The Dr Louise Newson Podcast - 133 - Recognising and getting help for your perimenopause with Dr Rebecca Lewis

Episode Date: January 4, 2022

Dr Rebecca Lewis, Clinical Director at Newson Health, returns to the podcast for the first episode of 2022 to discuss the perimenopause with Dr Louise Newson. The experts explain what the term means, what’s happening to your hormones during this phase, and how it can be diagnosed. Rebecca offers practical advice on how to speak to your healthcare professional to convey the range of related perimenopausal symptoms and raise the issue of hormones. Find out what your increased health risks are when your hormones change and what you can do to mitigate these risks. The perimenopause is discussed as an opportunity to take stock and consider introducing some small changes to your lifestyle that will improve both your physical and mental health. Rebecca’s 3 top tips if you think you might be perimenopausal: Take control and think about balancing your hormones and protecting your future health Get a diagnosis earlier rather than later, download the free balance menopause support app and start tracking your periods and symptoms Consider HRT to help your symptoms and feel better, and then you can look at making changes to your lifestyle that will benefit your future health and wellbeing.

Hello, I'm Dr Louise Newsome 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 I've got back with me in the studio, Dr Rebecca Lewis, who some of you will know. She's the medical director with me here in my clinic instructor, Bonavon. She's also one of the directors of the balance app, the free app that

we have. She's also a director of the not-for-profit company. We have Houston Health Research and Education. She's a very good friend, mentor, and also a GPA of menopause specialist. So lots of great things. Thanks Rebecca for joining me today. Thanks for inviting me. It's lovely to be here. So we thought we would talk today about the perimenopause. Obviously, I spend the majority of my life thinking and talking about the menopause, but the perimenopause is something that happens to most of us actually, and often when we're not expecting it. So we thought we'd spend a bit of time talking about today because I haven't done a podcast dedicated to the peri menopause. So just explain

a record, what does peri mean? What does peri menopause mean? It's a new term for a lot of people. Yes, it is. It's a relatively new term actually in the world of menopause. But well, let's start with menopause. Menopause is really a year and a day after your last natural period. Meno means month pause to stop. So the peri menopause is the time leading up to that last period, which can precede the last period by about 10 years. It's a time when the ovary starts to fail. It doesn't just stop completely. It starts to fail as we run out of eggs. And at this time, as we're running out of eggs and the ovaries beginning to fail, we start to fail to produce reliably the hormones, estrogen, progesterone and testosterone. And so the perimenopause can actually precede the final period by 10 years, actually. That's quite a long time, isn't it? It's 10 years. Well, it is actually. So it often takes women by suburb. surprise because if we look on average, the average age of the menopause here in the UK is 51.

So if we said the perimenopause can proceed that by 10 years, that takes us down on average to the age of 41. So that's interesting. So that means that most women will be perimenopause in their 40s. But we also know, don't we, that one in a hundred women under the age of 40, probably more actually, have an early menopause. Yeah. So if you're not peri menopause are in your 40s,

it's only really because you've been menopausal at a younger age. Exactly, exactly that. If it hasn't happened in your 40s, it's because you've already gone through it earlier. And that's quite hard for people to understand, isn't it? Because we see, and I certainly, I'm sure you've got friends, I've got friends who are in their 50s, and they say, oh, no, I've not menopause at all yet.

It's not approached me. My periods are still fine. But when you talk to them, they say, oh, yeah, I'm really tired. I'm full of sleep on the sofa. That's right. A bit more anxious. My daughter's learning to drive. oh my goodness, I'm so stressed all the time or whatever.

But if you say so, are you perimenopausal? Oh, good Lord, no, they'd say. No, they'd say no, wouldn't they? They would. And I think it's just, as you say, it's a lack of understanding of what happens during this time. You know, I was pretty naive about it, to be fair, that the information was not out there. And it's getting there, thank goodness. But how can a woman understand that if the information isn't there?

So many women are brought up to expect flushes and sweats. And, of course, you know, 20% will never have those anyway. way, let alone the myriad of symptoms, which are often much worse and much more devastating for an individual, that they don't recognise as due to their changing hormones. And this ambushes women and healthcare professionals, unfortunately. Yeah. And I know I went to teaching a while ago now about menopause and it had this graph about different symptoms. And it started with hot flashes. Yes. And then it went to mood symptoms. And then it went to vaginal dryness. I'm sure you've probably seen the similar side. And it was almost like the progression of the

menopausal woman. Yes. And I sort of started and I thought, well, I'm sure not everyone goes through the same. And then, obviously, having seen thousands of women through the trinit, a lot of women actually present with vaginal dryness, don't they? And never get a hot flush. Like you say, oh, I've seen some women who've only developed hot flushes in their 70s.

