The Dr Louise Newson Podcast - 125 - ‘Yes, I’ve had breast cancer but now I need help with the menopause‘ with Dr Sarah Ball

Episode Date: November 9, 2021

Menopause specialist, Dr Sarah Ball, makes a record 4th appearance on the Dr Louise Newson podcast this week, to talk about an important group of women that often feel marginalised when it comes to menopause care and treatment. One in seven women will experience breast cancer, and many more of us have a close relative who has had breast cancer. Thankfully, thousands more women are living longer after breast cancer, but this often means living with the menopause and symptoms of a lack of hormones. The experts discuss the risk factors of developing breast cancer and the complexities of the association between hormones and breast cancer. Dr Sarah Ball has researched the experiences of menopausal women having breast cancer treatment and her findings reveal women are having to endure menopausal symptoms for an average of 7 years before seeking, or being given, help and treatment, and sadly, only 10% of the women surveyed felt they were involved in decisions about their care. Dr Ball and Dr Newson are both passionate about helping women after breast cancer and believe it is essential that these women are listened to, that healthcare professionals discuss in full the treatment options for their menopausal symptoms, and that women feel empowered to make a decision that’s right for them, at that time, being aware of all the relevant information. Sarah’s 3 tips for women after breast cancer: Don’t feel guilty for how you feel about your menopause, you’re not complaining, or moaning or being ‘weak’. It’s really important that your symptoms are addressed. You are your whole body, not just your breasts. Don’t lose sight of the health of your heart, your bones, your skin, your sex life, your mental health and brainpower – these are important too. Symptoms relating to your vagina, vulva and urinary function are treatable by using vaginal estrogen. This is safe to use after breast cancer and is not absorbed by the whole body in the same way as HRT. You can tackle these symptoms successfully, even if you feel you do not want to take HRT. Understand you do have a choice. Guidelines recommend you should be listened to and have a say in decisions about treatments. Tell your healthcare professionals what is most important to you in terms of living your life, treating your menopausal symptoms, and managing the risk of cancer returning. Follow Dr Sarah Ball on Instagram @drsarahmollyball and Twitter @sarahball14 Making decisions around your cancer treatment and menopause is often a complicated and overwhelming process. There is a new factsheet on balance website about making informed decisions about cancer treatments here, and a personal story written by the partner of a woman having worsening menopause symptoms after breast cancer treatment here.

Hello, I'm Dr Louise Newsom and welcome to my podcast. I'm a GP and menopause specialist and I run the Newsome Health Menopause and well-being centre here in Stratford-Bron-Avon. I'm also the founder of the Menopause charity and the menopause support app called Balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause. So today on the podcast, I'm really thrilled because this person, I know well, and I work with her, but this is her fourth appearance on the podcast, which I think is a record. So Sarah is born, is one of our

doctors who works with us, and I'm really pleased that she's joined me again. So thanks, Sarah. Thank you, Louise. It's always a pleasure. So Sarah and I met a few years ago, actually, I've gone to give a talk for some healthcare professionals. Actually, with my husband, we were doing a sort of Mr and Mrs event. And there weren't many people there because it was Wimbledon and it was a really nice hot day. And Sarah was there and her eyes were just a light. She was just nodding. Everything I said about the menopause, she was like, yes, I really want to do more work.

So when we opened the clinic, she was our first real doctor that came, not that we're not real doctors, but she was the first doctor that I recognized came and said, because you come and work with us and it's been great actually and the rest is history as I say, isn't it? Yeah, it's been amazing. And Sarah and I are both also very honest and open that there is so much that we didn't know when we were with our patients over the last 15, 20 years of being doctors and so many women that we've neglected actually.

And I think the more Sarah and I talk about the menopause and we talk with others, obviously, the more we realise there are certain groups of women that are probably more neglected than others, wouldn't you agree, Sarah? Yeah. I think women generally are neglected when it comes to the menopause, but there is a lot of women who really struggle, particularly not heard. And one of the groups of women that we see and speak to more and more women who've had breast cancer. So we have spoken on the podcast before about breast cancer, but actually we're going to just talk about some research that we've done through my not-for-profit company, Houston Health Research and Education. And one of the things I think, as GPs we do really well is listen to patients. And I think other not just GPs, but doctors, nurses, healthcare professionals really are listening so much more than they were. Certainly when I qualified, we didn't really get talked to listen. It was more about telling patients and things have changed. So we wanted to talk about some research that Sarah had instigated. But before we

talk about that, let's just talk a bit about breast cancer because it's very common, isn't it, Sarah? Extremely common, yes. For those of us that were born after 1916, 60 will sadly affect about one in seven women and it gets commoner as we get older. But luckily, things are positive in terms of we're much better now at picking it up early and treatments have got far more successful, which is great. So actually the prognosis for most women is very good. But the quid pro quo for that is there's now an awful lot of survivors of breast cancer who are struggling with often menopausal issues and then that's the real thing.

