The Dr Louise Newson Podcast - 070 - Bone Health & World Osteoporosis Day - Julia Thomson & Dr Louise Newson

Episode Date: October 20, 2020

In this podcast released on World Osteoporosis Day, Dr Louise Newson welcomes Julia Thomson, who manages the Royal Osteoporosis Society's Specialist Nurses Helpline. Together, they discuss what exactly osteoporosis is and identify some of the major risk factors of osteoporosis. Julia and Dr Newson also talk about the various treatments options available for people at high risk of fracture; including hormonal therapies and non hormonal treatments such as bisphosphonates. DEXA scans are also an effective method of diagnosing osteoporosis and Julia discusses this along with the importance of a well balanced, calcium rich diet and regular exercise throughout life. Dr Newson chats to Julia about her work at The Royal Osteoporosis Society and what the charity can offer people with concerns about their bone health and World Osteoporosis Day. Julia's Three Take Home Tips: Make sure you and your family are getting the nutrition you need to keep your bones healthy.   Remember that bone likes to be exercised! Always try to keep as active as you can. Talk to your GP if you feel you may be at risk of osteoporosis. Find out more about The Royal Osteoporosis Society here.

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsome, a GP and menopause specialist, and I'm also the founder of the Menopause charity. In addition, I run the Newsome Health Menopause and Well-Being clinic here in Stratford-upon-Avon. So I want to welcome to my podcast today, Julia Thompson, who manages the specialist nurse's helpline for the charity, the Royal Osteoporosis Society. Some of you might know it as the National Osteoporos Society, but it was renamed in the recent past. So welcome, Julia.

Thanks for coming to the podcast. Thank you for having me. Thank you. So some of you might be thinking, well, this is a menopause podcast. So why hell is she talking about osteoporosis? And even what is osteoporosis? So I just wanted to talk a bit about bones

because a lot of women think about menopause as something that causes some flushes and sweats. And maybe some people know there's an increased risk of heart disease when women don't have hormones in their body. But osteoporosis, just to explain what it is, Julia, because a lot of women get very confused as to what it is. So just to explain what it is, if you don't mind. Well, the consequences of osteoporosis are really quite simple.

We break bones more easily than we should. But the lead up to that is a deterioration in bone strength. that really starts quite early. And I think certainly, you know, menopausal age is a really good time to start thinking quite seriously about risk factors, starting to think about discussions with GPs, about risk for osteoprocess and discussions around bone density scanning. Of course, we can be thinking about it well before menopause. And I think we all should be just thinking bone health and educating ourselves about the sorts of things that we all have in our power to influence, which are going to have an impact on us later in life and reduce the risk of

those awful fractures, which, you know, I'm sure everybody hears about elderly friends and relatives who've broken a hip or noticed height loss and the curvature that's associated with the condition. And, you know, if we can do all we can during our younger years to keep our bones strong, keep our bone in the bank, if you like, so that when we all start to lose, which unfortunately we do, we all start to lose bone strength, bone density. We're losing from a higher point, really. Yeah, that's a really good point. Is it because osteoporosis doesn't really cause symptoms, does it? There must be millions, if not billions of people around the world with osteoporosis that they don't know, like you say, until they have a fracture, do they? Absolutely.

The first sign. So unless you've had a bone density scan, or you've broken a bone easily, you don't know that you've got the condition. So being aware of your risk factors is a really important thing, I think, to educate yourself about what sorts of things might put me at increased risk. And what are the centres then? Well, being female is a big age. You know, as we get older, all of us, as I already said, we'll lose bone. But there are things like smoking and alcohol intake, which we can control ourselves.

But also there are some medicines that are used in the treatment. with other conditions, some medical conditions themselves can all impact negatively on our bones. So not letting it preoccupy ourselves, but just being aware that, oh, I'm on this drug, therefore I may need to think about bone health as consequence of taking that drug. Because there's lots of things people can do. So one of the big drugs is steroids, isn't it? Yeah. Lots of people have been on steroids in the past.

In fact, I saw someone recently in my clinic who'd had ulcerative colitis, and she'd had lots of courses of steroids. and didn't know that it could affect her bone strength. Yes, I think it is something, because as you say, people have been on them a long time, and maybe those discussions that they had right back when they first started taking them, perhaps didn't happen in those days. So they've been happily taking these steroids and not really realizing that these can impact quite severely on bone strength. So, yeah, we don't want to leave it too late.

