The Dr Louise Newson Podcast - 069 - Managing Menopause as a New GP - Gregory Monk & Dr Louise Newson

Episode Date: October 13, 2020

In this podcast, Dr Louise Newson is joined by Dr Gregory Monk, a newly qualified GP. Gregory chats to Dr Newson about his experience dealing with the menopause so far in his career and during his training. They go on to discuss Gregory's perspective of the menopause how this has changed during his time as a GP - particularly his perception of HRT and how Dr Newson's work has been a key factor in this. Dr Newson and Gregory also talk about the importance of GPs learning and understanding more about the menopause and the need for HRT to be considered a low risk treatment with significant health benefits - rather than a high risk treatment surrounded by negativity and fear.  Gregory also stresses  that it should not matter whether your doctor is a man or woman; all doctors should be able to offer a good standard of menopause care to women.  Dr Gregory Monk's Three Take Home Tips: For Patients - Keep Knocking On The Door! There is increasing awareness of menopause in primary care and the health benefits of treating it. If you think you are having troubles related to the menopause, go and see your doctor! For Health Professionals - You are never too experienced to put your hand up and ask for help. Information regarding the menopause, its diagnosis, treatment options and safety are getting more and more accessible. Take the opportunity to use some of the great resources out there and consider the benefits of treatments rather than just the risks . For Everyone - Talk about it. The more you talk about it, the more doctors will talk about it and the more doctors talk about it, the better menopause care will be. 

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsom, a GP and menopause specialist, and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. So today on my podcast, I'm very delighted to introduce to you Dr. Greg Monk, who is a newly qualified GP, who interestingly emailed me a few months ago now, to say that he was interested in knowing more about the menopause and that he'd realised it was a big unmet need really for women as part of his training and his general practice work.

So, hi Greg. Hi, thank you very much for coming today. No, no, thank you very much for having me. Oh, no, it's great. So before we get started talking about the menopause, which is clearly all I ever talk about, just tell me a bit. So you're newly qualified as a GP, which is very exciting.

So congratulations. Thank you very much. You're working at Whirl, so just tell me a bit about why you became a GP or what your training has been like so far. Yeah, absolutely. Basically, medicine, I think, for many doctors, kind of comes on the cards at some point during your secondary school years. And was something that kind of had always been interested. But I'd always been dead set from 1617 on becoming a GP, which has always got a few looks initially in med school. But I still think it's the right option.

you know, went through med school in Liverpool and worked on the Whirl, obviously the specialties within hospital, but kind of had always just been dead set in GP and decided to just run straight through my training, do the GP, and so here I'm today. And it's been, you know, it's tough and it's challenging as all medical training is, but there's still something I absolutely love about doing GP and meeting all the different and unique people and characters that we come across. Yeah, I mean, I don't know about you.

I certainly find it a complete. privilege and honor to be a doctor and to share often very intimate things with people and it's often things that they've never told anyone before, not even their dearest and nearest loved one. And I don't think medical school necessarily prepares us for that, does it? It's all about disease and treatment, but... Absolutely. I think that's one of the things. You certainly, you know, you get welcomed into these people's lives and patients' lives and they could be so different from yours and whether that be through some aspects of poverty and deprivation or even the total opposite of that. You get put into so many different situations and it is an honour because,

you know, the amount of times that they tell you I've never told anyone that or I've never spoken to anyone and I think obviously we'll come onto with the menopause, you know, it's one of the big barriers, you know, women have to it. And so I think when you are a doctor and you get some of that, it's a really nice feeling because ultimately you're there to help them and support them and and learn a lot from them as well. Oh, absolutely. I think, you know, I have learned the most from my patients and sitting in any lecture or listening to any learned professor. And I don't know if you know, so I did hospital medicine before I went into general practice. So I've got MRCPA and I wanted to be a cancer specialist. And I look back really with disgust at myself is how

I looked at and managed people when I was in hospital because I would do clinics and I would be very much focused on if it was an asthma clinic about their inhalers, their inhaler technique. I wouldn't think about whether they even had a pet at home that might be triggering their asthma or whether they were looking after a family or what their job was because it was all about the disease and with maturity and actually medicine thankfully has changed from being less paternalistic but you know once you think the disease is only part of why they're coming to see you it really makes a difference doesn't it and when I went into general practice actually my trainer said to me well Louise I think you're not going to be very good and he he said because people that have done as

of hospital medicine often do really badly as GPs because they're only focusing on the disease. And that reverse psychology worked really well. Because as soon as he said that, I thought, right, that's it. Yeah, he took to me. But it was really, he kept saying to me, which I'm sure you do in your practice, is asking people, what has brought them to come and see you? What is their concern? And it's something I've never been taught before.

