The Dr Louise Newson Podcast - 094 - Breast cancer treatments induced my menopause: what help is there now? - Caroline and Dr Louise Newson

Episode Date: April 12, 2021

Just before her 40th birthday, Caroline was given the unexpected diagnosis of breast cancer. The grueling treatments brought on the menopause and she endured a miserable seven years as a 'functional wreck'. Nine years on, Caroline reflects on this experience. She describes her search for help for the awful menopausal symptoms that were making her feel so unlike her usual, outgoing self and shares how she came to the decision to take HRT, despite being surrounded by advice to the contrary. Dr Newson outlines the complex and little understood relationship between breast cancer and estrogen, and reminds listeners that once accurate information is shared, the choice about menopause treatments after breast cancer ultimately belongs to the individual.   Caroline's three tips:   Keep an honest record of how you are really feeling and look back on it. If you notice menopausal symptoms and you're just getting through the day, see your doctor. If they suggest antidepressants, don't agree straight away, find out more about how effective they are for menopausal women. Talk to someone who specialises in the menopause, even better, someone who treats menopausal women who've had breast cancer. Then you know you're getting gold standard information. Don't beat yourself up if all you're worried about is the cancer coming back. It's normal to feel like that. But also allow yourself the possibility of a better, brighter future. You need to know there is hope and help out there - you deserve it.

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 on this podcast, I have with me someone who's very keen and willing to share her story, which I think is really important because we learn more from other words. women actually than often people do from healthcare professionals. And this lady Caroline, who I'm going to introduce in a minute, has had breast cancer. And breast cancer now affects one in seven women. When I was a medical student in the 80s, it affect one in 12 women. So it's becoming more common. And it's more common. We don't always know why, but often it's lifestyle factors that are increasing risk. And we now know obesity is the commonest cause of all cancers and probably breast cancer as well. But as you know, people who are listening, every woman will go through

the menopause. So this means every woman who's had breast cancer will either go through the menopause naturally or quite frequently go through the menopause either temporarily or permanently because of treatments. And a lot of these women actually really get neglected. And I feel very sad about a lot of women who are menopausal, but I especially feel sad for women if her breast cancer. So thank you, Caroline, for agreeing to record this podcast. Not at all. Thank you, Louise, for having me on. I feel really passionately about sharing my story, actually. Oh, thank you. So can you just tell me a bit about everything, if you don't mind? That would be really useful. Yeah, that's fine. So in 2012, it was just before my 40th birthday, and I decided to check my

breasts and I hadn't done that for a while actually. I had two young children. They were three and seven at the time and yeah, I just checked them one day and I was just horrified. I found two lumps in my left breast and my husband wasn't at home at the time so I was just in a complete panic and yeah, it took a long story short. I went for a one-stop shop appointment at a hospital and oh, you know, it was just fast-tracked into scans, biopsies, and then, yeah, diagnosis just before my 40th birthday. And I had two tumors. One was very low estrogen receptive and the other one was triple negative,

which I don't know how many people listening have heard of that, but it means it's not really receptive to progesterone and testosterone, and probably something else. I should know it's the other one that you can get her to. Per septic. So this was like a horrible whirlwind all over April 2012. And because of the nature of the tumours, I had to have chemotherapy. And then radiotherapy and then a bit of tamoxifen and then Zolodex. I had all sorts of treatment. Gosh. So Zolodex is an injection, isn't it? That blocks hormones being produced. So it stops all female hormones being produced. but especially estrogen and it's quite long acting, isn't it? Yeah, I found it quite severe actually.

Yeah. So how long did you have solidex for? About a year. I think they wanted to put me on it for two years, but I think the understanding was because it wasn't, I wasn't like heavily estrogen receptive and even that, I suppose there's still research to be done around that. And we've got to remember that,

that there's not a sort of finite decision on what is right and wrong with the hormones and what's happening. But anyway, they thought, well, just dot every eye, just take that. I tried some oxophen and I became neutropenic, which means my immune system. I think the neutrophils, which is a type of white blood cell, dropped. But then it had in chemo as well. So, I mean, if anyone's listening who's had chemotherapy or any kind of treatment like this one, though, it's extremely grueling anyway.

