The Dr Louise Newson Podcast - 118 - Testosterone: not just icing on the cake with Rachel Dawber

Episode Date: September 28, 2021

Rachel was a very active 45-year-old, who loved the outdoors and her job as a specialist teacher when her fit and healthy body began suffering with one problem after another. Joint problems and crushing fatigue curtailed her hobbies of hiking, climbing and cycling. The following months saw her list of unexplained symptoms grow and grow from being in constant pain, migraines, and gum problems, to palpitations, dry mouth and eyes, anxiety and electric shock sensations. Within 2 years, she describes herself as ‘just a shell who couldn’t leave the house’, she had given up her job, and living with this version of Rachel had a huge impact on her husband and son. After multiple trips to the GP and blood tests, she was given a diagnosis of chronic fatigue syndrome. In this episode, Rachel tells her story to Dr Louise Newson and takes listeners through her journey, including self-diagnosis and battles to get the help she knew she needed. After beginning on estrogen replacement and seeing some mild improvements but still experiencing severe fatigue, she learnt about testosterone and its importance for energy and stamina. Now, 6 months after starting on testosterone, Rachel describes the improvement as ‘life-changing’. She feels a fully functioning human again, is able to work part time, and even manage a 5 mile walk. Dr Newson explains what testosterone does, why we need it, and why it can be so hard to get hold of the hormone at your local GP practice. Louise reassures listeners that she is working hard with NHS England on this very matter and is hopeful that change will come. Both Louise and Rachel agree that testosterone should not be described as the ‘icing’ on the HRT cake but a crucial ingredient of the cake itself. Rachel’s top 3 tips: Remember GPs aren’t trained in peri/menopause, so go armed with useful information and the NICE guidelines to help you have a factual conversation. Don’t give up trying to get the help you need. Be kind to yourself and listen to your body. Note: Rachel had to see a menopause specialist to get her initial prescriptions for testosterone. After lots of persevering on her part, it has now been agreed to be prescribed via her usual NHS GP.

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, Rachel, who I've only actually just met, she very kindly emailed me out the blue to tell me about her transformation and experience with taking HRT, which included testosterone actually. So welcome Rachel to the podcast today. Hello, hi. Nice to meet you. So I get lots of emails from lots of women, lots of messages through social media. And they're one of the reasons that makes me work so hard actually, because I realise

the more I expose myself, the more people access me or my team, the more I realize how many people are suffering, not just in the UK, but worldwide, because of their inability to just reclaim their own hormones actually. None of this is rocket science. None of this is complicated medicine. None of this is dangerous prescribing. But it has become this real cloak and dagger specialty that people can talk about. People can't access treatment. And, you know, women are really suffering. And I do think there's a lot of gender inequality problems as well here. So I'd be really keen and delighted, Rachel, if you could just set the scene and start your story and just tell us a bit about what happened and then why you got in touch with me?

Okay, yeah, of course. I think my journey really goes back about five years. I was very much an all-action girl. I'm one of these women. I run in the mountains. I rock climb, I'm mountain bike. I've done quite a few endurance races in my time, running races, caving, mine exploration, like anything.

I'll give it a go. Girl scrambling. I'm just like an all-action girl. And my job, I'm a specialist teacher. I work with children with social, emotional mental health problems, but I take their learning outdoors and try and improve academic progress and social, emotional mental health and outdoor environment. And this is quite a physical job.

You're outdoors all day. You're lugging stuff in and out of woodlands. And about five years ago, I started to get a few soft tissue injuries. Both my hips, I gotisitis in both my hips. I got plantifaceitis. I got a shoulder injury that required a steroid injection. I'm coming from work and I just spend about two hours

just literally sitting and not being able to do anything at all. And how old were you then, Rachel, when that happened? I was about 45, 46. Yeah, I'm 50 now. Nearly 51, it's a bit scary. I don't know how that's happened. I got up for bike rides and I'd start bunking when I was out bike riding

and that's not what people in Britain normally think of as bunking. It's when your body just stops. It's almost like when you're extremely hungry and you can't move. and I was just getting all these weird things happening to me over a period of time. And then in about 2017, my period started going absolutely haywire, really heavy, clotting twice monthly. That went on for quite some time. And then I managed to get a coil fitted about six months after that.