And I thought, right, I'm going to try it. So I had this young lad who came to see me once. He was 17 and he had a sore throat. And I thought, what a waste of time. He's had a sore throat for a day. And he's coming to see me. And I was all defensive. And then I thought, no, I'm going to remember what my trainer, John Sander said to me.

So I said, well, what brought you here today? What's worrying you about your sore throat? And he said, my mother's actually in intensive care and she's really poorly. And I've been told that if it's an infection that's causing my sore throat, I can't go and see her. And I feel quite emotional. talking about it actually because I thought, oh my goodness, if I hadn't asked, I would have dismissed him. And he just had a viral infection. He had no past. He had no temperature. And he was so relieved to hear that. And it really stuck with me because I thought, actually, we can really misjudge people. And like you say, we don't know anything about these people when we come. And as an outsider, you can think someone's very privileged or they're not privileged. But how they view their life and how it's affecting them has such a big impact on the way that they manage. a disease or think about a disease or worry about a disease. And I mean, I'm hoping your training

was probably better than mine in that respect. I don't know. Well, they certainly put a lot more focus within the exams, within the training itself around this idea of ideas, concerns and expectations and addressing that. And I think initially for every doctor, when you first get told that, you stick it on the end of your history and you think, oh, yeah, well, that's the the bit at the end that you do. But actually, it makes such a difference. And the early you can get it in, the early you can understand

why someone's presenting to you and the bigger help it is. It's interesting you say about the cancer care and oncology, that was certainly, you know, an area of quite a bit of passion of mine. And during my, even my training, I've spent a couple of years working at our local centre,

Class Bridge Cancer Centre. And I have to say there, you know, I think cancer care is something that really, to doctors, kind of shows the way in which people deal with their health varies. to such a great extent. And we can walk in there as doctors, have an opinion on something,

have a thought about how we would react or how they should be expected to react. But you can never predict it. And I think you've got to be open to everyone's thoughts, everyone's wishes about how they want to manage the health. But it's also important to support them with all that right information to be able to do it. And I think the key to getting to that point

is obviously understanding why are they coming in, what are they worried about, and what were they hoping to get from you in the first place? Absolutely. And I think, you know, you've cracked a lot of the consultation if you've got that out on the table early on, because very much you can be thinking one thing. And then at the end of the consultation, they say something completely different or they're worried about it. Or they've read something. And I think, you know, I'm quite old, really. So when I did medical school, there was no internet. Can you believe that? I believe that at all. So I did an extra degree. I did a pathology and immunology degree, and we had to go to the library and get these journals. We had to blow the dust off the books that they had been bound in. It was so prehistoric. And so patient information leaflets were not really a thing when I started.

It was very much you would read it in Reader's Digest or you might read it in the newspaper. Whereas now you just put in a word and Google will help and really help transform a consultation because our patients can be more empowered. But it's also very easy for them to be given the wrong information. And then it's very hard. Do they believe you as a healthcare professional or do they believe something? or do they believe something they've read in a newspaper or they've heard from someone? And that's very hard, I think, for people because, you know, it's not Dr. Google, is it?

But it can often make a difference. So, I mean, I think that brings us quite nicely onto the menopause, which clearly we need to talk about, is because the menopause has not been spoken about for such a long time. And even when I set up my website, there were very few websites even mentioning the word, let alone what it is. And certainly when I was at medical school, when I did my hospital training, when I did my GP training, even when I did six months ofz and guile, I had no formal training about the menopause, which clearly it directly affects half the population. So when you were at medical school, Greg, did you have any formal menopause training or part of your general practice training? No, I think we didn't really. And it's certainly not kind of the formal training.