And then afterwards, after all the chemo and the radiotherapy, to then be put on something that blocks your estrogen further. I mean, I hadn't realized at the time how that would make me feel. I was glad to be alive. Yeah, of course. Absolutely. That is a, I mean, that goes without saying it's a priority. But did anyone give you any information about how you would feel with having all your hormones

blocked? I was looking back at this. And I think it's all very much erring on the side of survival and the cancer. so every bit of information I got breast cancer care were fantastic but a lot of it was about you know your well-being and your care they do mention the menopause but I think even us as women and you know I was fairly I think at any age I'm just going to say though for me because I was young and it was a complete it was the first time I've ever been ill I just did not want to get it again so I was kind of thinking about that but breast cancer care when I did go to one of their young people

people's kind of, they had an event. And there was a lady there who did talk about the menopause. And I think it was just very light, light touch, I'd say. And my oncologist may be meant, he, I think they talked about it in a medical way. So this will happen to your ovaries. This may happen to you. But nothing, Louise, like the way you talk about it and the way it's talked about a lot more now. I really understand what was happening. I thought it was me, something wrong with me. It's very interesting. Yeah, I mean, when I was a medical student a long time ago now, but in 1992, I did a research project with Professor Tony Howell, who is one of the most inspirational men that I've met, who's still working in his 70s. He heads up the preventative

breast cancer unit in Manchester. And Tomoxifen had only started really to be used. And my remit, a short 12-week project was to write some information about tamoxifen for women. And in that time, as you might know, the internet hadn't been invented then. So you couldn't just go on to Dr. Google and find out. And so I sat in his clinic and he, quite rightly, it was all about the chemotherapy, about the drugs, about, you know, you will survive, this is about breast cancer, which absolutely is the right thing. But I sat there, looking at these poor women, shell-shocks.

They didn't even know what cancer meant. They didn't know what chemotherapy went. So the thought of Tamoxifen was just nothing at all. So I did a little research thing and I asked women, what is cancer? What are your lymph nodes? You've had them remove. What are they? Do you know what they are?

No, they didn't. Cancer just meant death to them. That was what they thought. And when I said about chemotherapy, they didn't even know it was a drip or a tablet. They just thought it was some horrific thing that would make them lose their hair. That was all they said. And so I went back to Tony Han and I said, look, I'm very happy to write about Tamoxifen. But before that, I want to write a series of booklets, what is cancer, what's your lymphones,

what is chemotherapy? And he said, don't read Darth Louise, they all know. I said, right, you just ask your next five patients that come in, what they understand by the word cancer. And each one of them was really embarrassed because they couldn't answer to him. And he said, but I've had no idea. And as a medic, you forget, you use all this terminology all the time, and you forget that other people don't know it. So when I was writing these booklets, I'd be phoning up my poor mother, who isn't medical. and say, Mum, what's lymph node?

Have you heard of radiotherapy? No, is that chemotherapy? I use it. And I thought, gosh, actually, she doesn't know. And she's not stupid. She's not ignorant. She's very educated. But it's not terminology that she's used to.

And then, not long after Tony Howell went to, we was just learning then, really, in the 90s about how to communicate to patients. Because, you know, we've always been very paternalistic as doctors. And it was really, it was an amazing psychiatrist we used to work with in the unit at the Christie Hospital. And so he was doing some training about consultation skills. And so he got Tony and his wife

to go and they were pretended to be patients. And so it was all role play that he was saying to Tony, like, your wife has just been diagnosed with cancer. And Tony said, after that word cancer, he didn't hear anything else of the consultation. He tested him afterwards and said,

what else do we talk about? He said, I don't know. And he said, but your wife doesn't even have cancer. He said, no, but it was just the thought. So then made him realize, as a patient, menopause, why are you going to, even if it's mentioned, you won't think about it because you've got cancer. Menopause is a trivial thing, isn't it? So this all this has gone on and on and on and on in my mind thinking, I'm not blaming the oncologist saying, of course you've got

to have menopause top of your list. That would be absolutely crazy. But what women need is some information that when the dust is settled, when the immediate panic situation, cancer equals death, which often it doesn't, as you know, most women survive really well after breast cancer. Then you've got something, whether it's a written thing or something to listen or someone to talk to, to pick up the pieces. And I think as doctors, we just don't always think about our patients. I agree. I think it's a roadmap. I really do. Recovery is a long process. And you've really summarised how not just me, it's your immediate family feel. It's all about survival. And yes, I think timing-wise, for me, I naturally came upon your information and that kind of thing later.

