The Dr Louise Newson Podcast - 117 - Transforming the lives of men and women with Paul Anderson

Episode Date: September 21, 2021

In this unique episode, Dr Louise Newson talks to her husband, who is a consultant urologist, about the lack of menopause training among medical professionals, the importance of urologists understanding the consequences of the menopause on urinary function and the benefits of HRT and vaginal estrogen.   Paul Anderson explains some of his fascinating work as a highly specialist reconstructive surgeon, and together they discuss the rewarding aspects of each of their careers in transforming the quality of lives of men and women through surgery and menopause care respectively. If you’ve ever wondered about what kind of man is married to Dr Louise Newson, this is the episode for you! Paul’s 3 reasons why urologists should know about the menopause and HRT: Simply because it will affect 50% of the population Urologists need to know about conditions associated with Genitourinary Syndrome of Menopause so they can adequately treat the urinary tract infections that they will encounter frequently in postmenopausal women. We need to start recommending HRT to women as part of general health advice, just like you would suggest someone lose weight if it was impacting on their health. We should explain that the health risks of HRT have been overstated, and the benefits greatly outweigh the risks for the vast majority.

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. Today on my podcast, I'm really delighted and excited to introduce to you, Paul Anderson, who's actually my husband and also a great friend and mentor, and has known me since day one of medical school. So I've hoiked him in to talk about various things today. So thanks Paul for joining me today. I didn't have much choice. So Paul, as many of you might know, is a consultant

surgeon and has a very full-on career. And the last few years has really been instrumental in helping me escalate my career despite us having three children. So we do live in organised chaos, I'd like to think. But Paula, I just wanted to talk various things really today, but I'm very intrigued because when we were both at medical school, I don't know about you, but I don't remember learning anything about the menopause at all. And certainly my first 15 years as a doctor, it wasn't really in my radar at all. And I think about the thousands of women I misdiagnosed and not even thought about. And I know you had the same training as me. So I presume you had the same lack of knowledge about the menopause is me. Yeah, but I mean, as a urologist and seeing postmenopausal women with

UTIs, I was aware of the changes that happened, you know, with a vaginal floor and what have you, when you go into a low-eastern state. So I knew about that, but only specific to how they presented to a urology clinic. But you're right, yeah, it wasn't covered at all in medical school. No. So we'll talk a bit about your career in a minute, but you had a very general neurological training, and part of that is your only tract infections, UTIs, as you say, which are more common in women than men, aren't they? Yeah, totally. Well, you know, your urethra is a design fault.

It's four centimetres, it's a straight line, and it's not going to keep out UTIs. That's part of the problem. And, of course, when you go through the menopause, you lose that sort of vascular sponginess of the urethra, and you lose that coaptation, where the centre part of your water pipe closes on itself, forms a good valve.

That's certainly one of the reasons they get UTIs, also the change in flora, with a pH, with a change in the eastern state, you know, in the area of the choice. Which is all very obvious, and it's even more obvious to me as a menopause specialist that if you replace the missing hormone that's causing it, even locally by giving local vaginal estrogen,

then that will really improve symptoms and also infections. But certainly that wasn't really a treatment that I was taught about. There's lots of recurrent antibiotics that were and still are given to women. But thankfully, obviously, in your practice, you do give vaginal estrogen, but it's not generally common in, all urological practice, is it? No, unfortunately not. And in fact, I've been present at conferences where people have said things like, you know, well, you could give HRT, but it carries risks.

And, you know, I'm putting my hand up at the back because I've proofread all your stuff over the years. I think I'm pretty knowledgeable about the menopause. I'll say, no, no, you're talking rubbish. You know, the risks are vastly overstated for HRT. So unfortunately, no, not all urologists are using HR2 as freely as I would like them to. Or you would like to. And what's been the response when you did that in the lecture when someone was talking about the perceived risks of HRT and you challenged it? It's pretty easy to challenge a urologist on HRT. I don't know that much about it. As soon as I say you're talking rubbish about the risks of stroke, when you have it transderminally, they just tend to shut up.