And that transformed my periods. It took about six months, I'd say, for that to settle down. So that was a marina coil, was it? Yeah, marina coil. A lot of synthetic progestogen to thin the lining of the womb and then women often don't have periods. So it's great if you're having heavy periods. So that's good. Yeah. And it meant I could go out sometime. You know, I was struggling some days to leave the house because things were so bad. Then in about 2018, my mood started to decline. I became quite tearful. I just crying,

just randomly crying at nothing at all. And that's not me at all. I was always being really strong and independent and capable. and I think nothing of driving off by myself to the Lake Districts. I was an hour's drive away and go running and come home. You know, I'm just map reading by myself. But suddenly I was finding my world was getting a lot smaller. I was feeling a little bit anxious about doing things. And then from 2018, probably after I have my coil fitted, my body just rapidly declined.

And by January 2019, my body had completely stopped. I was like a shell. So it's quite emotional. I'm sure. I couldn't leave the house. I could hardly walk. Even talking was an effort. I had to leave my job other than I work for a charity. So the work I do is through a charity. So my boss has been absolutely amazing. I mean, I've dropped most of my hours, but I do 14 hours a week. And I'm still only doing 14 hours of week, but slowly ramping up. Doing admin and management stuff and leading one of the projects. So I can do that from home. and I can spread my hours over five days. So I was at that point, I've actually written down on my symptoms.

I've never done it before that I had at this time. I had what I call beyond fatigue. Like it wasn't just a bit tired. I can't go for a run anymore. I was struggling to walk down the street. I remember trying to play cards with my husband and son, and I couldn't even lifting my body forwards to put the cards on the table. My body was shuddering and shaking.

It just didn't want to do it. I was having to force that action. I had constant pain and tiredness in my head and my eyes. Vertigo, I had vertigo a few times, not continuously, but I get bouts a bit. I always felt a bit lopsided like I was, yeah, like I was slightly at an angle. And if I moved quickly, I suppose that might have been part of vertigo, but that was all the time. Very dry mouth, eyes swelling and going between running and really dry all the time. My hands stopped functioning.

I couldn't open lids anymore on jars. constant internal tremors, headaches, electric shock sensations in my pelvic area, gum problems, I was in and out of the dentist, migraines, never had migraines in my life before. Blood sugar was absolutely haywire. I was going from shaking because I needed to eat, I'd eaten and then I'd just have to sleep after eating.

And I did have a couple of high blood sugar blood tests with the doctor, but I'm not diabetic. Recurrent candida infections. Sorry, the list is massive. Night sweats. My digestion wasn't functioning properly. My resting part rate dropped down to 40 beats a minute. I have vaginal atrophy, urinary urgency, and I felt pretty ill as well. Like every cell in my body felt, it sounds really dramatic and a bit like a hypochondri, but it felt like every cell in my body was pretty rotten. It's really hard to explain it. And all my muscle just disappeared, like, for being really strong and physical. I've had, like, old lady legs. You know where little old ladies in nursing homes and

their legs just, there's just nothing there. That's where I was at. So very, very scary, actually, all these symptoms. And did you see any healthcare professionals? Presumably you did. I had been in and out of the doctor's surgery. It's just being ridiculous. And the number of blood tests I've had done. I've been in and out, in and out, and not one GP, not one doctor mentioned perimenopause to me, not one. And what do they think was happening to you? Did you have a diagnosis or a working diagnosis at all? I went through infectious diseases, endocrinology, immunology. I've had an brain MRI. I've had an ECG because I was getting palpitations. I've got to mention that. Loads and loads of blood tests and everything's come back, clear.

things come back normal. So in February 2020, I actually wrote to the GP surgery because I was on my knees. My husband, I feel so sorry for what he and my son have been through. This is often not talked about. It's the impact on partner. So important. And my heart breaks for what he has gone through, my husband. And actually, it has had a profound effect on him. He's happy for me to discuss it, but he's just come out of a period of depression as a direct result of what he's seen me go through. like his life partner had been together 30 years going from this all-action independent woman down to an absolute shell. I couldn't socialise, I couldn't drive my car, I couldn't do anything. Yeah.

