The Dr Louise Newson Podcast - 163 - When night sweats are not the menopause with Dr Susanna Crowe

Episode Date: August 2, 2022

Susie Crowe is a consultant obstetrician and gynaecologist who is passionate about advocating for and empowering women to understand their bodies and supporting them to make choices about their medical care and their lifestyle. In the midst of the pandemic, Susie noticed fatigue creeping in and put it down to burnout from her busy job. When she began having night sweats and saw her doctor, the menopause was the initial diagnosis suspected but there were no other symptoms of perimenopause occurring. Susie became more unwell and after months of having normal blood tests, further investigations revealed that she had non-Hodgkin lymphoma – a type of blood cancer. In this episode, the experts discuss women’s experiences of sudden onset menopause after treatments for cancer and the benefits and safety of HRT. Susie’s advice to healthcare professionals: Listen to your patients as they know their bodies best Have empathy for a women’s menopausal symptoms (as they may be worse than those from the cancer or side effects from treatments) and she may feel very vulnerable Prioritise personalisation and choice by providing the right information and encouraging your patient to make their own decision based on what’s important to them and their life. Follow Susie on social media: Twitter @susannacrowe Instagram @theholisticobgyn

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. Today on the podcast, I've got a patient and a healthcare professional. So it was really, really interesting because I'm going to listen to two perspectives, actually. So I've got

with me, Susie, who has recently reached out to me and has a very interesting story that we will go through. So thanks, Susie, for joining me today. Thank you so much. It's really nice to be here. So you were very complimentary in your email to me, which is very nice, but that's not why I invited you to the podcast. I have all sorts of emails and some are not as complimentary, but that doesn't matter. I think the important thing is about listening to women, actually, and we've all got different journeys. We all have different backgrounds, we have different lives, we have different experiences, but we also have different health as well. And I do, we'll tease this out, but I know from my own personal experience, being a medical professional

and a patient is just awful, actually, because you think you have more knowledge than you have. The first time when I was ill with sepsis after my first daughter, I thought I knew everything. And actually I didn't because I was ill and I needed someone to take control. But the junior doctors were too scared because I was a doctor. So then I got consultant-led care, which they never wrote in the notes. And there were all sorts of things that really quite scared me about being a patient because I don't think you get always the best care as a patient because people are bit apprehensive. So there's lots of things going on.

So if you wouldn't mind Susie, just explaining, because you're a gynaecologist. don't you? And so just explain a bit about what you do and then about how you became a patient, if that's okay. That's fine. So, yes, I'm a consultant obstetrician and gynaecologist. I've been doing it for 20 years this year, actually. And I love my job. So I'm a general obstetrician and gynaecologist. So I do intrapartum care really is my specialty around kind of high-risk pregnancies, but also managing risk, managing the labour wards, etc. And on the gynaecology side, I'm a benign gynaecologist. And I'm really passionate about advocacy for women, and that's why I went into the job. And one of the things I love about being a gynaecologist in particular is around informing women about their bodies so that they have the same amount of knowledge I have and then helping them to make the right voices.

On the obstetric side, I run a birth options clinic or ran a birth options clinic that really was around supporting women's choice and personalisation. So in particular women who want to birth outside guidelines, for example. So, yeah, that's who I am professionally. Great, yeah. And so important. I think being an advocate for our patients is really important, actually. And I don't know about you, but I didn't really learn much about that as a medical school. I had some great training, actually, with quite unusual then, actually, a psychiatrist that specialised in oncology.

And I always wanted to do oncology, cancer medicine. I did a lot of training towards it and then changed my job, really just for lifestyle and being married and everything. everything else. But he taught a lot about involving the patient right from the outset and sharing any concerns and also not just the patient, but anyone close to them as well. And also knowing that there's not a rush in medicine, you know, there are some things, don't get me wrong, if someone was having a heart attack, keep the time is in the essence. But a lot of things, even more serious diagnoses like cancer, we've got a bit of time to make sure we're really on board with our patients and we explore every concern, and it might not be apparent initially.

