The Dr Louise Newson Podcast - 102 - Melanie Martins: Treat me like a patient but there’s no ’one size fits all’

Episode Date: June 8, 2021

This episode features a very open and honest account from GP and Newson Health doctor, Melanie Martins. Mel was diagnosed with breast cancer at the age of 34 and, after a further diagnosis and chemotherapy, found herself 'flung' into the menopause with very little warning or discussion with the health professionals caring for her at the time.    Dr Martins shares with Dr Louise Newson why she believes every woman's experience of breast cancer is unique to them and a 'one size fits all' approach must be avoided. She shares about her own quest for help with persistent and worsening genitourinary symptoms and the psychological process of navigating evidence and making a decision to take vaginal estrogen, when she had avoided contact with this hormone for years.    Dr Martin's 3 pieces of advice for women experiencing menopause after breast cancer are:  Read this booklet and listen to the podcasts on menopause doctor website: https://d2931px9t312xa.cloudfront.net/menopausedoctor/files/information/601/Been%20through%20breast%20cancer%20(with%20links).pdf   If you're troubled by vulval and vaginal symptoms, stop using soap or shower gel and use an emollient wash instead. You can buy this over the counter in any chemist. These symptoms tend to worsen over time, don't struggle on and get desperate, seek help for them. Vaginal estrogen is safe, it can be used in the long term, alongside HRT, or on it's own.    Find accurate information about menopause and treatments after breast cancer. And then make a decision that's right for you and you alone. You need to be at peace with that decision, and remember it's not set in stone forever. We can only make decisions based on the information we have and how we feel at the time, so don't look back with regret about what you did or didn't decide to do. 

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 on this week's podcast, I'm very pleased and honoured to have with me, Dr Melanie Martins, who is a friend of a friend. I like a lot of the doctors that work with me. I've known of her through another doctor who works with me. And I first met probably about a year ago.

And so Mel's now started working with us. And I've been very grateful because she's agreed to talk a bit about her sort of own personal journey as well. So thanks for joining me today, Mal. Thank you very much, Louise. Thank you for inviting me. So you're a GP, aren't you? I am. Married to a cardiologist who coincidentally works at the same hospital as my husband.

So I'm very, I think I am a bit spiritual, actually, and I really like connections. And I also feel that life is a bit of a journey that's not set in stone, but it's sanded out for us. And we have to meet various things, I really believe. And so sometimes fate gets people together. And so you came and sat in the clinic that's probably about a, was it about a year ago? About a year ago now. Yep, absolutely. Well, initially a little bit longer and then with COVID there's been some silver linings, you know, being able to work remotely.

So actually, probably a little bit longer, but then things sort of expanded with COVID, yes. Yeah. So have you always been interested in men and pulse care then with your patients? Yeah, so I think women's health has always been a thread throughout my career. And then for me personally, out of the blue, 12 years ago, I was diagnosed in my mid-30s with breast cancer and that really obviously had a huge personal impact both personally and professionally and really kind of furthered my interest in in particular menopause and HRT and in particular in women who have been through breast cancer. So I mean women's health has always been a thread through my career but then our own personal experiences definitely shape then you know our interest

and our journey. So gosh so you were mid-30s and you've got children. I do. I do and at the time my children were, well my son was 19 months and my daughter was actually turning four that weekend. It was an absolute nightmare actually. I had 25 people coming for a birthday party the next day. But yes, so my children were very young. Gosh. And so did you just find a lump, presumably? Well, my story, and I think it's really interesting because, you know, everybody has a totally individual story and I think the more I learn about breast cancer, I think the more I realize it's so complex and everybody's story is very, very different. But for me, I actually, I actually, had had a benign lump, a fibroidinoma, so nothing worrying, removed actually in my early

