The Dr Louise Newson Podcast - 087 - Menopause Education for GPs - Dr Tosin Taiwo & Dr Louise Newson

Episode Date: February 23, 2021

In this episode, Dr Louise Newson is delighted to chat to Dr Tosin Taiwo who is a doctor currently in his third year of GP training. Dr Tosin has an orthopaedic background as he used to work as an orthopaedic registrar before changing to general practice. Since beginning his training as a GP, Dr Tosin has developed a keen interest in lifestyle medicine.  Dr Tosin discusses menopause education for GPs and how much he learnt from Dr Newson's 'Confidence in the Menopause' online education programme with FourteenFish. He feels like it should be renamed the “epiphany video”! Despite his busy career in General Practice, Dr Tosin also hosts his own Podcast series, called 'Dr Tosin's Podcast - Healthy Living Beyond Medicine.'  Dr Tosin's Three Take Home Tips for fellow GPs in training: Watch Dr Newson’s 'Confidence in the Menopause' video in the FourteenFish programme HRT reduces the future risk of Cardiovascular disease in women who take HRT, within 10 years of the menopause, by up to 50%  Always have perimenopause/ menopause in mind when seeing women in their mid 40s, especially those that present with non-specific symptoms or 'tired all the time' symptoms   Listen to Dr Tosin's Podcast here Find Dr Tosin on Instagram: @dioscuri2 YouTube: Dr Tosin

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsom, 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 on today's podcast, I'm really delighted to introduce to you, Dr. Tocin, who is someone that I connected with by social media, the joys of social media a few months ago now. So it's really exciting to have you here in the studio. So welcome. Thank you. Thank you. So before we get so, just tell me a bit about you. So you're a GP, but you're training to be a GP, but you've got

quite an interesting background. So do you mind just explaining about what you do and how you've come to where you are? Yes, thank you. So I'm a GP trainee. I'm in SC3. So for those that don't know, that's the third year of training. Hopefully she'll be rounding up in August this year. My background originally, I used to be an orthopedic registrar, scattered around the whole of England, really. I think the only place I didn't get to was Scotland. But down the line somewhere, I did the massive U-Ten that a lot of people do and came into general practice, which is what I've been doing and I've not regretted it since. Great. So tell me why you were interested to get in contact with me then, because orthopedics, general practice, people might not

say annual mail, clearly. Yes. So I think it all started with, the AKT exam. Now, the AKT exam is the first stage GP exam that we do in general practice. So doing that, someone like me, I'm sure with many people you've talked about. In medical school, we really never got taught anything about the menopause. All of a sudden, I'm in general practice, used to cutting bones, and as well as sawing bones and put together. And hey, I'm a woman presents and she's telling me about the menopause. And I'm like, uh, you know, so I had to start going to do a lot of research. And towards the exam time, I was able to get the four tin fish package.

And interestingly, your video was, and I think I've told my friends, we should probably rename your video, the Epiphany video. So we're like, oh, wow, okay. Oh, wow. And you know, like, the light bulbs were just going off here and there and I'm like, gosh, this is interesting. So that was like the very first time I had the base complete introduction, broken down in simple steps, best way to do about menopause and the HRT.

And that has helped me since. That's what got me interested in the first place. Brilliant. Yeah, so that's great, is it. So 14 fish, for those of you listening, who don't know, is a company that I've been working with and we've developed a whole confidence in the menopause remote program for healthcare professionals, but it's free, so any healthcare professional can access it just, I think it's about just under an hour, wasn't it, of me lecturing and just doing some very basics. And they did have one on there that Mark Coom, the educational director, had done, but there are a few errors in there, which I did point out to him. So I said, look, I'll just record it for you. And I'll try to keep it really simple. But it's like a lot of things in medicine. You're on this conveyor belts, haven't you? And you just sort of, you learn what you're told and you're a bit robotic because there's so much, there's so much that you need to do. And you very much are guided by who your trainer is or who your peers are or what you read.