So I think being an advocate is a really important part of our job, isn't it? Yeah, and I agree. But it's also, I think, you know, I really hope that I provide really holistic care as well. So I'm a really massive believer in looking at the whole picture, but also thinking about advising women from the whole picture's perspective. You know, I'm a big advocate of diet and lifestyle and kind of weaving that into my practice as well. So it's about thinking about how we can. can help ourselves whilst also helping women to understand their bodies and the potential

treatment options, because often, you know, things will go hand in hands, won't they? Well, we'll need, you know, conventional medical treatment. But actually that, you know, we all know that there are things that we can do to boost our own health. And I think particularly with women's health, I think, you know, we have massive opportunities, particularly through pregnancy, but then, you know, as a life course to actually really pick up and be promoting optimal health for women. And I really see my job as being a big part of that. And pregnancy is a massive time because I don't think there's any other time in a certainly a woman's life that she has that much involvement with healthcare professionals, not just doctors, but also other healthcare professionals who can drip feed information actually. And certainly when you're pregnant, you want the best outcomes for you, but also for your unborn baby as well.

So it is if you can't get as healthy as you can or get as much knowledge then, then it's really hard. But to have months of time actually and even postpartum, you've still got time. Most of us never go and see a health care professional at all, do we? And we want to avoid it. So actually, it's a really prime time to get as much information. And like you say, holistically is really important. And certainly as a general practitioner, it's really important that we're not just focusing on one symptom or one disease. It's looking more. And preventative medicine has got to include holistic lifestyle education and information, hasn't it? Yeah, I absolutely agree. Yeah. So then moving forward,

as I said at the beginning, you've been a page, not one of my patients, I hasten to add, but what happened for you to become a patient? Yeah, so it goes back a couple of years now. So I think, I was reflecting on it this morning. I turned 40 in 2018 and just, oh, I was so happy to turn 40. I felt like I was in the prime of my life. I've got three children. I've got my consultant job that I absolutely loved, you know, and we have to acknowledge the effects of, you know, having pregnancies and children and, you know, the effects on your career and, you know, you're stopping and starting. And I finally felt that I was in just such a great place. I was really fit.

I was really healthy. And with hindsight, it was probably in the latter half of 2019 that I started becoming unwell, but didn't realize it. And obviously, beginning of 2020, we all know what happened in 2020. So the pandemic hit. And at the time, I was clinical director of women's services in the large teaching hospital in which I work. So changing and delivering the care that we needed to was just huge.

maternity care had to keep going throughout the panics. But we also had to completely change the way we worked. We had to make new guidelines. We had to work so hard. And we also had to really sadly and really awfully pause all of gynaecology, which we had to deal with as well. So I think in the midst of that context where I was working all the time, which I really was, and was also had lost, as we all did, the normality of our lives at the beginning of the pandemic. So those things that help us to feel well, you couldn't do anymore. You know, I used to have these fixed sessions where I would go to the gym on these two days a week and do what I did, which I absolutely loved.

I loved going out to gigs. I couldn't do that anymore. And so in that context, I was becoming more unwell, but not really recognizing it. And obviously, you know, it was burnout. I think there may have been a degree of that as well, being completely honest, because trying to work at that level in the NHS, that much pressure can be quite challenging. By the autumn of 2020, my night sweats started. So essentially, I was getting fatigued, but without really recognising it, still managing to do lots of exercise, still managing to work.

And then my night sweats started. So it was at that point, interestingly, that I first went to the GP, probably in about the autumn. And really interestingly, everybody said that it was menopause. Yes. So this is the interesting thing about my story. And I remember saying, it's not. I know it's not menopause. because I am a gynaecologist, but also I've breastfed three babies, and when you breastfeed, you'll have lower estrogen levels. I know what it's like to have lower. Was it a different sort of sweat? Yeah, it's completely different. It's so different.

