The Dr Louise Newson Podcast - 075 - Premature Menopause & Fertility - Dr Rebecca Gibbs & Dr Louise Newson

Episode Date: November 24, 2020

In this episode, Dr Louise Newson is joined by Dr Rebecca Gibbs, an Obstetrics and Gynaecological Consultant at The Royal Free Hospital in London. Dr Gibbs is also an ambassador for The Daisy Network, a charity dedicated to providing information and support to women diagnosed with Premature Ovarian Insufficiency. In this podcast, Dr Gibbs and Dr Newson have an in-depth conversation about the challenges of being diagnosed with Premature Ovarian Insufficiency (premature menopause) whilst going through fertility treatment. They also discuss the reality of menopause education for gynaecologists in the U.K. and why it’s so important that women take their HRT when diagnosed with the menopause younger than expected.  Dr Rebecca Gibbs' Three Take Home Tips for women dealing with POI: Take your HRT. You may well feel much better.  Take your HRT. It’ll prevent long term health problems. Don’t be afraid to push for the help that you need when dealing with healthcare professionals. Find out more about The Daisy Network: www.daisynetwork.org [e-mail] 

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 today I have with me, Dr Rebecca Gibbs, who is an obstetrics and gynecological consultant at the Royal Free Hospital in London. And she's also an ambassador for the most amazing charity called The Daisy Network. So welcome Rebecca to the podcast. Thank you. It's a pleasure to be here. So we connected not that long ago, a few months ago, by a mutual friend, actually. And it's really interesting to hear not only about your work, but your journey and also the charity as well.

So in half an hour, I want to try and get as much as possible from you about each of those three areas, if that's possible. So let's just start off, obs and guine. Why did you choose it and what led you down this career? Goodness. So women are fascinating. I think you have to start with that. And as a medical student, I found myself sitting in on obstetrics and gynaecology clinics where women would talk about everything.

They come in and tell you that their periods were heavy, for example. But then you end up in a really long conversation with them about what that means for their life, for their sex life, what they do at work. All sorts of interesting things. that come out of those conversations. You have a really privileged access to women's lives. And it's so nice to be able to make a difference by quite often doing relatively straightforward things. You get to fix stuff. So whether that's prescribing some medication that suddenly means that, you know, your periods aren't awful and aren't making your work life really tricky, or whether you're doing

some actually relatively straightforward surgery to fix a problem that's really being in acting on someone's life. And it just felt like a natural fit. So I do really enjoy going to work. Great. And so obstetrics, for those of you who don't know who are listening, is looking after women who are pregnant and delivery. And then gynecology is all the women's health bits, aren't there? So do you specialise it one more than the other? So I still do a bit of both. I would say that 80% of my job is gynecology. And the area of gynecology that I work in is, so I see women who've had an abnormal smear test or vulval disease. So, you know, itchy, lumps or bumps, any conditions from the down below knicker area. And that's where quite a lot of

my menopause work comes in because a lot of those conditions are linked to the menopause or can be improved by silting out people's hormones. And then I suppose other 20% of my job is running around a labor ward, delivering babies, working with midwives and junior doctors, sometimes at three in the morning, sometimes during working hours. But it's a lovely balance between the two very, very different areas of obstetrics and gynecology. You see every aspect of being a woman. And it's constantly interesting, no two days are the same. And I think you're absolutely right there, aren't you? It is a real privilege being a doctor. And certainly, you know, I learned. And certainly, you know, I learn so much every day about my patients from my patients as well.

You know, they're constantly telling us things and helping us explore so much that we don't know sometimes. And it's so different, isn't it? When you're at medical school, it's all about a disease. And it's very different because it's about how women respond to different diseases and conditions. And like you quite rightly say, how it affects them, whether it's in the workplace or at home as well, which is so important, isn't it? Oh, definitely. And I think one of the big things that I have learned as I've experienced more personally and professionally learning about the menopause is the little things or things that seem

little that aren't. So sleep, for example. If you're not sleeping because of your menopause symptoms, you're going to be ready with your kids and your husband. You're not going to work very well. Work is going to be difficult. And you don't learn about that at medical school. You learn about that through talking to women and experiencing it every single day I learn something. It's really true. Yeah. And it's so important because it's the way diseases or even not the disease, if you talk about menopause, which is an natural process, can have a very negative effect, not just in the workplace, but at home, like you say, as well, and on relationships. And if they're not managed earlier, that's when problems just get worse and worse, didn't they?

