The Dr Louise Newson Podcast - 105 - Living with Premature Ovarian Insufficiency and starting a family

Episode Date: June 29, 2021

Emily Fisher had always known her mother experienced an early menopause and was wary the same could happen to her. When she went to the doctors with her concerns, she was merely given the advice to 'have children young', but she wasn't ready to take this step in her early 20s and decided to look into her fertility options. Investigations did indeed confirm her fears and with the help of a fertility specialist with an interest in POI, she was able to become pregnant.    After having twins, Emily suffered with multiple symptoms that could have been explained away as related to post-pregnancy hormones, but she knew there was more to it. Specialists offered conflicting advice on how best to manage her very low mood, brain fog and hot flushes. With the help of a POI specialist, Emily had to advocate for herself to get the right type and dose of HRT, and she's now becoming more confident to talk to family and friends about what she has gone through and about the treatment she takes.     Emily's tips for young women who may have POI:  1. Find out your family history, ask your mother, aunties, cousins, grandmothers what age they were when they started menopause. If any of them had it when young, try and speak to a healthcare professional about it. If you're having any trouble getting pregnant, act early and if you can afford it, see a fertility specialist that specialises in POI.    2. Do not give up! If you think something's not right, see another doctor if you have to, or a nurse specialist.      3. Talk to you partner, tell your friends and family. Don't be embarrassed, we need more women to speak about this. Doing this will help you feel less alone.   You can follow Emily on Instagram at @motheringandthemenopause 

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. In this podcast today, I've got with me, Emily, who I don't think actually is my youngest person that I've interviewed, but she's down there as one of the the youngest, but she certainly has a huge respect for me because she has three children, but three very young children. I have three children and it's always difficult coping with three, but she's got three very little ones and she'll explain more. But thank you ever so much, Emily, for coming to the podcast today and just agreeing to talk about your own experience. So thank you. Thanks so much for having me. It's really nice to be asked. So tell me a bit about you if you don't mind. Yep. So my story is quite different to a lot of the people that I've connected

with over social media, mainly because I kind of had a suspicion that it was coming, because my mum went through a really early menopause around the same age, like early 30s. So I was always hyper aware of that. I don't know why, because nobody ever told my mum that she should really keep an eye on her daughters. It was just something that I felt quite anxious about. So from a very young age, I was back and forth to the GP, just asking them, you know, do you know about early menopause? do I need to be concerned. And every time they just sent me off and said, just don't wait till you're like mid-30

to have a baby, have a baby young. But that wasn't really something that I wanted to do. So I met my partner and I was still young. I think I was 23 or 24. And decided that I wanted to go and talk about freezing my eggs. So we went together to this appointment. Again, it was GP referred me to a gynecologist. The gynecologist that I saw luckily just said that she didn't feel

she had enough experience in this area and that she would refer me to fertility. Well, thank goodness she did, because without her referring me to fertility, I don't think I would be in the position I am now. I saw fertility and I had some blood tests done and the scan, which was all very negative. And I remember leaving that appointment feeling really, really disheartened and quite angry that I'd kind of got to this age and it hadn't been investigated before. And I'd see many gynecologists before. Yeah, so were you still having periods?

at that time? Yeah, so at that time, everything was completely fine. I had no symptoms. I was on the pill. So I guess it could have masked anything that was going on, but everything seemed okay. So I went to my appointment and my AMH was really, really low for my age. And I had an ovarian scan, which made everything look really dormant and it wasn't really anything going on down there. So the fertility consultant I saw advised that I came off the pill straight away because he didn't know whether the ovarian suppression was from the pill or was that I had an early menopause. And it was potentially too late to have children. Oh, so, yeah. So I came off the pill and by miracle got pregnant really quickly.

Had that pregnancy, a successful pregnancy, went on to have another pregnancy, but unfortunately it was a miscarriage. and then I stopped ovulating after that point. So that was kind of, for me, evidence that the medicals was coming quite quickly. And I did start to feel some symptoms just like anxious and quite low in mood. I guess that could also be when you're trying for a baby and it's not happening. So we decided not to kind of hang around and we went privately for fertility. All the way through this, I was having those AMH blood tests done, which were coming back lower and lower and lower every time.

