The Dr Louise Newson Podcast - 092 - Menopause care and education in the United States and Britain - Heather Hirsch and Dr Louise Newson

Episode Date: March 29, 2021

In this episode, Dr Newson has a lively discussion with Heather Hirsch, the Clinical Programme Director for the Menopause and Midlife Clinic at Brigham and Women’s Hospital in Boston. Heather was shocked to see, during her fellowship, that what was being taught about menopause principles and care was actually wrong and realised that menopause was the biggest gap in women’s healthcare across America.   The experts discuss the problem of unregulated compounded bioidentical hormones and the reasons why 2-3 thirds of American women use this type of non-approved hormone treatment, rather than FDA approved body identical HRT that is prescribed by doctors in the UK. They reflect on the shift away from using HRT over the last 2 decades, and the devastating consequences to women’s health because of this, and offer practical advice on how to educate other healthcare professionals to unlearn the pervasive myth that estrogen is dangerous.   Heather’s three take away messages are:   Medical students should spend time with a menopause doctor and see how they help women.   Menopause care is a team effort and a global effort; everyone has to come together.   Tell a friend,  colleague or family member about evidence-based sources of menopause information such as podcasts, youtube channels, or social media. Help spread the truth about HRT. IG @hormone.health.doc Website: heatherhirschmd.com YouTube: Health by Heather Hirsch  Podcast: Women's Health by Heather Hirsch   

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 someone who doesn't live in the UK, someone from across the pond, and we've had a few doctors actually already on the podcast. our series. So welcome. This is Heather Hirsch. She's a clinical program director for Menopause and Midlife Clinic at the Bering and Plus Women's Hospital. And she's also staff at Harvard Medical School. So quite a mouthful really. So welcome, Heather. Thank you. I'm so excited to be chatting

with you today. Oh, great. So we sort of, I've had you in my radar for a while and you've probably had me in your radar for a while. So we sort of first spoke just last week, actually. And as many of you you listen to me, no, I'm constantly trying to think of ways to reach more women, to help more women, to give women choice about their future health. So in the UK, as many of you know, only the minority of women receive good quality, evidence-based menopause, care and treatment. And sadly, it's the same in America. So I'd like to hear more, Heather, if we can. Sure, absolutely. It is unfortunately very similar. And there's a couple of reasons why I think that this could be. But what I found during my medical journey is that I completed my

internal medicine residency and then I went on to do a fellowship in women's health. When I went to do my fellowship, I became very interested in menopause and midlife. I was at the Cleveland Clinic, which is a big institution and people from all over the world would fly in. And I was floored that what I learned just a year ago in an internal medicine residency between 2010 and 2014 was actually wrong about a lot of the evidence-based principles about menopause care. I was floored to see that women from all over the country were flying into Cleveland to be treated, to be understood, to understand hormone therapy when they were denied hormone therapy. And it was at that moment that I realized it was the biggest gap in women's care. And I really wanted to be a part of changing that because

it is such a crucial part of a woman's life. So there's still a lot of misinformation here in the United States. I mean, it's exactly the same here, but globally as well. And I think for many years, women have been fed wrong information. Journalists have been fed wrong information. But actually, more importantly, and more disappointingly, actually, doctors and healthcare professionals have as well. And, you know, we learn from our peers, a lot of medicine. We learn from experience, but we learn from our more senior clinicians. And, you know, who are we to judge them when we're medical students, we wouldn't question what they say, would we? So I can see how it's happened. It's no one's fault. And we're not here to blame anyone, but what we are here to do is to try and change.

But making changes is really hard, isn't it? It is so hard. You know, I always say at the time of this recording, it's 2021. So if you didn't think science was political before now, now you know, and women's health is certainly, you know, right in that group as well. It totally is, isn't it? And I think what's very interesting for me, as you know, I'm not a guy in a question. And yes, I'm interested in women's health, but I'm interested in health in general. And for some reason, and maybe you'll know, but menopause has always been thought of as a gynecological specialty. But actually, menopause is about period stopping.

So why would you want to see a gynaecologist? It doesn't actually make sense, isn't it? It really doesn't. You know, I have to say, I actually was thinking about this today that I even wonder so far about like the annual exam after you've had children and if you no longer need surgery, You know, obviously, as an internist or a GP, we don't do surgery. We certainly can do minor procedures. But, you know, it is something that should maybe then be sort of softballed back to the internists or the family care physicians or the endocrinology specialist, perhaps, because we have such in-depth knowledge of chronic disease and chronic disease management. Whereas our gynecology colleagues, as brilliant as they are, are really great at surgery and delivering babies and doing complex other things that they learned in their training.