So I wrote to my surgery. Can I just read what I wrote? Is that okay? Absolutely. Yeah, of course you can. I won't read the whole thing just a couple of bits. I said, I'm struggling with day-to-day life to the point that I've had to change my job, cut back my hours and I'm unable to partake in many aspects of life. I feel very sick at the moment and I'm now considering having to stop work altogether.

You will see from my records that I've made several visits to different GPs and have many blood tests. I'm still no closer to an answer. There's been no diagnosis. What's been particularly difficult is that there is no continuity of care at all. I feel this is essential for me and my health. This would enable a medical professional to look at my case holistically, hopefully get to the root cause and define a plan for recovery. Please can you let me know what can be done to make this happen? I know I am not well and I'm concerned that's not.

something has been missed. This is especially important for me as it's impacting on my ability to work, be a mum and function in general in society. After being so fit and healthy for the preceding 47 years, I'm not prepared to accept the lack of diagnosis. I wrote that to my surgery. I don't know what it's like in most practice, but you just see different GP after different GP and most of them are, they're not practice GPs. They're the temporary ones that are bought in, most of them. So you're just seen GP after GP and I got a, I actually got a letter back and it's from a GP who is really, really highly regarded, very highly regarded. He's the one everybody wants to see at the surgery because he's amazing. First of all, he said he couldn't provide continuity of care for me. And then

secondly he said, my suggestion would be to consider referring you to a chronic fatigue service, as this would seem based on all your results and consultations I've reviewed today to be the most like she'd diagnosis. So I was diagnosed with chronic fatigue syndrome. So I think many of you listening probably know where this conversation is going otherwise Rachel wouldn't be here talking on a manifest website. And I feel like crying and screaming at the same time actually Rachel because I've heard stories to many of your yours so often and I can see what's happened. Many of you listening could have seen what's happened but it's no individual's fault but there's lots of ways that really can improve so this doesn't happen again. So clearly you're not like this now,

which is fantastic, but just tell me sort of what made the penny drop for you to be able to realise what was going on. It was probably in, it's about spring 2020, I was reading the news on my phone and there was an article was on there by a woman called Emily Barkley, who was a triathlete and she hadn't been able to do any sport at all and she was having to sleep in the daytime. That's the other thing I was having to do a lot of. And she couldn't do any competition anymore. And hers was perimenopause.

And I remember sitting and saying to my husband, I think that's me. I think I must be in perimenopause. So I thought, great, I can do something about it. And I went, I got an appointment with my GP, yet another appointment with my GP. And the GP sat there and I cannot believe now what he did. Again, he was another locum GP. I asked if I could trial HRT. He literally pushed his chair

away from the table, through his hands in the air, and told me that it was too dangerous for women to go on HRT, and he would not prescribe it to me. And I mean, I'm quite an assertive person normally, but I was absolutely gobsmocked. I didn't know what to say in that appointment. I went away. And he's, oh, sorry, he sent me to a self-help website for night sweats. Oh, dear. Yeah. So there might happen. He reconfirmed my chronic fatigue syndrome as well. But it's weird once they hear fatigue and you've got this label of chronic fatigue syndrome.

That's all they focus on. They don't listen to anything else at all. Well, my experience, sorry, I'm sure not all GPs are the same. So I then went to us for a second opinion. And this is in the midst of feeling so ill. I was having to drag myself out of the house to get there. and even talking to them, I was having to force myself to have these conversations with them. And they actually put me in from an appointment with the practice nurse who was amazing.

She looked at me, she listened to me, she went on her computer and said, okay, yeah, I just used this flowchart here. Yeah, you need this, you need this. And I walked away with a prescription for HRT patches, a low dose, a low dose. and they made no difference at all. So I thought, oh no, what's going on? Maybe it isn't perimenopause. So I tried to get an increase in my eosogen, and that was refused.

So then I actually paid to talk to a menopause educator. She's not a GP. She's an educator, and she writes a lovely report that then goes to a GP. And she did that for me. so I've had to pay privately for that. And I feel very, very lucky that I'm in a position where I can do that. And did that help? Yes.

I had an increase to three pumps. By that time, I'd gone on to Easter gel because the patches are in short supply. So then I was increased to three pumps. And then that had a small impact. And then I was moved on to four pumps. And within about two or three days of being on four pumps of gel, I was starting to sing a bit again. I always sing in my head and I sing, you know, I'm on these people.