and they're most neglected because there's so much fear about where to go with them and how to help. Yeah, and I think, I mean, one is seven. So when I was a medical student in the 80s, it was one in 12. And then when I graduated, it was one in 11. So it's now one in seven. And why is that? There's lots of reasons, isn't there. But let's just talk through a few, why it's become more common. Mostly, because we're increasingly large people, obesity is a big problem. And lifestyle, unfortunately, has a big impact on breast cancer. It's thought that probably about 30% of breast cancer would be prevented if it were healthier lifestyles that we led. Yeah, and that's very interesting, because obesity is overtaken smoking, hasn't it, as a common cause of all cancers,

so not just breast cancer. And when I was younger as a medical student, a lot of people, and they still think now that there's estrogen in fat cells, therefore if you're fat, you're producing more estrogen, therefore estrogen causes breast cancer. Now, it's not quite simple as that and we're not going to go into too much detail today but what I am sort of trying to think in my mind to try and explain is that the type of estrogen that fat cells produce is very different to the type of estrogen we produce when we're menstruating or in the type of body identical HRT we give isn't it? Yeah. And that's really important for people to realize because there's lots of different types of estrogen but there's one called estrogen which is quite a sort of nasty

estrogen it's quite pro-inflammatory it's not always nice but also fat cells. produce other inflammatory chemicals, if you like, don't they? And that's why other cancer such as lung cancer are more common in people who are overweight because of the way these fat cells are acting and producing all these horrible chemicals, if you like, and that's why people are more likely to have heart disease and diabetes and metabolic syndrome and so forth. So I think that's quite important to say because I think some people are just saying, well, that's because they produce more estrogen.

But the other thing you said right at beginning is because we're getting older. And by definition, older people, unless they take HRT, have low hormone levels. But we see more breast cancer and postmenopause are women, don't we? Yeah. Who don't have any of the natural estrogen on board. So I think that's another thing that's quite important to really think about, isn't it? So what other lifestyle factors can increase risk of breast cancer? Alcohol.

So thinking two units of alcohol. which for most people these days can be one large glass of wine with your evening meal actually has more association with breast cancer than a lot of other things. For example, you know, we always live with this huge association between people thinking that HRT is the cause of breast cancer. It's not the cause of breast cancer. You know, there is an association, but it's not the direct cause. And the association is very small anyway.

So it's being a drinker, being overweight, being sedent. So if you don't exercise, you're also at increased risk of breast cancer. And smoking also has an effect as well. So unfortunately, what we see is that when women are menopausal, that their lifestyle often starts to falter because of how ropey they're feeling. And so therefore, there is increased risk of breast cancer if you're not able to control your lifestyle. So it's all a very complex interplay and often the simple picture, which is painted to the media, which is that all hormones are bad and all the cancer is to do with hormones is simplistic at best and wrong. Yeah, and it's far more complicated, is it?

Because it's often multifactorial. It's not just because someone's overweight or just because they drink wine. There can be genetic involvement as well and bad luck actually as well. So I don't want anyone listening to think that it's because they've eaten something or drunk something or not exercised. It's very, very complicated. But we are where we are, one in seven women. So the prognosis is so much better, which is wonderful. and the outlook is better so people are living longer

and as you say they will become menopausal. Some women will become menopausal earlier because of treatments, won't they? So just to explain what sort of treatments can affect hormones. Yeah, so having chemotherapy can really upset the ovaries and switch them off. Radiotherapy often doesn't help and some women have their ovaries removed

as well as part of their breast cancer treatment which launches them straight into the menopause. And then often the treatment, So about three quarters of breast cancer is what we call estrogen receptor positive. So in other words, it wasn't caused by the hormones, but it can be promoted further by the hormones. So they're often given what we call anti-estrogen therapy or medication often to moxophen or what's known as aromatose inhibitors, which help to block estrogen. And so that induces menopausal symptoms as well.