The specialist that I chose, I chose deliberately because she had an interest in premature ovarian insufficiency. And she straightaway was really great and telling me all about HRT. And she did put me on a little bit of HRT when I was trying to conceive. But she was really positive that we could do this with my own eggs at that point. So I had a success of pregnancy the next time, which was twins, which was quite a shock, but also very grateful for them. But my specialist was really on the ball saying, you know, as soon as you stop breastfeeding, you need HRT.

And this was all documents sent to my GP. So I had the twins, breastfed for four weeks, came off breastfeeding, and then I noticed changes. I felt awful. I mean, I think what I found difficult was a lot of postpartum symptoms, can also be menopause symptoms. So it was hard to distinguish what was going on. I mean, I had hair loss, night sweats, very, very heavy leaves, needing a wee a lot, poor pelvic floor, tired, not sleeping, but you're not sleeping anyway. So it was hard to think what's going on.

But then I started to get other symptoms and because I'd had a baby before and because of my job, I just knew these are not symptoms from having a baby. I was getting palpitations, nausea, but to the point where I would have to go to bed because it just felt so sick and sometimes vomiting if I'd had like a really strong coffee. Hot flushes, so I'd have a cup of tea in the morning and then it'd be like sweating and flushing, unable to walk up the stairs and get to the top and think, oh my gosh, I need to lie down and just really, really severe brain fog where I just felt like I had a bag over my head. It's like the only way I can really describe it. So around my GP twins must have been around three or four months and just explain what's going.

on. I'd actually been referred to her from another consultation because I'd been speaking to a male GP about the abnormal periods. And he just said, look, we've got menopause specialist in our practice that referred her. So I spoke to her and I was thinking, oh, this is great. There's a menopause specialist in the practice because I've been playing to see my doctor, which I was really happy to do, but it was nice to know that there might be someone there who has an interest. So I rang her and just straight away, it was just like, no, this is. isn't the premenopause, you're still having periods, your FSA-H was fine, you're tired, you've got twins, you need to sleep more. So what did you say to that? I still beat myself up

that I should have kind of thought more at that point, but I was so tired and you do trust your doctor. I mean, I'm quite annoyed with myself now because fair of mind, she had my letter from my specialist and she was even like, no, a specialist is wrong, you don't need HRT. So I was like, okay, fine, and that's the end of that conversation then. And a few months later, I decided to ring my specialist just because the periods were not getting better. And amongst all this, I've even gone to see a gynecology consultant who scanned me. And she told me, oh, I think we need to give your pill. My specialist said take your pill back to back for the Eastertons to try and help your period.

The gynecology consultant told me, no, you need to be having a break. Let's try and get a regular cycle. So I was just having loads of conflicting information. So I went on the pill for a few months. I think it did help with the periods, but all the other symptoms were still there. And this was around August time. I got to November,

the twins were 10 months old, and I was just so low. I just felt so low. I'd just cry all day. I've had such low self-esteem. Yes. Yeah. But I mean, I think a lot of moms who might have twins

might have low self-esteem because your body changes. But I just, this all seemed so late that I thought, this isn't really to do with the babies. I just knew it was my hormones. So I spoke to my specialist then, and because I'd seen her quite a few times, she could just tell from my voice that, you know,

just not right, it was just so fat. Yeah. So she started on some Easter gel. I started doing quite a low dose, I think it was about three pumps a day. And I felt so much better. I think three days later, I was like, oh my gosh, I can think.

I remember doing the washing up looking into the garden and like swinting because the sun was so bright just things that I just could not believe the difference and since then it's just been trying to find the right HOTT but it's just been incredible to see that difference in my mood and my students. Yeah I owe a lot to my specialist really. There's a lot to sort of unpick there really for people who are listening obviously it's a huge journey for someone who's so young and you've had some sort of warning signs, if you like, right from the start, knowing that you've got a family history of early menopause. And none of us know when our menopause or perimenopause is going to start. But if people have family members, so sisters, aunties, cousins, mothers, who have had early menopause, it's more likely that you yourself will have one. So you were sort of primed

from the start with this knowledge. And as you know, there's no actual test to know how fertile or infertile a woman's going to be. There is this blood test, like you say, this anti-malarion hormone, which is often done in fertility clinics. It's not recommended as a test for the menopause or perimenopause because it's not reliable enough, but it can give an indication to say if there are sort of eggs left,

if you like, and obviously the scan as well. But when women are on the contraceptive pill, people, if they take it for three weeks and have a week off, then they will have a period. As you know, it's a withdrawal period. But that's not the same as a period that occurs due to hormones. So obviously you had these symptoms after having your twins, but that can quite often happen that people get night sweats and they have fatigue and everything else because of the

