The Dr Louise Newson Podcast - 088 - Endometriosis and the Menopause - Chris Mann & Dr Louise Newson

Episode Date: March 1, 2021

In this podcast, Dr Louise Newson is joined by Chris Mann, a consultant gynaecologist and one of the world's leading experts in endometriosis. Chris has received extensive training in many countries in the surgical treatment of endometriosis from some of the world's leading laparoscopic surgeons. He talks to Dr Newson about this condition, which affects around 10% of women and explains how, for many women, it takes seven years for a diagnosis. Far too many women do not seek medical help and those that do are often dismissed and given inappropriate advice or treatment.  Chris and Dr Newson talk about the different treatment options available for endometriosis and how women with endometriosis can be given different types of HRT during the perimenopause and menopause. He recommends that any woman who is not receiving adequate help should persevere and see another doctor.  We are releasing this podcast the first week in March to coincide with Endometriosis Awareness Month. Taking place across the world, Endometriosis Month exists to help increase awareness and highlight the symptoms of this debilitating condition that affects an estimated 176 million women worldwide.  Chris Mann's Three Take Home Tips:  If you suspect that you may have endometriosis and the symptoms are negatively impacting your life then please seek help. Too many women suffer in silence. If you are not getting anywhere with your GP then you can ask for a second opinion. If you still are not getting the right help then book a private consultation with a specialist, if you can afford it. A specialist can then write to your GP and advise them on your treatment going forward. Don't give up! For too long, too many women have been fobbed off. It isn't something to just 'put up with' and there are now more of us out there that want to help. Visit Chris Mann's website: https://www.theendometriosisclinic.com/christopher-mann/ 

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 delighted to introduce to you Chris Mann, who I've known for a little while now, who works quite close to me in Birmingham, and he is a... consultant gynaecologist, but he has this particular interest in endometriosis. And I think he's probably one of the world leading experts in endometriosis. So I'm very honored to have him here today. So welcome, Chris. Thank you very much. I'm pleased to be here. So before we start talking about

endometriosis, I wanted to talk a bit about you because you didn't have the really quite conventional career that some of us do, that we go to school, we decide. I decided I wanted to read medicine when I was seven and I stuck my guns and went straight from school to medical school. But you didn't, did you? I did, no. Let's listen to your interesting background. No, I did go to school. But my main interest at school was really sport and PE.

And after I left school, I spent a year as a racing cyclist and then came back and really didn't know what I was going to do long term. So I went off to university in Loughborough and read human biology. exercise physiology, which I think is now known as sport science. And for the first time I've ever really studied very hard and did well and was very fortunate in that one of the professors in the department had originally been a medic. And in my final year, Professor Marshall asked me what I was going to do once I finished.

I expect that really had no idea. And he suggested considering medicine as a career. So I looked into it and it appealed and I applied and I was forward. to get in, because in those days, it was very unusual to have done a degree before, doing medicine. Most people, as you say, would go straight from school. So I was accepted into medical school. So I was four years behind most of my contemporaries, but I was fortunate to be in a medical school where they reserved about 10% of their places for people who've done other things, other jobs, other degrees. So I wasn't alone. There were 10 of us out of 110, and that was at Leicester

medical school. So graduated from there and then moved to the West Midlands after house jobs, so in 89, and did a fairly conventional training program in obstetrics and gynecology. And then towards the end of my training, I went to work for Professor Newton, who since has passed away, but he was instrumental in furthering my career because as part of my training in laparoscopic surgery, he sent me off to France. And it was, well, the idea behind getting there was originally to do some laparoscopic oncology training, which I did do, but when I was in Lyon and Leo, I came across these gynaecologists who were excising endometriosis,

which was something I had never seen before. And in fact, this was 1999, in fact, there were only two other gynecologists in the whole of Great Britain that were excising endometriosis. And they'd had to go abroad like I did to see this and experience it and get trained in it. So I spent a number of months learning how to do excision of endometriosis and then came back and introduced that technique. Whilst I was a senior registrar into the West Midlands, one into the Midlands generally,