It's so different to the sweats you get with menopause. It was just completely drenching. They just come on out of the blue. So, you know, they weren't having night, obviously, because they kind of start quite slowly. But I would be in a really deep sleep and I would wake up initially, like as though a bowl of water had been thrown over me. I suppose towards the end it was like a bucket had been thrown over me. Did you feel any warmth at all? No, no.

No warmth, no. And so I felt really strongly that actually if it had been menopause and I had that bad night sweats, I'd have other symptoms that were associated with low eustrogen levels. So I couldn't have night sweats that bad without having hot flushes as well, for example. And it's interesting. I mean, some people, I had nightswecks. I never had a hot flush at all, but I did have other symptoms as well. Exactly.

And I did feel this sort of warmth. but also when I woke up, I felt that I was then become more anxious, you know, very common isn't it, in the early hours when your hormone levels are low. My sleep was very interrupted. I got quite a lot of muscle and joint pains. I sort of these early morning symptoms were, so I did have this sort of variation with the day. So there are little things that, but the other thing is what's really interesting is that you as a woman felt that you know. And we'd learn so much from our patients, don't we? And I think certainly in women's health issues, not just in menopause, but endometriosis and PMS.

Women actually often know, don't they, whether it's their hormones or not? I know that sounds a bit weird, but they do, don't they? They do. I think this is it. You know, women understand their bodies. I think because of our hormonal fluctuations. We see it all the time, you know, I sit all the time my gyne clinic. I see it with my pregnant patients as well.

But actually, women know they know their bodies. We become quite attuned to them. And I knew as well that I had had no perimenopausal symptoms. Yes. None whatsoever. I felt completely well up until the point at which I was starting to get tired, essentially. And then these night sweats started. So yes, initially the first set was done in terms of blood tests and they obviously came back completely normal. And so we were kind of so watch and wait because all my bloods were completely normal. And then we did another set of blood tests and they were still

completely normal. And by this point, actually, I was just getting more and more unwell. So it was it was the fatigue and I think if people haven't experienced fatigue, you can't, it's quite difficult to describe it actually. It's just this absolute exhaustion. I literally felt exhausted to my bones and I would wake up in the morning having had a full night's sleep and just, I would want to cry because I was just so tired. In the midst of it all, I'd self-referred into the practitioner health program or practitioner health as it's now known, which is for doctors with burnout mental health problems, etc. I'd been seeing just the most of the amazing woman through there who's a GP by background, who I've been talking to a bit about this,

who were saying, actually, you need to go back. I'm a bit worried about your physical health, but also recognised actually that I was becoming really unwell and kind of really advocated for me to go off sick, which actually, we know what doctors are like, you know, and we'll be completely honest, you know, I felt terrible about it. I felt terrible about, you know, letting my patients down, let's my colleagues down, but actually went off sick around the Christmas, which was around the second wave of COVID hitting. And it was during that time that having that space made me realise just how I'm well I was. And in that time, that's when I started getting other symptoms. So the other symptoms I started getting abdominal pain and bloating, feeling sick

most of the time, and just not being able to eat properly. So by the early part of the next year, I went back to the GP. Again, this is COVID, so it was really difficult to get, you know, face-to-face appointments because that was the nature of it, but saw a really wonderful and amazing GP who did a battery of tests. You know, this poor doctor, sister. This poor doctor, with a doctor sitting in front of her going, I'll genuinely a bit on well. But at the same time, I was already active. I'd cycled there and it was quite a long way.

You know, it must have been quite difficult for her. It's hard, I think, treating doctors. But anyway, she did a battery of tests and ultimately what then ended up happening was it came back that I had non-hodgkin's lymphoma, basically. Right. So that's a type of, well, if you just explain what it is, so some of the listeners might not know if that's okay.