And when I say the risk of breast can massively overstated, as it has been discussed in many of your previous podcasts. If indeed there is actually the real risk there, then they tend to not really challenge. But it's a real shame because these people are seeing women all the time and it can really make a difference. And as the urologists, you still prescribe, obviously, your surgeons, but you can prescribe medication. And certainly over the last few years, you've told me quite a few stories where you've even seen men who have problems and have actually turned to their partner in a consultation room, female partners and help them, haven't you? Yeah, totally, because I specialize in male genital surgeries. So I see lots of men who, for instance, have.

coroner disease and they've got a curved penis. And I'll look at their erect penis. I think it's not that bent. You know, what's the actual problem? And what they've got is a postmenopausal one if it's very dry. And that's why sexual intercourse is difficult. And so, of course, I direct them to your excellent evidence-based website. Very good. To speak to their, you know, GP and get onto HRT. Along with all the, you know, health benefits that I get in terms of osteoporosis and, you know, risks of dementia being decreased, more heavy. Which is amazing, isn't it? And certainly at medical school, we always taught 90% of the diagnosis is in the history,

and patients will tell you if you ask them the right questions, and your history taking has always been a lot better than mine because you like detail and you go into things and a lot more depth than me. But it's very interesting that you can twist this consultation and see men who think they've got the problem, and it's actually the woman. And I wonder so much in so many consultations in secondary care,

how much has been misdiagnosed or not even being diagnosed at all. Yeah, definitely, because even in my general eulogical practice, seeing females with blood and the urine due to water infections, if I will save them, well, I think you should be on HRT, they're often under the impression that, you know, HRT is dangerous. Or they've asked the GP in the past. They've said, no, no, you shouldn't have that because three relatives six centuries ago once had a whiff of breast cancer.

They've been scared off it. You're absolutely right. I think it's not just GPs. It's all healthcare professionals, nurses, pharmacists have been really scared of thinking about HRT and let alone prescribing it. And now what's really happened is people don't know how to prescribe it and they feel that it's too difficult. And when they try and get guidance from the British National Formulae, our Bible for medication, it still lists all their perceived risks. So then it can be quite scary. So I know there's a lot of people out there who would, often quite want to prescribe HART but don't know where to start. That I think you're totally right.

I think that the insert or what the MHRA put is just scaremongering mainly. So hopefully with some of the work certainly that I'm doing, then HS England, we're hoping to really change that and make a difference because I think it's all about, as you say, trying to be evidence-based in our practice and certainly we do in everything else that we try and do in our clinical practice so we should do with H.R.T. prescribing as well. But also just the local estrogen. You know, you got that genius idea which you spoke to Tams and Greenwell,

it's fairly high from the section of female urology about using eString, which is that eastern-impregnated ring for elderly female residents. In nursing homes, we often come in with sort of UTIs. If we could improve the local conditions of their, you know, vagina and entroitus and decrease their UTIs, that would be great. But I think that we are starting to listen to you within the urological community. I believe that you may be part of our next national conference even. I hope so. I hope so. I think the more people that I can convert the better. You know, it does make a big difference. But it's hard work. It's really hard work being listened to, as you know. And I would like to sort of publicly say that you've actually been a great mentor because it all looks like I'm doing incredibly well. You know, I've got a number one bestseller. I've got a great website. I've got an amazing app with a huge number of downloads from people all across the world with incredible reviews. But actually it's been really hard work, hasn't it? And without you, I would.

have just fallen over so many times because it's very hard when you expose yourself and I think especially as a medic and especially as a woman maybe, I don't know what you think, but I think it would be easier if you'd been doing this work and not me. What do you think?

I could probably prescribe HR efficiently. I don't think you could operate vaguely, to be honest. I think, you know, over the years you've got much more thick-skinned. You know, you put people on the podium and then you just want to knock them off them and you know that as an absolute fact

that, you know, people focus on the fact that you have a private clinic, but they don't focus on the fact all the time you give to NHS England and the educational programs, you've just written off and done for nothing, and hundreds of thousands have gone into your educational research program. Yeah, so I get quite angry on your behalf when people keep knocking you, as you know. I suppose I'm quite naive because I'm very transparent.

I think that everyone's really going to help, because that's why we went into medicine, wasn't it, to help people, and it still is, and it's a great privilege being a doctor, but I know when I started my clinic, and as many of you listening know, it was only set up privately because there wasn't capacity, and there still isn't capacity for more NHS menopause work, and I couldn't find a job locally,

either in general practice or in secondary care, to work in a menopause clinic. But quite soon after I started, I got quite a few letters of complaint from other colleagues, also from women, quite nasty messages on social media, And I quite often would go to bed crying and say, I can't do this, Paul. I really can't. This is awful.