If I hear a word, I'll start singing a songling to that word. It's just what I do. And I remember saying to my sisters, I feel like there's a little bit of life and a bit of warmth coming back into my body finally. But that's as far as it went, this little bit of warmth, a little bit of energy. Yeah. And I was so weak at this point because I'd done so little. I remember trying to do a very simple restorative yoga class on Zoom with my old yoga teacher. and I couldn't even do the pulling your arm across your body.

I was just, yeah, I was so, so weak at that stage. And I was having to rest four or five times a day just to get through the day still. So I was still, a lot of my other symptoms went though. So that was the good thing. It was the fatigue that remained and this general sense of sickness that was all through my body, which is really hard to explain. Oh, and at that time I got shingles as well. I think my body was so run down, I ended up with shingles.

So I'm talking loads on time. That's very interesting. So you had your estrogen, which is one of the female hormones. And as for a lot of women, symptoms improve. So they're better than not on anything. But there was still something missing in your body because you were still experiencing symptoms. So then what did you think about or how did you get more help

to try and find another missing hormone? Well, it was around that time. I actually started listening to your podcasts. I discovered them. and I really enjoyed listening to, and I've learned so much from you and from my own research, really, about perimenopause and menopause. And I heard one of yours, and it was about, you mentioned testosterone. And I thought, oh, maybe this is what I need to go and find out about with my GP. So I was lucky that I was able to get blood tests in my GP.

I know a lot of women, the GPs refused testosterone blood tests, but I did get one. and it came back as virtually non-existent on testosterone. And I then had two or three months of battling with my GP surgery to try and get prescription for testosterone. And then did you manage to get it eventually? No, they wrote eventually to a gynecologist who wrote back and said to my GP that she was only prescribed testosterone for libido,

problems with libido and women. That was all. It's the only thing it would have an impact on. But it's interesting actually because I know a man who's on testosterone and his testosterone was low, but he was given a big list of things that testosterone is useful for. But for women, I was just told it's only libido. So it was refused. And then where did you get it from eventually?

Eventually, I paid privately. I went to see a wonderful menopause specialist and I started testosterone. I'm on testagel, which is in a man's portions, is it? I don't know what the word is. Yeah, it's a sashay. So you're just using a smaller dose every day, are you? Yeah. She looked at everything.

She said, you need testosterone. There's no doubt about it. Your bloods, I had my bloods done again. It was still non-existence. And I've got a sashet and I put a tent of a sachet on every day onto my abdomen. And it's improved some of your symptoms? To say it's improved things would be an understatement. I was still only able to walk, very short walks, very slow pace.

kind of made it a mile and a half. I couldn't work for more than, say, 40 minutes at a time without needing a rest. My boss has been amazing. We'd have Zoom meetings with the team and he'd put breaks in every 45 minutes so I could go and lie down and have 15 minutes out. So this is what I was like even with the estrogen. And then within about three weeks of being on testosterone, I felt this huge change inside me. Yeah. And I think that was at the point where, I actually wrote to you. I wrote to you and I was like, thank you so much for talking about testosterone

in women. You've just, it's been absolutely life changing. From that point, from that shift, I'll be honest about six months now, so it's been a very gradual increase over those six months,

but I'm now, I mean, I'm laughing, I'm smiling, I'm singing again, I've become opinionated and bullshit again. Physically, I'm starting to, I did a five-mile walk on Saturday.

Brilliant. With a few hills in, I've started to increase as a little bit of running into my walks. It's like the push had come back into my legs again, that it completely gone and I'm functioning. I'm a fully functioning human being now. I can be a mum again. I can be a wife again.

I can be a friend. I really let my friends down as well throughout this time. You know, I can drive to go and see my mum again. It's been very, very transformational, hasn't it? It's absolutely huge, yeah. And I know it's often talked about as the icing on the cake, but for me it's been a key ingredient. Yeah, and I think this is so interesting.

And I'm really very thankful for you talking so openly because obviously I know it I can hear and see it's bringing out lots of emotions, understandably so. And it's very interesting, actually. So if I'd met you six, seven years ago, I would have said to you, quite honestly, that I know nothing about testosterone in women. I know that maybe they have it, but no one's told me about it.