Which can actually be a harser menopause, can't it? Yeah. The sort of natural menopause, if you like, because there's not this gradual. decline. It's a bit like when people have a surgical menopause, it can happen very, very quickly. And a lot of symptoms of the menopause, we all know we've spoken about many times, can be very disabling and really affect women. But certainly women have had breast cancer often say to me, when they experience manifolds and symptoms and they've had brain fog, headaches, bone pain, they've been really worried that they've got metastatic disease actually because breast cancer

can spread to the bones and cause bone pain. It can spread to the brain and cause headaches. and memory problems. And so understandably they go through investigations, which is absolutely the right thing to do. But when they're normal, then they get really worried actually because they think, well, maybe it's such a small growth or there's something else that hasn't been picked up. And a lot of women then say, well, no one talked to me about menopause.

No one told me that this could happen. They mentioned menopause at the beginning, that it might happen, but actually at the beginning, quite rightly, the women are so focused on their here and now treatment, Menopause is just a word, isn't it? They maybe think, oh, it's my period stopping. Well, don't care about my periods. I've got breast cancer.

But it's the whole symptoms and array of symptoms that can occur. And also the permanence sometimes as well, especially as they get older as well, which can be very frightening for them, can't it, actually? So we see a lot of women who really just want advice, they've realised that they're an appraisal they might have downloaded the free app and read information or they've just spoken to other people.

But then they often don't really know where to go. And then the other thing is that most women, because they're living so long, the commonest cause of death in women who've had breast cancer is actually heart disease. And so when people have lasted and living longer, they start to think about other conditions, don't they? And they want to try and work to protect their heart,

protect their bones. And so they've read that low hormones can affect the heart and bones. So they just want to come and have a really open discussion, don't they? And so this is why you decided to do some research. So can you just explain, if you don't mind, what you did? Yeah, so I wanted, I suppose, to have more of an understanding of what had gone before with women that came to see us at the clinic. Because certainly when you opened the clinic three years ago, it would have been a very unusual thing for someone with breast cancer to even consider, I'd probably coming to a menopause clinic, but there was a huge sort of surge in demand

and women realizing that there may be somewhere they could go to get help. And I wanted to understand more about what led them to come to us. So I essentially, the first 75 patients that had come through our door that had a diagnosis of breast cancer in the past, I sent a questionnaire out to find out really what had happened before they came to see us. Yeah, and it was hugely illuminating. There was really good feedback from the questionnaire, which is quite good and probably shows the enthusiasm of what the patients felt about their experience. But, you know, we asked lots of questions, but essentially about like how long they'd been having symptoms, for example. And the average time for the patients that responded was seven years, which is, you know, seven years is a hell of a long

time to be struggling. And that actually can be the case for women that have not had breast cancer. but I mean the worst case had been struggling for 24 years without having... 24 years. Help or advice. That's 30% of most people's life. You know, that was very illuminating. And I wanted to get an idea of what sort of symptoms were troubling them the most. And yes, hot sweats and flushes were extremely troublesome for most of the patients.

But actually, as we often find with all women going through the menopause, the psychological symptoms always come out at the top as the most. problematic. And that was, wasn't it? Because it's 42% was the psychological, whereas the vasor motor flushes and sweats was 36%. So the symptoms, the psychological symptoms affect women the most with their jobs, their home, their lives, don't they? Yeah. And the brain fogs, they can't think straight, they can't plan anything. And the poor sleep obviously has huge knock on effects to your fatigue levels and, you know, lack of sleep is a form of torture, isn't it? And then there were, you know, there's plenty of other symptoms as well, but also one of the most problematic symptoms,

probably two most problematic symptoms that are often even worse for women that have had breast cancer treatment, the vaginal symptoms, which can be very difficult, and also the aches and pains in the joints, especially women that take aromatase inhibitors, that can be very problematic as well. So they were the main things. And, you know, we need a big awareness for women that yes, they need to know about the menopause, but we also need to be really open and talking about sexual health after breast cancer, because that often is the hardest thing to talk about, but is so common and can be extremely severe in women that have had breast cancer treatment. And that of all of the symptoms is actually the easiest to treat and we have the

most sort of safety data and reassurance about treating that treatment is just hugely effective and so many women have inadvertently delayed getting treatment because they either didn't mention the symptoms or they did mention them but weren't getting help. So we found in our survey that 60% had vaginal symptoms, but only 10% had actually received any vaginal estrogen for it. And as we know, that's safe. That was really difficult to know that there's so many women out there struggling

and that there should be easy ways to tackle that. So say those figures again, Sarah. So 60% of the women had either vaginal symptoms or vaginal symptoms and urinary problems as well. So often things like recurrent UTIs and cystitis and things. But only 10% of them had received any vaginal estrogen prior to coming to see us. And vaginal estrogen, just for those of you who aren't aware, is very different to systemic HRT. It just localises, isn't it?

