The Dr Louise Newson Podcast - 103 - Dr Radhika Vohra: When will women’s health become a priority?

Episode Date: June 15, 2021

In this episode, Dr Louise Newson talks to GP and Trustee of The Menopause Charity, Dr Radhika Vohra. Radhika is a GP with a special interest in women's health, particularly the menopause and perimenopause. She is also an educator for GP trainees and other healthcare professionals.   Together they discuss the current landscape of menopause care in the UK, the poor profile menopause has in healthcare, training and research and the improved appetite professionals now have for more menopause education. Radhika shares her insights from a women's health perspective and hopes the work of The Menopause Charity will be a voice for everyone.   Radhika's 3 hopes for menopause across the globe:   Greater recognition of the impact of perimenopause and menopause on women's lives More education for women and healthcare professionals alike Better support for women and professionals working with menopausal women.

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 have with me a good friend, colleague, and actually someone I've met, but never even mess in real life, the whole virtual world that we live in now. So I have in front of me, Radhika Bora, who is a GP and educator in women's health. And we've been liaising, I guess, behind the scenes for the last maybe year or so. And both share similar passions. And also, Ritika is one of the trustees for the Menopause charity. So welcome today. Thanks ever so much for joining me.

No, thank you for having me. It's a pleasure to be here. So I can't actually remember, can you, when we first sort of met virtually, if you like? I think it was just post-pandemic around April. that's what we first connected and then did some translation work to try and help women have more access to counselling material

and looked at diversifying what was out there for different ethnic minority groups and took it from there and we've moved on. Absolutely, yes, so for those of you that haven't looked under the resources section

of my Melopoul's doctor website under videos, Ritika very kindly has translated some of the videos into Punjabi and we've had some great feedback about that And as many of you know, I spend a lot of my time trying to work out how to reach other women and men, actually, anyone who will listen about the menopause. And we know there are a lot of really disadvantaged. Well, I think most women are disadvantaged in the menopause, but there are some that are disadvantaged even more. And it's so important, isn't it?

With all our workers, medics, you know, we are not judgmental at all. We help. And I think that's one of the beauties. And actually privileges of being a doctor is that we are. let into people's lives without initially knowing much about them at all and then they open up and we share their lives don't we in often quite a vulnerable time for them? Absolutely and I think women feel far more vulnerable once they start going through the menopause and sort of losing themselves in this process and as GPs we're pushed for time we know it's difficult to treat them

but actually it's so important to consider what impact the menopause and estrogen deficiencies having on them because I think it's fundamental moving forward to be able to look after them well and do that job that you've described so beautifully and, you know, do it justice, really. It's really important. It seems very difficult, isn't it? And I think as a GP, you don't know who's coming in, what's coming in, and you have to be very flexible with your mind, with your decision making, and also the way that you consult, when I was training to be a GP, before I trained to be a GP, I was a hospital doctor for many years. And my trainer at the time for general practice said to me, Louise, you're going to be terrible as a GP because hospital doctors are generally not very good

communicators. So he spent a long time talking to me about the power of communication and the power of just treating everyone individually, which obviously is really important. And this was in the sort of late 1990s. And people didn't really think so much about how we need to involve. patients and it needs to be shared decision-making. And he's really been very pivotal to how I practice medicine now. And we have to, don't we engage our patients right from the time they come in at the door or appear on our screen, it's really important, isn't it? Absolutely. And they have to be involved in the decision and the understanding of because we know the more they understand, the more compliance improves. And actually, one of the things that we need to move forward with in

this country with health care is being proactive and preventative medicine. and needs that push. So if you're going to help somebody not only manage their condition, but prevent complications, they need to understand. And of course, it's so important for compliance. You know, currently we know the RCGP shows some literature and evidence that, you know, most people in their 30s will be on one or two drugs. So in order to comply by them and use them properly and adequately, they need to know why they're taking them and be involved in that decision. And of course, it has cost implications. It has healthcare expectations. It has healthcare expectations. attached to it. And for women, it becomes even more important because they're in the throes of their

