The Dr Louise Newson Podcast - 065 - HIV, Menopause & Sophia Forum - Sophie Strachan, Dr Nneka Nwokolo, Dr Jacqui Stevenson & Dr Louise Newson

Episode Date: September 15, 2020

In this podcast, Dr Louise Newson is speaking with Sophie Strachan, director of Sophia Forum, Dr Nneka Nwokolo, honorary HIV clinician and menopause specialist, and Dr Jacqui Stevenson, researcher and advocate for Sophia Forum. Together, they talk about the charity Sophia Forum and their 'We Are Still Here' campaign which is calling for:  Opportunities to pass on experiences  Peer networks for older women  Holistic services and standards of care  Dr Jacqui Stevenson recently carried out research exploring women’s experiences of ageing with HIV in London. Many of these women were experiencing menopausal symptoms yet were often receiving inadequate advice and help. Understandably, many women were worried that their symptoms were related to their HIV or their treatment and a large number of women expressed frustration in not receiving the right support or treatment. The expert guests in this podcast discuss how important it is for women to receive education about potential symptoms of the menopause and also health risks related to their low hormones. Jacqui talks in more detail about her research and ways of potentially improving access to evidence-based information worldwide to women living with HIV.  Sophie Strachan, Dr Nneke Nwokolo & Dr Jacqui Stevenson's Three Take Home messages: Women living with HIV should expect the same care and menopause support as women without HIV. These women should not have any less expectations that they can have their symptoms managed. It's important that we break down the silence around issues like HIV and menopause and provide the space for women to demand the care, support and information that they deserve.  In the context of health professionals, don't be afraid in how to look after your patients living with HIV. We are asking you to get educated about this condition as we have had to and start having menopause conversations with your patients when they are in their 30s - not 50s! Find out more about Sophia Forum at: www.sophiaforum.net www.instagram.com/sophiaforum/ www.facebook.com/SophiaForum/   Click here for more information about the We Are Still Here campaign.

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsome, a GP and menopause specialist, and I run the Newston Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. So today I feel very outnumbered because I have three women that have appeared on my screen at the same time to join me in this podcast. And actually, this is very exciting for a number. number of reasons. It's also exciting because it's the first in a series of podcasts that we're doing. So this is actually, we're going to be talking about the impact of HIV and the menopause, because women living with HIV have been shown to have more symptoms often and sadly less

likely to receive treatment. And as many of you know who listen to me, I'm constantly trying to think of ways for more women to access good quality information and care for their menopause. globally because it's a global problem that menopause care isn't being addressed properly. So I've been working behind the scenes over the last few months with a fantastic charity called the Sophia Forum. And we have co-written a booklet that is available on their website, on my website. It's available for anyone to read and learn. So we wanted to talk a bit about this, really. So with me today, I have Sophie, who's the director of Sophia Forum. I have NECA, who is an honorary HIV clinician and also a menopause specialist.

And I also have Jackie, Dr. Jackie Stevenson, who's a researcher and advocate. So welcome all three of you onto this podcast. So thank you for coming. Thank you. So just to get started maybe, Sophie, could you just say a bit about you and about the charity and about, you know, why we've sort of got together to collaborate on this piece of important work? Yes. So the Saffir Forum is a charity in the UK that promotes and advocates for the rights, health and welfare and dignity of women living with HIV.

And we do this through a variety of ways. One is through research. One is through raising awareness and one is around influencing policy. And we have a running peer support program called Wise Up, which stands for women inspire support. empower, unleash positive potential. And the bigger picture of this conversation today has been based on research that Dr. Jackie Stevenson has done, which she's going to talk about, but also how she brought that into one of our Wise Up weekends, which then NECA was involved in, which had a very specific focus around women and aging, and in particular, the menopause. I am also a woman that is living with HIV.

I've been diagnosed for about 18 and a half years. And I entered the menopause, I think maybe about four years ago now. And my experience has been vast. And it's just something that I just now feel so passionate about because of my lack of preparedness, my lack of awareness, which is very much informed, certainly from a Sophia perspective, why we needed to ensure that women were better prepared, better informed, that know about the services that are out there to improve our life as we age with HIV.

And even to be sitting here saying that, you know, 18 and a half years ago when I was diabetos, I didn't know that I'd be sitting here saying I'm now aging with HIV. And there's just been such huge advancements on one level around treatment, which is giving us what, you know, everyone would say a normal life expectancy if we're privileged enough to have access to that daily treatment. But with it comes some complexities and unknowns. Yeah. So I think we're all on a big learning curve.

