The Dr Louise Newson Podcast - 160 - Thinking hormones in psychiatric consultations with Dr Devika Patel

Episode Date: July 12, 2022

Dr Devika Patel joins Dr Louise Newson in this episode of the podcast to share how a chance encounter when overhearing an educational webinar on the menopause was a light bulb moment for her practice as a psychiatrist. Devika takes us through her journey of how this knowledge from learning about menopause has transformed the psychiatric care she now offers to her patients. Devika’s 3 tips for those with mental health challenges who are in perimenopause/menopause: Don’t forget the important lifestyle changes (healthy diet, exercise, reduce stress, improve sleep and have meaningful connections with others) apply to mental health just as they do with menopause. When seeking help, go with your own data to your healthcare appointment. Track your moods with your cycle and really make any links clear to your clinician. If you don’t feel your healthcare professional is the right match for you, see someone else and advocate for yourself. Website/socials details – Instagram @drdevikapatel Twitter @drdevikapatel Podcast: “Our Extraordinary Stories with Dr Devika Patel”

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 Wellbeing 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 with me, I've got somebody who reached out to me like a lot of people do online and she hadn't really thought about the menopause for a long time, but she is a medical professional and she's actually

a psychiatrist and we're going to talk about how her eyes have been open to the world of the perimenopause and menopause. So DeVica, thanks ever so much for joining us today. Thank you for having me on the podcast. So I was doing, was it me that was doing a webinar? And your husband is a GP, isn't he? And I think you weren't really, it wasn't on your radar, but he was listening to and you started to listen. And you had this light bulb moment, didn't you? Yeah, yeah. It was an evening webinar that you were doing. It was during COVID lockdown. So we were doing all these kind of online learning sessions in the evening. It was quite the thing then. I was literally eating my dinner. It was there in the background. He was watching. and kind of 10 minutes in, you were talking about particular patients that were coming with lots of antidepressants and different medication, nothing working and then thinking about the symptoms in terms of the menopause.

And it really clicked for me. At that point, I had so many patients that I had seen throughout my training kind of come to mind thinking, oh my God, did I miss something there? Was that actually the menopause I should have been treating? And since then, it has really changed how I practice and how I think about women in a more holistic manner and definitely considering men. menopause their hormones in every single consultation that I do now. Which is amazing. I love it. I love hearing this like this. And it's very true because I think for many years, and it still is actually, menopause is thought it's a women's health specialty. And I was actually talking to the organisation of conferences and events for the Royal Society

of Medicine, of which I'm a member. And she said, oh, which category did you tick? Because there's lots of categories, you know, are you interested in heart disease, diabetes, mental health, barmacology, da, da, da. Actually, I can tick all of them because menopause is across every single thing. And I said, well, you're only allowed to tick a maximum of, I think it was four or five. So I ended up leaving it blank. So she is changing that.

But she said, well, we can do a women's health event. I said, no, it's not women's health, actually, because women's health is often gynecology, so it's contraception and endometriosis. Very, very important. But actually, it was only when I started my clinic where I just dedicated, obviously, my life to menopause. and hearing stories time and time and time again where women say to me, oh yes, I have 30 hot flushes a day, but it doesn't matter. I've got a bag full of clothes. I just change all the time in the toilets at work. But what really affects me is my mood. I'm not interested in things. I'm just existing. I'm not living. My zest for life has gone. I have no appetite for any enjoyment. I stop going out. I stop seeing friends. I'm a shell of what I used to be. And I don't know what's happening to me. And all these words are really strong. And then I look at how do we diagnose clinical depression? And in general practice, you know, we fill out these questionnaires, as you know. And every single practically perimenopause and menopause a woman would actually fulfill the criteria for being either mildly or moderately or some severely depressed. So I can see why people have been given antidepressants. But then I also have done enough psychiatry to know that there are differences. So a lot of the Women have really good eye contact.

They often really present themselves very well. And they've got really good insight. They say, this isn't me. This is not me. I'm scared of the way I'm feeling. I'm scared of these intrusive thoughts. I don't want to act on them. I don't want to harm myself.

But I'm just overwhelmed. And when I was doing psychiatry and you'll tell me whether I'm right or wrong, but there are a lot of people with severe clinical depression, they really don't care what they look like. They have no insight at all. So it is quite subtle. On paper, it's exactly the same, isn't it? But, I mean, what's your experience as a psychiatrist?