estrogen levels dropping after having a baby. But obviously the symptoms persisted. And the contraceptive pill, often people think could be a treatment for early menopause or POI, premature ovarian insufficiency because it contains hormones. But for many of you who are listening, know that it contains quite synthetic hormones actually at very different doses. And actually, the estrogen dose is slightly higher because it works as a contraception, whereas HRT isn't a contraception, but it's a very different type. It's a very synthetic type of estrogen, whereas the estrogen, as you say, you had through the skin as a gel, is the body identical estrogen. So it's the same structure as the hormone that you're missing. And so people,

often find that they symptomatically improve so much better. And also their sort of future health benefits are better as well because it's better for our hearts, our bones, our brain, all our bodies, because it's stimulating the cells in the right way. But it's really important, as you know, that women get the right dose and type. But I also think it was very important that you said, and I'll repeat it in case people didn't pick up, that you were given some HRT before you had fertility treatment. That's right, isn't it? You said you were started. And it comes up quite a lot and a lot of people ask me, either in my clinic or on social media, or I'm going for fertility treatment, can I take HRT? And some consultants and specialists think they can't. But actually,

of course you can because it's just your natural hormones that you're topping up. And there is some evidence actually that if women with POI take HRT, their fertility can actually improve because an egg might be more likely to be produced because the ovaries are less likely to work quite as hard because they're having some hormones as well. And all they are are in natural hormones, so it's the same as a woman going for a natural pregnancy. They're going to have hormones in their body. So this is the same scenario. But sometimes people think that HRT is some dreadful drug and it has to be stopped. Like you would obviously stop other. drugs before you were wanting to become pregnant. So that was great, wasn't it, that you were given

some HRT beforehand? Yeah, like I said, I'm just so grateful for my specialist that she had that kind of knowledge because the GP that did deny me HRT is a fertility specialist. So I just think there's just such a lack of understanding around POI. It is scary when you think about it. It is very scary. And, you know, I have mentioned on this podcast before and I will mention again, but I feel very embarrassed to say that, you know, when I was at medical school, I was taught that if someone comes to see you as a patient who doesn't have their periods and is young, make sure they're not pregnant. And if they're not pregnant, you can reassure them. Sometimes people talk about making sure they haven't got something called polycystic ovarian syndrome, but that's it. No one even

talked about the possibility of having an early menopause or premature ovarian insufficiency, which is a woman under the age of 40. So over the years, this of 30 years, I've been a doctor, I must have missed a lot of women and reassured them and said, no, don't worry, because you're not having your periods. And I shudder to think about those women who I've neglected because not only will they have been experiencing symptoms, but also there are health risks, as you know, from not having hormones. And that's something that I feel really bad, really bad about it as a doctor. And I think that's probably one of the things that makes me drive to work even harder now because I realise with proper education, I could have given the women I'd seen an even better,

a service and which is difficult for doctors, but actually we've now got education and guidelines available, which there weren't when I was younger. So we have the nice guidance. There's also the International Manipal Society guidance and there's a European guidance, the estuary guidance, which are very good for management of premature ovarian sufficiency and they're all available to read on my website or their own websites as well. But it's very hard, isn't it, when you're told something by a doctor to then challenge what that doctor's saying. Yeah, it is. really, really hard. I mean, I think with POI, like you say, there isn't enough training about it. And I think for a lot of us who have got it as well, your first worry is fertility. And you just

don't realize the impact all the symptoms are going to have on your life. I mean, I am so grateful that I've got my children. And I mean, sometimes I feel bad moaning about my symptoms because I know a lot of girls have got the symptoms and no children. And I just feel so bad to them. But I know that if I hadn't pushed and pushed and pushed, I would not have them. because I mean we wouldn't want children yet I mean we hadn't been together that long luckily it's been okay but it's a huge strain on your relationship to have three under two and then go through the menopause I just think so much more training needs to be done it does infuriate me when I hear things I mean I've read it in a few books recently

and heard it on a few podcasts and people say they've gone into the menopause oh there goes my fertility it's not just your fertility it's everything no because it's not no and I think it's very difficult. I, you know, I get quite a lot of pushback what I do from other healthcare professionals and sometimes from other women as well. But I think actually, even if I ignore the sort of so-called natural menopause, so people over the age of 50, if we just concentrate on women with POI, so that's one in a hundred women under the age of 40 who have an early menopause, one in a hundred women are often being neglected. That's a one percent. That's a huge number of women when we know we've got a really good safe treatment, but also there's no risks, as you know,