I don't know anything about the benefits at all. And then when I sat in the first menopause clinic, just after the NICE guidance came out, the National Institute of Health and Care Actions guidelines, and they mentioned testosterone can be considered for women with reduced sexual desire. I sat in a couple of clinics and saw some very expert gynecologists prescribing testosterone. I said, oh, I've never prescribed that. Why do you prescribe it?

When do you know how to prescribe it? You know, all the questions. and they said, you'll notice once you start prescribing it, people will really thank you. And then I couldn't just go off and prescribe because I'd seen someone else do it. Of course you don't do that as a doctor. You have to go and read the evidence and work it out for yourself. And I was really shocked by how little evidence and studies have been done. And most of the studies have been done looking at libido.

And the cynical side of me will say, well, that's because they're being run by men. And the bina is obviously very important. And obviously libido, I'm not undermining the libido. I'm not undermining libido. It's really crucial for couples, whether they're in a heterosexual or homosexual relationship or whatever relationship they're in. But libido is not just about a hormone.

Anyone who's experienced your symptoms is going to have low libido because if you can't get out of bed to make a cup of tea, you're not going to be thinking about a sexual relationship. But we also know that testosterone affects our brains as women. It also affects our muscles. It affects our hearts. It affects our bones.

It affects our urinary system. It affects every single area of our body, but it's been neglected for so many years. The other thing is, is that we produce three times more testosterone than estrogen. So people talk about estrogen being important, but actually, should we be changing the narrative and saying testosterone is more important? And estrogen is the icing on the cake. And I can't answer that question, of course, but they're two very different hormones. And they work together, and they're produced by the ovaries. So when ovaries stop working or reduce in function, then estrogen declines and testosterone declines.

Some women miss estrogen more, some women miss testosterone more and many women miss both, actually. And so they should be considered in separate hormones. In the same way we consider thyroxin and insulin as separate hormones, we don't try and combine them in any way. And the more I've prescribed testosterone, the more I've seen over the last five or six years, how women's stamina has improved, their mental states improve, their mental clarity. They're just joy for life improves. People tell me that their memory has come back. Their brain fogs better. Their ability to exercise is so much easier. They can build muscle like they haven't before. They often lose weight, their body shape changes because they're not piling

on the pounds of fat. They're actually laying down more muscle, but they have less muscle and joint pains. Their sleep improves. So all these things just make them feel better. There is some evidence that it reduces risk of osteoporosis, heart disease, and dementia actually as well. So it's a very good hormone for our future health. So all these things, people will be listening on saying, well, why doesn't everyone get it? Well, it's not licensed for women on the NHS, which in my mind is absolutely scandalous and outrageous that women are not allowed their own hormone back. There used to be a patch that was very expensive actually that was allowed to be prescribed through the NHS and then the company folded

and the MHRA decided to withdraw the licence for no real solid reason at all. So men clearly, as you've quite rightly said, are allowed their own hormone back. They're allowed testosterone. It's the same testosterone, but clearly we produce a lot lower amounts, but it still stimulates ourselves. So on the NHS it is able to prescribe it, but it's off licence. So it's still the regulated testosterone and it will have male. information all over it, but it is allowed to be prescribed. There is also a female testosterone cream

that is only now available privately called Androfem, which is made in Australia. This is again a regulated product. So it's allowed to be prescribed off licence, if you like, privately. It costs about 80p a day. But the work I'm doing with NHS England, they're really trying to escalate the licensing of this female testosterone cream. And I feel very strongly that they need to be able to do it because there's no reason to say that they shouldn't. And so certainly that is going to be a real priority and they're working behind the scenes on that at the moment. Because I sometimes sort of think myself, how would the world look if women were taking the right hormones? How would it be?

Would there be such a thing as chronic fatigue syndrome? Would there be such a condition as fibromyalgia? And now also some of you might know I'm trying to do some research with long COVID. because if you'd experience COVID infection at the beginning of your symptoms, you would now be diagnosed as long COVID. And actually all the symptoms of long COVID are exactly the same as symptoms of the perimenopause and menopause. I'm not saying long COVID is a hormone deficiency,

but I'm saying people are being misdiagnosed. And so it's really crucial that we are allowed to have our own hormones back in a very safe, controlled, regulated way. And I personally take testosterone. I did improve, like you, with some estrogen. I was lucky my symptoms weren't as bad, but they would have been if I'd ignored myself for longer. But I was really struggling to remember things. And my yoga practice was really nonexistent.

