The Dr Louise Newson Podcast - 078 - Urogenital Symptoms of the Menopause - Lavinia Winch & Dr Louise Newson

Episode Date: December 14, 2020

In this episode, Dr Louise Newson is joined by Lavinia Winch, Ambassador for YES organic vaginal moisturisers and lubricants and a patient representative for all aspects of women’s gynaecological health, but especially for menopausal urogenital symptoms.   Lavinia shares her story and talks openly about the 30 years of misdiagnosed vaginal and vulval symptoms which were eventually resolved by choosing responsibly formulated lubricants and vaginal moisturisers. Also touched on is Lavinia’s diagnosis of endometrial cancer, and the importance of recognising the signs and symptoms, of which the most common is post-menopausal bleeding.   Dr Newson and Lavinia discuss the lack of progress since 2000 in terms of healthcare professionals’ training and treatment of menopausal symptoms, both for vaginal health and for the wider range of symptoms.  The difference between bio-identical unregulated hormone therapy and the regulated body identical HRT available on the NHS is another topic covered, and the importance of women using self-knowledge and seeking evidence-based information in order to work collaboratively with GPs to reach individualised solutions.  Lavinia’s Three Take Home Tips: Be aware of the main menopausal symptoms but particularly those relating to urogenital function. Learn about the make-up of our vaginas and vulvas and how to maintain a healthy intimate environment. Seek out a GP or specialist who has a real interest in women’s health and continue until you get the help and support that’s right for you. Don’t give up! 

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'm very excited to introduce to you someone I met a few years ago now, actually, called Lavinia Wint, who I actually, first phoned up just before I started my clinic because I was trying to reach out to other people to help me on my journey to assist as many men and pals of women as possible. And Lavinia answered the phone and it was a start of quite a long relationship really. So hi Lavinia. Thanks for coming on to the podcast today. Well, thank you very much Louise. It's lovely to see you. And as you say, yes, it was a while ago, but it's been a really interesting journey. So before we talk about sort of you and your journey, just explain a bit about how we first met really, because it's quite interesting, I suppose.

Yeah, so I was working at the Yes Yes Company, which is a company that manufactures a range of intimate products for vaginal dryness, specifically and for painful sex. And my role was medical liaison, which meant that I was engaging with healthcare professionals across this whole area of menopause and gynecological health generally, going to a lot of medical conferences, including all the menopause conferences, cancer conferences, conferences on valval dermatology, women's health generally. And so it was a really fantastic opportunity to learn more myself, but also to be able to make sure that as a company, we were able to signpost people who came to us to the right place to get the help that they needed. And I remember you contacting us and thinking, right, how are we going to make this work?

And you were on your journey, really, in terms of being able to provide a wider service for people because the support for menopausal women out there within the NHS was really quite poor. And it still is, sadly. I don't think it's improved at all over the four years since I last spoke to you at all, since I first spoke to you, I should say. And I really wanted just some samples to give to women in my clinic. Because, as a lot of people know, vaginald rhinos is very common, can affect up to 80% of women without treatment.

and there are some great products which we'll talk about on the podcast, but there are also some products that aren't so great. So I just wanted a selection of some samples to give to women because it can be quite embarrassing going to a local supermarket or pharmacist to ask for something. So I had them when I was setting up my clinic. And at the time, my clinic was just going to be one day a week to help a few local friends. It really wasn't going to escalate to what it has.

And I only set it up privately because I couldn't get a job in the NHS. So it's so sad, actually, the stories that we hear. But why did you start, just talk us through, you know, your experience with you, so you haven't always done this job, have you? Or I know you're not doing it anymore, but you, what sort of led you to your journey, really? Well, it was a chance meeting of Susie and Sarah, the co-founders of the company. When I was about 57, I met them, and they were running the business locally.