Totally. They really, really do. So you mentioned, or you mentioned, you mentioned a briefly then about your personal journey. Because you're young, aren't you? Well. Well, you're younger than me. Okay, fine. So I'm 37. And it's funny,

obstetrics and gynecology training. So, you know, you go to medical school, you choose to specialize. There's this training program that's meant to take about seven years to get through, but most people it takes them about a decade to do.

And you learn a little bit about the menopause in it, but it tends to be in sort of teaching sessions on a Friday afternoon rather than anything really integrated within your training because a lot of menopause is now managed and managed brilliantly by GPs and specialists in community gynecology. So I didn't really think that much about the menopause and occasionally have a patient come in to see me in clinic about something else and they bring their HRT and I'd sort of look at it and think, oh my goodness, I don't know what that preparation is. It wasn't until my husband and I started having fertility treatment. So

I fully admit I was quite smug about it. We started trying to have a baby when I was 29 and I really thought that actually for a young professional couple, we got ahead of the game a bit then. I mean, you know, the stereotypical doctor starts having babies in their mid-late 30s, but no, we were ahead. And it just didn't happen. And I'd been having fairly normal, regular periods. But when I started having blood tests as part of my fertility investigations. My FSAH, so the blood tests that we used to look at sort of menopause, slowly climbed every single time I had a blood test. We're incredibly lucky. We live in lovely Tower Hamlets in East London where you still get three rounds of IVF on the NHS, many more than so lucky. I know exactly, really fortunate. But unfortunately,

every time I was given the drugs to try and make my ovaries produce eggs, I was getting the sort of yield of eggs you would expect in someone in their 40s, not, you know, just turning 30. And my blood test started changing to fit with that. And by the time we were having our third round of IVF, I was having proper menopausal symptoms. Now, I didn't really think that much at the time because some of the hormones that you're given for your IVF cycle, they suppress those hormones and so you do. You do. You do. feel menopausal and lots of women going through IVF, it'll be their first taste of what a hot flush feels like, but they just didn't go away. And I was diagnosed with premature ovarian insufficiency, so popularly known as premature menopause. When I was, gosh, sort of 31, 32, I started taking HRT at 32. Admittedly, having resisted it, I didn't want to accept that that was happening and that that was my diagnosis, like many women go through. Ridiculously, it was the fact that one of my best friends and I took up roller skating one summer, I managed to fall over and fracture my wrist. And it was a horrible, horrible wake-up call that

if I didn't take my HRT, I was going to end up with broken bones. And my wrists as someone who does surgery, I mean, they're important to everyone, but I couldn't operate. I had six weeks of being unable to go to labour ward and deliver babies, of being unable to scrub him for surgery. And it was this horrible wake-up call that I'm sure my bones weren't brittle at that point, but my goodness, hormones are important. Yeah, absolutely. And, you know, we see us a lot, actually, women who've gone to fertility clinics and have been told, oh, it might be your menopause. But actually, a lot of these women are quite pleased because they say, well, the periods have done me no favour because I'm not pregnant. Yes. And actually, wouldn't it be good for them to be stopped?

But then what saddens me as a menopal specialist is that very few patients get given any proper information about the menopause, how safe HRT is for young women, and also the health risks of not having your hormones. Yeah. You know, like you've alluded to, it's not just your bones that are too at risk, is it, if you don't have your hormones. It isn't. And I think, I mean, everyone who has premature ovarian insufficiency, premature menopause diagnosis comes to switch from a different perspective. I think the fertility one is really interesting because the fertility industry is built on hope. It's constantly during our treatment, my husband and I were told, you know, when they'd only

harvested four eggs, but some of my age you'd kind of expect maybe three or four times that amount. Never mind. It only takes one. Maybe one of these will be the egg that makes a baby. And I knew that that probably wasn't going to happen. But, well, I go for my follow-up appointments with my husband and my blood test results would be up on the screen and the gynecologists and I would kind of, you know, make eye contact and say,

yeah, this isn't great, is it? My poor non-medic husband wouldn't be told anything about it. And he'd sort of work out what was going on from my facial expressions. And nobody ever actually told me, you know what, Rebecca, your ovaries just aren't going to work. Instead, the conversation was, well, we can improve the success rates if we use some donor eggs instead. Now, yes, that's the thing. And if your chief objective is you're going to have a baby, donor eggs, fantastic. Many women have children with donor eggs. We chose not to. But nobody ever really sat me down and said, right, so you are menopausal and you need to take some HRT so that, you know, your cardiac risk factors are approved so that you're less likely to get Alzheimer's disease in the future. And those conversations

didn't happen until much, much later when I pushed to go and see a menopause specialist. So I think women diagnosed through fertility clinics have some slightly additional struggles to deal with that. Yeah, and it's totally true. We see a lot of women who have in the past gone through fertility clinics, and they've still never been offered hormones at all. Yes. You know, we're very fortunate we have John Hughes, who's a gynaecologist in Worcester, who is a fertility specialist.