So they've had 20 years of these other quite vague symptoms. They've often seen by cardiologists for their palpitations and rheumatologists for their joint pains. They've often been on an antidepressant or two or three different antidepressants. And then they've presented with flashes and people think, oh gosh, what else is going on? So this whole, it's not a formula, is it? You can't predict with a symptoms. It's not a sequence of events that's going to be the same for everybody.

And that's the key is, you know, it never ceases to amaze me that some women will have drenching night sweats. Another woman will never have a night sweat in her entire life. Yet they're both men are pausal. It's as individual. The symptoms are as individual as the person as a woman in front of it. you actually. So then there must be a blood test or something. Can't we just get a blood test? Oh, that's it. Well, no, because, you know, as we know, Louise, it is so important that the woman understands what's going on because the diagnosis is a clinical one. Actually, at any age,

doing a blood test to look at your hormones over the age of 45 is a complete waste of time and not recommended. But even younger women, actually, I don't know what you think, but even younger women, I know we work out for the nice guidance, which is the National Institute of Health and Care Excellence, guidelines now six years old. Yeah. And they say a blood test may be helpful between the ages of 40, 45. Under the age of 40, we should be doing this FSA-B blood test, but I've stopped doing them actually in my clinical practice because I don't think they're

reliable, are they? Yes. I don't find them helpful at all. I mean, sometimes one can do them. If it's elevated, it's a little addition to the diagnosis. But so often a woman may come and see me and she's 42 and she's got bond or symptoms of menopause, she can't sleep. She's exhausted all the time.

She's got her migraines getting worse. Her muscle and joint pains are worse. And her periods have changed ever so slightly. And her FSA is the level we use. It can be normal. And that should not cloud a clinical judgment. Clinical diagnosis of the pain and manor is absolute key. And so often these blood tests are not helpful for us.

No. And I see quite such a women who have had a blood test or they've done it themselves because there's some ridiculous things that are advertised. There's a urine test, there's deliber test, there's the finger prick ones. They're all very, very unreliable. So any of you listening, do not bother. Don't waste the money on them. But we see people who have gone to various places, they've had blood tests.

And they say, well, I've been told I'm estrogen dominant. My estrogen level is very high. So therefore, I don't need estrogen, but I think I might be perimenopausal. And often, they're only got high estrogen at that time, haven't they? It's a snapshot, isn't it, really? Yeah. And I think, you know, at three in the morning when they've got crippling anxiety or a night's wet, their level won't be high then, it will be low. So our hormones are changing all the time,

aren't they? Completely. I mean, you do a blood level and it can be quite high that morning, but that very afternoon, low again. And this is characteristic, particularly of the perimenopause, isn't it? We have, you know, the oscillation, the fluctuation of our eastern levels is enormous. High one minute, low the next. And actually, when I tell women this, they nod and they say, oh, that makes sense. I feel that in my body. One moment I feel that. okay, next minute I'm plunged into terrible anxiety or out of nowhere the palpitations come and my confidence has gone and I feel at the whim of my hormones because the eastern levels are fluctuating so much and that is really bad news for our recent receptors all over our body

and gives rise to such disabling symptoms, often symptoms of perimenopause are much more dramatic in fact than a woman who is older who has had a period of adoption. Perhaps in the late 50s. Yeah, and I think that's important, isn't it? So our hormones don't just decline. Their average is declining, but they're going up and down in a very chaotic way, aren't they? And so for some women, that means they have times where they feel absolutely fine. And then they'll have other days or weeks or months where they're feeling awful, like you say, but some people will have very high levels of estrogen. And there is this term estrogen dominance that's branded around. And I'm not really aware it's such a thing, because

women don't remain estrogen dominant for a long time. As you say, that average level is low, but if you catch them it could be high for one transient snapshot, really. That's right.

I mean, we know for some women their progesterone seems to lower a bit sooner before their estrogen, but we also see a lot of women who have only been given progesterone, because they've been told they've got too much estrogen in their body.