Now you've picked up on the menopause. Yeah, so I'll kind of take you through a journey of how I thought about using the knowledge I'd learned in practice. Of course, the main thing that I was doing was kind of listening to your podcast, accessing your educational material, but it wasn't anything formal. I wasn't taught by a psychiatrist how to kind of deal with this. So I kind of had to find my own path. So initially I got very excited by it.

And every patient I saw above the age of 40 that told me they didn't. have periods. I was like, this is the menopause. They don't need to be seen by me. It's the menopause. And actually, when I kind of spoke to them about it in that manner, that was actually very invalidating for them, because they had waited so long to be referred to me. And what they wanted from me was a diagnosis and then some medication. They'd already tried some stuff with their GP hadn't worked. So I was there to give them the strongest stuff. So I realized that approach was the wrong way. And rather than thinking it as it's either menopause or depression, just understanding, I need to see my patient in a very holistic manner. I need to be open to

the idea that there are possibly menopausal symptoms that are impacting on the depression, or it could actually be a depression mimicking a menopause. And when I started thinking about it in that way, rather than trying to be too rigid, working out which one it was, I was able to give my patients better care. So what I do now is I'll start having the conversation about periods, menstrual cycles, try to get their understanding of what they think is happening, try to get an understanding if they've heard of the perimenopause or menopause. I'm dealing more with the perimenopause I've found because people, when I ask them out the periods, then they'll be like, oh, actually, yeah, I have noticed a difference. But before they've been asked, they've not

really noticed that their changes in mood have also been linked to changes in periods. So I'm trying to get the answers out of them and tease out what's happening. And then what I'll do is I'll decide, okay, we're going to treat it as if it's a depression or anxiety and we're going to go for this. There's also going to be a point where we're going to stop and have to review the diagnosis. But at the same time, I want you to speak to your GP. download the balance app. I give them leaflet that you've also produced, which is really, really helpful, which it gets them to see that actually brain fog, poor memory, low mood, all these things. There's so many similarities between the depression and the perimenopause

or menopause. And that way I'm equipping them with the knowledge. They can go back to their GPNC, whether they need to start HRT or optimize their treatment already. And they can also be given them into health support alongside it. And I found that approach works much better. And I'm working. And is that helping? It definitely is. when I first started with telling patients, it was just all the menopause. It was not the right approach, obviously. But now what I have is patients coming back to me saying, thank you for that, because it has helped how I'm feeling.

And that's all I need, even if it's helping just 20%, 30%, it's not about finding the one cure. In psychiatry, we always think about things in a holistic manner. But somewhere along the line, menopause has been forgotten, and the impact of hormones on mental health has been totally forgotten. It's amazing, isn't it? Because certainly a lot of people out there, and I probably know have a lot of sort of haters and bullies,

and they think all I want to do is prescribe HRT and give HRT to everyone. But actually, it's not just HRT. It's about our mental health, our physical health, our well-being, what we eat, how we sleep, how we exercise, how we look after ourselves. And, you know, the mental impact of everything we do, you know, has a massive, massive effect. I mean, I do stanga yoga regularly. And I was saying to my yoga teacher last week, actually,

I really wonder what I would be like if I didn't do yoga and not physically but mentally because I know my brain would be scrambled. Yoga gives me a lot of mental power really to compartmentalise what I'm doing, to focus on the here and now and to not sensationalise and get too worried about things. And, you know, this is amazing ability, but that's not the HRT. That's not what I eat. I know it's yoga does a massive thing to me. But that's my choice.

and that's fine. I've been educated. I can choose, and a lot of my friends go running outside. Love it. Great. But actually, you're absolutely right. It's this missing bit and it's almost like it's a white elephant and people are scared. And then when I talk to people, we say, well, how do you know you're not missing depression? And well, actually, for me in the clinic, it's easy because a lot of women have been on three, four, five different antidepressants. Tell me they don't work. But actually, there are also a lot of women that do have clinical depression and are also perimenopause and a menopausal. And it's quite fine to treat with hormones and with HRT. And when I've spoken to other psychiatrists, I said, well, if someone had an underactive thyroid gland and they were feeling very low and flat and not much energy, would you just concentrate on their depression? Well, of course we wouldn't. It would consider thyroxin. And it's the same, isn't it? It is.