Exactly. So it's a type of blood cancer, essentially. and it came completely out of the blue. I think one of my interesting things to learn about was that I had obviously thought about it. I know that night sweats are a symptom of lymphoma. What I didn't realize was that you could have completely normal blood tests and still have lymphoma,

which was obviously, you know, my education. Yeah, and that's really hard, isn't it? So, I mean, when I, my first symptoms were fatigue and night sweats and I felt like I've been drugged and it was just this mess horrible. but I did have these other subtle symptoms. But I did a haematology job as part of my medical training, and I worked with a hematologist who was an oncologist, and we did a lot of, especially leukemia,

but some lymphoma patients came through the unit in Manchester as well. And do I get saying to my husband, I think I've got lymphoma. I absolutely do. And he said, oh, gosh, Louise, oh, come on, you've just got over pancreatitis stops, you know, there can't be something else going on. And so I was convinced, but I knew that my blood test would be normal

because I'd done enough training, if you see what I mean. And for those of you listening, obviously, blood tests for menopause and perimenopals are a waste of time usually. So we can't do it. So how do you know the difference? And some of you might be listening thinking, oh my goodness me, have I got a lymphoma? And how do you know? And a lot of times with patients, we don't know. No.

And I could have been right or wrong. You didn't know. And actually, often within the clinic, we will give HRT. But if we're worried, then we would carry on with the referral. to a haematologist and have investigations, and also night sweats often improve very quickly with estrogen. So if, for example, someone had, you know, given you some HRT to try,

it wouldn't have harmed the lymphoma, but also if you were still having symptoms a few weeks later, then you would have known it definitely wasn't. So it's just to reassure people that listen to everyone, so then go to their GP's have a night sweat to think that it could be. But, and that's why actually, no disaffected gynecologist, I really feel like as general practitioners, we're in a really good place to help metaphors

because we're used to seeing people with unexplained symptoms or symptoms that could be due to other diseases. You know, how do we make sure that someone who's got brain fog, memory problems and headaches doesn't have a brain tumor? Yeah. And palpitations doesn't have a, you know, difficult heart arrhythmia. And that's what we have to do. But we're used to that. So sorry to interrupt, but I wanted to just reassure people.

No, no, no, no, no, absolutely. And I agree. And I think I did have an unknown diagnosis at the time. You know, nobody knew what it was, you know. No. I think people thought that it was likely to be a cancer diagnosis. But I think we have to be really clear about the fact that I was really unwell. This wasn't like, you know, I've been through menopausal symptoms now, which is why I'm here.

But, you know, this is very different. And that kind of lassitude and just being so unwell. But also other symptoms that then start creeping in as well. But at the time, it was unknown. You know, it was queer ovarian cancer, query bowel cancer, query lymphoma, query other, you know, there are other end-fine things. You know, we did a battery of tests. And yes, in the end, I had an MRI scan and that's where my lymphoma was picked up. So I was diagnosed as something called follicular lymphoma, which is a low-grade lymphoma.

Thankfully, it's very easily treated, which is great. Technically, it's incurable. So you're always in long-term remission, but actually the likelihood is that I will be in remission for a long time. you know, that's life for you. Yeah, but one of the treatments is chemotherapy, isn't it? It is. And so interestingly, my haematologist, who's been amazing, we're talking about personalised care, has been brilliant, and he's so good at listening to me.

And he really, really listened to me, he really empathised, but also based on my history and the scan findings, said very clearly, no, this is what I think it is. It had all started in my meson tree, which is this piece of tissue that can hold your bowel together. So that's why it was all hidden as well. I didn't have any of it, no. because it was all contained in my abdomen pelvis. And interestingly, he can have said to me at the time, look, I've seen this pattern before.

Really interestingly, I've seen it in younger men. I was in my early 40s with a very similar lifestyle to you. Interesting. You kind of talk to my back about the impact of stress on disease, which I don't really understand, talked a bit about, you know, I've seen these men with this particular pattern of follicular lymphoma, and, you know, you're going to be fine.

You know, we're going to offer you chemotherapy. You know, it said to me at the time, you know, I've got these male patients that I've seen who've got back to their normal functionality. They're all running 10 kilometres a day. You're going to be great in a year very soon. And obviously recommended chemotherapy to me. And my instinct, again, because I'm a gynaecologist and I thought, oh my goodness, I'm going to have chemotherapy. I'm in my early 40s.