and I was then able to go off and do further training with a surgeon called David Redwine, who was over in Oregon, and he's sort of the grandfather of excision of endometriosis. He really developed the laparoscopic excision of endometriosis technique, which gradually spread. and is now a worldwide recognised best practice for the surgical treatments of endometriosis. So I became a consultant. I was employed as a gynecological cancer surgeon. And at the same time as performing gynaecological cancer surgery, I always ran a parallel clinical service in the

surgical management of endometriosis. So that was initially at Birmingham's Hospital and then in Wolverhampton and then, well, latterly in Birmingham in the BMI Priory. hospital, which is where the centre is now based. So really interesting, but let's just, for those people who are listening that don't know, what is endometriosis? So endometriosis is a condition where cells that are very similar, but not exactly the same, but they're very similar to the cells that line the womb. They are found outside of the normal place. So normally those cells, endometriam like cells, would be found lining the wound. Now, in endometriosis, they're found outside of the wound. We think, nobody knows for a second, but we think it's probably an embryological origin

in the majority of patients. The cells are most commonly found in the pelvis, but they can be found elsewhere in the abdomen, they can be found on the diaphragm, they can be found in the lungs. So they can get all around. So do you think it's something that people are born with? Yes. Probably in the majority of cases, it looks like the women are probably born with it. And then at some point, this is something we don't really have a clear idea. There seems to be a biological switch that makes those cells become active, they become inflamed, they cause pain, they cause adhesions, that results in the two big areas of problems that our patients experience, that is abdominal pelvic pain, sometimes chest pain, and also subfertility.

They're the two big areas that patients present to us with those classes of symptoms. Because it depends where they are, doesn't it? So because they're the lining of the womb like cells, when the hormones change in the body and stimulate the lining of the wound, which happens naturally, these cells get stimulated as well, didn't they? So people can find... Correct in a psychical fashion. Yeah, so they don't always have symptoms all the time, do they?

They can come and go throughout the months. And that's another interesting thing about the whole world of endometriosis. Every single patient, and I've been doing this since 99 to 9. Every single patient history is different. There's a degree of commonality in that patients often say, well, look, I was the girl who was. at school. When I started my periods, I couldn't do PE. I missed time off school. I was put on the pill very early. I was just told to get on with it. I was just told it was period pain,

that this is normal for me. They were that sort of girl, rather than somebody who would have periods may occasionally need paracetamol and really didn't bat an eyelid. But when you then look deeper into every single patient, how they present is always subtly different. So it's quite a spectrum. patients can present with a whole variety of symptoms, but it's not that they just present with those symptoms, they present with a varying degree of severity of symptoms. So, for example, some patients will come to us from the subfertility clinics, will perform an MRI, will laparoscope them, and they'll have dreadful disease, what we call stage four disease. But when you talk to them, they have absolutely no symptoms whatsoever. Other patients at the other end of

spectrum will have very minor lesions of endometriosis in the pelvis, and they'll be requiring morphine because their pain is so bad. So it's a really unusual condition that the severity of the disease doesn't always reflect the severity of the symptoms or the impact that it has on the patient. Very interesting, isn't it? And it's very common, actually, isn't it? What's the percentage of women that they think have? We think around 10% of women have it. So one in 10 women, but then not all of those will be diagnosed, will they? Or they won't be diagnosed right from the start? Because it can be quite difficult to make the diagnosis as well, can't it? Yeah, so we published some work, gosh, 15 years ago, when we looked at the onset of symptoms and the timing of diagnosis,