20s, and I had a scar, and it was quite sizable, so I had a sizable scar. And actually, interestingly, for me, the first thing to alert me was that my scar started to become tethered and changed. And I had some kind of hardening. I obviously had a bit of scar tissue under there anyway, but actually I had some hardening of that kind of area, and it just didn't feel right. And that was what alerted me to go and get it checked. And I was actually 34 at the time. And as a general kind of rule of thumbs of guidance, they don't generally do mammograms under the age of 35 because our breast tissue is still very dense, you know, at that age. So I had an ultrasound scan at that time and that actually came back looking okay. But then a few months went past and it just, it just didn't feel right. And

it just didn't sit comfortably. So I went back and at that stage, they did a mammogram. And I had extensive throughout, this was on my right breast, extensive changes consistent with DCIS, which is ductal carcinoma in situ, very kind of, I suppose you could call it very early stage because it hasn't invaded and went to want to have a biopsy and that kind of confirmed the kind of high grade ductal carcinoma in situ. But it was really extensive. It was throughout my right breast. And so at that stage I had a mastectomy. And actually, I was, I was very young. I had absolutely no risk factor. you know, nothing at all, no family history, you know, like, no, it was really out the blue. So kind of with discussion and it was very much my choice, you know, my personality is I'm not a worry by nature,

but I just felt I was so young, my children were so young, this was so out the blue and there were a couple of possibly suspicious areas on the other side, so I actually opted for a bilateral mastectomy, but that was my choice because I just felt that I couldn't, I didn't want to live with the worry or the risk. So that was sort of how it's presented, and I suppose the first stage of, you know, my journey. And it is a personal decision, isn't it? You know, some people doing it in Austin's guided by medical advice. And I think that's so important because breast cancer is very different to very many people. And I think it's more unusual than some of the other cancers, isn't it?

I think if someone has a type of, I don't know, skin cancer or even an endometrial cancer, so the lining of the wound, Absolutely. And I think that's really important. Everybody's, you know, journey is absolutely individual. And, you know, thankfully, brilliantly, the prognosis and survive from breast cancer is just increasing increasing, which is absolutely, you know, fantastic. And surgeries remains, you know, very important in the mainstay of treatment. But then there's lots of other treatments, you know, on top of the surgery. And following my surgery, I did go on to have radiotherapy to the right side. And at that stage, I was then put on to moxophen as well, because, you know, the pros and cons and the risks and benefits are discussed. And at the end of the day, well, I felt, and I'm sure a lot of women feel the same, you want to do everything you can to reduce your risk as much as possible. And so, you know, I opted to go for every treatment, you know, that I could. And I suppose that was, for me, stage one, really, of, or chapter one, of what happened to me, and like I say, I think it's really important to know that for, I would say, probably the

vast majority of women who have DCIS, hopefully that's the end of their story and their journey. Unfortunately, for me, it wasn't, but again, I think it's really important to know that everybody's journey is very different. And for many women, you know, a lot of women with Dr. Carcinoma in situ never go on to develop any further problems at all. And obviously, they grade it as well. So your risk of developing further problems will depend on the grade in the extent. extent of it. So yes, it is really important to know that definitely everybody has a very different journey. Yeah. So then what happened in Chapter 2 then? Yeah. So Chapter 2 was a bit of a wobble, not really expected because I, so I'd finished my, I'd had my surgery, I had had my radiotherapy,

I was on to moxophan and I'd gone back to work about about five months later, five to six months later and I'd gone back to work. And then the following year, I was having some reconstructive surgery and I was advised to stop my tamoxifen for six weeks before my surgery. So I did that. And within that time, unfortunately, I developed a lump under my arm, which was obviously a little bit of a worry. So I went to have that checked out just before my kind of planned operation date. And when they biopsed that, that was actually an invasive cancer in my lymph nodes. So probably the first part of my story may not retrospectively been the whole picture because Dr. Castanamer in situ hasn't invaded into other tissues.

But for me, I had an invasive cancer in my lymph nodes. So that then led me, my reconstruction was obviously put on hold and that led me down the route of chemotherapy. And I suppose that's really the part where menopause came into my life. By now I was 35 because it was a year age. So my children were now three and five, still very young. Oh, man. It's just so sad.

