The Dr Louise Newson Podcast - 153 - Learning how to prescribe HRT as a GP trainee with Dr Thulasi Naveenan

Episode Date: May 24, 2022

In this episode, Dr Thulasi Naveenan talks to Dr Louise Newson about her experiences as a 3rd year GP trainee working in a central Manchester practice and learning on the job when it comes to HRT prescribing. The conversation covers working with patients from different cultures and with interpreters or family members, challenging misinformation, health risks after menopause and gender differences, and introducing the topic of hormones at 40-year health checks. Thulasi gives an honest and reflective account of what she has learnt about women’s health and hormones in her last 7 years of practising as a doctor. Thulasi’s advice to clinicians learning about menopause: Always have hormones in the back of your mind and there is no younger age limit cut off. Don’t be afraid to ask patients about their periods, vaginas and symptoms. Don’t be afraid to ask about what you don’t know, use resources like the balance app and NHMS to find out more information. Find your local expert and seek out their knowledge and experience. If you’re ‘junior’, don’t be afraid to challenge more senior clinicians – they may not be as up-to-date on the latest practice. You can follow Dr Thulasi Naveenan on Instagram at @tnaveenan and on Twitter at @ThulasiNaveenan   Since the recording of this podcast, there has been further discussions with Cancer Research UK.

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 on the podcast, I'm very excited to introduce you Tulsi, who I've recently met remotely, like a lot of people I know, and I thought it would be really interesting to hear more about the work that she's doing. And she's

actually just told me this is her first podcast recording, so no pressure there. So it's really lovely to connect with you and hear about your work. So welcome. Thank you, Louise. Yeah, you're definitely a role model for me as a future GP, qualified GP. The work you've done around the menopause is just so inspiring. So I'm really glad to connect with you. Oh, thank you. So Terriot, you're in Manchester and I trained as a GP in Manchester. So I really miss Manchester, actually. It's a great city. Lots going on. Lots of diversity. Lots of really interesting people. And I enjoy where I am now, but I still, my heart's always in Manchester. So I'm very jealous the thought of what you're doing actually. And I did say to you before, if I went back in time and was doing

my GP training again, I would give, especially women, a lot different time than I have done. So you're in a great opportunity, you know, to really change and treat women in a way that I have mistreated them. Unfortunately, because I didn't have any menopause education when I was at your stage of my career. So you're training to be a GP at the moment, aren't you? Yeah, so I'm in my third year of GP training in central Manchester. I think you're totally right about the diversity and also we have some of the worst health outcomes in the UK and lots of inequality. And I work in Wally Range, which is just such a beautifully diverse area. You literally have every different demographic.

And it really chime with me what you said about mistreating women because we had an excellent menopause teaching session with Zoe Hodson, who I think works with you as well. Yeah, it's great. And that just blew my mind. I had no idea about micronized progesterone or the risks of the transomeration, any of that stuff. And I'd already done my first ever HRT prescribing. And I'd prescribed, I think, L.S. Stuart, you know, tablet just like, because I didn't, I've suddenly got faced with,

I had the really great consultation. This woman wanted HRT. We'd really fully explored everything. And then I was like, how do I counsel about what to prescribe and how to prescribe and how do I do that? And I was completely flummock. So the lucky thing about virtual consultation these days is you can be Googling on the side. And just like, how do I actually prescribe HRT and what? And then there was 50 million.

It felt like there were so many different options. And so I went with the tablet. And then when I found out that it was the highest risks and probably the worst one, I felt terrible. I don't know. I've really done this woman a disservice. But actually when it came to a three months of you and I sort of had to say to her, look, I've learned a lot more so I could put you on this whole new regime.

She's like, oh, I'm totally happy. It's completely changed my life. Like, I'm really glad you prescribed me the HRT I have. So, you know, I think that's the thing I love about it. It's such a hard thing to do well, but when women really improve on it, they come back and they love you and it's really satisfying. It's very transformational medicine. It absolutely is.