and there's about a seven and a half year, on average, a seven and a half year gap between symptoms developing initially and actually reaching a diagnosis. Gosh, that's a long time, isn't it? It's a very long time. And how should women be diagnosed if they think they might have endometriosis? What's the sort of gold standard? Obviously, the gold standard really is to have a look inside, but that's not that easy, is it, to have a laparoscopic procedure and have a surgeon look inside, one in ten women. So what would you recommend? I think that the big thing that will help is patient awareness and doctor awareness. So patient awareness of symptoms, and the same for the doctors. As you said, the gold standard, and this is a Royal College of Obstetrics and Ganyacology

recommendation. The gold standard is a laparoscopy, ideally, with a biopsy and histological confirmation. Now, you can't laparoscope every single woman. who complains of a degree of period pain or other symptoms that may be endometriosis. So I think the important thing is if patients are aware of the symptoms that can present and that are due to endometriosis, it should have a matter of them being aware of them. And if these symptoms are recurrent or even if they're shortening, but they're having a significant impact on the quality of life, then they should seek medical help. Absolutely. And I think that's so key, isn't it?

because I think I can say this because I'm a woman, but a lot of women just get on with things because, you know, we just do. That's why we're made. So a lot of women have, you know, significantly impaired periods. And actually, it's only in the first lockdown. I realize how bad my older two children's periods have been because, you know, I see them crippled. And you think, oh, actually, gosh, is it really that?

And they're going to the toilet every two minutes to change their sanitary protection. I'm thinking, goodness me. They said, well, it's not as bad as my friends. You know, and you think, actually, it shouldn't be that bad. You know, people are missing jobs, missing school. If they are missing jobs or school, or missing work, I should say, and school as well because of their periods, it might not be endometriosis.

Of course it might not be. But they should be seeking medical help, shouldn't they, if they were? Definitely. Definitely. You know, we've had patients who've, they've lost jobs, they've lost marriages, they've lost their houses. I've seen people bankrupted because of the impact that the diseases have had on their lives. So it's really important that people get the right help.

And actually, I used to see quite a lot of people who I think had endometriosis in primary care, and I would often give them some hormone treatment, as in often giving the continuous contraceptive pill without a break. And they would feel so much better. So actually, those women, I hope I did the right thing, I didn't refer to someone like you because their quality of life improved. The symptoms improved. And so I sort of thought whether you make a diagnosis or not, it wouldn't change the management because they were feeling better. because the continuous contraceptive pill can help women contact with endometriosis. It can indeed and it can be a way of making a provisional diagnosis.

So we see it very commonly used in teenagers because ideally don't want to be sending every patient who's got the age of 16, 17 or even younger with painful periods in for a laparoscopy. That's just not going to happen for a whole variety of reasons and it perhaps shouldn't happen. So using something like the combined pill can be a way of managing them. One of the things that we don't really know is if you're managing

the disease with hormones, whether or not you can still get progression of the disease. Now, if you listen to some researchers, particularly from France, they'll say that the progression of the disease is inevitable. I don't think that's that case in every single patient. The problem is we don't know what proportion of patients will continue to have progressive disease or disease progression, despite the fact that there's been some symptom control. So that makes it a bit of a conundrum. It's very difficult, isn't it? And as you've already said, it's not just about symptoms.

It's the extension of the disease. And certainly when women want to try and conceive, it is, as you say, can be. Not everyone, women with endometriosis has fertility problems, but some people do, don't they? And it all depends where it is and how it's affecting people. But it is important that awareness is there, like you say, for doctors as well.

And, you know, as you know, As you know, my husband's a urologist, and he's diagnosed quite a lot of endometriosis because people, if they have deposits around their urethra, the tube that women weigh out of, then they have this excruciating pain and problems, but they might only be two days a month. And so the rest of the time, they're fine. And so they're dismissed as being fine. And it's only when you take a very careful history, which he's done, and then examine them and found this lump of tissue that's not right.