And they quickly run into trouble, actually, because it might stabilise things for a month or two. Yes. But the natural way, it's down for estrogen. So then they quite quickly find their estrogen's declining. And when you give HRT, it often equilibrates the estrogen.

It stops this up and down. Yeah, your effect, doesn't it? That's right. I mean, the whole problem is this high, low, high, low, like a graph, it looked like a map of the Himalayas because it's so up and down. And actually adding in estrogen to it, the right dose for the individual will sort of more create a flat line approach.

So the body has a reliable, continuous source of estrogen, which is so much better for the body all round and for the estrogen receptors. And symptoms settle then when the eastern levels are consistent and reliable. It's this up and down. It's so difficult for the body and for the woman. Absolutely. But you say that it's a clinical diagnosis, but actually it doesn't have to be a clinician that diagnoses it, does it? I mean, a lot of women should be able to diagnose it themselves if they've got the right tools, don't you think? I completely agree. Women know, because they can feel this up and down for a start. They might not be able to verbalise it

completely, but they feel different. They feel something has changed. And actually, if they can sort of find out what's going on by downloading the free balance app and documenting their symptoms and how they may change before our period, because just before the period, our reaching levels are naturally at their lowest. And that could be the time when the symptoms are much more obvious, the flushes, the sweats, the muscle pains, the insomnia, the mood lowering. And And they can document that on the balance app and download a personalised health report that they can take to their GP. And then that starts the conversation. Actually, I think there's a problem with my hormones leading to these symptoms.

What can we do about it? Because the problem is because there's so many symptoms of the menopause. If you just concentrate on the worst one at that moment in time, which might be your muscle pains, you think, well, I'll go to the doctor and talk about that. But I can only talk about one symptom at my appointment. So you end up talking about muscle pains. And then, of course, that's investigated, over-investigated. And the next thing, the woman's referred to the rheumatologist, perhaps, or being given a diagnosis of fibromyalgia, or other muscular problems.

When actually, if there was just a chance just to step back and see, well, it's not just muscle problems. It's insomnia, some flushes and sweats and a change in the period, just a little one maybe from a 28-day cycle to a 30-day cycle or 27-day cycle. the balance app has downloaded that health report, then immediately the healthcare practitioner can also see that this is perhaps all due to hormones. And the answer actually is replacing those hormones to alleviate symptoms. And for the future health, of course, because the other thing you were saying about Eastern dominance, if Eastern is not replaced, we have health risks

due to low estrogen levels. Yeah. So it's really important. And it's very difficult, isn't it, to know? Because if you look at the questionnaire, some of you have seen it on the balance app or if you put in search engine questionnaire for the balance hyphen metaphors.com website, you'll see the questions. And most of us at some time will have had those symptoms. And there's a snapshot, one off. It's very hard to know. But actually, if women are having periods, and it might be they're still regular, but they become more heavy or lighter. So any change is really important to document. But then there are other women who don't have periods because maybe they've got a marina coil in or they've had a hysterectomy. So again, it's doing this thing.

questionnaire every three months or so and then taking a bit of time to think has things changed and why am I feeling low and tearful and emotional and my sleep being poor and having it aching joints or whatever and then I think that would then alert people to start that conversation and certainly as a healthcare profession if someone comes to me armed with knowledge it's so much easier and it's not just in the peri menopause or menopause I mean I'm sure you've been the same when someone you've got someone in general practice who's tired and a bit worn out and they say to me, do you think I might be deficient in iron? And then I've done it a lot and I feel really embarrassed to say this. And they've been women and I said, oh, what are your period? It's like, oh, they're so heavy. I can't go out for two days

a month. And it's like, right, yes, you will be un deficient. Of course you'll be tired. And you know, it's the patients actually tell us, they guide us all the time if we're listening, but they have to be armed with the right information. So what's happening, we know is that women are going with one or two symptoms. And quite rightly, the healthcare professional is focusing on those one or two symptoms. Whereas I think if women, we have a duty almost, don't we, to say to our healthcare profession, do you think it could be my hormones? Do you think I could be perimenopausal? And I think the healthcare professional will thank that patient for us three months. Oh, I'd be so grateful like you, because it's so difficult in, say, general practice, when you