And I think it's really important because a lot of women and men don't know anything about the menopause. They just know it as a word and it usually for them means that's when period stop. They don't realize all the symptoms that go with it. And, you know, when I was at medical school many years ago, the life expectancy for women and men living with HIV was very different. And as you quite rightly say, you know, most people have a normal life expectancy. So most women, hopefully, living with HIV, will go through the menopause.

Yet so few are prepared for it. And because of the complexity of the disease often, but also the treatment, A lot of people I think are misdiagnosed or misdiagnosing their menopause or symptoms has been related to their HIV or their HIV treatment. I don't know how you feel about that, NECA. What do you think in your experience in your clinic? What you're saying is right. And what Sophie says resonates a lot because Sophie's experience is the experience of many, many women living with HIV.

One thing that I recollect very clearly as I was starting to do my HIV menopause clinic was a woman saying, to me, why did nobody tell me that it was going to be like this? And she wasn't necessarily speaking about it from the point of view of her HIV. She was speaking about it, I think, from a point of view of a woman who has reached the age of 54 and nobody in her life ever told her what menopause was going to be like. And I think, as you say, Louise, people think, oh, it's your period stopping. Yes. But so many women have no idea that it's not just about periods dropping. And what you say about the experience of the people living with HIV

is because they're not thinking about the menopause, many of them who have completely well-controlled HIV, no symptoms, suddenly start to have symptoms that are very similar symptoms they had when their HIV was first diagnosed. So they start to feel really tired, they have sweats. And their first thought is, oh my God, my HIV isn't controlled? And that's very scary, isn't it? It is.

It's even more scary, I think, because they go to their HIV physician who says, oh, there's nothing wrong with you, your viral loads fine, your HIV is completely under control. I don't know what's wrong with you. Go to your GP. And the GP doesn't know because the GP thinks it must be related to their HIV, because no one's clocked that it's the menopause. And so we go back and forth between their HIV position and their GP. And often it's many years before people realize that actually these symptoms are symptoms of the menopause. Absolutely, which is really, really sad, isn't it, to think about? But also, one of the things that struck me, I think, it was when I spoke to Sophie many months ago, was that for a lot of women who live with HIV,

to reach the menopause is a great positive milestone because it means they're living so much longer. And also, which is something I suppose I'm very naive, I haven't thought about, the thought of having a period every month for a lot of women, having blood that could be contaminated, especially if they go to public toilets, actually it's very liberating to not have periods for so many reasons. So it should be a really positive experience. Yet they're with symptoms and we know time and time again that, you know, around 25% of women give up their jobs because of the menopause, symptoms such as fatigue, anxiety, memory problems. And people feel more anxious because they don't have hormones in their brain. And then they're going to

even more anxious because no one's helping them. And they're always going to worry that is it related to my HIV, which is such a concern. And just for women to know, even if they don't get treatment just to know, yes, these are common symptoms, actually can make a huge difference, can't it, to their lives? So Jackie, Sophie, was talking about the wise up and the weekend, you know, what you've found. Could you just talk a bit about the research that you've done and the experiences women have spoken about to you? Yes, so my research was looking at women's experiences of ageing with HIV quite broadly, focusing on women in London and working with them to look at what's it like to grow older with them? HIV, what are the challenges, how do you manage it? And many women are doing really well. They're

coping, they're thriving, but there are challenges thrown in their way. And one of the major challenges, I think, is that there's so much silence around many of the issues that women are having to deal with and women can feel very invisible, very ignored. And you have these intersecting issues of HIV stigma, of ageism, of sexism, all coming together to make women feel sometimes quite isolated, even as they deal with things like the menopause that are hugely common, that we ought to all know about, we ought to all be prepared for, there's no reason for it to be this kind of hidden away unexpected thing. And yet I find when I was doing my focus groups and interviewing women, they were saying things like, it didn't occur to me, this was menopause

until I went to a peer support group and someone else said it was. And yet these women had been to their HIV consultants, they've been to their GP. And as NECA described, have been ping ponged back between the two because everybody is saying it's somebody else's responsibility. It's a different issue. And all the time these women are feeling really anxious that it might be their HIV, medication becoming less effective, that it could be some other issue. And really struggling to cope with this change your life transition that often, especially for women diagnosed earlier in the epidemic, they didn't expect to reach. So as you said, it should be this positive milestone, but also it can be a really emotionally difficult milestone for some women.

