The Dr Louise Newson Podcast - 119 - Testosterone: why can’t we have our own hormone back? With Dr Zoe Hodson

Episode Date: October 5, 2021

Dr Zoe Hodson returns to the podcast this week to talk to Dr Louise Newson about the hormone testosterone. Zoe is a GP and senior doctor at Newson Health, and together they discuss the impact of low testosterone on your daily life, why it can be difficult to get hold of, and gender inequalities in healthcare provision when it comes to this particular hormone. Zoe is on a personal mission to ask every local health commissioning group if their clinicians can prescribe testosterone and, if not, why not? Change is happening slowly within primary care and Zoe and Louise are committed to continue to push for testosterone to be regarded as an integral part of menopause care at a free, local level for all. Zoe’s 3 asks for change: We need to normalise testosterone in women, so please keep talking about it. If you take it already, tell people, and tell your healthcare professionals about the difference it makes to you. Keep alerting your GP practice to the ‘Confidence in Menopause’ course on fourteenfish.com. It is now free for all healthcare professionals across the globe. If you’re going to a menopause clinic and they haven’t mentioned testosterone, ask them about it. Zoe would like to thank all her followers on social media for their wonderful support and encouragement to keep speaking up for women and trying to bring about change for good. You can follow Zoe on Instagram @manchestermenopausehive

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 back with me, Dr Zeri Hodson, who has been before, and I don't think this will be your last time, Zeri. You don't get away that like me. So thank you very much for agreeing to talk to me today. So he is one of our, if I say senior clinician, that sounds like she's very old and she's not younger than me. So she's one of our very experienced clinicians that work with us in the clinic, but she does more than just work in the clinic. She's constantly trying to help reach women, reach men, reach anyone that

will listen to try and improve menopause care. And also try and look at the disparity of care, and trying to reach women that we can't reach through our clinic or even the app or some other of our resources. So she's worked incredibly hard behind the scenes. But today, we wanted to just really talk a little bit about HRT, but really focus more on testosterone because this comes up a lot. And we just thought it would be really useful to have a bit of a discussion about it. So I hope that's what you realise you're here for today.

I know. I have brought bigger soap boxes for both of us. We need the massive ones. today, I think. So let's just take it really far back. So if I had met you 10 years ago, and I had said to you, so how much testosterone do you prescribe for women? What would you assess? Well, this is really where it all started. I actually had this case. And a lovely lady came in to see me, and she's up and running on HRT, taking a bit of navigating. And she said, I've been reading around testosterone, and I think it would really benefit me. And I had never really

really. I'd heard of introns of patches occasionally, but it took ages to get a referral to get them, so it wasn't. And then again, we didn't prescribe them. They were all done from secondary care. And I actually, looking back, felt really cross with her. Because I thought, why are you asking me to prescribe something that should be done in really specialist clinics? What do you mean you are asking me about it? This is clearly something that is only done in hospital and under really specialist-tight guidance and must therefore be incredibly dangerous and complex. And that was the only time that it really crossed my radar. Had you had any training about testosterone or read anything about testosterone at that time?

No, so we always sort of say, I mean, I think both of us, I had two hours training in menopause during 10 years, and that was basically to tell me never to prescribe HRT. and then every message she got from the snippets, from journals from then were constantly, do not prescribe, do not prescribe. And I think it only really changed five years ago. Yeah, absolutely. So, I mean, I know 10 years ago, I was not on my radar. No.

I feel really embarrassed to say this, but I will. I didn't even know that women produced testosterone. No, it was never mentioned at medical school. No. And so I know that men produce some estrogen. I've known that for a long time. But I didn't know that we did. And actually it was when I was at a clinical update with lots of different topics.

And one of them was about menopause. And I started to get more interested at this time. And I went and heard Nick Panay, who's the king of menopause. He's been on the podcast series before. And he spoke about testosterone. And I thought, what? What's he talking about? Have I come to the wrong lecture?

And then I didn't think any really thing more of it. And then the nice guidance came out. And they mentioned testosterone, don't they? They say women can be considered for testosterone. if they have reduced sexual disdive despite taking HRT. I thought, all right, I better know a bit more about this then. But it was quite hard actually to find much about, wasn't it? It still is in some ways, but it's a bit better.

But like you, no one prescribed it. So I thought it was something that was quite hard and quite difficult to prescribe. And the other thing, when I started to ask people about it, the women that have been on it all said they felt amazing. and some of the doctors who were sort of my era said, oh yeah, when I was younger and did obs and guine jobs, we used to give implants to people after their hysterectomy and they would love it.