if you take body identical estrogen, body identical progesterone or a marina coil, and testosterone is often really beneficial for young women, there are absolutely no risks at all, whereas there are risks, actually, if you carried on taking the contraceptive pill. So it's quite ironic, actually. The contraceptive services are really good, quite rightly. Of course, they should be. And a lot of nurses, pharmacists can advise about contraception, whereas there's this massive negativity and pushback about HRT, which is pivotal actually for, as you've clearly said, improving your symptoms, but more importantly, improving your future house. You know, you don't want to be having osteoporosis in your 40s or heart attack in your 50s. Of course you don't. But it's

investing now is really important. And I know you've been great because you've been talking about your experience on social media and I follow you on Instagram, which is amazing. But you must be hearing some quite heartbreaking stories, are you, from other people going through similar experiences? Yeah, and even like my mum, I mean, she didn't have HR, like proper HRT, until I saw my specialist, I made her go. But all of that time, she's been really suffering. And I just think, I just never ever want anyone else to feel like that. And if I can share my stories and help some people that's great i mean i have got a daughter now and i'm so hyper aware that there's absolutely no way she's going to suffer like i mean i only suffered for about a year but it was bad enough

it's just the lack of understanding i mean i went on to progesterine because of being on estrogen and i was really struggling progesterine intolerance and i was told by my gp we're going to have to come off hrt if you can't cope with it and i was just thinking oh my gosh do you not understand and I said you need to have a look at the menopause doctor guidelines and she said I'm not following that because it's not licensed to use it vaginally when I said can I use it vaginally she said just come off your HRT and I said I cannot come off it not only is it bad for my health but it's really negatively impacts in my whole life so I actually just didn't take gestron which is terrible and really dangerous but at that point I was so low I just thought I'm going to have to balance what

was worse and I just cannot come off my HOT because I can't look after my children. So I'm going to have to do in this small window while I'm waiting for my coil, just pray that everything is okay. Yeah, and I think you say it's risky. It's all relative, actually. The risk is still quite low. Women who have a womb, we still recommend to have a progesterone or a synthetic progestogen or the marina coil, as you say, because it protects the lining of the womb. If women have estrogen on their own, it can build up the lining of the womb. And for a very small percentage of women, it can develop into a cancer. That doesn't happen if women have progesterone. But progesterone intolerance probably affects around 10% of women. So it's very

common. And often in our clinic, we're really trying to sort of juggle how we can get away with less progesterone and carry on, as you say, with the important bits of estrogen and testosterone if those women need it. And it's always a risk. It's a little bit like crossing the road, it's a risk of, you know, how quickly you cross the road if a car's coming. But actually, it's looking at the benefits as well. And there are always ways. And we do sometimes give or recommend that the progesterone is used vaginally, which is off-licensed. But when we say off-licensed, the actual drug is still licensed. It's still a regulated drug. It's the way we use it. But that's the same with a lot of medications. There's a lot of medications, for example, we use for nerve pain or

migraines that are not licensed for nerve pain or migraines. But we know they were. and a lot of medications we give to children are not licensed for children, but we know they work. So it doesn't mean it's dangerous. We just go back to the evidence, and if there is evidence to support clinical practice, then we do it, and that's the same with vaginal progesterone, or, like you say, having a marina coil can be very useful as well. But young women with POI often need a lot higher doses of estrogen. So the dose of estrogen I would give to a 50-year-old whose menopausal is a lot lower often

compared to a woman who's in their 20s or 30s. And some healthcare professionals get very scared about giving higher doses of estrogen as well. I don't know if that's something you've experienced. Yeah, I have, and especially when I'm picking it up from the pharmacy frequently, like, why are you picking it up? I basically had to just keep relying on my specialist to update my GP, and basically she's just had to keep reassuring them that it's okay for me to be on. I mean, I was on six pumps of gel, just keep reassuring them,

and that that was okay for this time. And I have also found that I'm still getting like a lot of fluctuations in my own hormones, which I guess I don't know, but I get older, maybe that settles. So it's just important to try and find the right balance that kind of suits you. Absolutely. And it's a very dynamic process, finding the right dose of HRT. And then often we think we've got it and people are fine and then suddenly their symptoms change. And as you say, often for women who still have ovaries,