life, trying to balance it as well as they can, but at the same time, feeling completely out of source. So that's why I feel we need to really voice and change their health care as much as we can, so they get a fairer start at the beginning. So important. So have you always been interested in women's health, or is this something that you've sort of moved into over the years? It's a bit ironic, really. I was probably one of the fewer GPs that didn't do a women's health job in my rotation. And I think that's a benefit because I didn't see it as that functional gynecology element of healthcare. I learned it in general practice where like you describe, it's the whole person you're treating. You have a much more holistic approach. You're thinking

about why is this individual not ticking in the correct way for them today? And it's not about which part can I fix and as a plumbing experiment. And it's so important. So I started doing women's health probably about 16 years ago, much more from the contraceptive side of things. As I saw women come through, I saw a pattern. But just like you during my hospital rotations, I certainly saw women coming in with pain all over in rheumatology or in A&E with chest pain and anxiety and palpitations in the middle of the night. And we used to rule out the acute causes and off they went in the same hole that they were in. So now looking back, you can see that this has been a problem for decades.

And it's just not being managed or uncovered in the correct way. No, and it's quite scary. When I was a hospital physician for many years, I just shudder at the people that I saw. And when I did my medical rotation, some of the jobs were in North Manchester. And there was quite a big actual Asian population there. And a lot of women would come in with total body pain.

And they would say, oh, Mrs. Bigham is here again. There's nothing wrong with her at all. And I thought, then I thought maybe she's depressed. No one's talking about her mood. And these women were often quite low in their mood, but there was more to it. And I could never put my finger onto it. And now I think back, I think, it's obvious. I bet they were menopausal. And no one spoke to them. And it's quite scary, isn't it, as a patient or a woman, if you've got symptoms, but you haven't got a diagnosis. And I think it's very, very hard because you don't want to be. labeled, but you want to know what's wrong so you can understand. And I'm sure like you,

I've seen lots of women who have thought that they've got a brain tumour because they've got such bad headaches or dementia because they can't remember or I think they've got an arthritis or fibromyalgia. Now there's a lot of women who have been diagnosed with long COVID. And a lot of their symptoms are probably attributed to their changing hormone levels and perimenopause and menopause. So it's very hard, isn't it? If you just get turned away from hospital or or a GP to say, well, nothing wrong with you. Of course, they've got symptoms, haven't they? Absolutely, and it's just so common. I mean, it's so common that the examples just get crazy. I mean, I've seen a woman who's seen 13 different specialists. This morning, I've seen a woman who is 57,

and she hasn't had a period for 17 years. So, you know, since the age of 40, she's been in this situation. And I think that we have to move forward in a way of empowering practitioners and professionals to be able to say, you know, you've had numerous investigations, you've had the CT head, this is not a tumour, but what is it? And let's treat what it is. And if at the same time we uncover something else, so be it. And again, you know, I think there seems to be a thought of it needs to be a condition or menopause. Yes. But one of the things that we have to consider is why can it not happen at the same time? I think that's so true. I had a meeting last week with some really learned professors from the Maudsley Hospital, as you know, the psychiatric hospital, and they write

guidelines for treatment. And I was talking to them about depression and Rebecca Lewis, who you know was on the call with me as well, who's very interested in mental health and hormone changes. And they were saying, well, you're making it sound like most women should have HRT. Surely that's not right. And I said, well, if you look at the nice guidance, the majority of women benefit from taking HRT. And I said, I'm not saying that every woman who's depressed, it's all due to her menopause because it's often multifactorial. There's lots of other conditions, you know, reasons as well, but this is probably one of them that's contributing to her, no mood anxiety and often suicidal thoughts as well. And he said, well, we don't know how to treat the menopause. And I said, well, it's very simple.