They'd feel amazing and they'd come back for more and we said, no, we'd just give you one to get you through your recovery or something. But it didn't matter because women just went back to feeling okay. And that was it, that was all the conversation. And it was always like, what struck me then was I was thinking, why are women not allowed to feel really good then? They're not allowed to. And then I just have this whole thing like you do, I know, but what if it is our own hormone? Why, firstly,

are we denied it? And why secondly is it so hard to prescribe? Because it's not difficult to prescribe, is it? Not at all. And I think that's the other thing as well as as you start prescribing it, it frustrates me on belief that the guidelines just mentioned libido. That in itself is an issue. Yes, where there should be much more openness of our libido and yes women why aren't we permitted is that shame about wanting a sex drive but we know from seeing so many women the thing that fascinates me and why I'm so interested in this is the recovery of cognition of energy of strength of motivation the mood and this is why I always say it's my favourite hormone because when women come back and their levels are sort of adequate if they're

running well, the commonest phrase that they will say is, I can see myself again. And all of these symptoms that they just put down to, or this happens when you get older, and it's just cobbler's. Yes, because let's just take it back. So what does testosterone do then? It doesn't just work in our brains, does it? We've got cells clearly that respond to testosterone, but where are these cells? You've got them everywhere, haven't you? It's sort of similar to estrogen. And again, we know that premenopause the ovaries produced three to four times more testosterone and that when I saw that. So say that once more, three to four times more testosterone than estrogen from the ovaries. So we should be thinking about it as important, if not more important than estrogen, shouldn't we?

Yes. So for me, it's the HRT is the three hormones, isn't it? And we've just lost it. And it's really, really sad. because again you just see these generations of women that get forgotten, discarded, accept this. Menopause and perimenopause are a really vulnerable time anyway. And the effort to try and get hold of this particular, I mean, it's bad enough with your other own hormones, but this is one step beyond. At a time when you're on the floor, I mean, the descriptions you get with low test, I've had some beautiful descriptions of, it's like psychologically and physically.

wading through porridge. And another lady said it's like fatigue of the soul. And it's, that is, it just says it so beautifully. It's just everything is hard. Thinking is hard. Moving is hard. It just is an effort. It is very difficult, isn't it?

And I, I mean, people know that I used testosterone and I didn't know I was deficient because I thought I was just struggling because of everything else. But it's like you have a lead weight attached to your brain. and your body and you sort of just, you know you can function. So you're not so bad, or some women are, but a lot of women aren't so bad that they need sort of medical help. They think that's just their lot. So they're not going to go for promotion.

They're not going to bother taking the kids to the park. They might as well sit down and watch telly because it's just easier. I mean, I found even little things like unloading the dishwasher, which takes two minutes. I just looked at it. I can't do it. I just can't do it. It's too much effort. But it's also really frightening, isn't it?

Because, I mean, I had time off work. And looking back, I think I'd never had time off work in 20 years. And suddenly, I was sitting in consultations and I couldn't remember the name of medications. And it was taking me, I'd sit with bloods in the evening and normally you'd go through them quite quickly and just leave the ones that need. And it was taking me ages because it just felt like someone had watched a big lump of cotton wool in my brain. effort of processing. Yeah, it's very hard. I mean, I was trying to write my website. How funny is that about the menopause? And I kept saying to my husband, do you know what? I just can't think. I feel like I've been drugged. It was just the weirdest thing. And he's like, but you're always

telling me you're tired. Why are you tired? It's a different feeling, isn't it? I said, but I'll go to bed and I won't sleep. It's a really weird feeling. And there is some research isn't there to show how important testosterone is on our brain and our muscles and our bones and our hearts as well actually. And I think there has been a bit of discussion. I go to every lecture I can at every conference about testosterone to try and find out more. But like you said, there's a lot about libido. There is a discussion is whether it's an age-related decline or whether it's a pure menopause, perimenopause decline. But my sort of question is, does it really matter? but actually I also think there's probably more younger women with low testosterone than we realize

because we never think about it, we never test it. We know that some things do lower testosterone, don't they? Things like oral estrogen can actually reduce the availability of testosterone. So that means actually some women and girls and teenagers who take an oral contraceptive pill, their testosterone might lower. And actually that might be a problem because, if they're having difficulty concentrating at school or if their libido's low or if they, just their motivations low, they're going to think about testosterone, are they?