You know, having children, young children, having a job is hard. Yeah. But it's nothing. It's nothing compared to what you would have gone through. And also, I think, going through something, again, which you weren't expecting, and thinking, oh, I've got out, I've done it, and then something else. And I think life is so unpredictable, isn't it? And sometimes I think it's a really good job.

We don't know what's in head of us because I wouldn't. So did anyone talk to you about chemotherapy and menopause? I know you're medical, but I think sometimes I've been in hospital with various conditions and illnesses, and people treat you a bit differently as a doctor because they expect you to know everything. And I've always said, just treat me like a patient. Absolutely, absolutely. But did anyone talk to you about menopause or? Well, you know, it's really interesting because exactly that.

You just want to be treated by a patient, but you can't help the fact that there is this sort of extra layer of knowledge. But absolutely you want to be treated by patients. And, you know, I've really, really thought about this, Louise, because honestly I've had fantastic treatment and care, and I'm, you know, it goes without saying, you know, I'm forever grateful for the amazing care I've had. But I can honestly say, and I've really racked my brains, I don't think anybody ever spoke to me.

I remember signing consent forms for radiotherapy and telling me the risks with that and consent forms, but I don't think anybody ever talked to me about the menopause at all. I've got no recollection of it. having said that, there is so much going on at the time. And there is definitely, I know this sounds absolutely crazy, but at the time, going back to the very first initial sort of diagnosis, my first thought was, oh my goodness, I've got 25 people coming for a birthday party tomorrow.

And then everything they were telling me, you know, sort of goes out of your head. And I know that sounds a bit crazy, but you're trying to process so much. Yeah. So I have no recollection at all. And that doesn't mean that it wasn't ever mentioned at all. No. I have no recollection and I certainly, there was no in-depth conversation about it.

So I have to say, when I started my chemo and it flung me into the menopause, and I think flung is, you know, my very first cycle, you know, that was it, just, you know, knocked off my ovaries and that was it, you know. I wasn't expecting it, I suppose, is all I can say. I wasn't expecting it. And I think, I mean, there's lots of things here really. I think people often don't even know what chemotherapy is, and obviously chemo is just chemicals, so it's just drug treatments. There's all sorts of different chemotherapy, but often the one that's

used, or the types that are used for breast cancer can damage the way the ovaries work, sometimes reversibly, sometimes irreversibly. And again, it's interesting. So I, because of me wanting to be an oncologist, when I was a medical student, so this is going back nearly 30 years, makes me feel really old. I did an eight-week project at Christie Hospital in Manchester, is one of those sort of world's best hospitals for cancer. And I did it with someone called Professor Tony Howell, who's a professor of medical oncology, and he runs now the preventative breast cancer unit in Manchester. It's a big unit. He still works, even though he's in his 70s. He's very, very inspirational and probably one of the most clever people I know.

And I was sitting in this clinic, and it feels a bit like, actually, sitting in my menopause clinic now, the stories I was hearing was really, really sad because these women were coming in medicine has advanced a lot since then, but it was a bit of a conveyor belt. These women would come. Here's your diagnosis. This is what you're having. You're going to have to have tomoxifen. You're going to have chemo. Here you go. Go to see the chemo nurse. And I sat there and I said, Tony, these women, haven't got a clue what's happening. So, of course they do. You've had cancer. They need to have treatment. I said, no, hang on a minute. What I want to do in my eight weeks is to write some patient information. And I want to write about tamoxifen because it was a

relatively new drug then. No one knew what it was really. So I said, right, I'm going to write a book about tooxifen. Then I sort of started talking to some women when Tony wasn't in the room and said, do you know what cancer is? They said, what it means death. It means dying. It just means an awful disease. And I said, well, no, it doesn't actually. And they were all talking about having their lymph nodes removed because back then, a lot of women had their lymph nose, all of them removed. It's very different to now. So I said, do you know what your lymph nodes are? No. Isn't it something to do with a cold or virus because they come up in your neck. Do you know you have them in your armpit? No. Well, you've had surgery to your armpit. Well, no, they just told me. So I go back to

Tony and say, do you know what? I'm going to have to do a series of booklets. I'm going to write one about what is cancer, one about what is lymph fluids, one about chemotherapy, because they didn't know anything about chemotherapy. And then my last one will be about tumultapine. And then he said, Louise, I don't think you need to do that. It's a waste of time. So I said, right, your next patient that comes in the room, ask them, what is cancer? So he said, okay, I'll do this. So next patient, he said, oh, what do you understand? The word of cancer? And they said, well, it just means something really awful, then I'll probably die from it. And he said, then he asked a few more patients. He said, Louise, I think you're right, actually.