This might affect my ovaries. So interestingly, one of the first things I actually did because I needed, you know, I was due to have a migraina coil change anyway, was going to get my rhina change. just in case I went through the metaphors, just in case I needed that as part of my HRT, basically. So it's interesting because in my head I knew it was a risk, but at the time, the quoted risk is about 4% going through it. So it's quite low, actually. I wonder how they get those levels, though, because it's very difficult to know because so many symptoms, especially even post-chemo, are attributed to chemo brain. And because there's no diagnostic criteria other than symptoms, I think it's probably a lot higher.

I don't know what you think, but I think it probably is. I think so. I mean, subsequently, I then read every paper I could because that's the kind of person I am. And don't get me wrong, I trust my chemologist absolutely implicitly. He's been so brilliant at walking that line between treating me as both a doctor and a patient. But he's also brilliant because he'll say, this is what I recommend, this is the evidence base, but also tell me the randomized control trial at which it's based so that I understand where that's come from. I'm not going to challenge him.

I'm not, you know, I trust him, but it's around that understanding, but absolutely. I have done all the reading, I think it's a lot higher than that. Absolutely. Yeah. So I went through, I had six cycles of chemotherapy last summer, which finished probably about a year ago, something like that. And I was coming out the other side of it. Interestingly, because my B symptoms have been so severe, I'd also, interesting,

the other things I've had by this point were weight loss as well. So I was very unwell. But interestingly, because for me, my lymphoma symptoms were quite predominated by night sweat. one of our concerns initially was are we missing menopause as well actually? So my hematologists have done to extra blood tests. Actually, my hormones, my ovarian profile for what it's worth, is completely normal in the, you know, still was undergoing chemotherapy last year. And again, I didn't have any comparing menopause or symptoms then.

And I think, again, the interesting thing, and I think this is where we all have to appreciate that as doctors, we don't know everything even when it's about ourselves. And we all make mistakes, even if it's about ourselves, was around what I didn't realize was there. that my ovaries could stop working several months afterwards. I think I thought it was going to happen. It's going to happen at the time.

I'm an optimist. And so I was kind of coming out of the other side of it, was starting to feel better. So my lymphomous symptoms had started picking up probably mid-chemotherapy. And then the cumulative effects of chemotherapy meant that the chemotherapy symptoms then started. And then probably by around the autumn of last year, that's when I started feeling quite a lot better.

And we started to think about phasing back into work, although that needs to be different because I'm still being treated with a monoclonal and antibody that presses my immune system so I can't work clinically. So there's a lot going on. But overall, you know, I carried on exercising throughout the whole thing. I've done those of yoga. I'd worked a lot on acceptance and balance, you know, all the nutrition and diet and all of those things. And actually I felt quite well.

And then probably about kind of September time, my first symptom was anxiety. Interesting. And I just started feeling really anxious. anxious and really anxious about little things, which just isn't me at all. I'm an obstetrician. You know, I deal with lots of anxiety. Yes, exactly. You know, I deal with adrenaline. That's what I love, you know. So firstly, anxiety, then a little bit of hot flushes, not huge, actually. I was applying for new jobs at the time and kind of came off a couple of kind of pre-interview meetings, teams meetings thinking, I feel a bit hot. And then interestingly woke up in the middle of the night one night,

with a night sweat, but interestingly, I just didn't think it was an informant. I just knew it was menopause. And it's because I was hot. Yes, isn't that interesting? So quite different experience to perform. Completely different experience. So I was hot. And so I basically woke up fanning myself in that kind of fairly physical kind of way. I was like fanning myself. And I was just like, I'm really hot. And I kind of sat on the side of the bed and thought, oh my goodness, this is menopause. I'm a gynaecologist and I've only just realized it. But I think the other thing about it is that, and this is where I think it's different for women who've been through chemotherapy, is it's not gradual. You don't go through the penny rail, of course. It hits you really hard. And that was it. I got hit really, really, really hard by it. So it kind of ramped up very quickly from kind of these mild symptoms to quite severe anxiety and insomnia. And I just couldn't sleep. So I went back to the GP to say, and I have to point out, I was with a big conglomerate GP practice at the time. which isn't necessarily set up for chronic disease,