It's about the end of fertility and perhaps the loss of a hope for having children that hasn't been realised or having more children. So it's hugely complex and it's made so much more difficult than it needs to be because really quite simple things aren't in place. You should be able to go to your GP and get access to menopause care and support that is informed, that is accurate, that is comprehensive. one of the things that kind of inspired the focus of my PhD many years ago was looking at an HIV and aging research report that had been done by an organisation in the sector. And there was a quote from a woman in it who said that she had tried to speak to her HIV consultant about menopause.

And the HIV consultant had said, I don't deal with menopause. I focus on gay men and African people. I don't know about that. I thought, well, African people includes women who definitely experience menopause. And that's not good enough, actually. it's not good enough for something that is having this huge impact on women's lives and on the well-being and their feelings of health to be just, you know, somebody else's problem. Yeah, and it's so sad. I'm sure you agree, Neck. I mean, any physician or surgeon who sees

women needs to know about the menopause. It's not a general practice problem. It's not an HIV specialist problem. It's not a gynaecological problem. It's a problem for every woman. And even if a woman has no symptoms, and we know there's around 25% of women who experience no symptoms or very little symptoms, they will all have low hormone levels forever, and they have health risks associated with that. And any medical student, but also any doctor who sees women, has to have some level of understanding about the diagnosis of the menopause, even if they don't know how to manage it, because it's not a biochemical diagnosis it can be made just by asking a few questions. And what do you think, NECA?

I agree completely, I do. And what's interesting actually is that the one group of people who you think would know about menopause, i.e. gynecologists, actually know nothing. I mean, there are some who do, but most gynecology registrars in training don't get specific training in the menopause. And so you can only have training in the menopause if you express a particular interest in it. Yes. That's something I think could be challenged as well.

Absolutely. And I think traditionally it has been thought of more as a problem. that gynaecologists see because it's related to periods, but actually, we've already said period stops, so why on earth would you see a gynaecologist? And I suppose I'm unusual because I'm a physician and I've done a lot of hospital medicine and also I'm a GP, but I'm very interested in disease prevention. And as we know, the rates of cardiovascular disease, osteoporosis, obesity, are increasing in women because we're living longer, but a lot of it is related to our low hormones. and some of the drugs that women take who are living with HIV can increase their risk of heart disease, can't they?

Can you just explain that? Because I think that's very important for women who are menopausal to understand. So, I mean, HIV itself is known to increase the risk of heart disease, particularly if it's not controlled. When people are on effective antiretroviral therapy, then rates of heart disease go down, but they don't go down to zero necessarily. Some of that risk relates to particular antiretroviral. So there are some antiretivirals that are associated themselves with an increased risk of heart disease. But even in people who are not taking those particular anthraithviles that are associated with an increased risk of heart disease, there remains some additional increase in the risk of heart disease in people with well-controlled disease. And what we don't know, although we're starting to do research into this, is how the risk of heart disease that exists in people with HIV is a fact.

by the menopause in women. So we know that women in the menopause who are not taking hormone replacement therapy do have an increased risk of heart disease. What we don't know is, is that increased risk of heart disease that exists already in people who live with HIV made worse by menopause?

Does HRT affect that risk? Yes. So there's a whole lot that we don't know, but we do know that HIV in itself has this risk. And so what you don't want is to have additional conditions and compound that risk, which is what may be the case with the men, of course. Yes, absolutely. And it's about knowledge and understanding, isn't it?

So it's not just about having to get through your symptoms and feel that you'll be a stronger woman when you come out the other side because certainly your bones won't be stronger, but your heart might not be as well. And, you know, it's very important. And I'm sure you agree, Sophie, that women with, well, women I've met, who live with HIV are really well educated about their health, probably more than other people, because often they've had so many encounters with health care physicians, and they've sometimes had to battle maybe for a bit more treatment and to be listened to.

So they want to know more about their health. And so it really saddens me how hard it has been for them to access information about the menopause, and what your thoughts are. Yeah, I mean, I think there's a balance. I certainly as myself, I try and access as much information as possible. But this is where peer support also plays a really key role, because there are some women who sometimes don't know what questions to ask. They don't feel confident in navigating a health system.