And this was 1992, so before the internet. Yeah. So it's very hard to get proper information. So I wrote these booklets. And in fact, then they were distributed to other hospitals and they were used a lot. And it was then that I thought, actually, the power of writing for patients can be transformation. And now I think it's taken 20 years to think about the menopause is in a way of getting through to patients. And back then, as a medical student, obviously I had no training in the menopause. I didn't even know these women would have gone through the menopause. Yes.

And I really kicked myself now, knowing what I know now. And then actually, again, this is something that I think is quite interesting. So Tony, because he just felt he needed to do better communication with his patients, although he was fantastic talking to patients. he went off and did a course with his wife at the time, who was someone called Leslie Fanofield, who was a psychologist, who did a lot of work, behavioural work, about consultation models. And so the two of them went off to a course,

as one of the cancer hospitals in London, and they were role-playing. So they were sort of pretending in this role-play that Leslie, his wife, had a new diagnosis of breast cancer. So the oncologist had come in. It was all just on a film. It was a role-play. And they said, right, your results have come back,

you've got cancer. and then they talked about treatment options, everything else. And then afterwards they said, right, write down everything you remember about the consultation. And Tony couldn't remember a thing. Now, he's a leading specialist, but he said the word cancer associated with my wife, I couldn't listen anymore. I knew it wasn't even real. He knew it wasn't.

She didn't have cancer. And that's the reality is that there's so much information, but so much is going through your mind at the time. and the leaflets and written information is so important because you can go back and refer to it because at the time there's so much going through your mind and there's so much going on and you know I'm a very practical pragmatic person I know this sounds crazy but I was thinking what am I going to do with the children and how am I going you know because you start thinking ahead so it is really difficult and so can I remember absolutely everything that was said of course I can't

I really can't. But what I do know for sure, there was never a discussion about the menopause ever. There was never a discussion. So it might have been mentioned, but there was never a discussion about it. And I do often wonder how I'd feel. I think I could recognise, even then it was very difficult because the problem is when you having chemotherapy, you've got all the side effects of chemotherapy. You've kind of been flung into the menopause unexpectedly.

So that's kind of like falling off a cliff a little bit. But it all becomes one big mess of symptoms. to be honest. And I think really now, it's only now, all these years on, I can't believe it really, you know, all these years on. And especially because I've got such an interest in the menopause and I speak to, you know, working with you, which is so fantastic. I speak to so many women with their symptoms with the menopause. I think it's only now that retrospectively I realize how many of my really difficult symptoms were actually more related to the menopause than chemo. Yeah. It's only now I look back. And I obviously recognised at the time that,

some of those symptoms were menopausal. But I think if I wasn't medical, I don't think I would have known that if nobody would have told me that, you know, because it all gets bundled in together. And it's also very frankly, so as many of you listening, know bone pain, muscle aches, joint aches, are very common symptoms, brain fog, memory problems. And some women who have cancer that spread, it can spread to their bones and cause bone pain. Some people, it can even spread to their veins and cause memory problems and confusion. And so I've spoken to a lot of patients of our breast cancer who have been petrified that they've got metastases.

