The Dr Louise Newson Podcast - 165 - When menopausal symptoms persist, with Dr Anna Chiles

Episode Date: August 16, 2022

Dr Anna Chiles is a GP and works in an NHS practice in Gloucestershire and at Newson Health as a menopause specialist. In this episode, the experts discuss the range of symptoms that can occur in the perimenopause and menopause and the impact of these on daily life, and they highlight what can be done for women when symptoms persist for many years. Anna’s 3 tips for women who have struggled with symptoms for many years: It’s never too late to start HRT and have that discussion with your health practitioner. If you choose to try it, you don’t have to continue with it if you don’t like it. You don’t have to stop taking HRT when you reach a certain age It’s so important to keep active, for your independence, your balance, joints, and muscle strength. This goes hand in hand with hormone replacement.

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 in the studio I have with me Dr Anna Childs who is a GP, she works in the NHS and she also works with us as well as a menopause specialist. Welcome Anna. Thanks ever so much for joining me today. Thanks very much for inviting me.

So it's probably the officially hottest day of the year for a long time. I promised to that I looked at actually got up to 38 degrees today. And I did actually have to. any hot flushes when I was perimenopause on I got some night sweats. But actually today's making me realise how uncomfortable it must be for those women that do have baser motor symptoms, which we know affect about 75% of population who are menopausal, don't they? And it's really quite uncomfortable, actually. So I am thinking that. But actually, I'm also reminding myself of all the other symptoms because we just looked at thousands of women who have been using the free balance app and the commonest symptom was brain fog, actually.

And we all know we slow down in the heat, but it's more than that. So these symptoms of the menopause can vary. They can change with time and everybody's individuals. So we thought today we talk a bit about symptoms, how they can persist, and actually what we can do when we're a bit older as well, because there's certainly a lot of women I see and speak to who they've missed out on individualised treatment because 20 years ago, nearly to the day the WHOHI study came out, everyone was told never to prescribe HRT.

And these women who might have been 50 then are now 70, but some of them are still having symptoms. So I thought I'd talk a bit about symptoms and then a bit about what we can do with helping older women as well because we see a lot of younger women and some very young women, but we need to talk about older women too. So what about symptoms, Anna? What are the things that surprise you when you see,

you now see a huge volume of menopause or women. And what are the symptoms that perhaps 10 years ago you might not have thought about were attributed to the menopause? Definitely sleep disturbance, not just related to vasimotor symptoms. They're not related necessarily to being hot or having night sweats. But just women and older people just accept that they're going to be awake in the middle of the night. And that's just standard fair.

Oh yes, well, I'm always awake. I listen to my radio for two, three hours. Then I get back off to sleep. and that's just seen as normal for ageing. And I think that's really important. I think also the brain fog that you've talked about that people write lists. That's normal for us to write lists. But actually sometimes it can be kind of more than that.

And then I think one of the big things in older population is urinary tract infections and vaginal dryness and how people just accept that they get two or three or four urinary tract infections. infections a year, that doesn't necessarily need to be that way. Yeah, very common symptoms. And you're absolutely right. Sleep disturbance, I hadn't realized how common it was because everyone just says, oh, I'm poor sleeper. I've always been. And it's only because when we replace with the missing hormones, we often find that sleep is one of the first things actually that people thank me for. And, you know, I know, even when I wasn't getting nightswets, I would often wake at early hours of the morning,

isn't it, when hormone levels are at their lowest, sort of two, three of the morning, I'd be wide awake and I'd lie there and think, well, I'm not really anxious. So it's not anxiety that's woken me up. But now I'm awake. I am anxious because I know I'm going to really die tomorrow. And then I start to think about all the things that I haven't done

or that I need to do. And a lot of menopause and perimenopals have ruminate, don't they? And they sort of catastrophize things. And that's very common in the early hours, isn't it? Oh, yeah. And patients are forever saying to me, well, you know, I'm awake, then I start worrying. And then when I wake up in the morning,