And certainly in the current climate, you know, if you are not from the UK, you're also navigating the health system from a very, very different perspective. and you have a very different experience, unfortunately. And, you know, the health inequalities that women experience across the board needs some serious addressing. I mean, sorry to jump a bit, but, you know, my initial learning about the menopause was not from my HIV consultant, and it wasn't from the GP. It was from online.

It was through Twitter, you know, I discovered you. NECA has been a massive source of support. it was only through NECA that I knew that a specialist menopause clinic existed. So it's this kind of information that needs to get out there. You know, experiences will be very varied in terms of how confident slash able women are to access information, whether that be face-to-face or whether it be online, which is why, you know, there is never a one-size-fits-all. And I think also just going back to something that you were saying, earlier, I think Jackie mentioned it about the role of stigma and intersectionality and language

that's used. We talk a lot about the language that's used around people living with HIV because it is so stigmatising. So even just kind of hearing that word contaminated, people need to know that if somebody is on HIV medication and they have a what's called an undetectable viral load, then they cannot pass on the virus. So, there will be people who will probably feel quite triggered by certain languages. And when you're seeing professionals who, I want to say, just aren't in the sector, but I don't think that's fair either. But if you're not in an HIV specialist area,

there's stuff that can be said that actually causes a lot of harm. No, I totally agree. And I certainly, you know, I didn't, it was especially, maybe it wasn't you. Someone else I spoke to you with HIV was talking about having had contaminated blood before. and it's just every time they had a period, they're thinking about blood and how to dispose of it. And I think you're totally right. There is, in medicine we've become specialised very early almost. And there are so many barriers.

You know, some people get scared talking to people with diabetes because they don't know about treating diabetes. And some people get scared with other infectious diseases because they haven't had. And some people with HIV. And it really saddens me when, and you've mentioned it quite a few times before, about women live with HIV. they are ping ponged between the GP and the, and you must see it a lot, necker in your specialty. And it's a bit like when women are pregnant, we forget that women have other illnesses and symptoms

that are not related to her pregnancy. And when I did obstetrics, they would come and the women would have a chest infection and a cough. And sometimes the GP, so, no, you're pregnant, you have to go and see your obstetrician. And the obstetrician will say, well, it's nothing related to you. And this is a really sad, don't you think, it's about joining the dots.

and being very holistic about how we speak to patients, but also how we manage them and help with their expectations too. Yeah, no, and I agree. And this is something that isn't restricted to the menopause. It's something I think that exists across the whole of the practice of medicine. And we're talking about menopause and so we're talking about a particular group of people, women who are getting older. But actually, even in the general population, as people start to get older and start to develop more problems that are related to aging, you know, both men and women, what happens in, because we don't have that joined up care that you're talking about, Louise, people end up being sent to lots and lots of different practitioners without any thought for the fact that this is one individual that actually has lots of other commitments, might have a job, doesn't have time to go to see seven different people in a week, and really we should be thinking about the prevention that you've mentioned earlier, but also about how to make our patient's experiences better,

make our patients' experiences, the kinds of experiences that we would want to have. And I think we often don't think about that. We don't think enough about what if this was me. Because if we did think that, then a lot of the stuff that we're describing would not happen. I totally agree. And I think, you know, certainly when I trained in medicine in the 80s and 90s,

we were very paternalistic. And I did a lot of hospital medicine. when I ran an asthma clinic, I would be thinking about their asthma. I wouldn't even think about, does this person have a pet at home? Do they have a partner? How have they got here? They don't drive. Have they got on a bus?

How many buses it must be exhausting for them? It was just never really ingrained into our training. And now I'm thinking this is absolutely inexcusable because we have to be holistic. And, you know, any aspect of medicine, it is not just giving a prescription or making a diagnosis. It's every person needs to have individualized. care, whether you're talking about HIV, you're talking about menopause, you're talking about heart disease, it doesn't matter, it's so important. And I'm really encouraged that you work in a clinic that is menopause and HIV, because that must be very unusual. I can't imagine there's

any in every city in the UK. There aren't very many. I think increasingly there is a recognition that it's an important area. And so there are HIV people who are training in this area. And I think that there are a couple of HIV services in London that do have facilities for women in menopause. Sometimes the clinics kind of run alongside gynecology clinics or with the gynecology. There is, I think, an increasing resource certainly in London. And also, I think, even outside London, for women who are living with HIV, who are also undergoing the menopause. But there's still, I can't imagine there's enough clinics to go around all these people.