And the registrar who had done some research said, yes, I can see that women want treatment, but we don't know what to do. And I said, well, if they had a headache, would you give them paracetamon? said, of course we would. And I said, if they had an underactive thyroid gland and they were feeling very tired and low in their mood, would you just give them antidepressants or would you give them thyroxin? Well, no, of course would give them thyroxin. And I said, well, do you not think it's a duty for psychiatrists to have some basic training in the menopause and give almost the first level of HRT? And they've sort of gone away to have a little think. But I think that's really sad, isn't it? No, I agree with you. And I think it's sort of

of not got its place. You know, there's the guine and the obstetric side of things, which is very much dealt with the sort of functional diseases that you can have with structures in your body. And then we have women's health in terms of contraception and we have breast health. But there's actually a whole pocket of hormonal health in terms of menopause and perimenopause that isn't dealt with at all or addressed. And perhaps that's somewhere where the recognition and the difficulty in owning who will treat this sits. But actually, It's about as common as having women. So, you know, like you say, it's got to be part of medical training.

It's got to be part of recognition in every speciality. And, you know, it's just like, I mean, I say to people, you know, when you have young people with puberty and they have acne, I don't go, well, let's just deal with your puberty first. Let that happen. Then we'll deal with it. We've become so much more proactive about acne. And, you know, every speciality will flag that up and say,

this is what we can do about it. But yet we're not doing that with menopause. And I don't see the reason why. with an aging population and a society that depends on women so much for employment, the care. I mean, you know, we know there's lots of evidence that the future of the coming generations depends on their female influences, yet we're not looking after them as we could do. And that you say, it's relatively simple.

It seems crazy, doesn't it? Because I think it has always been a sort of Cinderella specialty, if you like. And I remember reading about the hormones and how they were sort of diagnosed. So when they found insulin, it was discovered insulin, they linked it with diabetes. When they found thyroxin, they linked it with hypothyroidism. Really, really frustratingly, when they discovered estrogen, they associated with hot flushes. So it was just a symptom. So it wasn't a disease.

And so endocrinologists, who are doctors, as you know, who specialize in hormones, often, not always, but often know nothing about estrogen and testosterone in women. And I saw a lady in my clinic last week who'd never had a natural period actually. So she had what we call primary amenorrhea, which just basically means she's never had a period. And she's now 49. But she managed to have twins. So she went to see a fertility specialist about 15 years ago.

Her twins are now 15. And said, I don't have periods, but I'd really like to try and get pregnant. So they gave her some hormone treatment to stimulate her eggs. and she amazingly managed to conceive naturally, had twins, and then never had periods again. And I said to her, did anyone talk to you about the fact that you've not had periods for all this time? And she said, no, no, they were just concentrating on pregnancy.

She said, but I was referred to a specialist endocrine clinic five years ago in Birmingham, and they did a test of my brain and looked at my pituitary gland, which is a very appropriate thing to do. They did blood tests and they told me they were normal. So she said, I've got them here. So she reads them out to me. And her estrogen level was less than 40, which I think most people would understand that that means very low. But because the computer wasn't programmed to say low, the endocrinologist didn't pick up.

And they just said, everything's fine. You've just got something called hypogonadism. So basically means you won't have periods. But it doesn't matter because you don't want more children. And she came to me because she's actually got really bad vaginal dryness. and she's finding relationship with her partner very uncomfortable, but also sitting down very awful. And no one would give her any treatment

because they were a bit scared that she had a hormone problem. So her risk of osteoporosis, heart disease and everything is huge. And we always get people to fill out a symptom questionnaire and her symptoms weren't too bad. But I'm longing to see how they're going to be in six months' time because she's never had the right hormones in her body at all. I think that's what's really sad about this, isn't it? Women get accustomed to always feeling so terrible that they lose recognition of how they ever felt.