I guess if you think about the current training of a medical student through to a GP, you know, you spend five years learning, as you say, about the pathology, the physiology of the human body, in which you will become aware of menopause if you've never heard of it before, but you won't deal with any practicalities of it. And then you move into hospital medicine, which again, it's not a focus in anywhere of hospital medicine. It's to do with acute care and things like that. So then you're seven years through your training, you're aware of the men of course as a condition that women go through and maybe some of the

physiology around it but it's then actually in that when we move into primary care as part of our GP training where you possibly expect it to fit in a little more and it's very much I would say probably more anecdotal learning and experience on the job and that's the case for a lot of general practice because there is so much and we are generalists and so we aren't going to know everything, the ins and outs everything. But at the same time, with something that affects so many people, you know, inherently 50% of all the population, and with one in four women having severe symptoms, you know, with menopause, we must be constantly seeing it.

And yet we, I can't think back to a lecture. I can't think back to a particular session. And I've definitely had tutors and supervisors give me some advice with that, but no formal teaching and I think, you know, if that was the case for you and that's still the case for me, there's still some room for that to change. Absolutely. And, you know, it's outrageous really because I was doing some research for a presentation I was giving at the Department of Health recently. And I was looking at the benefits of taking HRT for reducing risk of heart disease compared to well-established treatments such as blood pressure treatment or a statin, a cholesterol

lowering drug. And actually, HRT has more evidence and it's more likely to reduce heart disease in postmenopausal women than taking a blood pressure treatment. Yet, I don't know, I had hundreds of lectures about blood pressure. And even statins is a bit controversial now. It was less controversial when I was training. But actually, doctors also get paid for lowering blood pressure, for reaching targets, for cholesterol levels and so forth. Whereas menopause is almost, HRT is like, well, we can give it for symptoms, but that's about it. But it's really not that at all, is it? It's about replacing the hormones and thinking about reducing future disease risk.

And so I feel it's not even a general practice problem. It's a problem for any doctor who sees adult women, isn't it? Absolutely. I think where this kind of started for me and what led to kind of get in touch with yourself or to be a little bit further down the line was, I was seeing patients within my practice. And I couldn't help but feel that when I was seeing them, there was a knowledge gap.

There was that thing missing that meant that, I clearly just knew that I needed to learn more and know more about the condition. And I think when you add that on top of what was wrongly a preconceived idea of HRT is this risky, hazardous, kind of problematic thing for GPs to give, which was founded on nothing, which was founded on no particular thing apart from possibly what I picked up throughout my training, that suddenly it just didn't feel right, you know, that this was kind of what the situation was. And I think when I then started learning more,

I used actually one of the first things I used was your website to point me in the direction of things. And then started learning some of the practicalities of prescribing with that. And then it was actually your talk last year at the RCP conference because I think you were the first lecture after the keynote. And, you know, I left kind of feeling that we have a responsibility.

both as male GPs, as female GPs, as general practitioners, and as you say globally as doctors, to address this situation with menopause. If I don't feel like I've got enough knowledge, I'm sure that lots of people don't feel like they do. And I actually left feeling so positive about the treatment for menopause, the impact that we can have on women's lives. And actually, I think one of the key things, the more and more I've learned through this process, it's as you say the benefits to health. It's not even just so much the treatment symptoms is the benefits to health,

which every time I hear any fact, I can't believe it. You know, all cause mortality reduced. Average life expectancy increase, you know, reduced risk of cardiovascular disease, osteoporosis. I just, I find it phenomenal that this kind of feels like new knowledge and new information. And you just can't think of a treatment that equates to this. No. And there isn't, is it, is there? I mean, I was doing a talk actually for the World College of Obson Ginez a while ago,

and it was about media influence. And it took me a long time to do because I'm not very technically savvy, and mocked up a pretend newspaper for my last slide, and it was saying new treatment that's cheap, it's effective, we've got good data, it reduces risk of all the diseases that you're saying, and women can take it forever, and it helps people get back to work, function better. And, you know, if I said there's this new drug that we've produced, everyone would say, can I have it, can I have it? But because you say, well, this is HRT, we've got this generation or generations now of people and healthcare professionals who say, no, it's too dangerous.