I don't know, Jackie and your research, did that come up where people are. getting help or whether they're struggling to receive help. It did. And I think both in my research and the wise up workshop that we ran to look at these issues further, for many women, it was just so hard to get the support that they needed. And often when they heard that there are menopause and HIV-specific clinics, it was like, how do we get there? How do we get one of these? And there's a really strong sense in our campaign that came out of this and the We Are Still Here campaign of one of our asks in that campaign is for comprehensive menopause support and advice in every HIV clinic because it shouldn't be just if you're lucky enough to be in London or if you're lucky enough

to have a consultant in your clinic that has an interest, then you can get the care you need because for many, many women, there was a barrier to knowing what care you needed, first of all. So maybe you didn't recognise it was the menopause, maybe you thought it was something else. For any often, I find as well, that there was a real sense of, well, menopause is supposed to be hard. I don't want to complain. I don't want to take up anyone's time. I'm not going to bother the GP. I wouldn't trouble my HIV consultant. I'm just going to manage. And I think that's such a huge barrier in women's healthcare across the board really, but particularly for women living with HIV who are often used to managing side effects and just feel quite lucky to be here, lucky to have

the treatment and don't want to rock the boat. And I think one of the things we'd like to do with our campaign is to say, rock the boat. Absolutely. Harder until you get the care you need. because it doesn't have to be hard and you don't have to just live with these really difficult debilitating symptoms. And any healthcare worker, any physician who is not picking up on this in their patient and isn't offering the care, it's actually really letting them down. And I think it's important to say that and to do it in a constructive way, but to say actually we should be doing better because we can do better. Yeah, and it's so important.

And I think there's a bit of confusion almost because the menopause is a natural process for most women. and it happens just part of age. It can be enforced if obviously ovaries are removed or damaged as part of treatment. But because it's a natural process, people think, well, like you say, I'm not going to go to my GP because it's part of getting older. But actually, you can argue it's not very natural because we used to die quite soon after our menopause in the Victorian times and we're living longer. So certainly a lot of work I try and do is to empower women.

So either through my website or through my free app balance, even this podcast so people can learn. And then when they go to their doctor, whether it's their GP, their nurse, their consultant in the hospital, they can say, look, I've read about the menopause and not only I think these symptoms are related to my menopause, but also I'm worried about the health risks to me. I'm worried about my bones, my heart, my brain. Can we talk about it? And if their doctor or nurse or healthcare professional says, well, gosh, no, it's not my area, then they need to keep trying to find someone. Don't you agree, Necker? It's really important that women feel in control and it can be quite hard. I feel very nervous going to the doctor because

I feel I'm wasting their time and they're busy. But I feel because there's so little education for healthcare professionals, women have to almost educate themselves, which is a shame. But if they can do, then they need to keep trying, don't they, until they get the right help? Yeah, and I think that's where the work of the Sophia Forum is so crucial because, you know, one of the things that they're doing with this Wise App campaign and with other campaigns is to reach women, to empower them to be able to do that and to support with the peer support to support people who might not feel that they naturally are able to raise concerns. And this work is crucial, you know, without the Sophia Forum and organisations like it, women would just not be able to advocate for themselves. Absolutely. Yeah. Can I also add as well,

because I almost feel like we've almost gone one step ahead, and I'm going to my own experience, but I know that I'm not alone at all. You know, you spoke about the different parts of the body that's affected by the menopause. So the general ad about the menopause is it'll happen maybe around the age of 50, and you might experience night sweats and hot flushes. Well, I had neither of those, and I haven't actually in the four years.

I had no idea how impacted I would be by the menopause. And I still get overwhelmed at times with trying to get my head round what is going on with my body. And Louise, you know, I know that we've spoken about this in NECA. I know that you know my story, but to the public who don't. When it was first sort of put on the table to me about, you know, I think you might be perimenopausal. I was 43. I was in the middle of conversations about having children and was told basically, if I want children, you need to have them now.