And, you know, it doesn't take a long time for that. It can take about a year and they've actually lost who they were. And whether they're working or running a household or looking after, I mean, with the current sandwich generation, you're looking after the parents as well as the children. And there's a real double pinch for them. And I think that it's really important that we try and refashion how we view this and chip away. at that to say actually this isn't just about having children. Of course, that's a beautiful primary function we have, but the estrogen has such a wider function than that, you know, about our

health and how we feel. And actually, the wider impact on the whole family, on the employer, on, you know, all those factors in terms of if a woman feels well, she'll perform better, she'll be a better person to be around and probably a better parent as well. And, you know, it has such a wider impact on everyone around her. And I think that's where I think it's really important because the examples we see do add up. And they cease to horrify me. I mean, like this morning, I was like, you know, 17 years without any hormones. And you think, well, actually you were 40 and she spent horrible 17 years. And it doesn't take a huge amount to change that around. No, it's totally transformational medicine, isn't it? I can't think of any other area in medicine

where people get better so quickly, but also you invest in their future health. I sometimes compare it with diabetes. I used to run a lot of diabetes clinic when I was working in the hospital. And it was then similar but different because you don't always get symptoms of diabetes, do you? It's more just on a blood test. And so people would come to the clinic and they knew they had diabetes and you'd say to them, you really have to reduce some of the food that you're eating, change your diet, exercise, stop smoking, look at your alcohol. And they would sit there and go, yes, doctor, yes, doctor. And you'd see them three months later and they would still be doing exactly the same. And you'd be really frustrated. And then

you'd see people who'd had amputations or people that had heart attacks or strokes as a direct consequence of them having unregulated sugar levels. So as a doctor, you think, oh, what else can I do? What else can I do? Whereas when menopausal women often come or perimenopausal women to the clinic, they have symptoms, like you say, and they really want to feel better, but they don't know what else they can do. And often they have tried diets exercise, but they still find it hard. And then often they find their diets gone to pieces because they have sugar cravings, because they've got low energy, they've got no interest in anything. And as you know, the metabolic changes often mean they put on weight. So they sit here really quite distraught. So we give them, obviously,

their hormones back. And then usually even three months, certainly by six months later, they're just telling me that their lifestyle's improved, their diets improved, their sleep's improve. If they were smoking, they're not smoking. If they were drinking, they're drinking less because they don't have to drink to numb their symptoms in the same way. So, and I know it's reducing their risk of diabetes, heart disease, osteoporosis, dementia. So it's like the most satisfying diabetic clinic. That's how I compare it because we know when women have their hormones back, we're really investing, like you said at the beginning in this preventative health, which is so important because the NHS is completely overloaded, isn't it? It is. No, absolutely. And it's on

its knees and it has been for a while, but obviously post-pandemic, it's got much bigger challenges. The waiting lists are longer and longer. And if we are ending up referring women to a rheumatologist or to an immunologist or an orthopedic surgeon for their joints, aches and pains, then actually if they fit those categories of fitting a menopause history, trying estrogen, just like you say you would for saying, you're low on thyroxin, here take a thyroxin, replacement. I think it's the misconceptions we have built up about menopause being a somehow created or a lifestyle fashioned entity that isn't impacting their body head to toe. And when we start to realize that the turnaround time is so satisfying to treat. I mean, it still wows me over every

week when women come in and they've gone from weight gain to completely know self-confidence to go into the gym three times a day and saying things like, I've got my life back. There's very few areas in medicine where you get that, particularly in general practice. practice. General practice is very much a short-lived window where you don't follow people up for too long, particularly at the moment you don't get to see the same person again and again very much because of the constraints on the system. It's in a recruitment challenge because GPs are leaving quicker than they are training. So it really needs to manage women who keep coming back. And we know that they're a third more likely to see a GP during that time of perimenopause and menopause than men.

so they are coming back again and again because they don't feel well. Absolutely. One of my patients recently said for the last two years, every month she was going to see a doctor. And she said since she's been on HRT, she's just been once and six months to get her prescription put on her repeat. And we see that time again. But one of the things that I'm trying to do with some of my work is empower women. As you know, we do a lot of work in education through my not-for-profit company. But I'm also trying to empower women with the right tools and knowledge so they can sort of, help direct this consultation and conversation with their healthcare professionals.

So obviously we've got balance the app, we've got the website, that Menopause Territory that you're a trustee of that I founded, to really just try and help empower women. But again, there's still a lot of women that have no knowledge at all. And I just wondered whether you've had any sort of thoughts or ideas of how we can reach even more communities of women across the world, because it's a big challenge. It is a big challenge.