But earlier on, if the health service had that capacity to have touch points with people like myself, for anyone who's had that diagnosis and treatment, there's this whole culture, I think we have, of ringing the bell at the clinic and saying, I've finished, I'm out now. and it's a little bit like going into Sivvy Street after being in a war, you kind of left. And, you know, there is stuff out there, but usually you hunker down and you try and carry on. I would have loved that if someone had said,

a bit like when you have a baby and you have a health visitor and you might have another appointment, someone to check in and say, what are your menopausal symptoms like now and how are you coping with them? Because you're right. I think that initial fear, it clouds everything. Of course it does.

And it's the fight or flight response. Yeah, absolutely. So then what happened? When did you start to experience? You obviously had an awful time on Zodotex when you were forced into a menopause then, as you like. Yeah, well, it's just a horrible period looking back. I mean, again, I've said it. I'll say it again.

You know, I'm obviously so grateful to the NHS and the doctors for giving me the treatment and for my family and friends for their support. But in me, myself, it was a huge struggle. I think the term I use is a functioning. wreck. I was kind of, I've always been quite a joyful, fun-loving sort of person, quite spontaneous. And then really what happened after my treatment was with, I know now is low estrogen, low testosterone. And all of those effects on me affected me physically. So I had joint pains, stiffness. I felt old. I had, you know, poor sleep. I was getting a few hot flushes, but not a lot,

which is why I'm glad you talk about that. And there's people like that saying it's not just about hot flushes. Because you'd have thought I'd have got the biggest hot flushes having a huge chemo-induced menopause. But actually I was very cold. You know, I was always in a blanket. But the mood change was the worst. Irritable, loss of joy, just walking around, thinking what's the point,

just functioning really. And it was really sad, you know, up to quite recently, really, until I've gone on HRT and it's definitely brought back the old me again. But, you know, I suffered that for about seven years. I have been struggling and trying different things. But, you know, really, I feel like I've missed out. I really do. I'm not angry about it because I understand why that's happened.

But I do feel I've lost that time, that second chance I've had after having cancer. You know, I could have enjoyed my daughters growing up, you know, when they were still young, now they're in their teens. I feel like I've missed quite a chunk of time, really, where I wasn't the mum I could have been. So did you get any support, or was it just a sort of symptomatic support? Or did you try and find out more? How did you manage?

Because it's really hard to feel like that. It's really hard. And I think part of feeling like that is sometimes not going for help, but I'm actually quite outgoing. And that part of me never died. And I will ask for help. and I will search for it. The internet is a problem because it is full of stuff.

And obviously I came across all the herbal and there's nothing wrong with things that are, I suppose, that are sold in a normal place. But you can easily go down a rabbit hole of finding something you think is safe and going for that. Obviously, there's a lot of horror stories out there about HRT that aren't rooted in, you know, facts. So you can get very bombarded. And when you're overwhelmed and menopausal anyway, I think that is just, it's too overwhelming. So what I did was I went to the doctors.

They wanted to put me on antidepressants, which I resisted for quite a while. And then I had just a horrible period of time where I'm looking back. I think my menopause just had hit rock bottom, no joy. The brain fog at work, and I work in an education company. I have to be quite on the ball, and it all was just sort of falling apart in my head. I was getting worried about things. worry, the level of worry about everything, you know, not smiling. And then I kind of just, sorry to be quite sherry here,

but maybe someone listening will have felt like this. I just didn't know what I was doing in my life. I kind of lost my sense of who I was of reality, and that was really scary. So then I went back to the doctor and did go on antidepressants, and it kind of numbed me, made me function, but I definitely hadn't got my mojo back. And I did go and see two gynecologists, one privately, who was really against me going on HRT.

She'd had breast cancer, actually, and I think that may have coloured her view. I'm not sure. I can't speak for that. But she was definitely saying, you need to stay on the cytopram, the antidepressant, rather than take HRT because you've had breast cancer.

But there was something in me saying no. And I think at the same time, then I discovered your information. I heard a podcast with Liz Earle. And I thought, do you know, there's more to this. There's things that are possible for me. I wasn't completely sure, but it gave me a glimmer of hope anyway. So I'd say in terms of help, I went out looking for it.

And it was like knocking at a few doors. Please help me. The nearest I got actually, Louise, was when I went to the gynecological clinic at the NHS here in Sheffield. And they were really lovely. she had a kind of glint in her eye when I said HRT, she said, you know, it could be an option for you. But let's find out from your oncologist and the surgeon. The surgeon said lowest dose only if it's to manage your symptoms, vaginal, fine.