and I've changed since and I've got a really wonderful GP practice that I'm with now. So they said, well, no, because you've got night sweats again, you've got to go back to your hematologist. Which is also this whole thing around, you know, this is I suppose what I want to say. This is just about listening to patients, really. But I can see why people are anxious about these things. Yes.

My hematologist, you said, I think it's menopause. You're just scanned you. You're completely fine. I said, no, I know. I was in remission. So I went back to the GP and said, no, you know, we're happy for me to have HRT. And essentially they weren't happy to prescribe it because they said that I needed to be cancelled on the risks. And because I'd already had one type of cancer.

And this isn't, obviously this is my story, but this is one of the reasons I've reached out to you is because actually this is fairly universal for women with blood cancers, actually. Yeah. And we see it up with all types of cancer, actually. So just to be clear, we're not talking about breast cancer. We've talked about this in other podcasts. but there are so many other cancers, and people then seem to think that HRT is bad. And when I do training for healthcare professionals,

because I was never taught any of this stuff at all, and actually I feel really embarrassed now, saying to you that I worked for six months with a leukemia and lymphoma unit, and we didn't even ask them, didn't give them any information, didn't tell them they could become menopause or life. Anyway, I can't go back,

but it's not on a lot of people's radar. And so I often, maybe it's very simplistic, of me, but I'll often, when I teach healthcare professionals, I'll say, would this lady have a type of cancer if she was young and would part of that treatment be to remove her ovaries? So if you, as, you know,

you were menstruating when you had your lymphoma diagnosed, did any of the cancer specialist or haematologist ever offer your ovaries to be removed as part of your treatment? Well, of course not, because your own hormonal function, estrogen, progester, and testosterone, were not

interfering with the cancer. And in fact, we're helping you to function. And we also know that eustodial and testosterone, actually very anti-inflammatory. And that's probably one of the reasons that women probably have less cancers, actually, when they're younger. And this is some really key work that we're doing it

with some really big team of people. So actually, then it makes it very easy. And then it's not just with cancers, actually, if someone has, you know, a clotting disorder or if they have migraines or anything. I'll often say to medical students and nurses and doctors and pharmacists, Well, would you advocate taking her ovaries out then?

No. Why would you do that? Okay, well, then HRT is just replacing that. And also, you know, you're young. So it's important that you do have the replacement hormones, as we know, for many reasons for your future health. So in that way, I think it's almost easier to conceptualise, isn't it? But there's still this myth.

And we see it sometimes in medicine, women, and I'm sure you're very aware, when we've got pregnant women, and goodness only knows, when pregnant women can still have other diseases and symptoms. But it's very much when I was working on Labor Ward. We'd often get phoned up, or this lady's got a migraine. Can she come into Labour Ward because she's 36 weeks pregnant?

No, you can treat her migraines. And I think you get clouded because people get scared. Absolutely. And we see the thoughts, again, we see this all the time, as you said, with pregnancy as well. We see this all the time where actually we have these gender biases. We've seen it with COVID. You know, the data with COVID showed that pregnant women, unfortunately, had worse outcomes.

because people were scared to treat them with the appropriate medicines. We now are safe just because they're pregnant. You know, we've seen the same around things like heart attacks in pregnancy, et cetera. And that's one of the reasons that, you know, again, to reassure people, this is getting it much better. This is how we're just, you know, this is all about how we're improving medicine and improving our understanding, you know, on that side, we've got these massive maternal medicine networks that are making a big difference.