So I agree with you. I think it's actually a ripe field for someone who is doing direct patient care within a primary care specialty, what we call here in the United States, and has had some advanced training so they know about hormone therapy, the safety and efficacy as well. Absolutely. And certainly enough of the work I'm trying to do in the UK is to think about nurses and even pharmacists taking on some of this role. Because certainly everyone's very stretched, especially doctors, I mean, all healthcare professionals, are, of course, but there's a lot of women who also, they don't see the menopals as a disease, because of course it's not a disease, but it can lead to diseases if not managed properly. So there are a lot of women, certainly over in the UK, who will go to a pharmacist and say, well, I'm having terrible hot flushes or night sweats or headaches or fatigue, what would you recommend? And if a pharmacist hasn't been trained, they'll say, oh, well, you could try

some black cohosh, you could try some red clover, but they wouldn't know to even say that hormone replacement therapy is a potential treatment. So would that be the same in America? Would people go and try and self-help or self-medicate if you're saying that doctor? Well, I have to now disclose a terribly embarrassing fact about myself, and that is that I have never traveled to Europe. But I do hear that there are some interesting ways of which you can go to the pharmacist and talk to them directly. Where in the United States, most things that you're going to do, you're going to go through your doctor and a pharmacist is not going to be able to really recommend things because they will be too worried about malpractice here. So they

They would never want to recommend something unless they know everything about you. But similarly, in the United States, we have a big problem with pharmacists prescribing under the direction of a clinician, compounded, non-FDA approved, potentially dangerous substances of which has really become a billion dollar industry here in the United States. And I always say, while we really, as providers, whether we're in the UK or in Australia or here in the United States, are really starting this movement to encourage physicians and women to consider the safety of FDA-approved medications. I certainly understand why that niche developed because they couldn't find relief from their primary care or their GP doctors. And now we do have a culture of compounded pharmacies and pharmacists writing for all types of compounded hormones. Yeah. And it's a real concern over here. It's not nearly as big as it is in the USA, but these are the

compounded bioidentical hormones which are neither regulated nor licensed and we see a lot of women that come from all sorts of clinics i saw one this morning who um had been seen for four years and been given some compounded bioidentical hormones and they're very extensive but they also you know she still had hot flushes and sweats and she didn't feel right and you just don't know what they contain so they're actually more of a concern than the regulated HRT which everyone is scared about. Right, exactly. And you and I and others who are really working to change and to shift this social culture are really saying that bioidentical is a little bit of a marketing term and that there are plenty of bioidentical options that are FD approved and that have been

well studied and that are safe. But I have to say, many women are superiors. rise, their minds are blown when they realize that something compounded or bioidentical compounded is not regulated. They have no idea. And then they're actually so afraid of what they took because they didn't know that it was unregulated. Sometimes they do, a lot of times they don't actually. No, but they're marketed very well actually. A lady today said to me, but you can't just start HRT. You have to do my hormone blood test first. And I said, well, you're 58. You've not had a period for six years. I can tell you what your hormone blood test will be. They'll be low. But don't you need them to match? I said, well, you don't want matching. How can you be matched? So it's a real problem, actually,

because women are being misled. And I mean, over here, probably between 10 and 14 percent of women take HRT who are menopausal. That's regulated HRT. What would it be over with you? Do you think it's that high or do you think it's even lower? I'm not sure at any given time. And that's really because we don't know the exact percent of women that are getting, if you want to include women who are taking HRT, that's unregulated. So it's probably somewhere in the 10 to 20 percent. But in 2019, we knew that about a half to two thirds of women were using unregulated, an FDA approved, compounded prescriptions, and only a third or so, we're actually taking FDA-approved options, which to me really signals that the gap is that clinicians don't have the right.