And knowing what the reference ranges are as well as the GP, isn't it? Because the only time I had experienced testosterone bloods was looking at polycystic ovarian syndrome. Yes. And so the range can look quite large. So I've spoken to women who've been really upset, terrified that they've been. got dementia, they've had some testosterone bloodstern that have been reported as normal, but they're normal because they're not in the range of polycyticovarian syndrome. And those women have higher levels, don't they? So I saw a woman the other day and she'd

had a bloodstown with her endocrinologist actually. And she said, oh no, the results are all normal. And I said, just read them out to me. And the testosterone was down as 0.1, which is very low. Yes. But the result just said normal. Yes, because it's in the range, isn't it? Yeah, so we have to be, and actually blood tests, you don't always need a blood test, do you, before you start testosterone? Because if a woman has very classical symptoms, especially if she's perimenopausal or menopausal, then often it's a bit like starting HRT, isn't it? You don't have to have a blood test. But I think this all comes back, isn't it?

It's to this, the fear of the unknown. So we really have to go, like many other things, we have to go right back to the beginning again, that it's taught and it's taught repeatedly. and it's normalized because we shouldn't be doing this in our clinic. Absolutely. I totally agree. But I do know, actually, when I first started prescribing testosterone as a GP, but the nice guidance had come out, I'd finally managed to get H.R.T. from a specialist, and then I'd started H.R.T. with testosterone. My brain was coming back, and I thought, right, I'm going to start giving it some of my patients.

I realize it's safe and easy, and I did more monitoring them because I wanted to make sure what I was doing was right. and I'd quickly see the results of these women and think actually this is one of the easiest things I've prescribed because some of you, I'm sure, know that when women take HRT with estrogen and progesterone, quite often people get symptoms such as bloating or breast tenderness or bleeding is a really common symptom, isn't it? Side effect for the first three to six months. But actually testosterone doesn't, it can cause occasional bit of bleeding sometimes,

doesn't usually cause significant side effects, does it? No, and I think this is, again, because we're getting it into normal female range. I'm just going back quickly because what I meant by saying, we shouldn't be doing it in our clinic. We should be doing it on our clinic. But I firmly believe that this should be in the realm of general practice. Absolutely. People shouldn't come to a specialist clinic, is what you're saying, because it's so easy to prescribe. And actually, I don't know about you, but when I started as general practice,

I was a bit nervous prescribing thyroxin because I was worried about getting. the dose right and how would I know? And then actually I thought, well, you just try it and see. And then you can monitor their blood test, see what their symptoms are like. And some women, as you know, need very high doses of thyroxin and others need a low dose and they're fine. And then when I've had people with type 1 diabetes, starting insulin in general practice can be quite difficult depending on the patient.

But that's a lot more specialist. And it's a lot more risky because you have to get it right. Because if you have too much insulin, obviously your sugar level will be very, very low. But these hormones are so much safer, aren't they? Yes, and they're so much easier as a GP to, again, I started prescribing it in general practice as well. And it was just wonderful. There's so many women that had been misdiagnosed with things like chronic fatigue, with fibromyalgia. We had women that had been referred to the dementia clinic.

And it was just, thankfully, unthankfully, the waiting list for that was incredibly long. So I just said, well, can we just try this whilst we're waiting? And then, of course, they didn't need to go. And the relief at having your cognitive function back again. Again, we see so many women, don't we, through the clinic, that have been under chronic fatigue clinics for years. And nobody has looked at the woman and said, right, what were you doing five years ago?

You were running marathons. What has happened? What stage of life are you in? Yeah. And this is what's really important. And we should be picking up not just on ourselves, but on our friends or, you know, anyone should be thinking, and actually women can help themselves a bit if they know more.

And I saw a lady yesterday, actually, in my clinic, who'd had chronic fatigue, fibromyalgia. She had an autoimmune condition. And she used to be a yoga teacher really fit and well. And she said she had a hysterectomy in 2015. And I said, when was your autoimmune condition diagnosed 2015? when did you have to stop exercise and when did you really struggle? She said, well, 2016, but I was given high-dose steroids.

I was given some really toxic drugs for this autoimmune condition. And I said, well, at the time, did anyone ask you about, you know, whether any of it could be related to your periods, or to your hormones, you were 47 when you had your hysterectomy. And so it's likely that your ovaries, although they were left behind, probably weren't producing much. And certainly now, six years later, they won't be producing any hormones. And she said, well, I've tried one pump of estrogen and felt a bit better.