I was just going through the motions. I didn't enjoy it. My joints were stiff. I was just losing muscle tone. And I just felt a shadow of myself, actually. And started testosterone, and after a few months, my brain came back. and I quite pride myself. I have an amazing ability to marketaast

so I can be talking and emailing and texting and thinking about what I'm going to cook for suffer at the same time. But I'd miss that for the last 10 years and my youngest daughter's 10. And I just thought it's just because I've got three children. Just having her as being the final nail to the coffin for me to multitask. But it's now come back far better than before I was pregnant

and I wish I'd started it years ago. So there are a lot of women who are perimenopause, or who are still producing estrogen because they're having periods, but their hormones are starting to decline. And it's very difficult to know. A blood test is not always reliable. It can be useful if it's low. But it's about women recognising the symptoms themselves.

And so downloading the app, reading my book, getting the information. But women such as yourself who are very, you know, action man, women, who are very physically fit, very mentally fit, very on the ball, they often miss testosterone more than, other women and it's probably, I don't know what your level was, no one does 20, 30 years ago, but it was probably higher than women who are more sedentary who don't have that lifestyle. So if women are sort of evolutionally have a lower testosterone, they're not going to miss a

decline. But if they come from a higher level, especially women with polycystic ovarian syndrome, PCOS, they often have an higher level of testosterone and they really miss it during the perimenopause and menopause. So it's amazing hearing your story. And I know I'm a bit nervous about putting this podcast out because there'll be a lot of women saying, well, I can't get it, why can't I get it? And one of the doctors that works with me, Dr. Zoe Hudson, has been looking at this postcode lottery. And a lot of GPs are not allowed to prescribe testosterone. It's been forbidden by their CCGs. They've not been allowed to prescribe it. So it's not even the GP's fault. So there's a huge piece of work to actually allow women to be able to

get their own hormones. But having this conversation is hopefully going to enrage a few more women. so it won't be just us that are frustrated. And collectively we can maybe try and make a bit of a difference by making a noise, but just to reassure you that the work with NHS England is going to get there, and it will make a difference. But because we're talking about so many millions of women, it has to be done in a very clever, strategic way, otherwise it will fall over very quickly.

But I'm really hoping that people listening to your story today, Rachel, will really resonate and think. and I especially really very grateful for you talking about your son and your husband as well because it's not just about women. It's more than that. And I'm really trying to change the narrative about the menopause. It's not a women's health problem. It's a global health problem.

It's a mental health problem. It's a physical health problem. It's an economic problem. Wherever you look, it's affecting people. And we need to really be very bold and think about it. So this suffering does not happen again. It really can't continue. So I'm very grateful for your time.

It's been really great. But before I finish, could you just give three tips maybe? For women who are listening and thinking, right, I really would like testosterone. What three tips do you think you would give them just to try and help them on their journey? You know, I should have thought about this before because I know you do this at the end of the podcast

and I didn't. I forgot to do it. I think number one is we have to remember that our GPs aren't trained in perimenopause and menopause in the way that they should be. And that's no fault of their own. So go to your appointment with as much information as you can and including the nice guidelines just so that you can have that factual conversation with your GP. I think that's very important. Secondly, please don't ever give up. If I'd given up 18 months ago, I probably would have been institutionalized by now and, you know, I'm not, etc.,

I was very, very poorly indeed. Thirdly, be really, really kind to yourself. It is a difficult time in a woman's life. It certainly changed my outlook on life and I think in some ways to the better, I've become a lot kinder and gentler with myself and yeah, be kind to yourself and listen to your body. Yeah. Excellent. Really, really good advice, which I hope people will hear and take on board and just talk about it as well. It's really important. And if you don't get your help initially, go back, see someone else, have someone with you to really help prop you up. And, you know, we all deserve to have the right treatment. And I really feel very strong and we all deserve to have our own hormones back if that's what we want. So watch this

space. Let's see what happens with testosterone prescribing, but I'm feeling quite confident about it. So hopefully we can announce more with time. Really exciting. Thanks ever so much, Rachel. It's been really lovely speaking to you today. For more information about the perimenopause and menopause, you can go to my website, menopause.combe, or you can download our free app called Balance, available through the App Store and Google Play.