And you just sort of keep going a bit like a hamster in a wheel because you just want to do your best. But it's so, so busy. You haven't got time to really reflect and think. Sure. And it's sometimes, isn't it? When somebody just says something that makes sense, you think, well, why didn't I think about that before? it's so obvious. And I think this is very key with the menopause and even I had no training and it was all about hot flushes and it was only taking a step back thinking actually this is a long

term hormone deficiency with real health risks and why isn't it being addressed? What's going on? Women are living longer and then the more you ask in general practice about from patients the more you realise how many symptoms there are as well. Yes and with everything like going back to the video when I listen and you now start having flowers. flashbacks and seeing things. I mean, the picture I had in mind at that time was, I remember there were periods when my mom was going through it, for instance, you could see times where she would just dash us and she'll have to have the fan on all of a sudden. And as a young kid, then, you know, I really didn't know. So now you reflect back and be like, oh, well, women were struggling with

all these things. Yeah, so with learning through it with 14 fish and everything, I was able to now start looking at it, starts addressing more of the symptoms that women were presenting with. And are you prescribing it, Shatir? Are you helping women? Yes, so I have started prescribing it, thankfully. In ST1, I struggled a bit, but after watching the video in between, coming to my ST3, I actually probably watched that video like five, six times just to re-govite. The good thing is you're able to, sometimes you're able to speed it up, so I've been able to listen. Oh, yes, and the webinar with Dr. Coombe recently, that one as well, that was like a refresher course.

So with that, I had formed a bit of. and I'll agree with them in mind how to go about it. And it did help in the exam as well. So I've prescribed for a lot of women now. What we tend to do, especially with the help of my trainer, I've got a very good trainer in my practice and my colleagues, the GP's there as well. They've taken me through it as well. And they've done what we do, like video cuts. That's the observation tools where they sit down and watch you consult and make a few tweaks here and there. So it has been quite helpful. That's brilliant, isn't it? Because I think HLT has always been quite complicated or made to be quite complicated. And even now, as you know, when we prescribe there's all sorts of warnings that are inaccurate and you open the BNF, the British National Formulae of all the drugs, and it can be quite confusing. And so I think a lot of people are sort of scared away from it. But actually we know, don't we, that for the majority of women, the benefits, that weigh the risks. It's really important because you were saying earlier that you're very,

into lifestyle medicine. And this is really key. And in fact, we did, I've got a not-for-profit doing research education. And we did a survey of just over 3,000 women recently. And we found that only 24% of women have been given any lifestyle advice or even asked about any lifestyle. Wow. Which I was quite, I was shocked, but not surprised.

I don't know whether that low amount surprises you at all in general practice. Well, it doesn't. I think everybody knows we. the whole way general practice is, unfortunately, it's more like a conveyor belt system where the patient is coming in, you've got one symptom to deal with in the 10 minutes, so you're just going through it and trying to give everything out. So it's now we've kind of taken a step back and we're trying to incorporate more lifestyle into the way we treat things. Because it's so important. I mean, one of the, well, there's lots of things that I want to do,

but one of the things I want to do is improve the health of women globally, no mean feet. But what I want to do is to prevent as much disease as possible. And that's quite hard, isn't it? Because also in medicine, we get presented with a patient who has a disease and we work out the treatment. But actually, I want to take a step before that and think, how can we prevent the disease happening? And of course you can't prevent every disease. And of course, not all diseases are due to lifestyle. But a significant amount are when it's increasing, isn't it?

With obesity increasing, type two diabetes increasing. I think COVID's making us even more aware because people with comorbidities, such as type to diabetes, cardiovascular disease and obesity are far more likely to die and go to intensive care, aren't they? True, true. I mean, we ask in my clinic all the time, do you smoke, how much alcohol do you drink, if you drink alcohol, and what exercise do you do? And just that question, what exercise do you do?

It's quite revealing, actually, isn't it? It is. I mean, what's always get to me is when I once a. I say, what exercise do you do to a patient? Or I'd probably say, oh, how much exercise do you get? The first, there are two answers that are very common. Oh, I don't have time to go to the gym. Yes.

And I stopped them there and try and break it down. I actually, no, I did not ask if you were going to the gym. Yes. And one of the people I follow and, like, kind of has mentored me from afar is someone like Dr. Rangan Chatterjee. Yes. Go his four-pillar plan book, which was like from the baseline of what I've been using. So pointed out little small hacks for people here and they have.

how they can get exercise in. It's really, really interested. Yeah, and it is so key, isn't it? And I think you're absolutely right. People think exercise, you have to have a dedicated time and you have to go to a gym and you have to have an instructor and it's expensive and you have to have the most amazing lycra or gym shoes or whatever. And actually, sometimes for people, it's just going up the stairs, isn't it? Or just, you know, doing a few sort of squats while you're waiting the kettle to boil. It doesn't have to be for long, but it's really important having it part of your routine, isn't it? I think that's what's really important. It is, yes, it is. So with exercise, one of the things I, because of the lifestyle

medicine, one of the advice is I started giving people, one of the follow is trying to layer it on things they already do. Something that we're trying to push out my workplace, a small, a mini-competition, really, but it's just that on an average day, anybody would you go and use the bathroom if you're drinking enough fluids, minimum of three to four times. So, and I explain it to people, that is a space, It's a private space where immediately you've used the bathroom or toilet. You can do squats there and then for 30 seconds. And nobody knows. And you've got some exercise in and you've just moved on.