So they'll try everything they can to not prescribe it. But meanwhile, these women are coming back and forth to their surgeries. And were you finding that women were knowing it was the menopause or was it you thinking about it when you're piecing together with the jigsopuzzle? I think my experience for the first few years was a case of it would have to pretty much be a woman presenting saying I think I'm going through the menopause. However, one thing that kind of really hit me quite early on after I started learning about it was this idea of, you know, we need to suspect it and we need to look out for it because I've now think back and I see so many cases of whereby, you know, the most common one being, you know, we're treating things like low moods and anxieties with recurrent SSRIs and not having any joy and things like that and you just think okay let's say it wasn't the metaphors it was causing that you know have we considered that it could have been and have we considered the treatment and

I think now I'm increasingly more proactive about thinking about it and I think the one thing that I was thinking about when you go to the male the male GP aspect as someone who you know male GPs do typically see probably less women's health problems. That's probably more of a traditional thing and there's nothing up with a woman choosing to see a woman for her health. In the same way, she should be able to receive a book air from a man. But then I was thinking of myself, is that enough kind of excuse really? Because actually we see plants, I'm sure the numbers are far more equal in terms of those who present with depressing symptoms or low mood or joint takes and pains. And actually, there's definitely some of them that where we buy, we

should be considering perimenopause and menopause. Absolutely. And I think because traditionally the menopause has been dealt with by gynaecologist because they deal with period problems, actually menopause isn't a period problem because most people don't have period. And I understand if a woman has a sensitive gynaecological problem or if they have even, you know, vaginal or vulval symptoms, they might prefer to be examined by a woman. Obviously men can examine as well. But it's looking at beyond it, isn't it? It's thinking about, like you say, joint pains, muscle aches, migraines, urinary tract infections, you could not say, oh, I'm a doctor, but I don't deal with urinary tract infections.

You just wouldn't do it. So actually, those people that say, oh, well, actually, it's only female doctors that should learn about the menopause. It's absolutely not right, is it? And I think it is about trying to empower women with the right lunge so they can direct the consultation. And I know for decades, I will have seen menoples of women and not thought about their hormones because they wouldn't be telling me it's their hormones.

They would be telling me that they were having palpitations, and I'd be thinking, oh, right, they need heart investigations. Or their headaches, and I'd be thinking, well, they need a scan of their head. You know, because you're very focused in the way we've been taught medicine is about systems. So someone's got dry eyes. We see an ophthalmologist. Someone's got Burning Mouth syndrome.

Let's send them to an ENT person. But actually, all this could be related. So now you're seeing more women and thankfully recognising it, not just for symptoms, but as a long-term health problem. Are you more confident in prescribing HRT? Yeah, definitely more confident in prescribing it. I think I do create little kind of little rules for myself with it to try and simplify and make my management more clear. So, for example, I have decided that a 10-minute consultation is not a time to take the history, to sign an examination, counsel them and start at HRT. it would be the wrong way to do it in my eye.

So I very much have the kind of at least a couple of consultations to get them started. But I'm very clear they shouldn't leave. Patients shouldn't leave it. They should get back in touch with us. I think with regards to subscribing of HRT, I have become more confident, primarily because there's lots of resources now, with your website, the Women's Health Forum,

you know, the different courses and things like that, that basically says that if we're putting them on a topical estrogen, plus or minus the progesterone, and ideally the micro and ice progesterone, then the risks we're dealing with are very low. And I think if you can get that in your mind, you suddenly feel more comfortable with what you're doing. Absolutely.

Yeah, I still feel like I probably double-checked things quite a lot and I go over it quite a lot. But my threshold now for giving treatment is lower and actually I feel more comfortable in giving that advice. And now when I see oral preparations come through on prescriptions and things like that, I can't help but feel like maybe there's an opportunity here to rediscuss these things. And if they end up wanting to stay on it, they want to stay on it. That's fine. But it's about, you know, just feeling empowered to make some of those calls to put them onto a nice and safe kind of treat. Yeah, and I think it's really important because as doctors, we're constantly looking at weighing up benefits and risks for everything that we do, everything that we advise, everything we treat.