And it's obvious then. but it's not obvious if you don't ask the right questions. And that's why having a symptom diary actually can be really useful for patients, aren't it? It can indeed. I think the important thing, I say four Ds and a P. So this is medical. So this is perhaps more for the GPs and consultant, gynecologist, but dysmenorrhea, dyspariaunia, dysuria, and then pelvic pain. So in layman's terms, if patients of the general theme of,

population are aware, you're a very, very problematic period pain. Deep pain within the pelvis with intercourse. Pain when you're opening your bowels, particularly around period time, but it can be at other time during the month. Pain in the bladder when you're passing urine. And then pelvic pain. So pelvic pain is just pain in the tummy below the level of belly bun. Usually cyclical, usually associated with periods, but not always. Now, if any of those five things are impacting on somebody's quality of life to the point where they're not responding to simple pain relief such as ibuprofen or paracetamol and that they're starting to make them feel unwell throughout the month or particular times of the month or if they're losing time off work if it's having an impact on their

relationship if just functioning on a day-to-day basis is becoming problematic that's when they should seek help and that's ideal when they would get referred into well review by a gynaecologist who's got an interest in endometriosis, although these days, obviously not in the energy in the private sector, patients can self-direct because they are becoming much more their own advocates, which is, I think, is a good thing. It is. It's very different, isn't it? Certainly when we both trained in medicine, it was more the doctor-led, and now it's patient-led, and it totally should be that way. Very much, sir. I know you feel the same as me that if women aren't getting the right help for whatever condition, whether it's endometriosis or the menopals

or anything else, then they should go and see another healthcare professional. Absolutely. And, You know, it's fine. None of us mind if someone sees me and then goes and sees someone else, I don't mind. I think it's really important. And certainly if a patient has extensive endometriosis and needs big surgery, because obviously some of the surgery involves bowel and bladder, it's really important to find the right surgeon and ask the right questions and ask them how many cases they do in a year and what their experience is, even what their training is. And it might be that sometimes people just say to me, I just didn't feel right with that doctor,

and I'll say, well, go and see Chris, go and see someone else. It's just important, isn't it? And there's no rush. There's no panic for the surgery as well, is there? So they really need to find the right person to do it. That's so important. I have patients who come to me,

and then they'll go on to somebody else, and that's absolutely fine. And if I think somebody's not certain, I will recommend other colleagues, these are people that I've got professional respect for. I don't know them particularly well, but I know that they do a good job. and if they come to me, and I think this patient's maybe not quite happy or wants a second

opinion, I can recommend somebody who I think is a good surgeon or a good practitioner. I think you can go and get a second opinion, and it's much better to have that. You should never try and persuade somebody to have medical therapy or surgical intervention if they don't really want. No, absolutely. No. So we can't do a podcast without mentioning the perimenopause and menopause, Chris. I'm sorry. We can't get out to that.

So I see and speak to, and as you know, I engage with a lot of people on social media who are never going to be my patients. But a lot of women will say, I can't have HRT because I have endometriosis. So they've been told they can't because there's this theory, obviously, that estrogen can stimulate any endometrial-like tissue elsewhere. But a lot of women find during the perimenopause, when their hormones are going very high and low at different times, their endometriosis can be flared up and can be worse.

Yes. So there's that. But then also some women have. their womb removed as part of their surgical treatment for endometriosis. And often surgeons, such as yourself, know whether the endometriosis tissue has all been removed or not. But quite often, surgeons will say, I'm not sure. So because there might be some in the lung or there might be some somewhere else that

they haven't removed, but it's not causing symptoms for that person, but they still then become menopausal and maybe want HRT. So just to sort of unpick it really, in the first, instance, what would you say about women who want to have HRT because of the health benefits it provides and the symptomatic improvement who have endometriosis? Are you happy that they have it? I'm very happy that they use it. I would stress that I would prefer them to have continuous HRT, even if they've got a uterus. We think, we don't know for certain, but we think that the endometrial light tissue, the endometriosis seems to be more susceptible to the cyclicity of estrogen