But she said, I used to exercise very easily. I used to be able to build muscle very easily. And now I am so tired. But when I do exercise, I just can't get any muscle tone at all. And I'm sure a lot of it is related to no testosterone. And this is, we hear this as well because we ask women who are sort of seeing personal trainers or going to the gym. And it's one of the questions I am. ask us, for the work that you're putting in, are you getting stronger? Because often there'll be

very sort of puzzled personal trainers out there saying, but you're working so, so hard, and yet you're not getting stronger. And then when they're on the testosterone, their levels are back in the normal female range. I will say again, because again, look at Newsome Health, look at all of us. Many of us are on testosterone. We are not bearded, normal female range. So again, this is where it comes down to this sort of crowd effect that if we all start talking about it, we know there's a long, long way to go. We're both really hopeful that this, at some point, this will be in the realm of general practice. But we've still got an awful lot of work to do with this. And I know that you're working hard with NHS England at the moment. Yeah, absolutely. This is with their national

menopause programme, to try and help, not just with testosterone, but HRT in general. But let me just summarize then before we go further Zoe we're talking about a natural hormone that women produce we all produce and it declines maybe with age but maybe with menopause as we get older essentially it declines but it's not licensed but it is license for men isn't it yes so men are allowed their own testosterone back women that produce testosterone we all produce testosterone we all have it in lower doses are not allowed it back because it's not a licensed product. That's right, isn't it? It sounds crazy when you swear it out. It is. How dare you request your own hormone in 2021? It's quite shocking, isn't it? And we've all, when you look at the evidence, like you say, or the guidelines,

most of it talks about libido, and we both agree that libido is very important in women, as well as for men. But we also know that it helps with all this other mood, energy, concentration, stammer, and so forth. But even if we just look at libido, okay. So the guidelines are saying women can take it to improve their libido, but we haven't got a licensed product. If we think about men, there's lots of reasons why they might have reduced libido or even erectile problems. One of the ways that they might choose to improve their erectile dysfunction is by taking Viagra, which not everyone can take because there are some contraindications. But when they realised how good Viagra was, they managed to get it available

over the counter very quickly, didn't they? They did. And that's not, that won't reduce the risk of osteoporosis might help actually with heart disease, but it won't necessarily reduce the risk of dementia and obesity and diabetes. And it's fairly expensive, but men can buy it over the counter, can't they? They can. Freely available. And it is now actually freely available on the NHS as well.

It used to have. to be a private prescription only, but they changed that very quickly. Yes. When they realised how effective it was for men, and I'm not a man hater at all, but I am a feminist, I suppose. I believe in gender equality. So what we're talking about here is very unequal, isn't it? Yes.

Just to put it out there, really. So testosterone is safer than Biagra, really, I think you could argue, for a lot of women, but we can't even get it prescribed as a licensed product. Even that in itself, at this stage of life, if you have a male partner, they are allowed to continue enjoying a healthy sex drive. You are not. It just doesn't it say. So anyway, we're not here to moan. We're here to try and improve.

So how do we get around this? There are a couple of ways, aren't there? So firstly, in the NHS, we are allowed to prescribe drugs that are off licence. When we say licence, it means that when a drug has... a license, it's for a certain condition and a certain dose, isn't it? Yes. So for example, there's a drug called amyptylene, which is licensed as an antidepressant at a certain dose. But we also know that it helps reduce pain in the nerves. So if I had a trap nerve in my neck and pain down my shoulder, you as a GP might choose to give me amythotomythonyth for my nerve pain.

It's not licensed in that way, but it's a regulated product and you're just being. You're just prescribing it, we call it off licence, but that's still very safe because studies have shown that it helps with nerve pain. And that's 15% of GP prescribing. 15%. So yes, that's a loss, isn't it? It's about one in seven, one in eight of prescriptions are off licence. So especially a lot of children, pregnant women, all sorts of things, because we know they're safe and we've got some evidence. So that's fine. We're allowed to do that. We're not going to get stuck off from prescribing off licence. So with testosterone, we are allowed to prescribe the male testosterone off licence. So because it's exactly the same testosterone.