And I use the analogy of pain as well. So if someone comes to me because they're depressed because they have pain, their pain also needs to be treated. I can't just throw antidepressants. Yes, I understand they are clinical depressed, but we have to look at what might be causing that. And that kind of interplay between the menopause and mental health is so messy. We cannot ever be able to say 100% this is only menopause, 100% this is only depression, because the menopause can cause you to become depressed or you may be just depressed. It could be any combination of those.

And we don't have to come to a certain answer, like you've said. And you can always do a trial of HRTC, see how the people. patient gets on. The truth is that's what we do with antidepressants. When you look at the guidelines, it says trial of antidepressants. So you are trying it to see if there is any impact. And if you don't see impact, you're changing. Well, that's the same way that we should approach HRT alongside our treatment too. Yeah. And it's so important, is it? When I first qualified as a a doctor, we didn't have the luxury of the newer antidepressants, because I'm quite old. I'm older than you, clearly. And so a lot of it we gave dothiopin and even amatryptylene. And they have quite a lot

of side effects. And one of my consultants actually used to prescribe a lot of dothiopin to patients. We did a lot of rheumatology. Thinking back, I cringe actually, because a lot of these people were low in their mood. They had muscle pains, joint pains. A lot of them had lupus, actually. And he would always prescribe dothin and they'd often come back feeling better. But they had these horrendous side effects. And then I remember when Prozac was a big thing, great, but a lot of people found they were very anxious and became more anxious and hypervigilant. So then we had, paroxetine, which we don't prescribe as much now, but Certranine. And then we had Vendor vaccine. So these drugs are getting better with less side effects. So I think that makes

them easier to prescribe because they're better tolerated. And like you say, people either come back and say, I feel so much better or they don't, in which case these do sometimes change or reconsider the diagnosis. But then some of the drugs that are used in psychiatry actually switch off hormones as well, don't they? So if they weren't perimenopause, or menopause are beforehand. We might be inducing it. They will be after three to six months of some of your drugs, don't they? Yes. Yeah. That's really important to know. So any of the antipsychotics we use can increase the levels of prolectin,

and that can stop your periods. So we're inducing that as well. And it was really silly that I hadn't thought about that impact before. Like I think about it as, okay, you don't have periods anymore. We're going to measure your prolacting. But I never thought about how that can have a negative impact on mood. I thought about it purely from the physical health point of view. Well, I didn't either until literally a few years ago. So I remember working, I worked in style prison, a female prison, and a lot of those women are on antipsychotics, various medication.

And a lot of people have such low mood, but they also, they put on weight. A lot of people do their cholesterol because their cholesterol levels can raise. And we sort of talk, don't we often about burnt out sort of, you know, depression, But actually, I look at these people, you think, well, they must have all been menopausal. And we know cholesterol goes up when women are menopausal. We know blood pressure goes up. We know weight goes up. We know addictive behavior goes up.

And a lot of these people smoke a lot and then they smoke even more. And that's obviously compounding their cardiovascular health. And I think, gosh, I'd never even given them any hormones, didn't even cross my mind. And a lot of people measure prolactin levels. But then they don't think about estrogen but also testosterone. And it's a sort of medicine. castration really that's happening to women isn't it? Yeah, yeah, 100%. And just talking about kind of women and thinking about them as different, not just small men, in psychiatry, I still think

that we're behind. So finally, people are thinking about how women may need some extra support or a separate service. So perinatal services have emerged in the last five to eight years, which is brilliant. So it's looking at actually hormones are going to be massively different during pregnancy and someone with a pre-existing mental health condition or may develop something during that time so we need a specialist service for it. And the more I think about it, I think we need specialist services at the other two transition points, puberty and the menopause, just to make sure that we're looking at it carefully and think about. There just needs to be more research and more services into that area to think how do we manage this as something separate? Because

it is, there's an extra factor that's added in, not just your male counterpart. I totally, totally agree. And I think the whole reproductive depression is a really, John Stad has spoken about this for many years who sadly died now, he's a professor of gynecology. And it's really, really important because, like you say, mental health, well, even in adolescence, we always blame their hormones, but of course we probably should because they're changing all the time. But then postnatal depression, you know, we know women go from having levels of 10, 20,000 of Easter dial to nothing overnight. And then it's never given, hormones are never given back. There's a great unit, like you say, and they're giving heavy-duty drugs. But actually, no one's giving them a bit of

hormones. And then I read a paper this morning about treatment of PMS, Remenstall Syndrome or PMD, and they're saying, oh, just give short amounts of antidepressants for a few days, work really well, a lot safer than longer term, you know, everyday antidepressants. No mention in that paper, nothing about estrogen. And, you know, we see a lot of women, and I don't know whether it's PMS or perimenopause because they're in their mid-late 40s. They're still having periods, but the few days before they get this dip. it doesn't matter what the diagnosis is. The cause of their symptoms is usually this dip in hormones

so you can just top it up with some hormones. And it's much better to treat the underlying cause in medicine, isn't it, than put a sticking plaster on. Exactly. And with psychiatrists, we're using kind of two medications, antidepressants, antipsychotics mainly, and then we have our as required medication, sleep tablets, Benz diapines.