And my husband met them, first of all, and was helping them with their moving into, the retail side of the business. And he said to me, oh my gosh, you've got to meet these two women, because we've been having all sorts of issues, sort of right the way from when we had our first child. And he said, I think you really should meet them. And I met them. And I was between jobs. I was looking for something that would give me a reason to be out meeting people postmenopausally, so 57, getting towards retirement, but actually wanting to still be out there doing something interesting and proactive. And I thought there might be a role for me

within the company in business development. And so I sort of gave them my CV and they said, well, that sounds great. But they didn't know at that time that I'd had 30 years of problems with vaginal irritation really and vulval irritation. So what happened was it was like the meeting of,

oh my gosh, this is just such an incredible situation to find myself in working for a company with a product. that actually ended up helping me tremendously. And I went from business development into realizing that there was a very big market out there for people with medical issues because originally the company was formed

to be an organic pleasure product. But people started writing to us and saying, you know, with menopausal, vaginal dryness is a huge problem, people that have had breast cancer. And that's when we started going to the medical conferences. And that's when my role as medical liaison became something really fascinating because I was able to sit in on all the lectures at the conferences and learn so much about women's health. So 30 years, did I hear you write?

Three decades. So just... Honestly. Why did you have symptoms for so long? What happened? Well, because I didn't make the connection between... So what happened was when I had my first baby and I don't think many people realize that vaginal dryness is an issue at different stages of our lives. So you can be just during our cycle in terms of when we're menstruating, but actually postnatally when you're breastfeeding and your estrogen levels are very low, you're not ovulating. And so vaginal dryness is quite a key thing. And that's what happened to us, but I didn't know why.

So I sent my husband out to buy some K-Y, which was all there was in those days. And constantly I would get vulval irritation and soreness and itchiness, which I presumed was thrush. and most of my doctors thought it was thrush. So I was being given caniston after caniston after caniston. And I just didn't click. I didn't make the connection. I presume that if there was a product out there that was meant to be a lubricant for making love,

then it would presumably be suitable for use in the vagina and on the vulva. I eventually went to a valve dermatologist and had a biopsy in case it was lichenstlerosis. And they said there was no vulval cancer, no lichenstlerosis, probably just valval. lexema they said and so they gave me a steroid cream and I would use the steroid cream for a little while things would calm down and then we wouldn't make love and then we would start again with the k-y-y.

Or there was another product actually called sensilube which is a duerex product which I presumed was for sensitive skin but actually it was also very irritating. It literally took that I mean I don't quite know how we had two more children and somehow got incredibly sympathetic and understanding husband. But I think it's very common for a vulval irritation that might be caused by contact dermatitis or sanitary products or the wrong knickers or perfume, shard gels or whatever, to be diagnosed or self-diagnosed as thrush. Absolutely. Yeah. I mean, a lot of women we speak to have been trying different over-the-counter preparations for thrush treatments because there's a lot of talk, isn't there, about thrush, quite rightly, about symptoms such as irritation.

sometimes discharge. And a lot of women think that they have fresh. And obviously some of those women will, but a lot of those women won't. And, you know, I wish I could say that your story was unique. But sadly, there's countless women who have these symptoms. And often, as you say, they're related to the low estrogen levels that occur. And I've already spoken on other podcasts about the need for estrogen replacement, either as HRT or localized estrogen. And all women really can have localised estrogen, so that's different to HRT, but a lot of women need a lubricant for when they have sexual intercourse, but also a regular moisturiser as well. That we moisturise our skin, don't we, as women? And certainly the vulval and vaginal area often need a good quality

moisturiser. But there's a real problem because a lot of medics aren't taught that. And also, there's a huge number of products, and that's increased actually over the last few years. A lot of them are scented, aren't they? A lot of them have got. beautiful packaging, they've got a lot of money behind them, so they look beautiful, but actually they can cause more irritation, aren't they? Yeah, and I think one of the important things to know is that glycerin can be of mucosal tissue irritant, and also it's a sugary thing. So there's a possibility, I don't think there's a huge amount of proof, but there's a possibility that thrush is going to thrive on anything sugary. And this wasn't really known about until 2014 when

Nick Panay and David Edwards wrote a review article and looked at the analysis of all the products that are available out there, both vaginal moisturisers and lubricants, to see what their composition was and realised that the most important thing was that they are pH balanced to the vagina and also that they match the osmolality of the vagina. And that's a more scientific and a little bit more complicated message to get across. But the main thing is that glycerin and the glycol is really the things that can make these products more irritating. Yeah, and I think a lot of people see KY jelly, which we often use in the examination rooms and think, well, if they can be examined

or when people have smears, it's something that's often used. But actually, it doesn't last very long, it can be quite drying, and like you say, it can be very irritant as well. So it's really important. And I know we've talked about sex, but it's not just sexual intercourse that people have discomfort, is it? you've said that you know about wearing underclothes and a lot of women in fact I put a survey on my Instagram a few months ago about how many people had avoided a smear because of discomfort due to

vaginal dryness and it was about 30% of women it's horrendous it's really high and I'm sure that's something that you've heard is it from your experience absolutely and I think that we certainly recommend and I think people are recommending generally that maybe a couple of weeks of a topical vaginal estrogen before you have a smear or a good vaginal moisturizer can help with that and make it much more comfortable. Absolutely, because I speak to a lot of women when I asked them when they last had their smear and they often scrimmed and say, well, I haven't had one because the one I had before was so uncomfortable.