So it's a pezzaria gel, is a ring, it's creams. And they don't get absorbed into the brain. body so people can have them if they have been advised not to have systemic hormones and they really treat the underlying cause because they're caused by local estrogen and those tissues can become very thin, very friable and it's not just actually for sex isn't it? I've seen a lot of people who can't sit down. They can't run underclothes. They can't even walking can be very uncomfortable because the vagina valve or that whole area is meant to be stretching and move, isn't it, with us? And also like you say, urinary symptoms can be very much.

common, can't they? Yeah. So it's really, really difficult for it. And the longer the problem is there, the longer it takes to reverse it as well. So that's why it's really important that women don't just struggle on. Yes, there are non-hormonal treatments that can be used if things are very mild initially. So there's moisturisers and there's lubricants. But actually, as you say, to use vaginal estrogen is safe and highly effective and very readily. available and it can be life-changing for women. And so we really need to improve confidence in women talking about it and asking about it and also confidence in the healthcare professionals that this is absolutely fine and appropriate to do. Absolutely. And so you also ask them

whether they've received help or support or felt that they've been involved actually in their decision making that treatment. So tell us a bit about those results. What I kind of wanted to know was who do these ladies go to in their journey before they come to us? And actually, almost 90% of them had had a conversation with their GP about their symptoms. And 70% of them had spoken either to their breast surgeon or their oncologist or both, who obviously would be the sort of automatic people to talk to. You know, most women are still involved with their breast care team. and also obviously everyone has a GP.

So they're the most obvious people to ask, but only 10% of women that had spoken to anybody else before us felt they'd had any involvement in their treatment, which that actually to me is probably the most upsetting, I suppose, statistic that we did to know that actually all of us deserve to have a role in deciding our treatment about anything, whether we've got a sore toe or a chest infection or menopause after breast cancer.

And to feel that you've lost your autonomy to have any choice about your health is really sad. It's tragic, actually. I mean, that's really sad to the minority of women felt that they were involved in their decision-making. And, you know, I think that means that they've lost their autonomy almost. And, you know, if they went to go and buy a super-fast sports car, surely they can make that decision themselves, can't they? No one's going to stop them and ask them which study has shown which car is the safest? They can choose whatever they like or if they want to go skydiving or I don't know, whatever they want to do, it's up to them actually, isn't it?

And not just for women who are breastcuts, this is for anybody, actually. We can make our choices and decisions. And I think it's really important, especially earlier this year. And June of this year, Nice to produce some shared decision-making guidance. And I really feel very strongly that every healthcare professional, probably every patient should read them. They're quite weighty, but they're quite a good summary. they basically just say that we should be involved if we're a patient, we should be able to share any decision. And the decision should be based on evidence, but also based on patient preferences as well.

Yeah. So if you told me there was a treatment that was going to make my right arm drop off, but it would cure me of my migraines. Well, sometimes my migraines are so debilitating, I would be quite happy to not have both arms, actually. So that's quite an extreme example And I can't think there is a treatment That would do that to me But again, we could share it And you could maybe persuade me

Perhaps Louise, you do need your right arm Because you're right-handed And we could have a discussion about it And as a patient, I could weigh up everything Maybe go away and have a think, maybe read a bit more, talk to some people Then come back to you and say, Well, Dr. Ball, I've decided this

And then it's really empowering And that's exactly the same In these sorts of conversations because we have talked in previous podcasts and I'm going to do some more about the evidence and we haven't got black and white evidence about whether HRT is good or bad. There's a lot of people think it's very bad for women

who've had an estrogen receptor positive cancer. But actually, estrogen used to be a treatment for breast cancer, didn't it? Yeah. And we know from some studies that induces something called apoptosis, which is programmed cell death. So, and again, I think this comes down to what type of estrogen

it is, but we just don't know whether it's good or bad. But there are some studies that say women do better, but we know that women have less risk of heart disease, for example. But we also see a lot of women in the clinic who have had breast cancer 10, 20 years ago. And so a lot of oncologists and breast specialists say that if it's been more than 10 years, then their risk of recurrence is not really there. I know there are always exceptions to the rules. Of course there are. But we see women, I remember the first woman I saw who had breast cancer who just said to me, do you know what, Dr. Newsom, I want to die standing up because I'm on my knees and I can't live like this. And I know how hard it is to have breast cancer. I know how hard it is to have chemotherapy and