I think that's the point. So you said women are more prone to us dearly. So why is that? Well, I think there's just. things. I mean, firstly, women don't achieve the same level of bone density when we're all building our bone strength during childhood and adolescence. And we get to the grand old age of 30-something and we plateau. And in those years when we're building our bone strength, women don't accrue such a high bone density as men. So we start off with that against us. And then obviously,

as women, we go through a rapid period of bone loss associated with menopause when we lose that protective effect of estrogen. So that coupled with the lower peak bone mass, if you like, it's a double whammy, isn't it? It's a double whammy. It's still common in men, though. And I think that's something that's important to just to look after our male relatives and friends, because although, you know, it's less common, it's still one in five men will have a fracture. So one in five, that's 20%. That's a lot, isn't it? And then on the role of the Precious society, the figures for women are huge. Just remind me what they are. half, you know, one in two. So these are big, big numbers. And, you know, certainly these are

fractures that occur when we're older. And some of them may not be due to osteoporosis, but one in two women will break a bone mostly due to osteoporosis and one in five men. So really massive. Yeah. And it's not just, so one of my daughters is very accident prone and she's broken various bones over the years. But she's young, she's fit. She, you know, gets on. It's not quite the same, is it, when you have an osteopotic fracture? Talk around, for example, if someone has an osteoporic hip fracture when they're elderly, it does cause death, doesn't it? It's not just springing back.

Exactly. It's really serious when we're perhaps quite fragile anyway and, you know, just about coping, perhaps, maintaining independence at home. And having a fall and breaking a hip is a massive assault, really. And I think obviously there is an anaesthetic involved with the treatment of the injury. There's a stay in hospital and all of these things for somebody who's already quite elderly and fragile may mean that they can't return to independent living or unfortunately they may not survive. So these are very, very serious injuries in a population of people who are really very vulnerable.

Yeah, absolutely. I mean, I've certainly seen lots of elderly men and women who have just about being okay at home, just tottering around, getting into and then they trip over the carpet or a rug or up the step. And that's it. They never go back home again. And it's dreadfully sad. But a lot of people think about hip fractures and maybe wrist fractures because that's very common as it, wrist fractures in women. But it's the fractures that you don't know you've had that actually are the ones that I'm scared about. So my back. So talk me through what problems people have asked to raise to their spine. It's the hidden one. These are people perhaps who don't always go to the GP. They perhaps living at home, perhaps just thinking this is a consequence of. aging. You know, mum lost height. I'm now losing height. I've got back pain. I can't reach the cupboards anymore. My clothes don't fit. I really can't find clothes that suit me. We know, we really hear really sad stories from women who can't bear to look in mirrors because they've really

taken care of their appearance throughout their life. And suddenly, you know, they have a protruding tummy, which is quite common with fertile compression fractures where everything's pushed forward. And there are huge numbers of people that we just don't know how many there are because these are people who don't, they're not counted in hospitals. No, that's right. Yeah. And they have so many needs, really. And a lot of women I've seen over the years,

they quite often have problems with breathing because they're so bent over. And also even digestion, can't they? Yeah. All of these are consequences of a shortened torso, really. If you imagine that the spinal column is shortened. So everything that exists in that space is having to exist in a smaller space. And tummy gets pushed forward. As you say, people become breath.

even some people have to spend a penny more often, can't tolerate big meals anymore. So there's lots and lots of consequences of these fractures. Yeah. And treatment is quite difficult, isn't it, actually? You say obviously if you have a fracture, you can repair, but then that can be quite hard sometimes because the bone around is got thinning of the osteoporosis. But you can't zap the whole body in an easy way, can you, to build bone? No, it's a tricky one. think the treatments for osteoporosis really are aiming at working on that bone loss process that we've

talked about, perhaps slowing that up. Most of the treatments for osteoproasis work on the cells which break down bone and slow up their action. But I think we get lots and lots of calls from people who get really quite obsessed with this and I want something that builds bone. And I think what we have to remember is that in all the studies where these treatments were found to be so effective, people didn't break bones so often. And it's the fractures, we have to remember. And if you've got a high risk of fracture and you're on a drug treatment, that fracture risk is reduced.