I wasn't told that actually I could have started HRT then and still gone forward with trying to plan for children. I was put on a tablet that I didn't want. I asked for a patch because I take other medication and it was about managing and adhering. and her words were, just try it for three months and see how you get on. So I did. And when I went back three months later, just try it for another six months, even though I sat there and requested a patch. And at no point did I know that it would knock myself confidence in a way that I still find

really difficult to articulate. I just lost confidence. My memory is and was shocked bits. Just the things that aren't out there anywhere that prepare us, I became intolerant to dairy. I became intolerant to wheat. So I've had to make massive changes to my diet, which is fine. But again, with all that stuff, I went through a massive grieving process because I didn't end up having children. And it's like Jackie said, there was a massive lot of hope, loss of fertility. I didn't envisage feeling how I did about not being fertile anymore. And I never ever in my life thought I would look forward to having a period, but I did.

And I even said to Nekka the other day, you know, it's quite novel to have a bleed. Yeah, I mean, that's just like sounds super sad or insane, but that's the reality. And then as you know, it's like part of what I've been experiencing for the last year is hair loss. Now because I have a history of hair loss because of stress and trauma, it was automatically like, that's your history, that's what it is. And I'm like, no, I'm not convinced. You know, I do know my body. And this is where I will say to health professionals, however much we might not know a system or know everything about our health, we know our bodies. We know when something different is happening. And please listen to us. and please have a conversation with us, you know, and help us explore this, because I would just, I know, I keep saying it, I just was not prepared. Nobody prepared me. And so I'm still, because I'm waiting for some blood test results, I still don't know whether an element of this hair loss is linked to the menopause or whether it is just solely stress. And I'm somebody who is able to go back.

time and time again and say, I'm not happy. And there are a lot of other women out there can do that as well. But there's also always going to be a percentage of women who don't, because they have that narrative. I don't really want to bother them. Don't want to be a pain. I'll just suffer because that's what we do. Yeah. Well, my mother went through it. So I just, I guess I have to too. Yeah. I think there is that thing that, you know, my best friend or my mother or my partner, as someone else you know has got through it or got through it worse. So then I don't need to complain. I mean, it's been incredibly useful and informative.

And thank you so much for your time today to go through all this. And the overwhelming messages is about talking and connecting with others. And what the Sophia Forum has done as a charity and continues to do is so inspirational and fantastic. And hopefully when we launch our menopause charity, we can do some more collaborative work together, which will be really good, hopefully, and we can reach even more women. So we are going to go and record some individual or more individual podcasts so we can dig into each aspect that we've talked about a bit deeper because there's so many issues that we need to explore. And I feel we've only skimmed the surface and not done it justice. But I think actually this last half an hour has been really important just to get the conversation started, just to get people thinking, which is really important.

And no woman anywhere in the world should feel neglected because they're menopausal. And I think that's key. So just before we finish, I have warned you all that I would like three take-home tips. And because there's three of you, you can only do one to get my three take-home tips. So these are messages for women, really, or advice as to what you would recommend who perhaps have listened to this and realize maybe they are struggling and need help. So NECA, what would you say? I would say that women living with HIV should expect the same care and the same access to menopause support. as women who don't have HIV. We're in a situation where it's not easy generally, but it should not be any more difficult for women living with HIV and they should not have a lesser expectation that they can have their problems managed. Very good. Excellent.

So Jackie, what are your thoughts? So the We Are Still Here campaign is all about older women living with HIV saying we're here, we expect and we demand the care, the support, the information that we need to live well and really thrive in our older age with HIV. And I think part of that is making sure that we do break down the silence around issues like menopause and really provide the space and the support for women to really demand the care that they deserve and that they're entitled to. Absolutely. I think deserve is a really important word, isn't it? Every woman deserves help and advice. So finally, Sophie, what would be your

take-home message? I would ask, in the context of health professionals, in the broadest sense, Please don't be afraid in how to look after your patients living with HIV. In the same way that I have had to get educated about my condition, I ask the same that you get educated about our condition. This particular session is about the menopause, so we're asking you to access more information and education about the menopause so that you can manage our health better. This is going to be two.

start having conversations with your patients in their 30s about the menopause, not mid-40s. In their 30s, when you're having conversations about having children, reproductive health, these conversations need to be starting a lot earlier to help women prepare for it and manage it effectively. Yeah, I think that is so key. And certainly it's a lot of work that we're trying to do is to educate before you need educating. It's so important and I know it's been, understandably difficult, and you've been amazing just being so open in your own experience, Sophie, because it is difficult when you talk about yourself and how things have worked out for you.

But I'm so grateful for the three of you giving up your time and I really think this will make a big difference to a lot of women. So thank you. Thank you. For more information about the menopause, please visit our website, www.menopausedoctor.com.uk