in a progesterone that you get in a normal menstrual cycle. So you can avoid that to a degree by giving continuous levels of HRT. And that seems to be better in terms of symptom relief. And it means that they then get the benefits of these degener progesterone. Yes. And so certainly, so when people are still having periods, we often start a cyclical type of HRT where people still have periods, but then they only have progesterone usually for two out of four weeks, which, as Chris is quite rightly saying, we prefer them to have the progesterone. all the time. So it damps everything down, really. But some people still get nuisance periods with that, especially when they're perimenopausal. And if they've still got their womb and having problems,

sometimes we would recommend a marina coil, which has got a synthetic progestogen in, but it works locally. Some women with endometriosis find that that even helps some of their symptoms, I suppose, if their endometrial-like tissue is near the womb. But if it's distant, then they might need a progesterone as well as a marina coil. It all depends, doesn't it? Absolutely. So a proportion of patients with endometriosis will also have adenomyosis. That's where you get endopetriosis tissue in the muscle wall of the uterus. That's adenomyosis. And that can give symptoms very, very similar to endometriosis. And we think that the myrina can be helpful with the adenomyosis because the progesterone, this tiny amounts of progesterone, are released from the coil and they act locally.

they act locally exactly where the adenomyosis is. So it can be useful for that. And to some degree, for end of utiotosis, it's very close to the uterus. And I think that's perfectly reasonable. Oh, good, because that's what I do. But sometimes adenomyosis can be picked up by an ultrasound scan, can't it? It can, even better, by an MRI scan.

And if it's done well, you can get a pickup rate of between 80 and 90% with an MRI. Yes. It's a bit less with an ultrasound, but obviously an ultrasound is quicker. and I was going to say less invasive, but it's not. But it's easier actually, isn't it? It's quicker. It's cheaper. It's easy to arrange. But again, you know, we can arrange it never are usually within two weeks. I mean, we certainly see quite a few women who, as you know, have bleeding with HRT,

which can be very common. It doesn't always lead to disease, but if it carries on, we often arrange an ultrasound scan just because it's convenient and cheaper for the patient, obviously. And we've had quite a few of some of these patients you've seen, as you know, who've had adenomyosis. and these are women in their late 40s, 50s, no history of endometriosis, no history of any problems at all. And the first thing they'll say is, well, has my HRT caused adenomyosis,

which obviously it hasn't, but it's sort of unmasked it really, hasn't it? Because they've had the bleeding. But then often when you do ask a bit more, they'll say, oh yeah, no, I've always had quite bad periods. I'm going to say, I'm not sure it's unmarked it. And a lot of cases, because when you drill down it and ask them, they'll say, well, actually, they'll go back to Men, where they started.

and they were the girls that had paper pieces, but they were just told to get on with it, that this is normal. And I've had a couple that have actually been quite relieved to say, gosh, is that why I had a lifelong of having to take extra strong anodyn, you know, or missing sports at school because of my period. Gosh, at least now I know there was a reason.

Yeah. And they weren't just being precious or fragile. There was actual pathology there. And so some women who, like I said, have had a hysterectaries, they've had their wound removed. Sometimes they have their ovaries removed, sometimes not. And the surgeon says, the endometriosis we think is gone, but we're not sure. So usually women who have a hysterectomy

for other reasons, for example, if they've got fibroids, don't need to have progesterone. We just give them estrogen and testosterone if they need it. But women with some endometriosis, we often still recommend some progesterone for that reason to suppress any endometrial-like tissue, which is quite reasonable, isn't it, to do? I don't have a problem with that at all. What you would hope for in the first place, and nobody can guarantee this, but you'd hope that if somebody's having a hysterectomy because of endometetriosis and an amnomyis, that, again, the uterus is removed, but it's essential that any visible areas of endometriosis are also removed.

Now, you can't always see it, so you can't guarantee that in every single case. But if there is endometeotosis that's visible, then it's really essential that that endipatosis is removed at the same time. Otherwise, you're leaving disease behind. It's interesting because some women will know. So if their disease is responsive to estrogen and if their symptoms worsened. So I remember one lady actually came to see me from Kent and she was in her late 20. She had had quite extensive surgery for endometriosis and they were quite confident

that everything had been removed. And I said, well, we'll start you with some estrogen. But if you get a flare-up of your symptoms, the easy thing is fine. We can just add in some progesterone. And she initially felt great. I gave her some patches. She felt amazing. And then it was the summer.