And there are further caveats, aren't there? Yes, we'll talk about that in a minute. But so it's the same testosterone. Some people think it's a female testosterone and a male testosterone. It's not. It's just the same hormone, but lower doses. So there is a gel. And I think it's important to say, for those people listening in the UK, there's two really that we would recommend. There's called testim, which comes to a little tube or testo gel, the one that comes in the sashay. The ones that come in a pump for men, it's often very hard to titrate the dose. So I would really be very clear about steering, clear of those and just using the sash or the tube,

but making each one last seven to ten days. So that is available, you would hope, through general practice. First caveat is that the doctor has, or clinician, it doesn't have to be a doctor, a nurse prescriber or a pharmacist who prescribes, has to have some training. We know that's difficult in itself. But it also, each area is a CCG isn't there and there's a prescribing guidance. So can you just explain a bit about that? Yeah, so each area, I mean, in some areas of Wales, it's health boards,

but basically each area of the UK has a designated sort of catchment area, if you'd like. And there are pharmacists, clinicians, there's a panel that decides what is available to prescribe and advises and there will be a formulary and the GPs are strongly advised to stick to that prescribing formulary. So if there are queries about medications, the GP will go to their local formulary guidance. They'll look it up and they'll say, and very often it's something called a traffic light system. So it will be divided into red, amber green. Green, fine, go and prescribe. Red, don't go anywhere near. It has to be in a specialist setting. And Amber is where if it's started in a specialist clinic, it can then be continued by the GP if they feel comfortable to do so.

So when I started looking at this, I thought, well, surely the majority of the UK must be Amber, because surely lots of menopause clinics are doing this. And so there should be guidelines in place for this to happen because we don't want to clog up scarce appointments with women having to go back for monitoring and back for prescriptions. And that's when the eye opener started. It's very, very difficult to do this as a one-stop policy. It's incredibly difficult. So I am at the moment with a bit of, I don't know if I can call it a labour of love,

a labour of frustration, ploughing through, I think at last count there are 144 CCGs. So I am approaching them individually, trying to have a look on the formulary, which is often really tricky to navigate, to see what their stance is on, women having their own hormone in 2021. It's very variable, isn't it? Yes. And, you know, with both group GPs, and there were lots of things that were blacklisted,

so where I work, I wasn't supposedly allowed to prescribe each adjuster, which is the natural body identical progesterone. But I did it because there's more evidence to support it, and no one told me off. But actually, sometimes with testosterone, you're really forbidden, aren't you, as a GP? You're absolutely not allowed, to. So with the eutigestan, I just said, well, I'm doing it anyway because it's better for my patients

and I got away with it. And I did the same with testosterone, actually, and I got away with it. But actually, we've even got some doctors who work with us in specialist clinics, menopause, specialist clinics through the NHS, but they're not allowed to prescribe testosterone. Yes. And again, I think if you're as a GP, so eutrogen, as a GP, you're still familiar with progestogens. You've handled them with the pill. There's this familiarity. So it doesn't, feel as much of a leap to follow evidence base. If you're the only GP or nurse prescriber or pharmacist in a practice, then it feels very uncomfortable to be the only one doing this

if you don't have the support of your peers. It's very, very hard, and I've done it for a while, just done my own thing because I've done what's right. But I've also had the luxury. When I was a GP, I worked part-time. And it meant the other days that I wasn't working, I could plough myself through reading articles and journals and papers and guidelines. And I could absorb all this knowledge and work it out for myself because I've done a lot of

medical writing over the years and I'm quite good at reading some of the stats and everything else. But I had time to do it. If I was working as a full-time GP, it's exhausting to be a full-time GP. You can't do it. And you have to, often when you're busy, you go to your peers or your network. or you'll go to a journal for a summary. And if all these people are saying testosterone is dangerous, too difficult, don't do it. Why would you do it? You wouldn't do it.

And you don't actually, it sounds really awful, but you're a bit like a hamster wheel sometimes. You don't have time to reflect. You're just so busy with your job. And this is what's not just in general practice, lots of physicians, lots of nurses, lots of healthcare professionals. Everyone is very busy. And if you haven't got an engaging team, and I think what we've found working together is that we give each other more confidence. But it's really hard because women are caught in the middle of this, aren't they? And that's what's really tragic about all of this. And this is what I've heard

a lot is, again, that they'll find a GP who will really listen to them, be interested in it, and then say, well, I'll have to take it back to my practice team. And then it said, well, I'm really sorry, I can't. Yeah. And that's, again, it's lack of knowledge, isn't it? Yes, absolutely. So we've got the nice guidance that many of you, listening have heard about the National Institute of Health and Care Accidents guidance, which was produced in 2015 for management of the menopause, and it does mention testosterone. On the Menopause doctor website, if you put in easy to the search function, there's an easy HRT prescribing guide for healthcare professionals, which is written in an evidence-based way. And women can actually