Yeah. And it is important, because it's not, it's obviously what our bones look like, but it's about what they're like when they fall. And if the bone is almost too hard, someone said to me once, it's a bit like glass, it will shatter. Yes. So you have to be really careful. You want bones a bit bendy, like with baby's bones are very bendy.

So if they fall, they're less likely to. they can't they? So it's finally a balance, isn't it, between the strength and the sort of architecture of the bones. But obviously, I'm very biased because all I do is think about hormones, but, you know, estrogen helps build bone, doesn't it? It's very important. This is why you're saying this rapid bone loss that occurs during the perimenopause and menopause, and it's very quick, isn't it, actually, for a lot of people. Yes, yes. Because of the low hormone levels. that occur. And also in men, obviously, testosterone is very good for building bone. And we know

around probably 30% of men have low testosterone. And I'm sure they're probably similar to the 20% or so of men who have osteoprotic fractures, isn't it? I'm sure there's an overlap there. But women have testosterone as well, of course, and we produce more testosterone than estrogen. And there's been some very good work showing how testosterone is beneficial at reducing the process too. So it can't be neglected. And especially with younger women, it's really important, isn't it? So as a lot of you are listening, know about one in a hundred women under the age of 40, you have an early menopause. And sadly, a lot of these women are not given HRT, they're not given any hormone treatment. But we know from the guidelines they should because of reducing

future risk of fractures. And the longer they have without hormones, the more likely they are to have osteoborice or something. And I think also, you know, when we're treating younger women who have gone through menopause early, I think using a hormone replacement at that time is going to treat, obviously, the menopause or symptoms they're getting as well as keeping their bones strong. And I think also that's a benefit because then we can hold off using the non-hormonal treatments until later in life. Because one of the things that's come out over the last few years is good evidence that we can't use

these drugs continuously for many, many years. So it could be that HRT is the best choice in a younger woman and then you can move on to other treatments later in life. Yeah, absolutely. And certainly the evidence very clear that women can continue taking HRT because you're just replacing the missing hormones. So it is very different because the non-hormonal treatments for osteoporosis, certainly when I was doing hospital medicine in the 90s, I would give them to everyone because we've had fractures and you would prescribe the bisphosphonates and then they realized that there were some problems with some of them, didn't they? And so now often we give a drug holiday so people have them for three or five years depending and then have time off. And we don't know the long-term

data in the same way. Obviously, HRT's been around for decades so we know that it has more benefits and risks and it's important. But it's also important as a doctor that you've always got something else up your sleeve, isn't it? Because, you know, there are going to be people, even those on taking HRT who are going to develop osteoporosis. Nothing is a guaranteed prevention. So it's useful. But if I was choosing a bisphosphonate for myself, I would want to try other things, especially if I was young, and save it for the time that's really important. I don't know if you agree. Absolutely. Yeah. Yeah, I would agree. I think leaving non-hormonal treatments really until people are at high risk of fracture is the way that I think that they're used now. We know they work relatively

quickly and as I said we can't use them for a lot, hugely long periods of time. So let's reserve them for when we really need them, keep our powder dry if you like. Which is really important. And then there are other ways, aren't there, of keeping our bones strong. So other than obviously HRT or the bisphosphonates or the other drugs, we also, you were saying about ways of preventing bones becoming thin. So diet is really important. important, isn't it? What do you think? Well, throughout life, I think, you know, we know that a good well-balanced diet is important for so many reasons, but it's hugely important for bone health and obviously the big nutrients that we always think of, a calcium and vitamin D. But there's a whole range of other

nutrients that we need to keep bones strong. And I think if you're having a good well-balanced diet with all the food groups in the right ratio, you can really feel reassured that you are really setting your bones in a good state. So yes, it's very important. And obviously there are supplements, but they're useful, certainly if people can't get what they need from their diet. Yeah. So, I mean, certainly everyone, men and women and children should take vitamin D, shouldn't they? Because it's very hard to get back. Yeah, certainly. It's not much in diet, even in the best diet in the world. It's still, certainly over the winter months, it's very hard to get enough sunlight, isn't it, for vitamin D? Absolutely. So vitamin D, but some people think, well, they should take calcium as well.