I think we need to increase awareness and once we do that by normalising it. And I think it's looking at the pattern. We look at patterns in everything. So just take puberty, for example, you think 14-year-old is going to have some skin changes, is going to have some mood changes. Let's translate that to women. If you think about a woman, 45 to 52, periods are going to get a bit more erratic, possibly start missing some. You know, you are going to feel some body aches from recognising those symptoms and not just putting them down to other things. And then talking about it to your friends or your community and within your family, you know, it's really important for your loved ones to realize you're not feeling well because they might be the people that push

you to go and get some help. And then also, like you say, using the literature out there, there's a fast amount of information out there. It's on social media channels, it's on the internet, it's often on TV things, and coming up, it's going to be more talked about as well. And going to your doctor equipped with that information, the guidance that exists, the nice guidance, has been around for several years, but it's only as good as the paper it's on if it's not being implemented. You know, we need to have our doctors putting it into practice and following those guidances. And, you know, 66% of women are almost given antidepressants. But the nice guidance says use the antidepressants if a woman isn't able to take HRT. So we're jumping that rung,

and we shouldn't be. We shouldn't be afraid of doing it. And if we change the culture around it by educating the women and the doctors or the health professionals looking after them, we stand a better chance of the two finding a meeting point and being able to find that holistic care that we were talking about. Which is so important. So with your education, because I know you're an educator, so you educate lots of healthcare professionals, not just GPs, but others as well, is there an enthusiasm out there for menopause education, do you think?

Yes. Yes. Yes. Definitely. I think there is. And I think that there's a curiosity. and there's a realisation that these medically unexplained symptoms. I mean, we actually found a code for them.

It was called M-U-S. So code somebody, which was largely a middle-aged female, has medically unexplained symptoms. But, you know, this coming back and forth and trialing different medications is not healthy. It's not economic, and it's not helpful. So there's definitely a curiosity about menopause, and I think that when people start learning,

seeing women treating them seeing them back is really important following them up i mean we would never start anybody on any hormone and just go off you go see you in 10 years so why do that with hrt they must have an annual follow-up and then see them and see how much they've improved and if they haven't the guidance is then there on what to do next i don't think it's that black hole of you're just giving them something that hasn't been tried and tested this is all verified medically approved treatment and I think we need to unpeel those barriers to get that next step. Yeah, absolutely. I was talking to a doctor this morning actually who had been to a couple of my training

courses and she said, I had no idea. She said it's really transformed my practice because I didn't really think of it in the same way. And it's certainly thinking of it as a female hormone deficiency with health risks. And I think what we want to do is certainly with the charity work we're doing, we want to change the narrative. Instead of thinking, oh, I'm going to try everything else. and then I'm going to give in to HRT.

It's thinking, why am I not taking HRT? What is the reason? And it's usually actually often misunderstanding by the woman about how safe HRT is and poor education for the healthcare professionals. So a lot of healthcare professionals have been taught you shouldn't use HRT or you have to stop it at a certain time or it's going to have more risks than benefits.

So changing that can be quite difficult. It's just getting your head around something that you've been taught in a different way. And I think that's very difficult. But I think as healthcare professionals, we should always be challenging the evidence. And everyone, hopefully, who's listening, knows that I think evidence is the most important thing. And when I started as a GP, I wrote a book called Hot Topics for the MRCGP,

which is a member of the Royal College of GP exam. And we actually wrote four editions in the end because the evidence was changing so quickly. And it was quite interesting, actually, thinking how you have to be so up to date as a doctor, but it's so difficult to do. And when I wrote the book, it was just before the internet. So it was very, very difficult to access information. And the book did incredibly well. And then I stopped doing it because I had my second child and my energy levels were at their lowest. But also the internet was there and there were other resources and everything else as well.