But I really think it's time that we are adding more things to our repertoire and hormones seems to be something that can help, especially for women's mental health, talking about things like PMDD. There's also, it can get as severe as having psychotic episodes during menstruation. And I've seen one case of that in my training so far. It's quite rare. But again, because it's rare, there's hardly any research done into it.

There's one really good professor in Brockington, who actually was the leader in getting mother and baby units set up and really looking into women's mental health. And that was in the 1980s, 1990s. we're kind of 30 years on and it doesn't seem to have really moved anywhere. And I feel the menopause, that's the biggest change that has happened really for women's health if we look at the last kind of two decades. But it's still we've got a long way to go, as you know, I feel like I'm starting what we're doing.

And in fact, someone came and spoke to my school. So this was in the 80s. And she came and spoke about her work. And she was a doctor. She's now sadly died. She retired soon after. So this was in the 80s, she must have been about 60 or then. And she was talking about hormonal variations that occur.

She was talking a lot about progesterone, but she was saying the natural progesterone. So this is the body identical progesterone. So not the synthetic progestogens have a really good calming effect on the brain and how they should be considered for postnatal depression and also for PMS. And the menopause, bitchy mentioned about estrogen, but I was looking at her Wikipedia recently and it's all there but everyone ignored it because she was a bit of a crazy woman and why would you believe women in the 80s who were in their field and I thought goodness me I don't want to go to my grave and not had any made any advance she must have been as frustrated as

I am and so but I think it's about how we train and educate and help psychiatrists and I'm very grateful because you invited me to give a presentation didn't you do want to talk about that Yeah, so as soon as I'd connected with you, and it was over kind of Instagram, and then you very kindly called me and I had a discussion and I actually, until then I knew that the menopause was impacting mental health, but when you discussed a few cases, I realized kind of how severe that impact was. So then I kind of, my brain switched on and I was like, okay, I need to get Louise in to speak to the rest of psychiatrists because I was kind of talking to my colleagues, but I was like, the impact needs to be great and then this. So I found my way onto a

organizing committee for a small conference that we do. in the West Midlands, and you were luckily free for that date, so you came to speak to us, and there was about just under 200 people that had signed up, and during your talk, we had 100 people live, and you were the first speaker to open the conference, and it was a virtual conference, but there was so much interaction. The chat was constantly throughout when you were speaking. There was an amazing question-answer session, which not only did people ask about, well, how do I manage this, how do I treat it, or, yes, I see this in my practice. It was psychiatrist talking about their own experiences and sharing tips like well if you want this you should

try this way I've tried this and even asking you well I want to get access to this how do I get around this or is there a loophole through this so I'll be honest with you when I the day before I was getting bit worried and I spoke to my husband and I was like I'm I'm not sure if people are just going to say like why did you bring this GP to speak to us about mental health we know what we're doing and I was really worried about how it would be received but my husband said look look, if you think that it's useful, I'm sure even a small percentage of your colleagues will find it useful. And that's all you need to do to have an impact for your patients. So I thought, okay, well, it's all organized now.

We'll see how it goes. And it was even better than how I'd imagined. And actually, it's been a month since that conference. And I still, when I bump into colleagues, they're telling me how great it was. And I've had some really good kind of just people telling me about scenarios where they've considered the menopause. So one of the most acute assessments that I will do as a psychiatrist. is a Mental Health Act assessment. And in that, we're considering where we're going to section a patient, they need to come into hospital, or we need to do something quite urgently because they're

quite unwell. And one of the doctors that come had mentioned in this assessment, which usually happens in A&E or patients on home, about their periods and their menopause, just showing how important it is that we talk about it at every point of care, whether it's the first assessment, it's in an emergency, because we don't know when it's going to be important to the patient's care. So it's something that we should just get into our kind of usual questioning. So yeah, that was really great. And I think there's been a lot more appetite for it. People are considering it. And I do hope that we can continue sharing and spreading the message amongst psychiatrists. Because like you said, education is the first step in awareness. It absolutely is. And it was really, I mean, I was equally