And of course, every medication has a potential for side effects or contraindications or, you know, you know, and looking at other medication. And traditionally, HLT has had a lot more of contraindications because, as you know, it was a tablet estrogen and the synthetic progestogens, a bit like the contraceptive pills. So if certain medications like epilepsy drugs, there's contraindications with the older types. If someone's had a clot, for example, you can't give an oral estrogen.

Whereas now we've got these new, well, they're not that new, they've been around for years, but there's, like you say, through the skin estrogen, the natural person, progesterone, there's very, very few people that can't have it. But actually, when we prescribe it as GPs, it still comes up with warnings, doesn't it? So that's quite scary. Yeah. I actually picked out up in the new course that was released by 14 Fish, the Metaphorous and Confidence

course. It talks about that, and it suddenly hadn't really clicked for me before. But, yeah, you would still get those warnings and then suddenly you back to that fear again. Well, that's right. So I constantly think about barriers to prescribing. And actually, we get a lot of pop-ups, don't we, when we prescribe. certain blood pressure treatments or aspirin or something like that. And we're so confident in what we prescribe, we know we can ignore them. It's nice to have them as a warning. Sometimes it will make us

think, but often they're over-cautious warnings, whereas actually these warnings are incorrect, and it's because they're grouping all types of HRT together. But if people aren't confident enough with prescribing and they're a bit sitting on the fence, then try and they get this warning, you can see how they come back down and think, no, I can't do it. And I've definitely been in that position, I think, probably before I started to engage further with it, I've definitely thought. And they're throwing supply issues. Yeah, well, that's right. And that's been a real problem. It becomes even more challenging. But thankfully, that seems to be okay at the minute. But are you now seeing women who have been on HRT and noticing a difference? I am. I would say just because of the

cycles of training that maybe I've not got some of that longevity throughout to see it. But what I do see quite commonly or what I certainly saw more of was, patients who I suddenly started raising menopause with discussing the potential of HRT, even commencing HRT, and even though I've sometimes gone, you know, I need to just check things, I need to look up something or something. They feel good about the fact that your doctor's taking this into account and starting that process. And I think I've definitely seen some patients who've come back and said that HRT has just been amazing, it's been great.

I've had that somewhere they haven't quite noticed the difference quite so much. but then there's just another level of confidence around actually well maybe I need to increase the amount of estrogen I'm giving you or do I need to try something you know are that perhaps you're sticking or they do some little things and so I think hopefully now I'm in a place where I'm going to be here for a bit more time you know I will hopefully see kind of more of that and I think you know some of it will be that we do see less women presenting overtly with menopause to male doctors but I think definitely I will see that more For me, there's definitely been a couple of times as well where I've looked to want to prescribe something like testosterone or at least had it in the back of my head that potentially we're not quite there, maybe something like that. I think that is where, for me, is going to be a next step in the sense of learning and trying to get more comfortable with it because that is something again, you know, I've seen your lectures on it and so on that it's challenging when you get told things are off licence, when you get told these different things. But I think with the right learning and if more GPS see it being prescribed, you know, coming. Oh, yeah, I totally agree because, you know, a few years ago I had never even prescribed estrogen as a patch or gel. And then a few years later, I'd never prescribed testosterone.

And I didn't even know women produced testosterone because it was nothing we were taught. And then when you look at the actual data and you see that women produce more testosterone than estrogen before the menopause, well, how shocking we're not giving our own hormone back. and especially for young women who've had their ovaries removed, they often really miss it. And as you know, we prescribe a lot of medication off licence. So a lot of things we prescribe for children don't have a license, but we know they're safe. And there's something about hormones, especially HRT, that make people quite scared because of all the negative connotations that have gone with it for so long.

But it is having that confidence. And actually, I find the doctors that work with me in the clinic often haven't prescribed the doses because we often do increase the doses, especially with the younger women of estrogen, often start testosterone. And then quite quickly, they go, goodness me, these women feel amazing. And what's really rewarding for me as a practitioner, is not only do women feel amazing,

not always amazing, but they feel often better. But more importantly, I know, and they know, that their future risk of disease is reducing. And I spent a lot of time doing diabetes clinics, and I often found it quite frustrating because I would say to these people, you need to lose weight, you need to stop smoking, you need to stop drinking alcohol or reduce your alcohol and take this medication and we'll watch your blood sugar come down as you improve your house.