I didn't expect it. And I remember you saying, just remember the last patient you saw, you've just told me about a woman who you've helped. But it's really difficult. It'd be very easy to give in if you hadn't. But you also used to keep that golden notebook in which you wrote down the inspiring stories about really help. The suicidal women were no longer suicidal. The people that wouldn't leave their house.

That woman had to buy a camper van. to come down to see you, the people with Tesco's carrier bags for the ridiculous supplements that don't actually do anything. And all those people you've improved. So, yeah, I would say to you were just looking in your golden book and forget those people who are after you. And a lot of those other doctors who are going on about you. At the start, it was just jealousy over, you know,

it all comes down to money. I thought you put their private income and they're still beaving away in private and doing absolutely nothing for research and education. But it's perceived. isn't it? I think I don't have a jealous bone in my body really because I think everyone's got another story and I think it's very easy to look at me even now with a clinic, it's been open three years and we're now the largest menopause clinic in the world. But I'm not actually

proud of that, which sounds really silly, but I'm not because it shouldn't be. It shouldn't be that it's so hard for women to reclaim their own hormones. It's just unheard of in any other area of medicine where there's a waiting list as long as mine with as that many doctors for something that's so cheap and easy. And certainly, you know, you do some private work, but people come and seek you out. But the waiting time is nothing like it is for my clinic. And it's wrong, isn't it, that women should be suffering in this way. Yeah, I tell you, the other thing that people realise that your goal is that GPs are educated to the extent that they give at HRT appropriately and freely. And for the patient's wants it. And only the people who specifically want to come and see you

privately should pay money to come and see you, but ideally every woman should get it from their local GP with no issues and that's your end goal. Absolutely. I certainly didn't set up to have as many healthcare professionals working with me as they do. But it's also incredibly rewarding and to have time with people to know that you're giving them the best treatment and the best advice is really rewarding. And certainly, you know, I think I've already said quite a few times that the work I do really is transformational and it really can improve not just the women's lives but those around them. But your work is very different to mine. You've already said you do male reconstructive surgery. So me that can't

even cut a piece of paper neatly in half would never be a surgeon. And I have very little knowledge actually about urology and men's health. So what you do is completely different, but it is also transformational, isn't it? Just explain a bit more about what you do, Paul. So I'm what they call a genital urethra-reconstructive surgeon. So I specialize in surgery to rebuild the male genitalia, which will be the penis, the waterpipe, essentially, mainly the waterpipe these days, to be honest. And so men can be born with a condition called hypospadias, where the water pipe opens up in the wrong place, and they might have a penis that curves down. And I can do operations, rebuilding water pipes, using my foreskin and getting the penis straight. I've seen

Men who are in car crashes and their water pipe gets ripped off their prostate. And then when they're finally well enough to undergo fairly complex surgery, I'll plumb them together again. I had a period in which I was fairly well known when I was doing the reconstruction with a colleague, the Queen Elizabeth with all the soldiers who were blown up in Afghanistan, and that was nicely covered in. GQ, hidden trauma. If you Google that, you'd be able to read about all the work we did with the soldiers.

So anything that goes on down there that requires a surgical solution, as opposed to creams or drugs or injections. That's the kind of thing I can offer to my patients. I did about seven years of embarrassing bodies with you. And that was really good because patients saw what was available and they could say, well, I've had this condition for years. I didn't know anyone could help me. You know, I saw this guy on a telly last night.

I wanted to be referred to him or someone like him. And I still said people like that, you know, with a repeat on telly. It's very interesting because obviously, as everyone knows, the men and the polls affects all women, yet very few of us get taught about it at medical school. What you deal with does not affect all my hen, thankfully. But again, it's something I was never taught about at all. And you're quite right as a GP.

If I wasn't married to you, I wouldn't have known about the surgery. And sometimes you make a new water pipe out of the lining of the cheek, don't you? That tissue there. And it's incredible surgery that you do, isn't it? I do feel sorry for our children when they know that you're a penis doctor. I'm a menopause specialist. you know, but the photos that on your computer are mind-blowing, actually, these before and after pictures.