And it's very interesting you say that. So I did a survey about six years ago now of healthcare professionals. And this was healthcare professionals that were part of the primary care women's health forum. So they were more interested in women's health. And what we did is we asked them how they prescribed HRT. where did they get their knowledge from? And some of them was that they knew already.

But quite a lot of them literally just were using the BNF in the consultation. So the BNF is the British National Formulary. It's either available online or there's an app or there's the old-fashioned book with very, very thin paper because it's got every single drug we can prescribe. And it is a minefield, actually. And you're absolutely right. I used to prescribe tablets all the time because I had no idea that there was anything else. I didn't even know patches and gels were a thing until about 10 years ago, which I'm very embarrassed about, because no one taught me.

And every time I opened the BNF, I would look at all these names and I'd think, what are they? What do they? And they all have different amounts of estrogen and different types of progestogen. I put one on one and then they'd come back and they'd have side effects. So I would try another one. And then I didn't even know if they contained the same amounts because they were different names and then they'd come back. And then it was just, I was finding it too complicated, actually. And so then I went to an amazing lecture and did some more education about menopause.

And then like you, like when Zoe came to talk to you guys, I thought, oh, actually, estrogen through the skin has no risk of clot. It's the same estrogen as we produce. So we're replacing like with like. How wonderful is that? The micronized progesterone, the body identical progesterone. Well, that's great. If we give it separately, women can then be in control of their dose a lot more.

They don't have to keep coming back to say I'm still having some flushes. I think I need a bit more estrogen. They can just give themselves a bit more. It just all made sense. And I was really cross that no one had told me before, actually. And then I was asked by the Primary Co. Women's Health Forum to write an easy HRT prescribing guide, which I did. And I've since updated it for the society that I have through my not-for-profit.

And when we first launched it, we had thousands of downloads very quickly. And they weren't just from GPs. they were from patients as well, who often then took it to their GPs and said, I would like this, actually. And I think GPs quite like it because they can learn from that as well. So it's interesting, isn't it? Yeah, for sure. I find it interesting. I had a patient, I just switched to patient onto, I added in microinized progesterone for a patient. And she was like, you know, I've been reading about this, but I just assumed that the GP would know this is what they needed to do in this situation. So I didn't want to bring it up because no one had before. And I thought, I think actually our patients,

often the ones that come forarmed and have read a lot about HRT, it makes it such a better consultation. And actually, what I found is doing an HRT consultation, it's more than just one. Because for some people, it depends where they are on that journey. Some people, the idea of HRT is completely foreign, never even thought about it. Some people know exactly what they want. I remember women came to me and said, I didn't think body identical was available in the NHS and I don't want a product made out of horse urine.

And I was like, I didn't even know they were made out of horse urine. I think they're made out of yams because I had teaching from Zerri, but it was such a different levels. And what I found really interesting is the cultural differences. So for some women, just the idea that menopause is anything, but a completely natural thing that we, you know, just have to live through. And when I've had to do it through translators, it's incredibly challenging. So I know you've made resources on balance, which I think might have become use in health now, but... No, it's not. It's still, it's balance. The website used to be menopause doctor, and now it's balance hyphen menopause. So, but you're right. We've got

few, we're desperately needing some funding so that we can do some more translations. But things get lost in translation. In some countries, the languages don't have words for menopause. They don't have words for vaginal dryness. Even some of the psychological symptoms associated with the menopause, there aren't words, are there? So then that's very difficult for people to describe. It's really challenging. There aren't the words. And I remember I've had to do consultations about sort of more sort of sexual dysfunction and issues around that. And the translator is just like, I genuinely don't know how to phrase this in a way to make her understand because she just doesn't understand, you know, she doesn't know how to talk about these things.