And then the consultants quite likely do lots and lots of scams, very scary when you're waiting for a result. And then you're told, well, it's normal. But then they're not given a reason, an answer for why they're having these symptoms. Well, I look back retrospectively now. I had a CT scan at my head because I was having really bad migraines and I'm not a migraine sufferer.

and I was having migraines and so I thought I had a brain metastasis because, you know, that's what you put two and two together. And I also had some bone pain and ended up having a bone scan. And I look back now and I think, honestly, I think that was all due to my menopausal symptoms. And did anyone tell you when the results were normal that it could be related to your hormones? No, no. It was very reassuring. I was very reassured that my results were normal, but there was no explanation or I don't know that the people, because this is the thing, which is, you know, it's great in a way, you know, medicines become very subspecialised. So probably the person who was reporting my CT scan and dealing with that

didn't think it was related to my hormones either because they didn't know the whole picture. No, and it is really important, isn't it? And it's not just for women who have had breast cancer, I think menopausal or perimenopausal in general have all sorts of symptoms, which medics often can't attribute to. So I know your lovely husband is a cardiologist. He sees lots of women with palpitations. And he reassures them and says there's nothing wrong with your heart. But they're still having those symptoms.

And often they're related to their hormones. So it's really nice to the patient because actually sometimes you think you're going mad or you're making it up. And there is a thing called somatization. So when people often are depressed or anxious, you can then manifest symptoms that aren't real. And lots of us, including myself, and I was experiencing manifolds or symptoms, say, well, am I going mad? Is it my mental state that's causing this overwhelming headaches, anxiety, you know, and so I think it's really reassuring if someone had said to even me five years ago, Louise, these are all related to your hormones, these symptoms. I would have gone, oh, okay.

Even if I didn't want any treatment, it's not about treatment, it's about making the right diagnosis, I think, isn't it? And it's about understanding why you're experiencing those symptoms, isn't it? Because when you know the reason why, you can either stop worrying about it because you think, well, I know why that's happening or do something about it if you do want to do something about it. Yes, I think that's totally true. And so a lot of people, I get a lot of criticisms, as you know, from all sorts of people. But some people say, well, all you're trying to do is medicalise the menopause and you're trying to push HRT onto everyone.

And obviously, there are a lot of women who should have HRT that are being denied it. But actually, my counter argument is I actually want to try and empower women with the right knowledge and information so they can make the right choices for them. And I think that's what's really important is taking a step back. You know, we've all seen women in the waiting room here who are worried they've got dementia because their mothers or their grandmothers have had dementia. So as a doctor, if we say to them, I don't think you've got dementia. I think this is related to your hormones. Well, then there's so much better already just with those words. Absolutely. And I think that is exactly it. That's the key. There is no one size fits all for any

of this, whatever your situation, breast cancer, no breast cancer, you know, HRT, no HRT, there's no one size of it's all. And I think the most important thing is, you know, having access to the right information and so you can make an informed decision. And that's not always that easy. It sounds very straightforward. But actually, there's so much information out there to navigate. You know, you mentioned earlier about not having access to the internet, you know, all those years ago. And, you know, it's a double-edged sword, isn't it? Because in a way it's great because you can access this information. But it's not always the correct information or the right information or applicable to you as an individual.

And that's the really important thing is making an individualized choice. And for me, I feel that I'm a healthcare professional. This is my, you know, my job and my role and, you know, my training. And I still found it very, very difficult to navigate the information and apply it to my personal circumstances to the right or wrong thing to do. you know, further down the line when I was considering, you know, we can talk about this a little bit more, but in particular when I was considering the use of local vagina oestrogen, I found that really difficult to navigate. And I just kept thinking, well, what about all those women out there who either can't access this information or if I'm finding it confusing?

Yes. How do you navigate it? It's really difficult. And also for GPs as well, you know, obviously I'm a GP and we can't know everything about everything. And we do our very best for all our patients. But I can understand as well for GPs how it can be really confusing and how they, you know, they desperately want to give their patient the right advice and they're nervous about, you know, doing the wrong thing or giving them the wrong advice. And it's just really difficult sometimes to navigate all the information.