only have 10 minutes, it's ridiculous, it's not long enough at all, you know, to make a full assessments. If the woman has done that work before and at once at a glance on this health report, you can see, oh, I can see, hang on, your periods are changing. They've got a bit further apart and a bit heavier. And I can see that you're having all these symptoms just before your period when we know your eating levels are low. And all at once, the pieces in the jigsaw fit together. And the answer is hormonal problems due to the perimenopause or menopause. And then solutions can be found and you can then have a conversation of how you'd like to manage that Yeah. And I think some people will say, well, if I'm having, for example, palpitations, and there are other reasons why people have palpitations. So there are conditions such as atrial fibrillation or SVT, a superventicular chakidia that clearly needs appropriate investigations and often the correct treatment.

Yes. So then some healthcare professionals I train to say, well, isn't that dangerous that you're saying it's all due to preparing menopause and they might have a heart defect, for example. So I often say, and I hope you agree that if you think someone's perimenopausal, you can absolutely manage that. But anything else you're worried about, if it's their heart or their joint pains, of course they might have arthritis. They might have a heart condition. Well, they can still be referred to the appropriate investigations or given the right treatment. And the chances are everything will improve by the time their referral comes through. But what's happening is a lot is that some people are thinking, well, let's. Let's work out your palpitations first and then do the hormone bit, whereas I'm sort of saying, well, we can give hormones anyway, but we'll carry on doing the other investigations.

So would you agree with that? Completely in tandem. I completely agree because, yes, you're absolutely right. Other things cannot be missed, just like you've said about palpitations. And that may be a very appropriate thing to be referred for an ECG or 24-hour ECG, now I'm even seeing a cardiologist. but also if the hormone problem is being dealt with at the same time, we can see how these symptoms, if it were to be due to the hormones, how they improve with time.

And that's helpful. Absolutely, which is really important, isn't it? So let's just think about treatments. So we've talked about, or we've mentioned, HRT, hormone replacement. Well, if a woman's perimenopausal, we're not replacing, are we, hormones? We're sort of topping up, really, because the over is still working, albeit not 100%, but it's a woman. it's perhaps dropped down to 80%.

So we just have to top up a little bit to get back to the normal physiological female levels. Nothing higher, but just back to the normal levels. So HRT is really bad, actually. In some countries, it's called MHT, so menopausal hormonal treatment. Yes. Hormonal therapy. But actually, I still think that's bad because it's not menopause in this case. It's perimenopause.

Yes, exactly. So it is just a hormone. And so, but if you look at the way that HRT is, license in the UK, you know the BNF, the British National Formula, the Bible that we all have, or you can look online, then we're actually, as healthcare professionals, only allowed to prescribe it if it's really a year since the last period, people are menopause on. Isn't that right? Yeah, ridiculous. That is actually what it says on the licensing part of HRT. I mean, how ridiculous is that? Why do we have to wait for a year after our last period? Well, we've been deficient for 10 years

prior and having health risks due to that deficiency, importantly. Well, I think this is the other thing, isn't it? And I think for some women, actually, their perimenopause can be worse than their menopause. Oh, I do think that's true. Yeah, I really do. You know, we see a lot of women who have been five, ten years after their menopause. And they, when did you first get symptoms?

Oh, I remember because my cat died and I was 42 and I started to get symptoms, but I thought it was because I was buried, you know. Yes. And then you sort of talk and they say, oh gosh, yes, I remember now. I gave up my job then. And then actually I couldn't concentrate. And I thought that whole window was really awful. And I was getting these sweats.

And the sweats are seem to improve. And they talk through this history. And then they're often saying, well, I feel so much better now. Maybe I don't need HIV. But it's not just about making people feel better by giving the topping up with the hormones. It's actually, like you say, these health risks. And we know that estrogen, and hopefully some of you have heard me talking before about it, is so anti-inflammatory in our body.