She came back to see me. and she said, oh, do you know, it's got so much worse, my endometriosis, and I've got this pain, and it's very typical to the pain she used to have. And so then when I was talking to her a bit more, she also said, well, it was also a bit bad sometimes in the spring and the winter, when I used to sit in the car and I had my heated seats on, and the heat of the patch would absorb more estrogen. And she said, I get this.

And then in the summer, she said, I don't know why, but it's got worse again. And it's interesting. So she was obviously very sensitive to small changes of estrogen. And so some women find when they have endometriosis, when they start on HRT, any sort of pain can flare up. But then it often settles down as their body almost gets used to it, doesn't it? And if the patients can persist for six months, then some of those are a significant proportion.

I don't know what percentage of a significant proportion anecdotal will settle down. Some patients, they won't. And you have to accept that every single patient response. differently to hormones, but generally they will settle that if they're able to just push through, go for six months. Yes, and the beauty of the type of HRT that we usually prescribe is that we give the estrogen, the progesterone and the testosterone separately. So some women need a higher dose of progesterone to suppress their end of mutiosis.

And often we start with a very low dose of estrogen and we can gradually increase. So it can be sort of a bit more tailor-made. And this is HRT that's obviously available on the NHS as well. And then the women can be in control, actually, because often women who have quite severe endometriosis have had such, sadly, dreadful times, they're very used to controlling and knowing what triggers their disease and their symptoms.

So it's really useful for them to be in control of their HRT as well, I think. Very much so. They've had years and years and years of this. So, for example, on average, my average patient is, I'm the third consult that they've seen. Gosh. And that's having been through GPs as well. It's almost akin to men.

isn't it? I mean, I feel emotionally dained every day when I think about menopause or women, but certainly my clinic, the stories that I hear, like you say, are people giving up their jobs, remorgeting their house, getting nowhere, their partners leaving them. And endometriosis is very similar because it's just not diagnosed. It's similar to, I always think, women who have premature ovarian insufficiency. So as you know, one in 100 women under the age of 40, have an early menopause, average length of time to diagnosis is between seven and ten years. And certainly when I was at medical school, I was taught, the woman doesn't have periods, make sure she's not pregnant, Louise,

and then we can reassure them. I mean, how wrong is that? So, you know, it's absolutely scandalous, but I feel ashamed because I have missed some of these women, because I didn't know that POI was actually a thing. And like a lot of doctors, haven't been trained, what endometriosis is, or how to diagnose it. I was the same.

Before I went to France, I used to see the general gynaecology clinic as a registrar, junior registrar, and I'd see endometriosis in the notes, the patient who's about to come in, and my heart would sink, because I think, gosh, I don't know how to do with this. You'd give them some medical therapy and say, come back in six months, knowing full well that you'll have moved on on your six-monthly rotation and that you'd hopefully, you know, somebody else could deal with that problem. And it wasn't until I was lucky enough to be sent to France,

that it all made sense that we can actually treat this disease logically with good results. Yeah, and transform women's lives, can't you? And that's what's so important, I think, to be a physician or a surgeon and be able to make such a huge difference is absolutely. It's very humbling, very rewarding, but really important. It's a complete privilege, isn't it? But it should never get to that stage. And I think, you know, having this conversation today, which is fantastic, but some of the charities that are working on endometriosis and the women behind them are doing the most incredible job, actually. And I think it is about being strong. And for those women who think they have endometriosis or know they have endometriosis, really trying to be as strong as possible to get the right help and treatment. Yes. I mean, so this is the 22nd year I've been involved in managing endometriosis. And one of the things that I've learned is that an individual doctor or surgeon putting the head above the parapet and trying to make changes into a big system like the NHS,