But just explain how you got into even doing that because it's not, again, something that you would have been taught about as an undergraduate. Oh, gosh. Well, especially the first thing I say, it doesn't really matter too much of GP's, don't know much about what I do, because virtually everyone who's referred to me is from a consultant urologist. There's someone with a urological problem with poor flow

would get referred off to the urologic department to find out they needed someone like me because their problem was not their prostate. It's a narrowing of the water pipe. I got into it because I always wanted to do surgery. I used to watch MASH when I was younger. I'm 52, so that ages me. But I always wanted to be a sort of army surgeon. And then going through my training, I thought other way would do gut surgery.

And then whilst I was going through my training, I worked for a guy who inspired me called Steve Payne at Manchester One Infirmary, who was still in touch with. and he was a urologist and he sort of persuaded me to look into urology. And then I worked for another inspirational surgeon called Iva Bracker in Russell's All, who was one of the sort of godfathers of Genesville Reconstruction. And when I worked for him, I thought, gosh, this is exactly what I'd like to do. It's really meticulous. It's very fiddly.

There's not many people that do it. You can really transform people's lives. It's a quality of life operation. There's no, I don't do any cancer surgery. But you can really improve the quality, you know, people's lives. And patients do say to me, just like I say to you, you know, it's transformational. When I see them in clinic, no, three months or five years later. And so I ended up just doing open surgery.

I don't do robotic. I don't do laparoscopic. I just use a knife and fork, as we say. So just, you know, cutting with a scound and scissors. But I tend to use small stitches and it's all quite delicate and often done a depth down a hole. I mean, you are artistic, aren't you? Your mother has the most amazing talent. and, well, just explain what she did.

Not just about autistic, because that's very nice to be to say that. Well, you're both, but... Well, it's good. You have to be single-minded. We ought to do something well over and over and over again. The two do go hand in hand. So explain about your mother, because that's where you've got your artistic skill from, I think. Yeah, so my mum was, my mum is.

You know, she used to work for swallow rainwear and other fashion companies, and she was a fashion designer, and she used to make her. wear them closed and extremely high standard ballgowns and all that sort of stuff. And so, yeah, she's very artistic, obviously all the sewing. And when I was brought up, I was, you know, making curtains at her knee and helping with the sewing machine and all that sort of stuff. So, yes, it was a good combination of art and sewing that she gave me a background in prior to me becoming a surgeon.

And of course, your father was medical, wasn't he? Yes, that was a GP. He started off in surgical training and then he moved across into. to being a GP in inner city Birmingham. And then he moved out to Southern Coldfield, Four Oaks specifically, and he was a single-handed GP for decades there. But he did surgery as well, didn't he? He did he start off doing surgery.

Well, back then, you know, GP's did everything. So the need of this would come to his practice, and he would do, you got to realize that the area this was, they would do terminations, they would do tonsillectomis, occasionally even did appendicitis. And when we cleared out the surgery, when he retired from being a GP, we found all sorts of specimens, which we had to get in touch with the Home Office Pathology Department to be allowed to get rid of because of lots of bits of bodies he'd removed

over the years. But that was normal back then. He was a GP in the post-war years. So very, very different. Very different. So he was single-handed, often on call a lot. He was part of the obstetric flying squad in Birmingham. So he tells stories about, but in the back of an ambulance trying to squeeze a woman's cervix shut without having a postpartum hemorrhage.

So if you've given birth and you're bleeding a hell of a lot, there was a way of clamping at the top of the vagina with your hand. And you tell me stories about, you know, all this exciting stuff, surgery. And that was very inspiration as well. My father was an inspiration on that. Very much so. So he would be very proud of what you're doing today, that's for sure. But COVID's changed your work. It's changed everyone's work to unrecognisable.

and obviously the demands on you as an NHS surgeon have really increased. But you also did a lot of charity work, which you really want to do again. So just explain a bit about the charity work, because I think it's really amazing what you've been doing. That's been the most rewarding, actually. So the past five years, well, not six, but one was sort of COVID, I would go out to Africa twice a year, and I was the lead in Zambia, Lusaka, and I was part of the team in Owasa, southern Ethiopia. Yeah. And I've been to other low resource income countries as well. And we would train the surgeons and doing my sort of surgery. Because, you know, if you've got some young African guy and he's got a narrowing of his water pipe and he can't pee, then they get stones in their bladder. They can't work. They have a catheter. So that's a tube that comes straight out of their belly below the belly button. And if they can't work, they can't support the family. And they may have a family of 15 people to support because they are young and fit. So they have financial. catastrophe. So going out there and operating on them, maybe I only operate on, you know,