It is. And I think it's really hard because then for busy doctors, like you say, you want to do the best, but then you'll read the top line of everything. You can't, you haven't got time to read all the references, all the articles. And then if you do, there's still, when we haven't got, anything black and white, it makes it really difficult. It's very easy when we have really clear evidence. But this area, we don't have clear evidence. So there's some evidence saying one thing, some saying the other. And it's fine to be general, but when it's for you, you want to know

and you want to do what's right. And then some people are telling you one thing, one thing, and your mind's exploding. So I know you've been very open and you've written an article that's on Manifles Doctor website about your experience and your choice about having vaginal estrogen. So So for those of you listening, vaginal estrogen is not HRT, it's a local preparation. And some of you are listening have hopefully learned from other podcasts that we now term it genital uralis syndrome with the menopause, which is GSM. It's a long term. But basically it means there's lack of estrogen in the vaginal tissues and the surrounding

tissues. So not just the vagina, but the vulval, the external area, but also the pelvic floor, the bladder. And so a lot of women, about 80% of menopoles are women, experience. it's these symptoms which cause irritation, burning, so lots of women find it very difficult to wear underclothes to sit down, but also can have urinary symptoms. And one of the main treatments we often offer or give is vagina on estrogen because it works very locally. So it doesn't get absorbed into the body, which means it has far less contra or relative contraindications than HRT. But like you're saying, man, you know all that, but you were still very

scared of having anything labelled estrogen close to your body, won't you? Which I understand. Yeah, I was. And I think the thing is that I'd spent the last 10 plus years doing everything in my power to get rid of every single drop of estrogen. So I went through the menopause during chemotherapy. But then after my chemotherapy, because I was still young, I was still only 35, because I'd previously been on the tamoxifen and then that had stopped and I'd, you know, I'd obviously had this cancer in my lymph nose really effectively whilst I was on the tomoxone, and they decided to change me to an aromatase inhibitor. So I was on something called an astrosol.

And you can only have that if you're postmenopausal. And because I was still only 35, obviously there was a risk of, I say risk, you know, who knows, whether your ovaries might start kicking back into action effectively. So I was put on a Zolodex injection to make sure that my ovaries, you know, didn't kick back into action. and then I was on that for you lose track of time, maybe, you know, nine to 12 months. And then I actually had my ovaries removed. And then I stayed on my aromatos and hipas for an astrosol for 10 years.

And so I'd spent the last 10 years making sure that I did not have one drop of estrogen in my body. And that's fine. And, you know, that was my choice. And I wanted to do that. I wanted to do absolutely everything to, and I don't want to sound dramatic, but to survive, you know. Yeah, totally. And, you know, it's been a journey with lots of twists and turns and unexpected things. along the way. And so, you know, I'd spend all this time making myself as deficient as

as a bitrine as possible. And, you know, my menopausal symptoms when I was having chem therapy, you know, I had, I mean, dreadful, drenching night sweats, joint takes. You know, we talked about kind of migraines and headaches. But actually, those things, you know, actually did get better over the years. They did improve. So that was great. And I'm very lucky because for some women, they don't improve, you know, like my night sweats, for example, you know, when I say drenching nights, you know, I should have to sleep on a towel. I mean, it was terrible. I mean, it was terrible for about, you know, a year. And then another year where it was bad, but not so bad. And then a couple of years where, you know, the normal triggers alcohol, caffeine would

trigger it, but it was manageable. I could make lifestyle changes to control it. So that was all fine. And then actually, I'm very lucky. They've gone away now. So in that respects, I'm very lucky. So a lot of my menopause of symptoms over the years got much better or completely resolved, which is fantastic. But unfortunately, vulvaiginal symptoms, GSM, as you've said, as we call it now, geniturin syndrome of the menopause, you know, without estrogen, that just gets worse and worse and worse over the years. And that's been my experience. And despite, you know, trying all the non-hormonal treatments, ammonia washes, moisturizers, et cetera, et cetera, for me, actually, and again, everybody is individual and it works very well for many women,