I think, why was I worrying about that? Actually, I can see the reality that it doesn't really need to be worried about, but actually at two or three in the morning, it feels like the world is ending. Yes, and lots of people worry about things that would never normally worry about. So they worry quite serious things, actually. A lot of women have said to me, they worry about the mortality of their children. They worry about their jobs. And then sometimes it's smaller things. They worry that they'll never be able to get their stuff together to pack a suitcase or pack a bag for work or their children's pack lunch or what they're going to do for supper and that sort of thing which is completely out of character for them and that can be really disabling and we

know lack of sleep is a form of torture isn't it? Oh yeah. I mean I'm surprised by how little sleep some people survive on. Oh I know sometimes some people will say you'll ask them and they'll say or are you, how's you sleep? They say, well, it is disturbed. I probably get between two and three hours a night. And I'm thinking that sounds horrific. I wouldn't be able to carry on the next day with two or three hours. And then you say, how long's that been going on for?

Oh, five or six years? And you think, well, my goodness, how have people managed? Yes. Well, of course, in the, I mean, I graduated in the mid-90s. And we used to give a lot of Tamazepam, actually, because it's slightly longer acting. We would give Tamazepam a lot to, women in their 50s and 60s who'd come with sleep problems. And then there was obviously the

abuse side of Tamazepam. So it was changed and we gave diazepam. And then there were the newer sort of sleep medicines like Zolpidem and other drugs. But they're not very nice, actually. And they're highly, highly addictive. So then you have a lot of problem. And I'm sure you have in your general practice. I saw a lot of women who, and then they're 70s who would come for another prescription. And they'd seek out the doctor that was more likely to say yes. And it's usually a neurodoctor and you'd spend longer in the consultation trying to get them off. But, you know, I'd have had my time again, I probably would have talked to them about the menopause. I don't know about you, but I didn't even think about it. Yeah. And interestingly, when I first became

slightly hormone obsessed about sort of three, four years ago, I did a little audit of a month of all my appointments that I was seeing. And I included anyone who was over the age of 40 and anyone who was female, and I didn't have an upper age limit, actually. And I think it was something like between 75 and 80% were related to menopausal symptoms. It was huge. So it was their joint pains, which people just presume they had arthritis as they were getting older. It was sleep. So it was often a repeat prescription for either their sleeping tablet that they hadn't been able to live without for 20 years or their antidepressants. And suddenly, I opened this conversation about, obviously sometimes if they were still sort of young enough

what's happening with your periods or then I'd say, and what age did you have your menopause if they were older? Did this start with your menopause? And they'd say, oh yeah, I used to sleep fine until my menopause, you know, actually it was, has been about that time. And suddenly there were this big group of patients that I could suddenly manage with their sleep disturbance, their mood, their anxiety, their palpitations,

their joint pains with simple hormones. Actually, and suddenly, giving their hormones back, And it sorted all these problems out for most of them. And then you can deprescribe. And that's the key thing is actually deprescribing the nasty drugs just by giving them back their hormones that they would normally have had. And that's quite amazing actually because we know there's been a lot of narrative over the last few weeks about menopoles being medicalised and how inappropriate it is. And we know there's a big article in the British Medical Journal about medicalisation of the menopause. But actually, before I wrote the response, on behalf of the society, I actually was thinking it is being medicalised already, but actually with inappropriate medications. And you say, as you say, it's not just one medication. Often it's a number.

So antidepressants, maybe drugs for palpitations, statins to lower cholesterol, blood pressure lowering medication, anti-inflammatories, pain killers. And then migraines, we see a lot of women who are on heavy-duty drugs, actually, epilepsy drugs sometimes to try and stop the migraines. So there's layers and layers. And actually, we know this whole thing about polypharmacy, so prescribing too many drugs is huge. So it's not just about adding something in when we medicalise the menopause with HRT or hormone replacement therapy. Right. You say it's actually reducing the number of prescriptions.

It's really good, isn't it? Yeah. And I quite often say to my patients, remember, this isn't actually a drug. This is replacing your hormones that you've naturally got with body identical hormones. hormones that are the same as your own hormones. This is not like, even taking a paracetamol or an ibuprofen, they are not naturally within your body. These are naturally within your body. And that's what everyone's sort of forgotten or is missing the point, I actually think, that actually this is not a drug. This is a hormone replacement. And that is all we're doing is topping up your bodies, hormones that they are losing and reducing or have stopped producing.