And you've exercised the biggest muscles in your body. And so quick. So yes, we're trying to push that around for people to do. It's very important, is it? Because I think even if you did five minutes a day, that's still, you know, seven days a week, five, that's over half an hour a week. That adds up, doesn't it? It does. It doesn't have to be a huge amount.

And as many people that listen know, I do Shangha Yoga, and I do it on a Wednesday at 10 o'clock without fail. And I was dropping my daughter off, one of my daughters off to school today. And I had my yoga stuff on. And one of the dads from school said, oh, you're not working today. I said, yeah, of course I am. I've got a full-on day. And he looked at me. And I said, no, no, I just do yoga in between meetings.

And I have to do it on a Wednesday at 10 o'clock, as well as I do it at the weekend as well. Because if I don't, my head will go, my brain goes. and then my sleep goes and it's just so good. And I'm very lucky because I have a shower here at the clinic so I can literally, you know, it doesn't take too much time out of my day. But it would be very easy to fill up that hour. And I think exercise is underrated,

but I think nutrition is underrated. And certainly at medical school, we've got to talk very little about nutrition and certainly about the gut microbes and everything else. And if I wasn't do menopause work, I would certainly do something with nutrition because that's so important, isn't it? And so many questions.

are not given the right information actually, and they're guided by advertising, I find, rather than what's really good for them. I mean, that's rather. It's just rather the unfortunate thing, isn't it? What's out there and what they can see. And then like you said, when I sat back and looked at it, and I'm like, oh, actually, that is true.

I mean, in six years of medical school, probably maybe just two weeks of nutrition. And when you sit back and you try and unpick the change and lifestyle disease, I mean, nutrition plays a big role. Yeah, there are other things, obviously, but yes, with nutrition. And people do not just get that information. Yeah. And there's a lot of mixed messages, isn't there, that people are really guilty. And certainly a lot of my patients just tell me that they stop eating. So they skip breakfast and they'll have maybe a sandwich. They say, all I have is a sandwich

and a low-calorie snack bar for lunch. And then they'll have some ready-made lasagna or something or pasta dish or something that they've bought. And they said, but that's all I eat. And I'm saying, my goodness, no wonder you feel so tired. And, you know, they're counting their calories. And they think that's what's right, that they think because of the way the food's being labeled. But it's not the right way to eat at all, is it? No, no, it isn't.

And it's a big thing out there. So for people, most times I always try and push, okay, maybe try and see if they can speak to a dietitian or there are some people, especially if I do this for people back home in my country, Nigeria, where I can try and take them through things step by step. because you can't sort everything out in a short 10 minute appointment or with that. So it has to be something longer. And there are a lot of nuances in nutrition. So I just say, look, just take it easy, see what fits you and we can work through things.

I mean, but everything ties into place. And especially with women that are going through the menopausal period as well, it's something that kind of comes up to the floor where they are struggling and you find some of them having to do comfort eating as well. Yeah, definitely. And certainly so many women find out. that their sleep is negatively affected because hormones work so well in our brains. And if you don't sleep and you're tired and you have sugar cravings because you have low estrogen levels,

it's very easy to say to women to know you have to cut out sugar, but they crave it. You know, it's addictive as well, isn't it? It is. It's very hard, actually. But so tell me, in Nigeria, what's menopause care like over there, do you know? Well, to be very honest with you, looking back now, I probably never prescribed anything menopausal in Nigeria. I think even going back to remember my mother, I think she just went through it. So unless now there'll be a specialised niche, I've not been home in a number of years and I've not looked into that area completely. But I don't think it's something prescribed on the regular back home for people.