But he was very cautious. But it kind of gave me a bit of a, it pushed the door open slightly for me. Yeah. And have you read the book, Estrogen Matters, by Avvam Bluming? Is that on your radar at all? I've read bits of it, yeah. I want to read it properly actually because I think it's really important that we understand estrogen that I can feel the benefit of estrogen now and that's, this is going to be cool

but feeling it is believing what I've missed, you know. And I think this is, for those listening, so Avron Blooming is an oncologist in California in America and his wife and his daughter both had estrogen receptor positive breast cancer and they are both actually chosen to take HRT, but he's written this book, and I've done a podcast with him as well, about the role of estrogen, which is obviously, any of you have listened to podcasts before,

I'm not going to talk all about it now, but there are estrogen as very beneficial effects. Clearly, as you know, you're explaining Caroline's your symptoms, but also future health, so it's looking at reducing risk of heart disease, diabetes, dementia, osteoporosis, the list goes on, really. But actually then you've got the whole,

breast cancer and it's very interesting because a very simplistic way is that you have estrogen receptor positive or negative breast cancer. So a lot of people think, well, therefore, estrogen has caused the breast cancer. Now, we have estrogen receptors all over our body. So if I took out a bit of muscle from my arm and tested it for estrogen receptors, they would be on there. You know, if I had a tumor in the muscle of my arm, tested it for estrogen receptors, they would be there. But has estrogen caused that tumor? No, of course it's not. But because it's breast, yes. And we don't still don't know what causes it. And I've already said most cases of breast cancer, probably the biggest risk is obesity, clearly obviously not in your case and not in lots of

women's cases. But they're multifactorials. So some people, it's genetic. It's the way that their genes are. They can't change that. Other people, it's lifestyle. And a lot of people, it's different hits. So it might be slightly genetic, slightly lifestyle. A lot of it is just bad luck. You know, it's just one of those things, but it doesn't mean it's been caused by estrogen, even if it's an estrogen receptor positive cancer. And if it was all about estrogen, we would see loads more breast cancers in young women who have loads of estrogen in their body and certainly pregnant women. And you wouldn't really see much in older women who have gone through the menopause and have low

estrogen levels. So even as a non-scientist, you can quickly see it's got to be a bit more than estrogen. and before Tamoxifen came out, estrogen used to be a treatment for breast cancer. And Tamoxifen doesn't just block estrogen, it stimulates some cells. So that's why there's an increased risk of cancer of the lining of the womb because it can stimulate the lining of the womb in a positive estrogen way.

So it's so complicated. And as you know, the best treatment for breast cancer is surgery. And then there's a really good, it's called a Predict tool. I don't know if anyone did it with you, Caroline. And it's all based on statistics. but it shows you how your mortality and your outcome will improve by surgery and by hormone treatments. And it's a graph and it will show you with time. And the maximum benefit is always going to be surgery.

And then depending on the type of cancer, the stage, the grade, whether it's estrogen receptive, it will show you how much extra you'll get from hormones. And that extra bit really varies, but most times it's very, very small. And so a lot of women say, well, let's try everything. Obviously, you want everything at the beginning. But then with time, it's got to be an individualised option. And it's very hard because, as your doctor, I'm sure, has said when you started HRT, we haven't got good evidence to say that HRT in women who've had breast cancer,

even estrogen receptor, is dangerous. There is one study that said women might do slightly worse, but there's other, a lot more studies that show that women do better. But all the studies, they're not gold standard, randomised control studies. They have not got long follow-up. So we can't say the numbers are so small. So it's really, really difficult. And I think it's really important for us as doctors not to say, yes, you must or no, you

mustn't. It's about let's share the uncertainty and see. And any choice is reversible anyway. It's not set in stone. And we see a lot of women in my clinic who have had breast cancer. And then with time, their periods have come back. because they've often had breast cancer when they're younger, they've had treatment, their periods come back,

and then they become menopausal just because they've got older. And often I'll say to them, well, what did your oncologist say about your periods coming back? And they said, oh, they were really pleased because my symptoms are better. Right, so now your menopausal, or perimenopausal age 49, and I'm going to give you some HRT, they will go mad, and they'll say no. But what is the difference between having some natural hormone in a low dose as HRT to your ovaries producing exactly the same hormone. And of course, common sense tells us it isn't,

but it's just something quite scary about those three letters. And in fact, I invited Avron Blooming to come and talk to all the doctors that work with me at a meeting a few weeks ago. And one of the really good things he said was that actually he sees his role with women who've had breast cancer, not as a doctor, but as an advocate. It's about helping them make the right decision for them as an individual. And I think that's really important. You know, we're not recording this podcast saying everyone who's had breast cancer has to start HRT.