If we've got inflammation that's occurring without estrogen, there's an increased risk of diseases, isn't there? So talk us through the diseases. That's right. We know that the health risk, the menopause, due to low estrogen levels or fluctuating the low estrogen levels, are increased risk of heart disease, increased risk of osteoporosis, type 2,

diabetes, poor cholesterol profile, increased risk of obesity. The brain tries to compensate due to a lack of estrogen and lays down fat cells around the middle area, which is not good for our cardiovascular health, because these fat cells do secrete a very weak type of estrogen, which isn't really helpful, but it's the way the brain tries to react when it detects these low eastern levels in the periomopause and menopause. So obesity or gaining weight around the middle is also another risk factor from that menopause. And other things like increased problems with cognition and not being able to think straight and correctly. And we know that young women who've had their ovaries removed under the age of 45 and are Eastern deficient, therefore,

have a much increased risk of all diseases, about 34 diseases, including dementia, diabetes, obesity, heart disease, even things like asthma. And, you know, and drug addiction is increased if the hormones aren't replaced at a young age that has been shown. Yeah, and certainly mental health issues as well. Oh, yes. Even psychosis and mania and obviously clinical depression as well. So the power of hormones is really, really important. And often it's not until you have them replaced or topped up depending on where you are,

you realise how much you've missed them. And I think we hear that a lot, don't we? Yes, it's only when you look back, don't you feel? you can see how much you were suffering once you're feeling better. Patients often say that to me. Yes, because they sort of think, oh, they're not too bad. And I think it's because it's a gradual thing. And the other thing is I think we're saying about women diagnosing it.

I actually feel that others should be looking out for it in their friends or family or work colleagues, don't you think? Because some women, insight is lost almost because you're so busy often at this time of life. The children perhaps might be leaving home or you might also. alternatively have very young children because you've had them later in life. Plus, you might have older relatives to look after. You've got a career to run. It is exhausting anyway. So naturally, a loved one will say, well, no wonder I'm exhausted.

I've got all this on my plate. I'm feeling a little bit low and flat because life is tricky. You know, bereavements are common at this time of life, unfortunately, as well. But actually, it's not just that. It's their hormones that are causing these problems. And we normalise so much. we normalise our symptoms time and time again. Yes, I'm a bit stiff and achy. Oh, well, maybe I'm getting older. This is what it's like on my 40s and 50s. And it doesn't have to be this way. Women put up

with so much without questioning it and they don't have to. And it's insidious, as you say, because unless you've had a surgical menopause where your ovaries have been removed completely, as we were saying, the ovary just doesn't stop. It's a stuttering stop. So some months it might be working quite well. And the next few months it doesn't. And then when you've got your symptoms, when the ovary is not working well, you attribute it to the normal things going on in life, work, children, you know, pressures of life. And then it happens again. But because it's not every single day and every single month to start with, it's insidious.

And it can take some years for women to realise what's happening to their bodies. But if we can get onto that quicker, then we can save women leaving jobs. We can save a lot of mental health problems, which is vast. Women are really suffering due to their hormones. some women very severely. We know that many women are given antidepressants inappropriately because their mood is low. And if they just talk about low mood, understandably, many healthcare professionals will think it's depression.

But actually, when you dig down, it's not just low mood. It's increased anxiety and a host of other menopausal symptoms due to their low hormones. And actually correction of the hormone will help their mood and sleep and anxiety. So it's really clear that a woman gets onto the diagnosis. notice or their partner. I think partners are really quite insightful because if the woman can't see this fluctuation because life is so busy, often someone standing outside, so maybe a colleague at work or their partner at home can see a change, can see something happening. So it's education, as you say, of women, their partners, the workplace, everyone, society. Absolutely. I think it's so important.

And we've just developing an area on the balance website actually for partners because it is often quite partner seeking help that's really important. But even my 10-year-old actually came home recently and she said, oh, mommy, I think Mrs. Whoever, I'm not saying her name, is menopausal. And I said, why do you say that? She said, wow, she has a fan on her window. And every sort of, she just walked out and she looks flustered. She didn't used to be like this. I think she's menopausal. I said, why didn't you give a copy of my book? Oh, Mommy, that's too embarrassing. But it is interesting, actually. And she will be right. I know exactly she will be right, because this lady, I don't know how old she is, but she looks, she's in her late 40s.

So, as you were said at the beginning, in the podcast, by definition, she will be peri menopause or menopause or if she's had an early menopause. So we need to sort of realize actually the importance of picking it up. And there's two reasons for that. There are options to help improve symptoms, but also for future health as well. And having the right dose and type of HRT, so that means estrogen, that means progester, That means progesterone or a progestogen, if women still have their wound. And often it means testosterone as well for women, because that's an important hormone too, isn't it?