but it's a double-edged sword sometimes having the internet because even as healthcare professionals we go on and we Google but it's only as good as what's written and it's only as up to date as whoever's putting that information in so when it comes to HRT there's a lot of barriers on there because even the books or the resources that we use a lot such as the British National Formula the BNF and the MHRA are giving us wrong information about HRT so that's very hard isn't it? It is and I think that you know it's compounded by so many different factors but to some extent I so think it's difficult to keep learning GPs and other health professionals have to. It's part of our professional obligation to always be learning and there's a huge acceptance that literature

and evidence keeps changing and that happens in every other disease area. I mean not endocrine but if we look at statins you know they're good for you they're not good for you they are you know wine it's you know a little bit of red wine is good for you it's not good for you we've always changed but there's a reluctant to accept that with women's health. And perhaps that's because we're not treated. I mean, I would challenge that as is it not accepted to be important enough? And when will it be? Because there will always be something. In pre-pandemic, there was NHS priorities which are called five-year forward views long after the nice guidance was written. And women's health hasn't been part of that. Permanatal care has, so mental health for women who are about to give birth or post-birth has become

a priority and that's incredible because you know mental health and suicide in women post delivery was really recognised and we to some extent need that movement of recognising this is a massive issue here it's not going to go away it's only going to get worse with an ageing population who works longer who's expected to contribute for longer and longer having children later that's the way society's heading so unless we change that it won't happen and the second point that I think is really important to make is why not while you investigate, try HRT? Yes. I mean, I found that so many times that the amount of drugs that are tried, antidepressants, given six months to a year, sleeping tablets, beta blockers,

tricyclic antidepressants, which are very old-fashioned, full of side effects. While you're trying them, try the HRT. Or don't try them, try the HRT first. Yeah, and that's totally, I mean, we see a lot of women in the clinic who've had intractable migraines and they're often given unlicensed drugs such as progabalin, like you say, something like norotryptylene or amatryptin. They've been given some of the really horrible actually anti-epileptic drugs and they often be limited by their side effects. And I often say, well, I don't know how much their migraines is related to their hormones, but they've also got blushes and sweats and joint pains and low mood. And so I'll give them HRT because the nice guidance tell us the majority of women,

the benefits, that way the risks. And within three months, they often say, goodness me, I haven't had migraines. Whereas when I speak to migraine specialists, they have no training in HLT, and they think it's dangerous because, as you know, tablet estrogen shouldn't be given to women who have a history of migraine, especially with aura, and some of the older progestogens have a small clock risk. But the natural body identical estrogen through the skin, the natural progesterone has no clock risk. So it's very, very, very, very. safe. And like you say, I actually have migraines. And if I had a choice of taking one of these drugs or HRT, I would certainly try HRT first. And I did and my migraines are so much better. So,

you know, but like you say, there's nothing that HRT interacts with. So you can have, you know, sometimes we don't know is someone clinically depressed or is it their hormones. And if I'm really worried about someone's mental state, then I will often give them both because they work differently and there is some evidence that antidepressants work better when their estrogen's on board as well. Absolutely. No. And I think it's trying not to separate the two. I think that's a really important message to put out there is it can be menopause and something else. And there's nothing stopping you from looking for both. But pretending menopause isn't there is not the long-term solution because many things will get better. And I think it really

empowers women to understand themselves and recognize who they were because they almost feel quite lost. And there is no evidence that antidepressants help mood or hot flushes as well when it's perimenopause or menopause related. So, you know, it seems irrational to try them first. And it goes against the grain of the guidance that does exist. Absolutely. So I think if women listening or any of their friends have been offered antidepressants,

they should really be questioning why. And certainly antidepressants do have a role for a lot of people, men and women who have clinical depression, But if a lot of women say to me, I know I'm not depressed, I know I'm just feel flat. I feel joyless. I have very low mood and anxiety, but I know I'm not depressed. Or indeed, a lot of women take antidepressants for a few months and say, it's just none my symptoms, but I don't feel better. And that's the time to have a conversation with your healthcare provider about should I be just trying some HRT? Because, you know, it has health benefits as well.