but for me, it just caused more irritation and actually started really, really negatively impacting on my quality of life. But actually, I was in a bit of turmoil about it because I spent all these years thinking I can't have any estrogen, no estrogen, estrogen is my enemy. And then to actually give yourself some local vaginal estrogen, even though, like you say, there's no evidence of there any increased risk, it just felt very counterintuitive. And it took me really quite a long time to go for it. And I have started using local vagina estrogen, you know, not that long ago, really within the last kind of six, nine months. And it has really, and again, I don't mean this to sound dramatic, but it's really transformed my life and my quality of life. It was really

impacting on me really, really negatively. And, you know, sometimes I think, oh, should I have just done it earlier? But, you know, the truth is, Louise, I wasn't ready to do it earlier. You have to be ready and comfortable with your own decisions. I suppose that's, I think I've said earlier, you know, I'm a very pragmatic person and I think, I've always think in life, you can only make every decision based on the information at the time and how you feel at the time. And so you can't really look back with regret because I kind of came to this junction a few times and thought, should I, shouldn't I, should I, shouldn't I? And clearly in myself, I wasn't ready to make that step.

I was still also on my aromatase inhibitor and I just, I suppose I hadn't completed my breast cancer treatment at that time. But actually for me, you know, more recently I've made that decision. It's a decision I'm very comfortable with. I'm so happy I made that decision. and for any women out there who do have really severe vulgar vaginal symptoms, you know, it works very quickly. And, you know, the other thing is no decision is ever set in stone.

You can change your mind, you know. And I think that's so important, isn't it? I think you have to be ready for your right decision. And that's not just about what treatment to take. It's about what car you buy or what holiday you go on if we're allowed to go on holiday or, you know, what to wear in the morning. It's an individual choice. and you shouldn't be judged by other people.

I think that's really, really important, but also any decision is reversible. And we see a lot of women who've had breast cancer in the clinic. And sometimes it is just talking. I saw someone the other day who's on aromatase inhibitors. She's about four years since her breast cancer diagnosis. And she said that her body feels numb from the waist downwards. And she cries out in pain every night

because she feels like her bones have been wrung and they're so painful. But no one had talked to about the menopause. And she's just now gone away to listen to a few podcasts that we've done, to read a book, to just have a think about even just taking four weeks off her aromatase inhibitor or six weeks to see if that just helps. You know, not any radical treatment. Yep. And she came away really happy. And I was thinking, gosh, as a doctor, I haven't prescribed anything. I haven't. But actually, she needed a bit of time to talk. And I think that's absolutely right. It's fine. whatever anyone decides and no one will judge anyone for what they decide. I find that commonly in consultations. You know, sometimes you think, oh, have I actually done that much? But actually, women are really, really grateful to just talk it through because it's so individual. There's no one size fits all.

So it's talking through what may be right for them and what their options are and having the right information and the time and space to come to that decision in their own time and a decision that they're comfortable with. And I think if we can help women do that, then I think that's really good. I totally agree. And I think there's two things. So I've written a consensus statement for the British Society of Sexual Medicine

about the management of genital urination and genital menopause, which I know you've read. And that took me a long time to do, thank you, because we've referenced it. But I've already said there isn't great research, but we do know that there isn't this systemic absorption of estrogen. And so I feel very strongly, for those women with severe symptoms or symptoms impacting,

that it should be a choice to have vagina and estrogen. And so we've written this, which I'm hoping really helps healthcare professionals. But more recently, we've just published a book. And actually the written ones are downstairs in the clinic. I'm very excited. I've seen them for the first time. They're actual paper versions of this booklet for women who've had breast cancer. And I'm really, really grateful, and I'm saying it publicly because I am so great for to email

because you and one of our other doctors, Danny McCracken, have contributed to us as well and we've written this booklet and I think actually it's probably one of the hardest pieces of work I've done and even though I know you did a huge amount of work I still kept reading it and editing it and rereading it and I've written a lot over the last 20 years being a medical writer as well as a doctor but this was really difficult because every word was crucially important to get right and I hope we've had some lovely feedback already but I hope it's been written in a really sensitive but also I love your word pragmatic because I think it has been pragmatic as well, but we've done it so that we're not saying, you must do this, you must do

that. We've just laid out facts in a very, I think, sensitive way. So if you had been given this when you were having your chemotherapy, you might have thought this isn't relevant to me and put it on a shelf, but then you might have been able to come back to it or your husband might have read it or your relative, you know, someone might have read or your friends. I think that's it. I think you come back to these things because you're so in the moment of beating the breast cancer, as you should be, that is everybody's goal and that's great. But what happens is you get 10 years on plus or five years, wherever you are. And actually, often you're discharged from, you know, the cancer care part of it by then.