And I don't know how to talk about these things. And it's really always makes me quite sad. And it's not maybe just a cultural thing. It's probably a worldwide thing in terms of women's health has never been as bigger priority as men's health or just the things that affect men. So women are just expected to sort of put up with a lot of things like, you know, having heavy problematic periods. Oh, that's just what everyone's going through. I'm like, no, there's definitely something that can. be done about this. And I was so, I was trying to think actually when we're talking about education,

I don't think I had a single lecture on the menopause in medical school. I did some teaching with the foundation trainees and that helped make my flowchart to some extent. And it was great. They're so interested in doing it well and prescribing well. But, you know, it's taken me, I've been a doctor for a very long time because I did some other things before GP training. So I've been about seven years qualified and it took this long for me to actually get some good education around it. I suppose it's what GPs do as opposed to other types of hospital doctor, but it's just sad. It's not prioritised. Yeah, but it should be, isn't it? So every specialty sees adults, and if they're seeing adult women, then they have to know about menopause,

because obviously it gets everywhere. Either the symptoms or the health risks that occur, the diseases that are associated with the menopause. But I do worry about how to reach more disadvantaged women. And, you know, when you're talking about translations, I remember doing a translation just before I left general practice and I worked near Birmingham. So a lot of women who are Asian and one lady came and she came with a translator but it was her son. And she was coming with total body pain. She was really struggling. She had been putting on weight. She was just generally not happy and she'd been given lots of painkillers. And so I started to ask about the menopause and so her poor son was just awful. And

Well, not awful. He was awfully embarrassed and didn't really know how to ask the right questions. And I remember asking about whether she had any urinary symptoms, whether she was getting up at night time to pass water or going to the toilet more frequently. And he asked the questions. And she answered with loads and loads and loads of words. There were sentences and sentences. And he just said, no, she's got no problems. And I said, oh, is that really right? Are you sure? Do you mind asking her again? Is she needing. to go more often at nighttime and she could understand the nighttime and she started, you know, nodding and talking and he just closed it and didn't want it to me. And I thought, isn't that interesting actually? Is it because he's embarrassed and it might be because it's his mother? Is it because he's male? Is it because she's female? Is it because she's Indian? Is it because

I'm Caucasian? I just got no idea and it was really difficult and I thought actually I'm going nowhere this consultation, this is really difficult. So it made me realise how hard it is, because if these women can't access the information, then they're never going to get help, are they? No, not at all. And I've noticed a lot with the women that need translators. Often it's the husbands who are, you know, writing in because we use an online system. And then they do the consultation on behalf of their partners. And I've actually taken to just saying, no, I'm going to do this with a translator. I do you like to do it face to face because that helps a lot as well. and that's really improved things

but you're right I think it's a lot that for men these are things that well actually older men might also understand the need to get up in the night time and go to the toilet and understand what age because men sort of go through a you know their hormones change as well so and more elderly person might have been able to

I guess it was probably a whole combination of those things or it was partly like I don't think any of these things are particularly medical so I'm not going to translate them for the doctor so it's really difficult yeah and it says perceptions as well like you say I did a presentation yesterday for the government legal team

and they're a really great audience but somebody, one of the questions, said, what about those women like me who absolutely did not want HRT because why would we have anything unnatural in our bodies? And it's a very interesting concept and then I was also

battling, I do a lot of battling emails where I'm just so in despair with misinformation and there was one to cancer research and I don't know if you've seen they've got this lovely poster about ways to reduce cancer and they've got things about obesity and smoking are really important. And at the bottom, they've got reduced taking HRT. And so I challenged them about it and they said that their cancer prevention team

have worked out that 1,500 cancers a year could be saved by women not taking HRT. So I said, well, where's the evidence for that? And then they came back and said, well, we know that estrogen and progesterone are carcinogenic, i.e., they cause cancers. So I said, sorry, there isn't any evidence for that either. And certainly when you talk about estrogen, we know that estrogen reduces risk of cancer, including breast cancer. And they said, oh, no, we didn't mean estrogen.