Which is quite something, isn't it? Can you imagine saying all the ladies who have an underactive cyrogram if we don't give them cyroxin? Yeah, that's a straight thing, is it? But I think it's more the investigation part of it. Of the top of my head, most doctors back home, they wouldn't. put that as a top priority. In fact, most women back home will probably look at it as the natural phase of things. And this is what I have to go through, that kind of feeling, which is shameful, really. It is. It's so much a misunderstanding, isn't it? Because, and I understand that it is a natural

process, of course, but because women are living so much longer, it needs to be addressed. And the health risks are huge. And we certainly, or I certainly engage with a lot of women from all across the world and certainly the app that I've developed has been downloaded by women from more than half the countries across the world. But a lot of women can't access HRT, but they still don't know the health risks of having low hormone levels. So, you know, for example, women who have hot flushes have a higher risk of heart disease and stroke. So let's look at ways of reducing heart disease. You know, that's what's really important, isn't it? Look at the risk of osteoporosis and dementia without your hormones. So, you know, it's a bit like obesity.

is not a disease, is it? But it leads to a lot of diseases. It does. It needs to be addressed. And low hormones are no different in the menopause, but it's changing the education because I think a lot of doctors see it as a bit of a frivolous specialty, actually. They don't see that it's so needed.

I think for my experience is more the lack of knowledge that makes people put up that front of, oh, you don't need to do that. It's more the lack of knowledge. If people were able to get the amount of information and they understood it in a slimpified version, more people might be open to it. I feel that's what it is.

Because interestingly, I was able, we've got the chat groups on Telegram and where we've got large court of ST3s and African doctors. And I put a poll recently. And start only, I think, I think, 50 respondents and only less than 20% of them felt very confident prescribing HRT.

So that kind of showed a lot. It is, isn't it? I did a survey, well, did two surveys, actually, one through the primary care women's health forum, which is predominantly with doctors, nurses, physios who are confident in, or have got special interest in women's health, and the same questionnaire I put through GPs. It was a few years ago now to see how confident they were, and it's very similar. Very few were confident in HRT, and when I said, where do you work out or how do you find out which type of HRT to prescribe, a lot of them would just open the B&F, so it was very much just, you know, finger in the sky just trying to work out. They didn't really know. So that means that the

women are not being given necessarily the right dose and type of HRT. And as you know, the body identical HRT, the estrogen through the skin is a patched gel spray is best. And there was a study recently in the British Journal of General Practice that showed that women from disadvantaged backgrounds are less likely to get estrogen through the skin. They're more likely to have tablets, which has more risks. So, and then when I spoke to some doctors from areas of social deprivation, they said, Louise, we've got more to worry about than just the menopause. Yeah, that's the interesting thing. In fact, like, I think what you said was if you were able to treat the menopause, maybe the symptoms they were worrying about will also be taking care of at the same time.

Absolutely. And it's not just the symptoms. You know, we know that giving HRT to women reduces their risk of heart disease more effectively than women who take a statin for raise cholesterol or take a blood pressure lowering treatment for hypertension. But it doesn't just reduce heart disease risk. It also reduces osteoporosis risk, diabetes risk and everything else. But actually, thinking about orthopaedics for a second, women who take HRT are less likely to have hip replacements and knee replacements. Yes.

Because estrogen is an anti-inflammatory in the muscles and joints. And we see hundreds, if not thousands of women, who have joint pains. So they often have joints in their fingers and their feet. can be very uncomfortable, especially in the morning, but also their large joints can be uncomfortable. And a lot of them have been seen either by rheumatologist or orthopedic consultants or surgeons and have been told we've got a bit of arthritis, spit, point, and nothing we can do about it. And I just think now you know what you do, thinking back to your orthopedic practice, do you think there were women that maybe were menopausal that you didn't realize?

Oh, yes, most definitely. I mean, you know, the saying is that to a carpenter, every problem is a nail, isn't it? So then in all the field, you see in the joint, it looks so arthritic. More than likely, we give them a bit of lifestyle. We just say, go, do some lifestyle changes. But we can't be too specific, isn't it? And you either give them some physio, then next thing is a steroid injection, then probably you're working away towards a knee replacement. Whereas, looking back now, some women might just have benefited from some HRT. Yes. And certainly, we see a lot of women who have frozen shoulder, which is far more common in women, and a lot of it melts away with the right dose and type of estrogen, often testosterone as well.

And it just makes me think, because I had never thought about it at all before in my training, because no one pointed it out. But, you know, a lot of arthritis, even rheumatoid arthritis is more common in women. It's an autoimmune disease, but autoimmune diseases are more common in women, especially after the menopause. So, yeah, there's a lot of orthopaedic surgeons that probably need to be educated about the menopause, don't you think? I think they do.