this you might know him and he just does some remote consultations for us on women who are really quite confused because you know a lot of women think you can't take HRT if you're trying to get pregnant exactly and that's not true at all is it no no it's not HRT is not a contraceptive and one of the really nice things about working with the daisy network is that a lot of the women who are members and who sort of chat with us on our Facebook group and through the charity are still hoping to become mothers. And we talk about, you know, what forms of HRT you can be on that still leave that option open.

And they know that they're incredibly unlikely to feel pregnant spontaneously. But very occasionally, it does happen. And if you are continuing to have regular sex and taking a form of HRT that's, you know, not a Myrina coil, for example, it might happen. and leaving that sort of window open can be a really positive thing in coming to terms with the diagnosis or trying to work out what you do next if children are still on the agenda. Yeah, and I think so. I mean, we've had two pregnancies actually in our clinic.

And both times, the reception said, oh gosh, there would have been any problem. If you're not concerned about contraception. And actually, both times the ladies are burst into tears when they've found out so exhausted. But actually, we do know that giving the right dose in time, type of HRT can improve fertility for some women. I mean, it depends on the reason, clearly, doesn't it? Well, P.O.I. If someone's had their ovaries removed or damaged, then it's less likely. Certainly, if they've had a hysterectomy, they're not going to get pregnant. So I wouldn't want people to listen and have false hope. But actually, I saw someone in my clinic actually

a couple of weeks ago who has symptoms related to long COVID, but a lot of them are menoples or symptoms as well. And she was going to have her first round of IVF when the first lockdown came. So she didn't have it, had all these symptoms as well, and her periods have been very scanty. And so she was worried about having HRT because of wanting to start fertility treatment as soon as lockdown finishes for the second time. But actually she can have HRT and she's already, you know, thankfully check with her consultant who said, yes, that's fine. So she's going to start. And I'm sure it will make her feel so much better because, I mean, the psychological impact, of the menopause is huge.

Massive. And the psychological impact of fertility treatment and reduced fertility is massive as well, isn't it? It's huge. Also, there's a fact that by the time you're going to have IVF, you probably don't really want to have sex anymore. And so if you've got awful menopausal symptoms that are impacting your libido as well, then oh my goodness, absolutely not. So HRT in that time, yeah, make yourself feel a little bit more like you. And maybe. you'll be able to get your sex life just a bit better, which is so important for a couple about to go through something really stressful

that fertility treatment is. So, yes. Absolutely. And, you know, a lot of people I see in my clinic have come through some sort of marriage counselling or a lot of them have left their partners. So actually for the partner of the person, they see this person who's changed because of the menopause.

And they're blaming it on the stress, anxiety, poor sleep because of the fertility, but actually it might be related to the menopause. There's a big overlap, isn't there? There's a massive overlap. And, you know, anything that you can do to get yourself through that time, feeling a bit more like you with a clear ahead to make those decisions about what next is so, so important, really important. It is very hard, and I've certainly over the last few years really tried to engage with a lot of fertility clinics and networks about the menopause, about giving information out to women. And there's been quite a lot of resistance. And I think, think some of it is just due to poor education and lack of knowledge of how big the problem probably is. Oh, definitely. And there is so much that we could do to improve training for general

obstetricians and gynecologists. Fertility doctors do wonderful, amazing, incredible things. But if you're going to be a fertility specialist in the UK, you've normally decided that pretty early in your career as an obstetrician and gynaecologist. So fertility specials, specialist in the UK, for example, generally don't deliver babies. They generally just do fertility. And so your average Obs and Guine Doctor has done, you know, had a few teaching sessions to learn a bit about menopause. Fertility doctors, probably even less, you know, off they go. They learn how to literally make babies. It's just incredible. But the joined up thinking with the rest of menopause and being a general gynecologist isn't always there. No, which is really sad to hear,