their ovaries still squirt out a bit of hormones. and that can complicate things a little bit as well. But it can be quite common that women have more than six pumps of gel or quite often we use the patches, the higher strength patches, but people who are young can often use two or sometimes three patches together. And again, some doctors or healthcare professionals get very worried. But actually, I always think, well, what's the worry? The worry for me is if women don't have enough estrogen,

then they've still got health risks and often they've still got symptoms. We're very fortunate being able to give estrogen through the skin, so it goes straight into the bloodstream. So then there's no risk of clot. There's no risk of stroke. So it makes it very, very safe. It's very different to tablet estrogen. And it also means that women have control

because often, as you say, your hormones can change, which is what happens naturally. We all our hormones change all the time. So it's really important if women understand that they're allowed to change their dose themselves, then that's fine, there's no harm. And if you look at women and men with diabetes, they're constantly changing their insulin.

And that's really important to maximise their future health. And we need to start thinking about estrogen a bit like that as well. And so we're not scared about it because I think for so many years, we've all been so scared of our own hormones. Yeah. And we need to change that narrative, really, don't we? Yeah. And I've had a few GP saying, you know,

you just come off it at the normal age, but I'm not coming off it. I think if we can just get more GPs to understand better, it will just solve a lot of problems. But I think it is really hard with P.O.I, like trying to get it managed properly. But like you say, one in a hundred, that is quite common. It's very common. And sadly, if you did a search in GP practices, you know, you can do computer searches to see how many of their patients have got high blood pressure or diabetes.

If you look for P.O.I, it wouldn't be one in a hundred. So a lot of these women are not being diagnosed. And some studies have shown it can take seven years. for diagnosis and it can take numerous consultations, which is wasting actually NHS time, doctors time, but also the patients, a lot of women we see who have POI have really tragic stories where they've not been able to function and work. And as you say, it's really hard for your brain actually to function without hormones. But it's also, I think there's still a stigma as well. I know even when I started HRT, I was in my mid-40s and as some of my friends said,

oh gosh, aren't you a bit young to start HRT? And I then reflected and thought, you know what, I'm very fortunate. I've got three children. I'm in my 40s. How would I feel if I was in my 20s without anybody to talk to? Because you say, obviously, you're very fortunate having your three lovely children. But for a lot of women with POI, they haven't got that luxury. But also just to be able to talk about HRT, which is still thought of as an old person's sort of treatment with breast cancer associated with it.

And obviously when you take hormones when you're young, there's absolutely no risk of breast cancer because you're just replacing your missing hormones. So it's a difficult conversation, isn't it often? Yeah, it's so difficult. And me and my husband always talk about that. So when I first got diagnosed, I mean, that's the thing I do feel that's different with my story

is that luckily when I got all these symptoms, like you say, the brain fog and everything, I knew it was down to that. But if you had to just go through that and you had no idea what was going on, it probably would have taken me a good few years to get help and get support, but luckily, I just went straight to my specialist because I knew. And that just hurts because I hear lots of stories of women suffering for years.

But when we first got our diagnosis and I first got pregnant, like I said, we hadn't been together that long. So we kind of felt we had to justify to everyone. So we were telling everyone. A friend and family that this is why I'm pregnant. And it really felt like I had to justify it. And now, kind of four years later that I am going through it, And I have been really open the last few months. But before that, I mean, it was during COVID.

So I wasn't seeing anyone anyway. But I was really, really embarrassed. I didn't want anyone to know. But now we're kind of being more open. It's things like going to the pub last week and not wanting to drink red wine because I knew I'll be up all night sweating and just saying openly, yeah, I'm not drinking red wine because I'm menopausal. And then our friends have been, oh my gosh, I forgot about that

because of so much has happened in such a short space of people. And it's just trying to over that stigma. And it is trying to normalise it. You know, if you weren't drinking red wine because you suffered migraines, you would say that in a conversation, but it's just another M word, isn't it? And I think it is really making sure people know, actually, that young women can experience menopause. So when some of the sort of media work I do, it's always about sort of midlife.