I wonder how that will go with it. a very, very, very big mountain to climb, I think I would say, you know, because of the way the mindset is set towards how they do things and structuring the treatment for the bone and the muscles and everything. But whereas, yeah, a lot of lifestyle changes needs to be talked about. Well, I think also now with COVID, a lot of people who are waiting for elective operations, so knee and hip joint replacements for arthritis are being cancelled or delayed. So actually, ways of helping them is going to be good because the more that they're they can be mobile, the more they can exercise, the better.

So actually, to have an anti-inflammatory in the form of a hormone as opposed to an anti-inflammatory medication or even a stronger painkiller, you know, there's no harm trying, but a lot of people don't think. Oh, yes, oh yes. I think that does make a lot of sense. The thing about the things is the most stuff that was printed out, the MHRA guidance and the recent Lancet paper that came out about the estrogen. I mean, with the way it was put in the paper,

it's created a negative bias in pretty much a lot of people's mind. Absolutely. And it's been a real problem because when something comes out from the MHRA, you read it and you think, goodness me, this must be correct. But what the MHRA failed to tell us was that this was based on older types of HRT and it only looked at risks. It didn't look at any of the benefits. So it does make people scared and often people don't have time to go back and look at the original evidence. But I have managed to change some orthopedic surgeons practice near to where I work because they were stopping women who take HRT before they had surgery, so joint replacement surgery, because as you know, if someone was on a tablet estrogen or the contraceptive

real, yeah, there's a small risk of clots. So they did this because that's what they thought. And so I sent one of the lead orthopedic surgeons for a big group of hospitals near here some evidence, and they've changed their practice. So now they allow women who have estrogen through the skin with micronized progesterone, because there's no risk. of clock with that either to continue their HRT and actually it improves their recovery because if you suddenly withdraw HRT and you're getting symptoms and as you know estrogen but also testosterone can improve sarcopenia this muscle wasting what happens when they're trying to rehabilitate after a joint replacement they need as much muscle strength as

they can get so I was quite chuffed but we need to it's the tip of the iceberg But that is impressive, to be honest. I mean, that's really good. Yeah, there's a long way to go. But it's also, I think, empowering the women, isn't it? So that they know what's going on with their bodies. Because it can be very scary for a lot of women. And I'm sure you've seen women in general practice.

I certainly have who think that they've got dementia because their brain is going or they think they're depressed or they think they've got a brain tumor because they're getting worse than headaches. And it just takes the right questions to ask to realize that it's a relationship. to their hormones. Especially when you're seeing people, one of my recent patients was brain fog, poor sleep, especially,

then high irritability and low mood. So immediately all those things come up and unfortunately, first in one goes, oh, he's this patient depressed and they go into depression. You've actually had to take a step back and say, hang on a minute, let's go through the questionnaire. That's the questionnaire from your website. You send it to them and they said,

oh, they've ticked a lot of boxes here. And I ring them up and I said, I think you might be going through the menopause. and she tells you, oh, I actually haven't thought of that. Then it ensues into another discussion. So it's always interesting. Yes, and I mean, I must have missed so many women because I wasn't thinking about it. And I wish I'd used the questionnaire that I use now for all my patients.

Because it's very hard, isn't it? When you're busy to ask all the questions, whereas the patient can answer them beforehand, you've saved a lot of time in your consultation, haven't you? So, yes, luckily, with the whole COVID pandemic and the shift in practice to a lot of online-based work. Most people send in a request and if they have detailed in what the symptoms they are having, we are now

sometimes able to reply and say, hang on, answer these questions for me. And depending on your answers, when I'm going to call you up, we can have a discussion. So it is starting to work in that way now. Yeah, which is ideal actually because you know, patients need to leave their consultations. I don't believe anymore they should be

led by doctors. I think we're here to guide and assist and help and show them the best evidence. But it's about listening. to them is really important. And certainly one of the things I'm doing quite a lot of work on is creating some sort of treatment pathways as well, which will really help doctors once they have the diagnosis. And hopefully women will download the free app that I've developed for balance. Yeah, Valance app. Yeah, and then create a house report from it. And then the doctor will be able to access a treatment pathway. So they will be advised and guided as to which