isn't it? Because you mentioned earlier about the health risks. So talk us through, if you don't mind, Rebecca. Why do women who have early menopause have these future health risks? So this is something that comes up so often with our online chats, with our Dacey Network members, because, again, going back to the fertility thing, this ends up being the focus. But the reality is that if you don't have those estrogen levels of someone in your age group, your body essentially ages and you start ending up with problems that you'd normally expect much, much later on in life. You can prevent them and reduce those risks by taking your HRT, so the estrogen that you need to top yourself back up again. But the things that we really worry about are bone health. So you are at an increased risk of osteoporosis and then

tense fractures of your bones if you've got low estrogen levels. We worry about cardiac risk as well. So women with early menopause or premature ovarian insufficiency can end up with sort of cardiac problems earlier than they would do otherwise. And there's also evidence that it affects memory as well. So there's an increased risk of Alzheimer's disease, for example, if you're not taking your hormone replacement therapy. It's never too late. And I think that's really, really important to know. I've met several women who have resisted taking HRT after their diagnosis because they just haven't felt ready to do it or they've been scared of potential risk factors, which it's really, really important to remember all you're doing is you're topping up your hormones

to the levels of your peers. So risk factors are minimal. But if you haven't taken your HRT for a decade and you've been diagnosed with osteoporosis, talk to a menopause specialist about starting some anyway, because there are still benefits and still things that can work. Absolutely. And HART is actually licensed, isn't it, as a treatment for osteoporosis. It is. Yes. Yes. But you're right, it's never too late. But it's interesting because you said that you resisted starting HLT and you are talking as someone who has some knowledge. So why did you resist it? Because I didn't want to feel old. I mean, it's a simple. I was 32 coming to terms of this massive diagnosis.

You know, my husband and I are both very sensible, pragmatic people. We had actively chosen, you know, exactly when we were going to start planning to have a baby and it was going to fit in with our careers and our lives. I must admit, at the back of my mind, I probably did know that HRT wasn't contraceptive and wasn't going to stop anything from happening, but the idea of taking hormones was slightly terrifying. My mother and her peer group are very much of the age of women affected by the million women's studies. So they all think that HRT is very, very bad indeed. So growing up, you know, the chat was very much, don't take it. It's terrible. You'll end up

with cancer. And I think, honestly, think, had it not been for breaking my wrist, I probably would have resisted it even longer. It was a few months after my diagnosis that I found myself, linking in with the Daisy network and sort of saying, you know, hi, I'm a gynecologist who's recently been diagnosed. I'd love to meet some people who understand what this feels like, but also I think I might be able to provide you guys with a little bit of extra medical help if you need it. And it was meeting all of those wonderful women that actually really brought home to me that, you know, here are thousands of young women taking their HRT, living happy, productive, healthy lives, they're fine and I'll be fine too. But it was a big thing to start

taking it. Yeah. It's so interesting, isn't it? So I started taking HATO when I was in my mid-40, so I was really very average perimenopause a woman who didn't diagnose my son for quite a few months, which is pretty standard. But even when I told some of my friends that started taking HATI, they said, gosh, doesn't that make you feel really old? And then they said, well, what about your fertility? It means you can't have trouble. And I mean, I mean, I don't have children. I mean, I mean, I'm very fortunate I've got three children and I was sterilised in my third. I don't, I wasn't, I didn't, I don't even know. But it was still that negative connotation.

And that's when it really made me reflect and think, gosh, if I was 25 or 35, not 45, how would I feel? And it shouldn't be because HRT is so much safer than the combined oral contraceptive pill. So much safer. Absolutely. And I was on that for quite a lot of my teens and 20s without a second thought. But unfortunately, any scare messages about HRT for women going through menopause at the expected age filter down into the premature and their own insufficiency community.

My own mother, when I sort of mentioned that I was going to start taking it, well, you can't. That's terribly dangerous. And it's really, really frustrating. And it is incredible. I mean, every time I prescribe HRT through the computer, it comes up with warnings. Yes. And actually, the MHRA of updating. to their warnings to say that it should be given for the lowest dose for the shortest length of time.

Now that is completely wrong, isn't it? Yes, it really, really, really is. One of my most inspiring patients, perhaps the woman I talk about the most to my patients when I'm prescribing is 90 and is still taking her HRT. She has a pump of estrogen gel every other day and she goes swimming in the ladies' ponds in Hampstead most mornings throughout the winter. She is living a wonderful, productive, happy life. It's something that gives her a bit of extra pep. She feels wonderful. And if any doctor tried to take away her HRT now, I mean, what are you doing?

It's awful. Keep keeping, you wouldn't. Totally. Well, you wouldn't stop someone's feroxin, would you? No. No. And that's how it needs to be seen, doesn't it? I think so.