But we're saying that there are choices. And in fact, we had quite an abusive message just came through about half an hour ago on one of my social media platforms to say, I can't believe you're a doctor and you're promoting eustrogen. What about us who can't have it? It's absolutely disgusting. You should be reported. And actually, I'm not saying everyone should be on estrogen. but I say everyone should be given a choice to how they live their lives, really.

It's really hard. Definitely. It's that informed choice, though. You can only really choose something so personal and potentially serious, but any kind of drug or treatment that you have. You just want to be informed, don't you, and have the choices? And something that the nurses at the cancer place always said to me, when I got worried about another woman coming in and it had come back,

She said everyone's cancer is different. Everyone's makeup of their cancer is different and they respond in different ways. So it is really important to see somebody who knows what they're talking about and they know the type of cancer you've had. And you can weigh up the risks and the benefits together. In my case, it completely outweighed. But you're definitely not promoting estrogen across the board. I think what you're saying is it's about information and women feeling more empowered. because what you said at the beginning about cancer word

and people are not understanding that, I think that's a hangover from that time when people didn't really mention it. Like my grandma had breast cancer, but it was just, she's got a lump or, you know, the C word. So we've got a bit of a hangover from that and that we don't understand all the terms around it. Yeah, and I think you're totally right.

You know, my father died from a brain tumour when I was nine and it was all the big scene. You don't even mention the word. You could say tumour maybe, but you couldn't say cancer. actually, and I think people don't realize it's a bit like HRT, it's just three letters. Cancer's just six letters. But there are so many different types, grade stages, depends on the age of the woman.

And also, I think, you know, if a woman's just been diagnosed last week, the last thing I, even me is going to do is give her HRT. But, you know, you'd had seven years of really struggling. And also, your risk of recurrence then, you know is a lot less than it was the first day after your diagnosis, for example. But now you've got this risk, as you know, without hormones of osteoporosis, heart disease, dementia. And most women who've had breast cancer,

their commonest cause of death actually is heart disease. And taking HRT reduces at risk by 50%. So again, it depends if a woman is worrying every day that her breast cancer might come back, then she probably shouldn't take HRT because if it did come back, she would be blaming her decision. But if she's worried about how she's living,

how she's functioning whether she can work, whether she can function as a mother and a partner or whatever, then maybe it is. But the dose, as you know, can change. It can be low. It can be reviewed. It can be stopped at any time. You're not signing a contract to say, that's it, you run it forever. It's individualised.

And I think that's what's really important, isn't it? Yeah, definitely. And to just go and find out, you know, if you're in my situation, I think you summed it up there, really. It's got to a point where my quality of life. was more important than that nagging fear. And in fact, the nagging fear does subside. So anyone listening who's going through breast cancer or that is in that heightened state of fear,

I know what that's like. And you think it's going to be with you forever. And in some ways, it is part of you. But for me, I just didn't want to carry on just functioning. I wanted to feel a bit more like myself again. And when I found out more about it, all of that combined gave me, I think a bespoke bit of knowledge for me and seeing your colleague, Dr Lewis, you know,

it just sort of made it more personalised and then I could make the decision. And like you say, you're always in control, you can stop, I can change the dose. That is very important. Absolutely. And have you managed to get it from your GP? Has your GP been supportive? Yeah, they have actually. You know, at first they were very reticent because of my history.

But I think when I told them about that I'd gone to the clinic in Newson, clinic and that I had already done about six months, I think, with eustachel. And when I told them how I was feeling and that I'd come off antidepressants, I was, I was even better than when I was on that, you know, mentally, I think they thought, yeah. And then I had the marina coil as well, so I get a bit of progesterone. And then I upgraded to testosterone and I have a little bit of that. And that has been a game changer for me, actually. So yeah, they're happy to, obviously, they can't do the testosterone, but I had the coil put in through them and the estrogen gel, yeah, and I feel like quite supported by them really. That's great and that's the way it should be. Sadly, we have

quite a few doctors who refuse and I spoke to a doctor not very long ago who said that the only way her patient could have HRT from her is if she signed a disclaimer. And I said, well, okay, what are you doing well? Because if her cancer comes back, it's to say that she won't to me. And I said, okay, are you also going to sign a disclaimer if you refuse to give her HRT because then if she has an osteoporotic hip fracture in 10 years time and you can say, well, I refuse to give you treatment that would reduce your risk of osteoporosis, how would that be? He said, oh gosh, I haven't thought about that. It's a bit more to it, isn't it? I said, well, there's more to a woman than her breasts. Yes, you're absolutely right. So how about her making the decision herself? And actually, if she's

going to sue someone, she'll sue me because I started the HRT, not you. So they still had to go back and have a group decision with their partners. And they still haven't quite decided yet because the oncologist said that he wouldn't be that happy without having it. And I think it's actually our patients are not our babies. Women are not stupid. Women can decide for themselves. And we also know with the GMC consent that if we have a consenting adult in front of us, they are allowed to agree to treatment, even if it has more risks.