They'd come back three, six months later and they hadn't taken the tablet because they didn't want another tablet. They carried on eating McDonald's. They're smoking maybe 18 and so 20 cigarettes a day. And I just thought, this is really painful. Whereas actually women often, once they've got their right dose and type of HRT, they'll say, do you know what, I'm running again, I'm exercising, I don't need to eat unhealthy, I don't have these sugar cravings, I'm not drinking in the same way because I was drinking to numb my

symptoms before. So already women's lifestyle has improved just because they're feeling better as well as having estrogen, which we know improves their various risk of disease. So actually for a doctor, it's very rewarding. And we also know from research that we've done that women are far less likely to come back to their GP. And I did some research of 5,000 women and we found that 10% of them had seen at least eight different doctors before they had the diagnosis of the menopause.

Wow. Which is quite something, isn't it? If you think, not only do these poor women have to probably take time of work, make the appointment, but it's such a waste for GP resources. And it's having that in your mind, isn't it, to ask those questions? And people won't always think it's connected to their hormones.

You know, why would their migraine be affected to their periods. Why would they tell this busy Dr. Monk that they're having the period changes when they're coming with migraines and you're busy and they're busy? But as soon as you ask the question, it will all be there for you, isn't it? Absolutely. And I think then it can open up their thoughts and then they may start to themselves, you know, kick on with that and start to think, and actually, yeah, I've got this and this and this and actually all weeks in.

Absolutely. And I think it's very interesting because quite rightly you say 10 minutes is really not long to make a proper diagnosis, to really enforce women and then to give treatment sometimes as well. But actually a lot of women find it really reassuring to know that their symptoms are connected, that they haven't got dementia, that they don't have to go on antidepressants, that they can have some information and then having a couple of appointments close together will really invest in their future health. So it's worth the investment.

And some doctors say to me, well, I'm just too busy. they need to go to a specialist clinic. Well, that's not a good use of resources, is it, in the NHS? No. I mean, it brings me on maybe as a question for you, actually, is we see in general practice a lot of, we do refer a lot of things where gatekeepers to specialists, we couldn't think,

do you not think it'd be great to the menopause? Was the GD specialty? You kind of think now what is kind of our specialty? Our specialty is being this gatekeeper to everyone and trying to assess acute and chronic need and stuff. You can't help them feel that rather than put them more, on a waiting list for Guy, and even three months time or six months time. Yeah.

Well, there will always be a role clearly for a specialist. Yeah, I mean, I totally agree with you, Greg, because actually in my clinic we have, I think, 15 GPs now working with me. And we're all very used to people having other conditions. So if someone comes and they've got rheumatoid arthritis and they're on something like metachyxate or they've got migraines in there on an anti-epileptic treatment or something for their migraines, we're not phased because we're very used to, obviously, like you say,

dealing with a whole person and their diseases associated with them, whereas gynecologists are not trained in that way. And so I think it definitely lends itself to be done in the community. I actually think it probably even shouldn't be GPs. I think it should be nurses and pharmacists that should be doing it. Because traditionally nurses have been fantastic for contraceptives and for asthma. They have revolutionised asthma care, diabetes care. They are so good at looking at sort of formulas and protocols

and they're very structured. Doctors, we're very chaotic and we don't really conform very well in the same way. And also, nurses often have a 20-minute appointment, and that extra 10 minutes makes a huge difference. So I've got four nurses who work with me at the moment, who are fantastic and we're getting more, because they can help in that way. And actually some women find it less threatening almost to go through with a nurse.