radiotherapy and a mastectomy. And I actually, those treatments were nothing compared to how I'm feeling now. Every night I'm waking up in pain. I'm screaming out because I've got bone pain. I'm seriously, don't want to carry on living like this. I worry about what I'm going to do. can I have some of my own hormones back? And actually that was quite an easy decision for me to make because, you know, also giving HRT is reversible. So she could, I often say to women, you can try it for three months

and then you can make an informed choice based on how you feel. If you want to stop it at any time, you can stop. But actually, you know, if you were overweight, you'll be producing more estrogen than what I'm going to give you because it's very low dose. And then they often come,

back and say, goodness me, I'm taking any risk. And that's up to them, I think, isn't it? Yeah. And I think I always remember when I first became a GP and on my day number one, my trainer said to me, the great thing about general practice is that there's always something else you can do. And I've always remembered that. And I think the problem with women with breast cancer is there is so much fear and misunderstanding about why they got their cancer in the first place and what's going to help them in the future, that the overwhelming sense that we got from these women, because we also invited them to actually, you know, write about their experience and why they came to the clinic was that they felt made to feel guilty that they had had treatment and were lucky to

be alive. Or that's how they were made to feel after breast cancer. But they felt so awful as a result that they felt it was wrong of them, it was unjustified of them, to mention their quality of life was rubbish or to ask for more help, like they were ungrateful for the treatment they'd had, or that they might be discharged from their breast clinic if they started to complain about their menopausal symptoms. And so I think some of them come, because they do want to explore whether hormones is an option, but actually some of them just want to know about other options. And unfortunately, other options are often never discussed beforehand. It's like, sorry, you've had breast cancer, the doors shut.

And that's just not right, because there is always something you can do. And talking about hormones is important, but talking about their lifestyle is crucial. And most in our survey had never, no one had ever talked to them about their lifestyle before. And there are, you know, complementary therapies like CBT, for example. And there are some alternative medications that don't involve hormones. They have their pros and their cons, and there isn't able to. perfect alternative, but there are other things. And women want sometimes just someone to listen to, which is really crucial. They want someone to validate how they're suffering and to make them feel

not guilty. And they want to know, is there something I could do? And what are those options and what are the pros and cons of those options? And so I think even, you know, I don't expect GPs to be able to have the sort of in-depth consultations that we can do in the setting that have. But to shut the door is extremely dangerous because that woman gives up hope and probably won't have the wherewithal or the resource to come and find additional help. And so I think we have to all learn that there are always options for anybody with anything and that you have to keep the door ajar. And you've done and been responsible for producing so many helpful resources as well. There are now more ways of women finding out whether there is no option

for them and that they could And I think that's really important. I certainly always try and say any patients I see, if this doesn't work, then there is something else because I think that's really useful because when they think they've come to them to the road, they think there's no point coming back

and that's not just with patients, breast cancer, any patients, I've always done it as long as I've been a doctor because I think it's really useful because I always want to know that there's something else that I can do. But it is being listened to, I think, is really important because we know how,

frightening and lonely it can be to be menopausal. And then I think to be menopausal and have had breast cancer is even more scary. And then to help meet menopausal, breast cancer and not be listened to, is it absolutely crucifying for these women? And I remember a few years ago when I was working with them's police, I was doing an event in an evening, just educating people. And there was this lady who was sitting there and I could see her crying as I was talking about the menopause and I felt so guilty. And then afterwards, I went up to her to see if she was okay. And she said, you know what? I am that woman with all those symptoms. And I've had them for years and I've now got osteoporosis.

And she said, my spine is so painful. Just walking's really uncomfortable. And she said, I had breast cancer 25 years ago. And I just haven't had any help. And I don't know what to do. And I think it's too late now. And I'm thinking about all the years. And it was so, so traumatic. And I remember them thinking, but there's always something. There's always something that anyone can do. And it was a great article that I'm sure you've read by a professor talking about women who've had breast cancer. And it said they've fallen off a cliff. That sounds really dramatic, actually.