and benefits if they are a consenting adult or they could refuse treatment even if refusing treatment is going to do harm. And so I think that is really, really important when we think about not just HRT for women if have breast cancer, but any treatment. For me as a doctor, all I can do is advise and support and it's up to the one. I have to respect my patients into the decision they make and I wouldn't judge them whether they did or didn't take HRT or I wouldn't judge my patients if they eat McDonald's or not. Of course it would be horrendous, thinking of all those people that eat McDonald's every day. But that's their choice. I'm not going to judge them differently. I'm not here to judge anyone. Yeah, so it's advice, but not refusal or, you know, denying someone, something that

they want, especially if they've got the information, they've started it. And there is no, there is no real reason, given what we know now, like you were saying about the research, it's just taking that decision out of the woman's hands when they've come well informed or they've already started treatment and they're saying, can you carry on? So I do feel fortunate, but I think it's a real shame like you say that it's a bit of a lottery about who you talk to. Yeah, absolutely. And that needs to change. As people listening, now I run a private clinic. It shouldn't be private. It should be available in the NHS. And we're doing a lot of work to really make a difference. And going forwards, as you know, I've founded the Menopause charity.

and one of the things we want to do when we start to get some proper money in is to fund some research. And certainly looking into research, women who've had breast cancer, I think is really key because everyone's too scared to do it. But so what, let's see if the women who've had breast cancer want to have some research. And I bet they will. I'll be on that list, Louise. Yes. So watch this face. But, you know, the more we can get donations into the charity, the more we can really crack on with some good quality research, which is what's desperately needed.

So I'm really, really grateful for your time and your honesty and openness, Caroline. It's been really useful for me as a doctor to hear, but I know women and men hopefully listening. It might make them think of it differently. So thank you. But before we finish, I always ask for three take-home tips

and you're no exception. You can't squirm away. So if someone has been listening to this and either has had breast cancer or knows someone who's had breast cancer and is also now experiencing menopausal symptoms. What are your three tips that you would recommend for them to do? I would actually just audit how you're feeling.

So log it or make an honest record. So for me, I wrote down in a little book, you know, how rotten I was or even a face or whatever it was, just to actually record how bad you're feeling, maybe do it over a week or two and then look back on it. And if most days you're feeling miserable or if you've got achy joints or whatever it is, you know, these are menopausal symptoms and you're struggling with them. And you're getting through the day rather than enjoying any aspect of the day.

You're just getting to the other side. Then I would, if you can approach your GP, I would. I'd make an appointment. But I would also say, think about if they're sort of suggesting antidepressants, don't agree straight away. go and find out a lot more from Louise's website, there's a lot more out there actually on social media now. Go and talk to some people, go and find out proper information

and inform yourself, talk to someone who specialises in menopause and even better someone who knows about breast cancer or who treats women who've had breast cancer. Then you know you're getting gold standard information, as we know at the moment. So that would be two tips, aren't they? And then the third one, I think, is don't beat yourself up if all you're worried about is the cancer coming back. And your fear is at like level 100.

It's normal to feel like that. You know, even the most confident of us have felt like that and know what that's like. So allow yourself to feel like it, but also allow yourself the possibility of a better, brighter future, where you don't feel like that all the time. it's almost that you just need that hope, even in the darkest time, you need to know that there is help out there and there is hope for you and you deserve it. Absolutely. I think, yeah, we all deserve the best and it's such good advice and thank you ever so much. And so for those of you who are listening who want more information, we have got multiple resources now on the Menopause Doctor website and also our app balance and we will continue to add to them. So if any of you think we're missing out or you want more, then just contact us through the website.

And we're constantly changing what we're doing to try and reach more women and give more women as much information as they can have. So thank you ever so much again, Caroline. It's been great, really good. So thank you. Thanks for having me on, Louise. For more information about the perimenopause and menopause, you can go to my website, menopause.com. or you can download our free app called Balance available through the App Store and Google Play.