Completely, yes. The ovary produces more testosterone than estrogen, actually, three or four times the amount. And we see a natural decline in testosterone levels from midlife onwards. And we know that testosterone can really help, not only libido, which is proven to help, but we have seen how much it can help in cognition, memory, concentration, fatigue, even sleep and mood, a lot of women have found felt much better with the testosterone replacement. After all, it's our missing hormone. It is a hormone that if it's not replaced, women will feel that quite often.

Yeah, and I think it's also very important when women are thinking about their perimenopause, is thinking about, right, this is a start of something that's happening to me and my body. And like you've said, it's an individualised experience and journey, if you like. but actually it might last half, a third, a quarter, I don't know how long of their life. And so it's a good chunk of time. Yes. So I always think, isn't it really important to be as healthy as we can? So you know like that time when you might be thinking about having a baby and you think, right, I really need to, not that I did smoke, but I would really need to stop smoking, reduce my alcohol. I want to be really fit. And I don't want to be overweight when I start to get pregnant because it's going to be harder to shift that weight. So all these things, which are very important. And I also think with the perimenopause, it's almost like a really good time to think, right, what is my diet like? Can I really eat rubber? like I could as a teenager. No, I can't because my metabolism is changing. Now, I know I've got an increased risk of osteoporosis and heart disease and dementia. What lifestyle things can I do? Right, let's look at any bad behaviours. Let's look at my sleep. Right, maybe I should be changing my

exercise. Maybe I should be thinking about how much alcohol I'm drinking. And then also looking at making the right diagnosis, having the right treatment, thinking about hormones. But it's that whole, it really takes a bit of time, doesn't it? But it's an investment for our future health this time. Completely. It's a real trigger time, actually, because we potentially, if the average age is 51, we've got 30 or 40 years ahead postmenopausally, which is an enormously long time.

And, you know, most people would like to live for as long as possible. But the key here is as healthily as possible. You know, we really want to not become disabled and weak and have dementia and muscle aches and pains and be miserable in 80 years. We want to live life to the full for as long as possible and be as healthy as possible. So as you say, it's an ideal opportunity to sort of take stock. And lifestyle is so important, as you've said, you know, the diet, the exercise, the weight loss, the alcohol intake.

But actually, if you're suffering with the menopause so badly, often your mind is not in the right state. to take on lifestyle changes. For example, how on earth can menopause a woman who is so tired and has so much muscle and joint pain, how can't she exercise properly? Of course, she can't. So what I've seen is, of course, giving HRT, replacing, correcting the hormone deficiency. Woman then feels back to her normal self. And then is in the right mindset, her body's feeling able to exercise, challenge herself

about perhaps stopping smoking or reducing her alcohol intake because she's feeling strong. She's feeling well. And we all know to make changes, you have to come from a good place and start feeling well as a platform to launch that change. Yeah, I think that's really important, actually. And I think also people should not feel guilty that they're not making all these changes together. There's a lot of pressure actually out there from various menopause groups, but also lifestyle groups, well-being groups, to say, come on, exercise your way through the menopause or change your diet and you will fall better. Absolutely not for a lot of people. It's looking everything together is crucial. That's right. I think it can be just too much for some women

and overwhelming when they're feeling overwhelmed anyway. Some people will be fine, but others really do need to feel better before they can make the next step in changing their lifestyle. Absolutely. So hopefully that's given people a bit of flavour. There's more information. There's actually a booklet on balance website of balance hyphen menopause.com website. Obviously my book is called preparing for the perimenopause and menopause. It's not a plug for the book, but I took quite a lot of, well, I had to force the publishers actually to add peri manopause to the title because they weren't keen on it because it's a long word. But it's really important that we all are aware of it. So I'm very grateful for your time, Rebecca, but you're not going to escape without taking home tips.

So for three quick tips, for women who think they might be perimenopausal, what should there be three things they should do? So take control. This is a time to think about getting your hormones balanced, your future health. Number two, get a diagnosis early rather than later and download the free balance app to help you do that, to track your symptoms and your periods. Number three, think about having hormone replacement therapy to help your symptoms and then feeling better, you can launch from a healthy platform to look at your lifestyle to make some changes that could be then forever for a healthier life.

Brilliant. So thank you ever so much. And I look forward to welcoming you back to the studio before too long because it's always great to talk to you. Well, it's lovely talking to you. Thank you very much for having me. 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.