But actually you should be able to get it from your diet, shouldn't you? Yeah, absolutely. And I think, you know, the charity website does have some quite useful tools to help people. Because the question is, well, how do I do that? And we do have some really useful information about making sure that you're getting that magic sort of 700 milligrams a day from your food and higher if you've got a diagnosis of osteoporosis. But, yeah, it's doable, certainly. And I don't think, you know, we want to take supplements unless we have to, unless, of course, it's vitamin D. calcium, a lot of people prefer to get that from their food and then take a vitamin D supplement

on top. Yeah, which makes a lot of sense. And also it's important, as you say, when we're younger in adolescence building our bones, that's a really important time to look at our children's marriage, isn't it, as well? It really is. It's a very precious time and it's a challenge. It really is to try and get messages like bone health across to a young group who, you know, are struggling with messages that really do apply to them at the time because what we're actually trying to say to somebody is do something now to prevent something happening in the future. And the tragedy is that whilst we're building our bone density,

it's a finite time. You know, we don't have long to actually influence that peak bone density. And then we will all start to lose. So getting as much in during childhood and adolescence is crucial. It's really important, isn't it? And I think certainly as people's diet change, they often have fads, you know. Yeah. I know my children have gone through phases of not wanting to eat meat, and I don't eat meat,

but I have a very healthy diet and they look at some of the food I eat, and there's no way they'd eat it. And I said, it's not just about stopping something, you know, and if you don't have dairy, then you can't just think, well, I'll just stop dairy. Of course you can stop dairy, but you have to think about what you're going to have instead. And that's what's really important. And it can be quite misleading unless you know what you're doing. And when you're young, of course, we all have done it. we've got away with eating all sorts of rubbish and it doesn't matter if you still look okay.

But it really does affect your internal structure and framework. Without our bones, you know, we can't function, can we? So, yeah, really important. So an exercise, obviously, is key, is it? Hugely, hugely important. And I think, you know, there's been some really interesting studies looking at astronauts, for example, which have showed us the really awful effect that a sedentary or completely non-weight-bearing lifestyle can have on our bone strength. And obviously these are fit young men, put them back down on earth and they quickly accrue the bone they've lost.

But if you equate that to an older person, perhaps, or somebody who's working in an office and not getting out of the chair all day, you know, the effects of a sedentary lifestyle are so, so damaging to bone. And certainly now, as we're doing this, we've got COVID around us. So most of us are sitting down. I mean, in my clinic, I've got a lovely staircase so I can run up and down a few times a day. But, you know, it's even harder, isn't it, to get exercise, actually? Because we're sitting in front of the screen all the time. And that must be careful for our backs and our bones. I think, you know, lockdown and certainly the situation we find ourselves in now has not been good.

And I think certainly, as you say, exercise has been a huge issue. People sometimes when they were shielding were reliant on other people doing shopping for them. And so they weren't in control of what they were eating so much. So people are really anxious about getting things right. But the other big thing I think with exercise, which is a massive issue for people who've got the diagnosis of osteoposis, is that they're frightened. They don't know what they should do and what they shouldn't do. And that is a constant dilemma. And we do have, again, some really useful exercise resources on the website written with justice in mind.

You know, read these, do these exercises and you can feel reassured that they're safe for people who've got fragile bones. Because I think it's quite frightening, isn't it? If you haven't exercised, you don't know where to go, do you? And you don't want to suddenly, in your 60s, 70s, maybe if you've had a fracture, suddenly go to the gym and do a hit class. It's not going to be. Yes, exactly. Exactly.

But just some simple measures, you know, even going up the stairs a bit more. Just little things, yes, absolutely. You know, I used to say walk to the next bus stop. That's not really real life at the moment. But, yeah, just tiny things. Yes, I know my grandfather was incredibly active and he used to resist having a newspaper delivered. So he would just walk and go and get the newspaper. And it was just, it wasn't too far and it was great.

And it got him out every single day, rain or shine because he wanted to read his newspaper. So, you know, if I said to him, do you exercise, he would say no, but he walked more than the rest. I think, you know, if we think of it as a spectrum with immobility at one end and, you know, the really high impact aerobic exercise at the other, the further you can get away from that inability along that line, the better. And that might just be, as you say, just doing a little bit walking, using the stairs more often, just doing what people can really without obviously putting themselves at risk of falling and fracturing. Because the other thing we've talked about, obviously, bones becoming weaker, but our muscles become weaker. We get this sarcopenia it's called, isn't it?