10 people in five working days because it's a very difficult surgeries, but I've been training the surgeons over there and they've been operating whilst I, in between, you know, the times I, you know, come back. And so they're treating many of these men now and they're getting good outcomes. And so, yeah, we are preventing financial catastrophe for these young men who otherwise had a catheter through their belly couldn't work, repeat of water infections, bladder stones, So it's great. And also it's a busman's holiday, but it's what I love doing. If you go out there, they treat you very nicely. It makes you adapt a lot working in operating theatres with no air conditioning and sometimes the power goes off.

It's difficult, but you come back and you've grown as a surgeon and you're also grown as a person. You've started to really respect what the NHS delivers. Yeah, I love it. But unfortunately, the vaccination programs in countries which are poor is terrible. So God knows when they're going to stop being red zone and I can get back out there. and operate with my friends and help the patients were waiting for it. Yeah, I remember the very first time you went, you came back absolutely exhausted. I think you slept for nearly a week because emotionally, physically and psychologically,

was really draining for you. But I remember not so long ago you got a letter from someone who'd been in an orphanage, hadn't you? That's right, yeah. I did. Yeah, well remembered. So that was an example. Thanks.

That's right. The owners of the orphanage were friends with the surgeon. I work with. And when they realized it was me, they got a message from him to me saying how his life had improved. He was able to work again and how happy he was. And yeah, it's very satisfying. Very satisfying. I can't wait to get back out of there. I just don't know when I'll be there. But I think people don't realize. I think over here there's lots of people, aren't there, that live with catheters, but they can still work. They can still hold down a job and family, but it's not the same in other countries as it?

Well, even if they have lots of money, a hot country in catheter's not great. You get dehydrated, you get sediment. But these are people who can't change their cfters regularly. So you see people who've got a big fat catherine going through their belly. It's not been changed in two years. And you're doing the operation to fix them. And then you find there's a great big lump of stones stuck onto their catherine. You've got to do another operation to sort that out as well.

So these poor people are just, I don't know. they're getting by, but there's nothing like, people in this country, there'll probably tens of thousands of people's country walking with catteras, you wouldn't know. They're well-being, they have fresh sterile supplies, they keep themselves clean, they've got support from district nurses,

and they're fantastic, the clinical nurse specialists as well, in hospital, and they just get on with their lives. But if you've got, you know, no money in a hot country, and the healthcare system is not ideal, you know, they have all sorts of trouble. But even catheters in Western countries can be really unpleasant actually and I think like you say people can manage

but I know even after an operation I had I had a catheter for a short period of time and it was removed and I couldn't wait so I went into what's called retention and in fact I probably shouldn't be showing this but you catheterise me because I was in so much pain and I knew it would take me too long to go to hospital and the relief I had afterwards was incredible

and it just made me realise for so many people especially men go into attention more, don't they, than women, how disabling it can be. And it seems quite a trivial thing having a catheter when there are people with, you know, other diseases or other conditions. But with COVID and the waiting list and the way the NHS is really creaking at the seams, you're seeing a lot of people that are waiting so much longer, aren't they? Well, you always find that the cancer surgeons will grab the glory

because they've saved someone's life. But one of the things that attracted me to urology when I was doing the general urology training was the old men with prostate problems who went into retention. They had a catheter. He did an operation on them. It took me about 45 minutes, where the older techniques have been in hospital one night, maybe two. But then you get a catheter out and they're peeing and they would almost be kissing your feet. You know, they're so amazing.

You could just see how much you improve the quality of their life, an operation that isn't that difficult. And it was lovely. And it was one of those things that, like I say, attracted them into that specialty. I still do that now, but it's not the prostate that's the issue. It might be, for instance, I saw a skateboarder today, who fell astride a bar and completely wrecked his part of his body called the perineum and smashed up his waterpipe, and he needs surgery. But he's having very poor quality of life with a catheter through his belly at the age of

at Fienek-on, and it worked properly, and he's getting pain. And so I know that once I sort him out, he will be incredibly grateful, just get on and go back to his work and being a productive member of society. him being very happy again. But how long is he going to have to wait before you can do his operation? Well, you know, it's awful to say, isn't it? But I mean, he won't wait that long because I do expedite surgery for younger men with catheterzin who can't work.