And then I think the GPs should be seeing the slightly more complicated patients. And then people like me who's a menopause specialist should really be seeing women who have had breast cancer who are considering taking HRT because that is a very specialist area. But in my clinic, every day we see women who have had their ovaries removed 10 years ago and not given HRT. We see women who have just gone through the menopoles at 51. they're now 58, they've given up their job, they've given up their partner, they can't function and no one's giving them HRT and that's wrong. So it's getting the education right early on, isn't it? So you're thinking at it, when you're a medical student, you're thinking it as a

marker for future illness in the same way as obesity isn't a disease, but it's a marker for future illness, isn't it? And it's shifting. And I don't know if you've got any good ideas, how much more we can do to try and shift, make a change. Well, I think clearly what you're doing with your work is making a difference in that, you know, I was sat there at that lecture last year, and there was probably a good mix of both male and female doctors and GPs. And everyone who spoke to after, we spoke in GP teaching, we spoke after from our supervisors to our tutors, to everyone else, people only have positive things to say about it.

And actually, we're kind of inspired to kind of make some changes to have a thing. there is this Metapause and Confidence course online that now people can access, which is obviously going to be great. The question is, is how do we make that next step? And I feel like GPs do have responsibility to try and kind of learn more, engage more. And I think initially that will be down probably at practice levels at the time, and it will be part of training. It's about probably getting it into the new GPs,

but also giving opportunities for more experienced GPs to have opportunities to learn as well. And I think that'll be a lot through some of the traditional methods. But obviously the big thing being that as well, the more patients talk about it, you know, the more helpful would be. Absolutely. Toby Green, I think it's also knowing that we won't get it wrong. You know, some people I was doing a lecture this morning actually, and people were saying, well, how do you know this person hasn't got fibromyal or hasn't got a brain tumour when they've got

worsening headaches? Well, actually, if you give them HRT for three months and they don't improve at all, then let's be thinking about other things. It's not dangerous to give HRT, actually. And you can't really start it too soon. So starting it in the perimenopause or giving some estrogen when someone's got PMS on those few days before their periods start.

It's actually very safe. We give some quite nasty drugs, don't we as doctors? And I think there was a quote in one of the lectures or teachers that I see. So why can't we do it in primary care when it's such low risk? Absolutely. Yeah. And I think if we can get across to enough GP, and enough colleagues, that what we're dealing with here is ultimately a low-risk treatment

that improves people's lives and can be reviewed and can be assessed and has health benefits, then we'll eventually. We'll change the world. Oh, brilliant. That is such a great place to end because I've really inspired, and I think, you know, you are the future generation of GPs, so we've got to stick together and try and do as much as we can. I'm really delighted that you've given up your time and I know you've had to change your shift to working to do this podcast. So thank you very much. But you're not allowed to escape until

you've given me three take-home tips. And maybe three tips really for junior doctors who are worried about HRT and the menopause. What would you say to them? So I think one of the first thing is, and possibly extends beyond junior doctors, is that regardless of your experience or, you know, whether it be very little or even an experienced GP with something like the menopause, it's okay to go. Things have changed. The evidence has changed. The information available to us has changed.

Have a look. Have a look. Have a read. There's so many different resources. And as soon as you start, we're currently seeing the positives, the facts, the stats around it all, you will start to think more and you start to practice differently. So I think that would be probably one of the key ones for doctors. I think from a patient perspective, what I would say is, is keep knocking on the door.

You know, it shouldn't be a case that you need seven or eight consultations. But at the same time, if you do feel potentially shrugged off or that it hasn't been maybe considered, as frustrating as that can be and shouldn't be the case, speak to another GP or speak to someone else, because there will be people with a different skill set and a different breadth of experience that will be able to help. And I just really encourage you to do it. And if that means you have to say, could it be the menopause or it shouldn't necessarily be the case, do it because, you know, the doctors will hopefully over time get better and better at this. And I think the final thing would be, and it's something I do as a doctor and I hope

patients do more through whether they've seen you on your book or whatever it may be, is to talk about it more. Talk about it to your friends. Talk about it to family members if you need to. doctors talk about it to other doctors because we'll all still have worries, we'll all still have thoughts and be unsure about things. If we talk about it more as patients and as doctors, our experience will grow and will feel far more comfortable when it comes to prescribing and hopefully reaping the benefits of treating women how they should be. Brilliant. I love them. Absolutely brilliant. Just fantastic. And I'm just so grateful that you connected to me and you came to that lecture that day. Yes, absolutely. It was brilliant.

Thanks ever so much. No, thank you very much your time. Thanks always. Thanks, Greg. For more information about the menopause, please visit our website, www. www.comptor.com.