We only meant the estrogen in HRT. So then I went back to them and said, well, actually, Easterdalen, the HRT we prescribe is exactly the same. And so how can our own hormones be carcinogenic? I'd really like to speak to your cancer prevention team. Anyway, they got an automated email after that to say they'll be responding within 10 days and I haven't heard yet. But there is this thing that what we're giving as HRT, like this lady in this question yesterday, is like it's some awful drug and we shouldn't be using it because for most of us,

the menopause occurs naturally because we age. But actually, there are so many other things that happen to us because we eat. age in medicine such as hypertension or raise cholesterol or even you could say osteoarthritis is an ageing process but do we not treat it of course we do so how do we say well sorrow we can't treat a hormone deficiency that's going to affect you for at least a third of your lives probably it seems madness and I do remember you know that is actually a graph that stuck with me since medical school the cardiovascular risk the way it just shoots up after the menopause a lot of our risks shoot up to the same level as men and And so it's sort of in passing, it probably is something to do with the hormones changing.

But there wasn't then made a link to, guess what, we're going to make drugs that can help that and help reduce people's cardiovascular risk. It's interesting, isn't it? And it's a bit like osteoporosis, if you look at the figures of osteoporosis in older people, when I say older over the age of 50, so it's still not old. I'm only just over 50. I don't want to think that I'm old. But it says that one in two women develop osteoporosis over the age of 50 and one in five men. So, you know, you don't have to be a medical person to understand that the incidence is far higher in women than men. But then you look at Alzheimer's disease and dementia so much more higher in women than men. Then you look at autoimmune diseases, so, you know, rheumatoid arthritis, celiac disease, thyroid disorders, far more common in women than men. Then you look at clinical depression. Who's more likely to be depressed?

women far more common in their 40s. You know, fibromyalgia, far more common women between the ages of 40 and 50. So if you were coming from outer space and trying to help improve disease, you would see this pattern, wouldn't you, and say, well, what is it about women? And especially women in their 40s, because their health seems to get worse. And then in their 50s, it gets even more worse. And then look at COVID even. You know, there seems to be something going on where COVID, you know, the

mortality far higher in men than women. Oh, but then over the age of 50, that mortality difference seems to be less. What happens? So it's all there, isn't it? But no one's joining the dots, are they? Yeah, it's interesting. I did have somebody come back to me from a long COVID clinic saying their respiratory consultant, I think, had said, you know, HRT and long COVID is shown to be beneficial. So I think people, there are connections out there, but I almost think, you know, we do this sort of 40, I think it's a check around your 40s. I don't know if it's really happening as much now because of our backlog in general. But we offer people this a check at 40.

And I don't know if anything is included in that for women. No, it's not. About HRT and about the menopause. And you think it's such a key transformative thing in your life. And in fact, the way I found out the most about the menopause, I feel slightly sad about it. But it was mostly my mum telling me about everything that she was going through. And she was reading a lot about perimenopause and menopause.

And I mean, I was younger then. I think I've just come out of medical school. And I just thought, I don't want to know. I don't want to fear these things that are going to happen to me in the future but I wish at the time I sort of thought about it more from a health perspective and thought how can I make my mom's menopause a better one but it's just it's interesting isn't it it's something that all women go through but it's been a hushed up subject I don't want to medicalise something that's normal but we do have body

identical drugs out there that can make women's lives not better to improve their health outcomes I know I totally agree I mean I'm absolutely not for giving medication unnecessarily But, you know, over the years, we've been giving statins for raised cholesterol. Without good reason, often with women for primary prevention of heart disease, we've been giving antibiotics for a current urinary tract infections. We've been giving antidepressants for low mood. We've been giving painkillers for headaches. But we haven't been thinking about the underlying cause as well.