download and print that off, and it's very clear it talks about which testosterone, and privately women can get this testosterone androfen, which is a female testosterone cream, which is now licensed in Australia. And at the moment, we're only allowed to prescribe it privately. It works out about 80p a day. But we're really hoping with some of the work I'm doing with NHS England that it will be licensed as a product for females. I'm very excited actually, aren't you, for that day, Zoe, when it happens. Oh, we'll be out with the focons. Yeah, absolutely. So, but I think there is a move. And I think what we're trying to really say in this brief sort of conversation about testosterone is it is a

hormone, we should be allowed to have it. We have to stay really strong and for some women, they're going to have to just stay a bit patient. But I really want to try and let people know that we are working behind the scenes. We are really trying to show there's a massive inequality. There's a big postcode lottery of prescribing of testosterone. But also we're trying on this podcast to support our colleagues out there in primary care and second. secondary care because we do understand that it's not their fault if they can't prescribe it. No, it's so many factors, isn't it? It's lack of training. It's lack of support from your formula. It's lack of adequate preparations. And again, because it's been interesting

approaching the different formula is to hear the reasoning behind this. And they are wide and varied and some of them absolutely nonsensical. So it is things from it's off license. Well, that one is relatively easy to challenge. There are other ones with the test to gel session. saying, well, we can't advocate for something where you have to leave half a sashay lying around. And again, if you're really being sort of pedantic, it's difficult to argue that one. So, I mean, I think even the fact with the huge, huge uptake with the confidence in menopause course, there is a real interest in this, but we're at a really sort of tight point in the NHS, aren't we, with the COVID and coming out of that.

And I think ideally, this needs to be at junior training. know when you're talking about diabetes, you're trained on that three times a year. And it just becomes, you just know about it as you know how to navigate and everybody knows about it. My other huge frustration that seems to be happening at the moment is one clinician in a practice will be earmarked to do menopause care. It's wrong. Absolutely. It should be every single doctor, nurse, pharmacist, clinician who sees an adult woman, not just in primary care, but secondary care as well. So it's normalised.

The same way that when we manage high blood pressure, you don't go and see a specialist, everyone should do it. If someone's got a headache, you don't go and see a headache specialist. I wrote about this a couple of weeks ago. I said if as a GP, if a male had come into me with, for example, erectile dysfunction and I'd said, oh, no, no, I don't do willies. You'll have to go and see a male GP. But I would have been called up in front of the, and what are you doing?

Quite rightly so, really. Yes, yes, absolutely. So, no, it's exactly the same. So we've got a lot we need to do, but I hope this has given people just some food for thought and something to think about really. So just before we finish, you know I'm going to ask you. Three tips really to help women, because I feel uncomfortable talking about testosterone because I know so many women can't get it. So three tips that women could maybe take away to try and help them either receive testosterone now or when it's licensed in their hopeful not too distant future. I think the first one is we've got so much work to do to normalise this.

So it's the whole thing of just keep reading, keep listening, keep talking to people. Again, with the women that are on testosterone, if you speak to your GP or another healthcare professional and you're feeling better on it, tell them that. So just keep talking about it, keep normalising it. It's our hormone. The second one, I would say, please, please, please keep unable, done a sterling job, but please keep alerting your practice to the confidence in menopause course. It's making a huge difference. I heard a wonderful story the other day about an area in Scotland that somebody had noticed that the email consult template had changed and it now included all the menopause symptoms and asked

about function at work, home life. So it is, it's starting to change. We are changing this. And I think the other thing is, again, if you are going through a menopause clinic and they haven't mentioned testosterone, ask why. And then I'll have number four, which is to say a massive thank you to everyone out there. I think this is one of the things that social media has been brilliant at. The support that people give each other is incredible. And we see it all the time. And just to say we cannot thank you enough. because there are very few of us.

We are working incredibly hard to change this because it's wrong, but we do recognise it, we do see it, and just a big, big thank you. Well, you're the first person that's pushed the boundaries there, Zohey, and had number four, but I'll let you have that. I'm sorry. It's very good, and I think lots of powerful things happen when women help women, and we're seeing that, and we can just keep working together, actually,

because, you know, none of us are doing this in isolation. We're all working together, and we're loving, seeing how much we're making a difference, but we've got a long way to go and we're not going to stop, are we? We're not. Thank you very much, and I'm sure you'll be back in the hot seat, having another podcast soon. So thanks, Zoe, for tonight.

Take care. For more information about the perimenopause and menopause, you can go to my website, menopausedoctor.com. Or you can download our free app called Balance, available through the App Store and Google Play. Thank you.