And then I said, well, did anyone talk to you about why it might be uncomfortable? Oh, no, not at all. They said it can often be when you're going through the menopause or your perimenopausal. And obviously, yes, it can be very common. but actually there's some really easy treatments. And like you say, either using vaginal estrogen or usually with a combination actually of a good quality moisturiser can make a huge difference to women, not just to having smears, but we know smear uptake can be very low.

And obviously it's important that women go for their smears. So it's a very easy way of encouraging more people to get smears, isn't it? Absolutely. So then you realised that it wasn't thrush that was causing your symptoms. after a horrendously long time. And then did you manage to get any hormones at all to help your symptoms? Well, yeah, that's quite an interesting story because I hadn't thought about menopause at all. My mum, all I remember about my mum was that we were in America and we were travelling around

about the time that she was 50 and she kept popping into shops to get, she was obviously hot, but she didn't talk about it. So I honestly knew nothing about the menopause, but around about the age of 50, I started to get some of those symptoms of urgency and frequency, beginning to feel like you might be getting a urinary tract infection. I certainly had had a couple of very nasty bouts of cystitis through my sort of earlier years. And I went to the doctor and I was eventually referred to in urologists for a stastoscopy and told that there was nothing wrong. Now, I cannot understand why that urologist, knowing my age, didn't click that there was a relationship. between those symptoms and the lack of estrogen.

I was really cross. I actually wrote to him afterwards when I finally got myself referred to a urogynicologist who said, this is Kassick. And again, we are talking, I mean, I was 50, I'm now 68. So we're talking, you know, a long time ago, there wasn't much going on out there. There was very little information.

And even now, there's still very little information for women to understand that those symptoms are one of the symptoms of menopause. Absolutely. And I think when you think about, urinary symptoms, like you're saying, the urgency frequency. For a lot of women, the menopause is about hot flushes, so why on earth would they put it together? And it's the same for urologists as well. And as you know, my husband's a urologist,

and it's very interesting talking to him and some of his colleagues because there's a real sort of split camp, almost. Half of them, thankfully, like him, will say, of course we'll give vaginal estrogen and of course we'll ask about their menopause and so forth. But the other half we'll go, no, we've got to do investigations, we've got to do all this. And actually having an instrumental investigation like a cystoscopy is very unpleasant, especially if you have had vaginal dryness, the tissues will be thinner, they'll be more susceptible to trauma. And also more likely to have a urinary tract infection.

We know around 30% of sepsis is due to Euro-sepsis, so this is sepsis due to a urinary tract infection. And it's far more common in women. and, you know, the incidence of urinary tract infections reduces a lot in women who have vaginal estrogen. So it's vitally important that urologists are thinking about women's vaginas as well as a urinary tract. But we have estrogen receptors in our urinary tracts and pelvic floor, don't we? So it makes sense that they're affected, yeah. So I think you're a gynecologist, there are gynaecologist who has a subspeciality in urology is who I saw. And he did recommend that I went to,

on HRT and I'd never had a hot flush. I still never had a hot flush. Oh my God, how lucky is that? But I did begin to feel a little bit more anxious, perhaps a little bit of depression. So looking back on it now, I can see what was going on. So I was recommended to go on HRT and being a sort of person that was interested in natural, I started Googling natural HRT. And I found a lady called Dame, Dr Shirley Bond in Harley Street. I think she was one of the first people to realize that there was a natural progesterone. I think she probably was recommending a cream.