education and confidence and counseling skills to provide them something that's ultimately much safer than what they will do if they are left to their own devices. Yes. And so the training that you're involved in is really key because it's about helping future generations of doctors as well. And I know when we spoke before you were saying how much interest there is and enthusiasm. And I find that the same. When I teach doctors or junior doctors or students as well, it's the first time they've ever heard any of this. And they don't know that even the menopause increases risk of diseases. It's quite something, isn't it? It is just like when I learned it, once you see it, you can't unsee it. And once you actually,

for those of us who are true clinicians who see women, you know, day in and day out, you certainly once you know it, you can't unsee it. And I have students, medical students at Harvard and residents at the Brigham and Women's who have never, ever seen a prescription for estrogen or an estrogen-progester combination ever. And they are so floored. And they sit with me for a whole day and they get to see me prescribe it. And they sort of walk away with feeling like, ah, they see women come back giving me big hugs or flowers from their spouse, right, that their wives are back. And they really realize how much this really changes people's lives. And then on the other spectrum, I am junior faculty. So I was not a physician in the 80s and early 90s when hormone therapy

was declared first line by the American Medical Association. But I will have some of my older colleagues come up to me and say, you know, I never took my wife off estrogen. I wish you, you know, could have seen the days where we prescribed estrogen and that was considered first line. And I'm so happy that you've given this talk because I have witnessed a 20 year span or so, where it fell off and my patients really suffered, but I was still confused, although I did not take my wife off her hormone therapy. Well, that's the thing. I think people that know have carried on and my mother and my mother-in-law still take HRT, but they've been tried to have it taken off them many times, you know, and I'm older than you. So I qualified in 1994, where we did

use to give HRT a lot, and then it obviously stopped. And I have had stand-up rows, actually, with the partners in my work because they've been trying to take women off. And I've said, no, actually, I want to carry on. And it's been really quite awful. I can't think of any other aspect of medicine that has so much anxiety and so much sort of uncertainty. And in fact, I was talking to a lawyer this morning actually about it. He said, well, of course, there's so much controversy. And I said, but there isn't any controversy. We've got data. We have facts. And he said, really? I said, Absolutely, because over here our MHRA, the Medicines Health Regulatory Authority, are advising doctors they have to prescribe for the shortest period of time at the lowest dose, which contradicts menopause guidance, but not just in the UK, but the International Menopause Society as well. And so I sit in there is no good evidence to support the use of hormonal HRT for the lowest dose for the shortest dose of the shortest of time.

Would you agree with that? Absolutely. You know, so I was trained by Dr. Holly Thacker. She's a brilliant clinician and menopause expert at the Cleveland Clinic who started my fellowship. And she too remembers that time and going through that transition where it was first line and then there was so much controversy. And I will have physicians say to me, you know, Heather, you were probably in college at the time and it was not so much on your radar while you were learning anatomy. But nothing has stuck around with clinicians that it became such a pervasive idea. You know, the idea that estrogen is dangerous and harmful just became so ingrained during that time that just like you said, there's been nothing similar in the medicine world that's been like that. And to your point, I also learned in residency the tiniest, tiniest, tiniest, lowest dose for the shortest, teeniest, littlest time that you need, right? And then you have to come off right away. And I re-learned that when I was in fellowship.

Another thing that I was so floored and then appalled that I had taught other people. And certainly, I see women come to my clinic. Just last week, I had a 67-year-old who had been taken off her hormone therapy because she had a birthday and she turned 65. She'd been on her estrogen patch for, and she'd had a hysterectomy, which is, we know there's actually some even more benefits of taking estrogen alone, been on it since she had her hysterectomy at 4.4. 47, was pulled off at 65, was miserable for two years, found me on the internet because we do a lot of outreach here. And I explained to her the safety that your body has had this low dose level of estrogen for the last, you know, whatever the math is, 12 years since you had your uterus removed and since you were menopausal, your endothelial lining, your heart, your blood vessels, they're also

used to that very low postmenopausal dose. And there's nothing magic that happened when you turned In fact, we're taught the biggest risks, especially for the risk of a blood clot or a deep phange thrombosis, or actually in the first six months. I said, you're way past that. So, you know, we restarted her on the patch and she's doing great. And so we know that it's something that needs to be individualized, that you continue to discuss with your clinician and that it really is really a patient and clinician discussion. But, you know, certainly I always say, I have two groups of women, those that say, never take these from my cold dead hands, which I won't. And those that do kind of want to taper off and then we see how that goes. But there are these pervasive myths. And again,

I'm a little bit younger in that I wasn't around to see the shift, but it's almost more interesting to learn it almost in a historical way because it just makes you have even more fuel to the fire of how unfair women have just been mistreated. And it is totally unfair. I mean, I was looking at a a presentation recently, and they showed a map of, I'm sure you've seen it, it's a map of America, of all the states, and it's showing cardiovascular disease, a heart disease incidence, men and women, before 2002, before this big study came out, and then what it's like now. And there's red with the incidence of heart disease. And it's not very much red, actually, before this time.

