Yeah, definitely. So thank you so much for your time. Stephanie, it's brilliant, really interesting and informative. And I hope it's helped lots of people. So before we finish, do you mind just doing three take-home tips for people who

maybe are struggling with having sex or thinking about abido at the moment. Okay, so I know that you like your three questions, so I'm prepared. Very good. So the first thing is, for people having cancer treatment, discuss sex before everything starts. Find someone in your clinic who is comfortable at discussing that with you. So bring up the topic of conversation early on. Don't be worried about doing so. resources, so where to go for information.

There's the British Menopause Society, the Daisy Network, which is a charity for women who have early menopause for all sorts of reasons, including cancer and the Macmillan Cancer Trust have got some excellent and cancer research. So there's lots of good information out there. And the other thing is, if you're having problems, don't be afraid to ask when you go back for your follow-up appointments. So I think, as you said, Louise, lots of women feel that they shouldn't bring up sex

because if you're lucky enough to be alive, then that's good enough. But if you go to a follow-up appointment and you're having difficulties and you're not asked about it, ask the person that you're seeing. And if you're not getting right help, then ask to be referred. There's also the Institute of Psychosexual Medicine, of which I'm a member, have specialists who run private clinics and there are still some NHS clinics running and the information of those are all on the Institute of Psychosexual Medicine website. So that's my three tips. Brilliant. Very good. So the most important thing really is to talk. Absolutely.

To someone that listens and if you don't get help the first time, keep trying. So thank you ever so much for your time today, Stephanie. It's been really good. Pleasure, Louise. Nice to see you. Thank you. All right. Take care. For more information about the menopause, please visit our website www.menopausedoctor.com.