So it's a loss of muscle density as well as strength. And we need our muscles to support our bones, don't we? And so, also, you know, if we fall, we want to be able to get up from our fall. We want to try and stop ourselves falling even by putting our arms out. And if we don't have any muscle strength, that can be really difficult. And also, if we have a fracture, our recovery will be better if our muscles are stronger, won't they? Absolutely.

And I think, again, you know, the fact sheets on the website, there's nine of them. And they are looking at muscle strength as well as the sort of weight-bearing. aspect. They're both hugely important. It's really important. So tell me a bit about the Royal Austroaist Society because your role is obviously really important helping people. But just tell a bit about the charity, if you may, and then what your role is for them. Well, the charity, I can't remember exactly. I think we're 30 years. I think we've been going a long time and we're lucky enough to have our royal president who is hugely helpful to us in raising our profile. We do a lot of different types.

of work. We obviously do that, we call it beneficiary facing things like the helpline. In a normal world, we have a network of support groups, which are obviously opportunities for people to meet other people with the condition. And we are now moving towards producing digital meetings for people to have locally, which I think is really important. We obviously have a research arm, fundraising, a media team, a communications team. So we do do a little bit of everything, really, as a charity. And the role I have with my team is that we have a free help line. We're really lucky to be able to offer a free helpline number to anybody who wants to use us. And we're at 9 till 1 and then 2 till 5, Monday to Friday. It's a busy helpline, but if anybody's got any questions at all,

we'd love to speak to them. We're all specialist nurses on the line. We can email us. You can even write to us still. Oh, maybe. I know. And we are hoping to get back into live chat later this year. That's something we did offer prior to March when we had to sort of scale in what we could offer as a charity. But now things are improving. We hope to offer live chat via our website as well. So a range of ways that people can get in touch with us. Which is really great, isn't it? And it's interesting you're saying about a media team because Osteophrosis, isn't it a very media-friendly condition, is it? I don't think I've ever seen it on the front page of a paper. No, no. It really is a struggle. And I know that our new chief

executive is really keen that we do get ourselves out there. We have done some work recently looking at awareness of osteoporosis and it's low. It's shocking among people who perhaps don't have an interest. And really, we can't expect to have conversations with people about osteoporosis if they don't understand bone health. So one of the things we're doing for World Osteoporosis Day, which is the 20th of October, is working with a partner, Vitabiotics, to put some online bone health quizzes on our website and via social media just to educate people about the condition and try and get people who perhaps don't have a family member or a personal connection with a condition just to think about bone health because it's so important. So, I mean, I struggle with

menopause, as you know, because it's such a derogatory term almost and so negative and people just think, oh, it's a bit of hot flushes and in fact I really want to rebrand it so we think about it as a long-term hormone deficiency with health risks. And As you probably know, I've recently founded the menopause charity and we want to do collaborative work with other charities. And so in the future, it'd be lovely to have your charity and our charity together doing some work and some awareness because people would think menopause, osteoporosis, oh sorry, I've got no idea. Because it never reaches. The only time the menopause reaches the headlines would be if there's a scare about HRT and it's

all about misconceptions. And osteoporosis, I just think. the only time I've really read about it in the paper is about brittle bone disease. And often it's not really brittle bone at all. So there's so much confusion. And actually it's quite hard to diagnose osteoporosis or even osteopenia because to look at your bone density, you can't do it by an x-ray, can you? Just a normal x-ray. Absolutely.

You have to have lost quite a lot of bone to actually, if it show up on x-ray. X-ray is really good for looking for fractures. But if we want to assess bone strength and diagnose osteoposis, it is a special scan, a bone density scan, which people need to access. And they're quite hard to come by, actually, aren't they? Yeah, you know, I think certainly in some areas, waiting lists are shockingly long. And also, obviously, during the COVID pandemic, a lot of services closed. So they're out now reopening, but there's a backlog, unfortunately.

As you know, my clinic is private because I can't get a job in the NHS doing menopause work, because there's not enough funding in the NHS. So we've actually got the luxury of having a dexas scanner here. And one of the reasons I decided to invest in one is because even though local private hospitals don't have a dexas scan, which is quite something, isn't it? Absolutely. And things are changing, but I know certainly when I was younger

in doing hospital medicine, when someone had a fracture, they would never be assessed for osteoporosis at all. They have a dexas scan. But actually, like you say, it's always too late to wait to have a dexas scan until you've had a fracture because you can make the diagnosis. If someone's tripped over and had a very low impact fracture, then they're likely to have osteoporosis. So it's capturing people.