The men and women, men always have a bit more heart disease than women. And then they've showed it now, and the men haven't really changed much, actually. but the women, it's bright red across the whole of the US. And the only thing that's really, well, there are things, obviously, like obesity is increased, but it has in men as well. But the big difference is no HRT. And isn't that interesting? Whereas if you look at the incidence of breast cancer,

you would think that that would reduce because everyone's off HRT, right? And if HRT is such a devil for breast cancer, there'd be a huge difference in there hasn't. Has there? In fact, there's probably been, if anything, a slight increase. because people are more obese and that's the biggest risk factor. And we know women put on weight after the menopause. So even if you're not a scientist, doing all the really clever statistical analysis, you can just see that. And so you're smiling at me. So I know you've seen that picture as well. Yes. And it is something that when you carry the lens that you and I and many other

menopause experts do, how is there any other explanation? You know, and it is fascinating. So we both know Dr. Phil Sorrell, who has done a lot of research, epidemiology research, on deaths potentially caused from the lack of estrogen replacement after the initial 2002-2003 W-H-I study came out. And it's astronomical. And that was just women who've had a hysterectomy taking estrogen alone. But you're absolutely right here in the United States. Going back to one of the first questions you asked me, the fear is still breast cancer. And while I always say, I certainly don't want anyone under my watch to develop breast cancer. The rates of breast cancer are one in eight just by having breast tissue.

And we certainly also know that many things that we do within our daily lifestyle or the way we live our lives already increase our risk of breast cancer significantly more than the risk of taking estrogen if it's not baseline in general, actually. And that to compound that, the leading cause of death is cardiovascular disease. And when you think about the preventative effects that we see from estrogen replacement when given to women within the first 10 years of menopause, ideally, you know, we don't, clinicians don't push you off way too far before you find a menopause expert, but that what an improvement in lifespan we see and in quality of life we see. And while breast cancer is still complex and certainly is always an emotional thing, it is something that is, unfortunately, somewhat common and more of a chronic. disease that we can, you know, control, but it shouldn't be the thing that keeps people from hormone therapy, but it's the thing that keeps patients and clinicians from being very fearful of prescribing hormone therapy. Yeah, absolutely. And there's never been a study, has there, that's shown that women who take HRT actually have an increased risk of death from breast

cancer. There's one thing being diagnosed as another thing actually causing death, whereas we know that mortality actually reduces from other conditions when women take HRT in the long term. Yes, in the summer of 2020, research was really, and the media was really covering the virus that shall not be named. But in the summer of 2020, they looked back at the women's health initiative and the women who did get breast cancer and found that they died less than the women who got breast cancer but weren't taking hormone therapy. So if you ask me, I actually think hormone therapy really sort of has a null effect on your overall risk. I think it's a genetic risk factor or an environmental risk factor. And if it is in your fate, it's in your fate. But we know that women who take hormone therapy are a slightly different population.

They tend to be a little bit more proactive. They never miss a mammogram. And oftentimes, if you do have a cancer that's going to be responsive to estrogen, it's going to show up faster and you usually get treated faster. And so, you know, there's certainly a lot of focus on incidents, the number of diagnosed cases. But no one really looks at mortality, which means, you know, actually dying, from that condition, which is actually lower in women who took hormone therapy. It's crazy. It's absolutely mind-blown. But the other thing is I also sort of think a lot when I think

clinically about my patients is it's about choice as well. It is. So if, for example, someone said to me, well, Louise, you are guaranteed to have breast cancer if you take HRT for 10 years, which obviously I'm not. For anyone that's listening, this is not right. But if I was, then actually I could still decide that I want to take HRT because without it, I wouldn't be able to, work because my brain was so awful, but also I'd probably be divorced because my husband was just infuriating me. My children would have just given up on me. But also, I would have had this increased risk of heart disease, osteoporosis and so forth. So actually, for me as a consenting adult, I could say to my doctor, well, actually, yes, I'm taking that risk. But the risk isn't

that high. There's no guarantee that women taking H.R.T. actually have an increased risk of breast cancer, especially with the regulated body identical of HRT that we usually prescribe. So why are women denied something? This is the biggest thing. Is there any other area of medicine that you are denied a treatment, even if there are risks with it? So there are risks with statins. There are risks with some of the cancer drugs. If you have steroids, there's risk of immunosuppressions. There's all sorts of risks, isn't there? But we just give it out as doctors and the patients take it and they, you know, It's crazy, isn't it? I say even aspirin, you know, usually lands people in the emergency room for bleeding risk,