But she suggested hormon, which was an estrogen-only pill. I don't think it was eustodial. I'm not quite sure which eustodin it was. And euggestin, which was the natural progesterone, the micronized progesterone. But in those days, it wasn't licensed in the UK. So I have a brother in France, and he is to send it. over to me from France. I think I used to send the prescription. And that seemed to be, certainly my symptoms were better. But then I heard about bioidentical HRT. Oh my goodness,

this sounded even more tailored, especially to me. So I went to a clinic in London and was told that I had to have some blood tests to see what my hormone levels were like. And this is a case if I'd known then what I know now about the fact that our hormones go, and down all the time, so you can't tell at any one time exactly what your hormone levels are. And I was prescribed these compounded lozenges for estrogen, progestin, I think, and testosterone. And I was okay. I probably was helping a little bit. But I think it was in about 2011. As my job for yes, I went to a British Society of Sexual Medicine conference. And Nick Paneh was a talk and it was about body identical HRT.

And that's when I clicked for the first time that actually you can get something that is body identical, properly regulated on the NHS rather than going through something which is unregulated, very expensive because of the test that you have to have. And I actually didn't feel I was being particularly well looked after in that way. So what did I do? I got myself referred to see Nick at Chelsea and Westminster. And there was something called Book and Choose or Choose and Book. So through the NHS you could choose to go to a specialist menopause clinic.

And that clinic at the Chelsea and Westminster is, you know, is probably one of the very few NHS clinics around. And I just was incredibly lucky to be able to get to London and go and see Nick. And it's a big problem. And we've spoken about it before and there's an article about body. the identical HRT on my menopause doctor website because you're quite right. A lot of people think HRT is so dangerous, which is wrong as we know. And so we'll go to these compounded bioidentical hormone clinics in which there's an alarmingly

increasing number across the country, so not just in London and in different countries as well. And these products are neither regulated nor licensed. And they're marketed very well. And a lot of women think they want to know what their hormones are doing. they want a blood test or sometimes they do a saliva test, but actually they're not always accurate. And like you say, certainly for a lot of women before they start HRT, you don't know what their hormone levels were 20 years ago when they were feeling well. So how can you match them? It doesn't make sense. And certainly when people are perimenopoles on every day, their hormone

levels are going to be different and they'll differ during the day because our hormones fluctuate so much. We see a lot of women who have spent hundreds, if not thousands of pounds on these clinics. And I did write an article with Professor Janice Reimer, who's the vice president at the Royal College of Ubson Gine, about the dangers of compounded bioidentical hormone replacement therapy because it's a global problem, actually. And there's a lot of people making a huge amounts of money from vulnerable women who are desperate to feel better. And of course some of these women will feel better because a lot of these products contain estrogen. So they will feel better, but there are risks. And one of the risks is that if you don't have enough progesterone,

there's a risk that it won't protect the lining of the womb properly. Okay, that is really interesting. And, I mean, I think I was lucky in that I found Nick Panay and was then put on the transdermals, an Easterdot patch, the eutogestion. And then I was prescribed vaguelym, and I would use the esters of a vaginal moisturiser or a lubricant as well. And that combination worked really well. interestingly I had some pain some pelvic pain and was found that I had a cyst on one ovary

and I had that removed and as a result of that I had an internal scan and the lining of my womb at that time was fine it was I think it was four mill something like that which is sort of fine but two and a half years later having been on what is absolutely the right prescription the right dosage is everything I did have some hyperplasia some thickening of the lining of the room and I was diagnosed with endometrial cancer. And there's a sort of temptation to blame it on the HRT. But actually there's no reason that that should be the case. And I didn't go down that.

I just said, you know, I'm one of the outliers. I'm just one of the unlucky people. The incredible thing was, again, because of my role, because of going to cancer conferences, because of listening to all these doctors talking about the importance of progesterone if you are on estrogen. And I knew that the first sign of any bleeding, postmenopausal bleeding, you absolutely must go to your GP straight away. And so I did that. So I was diagnosed with endometrial cancer, but caught it incredibly early. So I was very, very lucky. And endometrial cancer is, thankfully, one of the cancers, if it's picked up early enough, as you know, it's a treatable

disease. And certainly any woman, like you quite rightly say, who has bleeding, certainly if it's persistent bleeding really needs to get checked. And a lot of women who start HRT do experience in bleeding. And we always say you're sort of allowed to have bleeding, if you like, for the first three to six months, certainly when you change or start HRT because there can be this unsettling process, if you like, to the lining of the womb. But if it persists, then we often arrange for people to have a scan. Because there are other reasons, and not always cancer, of course. Some people have a polyp or fibroid or something else. And so it's very very, you know, very important. And so it's very important that women don't ignore any bleeding, whether they're on HRT or not. And a lot of women

actually avoid going because they're embarrassed. And no woman should be embarrassed, should they have any gynecological problem. And certainly as a doctor, I'm not embarrassed examining or anyone or talking about anything. So it's great that it was obviously picked up early. So that obviously has made a big difference, hasn't it? Yeah. So the consultant said to me, you know, it's a cancer that we can treat very easily, especially if you've caught it really early. And I mean, by that time I was 62, so I was a long way post-so. So it was very obvious that just even a little bit of spotting, it's just worth going. It's probably nothing, but it's always worth checking.