And I don't want this podcast to end feeling really doom and gloomy. But I feel like these women should have a parachute. So when they fall off a cliff, someone lifts them up and helps them. And even if it's helping them with knowledge. actually and a pair of ears and I remember one of a doctor who started working with us not long ago I had seen a lady who had breast cancer and she said oh louise I feel like a bit of a fraud because she came we had half an hour talking about various options about lifestyle about different ways of improving her heart health her bone health but she didn't go away with

the prescription and i didn't really talk to about HRT because she wasn't on the car so she didn't really want to and i said but did she thank you at the end she said yes she said that was the best half hour I've had when the healthcare professional. I said, well, there you go, actually. And like you say, the door's always open. And I think the other thing is, is that no decision you make today has got to be set in stone or concrete. And that's the same for all of us, isn't it? Because we've said no to a treatment today doesn't mean that in five days or five years or five decades that we can still say no. Because if circumstances change, then it might be that women are prepared or want to, take a treatment or stop taking a treatment as well. Yeah, I think I learned a lot listening one of the

earlier podcasts with our other amazing colleague Melanie Martins who talks about breast cancer from her role doing the same job as we do, but also having experienced this herself. And that really resonated with me because of that idea that you can only make a decision for you when you're ready with the information you have at that current time. That will change. And so, So the decision you make 10 years ago, maybe different to five years ago, might be different to today. And that's okay. But I feel it's our role as healthcare professionals to give the information in the first place.

And you're quite right. You said earlier that actually you may be told about menopause when you first have your diagnosis of breast cancer and your treatment is being planned, but you can't take that in at the time. Unfortunately, then what happens is the woman goes off on her treatment journey and never gets back to that point. she's forgotten that you ever mentioned the word menopause and she's just living in this physical and emotional hell often and can't find their way back to that information so the booklet

that you and jennie and mel have written which is on the menopause doctor website is really really helpful because you're having a booklet which you could get out again when you're ready to have that thoughts with yourself and those conversations is really helpful yeah no it's it is so important medicine is just not black and mine at all and i think it's also very important that people are treated and respected as individuals. And I know sometimes when I read comments on social media or just from patients telling me things and saying, oh, my cancer dogs, my oncologist would be really coarse.

They wouldn't allow me, they'd forbid me. And I do think in medicine we can never say no. I don't think anything. I mean, with my teenage children, I find it hard to say no, let alone with patients, because it's listening to them and understanding why they want to do what they want to do. And perhaps saying that's not a good idea, Let's talk about it, but not saying no.

So I think this research is fantastic, and it would be great to repeat it, actually, and see how things hopefully have changed in a few years' time. But it certainly sparked. And I really want to thank you for doing the research. Because of that, we decided to put the booklet together. And like you say, with two of our doctors, Jenny and Mel, it's been really great and really well received by a lot of people.

So that's available on the Balance website. So people can download it, they can share it, they can print it off, They can store it for when they want it. But thank you so much, Sarah, for your time. But before we end, you know, I'm going to ask you for three tips. So just for women who maybe have had breast cancer, either recently or in the past, what three things would you say for them just to feel that they've been listened to? I think, firstly, don't feel guilty about how you feel.

The menopause is a leveller of all women. And as we've mentioned, it can be even worse for women that have had breast cancer. cancer. So you're not complaining or moaning or being weak. It's really important that we tackle the menopause and that we are a whole body. So although when we are diagnosed with breast cancer, the health of our breasts is of crucial importance. We are a whole body with an attached head, hair, skin, bones, vagina, heart and all those things. And actually, if you only ever focus on the health of your breast, you're missing the much wider picture. So, you know, be on open about how you're feeling. Secondly, the genital urinary syndrome in the menopause is very

treatable and safe to do so. So always you really can't go wrong in trying to tackle that, even if you're not ready to tackle the other parts of the menopause. And thirdly, to understand about choice and that the informed decision-making guideline, which you mentioned, is absolutely crucial. And we should be listening to women, but we should also be finding out what's most important to them. What's not most important to us, what's most important to them, And even if they choose an option, which we wouldn't choose for ourselves, is actually irrelevant. And we should allow women to be involved in the decisions about their care. It's their life.

And that's what we went into medicine to do. Very, very wise words. So thanks again, Sarah. And I'm sure I will be inviting you back for future episodes. So don't think you've got away with it just because you've done for. So thank you ever so much for giving up your time. I really appreciate it. Thank you very much, Louise.

For more information about the perimenopause and menopause, please visit my website, balance hyphen menopause.com, or you can download the free balance app, which is available to download from the App Store or from Google Play.