That's a lovely comparison, actually. An extra bit of hormonal boosts to keep yourself. going and thyroxine, yeah, really important. So is HRT. Absolutely. And certainly with younger women, often they need higher doses of estrogen, don't they? So that's really important because I see a lot of women who say, yeah, no, I'm not better than I was. I'm only having 10 hot flashes a day and I was having 40. And I'm on the maximum dose. And actually, we then often give double the maximum dose or triple and then we often get lesses from doctors and GPs to say, how dare you give them such a high dose, they're going to drop them from a heart attack or stroke or breast cancer?

And of course, none of those are related with estrogen anyway. But you have to get the right dose to, like you say, replace what your body should otherwise be producing, don't you? Yes, that's a really important one. And it's something we come up a lot on the Daisy Network. So we have a series of live chats where gynaecologists like, me talk to our members and any advice we give. We're very clear about the fact that, you know, you must discuss that with your GP or your menopause specialist. But we will often talk to

women about how if we were seeing them, we'd have them on a much, much higher dose of estrogen than they're taking. And questions will come up over and over again. Well, you know, my gynecologist says that would be negligent. I'm on the maximum dose. And no, you know, they're on a normal dose for a woman in their 50s, but they're 25 and their, they're 25. And they're floridly symptomatic and they're miserable and they would be so much happier if they just increase those doses. Yes. And that's estrogen doses, isn't it? Because it's very important to have adequate estrogen. Absolutely. And then women who still have their womb obviously need to have a type of progesterone or progestogen depending. And then testosterone as well.

Yeah. This is another hormone which I don't know about you, but I learned nothing about in medical school or as a postgraduate. No. No. No. Nothing about at all. And so I decided to do an extra menopause qualification. So I very much inspired by my work with the Daisy Network and with my own diagnosis. So I did something called a advanced training skills module and I spent, you know, most of a year sitting in clinics with menopause specialists and learning how to do it. And the first thing I really learned about testosterone was when women came in saying, I'd like some please. And it's fantastic that women are starting to talk about this.

I worry sometimes that it's not a message that gets through to everyone. And the women coming to talk to me about testosterone, where, you know, very much that educated, good at accessing health systems, good at, you know, getting their GP to refer them to the right people. But again, it makes a tremendous difference. And I think a lot of our young women aren't on it or have difficulty getting hold of her when it really would give them a bit of a boost and make them feel a lot better.

Yeah, and it's interesting, isn't it? So as women, we produce more testosterone than estrogen. Yes. Yet it's always sort of as the male hormone. Yeah. And certainly my clinic prescribes probably the largest amount of testosterone in the case. I think you do, yeah. Absolutely.

But I didn't know anything about it. And it was only sitting in clinics and like you, I've got an advanced certificate. And actually, I've read a lot about it. Yeah. Sadly, there's not enough about it. And there's a lot of talk and it's mentioned in a nice guidance about libido. And libido is very important for women. So important.

But actually, more important than libido is our mood, energy, concentration, motivation, everything else as well. And it's not as easy as a on-off switch with libido in women. It's not just a hormone, is it? But actually, we found, and we've done some research this in my clinic, that women taking testosterone, their psychological symptoms improve. And that's really more important often. And certainly, if as a woman you're feeling better about yourself, you've got more energy, you're happier, you're more likely to have sex anyway.

And so that all the studies and the conferences I go to, they're always talking about Nabilia a number of times a woman has sex. And yes, sex is very important. I'm not shy talking about sex. But we don't need to be defined as a number of times we have sex. It's about everything else as well, isn't it? Absolutely. And, you know, I could make lots and lots of really quite not so politically correct comments about how it's men in. charge of these things and that's why number of times people have sex becomes this sort of benchmark. But I mean, my classic patient coming in asking for testosterone that I would see in the clinic when I was getting my qualification would be a woman at the peak of their career.

You know, they are in their early 50s and they have been promoted as high as they can go. They're managing a couple of teenagers at home who are difficult as I think teenagers. I certainly was a teenager. And they're exhausted. they can't concentrate, they're miserable, everything is really difficult. And then they get a bit of testosterone and life is just so much easier to manage. And they go back to being them again. And they've quite often managed to get some HRT prescribed by their GP. But the testosterone tends to be that thing that they have to fight for on top of it.