So I had a radical hysterectomy, the ovaries, the phallopian tubes, the womb and the cervix. And it hadn't spread into any lymph nodes. So I didn't need to have any radiotherapy or any chemotherapy. And I've been really well ever since. You know, so very, very lucky. and I'm still on estrogen, but I don't need to take the progesterone anymore because I don't have a wound. Which is great. And actually, I'm sure you know, there was a recent follow-up study from the Women's Health Initiative study, which came out in 2002. But the follow-up study obviously followed people up for 18 years, and it showed that women who've had a hysterectomy taking estrogen-only HRT have around 25% lower risk of breast cancer.

So that's quite something, isn't it? when lots of medics and a huge number of women think that estrogen causes breast cancer. That's so interesting, Louise, because I went to my doctor. We've got a female and a male doctor in the practice, and the female doctor was aware. So I went to the male doctor as a sort of, I think probably I had to get my prescription renewed. And he said, why are you still on estrogen? And I said, because I feel really well on it, it can help as well as the topical estrogen. It helps with the vaginal dryness. And it helps. I'm sure it helps prevent some of the bacterial infections or the UTIs and things like that as well as the topical. And I said, and I'm also aware that my risks of breast cancer are lower.

And he said, I don't think that's right. And I said, well, actually, would you like to see the nice guidelines? I think, you know, he was really quite surprised. But I did come away from that a little bit worried for a moment that I'd got it wrong. But I read the information and I read the research and I know that is the case. And it's really important that this is known. I mean, I feel it should be on the front page of the newspaper, but good news doesn't sell newspapers, does it? But a while ago, I did a study of primary care to doctors and nurses in general practice.

And also the same survey went out to members of the primary care women's health forum, which are healthcare professionals with a special interest in women's health. And the majority of these people thought that estrogen was the bad bit of HRT and estrogen caused breast cancer. And, you know, it's really sad that there's so much misinformation, and it makes healthcare professionals very scared of prescribing HRT. And it understandably makes women feel very scared, but also quite resistant to taking HRT. And we know the minority of women take HRT, whereas for the majority of women, the benefits that way there is. Yeah, and I think it's a quality of life choice. I mean, I don't intend to stop, quite frankly.

A, I know it's protecting my bones. be, I believe there's still good research to talk about heart health. Yeah, absolutely. And I would also say quite strongly that the role that I've had at yes has been incredible, but it's been at times challenging and I've continued to develop. And I'm sure that my sort of clarity of thought and my ability to, I mean, not my memory is a bit dodgy at times, but to have the confidence to do some of the things that I've done, including standing up and talking to, you know, 100 healthcare professionals and a real

about my patient journey or even just talking to you here today, I'm really not sure that without that little bit of extra estrogen, and I'm on 50 micrograms twice a week. So it's not mega doses, is it? And yeah, I mean, we know that estrogen helps the sugar metabolism in the brain. You know, there's some good pictures, actually, of women before and after menopause and how the activity in the brain just reduces so much. And we know, obviously, if you can use your brain properly, it really helps.

So we always read, don't we, about if you do Sudoku or crosswords or read books, it will help your brain. But I know myself, when I have menopoles or symptoms, I just wanted to stare at the four walls. I couldn't concentrate in anything. So it enables you. And whether it's a direct cause of the estrogen or whether the estrogen is enabling you to then function and do crosswords and read or whatever. And actually, a lot of it doesn't matter. We know it's good. And there is some evidence that it reduces risk of dementia.

if people have estrogen replacement. So it is important. And it's what you're saying is so true that it's about having a choice, isn't it? But having an informed choice. That is so important. If you can learn about your own body, how you react to things.