And, you know, certainly there's a lot of young women who have early menopause. And these women really need to have hormones, because the health risks really escalate. The younger woman is, the longer she'll be without her hormones. And so it's really just a natural replacement medicine as opposed to a drug, really, isn't it? And it's trying to understand and allow women to understand, but also allow healthcare professionals to understand

that a bit of investment in a woman's time, whether it's at their 40 check, or whether it's because they're coming with fluid, menopausal symptoms is really good investment because these women are less likely to come back in the future with symptoms, but also with those health problems such as osteoporosis or heart disease or whatever. We have, you know, it's every contact counselling for many things and I think menopause should be one of them and it's certainly something I often, when I'm getting to the point with a patient

who's around that right kind of age and we've got multiple symptoms, they come up to GP many, many times, I just start talking to them about, you know, this could be the menopause. It causes all of these various things. Is HRT trial something you'd be interested in? Because, you know, we've tried everything else. And you can end up giving someone a natural hormone replacement as opposed to 50 different other drugs for all the various individual symptoms. I mean, it seems like a bit of a no-brainer to just consider it more.

But I think it's just never been something that comes to the front of your mind until you really learn about it. And it is, you know, prescribing it. it can be challenging, which is why I try to make this flow chart to make it very straightforward. Yeah, so tell us about the flow chart then. So I'm a central Manchester trainee and everybody has to do a group QI project. My group is called the Weekday Warriors and we all are sitting around thinking, what would be important to us to try and improve in daily practice?

And the thing, even though we'd had Zoe's wonderful teaching, we're still finding prescribing for the men and Paul's hard. And one of my colleagues had got this sort of hand-drawn-out flow chart. and we thought let's try and make this pretty. And at the time I was actually taking some time off from clinical practice for a number of reasons. So I had the time to really just really deep dive. I watched all that. So there's a brilliant on 14 fish, which is our trainee program.

They've created a whole menopause, what do you call it, a course. And then there's a forum where you can ask questions, which is just absolutely brilliant. And they've got excellent videos on that. So I think I watched all the videos. I watched all the various consultations, read loads of the different guidelines. So you've got, as you said, the easy HRT prescribing guide is brilliant. But I thought, let me try and get it all onto the basics, onto one page, flag these other resources that I've used. So that when it comes to that moment of actually prescribing, you know what to do.

And I try and break it down into the different options and sort of explaining, okay, these are things with the lowest risk for these reasons. And I've got a lot of great feedback from you. And I've got, and most practices seem to have a menopause champion of some description, which is great these days. And there's always one GP who really knows how to. to prescribe it well. That wasn't my experience in my first placement because after I came back from Zoe's teaching and was mortified that I prescribed, you know, this. And I started chatting to my supervisor about Mike Kronized progester and he just looked to me rather blankly and said, I just prescribe a patch. And every time I get telling him about all these various different

things and how you could prescribe me, he was still like, can't I just prescribe a patch? That just seems a lot more straightforward than what you're trying to get me to do, which is actually some of the same things of the poor foundation trainees when I did my first flowchart and try to talk them through it. I remember one just kept asking, can I not just prescribe a tablet that has both the hormones and that's easy? So I think to prescribe well is quite hard, but having it kind of all set out in front of you so that you know exactly what to write in the actual box as you're prescribing it can help. So that's what I really tried to make it do. And I like different colours and trying to make it look nice because I think people like using things that are

prettier. Yes, it is so much easier. And it's a great resource. And I think you're right, People do get really concerned. And I hear concerns, two ways, actually. I hear concerns from healthcare professionals saying, can't we just prescribe one, it's so much easier. But also concerns about patients. A lot of people, healthcare professionals, will say, oh, but the women, won't they get really confused taking two products?

Or they might forget to take the progesterone. And then they'll just have estrogen on its own and it might cause problems. Well, in my experience, women are not stupid, actually. And if they're given information, then they're quite happy taking two products and having a bit of control and autonomy as well and certainly a lot of people I see are already taking an antidepressant, a painkiller. Often they're taking other drugs maybe for their blood pressure or for their cholesterol or something else as well, which they often can reduce with time. So you're giving them two medications, but it will reduce other medications as well. And

there's a big move, isn't there, with polypharmacy, trying to get people off as many medications as possible. So women in my experience aren't flummox. The big thing that I feel really sad about is that it's two prescription charges. So for women who have to pay for their prescriptions, then that's a real problem. But a lot of the combination patches, people still have to pay two prescription charges anyway. So the sooner we can, as soon as the government can work properly with NHS England to reduce that prescription charge, that's going to make a big difference, isn't it? You're right. That's going to be a huge difference. And I think we're trying to you know, prescribe for longer periods of time as well to help women in terms of prescription charges.