I mean, I personally had a bone density scan when I realized I was perimenopause or just before I started HRT because I wanted to know what my baseline bone density was. And also, I guess I wanted to see if it's going to improve on HRT, but also I wanted to see if my lifestyle was good enough for my bones. And, you know, I think that, That's really important, is it? Because I know that, oh, yes, well, okay, I do exercise and I eat well, but has that been any reflection on my bones? And I'm sure you've spoken to people, and I certainly have quite a few patients who've had a dexas scan for the same reasons as me as a baseline. And they've

been diagnosed with osteoporosis, no family history, no risk factors, actually quite fit people. But when I've talked to them again, they've probably been doing not quite the right exercise. But still, it's been a real shock for them. And one lady, about her experience on my website because she was absolutely beside herself. She could not believe, but she was so grateful that she'd found out when she was 50 and she's never had a fracture.

But that's really important, isn't it? But it's quite hard when you can't access. It's really hard. It's the challenge and it is the Holy Grail to prevent that first fracture. It's much easier to diagnose after a fracture that's happened easily. That's the sort of low-hanging fruit, if you like. The challenge is to get them before that fracture, absolutely.

And I know there are some places, aren't there, that do like an ultrasound heel or there's a wrist one, but they're not gold standard, are they? So you have to be very careful, I think, if you're going to these choices. And certainly as you know our scanner, we have a really good report by Professor David Reed, who you know, who's done a part of this. He's so wonderful. Because it is about the position of the patient and it's also about the reporting is really important. So it can't just be a press-a-button. Here's your report. Absolutely.

And that's why I think it's so difficult in the NHS because it's a big investment, isn't it? It's very difficult making sure it's the right equipment with the right staff doing the investigation and then the right person reporting as well. Yes, absolutely, yeah. So we've got a long way to go, but certainly the charity work is fundamental, isn't it, really? Absolutely, yes, yeah, I think so. You know, the longer we live, we're here for longer, aren't we? so we're more likely to have osteoporosis.

And if we can work to prevent osteoporosis, it's going to save the NHS, a huge amount of money, isn't it? Absolutely. And I think it's really short-sighted when we occasionally speak to people who are being refused treatment on cost grounds. Because, you know, if we can prevent these fractures, if we forget about the personal cost of a fracture, which is immense, and look at, in hard-nosed terms of the money,

I mean, a hip fracture is hugely expensive. expensive to the NHS. And if we can prevent those through, you know, raising awareness, getting people's lifestyle improved and obviously taking appropriate medication where necessary, then if we can reduce the risk of hip fractures, that's going to be hugely cost-saving. Yeah, I read something that it's about £2 billion a year that the NHS spend on osteoporbit hip fractures. It's a huge amount of money and only about 10, 15% of women take HRT. So if we could increase that amount, you would reduce, fracture, wouldn't you? So it would save. And for the NHS, HRT costs about four quid a month. So

it would never, it would be quite a lot of women to get to two billion pounds. So yeah, so there's a lot that needs to be done. But I think having conversations is great. So I'm really grateful that you've taken up your time to talk about. Absolutely pleasure. No, lovely to talk to you. So before we finish, I would really be grateful for you to give me three take-home tips for people who want to reduce their risk of osteoporosis. So what are the three key things that they should do if they've listened and think, right, I've got to think about my bones. What would you recommend? I would say it's lifestyle. So look at your diet. Make sure that you're keeping as active as you can. And I think thirdly, you know, if you feel you're at risk for any reason, have a conversation with your GP to get the ball rolling, I think.

That's hugely important. Absolutely. So really important to learn, talk. seek advice if you think you're at risk or indeed you've had a fracture and no one's spoken to you about potential of osteoporosis and certainly head over to the Royal Osteoporosis Society website for more information and start exercising. It's never too late. Never too late. Absolutely. So brilliant. Thank you ever so much, Dio. It's been really useful. Thanks ever so much. Absolutely. For more information about the perimenopause and menopause, you can go to my website menopausedoctor.co.uk or you can download our free app called Balance available through the App Store and Google Play.