And it's like, well, it's not the middle of your life. It could be the beginning of your life, actually. And it's your future life is really important. So I think what you're doing is brilliant. And I think it will help support healthcare professionals because the thing is you don't know what you don't know actually as a doctor. And if you're taught one thing, even if your patient's coming and telling you something,

you might not believe or realise the first patient. And, you know, certainly as a doctor, for many years I've had people cutting out articles from the Daily Mail telling me there's this wonder drug for Parkinson's or there's this cure for dementia. And then I look at the Daily Man article and it's been a study of about 10 people. I feel really sorry actually sort of popping these people's balloons

because they come thinking I'm going to help them. So I can understand if, you know, patients come to a doctor and say, look, I've read about POI and I want treatment and they're thinking, well, I've never been taught about it. But I think the tide is turning. I think the Channel 4 documentary with Davina has been a real pivotal point actually for menopause going forwards.

And I think actually, I think as women we have a duty to empower ourselves, and educate ourselves. So then actually we can go hand in hand with our doctor and have a really informed conversation. And certainly what's one of the reasons that I developed the free app balance so people can start monitoring their symptoms, download a health report from it.

And as you say, when you did get that pushback from your doctor, if you had a bit more information, even some written information to show, and sometimes I'll say to people, well, just park that conversation with your doctor, but give them some information, or write them a letter afterwards and ask for a follow-up consultation. Because I get really nervous going to see my own doctor because he's always running a bit late.

He's always really busy. I feel like I'm trivialising and wasting his time, really. Whereas if I didn't get the right help, and certainly I couldn't get HRT the first time I tried to get it, then I would reflect and writing it down actually is quite useful because it's not so confrontational. And they're making an appointment either with the same doctor or a different doctor or a nurse in the practice and saying, I'm just ready for another consultation because I'm just a bit confused

why I wasn't allowed HRT or why we couldn't talk about it. And I think it's opening up, but it's hard. You have to be brave, don't you, to have those sorts of conversations? You have to be really brave, I think. I am quite headstrong.

I think that's definitely helped. But I do feel bad like GP bashing because they do need to know so much. But I feel like P.O.I. is not uncommon. And, well, every woman will go through it if they live long enough. So surely we should know about this. I do need to do feedback to my GP surgery, but I have moved.

And I've had such a good experience in my new surgery. So it does show that it's not all the... Absolutely, totally. And I'm certainly not here to GP Bash. And one of the reasons that I founded the Menopause charity is really to help try and support my colleagues, because actually it is the most rewarding thing in medicine. It's transformational medicine to be able to help women in 10 minutes by giving them the right type of HRT.

And then actually they don't come back, you know, they don't come back and pesting me because they're feeling better. And I know their future health is good as well. Yeah. I have started testosterone as well and I have had a Dexas scan. So I do feel lucky, but that has all been guided from my specialist. It has been received quite well with my new practice. They've been really on board. Good.

And they're probably learning from you as well, which is brilliant. But certainly there's a lot more that needs to be done. And I think it's a combination of educating healthcare professionals and empowering women with the right evidence-based knowledge as well. So I'm really grateful, Emily, for your time today. It's been really enlightening and it's very rewarding seeing actually how much better that you are, but hopefully your story will reduce suffering for other women going forward. So before we finish, are you able to give just three take-home tips for women who have been listening either for themselves or maybe for a relative or friend who thinks they might have POI, premature ovarian, insufficiency,

and they're not receiving the right help. But there are three tips that you would say that might really help them going forwards. Yeah, so one thing definitely is find out when your mum went through the menopause and when your aunties, cousins, females went through the menopause and your family. If any of them were young,

speak to someone, try and see if you can have any investigations. If you're having any trouble getting pregnant, act quickly and early. And if you can afford it, choose a fertility specialist with P.O. Second thing, do not give up. If you think something is not right, see a different doctor, see a nurse specialist, or if you can afford it, go privately. You only need to go privately once and they will feed back to your GP. And it really is so worthwhile to getting your life back.

And the last thing, which I found so important, is taught your partner, tell him what it's like, tell your friends and family how bad it is, don't be embarrassed. Just because we're in our 20s and 30s, don't feel you can't talk about it because we need more people to talk about it. And now my friends, when they come around and say, how's your HRT or how you're feeling? I like that. I like that they ask me now because I don't feel so alone. That's brilliant. That's such a good way to end, not feeling alone. I think for any woman out there from whatever age who might be struggling and feeling alone. And it's very hard to feel strong and confident when you're menopausal often

because all that confidence and self-belief goes. So really important to not feel alone. so important. So thanks ever so much for your time today, Emily. I really appreciate it. That's fine. Thank you so much for having me. 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.