So it's really difficult. It's totally wrong because it's not licensed, is it for women? No. Which is, I think, scandalous and rather outrageous as well. Yeah, yeah, yeah. That we're not allowed. And it used to be. They used to be a patch that we could prescribe, but it's been withdrawn just because the company doesn't make the patches anymore.

So there is a move, and I think there should be more of a campaign, actually, to get testosterone prescribed for women. I don't know what you think. Oh, I definitely, definitely do. And I think actually, when you look at the relatively few risks involved to taking it, I think it should be something that, you know, if you're a GP who is confident prescribing other forms of HRT, you should be able to do it. these women shouldn't have to fight to see a menopause specialist necessarily. So GPs in the NHS have this function that they can use called

advice and guidance where they sort of ping off a little note to a gynecologist and I often find myself answering those queries and I will often say look I'm very happy for you to prescribe testosterone for this woman. If you'd like them seen in a specialist clinics certainly refer them in but why

don't you start the testosterone first so they then don't have to wait for ages. We can review and see how they're getting on. But writing the prescription, it's not a big deal and let's try. But there's often a lot of resistance. There is. And I think it's because of lack of education actually, because it is one of the safest things I've ever prescribed as a doctor, actually. It has very few problems. We do do some blood monitoring, but it's very seldom that women have levels outside the normal range. So it's very, very important that we, it's considered. And women have more confidence.

actually in being asked for it. And so many women are refused it. That's it. They just, they don't know where else to go. And I think GP should be able to prescribe it. We prescribe a lot of things off-licensed. So, for example, there are various treatments for migraines that are not licensed for that indication, but they're still given. There's lots of medications for children and certainly for pregnant women.

Yeah. It's just, there's nothing. Oh, absolutely. Most things are off licence. And I think you raised a really, really good point about thinking of testosterone not only being about libido, because it's quite a big thing, particularly during a national pandemic to, well, global pandemic, to walk into your GP surgery and say, you know what, I want this hormone to improve my sex life.

It seems really quite indulgence and quite bold to ask for. If we all accepted that testosterone is a normal thing for a woman to require and it's going to improve your energy level, drive, your mood, then asking for it from your GP, not such a big deal after all. So yeah, it really needs a bit of remarketing. I totally, I mean, the whole menopause needs rebranding. It needs to be thought of as a long-term hormone deficiency with health risks. And certainly, as you've so eloquently said, for younger women, it's really, they need to be thinking, why aren't they on HRT rather than why should they take it? So I think, yeah, there's a of work that needs to be done. So much work. Certainly the Daisy Network is a great platform for people

to go to to get some advice, help, support during this time. And so certainly any of you who are listening, it's certainly worth checking out and seeing what they do. So I'm really grateful, Rebecca, for all your time today to share. And sharing, because it is a personal story. And it's quite hard sometimes as a doctor sharing, but it really will help other people to listen. in and learn from. So thank you. So before we end, could I just ask for three take-home tips and just three things that you would say to yourself, maybe, when you were thinking about not taking HRT, what would you say that might help you? Gosh, goodness. So the first message really is, is the medical message, you know, take it. You will feel better. And I must admit, I hadn't realized. I hadn't realized.

how symptomatic I was until I started taking it and suddenly could sleep better and felt less moody and my joints didn't ache so much. So take it you will feel better. Take it because you will reduce your long-term health risks. It's a big diagnosis to get your head around. But actually, you don't want to be soaring up long-term problems for the future. You want to reduce your risk of all of those unpleasant things that we've discussed and live a lot of. long and healthy life. And I suppose something else is learning to be a little bit of a pushy patient. So as women, you know, we're conditioned to not make a fuss and to always listen attentively to what our doctor says and sort of, you know, nod and say that's okay.

But if you do think that you're not getting the support you need from your GP, you know, they're not really listening to what's going on with your symptoms, just be a little bit. little bit firmer or go and see if there's someone else in your GPs practice who you get on with brilliantly. I have to say now, I'm the luckiest women in the world. My GP is fantastic. But find someone who listen and who will advocate for you. It's so important. Absolutely. That is so important. It shouldn't be a battle. No, but it is for some people and it's really important that you stand your ground, look at information, make sure you look at the guidelines. The nice guidance I've got some good, really clear advice for women with POI.

So don't stand down and hold your ground. Really important. Yes. Thank you ever so much. It's been really important. Pleasure. A real joy talking to you. So thank you, Rebecca.

Thank you so much for having me on. It's been really lovely to chat. For more information about the perimenopause and menopause, you can go to my website, menopause.com. or you can download our free app called Balance available through the App Store and Google Play.