And, you know, I really, really hope that booklet does help women. I suppose as we were writing it, in my mind, I was thinking, well, what information would I have wanted at the time or wanted now to go back to, you know, take the doctor part away from it? from a very, you know, personally point of view. And as you say, the booklet isn't about, it's just about there are options. It's not about telling people what they should or shouldn't do. There's no right or wrong for it. It's about individual choice.

And I think for me personally, it would have been wonderful to have that either at the time or to go back to or for women to be able to access it now via, you know, the platform that you've created is fantastic because it puts it out there for women. And as you say already, you know, there's been a lot of feedback from women. that they're so grateful to just, you know, have that information and not be searching the internet and having conflicting information and trying to model through it themselves. So I really hope it's a resource that women can tap into and find really useful just for them to decide what's right for them as an individual.

Absolutely. So I really hope so. And it's available to download from the resources section of the Menopause Doctor website. And we're trying to get it out to other cancer centres as well. So I'm really, really grateful for you, Mel, because I know it's always hard talking about your own story and especially as a healthcare professional as well. But I know this podcast will have helped so many people, not just women, but other people as well. So thank you. And before we end, I just want three take home tips in a traditional style for women who have had breast cancer who might have been listening to this and thinking, right, how do I get help? What should I do?

What are three things that you think would be useful for them to do? Okay. I think the first tip is go onto your website and download that resource. It's, you know, it's there in one place now and there's lots of information, you know, podcasts and information on the Menopause Doctor website, as you say, under resources. And, you know, there's so much misinformation that actually, you know, finding that information and reading it through, I think that's the first thing. My second take home tip, I'm actually going to come back to the Volvo, side of things, if that's okay, because, you know, as I say, I've chosen my other menopausal symptoms got better and so I'm not on HRT, but I have used vaginal estrogen or I'm using vagina ointest, and I think, you know, a really simple take-home tip as well, which often we forget and it's really simple. If you do have all the vaginal symptoms, use of an emollient wash is absolutely brilliant and I know we don't really talk about it earlier, but as a take-home tip, I just want to sort of put that message out there, you know, stopping using it.

saps and shower gels and you can just bite from over the counter using an amelium wash is absolutely brilliant and it's a good starting point while you're deciding if you think you want to consider other options and again I suppose leading on from that I just suppose I want to say that whilst other symptoms sometimes do get better unfortunately vulgar vaginal symptoms won't get better in time they will get worse and so if you're struggling I suppose I just would like to say to you know women out there don't struggle on and struggle on and struggle on and get to the point of desperation. Because, you know, as you've said, there's not lots of data, but, you know, vaginal estrogen is safe. It can be used long term if you choose to,

and it can be used with or without HRT. So I suppose the take-home message, which I suppose ties in all those three points, is, you know, find the right information and make a decision that's right for you. But the most important thing is be at peace with that decision, you know, be at peace with that decision because everyone will have different opinions, but if you've got the right information, you can make the decision that's right for you as an individual. I think that's so important. And what a fantastic way to end. And for anyone that is suffering and hasn't got the right help, keep asking, keep finding the right person. And sometimes it might not be a doctor. It might be a nurse, might be a pelvic floor physio, might be someone

else, or just a friend who can come with you to the next appointment. So I really appreciate your time. So thanks so much, Mel. It's been really interesting. So thank you. you for having me Louise. Thank you. For more information about the perimenopause and menopause, you can go to my website, menopausedoctor.com.uk, or you can download our free app

called Balance, available through the App Store and Google Play.