And I suppose that's the other thing. I mean, talking about disadvantaged women, we don't want cost of the medication to be something that puts them off. And I'm not sure. I assume, I'm assuming that people that don't pay for their prescriptions, you know, HRT would be covered by that. Then it would be free anyway, yes. So, I mean, and other hormone deficiencies, such as if someone had an underactive thyroid gland,

they get thyroxin free, but they also get all other medication free. So the menopause being a hormone deficiency, in my mind, everyone should have it free. Certainly women who are young in their 20s and 30s because it makes a big difference. But we do know that women from low socioeconomic classes are more likely to have oral estrogen. And one of the doctors I know well I was speaking to yesterday was telling me that she's just done a audit. So looking, a study looking in her area of how women are prescribed HRT and when they're considered to me, able to take HRT or when people are thinking about the menopause. And she said, the more straightforward women that are seen, so they don't have any other medical history, they're otherwise written well.

Menopause is thought quite quickly. You know, if someone comes in and they're a bit tired or they're a bit achy or they've got some low mood or whatever. But once someone has two or three other comorbilities, then it's lost. So she said if someone's got a psychiatric history, they've got a history of heart disease, if they've got a history of sort of learning issues or other problems, then the menopause just gets lost and no one asks about it. And that's really sad because actually those women are more likely to benefit from HRT actually, aren't they? So once women have established heart disease or they have high blood pressure or they have osteoporosis, of course they can still take HRT but they're more likely to have a better future health if it's considered early.

for sure. I'm not sure if it takes like a flashing up template every time saying have you have you considered the menopause? Have you discussed menopause with this woman? I mean we were talking about it the other day in our clinical practice meeting about how a lot of serious symptoms can be lost when someone keeps presenting with anxiety and we can keep putting everything down to that and actually and occasionally it's really not. You can be anxious and have something underlying all of that. Yes and I think that happens a lot more with women than men actually. We've now got these. M-U-S, isn't it, medically unexplained symptoms. And there's a lot of sort of anxious overlay. We see a lot of women with something called vulva dinia, which is pain in the vulva. And a lot of these women are seen by psychologists as well. Sometimes they're prescribed antidepressants, sometimes for their mood, but sometimes to try and calm the nerve pain. But no one's actually thought, well, what's the reason for their pain? Often it's because

they're menopausal and you've given the vaginal, estrogen and HLTAC, and everything improves. But people forget there's actually a cause for a symptom. They're sort of making the symptom the diagnosis. And that shouldn't happen in medicine, really. No, and these are all, you know, very sensitive, intimate things. Talk about. Women often present quite late anyway. They've been, you know, just soldiering on for a long time.

I've seen that a lot with stuff like in sclerosis, like in plainest. They don't want to come to the doctor. They feel embarrassed. They apologize for you having to examine them. I just find that incredible. I mean, I've had some interesting discussions, as I say, with Dr. Boli, who's our menopause champion, about how to discuss, you know, vaginal dryness with women. And she, interesting, I think it's for the primary women's healthcare forum,

she'd seen something about basically saying, if you're noticing your vagina more often, it's probably because it's dry and therefore. So, like, I just thought that would be quite interesting thing to ask women. And it's lots of things. Like, we don't really talk about sex enough, I think, either. And I heard a great consultation where at the end, it was a postpartum one, and just have you started having sex yet? And I thought, oh, that's a really important question, actually, because for a lot of women, if they've had tears or episiotomy,

all kinds of reasons, sexual intercourse becomes an issue, or postpartum, and we don't, it's not something. I mean, sometimes occasionally mention contraception, if I really do you remember it, and I try to, but it's not something, you know, we prioritise, talking to women about their vaginas enough. No, and I mean, I prioritize it in the clinic because it's one of the questions we ask on the questionnaire,

but I'm really shocked how few women talk about sex, but also how few opportunities they've had to talk about it. And a lady was telling me the other day, I've known her for four years, and she's had really reduced libido, really bad vaginal dryness. But her husband also has had prostate problems and has been impotent. And so she's now better, but he's still got problems. So he finally went to see someone, and he had testosterone deficiency. So he was better.