HRT is best if HRT is appropriate. But if it's a doctor, but if it's a doctor, we'll be able to access to it is or isn't, regardless, they still need lifestyle advice. And I think a lot of people think it's all about HRT or nothing, whereas even women on HRT still need to look at their lifestyle. And certainly women, not on HRT, need to look about their lifestyle. So it's really important, isn't it, that everything in medicine is holistic. Oh, yes. Yes. And there's this, what's that same? Because when you come into medicine or you see a patient, there's that tendency to just become very microscopic and tunnel vision to just focus on that symptom. For instance, I mean, from this conversation that we've had, when you mentioned frozen

shoulder, I actually took a step back and said, hold on a minute. I've actually never really sat back and said, could this be coming from her hormones. It's frozen shoulder. I've done the movement, of taking it through the angles. It's not going through. We need to do this, this, this. Thank you. See you in two weeks' time.

Yeah. It's very interesting, isn't it? I think one of the doctors here, Sarah Ball, has. decided before she came to work with us, she was going to spend her whole morning in general practice, every woman over the age of 40, she was going to try and get something about the menopause into the consultation. And the last patient she saw was a lady who had diabetes and had had her driving licence taken away because she was getting low sugar levels overnight and having mini fits. And so obviously she couldn't drive. And so she came very upset about this.

So Sarah thought, well, how am I going to ask her about menopause? This doesn't quite fit in. Anyway, because she'd made this promise to her cell, she asked about when her last periods were, and her periods had recently stopped. Was she getting any flushes sweats? Yes, she was getting lots. What about overnight? Oh my goodness, yes, she was waking every hour or so with night sweats. And then she was getting these shaking episodes. So Sarah said, well, we need to give you HRT anyway, because it's got more benefits than risks, and it will help reduce future risk of diseases and so forth. And then a few months later she came out and she said, you know what, all my nighttime symptoms have gone. I'm no longer getting anything.

I'm sleeping through the night. Wow. And it just makes you think that we need to be asking the questions more and more. Wow. Yes. I probably need to pick up that practice because following one of the podcasts, I listened to your episodes I listened to, I think we'll be Professor Jeffrey Hackett.

That informed my practice. All men over the age of, well, like Pegman at 45, and I was asking all of them about erectile dysfunction, because it's something that was never discussed. And my pickup rate was probably about, 40%? Gosh. Oh gosh, what's going on here? And we have to book a follow-up appointment. So I'm building that into, I think I probably should do that for women as well and just keep asking.

Yeah, and it's so important because for those of you who haven't listened to the podcast, erectile dysfunction can be a really early marker of heart disease. And obviously there are problems associated with erectile dysfunction that need addressing, but also if it's a future risk of heart disease, we want to pick that up and manage it early. And it's a same with low hormones. We know that the earlier women are treated the lower their future risk of heart disease and cardiovascular disease and dementia kill most women. So we need to have ways of reducing to. We want to be away from doctors, don't we? The more that we can control our lives and our health, the healthier we can be and the less we can come and hound doctors,

which is so important, especially at the time of crisis that we're in now with the NHS being overwhelmed. Yes, yes. I think it is really important to talk about lifestyle. Yeah, absolutely. So it's been really useful. Thank you ever so much to listen to your insight. But I'm just also delighted that I've managed to help hopefully mold the way that you're going to work as a GP going forward. So before I finish, are you able to give three tips? So I always do three take-home tips. But I'd be very interested to hear what your three take-home tips to your group of people that you interact with your other doctors who are, like you, nearly GPs.

What are your three things that you would? say to encourage them to know more about the menopause and HRT. Oh gosh. Well, okay, I think first tip will be to know that menopause and HRT is not as complicated as we make it out to be. And they should just literally watch and do the confidence in menopause on 14 fish. It kind of builds up a lot of things for them. Second thing they should always come forward with is the benefits of HRT, women that take HRT, they have a 50% reduction in their cardiovascular risk, which is quite huge taking that into consideration. And she also know the benefits about osteoporosis and dementia, for instance.

That is actually a very good one. And the third thing is, all women over the age of 45, well, even 40, they should start incorporating and thinking holistically. If a woman comes in with non-specific symptoms, like even tired all the time symptoms, always have it at the back of your mind. Could this be a perimen, a pulse or woman? Brilliant. Yeah. Great. So really good. really sound advice. So thank you so much for your time today. It's been really interesting.

Thank you. Thank you very much. Thank you. For more information about the perimenopause and menopause, you can go to my website, menopausedoctor.com.uk. Or you can download our free app called Balance, available through the App Store and Google Play.