Yeah, I suppose, kind of going back to the ovarian issue, which is exactly as you described, if I as a gynaecologist took out, women's ovaries, which sometimes I've had to, and I've had to remove both ovaries, I would give them HRT straight away. And that would be our practice. And I suppose I also understand the history of HRT. I suppose I was at medical school in the late 90s when it was the wonder drug. And I remember sitting in a lecture with the lecturer saying, you have to tell your mothers to take it because it's the best thing ever. And I was an obstetrician and gynaecologist in the early noughties when those big studies came out. But actually, interestingly, I was working in a menopause.

centre that was one of the big research for centis for menopause where we were already saying actually we don't think this data is right you know we were drilling into it all the time that's kind of part of our teaching and so I suppose again kind of thinking about my own personalised care I completely understand that there are all sorts of ways you can treat menopause and there are all sorts of ways that women want to deal with it and everybody's individual but for me as a gynaecologist I'd always looked at the risks and benefit profile of HRT I've looked at you know the risks of breast cancer associated with drinking or obesity and that, you know, we can't modify all risk factors to prevent cancer as I have found because I had a bad. But, you know, I suppose I'd

always, I'd made a decision many years ago that I was going to have transdermal estrogen when I went through the menopause. So for me, it was just like, well, this is no different. But also, I didn't feel as though it was a gradual transition. I didn't feel like it was traditional menopause. I felt like as though somebody had taken my ovaries out. It was. so sudden and having looked after women who had their ovaries taken out, I feel like I kind of knew what that was like. And so to me, I felt that actually this was a hormone deficiency that I just needed replaced. And if it would be my thyroid gland, there wouldn't have been a problem over it, essentially. But it's that fear, isn't it? There is that huge fear around HRT that had prepped

in 20 years ago that I think we're still just, you know, hopefully is starting to ever weigh a bit now. Well, only a bit, unfortunately, because it's 20 years earlier in July, 2022, it's 20 years. And the 9th of July was 20 years since the publication went out and we're still trying to reassure. And I think it's a great way to end, isn't it? Because the most important thing for me actually isn't the evidence. It's about patient choice and it's about understanding and allowing women to make the decision when she's been given the right information. She's had the right time.

She's not pressurized. she's just deciding for herself. And also knowing that any decision for treatment can change at any time. Everything we do is reversible in medicine. Well, not everything, but certainly prescribing HRT is definitely reversible. Having a baby is not reversible. And I think knowing that we're there at every stage of the journey with our patients is really important. So we can help with doubt.

We can help with uncertainty. We can also reassure and educate those around them. So it might be their relatives at a more scale. than the actual patient. So, you know, the experience that you've had and very kindly have shared so openly, so thanks Susie, because that's been, I'm sure, will help a lot of people. So just before we finish, Susie, I'm going to throw three tips on you. And I'd really like you to try and help really answer three ways that you think women could be more listened to by the healthcare professionals to have this united journey together. Absolutely. You know, I think the bottom line is it is that

we just have to listen. You know, it's about listening to. people and understanding their experiences. And so I think the first thing is that listening, the second is about empathy. And what I have found on this journey is that actually my experiences of my menopausal symptoms actually in many ways were worse than many of the other symptoms that I'd had through other things. And as I said, I've got the advocacy to have got the treatment I needed, but not everybody else has. But despite that, actually, what I found dealing with people is that when you're unwell, you're very, very vulnerable. And just empathy goes a really, really long way.

And the other thing is just around personalisation and choice. So kind of having that really solid understanding or what makes the difference to people and giving people a really open choice that's not kind of paternalistic. But actually, if this is the information I have, you make the right choice for you and for your life. Yeah, really sound because we're all individuals, aren't we?

We choose every day what we're going to wear or how we're going to spend our day. And that needs to continue with the conversation. with health as well. So thank you so much for your time. And just to finally tell everyone that Susie's going to work with my team to produce more literature actually for women who've had cancer, but especially hematological cancers such as lymphomas to help educate them more. So thanks in advance for your help with this. And thanks for your time today. It's been great. Thank you so much. Thank you 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.