it just does not work. The one thing that seems to make the biggest difference that it's just really gaining some speed and some momentum now is patient awareness groups who are then lobbying MPs and Parliament, patient pressure groups. I strongly believe that if the management of endometriosis in the UK is going to improve, then one of the major ways that that's going to have to happen is by women getting together in organised groups

and pressuring the government and pressuring their local MPs. to effect change because it's very easy for the NHS or big organisations to ignore the voice of one or two doctors who are advocating, look, we should be doing this, we should be doing that, we should be in the other. It's very difficult to ignore big groups of women who are highly motivated. Yeah, totally. I think it is important because also women are very good at helping women as well, aren't they? And I think when people have had difficult experiences, then they learn from them as well and can help and guide. So hopefully things will only improve going forwards, which will make a big difference to 10% of women, which is so important.

So it's been really great, Chris, and thank you ever so much for giving up your time to share your knowledge. And I hope this has been really helpful because if some of you listening, obviously, don't have endometeosis. You might know people that do. And I hope this will help women from all ages. So before we end, though, I can't let you go without asking for three take home tips. So I thought I would just ask you about three things, really, that women can do if they either think they have endometriosis or they know they have, and they're perhaps not getting anywhere, especially if they're perimenopausal or menopausal. So if the patient suspects that they've got endometriosis, so that would be based on these sort of five areas of symptoms that I said broadly encapsulate most patients with endo, not all of the symptoms, but the pelvic pain, the pain with intercourse, pain with opening your bowels.

pain with periods and then pain between periods, if those symptoms are not resolving with simple analgesia, such as paracetamol or ibuprofen, or if they're impacting in such a way that they're affecting your quality of life, whether that's your ability to study, your ability to work, your ability to run your home if you're a full-time mum,

your ability to parent, your ability to be a partner, if it's now impacting to such a degree that the impact is negative and it's becoming more and more of a problem, then please, please seek help. So the first way to do this within the NHS framework is to see the GP. Now, if you're not getting anywhere with the GP, ask for a second opinion. That would usually be another partner or another GP within the practice.

If you're still not getting anywhere, you can always just make an appointment to go and see somebody in the private sector if you're able to afford a consultation. that doesn't mean that you have to then have your whole health care management program in the private sector. It just means that you'll get somebody who's dedicated, got an interest in end end uproxies. They'll be able to do the appropriate investigations. And all the way through, they give you a management, a recommended management plan that you can then either progress through in the private sector. We can go back into the NHS and those people like me, we will write to your GP and say, look, this is the reason that I think this patient has endipatosis. it's what I would recommend is A, B, C, and D.

The GPs will listen to that. The fastest majority of GPs will listen to that. Yeah. So it's awareness of the disease. It's seeking help. Not giving up. That's probably the third thing. Don't give up because for too long,

too many women have been fobbed off. They've been told, well, it's just something you've got to put up with. It's just women's trouble. Go and have a baby. That's cure it. Wait for the menopause. There's nothing to do.

in your mind. I've heard all of those things so many times. We had somebody earlier this week who was told, well, you have paid with sex and don't have sex. Well, she was in the 20s. Patients don't have to put up with that anymore. So be aware of the symptoms. Seek help if it's having an impact on you. And if you're not getting anywhere, try again. Don't give up. There are now more mothers who want to help. Really, really good advice. And like you say, if you can't help directly, you can always signpost. And sometimes the support groups, actually, and the charities will be able to give you more advice as well.

So it's so important. It shouldn't be like this, but it is, and it's very important, you know, women know their bodies. And if you're unsure, and you think you might have endometriosis, then make sure you seek help. So thank you again, Chris.

This has been brilliant to learn so much. Thank you. It's an absolute pleasure. For more information about the perimenopause and menopause, you can go to my website, menopausedoctor. or you can download our free app called Balance available through the App Store and Google Play.