A lot of men with catharsin can still work. So I'd like to say it'll be around three to four months. My secretary, I hope she's not listening. Because the normal waiting times at the moment is about 12 to 15 months, which is all. Absolutely awful. I mean, you're very calm and I'm very vocal. I get very frustrated when people have to. weight, but it's out of your control, isn't it? You can't work any harder. There's very few

specialist surgeons like you, and I know you do a lot of teaching and training, but it's not quite as easy as prescribing HRT, actually, learning the skills that you have. And it is a real art form. It's not something that I could teach most people, I think, to prescribe HRT and give really good quality menopause, education and care, but you certainly can't train everyone to become a surgeon, certainly not a reconstructive surgeon. It's also client-consumer. Very common, increasingly common problem in Britain and the world is buried penis through to obesity. Those surgeries take three, four hours. You can only do two in a day. You only have to try past a bus stop and there'll be 10 people that probably need that surgery standing there. The demand is just immense. It's really interesting talking about quality of life because it's not just the length of life, it's the quality of life.

and I think that's even more important and a lot of us during lockdown have really reflected and thought about what our lives mean but also it's about trying to be as healthy as possible which obviously we all know is really important but being healthy and having a good quality of life are key but so many people can't do it because they're not receiving the right care and treatment

or that treatment is being delayed for whatever reason so it's through no fault of theirs but it's very hard to measure quality of life, isn't it? Yeah, I mean, I don't get anywhere through the same volume of patients as yours. And for me, there's that definite point to which, you know, before the operation and after the operation, and you can certainly see the increase in their quality of life and what they do. So it's a bit more black and white for me and with smaller numbers to compare them to. But it's still there.

So it's certainly what you're doing is amazing. And so I hope, I know we've gone off topic and we haven't spent the whole time talking about the menopause, but I just thought it'd be really interesting for some. of you to listen to because I know a lot of the light gets shut on me, but, you know, they always say behind every good man there's a wife at home helping. So I think the other way around is I would not be able to do the work that I do or work as hard as I do or have children that are looked after as well without your support. And I think it's quite amazing that you can help support me so much when you've got a full-time job and really huge demands on your

career. So publicly thank you. But before we finish, I don't know that you listen to my podcast, but I always have three take-home tips, so you're not going to be excused. So I would like to ask you, just to go back to how we started the podcast, actually, talking about lack of training. What three reasons do you think urologists should have menopause training? How do you think three things that would help if urologists had menopause training as standard? Okay, first of all, I was going to quickly say that if people think consultant surgeons work long hours, which they do, their hours are nothing compared to. to Louise Newsome running a menoport, like a 120 employees,

and constantly dealing with work. So I just put that out there. But three reasons why you all just know about no pores. One is going to affect 50% of the population if they live long enough to want to go with menopause. Two, when they get menopausal atrophy, with a lack of estrogen and the change in the vagina flora, Genito-Uring syndrome of the menopause that was in.

I was looking for that. They need to know about that so that we can add a, could treat UTIs. And actually, just in general, just to commend to the women that we see that the health risks have been overstated with HRT and the health benefits greatly outweigh the risk for the vast majority of women. So it should be part of, just in the way that we've been told to recommend to patients, they should lose weight for their general health.

Perhaps when we see postmenopause or women with or without UTIs, we should be saying, and actually have you thought about going on to HRT for the future health benefits? Because after all, just as you're saying, if you keep the population healthy, they'll be staying out of the hospital. They won't be coming in with the funny cardiac arrhydemas, their joint pains, all that sort of stuff. You know, I know from listening to you over the years how much people are improved. And that study that you did in which they went to go and see 10 different specialties

before they ended up being diagnosed as being men, the pulse are going into HRT, and all their cardiac arrhythmias and their fibromyalgia and their joint pains all disappeared. and they stopped taking up time in hospital. So yeah, those are my three reasons. Very good. So hopefully you can help implement some training for your colleagues, which will be very good for all the people that they see and help. So thank you very much for your time today, Paul.

And I hope you can go back to doing some of the dishwasher stacking and washing because there's plenty that needs doing. So thanks very much. I'll go and do it now. 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.