as nervous as you the day before thinking, well, I'm a crazy menopausal woman who's a GP. Why are they going to listen? And, you know, we have spoken to all sorts of academic psychiatrists and have wouldn't have been taken seriously, as you know. And so I loved it because I didn't enjoy it because it was through teams. It's so much nicer to do it in real life. But you could feel the questions of the energy and it wasn't just about their patients. It was about them. But then I also afterwards, as I often do with these events, reflect and feel very, very sad and thinking, our own profession is being let down. Would it be that there was another condition? The only thing I think about that's similar-ish is migraine actually

because that's really badly managed for so many women. And I suppose I'm more in tune because I have migraines. My daughter has debilitating migraines. But most other things I think people can access, you know, if you're in pain, like you say, or if you've got arthritis or if you've got a heart defect or if you've got palpitations, if you've got bladder problems.

There's somebody somewhere that you generally could get first level advice. Obviously, we always, often, if we're struggling, go and see another specialist or someone at a teaching hospital to get really top of the range advice. But I can't think of anywhere where healthcare professionals are struggling. You know, I always think the advantage of being a healthcare professional, there's not many, but one of them is that you always know the best person to get advice from. So if my children have been ill or my husband or when I had pancreatitis and was struggling, I can pick up the phone and speak to somebody. Whereas actually even with my own menopause, I only had one person in the country that could help me six years ago and that was a struggle to get to speak to him. So that's wrong, isn't it? You know, we've got to look after our own. And I think for, I'm not being sexist

anyway, but for men to be in that webinar and see the comments that women were making that were their equals, helped you just bring it home to be like, this isn't a them and us situation, like there's someone that doesn't know about menopause and that's why they're struggling. These are highly educated professional psychiatrists that know what's going on and still unable to get the support and help that they need. So it just paints the picture of how difficult it must be for that person that has no idea. They are just going to their GP, they're getting referred to us and they may not even think about the menopause or perimenopause. And that's where we come in. We have 30 minutes, 60 minute appointments. We have the luxury

of time compared to DPs. So we should really use. use that appointment, I can spend five minutes talking about menopause and that is all I need to drop them the information they need, tell them a little about it, find out what their understanding is and give them some reading material. And that is nothing in the grand scheme. And that's pivotal actually because everyone's pushed for time, aren't they? Healthcare professionals really push for time. But I think actually if we can enable people to just plant the seed. So even rather than doing very technical, detailed questionnaires, I often think if it's helpful. healthcare professionals, we just say, whatever specialty we're in, we say to a woman, could it be

your hormones? Yes. Do you think it could be your hormones? 80% of the time, you'll get the answer from the patient. And then it's, you know, as you know, one of the reasons I've developed the app is so that people can just do it in their own time. They're not taking anybody's time. You don't want to be sitting down, going through every single manitial point or giving a

questionnaire and filling it out with them. Just let them do the homework. And I think when women are empowered, even women that have mental health, They're still able to use their brain because they want to get better. And if they can't, then they usually have a friend or a carer or, you know, you work obviously with nurses and nurse assistants and anybody would be able to help. And some of the work I've done actually since the webinar is some psychiatrists and some other healthcare professionals have reached out.

And they've just realized it's them as well. And actually I find, like myself, I'm more interested because I've experienced symptoms. And I know how helping getting the right treatment really makes the difference. So if we have like-minded people who are sort of experiencing symptoms need to help themselves or have got help, they're more likely to help their inpatients and outpatients as well. So it's this whole ripple effect. But it's really important to get it through the mental health communities, isn't it? 100%.

And I was just thinking because I'm a general adult psychiatry training. So I tweet anyone between the age of 18 and 65. So I was like, this is really important for me. But actually, when I thought about all the other specialities, forensic psychiatry is really important because we have patients in that system that are on the wards for three, five, eight years, they're going to be patients that will be going through the menopause whilst they're admitted. That's important.

Our learning disability population, they may present with things like aggression or irritability, acting out behaviour, and the first line is always ruling out a physical cause to it. And usually things like infection or pain are looked at, are we thinking about the menopause or their cycles? No, we're doing some work actually. It hasn't been produced yet, but for learning disability. Amazing. And it was triggered actually by a patient who can't communicate very well.