And if you can read some of the research, I mean the guidelines, the menopausal, nice guidelines are there for everybody. And I think this is a really important thing to be able to work with your doctor collaboratively so that you know what the risks are. are and you know yourself and then you work together to have the best solutions for you. You know, I'm really keen to make sure that women have that knowledge so that they can go to

their doctor with a certain amount. You don't want to antagonise them, but you really, you need to work together to make it the best solutions for yourself. Absolutely. And, you know, the most I have learned over my medical career is from patients, actually. You learn from them. And yes, there are some patients that come with a daily mail printout saying I want this new experimental drug that's been tried on three people and it's you know got to the front page. And obviously then even those people I will still go and find the original article and work out what the research is. But it's essential that medical practitioners are kept up to date. And I know a lot of the conferences you've been to, I've been to as well,

but it's almost preaching to the converted. A lot of these are women's health conferences. They're gynaecologists, their GPs with an interest and nurses with an interest in the menopause, they know the importance of good menopause care. But sadly, there's a lot of doctors who are cardiologists, who are migraine specialists, who are urologists, we've already said, who are rheumatologists. And these women are misdiagnosed. And so we see a lot of women who have been misdiagnosed with fibromyalgia. Rheumatologists have never thought about their hormones or migraine clinics. They've been back and forth, had time off work. Of course, migraines worse than during the perimenopals and menopause. So it's a huge educational.

problem. Obviously, women, we need to know the education. We need to know what's happening to our bodies. And that's really important. But also we need to have confidence in the healthcare professional we're seeing. And, you know, it saddens me actually, Lavinia, because your story started 30 years ago. But I don't think things have improved that much over 30 years. And that's a whole generation of women that are missing out on evidence-based treatment. So interestingly, since lockdown, there has been a huge growth in, information platforms on social media. And I can't speak for all of them, but I know that people like Jane Lewis,

who wrote the book My Menopausal Vagina, has been talking to a lot of experts. And the response from people following is fantastic. So there is a knowledge base out there that means that when the NHS is a little bit back up and running, I think people will, I think they'll have a better experience because I think there's a lot more education going on. And obviously you don't want somebody on

social media diagnosing or treating. But just signposting and gaining knowledge is so important. Totally. And certainly a lot of my work is about just trying to give evidence-based information. And people like Jane Lewis, Diane Dunsbrook, Sam Evans, there's some fantastic healthcare professionals and non-health care professionals, actually. And that's one of the reasons we've set up the charity, the menopause charity, to really be a voice for women and a safe place where people can experience and have first-hand knowledge really that is evidence-based because that's so important we need to be able to feel confident with information that we're given as women. Yeah, I think the other thing we haven't mentioned about misdiagnosis around menopause is the

depression and anxiety and we know, don't we, that so many people are being prescribed antidepressants instead of being diagnosed as being menopausal and being offered HRT. Yeah, and certainly studies we've done have shown the majority of. of women are offered or give an antidepressant. So we've got a huge amount of work ahead of us, and I hope the next 30 years will be more positive. But thank you ever so much for joining, because it's a big thing sharing your story,

but I know it will help so many women, and there's a lot going on in your story, actually, but I'm pleased it's got a happy ending. So before we finish, Lavinia, can I just ask you for three tips, really? And I'd be quite interested, really, to hear three things that you wish you'd known 30 years before, you'd started to receive help and treatment.

Okay, I think first of all is an understanding of what the symptoms to watch out for in menopause. That would be one to one, particularly the urine reed, because not everybody has the whole gamut of symptoms. You know, as I said, I never had a hot flush. So I think that's understanding more about the menopause and particularly the symptoms. I think understanding more about the makeup of the vagina and the vulva, understanding how important mucosal tissue is and how different it is to other parts of our skin. So really thinking carefully about what you use in the vagina or around the vagina and on the vulva. And then I think the last thing perhaps is just self-knowledge.

Self-knowledge and having the confidence to talk to your healthcare professionals and find the best people to go and see if you possibly can. And if you don't have somebody, you know, if your GP is not really responding in the way you'd like, try and find a GP who has a specialism in women's health. Yeah, absolutely. So the big message is not to give up. Just keep trying until you receive the right health. Oh, yeah, absolutely. Don't ever give up.

You will find an answer because all these gynecological and menopausal symptoms and things, they can be treated effectively. Yeah. So brilliant. So thank you so much for today. I've really appreciated it. Thanks. Thank you very much. I hope it helps. I hope it helps others.

I'm sure. Absolutely. Thank you. 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.