way more than me giving estrogen does. I couldn't agree with you more. You know, as you said that, I can't think of anything. And I'm thinking really hard. If something comes to me, I will email you, but I cannot think of anything. But you're right. And certainly I have patients who say, despite this diagnosis that I had, whatever it might be, that's considered a contradiction to the majority of,

of clinicians who are not well-versed in menopause, I'll say, I will take that risk, you know, because otherwise I have thought of X, Y, and Z plan for myself, which is pretty harsh things that you hear when women are really suffering. They're not thriving and they don't feel like themselves. Why do we deny women something that we were, as I always say, in the cave days, we died at childbirth or we died long before menopause. I think it's a hormone we were meant to have around for the majority of our lives. Absolutely. And it's very interesting. I mean, I don't know what it's like in the U.S. but over here, endocrinologists, so hormone specialists are fantastic with hormones, but they don't really get any training in sex hormones.

So I saw someone recently in my clinic who'd had a tumour in her brain, a pituitary adenoma, which actually stops a lot of the, or most of the hormones being produced. And she'd had it from a very early age. She was still quite young. She's still only early 40s. So she'd never really have proper periods because it affected her hormone production. So she was having replacement hormones, so she was having the replacement the thyroid hormone. She was having replacement cortisol. So the hormones that are really,

really important. And I said to her, well, what about your estrogen and testosterone? Oh my goodness, no. My endocrinology said, I can't have that. That's too much for a risk. She'd had a bone scan and her bones were already thin. And she was finally it really difficult to concentrate at work because of a brain fog and fatigue. She had such awful vaginal dryness, but she was Asian and couldn't tell her family or she couldn't tell her husband. So it was very, very difficult for her. So we had a very long detailed consultation going through everything and she decided at the time that she wanted to take HRT because of the benefit. She was young. She had no risk of breast cancer because she's so young as well. We went through everything and then a few days later I got an

email back to my clinic to say, actually I don't want to take any of this. I've read and I've realised the risks are too high. My endocrinologist isn't happy. So I'm not going to take it. So this is someone who's used to taking hormones, but there's something about sex hormones that's made her really spooked. So I see that here too. And this is not a perfect scenario, but I've come to try to include the care team so that we can all be on the same page because nothing is worse, as you just said, than when you have a patient in that scenario, I had a similar patient. She actually had a brachom mutation. So she was at high risk for breast and ovarian cancer. She had everything removed, both her ovaries, both her breasts. Okay? She had no tissue left. And I wanted to give her

estrogen replacement with some testosterone because she was 42. She had started smoking because she couldn't cope. And she was otherwise gaining weight because she wasn't really exercising. She was just so depressed. And I finally got her there because, of course, she was told, you know, your high risk, you have a brach mutation. You know, of course estrogen is contraindicated. And she took it for two weeks, felt a little bit better. Her oncologist scared the bejeepers out of her, and she came off. So very similar scenarios. It's almost like, just as you said, I was struck when you said, you know, starting

to include education for pharmacists and social workers. We really, there is not one sort of specialty physician, except for maybe pediatricians, except for rare cases of things like Turner's syndrome. But, you know, almost all specialty of medicine sees women going through menopause. I don't care if it's orthopedics, car. cardiology, endocrinology, sleep medicine, maybe not the ICU. But still, you know, they all see women in menopause and we all need to try to educate ourselves on this. And in these complex cases, it is nice to sort of try to have the team meet so they can really understand, we need to treat this

patient, not her breast tissue. We need to treat her so she doesn't continue to smoke so she can lose weight so she can go back to being a hairdresser and make money. Absolutely. But it's also very difficult for patients when they're caught between two or sometimes three physicians, all saying different things. And so often with these patients, I will say, well, I'll speak to your doctor, or I'll speak to your endocrinologist, or I'll speak to your breast surgeon. And often when I speak to the doctor, I remember there was one a while ago, and she said, of course I'm not going to give HRT. I'm not going to continue this trip to because this lady is overweight. She's a smoker. She's got a history of heart disease. I said, well, she'll benefit from HRT even more then. And

she said, what do you mean? Surely not. I said, no, do you realize? And And so then we had a lovely discussion at the end. She said, goodness me, I had no idea. I just saw HRT increase the risk of heart disease. I'm so pleased you spoke to me. So it does boil down to education at the end of the day. And, you know, if you do evidence-based medicine, which we should all do as physicians, then it's really important.