Like you say, behaviour became very erratic, just very distressing for everyone. Couldn't work out the cause. But actually, she had really bad vaginal dryness. So sitting down was incredibly uncomfortable for her. She didn't have any urinary tract infection. So she'd had loads of, because that's one of the things. obviously that's screened for, but she was getting a lot of urgency, discomfort, everything else.

And just giving her some localised hormonal treatment, you know, absolutely transformed her behavior. But you can see I was getting very irritable, very cross. My husband's breathing was annoying me. Everything was just, I was catastrophizing. But I could, if I couldn't vocalize, you're scared. You know, it's a horrible feeling when something is changing in your brain and you've got no control.

So, you know, women that don't have English as their, first language and difficult to communicate. When we take histories through interpreters, we know so much gets lost in translation. But actually for these women who can't express themselves, because they don't know, and a culture might not allow them to say what they, how they're really feeling. It's very difficult then for us as healthcare professionals to make a proper diagnosis often, isn't it? Yeah, of course. So I just think it's really relevant to every psychiatrist, maybe not CAMs. That could be the only one I could think of, but I've also heard that you had your youngest patient that's seen you as age 14.

So there's probably even an indication. But there it becomes how are we thinking about hormones and mental health. So really at any point we should be thinking about the periods. Starting with that simple question and then seeing where it takes you and just leading with curiosity. Yeah, I think it's so important those initial questions. And as you know, I'm talking at the Royal College of Psychiatrists as well, which I would have done by the time this podcast comes out. So we'll see what happens there.

But I feel like we're the start of a great journey. And I'm very, you know, openly thankful to you, Divica, for actually, well, listening over your husband's shoulder and taking this seriously. And let's see what happens. So it's very exciting. So thank you ever so much. And before we end, I'd really like three tips, really. For people who are perimenopausal or menopausal, they think that they might or might not need their antidepressant. But they've been told that that's all they can have is the antidepressant.

So it's really what else can they do? And how can they start that conversation, either with their own GP or with their mental health team, because a lot of these people will be under mental health teams. So what can they do and what else, in addition to HRT, might be useful for them as well? So if I start with the easier things, as with menopause, there's medication, but there's also lifestyle changes. Well, the lifestyle changes that I would recommend for the perimenopause and menopause are the same that I would recommend for someone with depression or anxiety.

So those are things that you can do without asking any permission. And that's improving your diet, doing your exercise, making sure that you're trying to reduce your stress and getting important sleep and having meaningful connection with people. All those things are going to improve. Then my second thing would be that if you suspect it is perimenopause or menopause, you need to almost go to your appointment as if you're fighting your case. So go with all the data. So if you've tracked your cycles and notice that they're reducing, take that. track your mood to see how it's kind of playing out with different stages in your cycle if you're still having periods or just coming to the end of them because that's really useful data that we

can't ignore if someone presents that to me I'm not going to say it's all in your head or it's just depression it's not linked so really spell it out for that practitioner whether it's your GP or your mental health professional and then the other thing is you aren't always going to find a good match there are going to be some doctors that haven't yet learned about the metapause and parametopause. And that isn't the fault of theirs. It's the medical education system that isn't yet up to speed with that. So then I would just suggest going to see another doctor, whether that's asking for another psychiatrist to see or another GP. And there's nothing wrong. So I think the main thing is just to be strong and make sure that you advocate for

yourself because you might be ahead of the education journey for menopause and paramedopause, even more than your healthcare professional. That's okay. You can put the information so they they can support you. If you're not getting the help, you need to find someone else. So I think that really, really important, isn't it, is that we as patients are our own advocate, but we also use others as well. And actually know that the first opinion is not always the one that's right for you. I'm not saying it's not right because a lot of things are right. But if it doesn't feel right and it's not what you expected or if it's your partner or friend

and they come out and you think that doesn't, then see someone else. And I don't think any of us as healthcare professionals, I'd never mind if someone, one of my patients, sees someone, someone else. I think it's really important to get what's right for you. So that's really great tips. And I'm very grateful for your time today. And I look forward to maybe you're coming back in maybe a few months, years, let's see and see how this conversation has changed. And I hope it's much more different. And we're talking about all the new advances that we've made and the progress. I definitely think that is going to happen. We're just starting, like you said. So thank

Louise for letting me join you on the journey. Yes. So beginning of an exciting journey. Yes, 100%. So thanks ever so much and look forward to speaking again. Thank you. 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.