So it's important. I totally agree that women should be armed with as much information as. possible that's based on the evidence and then it's always difficult challenging a healthcare professional but most of us like a healthy discussion with our patients i love it when patients push back or they say i've read this and what do you think of this and it's really important because as you said before it's also about compliance you know we've all done home visits and we've asked somebody what medication are you on and you open the cupboard and a hundred things fall out of the question and you think well i've been prescribing that to you

for the last year and you've not taken any of it. And they, oh, no, doctor, I didn't like the colour of the packaging or I didn't get the pill out of the blister pack or it made me feel a bit weird. Or I read the insert and I was too scared to take it. So it's really, really important. As a doctor, it's only as good as the medicine that we give and the people take. It's not just enough to write a prescription. And so having that understanding of what's happening to our bodies, so then we have the power to make the choices and see how we improve is really important, It is definitely. I mean, I think, you know, polypharmacy, which is too many drugs, is a massive problem we have as a modern health system. And also it's an issue of economics for the NHS. And I think that if the NHS is going to remain sustainable and we want to keep it, because it's a wonderful provision as we've realised throughout the pandemic, you know, we're very fortunate to have it. But if we want to keep it and we want to use it well, then menopause has to be addressed. And as the healthcare professionals dealing with that population, which is high, of our population, we can't keep ignoring it. And we have to address it. And women do come

equipped, but sometimes they do face resistance. And I think that one of the insights I have as a GP in the system and as an educator in menopause for healthcare professionals and lay public is understanding that the system doesn't make it that easy for health professionals to deal with somebody who has an overwhelming number of symptoms. So if you can do the questionnaire that's available, which is the green symptom questionnaire. If you can use apps like the balance app to track your symptoms, if you can remember when your last period was, all these things are really helpful to the health professional. But on their side, they have templates they can use. They can talk through the risks and benefits with you. But I would really say women shouldn't accept a blanket statement

that HRT is not safe because there's enough out there to say it's very beneficial. And like any drug you take, even if it's paracetamor, we balance risks against benefits in every single thing we do, whether it's what we eat, what we take, what we drive. You know, we're doing it all the time. So this area is never going to be something that you can go, well, I'll only come back to it when it's risk-free. Yes. So if the benefits are so big for you, then all of us have the capacity to think about we're prepared to take those risks. I think it's a really important area for them to take are they not feel turned away by. And we see this a lot, don't we, Louise?

We see women just being pushed away again and again and being told it's not safe for them. But question why and where is the evidence? Absolutely. Or turn it around and say, how might it be good for women? It's really important and certainly being individualised in approach is really key for every menopause consultation. So it's been a great talk today and it's been really enlightening hearing about your work.

So thank you so much. But before we finish, I just wanted to. to ask you, just to put you on the spot here, three things that you think the menopause charity can make a real difference to women globally. Let's think big, because we are going to be a global charity and we're going to help women across the world. So three things that you think would be really key. I think for me, as with the insight I have currently in my perspective, is I think the biggest thing globally, which would be phenomenal and achievable, is to recognise the impact of menopause and to get people talking about it. The second thing globally, which is the second thing,

The second key wrong that I think is really important is to educate not just women, but health professionals. And there are barriers for that, which are quite complicated. But just as menopause education is coming into sex education in schools in this country, if we keep that going and start with available information for health professionals and for women, but also moving on to offering evidence-based, non-sponsored courses that doctors or other health professionals can have access to or be signposted to. And the other thing that really is important is support, support for women, support for health professionals. It's a really daunting time to be working in the health profession.

And the last two years have not helped. But for certain, moving forward with the questions that are left with long COVID, long-term consequences and everything, we've got a huge pocket of area that leaves lots of questions and uncertainty. And I think making health professionals feel educated and supported. And for me, one of the benefits is when you're working in an area like we are, Louise, is being able to talk to somebody else and say, this woman's come in with this, this, and this. What do I do? Because as you do more and more, your own colleagues may not have the answers or the advice. And putting two heads together is so important. And offering that support, I'd love for it to be a voice

for everyone and not just women who need the help, because actually those that help them often need the help too. That's so important. What a great way to end. Thanks ever so much, Ritika. Really kind of you to spend your time. Thank you. Love me talking to you. Thank you. Thank you. Take care. Bye.

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.