But it's also important that women have the right knowledge so they can ask for the right treatment. So I think it's not just about us as doctors. It's about being able to empower women as well, because then it makes a consultation. that much easier too, doesn't it? I know, you're right. Doctors should do evidence-based medicine in all areas, and they shouldn't just exclude what we have on evidence-based medicine on hormone therapy because of a bias they have from 10 or so years ago or because of the bias they may have learned when they were training. It's almost like we all say we want to do evidence-based medicine, but then they cut this little circle out of hormone therapy and just put it away. And, you know,

I'm lucky at my institution when I came to the Brigham and Women's Hospital in the Boston area. I have had so much excitement from the cancer hospitals, from the endocrinologist, from the neurologist, from the psychiatry team, who are all really so excited to have me there to learn about this. So I'm very excited that perhaps we are in a time where there is some momentum, where we are spreading this word, and we are getting the word out. And women are demanding more from their doctor. And so I'm really so pleased to see everything that you've been doing in the UK and inspiring women and inspiring people all over the globe to participate in educating everyone. I think it's so important. And, you know, a lot of the work I do is not in isolation.

So it's about joining forces, women helping women. As you know, the app, the free app balance that we've created is for women to help empower. But actually, a lot of people who are using the. app, but empowering themselves are also menopausal doctors and nurses and physicians and, you know, 40% of our NHS healthcare are menopausal women. 40% is huge. So, you know, these women need looking after. Everyone knows a woman, don't they? So it's absolutely key. And the time feels right because this isn't a fad. We're not sort of talking about having a vegan diet and next week it will be a ketone diet or it'll be something else. This is really established evidence.

it's not going away. So I feel like it's our sort of mission to get it out there and to have this future generation of doctors and nurses and women really going forward. So their future health can be the best it should be. And I think what you're doing is so cutting edge because somebody else said to me, you know, that when women do better, everyone does better, society does better. Women are in the workforce longer. Women take better care of their children. Women take better care of their partners. So it is about us all benefiting our society and one another. And so I'm so excited for the app. I know I saw 50,000 people of more have already downloaded it. I'm excited maybe I'll get a chance to take a part in it because being a

part of this is it is such a wonderful time to utilize social media and to use this momentum that we have to keep everyone and all of our women knowledgeable, health. and educated. That's so important. Absolutely. So wise words from across the waters. Thank you ever so much. So before I end, I always ask for three take home messages. So I would be really keen to ask for three things that you think would make the biggest difference. Three quick, not necessarily quick, but easy way of making a difference for a future generation of women's health. Yeah. Well, that's a great question. One, I think that all students should have, even if it is a few hours in either medical school or residency, they should just see someone who is a menopause doctor talk and counsel a patient through. Even just one aha moment is all it takes for them to realize, oh, estrogen's not dangerous.

And even if I don't go off and do that or if I'm going to become a cardiologist or a GI doctor, I will not scare my patients and I will get some better education. on that. Take-home message, I think number two, is that you're right, it is a team effort and it's a global effort. And so much of what's happening in the UK is very similar, if not one small step ahead of the United States. And that's amazing to see that we're facing the same battles across the pond. And I'm interested, too, in other countries, but I'm starting to learn that I think it is pretty similar. So we all sort of need to come together, especially clinicians, as you, you said, allied health care professionals and women. And for my takeaway number three, I would say, for all your listeners here, tell a friend about this podcast or the social media or the YouTube

channel that you like, whether there's so many wonderful people, especially if it's an evidence-based channel, particularly if it's an evidence-based channel of which there are many. Tell a friend, because it's still a taboo topic, even though it's slowly opening up in the United States, it's still very taboo. I think the UK might be a little bit better in that regard. So tell a friend or a colleague or a sibling, someone you don't normally talk to who you think this might be an embarrassing topic. Tell a friend because almost all women are going to have symptoms. And if the 10% or 20% then don't, their body is still physiologically changing. And it's better if we all just know what's going on with our bodies. Just like we learn those videos in puberty in school, same thing needs to happen on the other

side. Perfect. Thank you ever so much. Really good. Great. So thanks ever so much for your time today. It's much appreciated. You're welcome. So glad to be with you and so excited we have gotten to connect. And I just love to see everything that you've been doing. Oh, thank you. Thanks, Heather. For more information about the perimenopause and menopause, you can go to my website, menopause. or you can download our free app called Balance available through the App Store and GooglePlay.