So she was telling me with his cheeky grain yesterday in the clinic, that she had the first time having penitished to sex since 2006. So a long time ago, they're happily married. And she just said it wasn't very successful because he had a few issues and performance anxiety of everything. But she was so happy that the thought of sex might be there in the future at some stage. And she said, I can't believe I'm having this conversation with you. She said, before I'd met you, there's no way I would ever thought sex would be

something we would ever encounter ever again. And I thought, I'm okay with that because I still love him, but actually it wasn't just the act of sexual intercourse, it was the act of having something intimate. And they could laugh about this sort of almost failed experience. But I thought, isn't that lovely, actually, because this intimacy is really lost so much from the menopause. And, you know, and us as clinicians, I think, often fail because we're not talking or asking the right questions. and then women and men aren't coming forward to explore how they're affecting and knowing that there is treatment available as well. I think it's knowing that there's treatment available.

And also, I mean, I don't know how many doctors would test for testosterone deficiency when it comes to impotence. It's various things. It's levels of knowledge, but also time. It takes exploring somebody's, their experience of sex takes quite a lot. It's an extra whole consultation in itself. So I think it just almost, if you're going to explore HIT, you need. at least 20 minutes to get the ball rolling, which I as a trainee am given that privilege.

This is hard, but it's a good time to be invested because it proves dividends going forward. So it's really important. But I think, you know, what you're doing with your training is amazing, with your knowledge is incredible, with the way that you're sharing your experience, actually. You're changing your lack of knowledge, not through any fault of your own, to actually be able to impart with others. So I'm very grateful for you talking today. what I wouldn't mind just to end with if that's okay, because I always end with three take-home tips.

If you could just say three things that you think any junior, not just doctor, but junior clinicians, so whether it's a pharmacist or a nurse or a doctor of any specialty who's just starting with their training, how would you encourage them to think menopause in their patients? I think it's just always something to have in the back of your mind. And in fact, there isn't really a younger, like a young. younger age limit cut off. It's one of those things that should just be incorporated, especially if you definitely are seeing someone around the age of 40, it's just a good thing to be asking and talking about. So don't be afraid to ask, firstly. And the second thing is, I'd probably say,

don't be afraid about what you don't know. Use the resources out there. I mean, News and Health is brilliant. The balance app is actually great to just have a look through. You know, I've made myself fake different versions of, you know, who I am. So I can, like, if I find I'm a woman who's had a total hysterectomy and what happens. But it's just, there's so much information out there. So don't be afraid to just deep dive. And don't be afraid to say, actually, I need to read up more about this before I go and prescribe HRT. Because I really wish I had just not prescribed anything that first time I was trying to do it and said,

you know, I'm going to go and ask some people about how they're doing it and do this properly well and just, okay, I figured out how this tablet thing works. And I think it's good to find your local expert and seek their knowledge and advice as much as you can. as well. And I think for juniors as well, don't be afraid to challenge more senior GPs who may have been doing their job for a long time, but they might not be as up to date on the practice. So if they're saying, I only know how to prescribe this one type, that doesn't necessarily mean that that's the right way to go. You might actually, sometimes you know a bit more. You'd be surprised, so trust your gut. Yeah, great. And I absolutely agree. You know, we can empower and educate anybody,

so not just junior doctors, but senior ones as well. And the more that we talk about it, the better. So I'm very grateful for your time today. And I really wish you success in your career, helping more and more menopausal women to have a very healthy and happy future. So thanks very much for your time today. Thank you. For more information about the perimenopause and menopause, please visit my website, balance-manopause.com,

or you can download the free balance app, which is available to download from the app store or from Google Play. Thank you.