Yes. And certainly I know when I started doing a bit of menopause work, somebody said to me, the average length of time for symptoms is four years. And then someone else said it was seven years. And I have seen countless women who have had symptoms for decades because they're very clear that their symptoms started just after their ovaries were removed when they have a surgical menopause. It's very black or white. And I've seen women in their 70s and 80s. And some of the symptoms I know are related, like their flushes and sweats. Other symptoms, like you say, quite rightly, could be due to other things like palpitations and joint pains, but actually when you give their hormones back, can take a bit longer sometimes in older people, but after

six to nine months, majority, if not all of their symptoms, have gone. So you know it's related. And so there are decades of symptoms often, but they can change, can't they Anna, so they might start with flushes sweats. And then they say, well, I'm through the menopause, because they only lasted six years. I don't have any sweats now. And then like you quite rightly say, they have three or four antibiotic prescriptions a year for their human tract infections. They're getting some discomfort, maybe sitting down or wearing trousers or whatever. And then they've got itchy skin and maybe dry eyes, stop wearing contact lenses. Restless legs seems a really common symptom in older people as well, actually. Yeah, absolutely. And again, that disturbs their sleep. And I think you're

right, I agree that people are still symptomatic, or forever, I would say, that they just, and it's not until you replace the hormones and they feel better, that they realize that those symptoms are related to their menopause or symptoms and their hormone deficiency. And it's often not until after you've replaced their hormones and they're feeling better, they suddenly say, actually, there were a whole lot of other symptoms that I just put down to aging or life. And then when they begin to feel better, they say, actually I suddenly realize that I can feel better, but also they're often a little bit grumpy, delighted, but grumpy with themselves, that they've missed these years of what they presumed was normal ageing, and they quite often will say, I'm so frustrated

with myself, I've missed 20 years of my life because I've been dominated by these symptoms, and that's really sad. It is really, really sad. And I speak to quite a few people, quite high-level meetings actually who still say that sleep disturbance, joint pains, they're just aging symptoms, they're nothing to do with the menopause. And I find that very difficult to know. And of course we don't know, but actually we know that there are other benefits from replacing hormones. And, you know, no one has forced to take hormones, but actually if they want to try, often symptoms can melt away. It's not a placebo effect, I'm sure, because we've seen it so often and people don't always expect certain symptoms like joint pains or restless legs to improve. So I think it's very unlikely

to be placebo, especially with a sheer number of women that we see. But there are also health benefits, aren't there? We've talked at length on the podcast before about the cardiovascular, risk reduction, osteoporosis, probably dementia, type 2 diabetes, bowel cancer reduces the women who take HRT, all sorts of things. But there's always been this thing about if you start HRT within 10 years of your menopause or under the age of 60, that's the time to do it. And that's great if you're in your 40s or 50s. Yeah, absolutely. But what if you're 61 or 71 or goodness, only knows, 81 or 91, Anna, what do we do? Do we just say absolutely no? Or where's this come from? Yeah. I think it's a hangover from the WHA study 20 years ago, that the conclusion of that was if you really have to take HRT, then you shouldn't have it for a longer than five years.

and then if you really had to, you shouldn't have it longer than 10 years. And I think we both as patients, but also as medical professionals, presumed that that was the cutoff and we became rigid about that. And actually, we don't spend long enough looking at our patients holistically, I think. And actually, sometimes you need to step back and think about the patient as a whole. For instance, I have a patient who is in her 60s and has been diagnosed with Parkinson's disease. and it's only sort of recently that I thought about her more holistically and thought about her menopause and I said to her, kind of talk to you about when you had your periods? And she had

really terrible postnatal depression to the point where she was almost hospitalized. And she was terrible and she had a terrible menopause and she'd never had HRT. And I have, we've talked about the potential benefits for her both from an emotional point of view, but potentially, you know, and with some impact on her nerve conduction and her Parkinson's, because we know that there may be some stabilisation or some support that it can do for Parkinson's disease. So I have started her on some HRT and she feels both emotionally but also physically better. And she was displaying signs of what they thought was Parkinson's dementia. And actually, I think it was testosterone insufficiency.

And now that she's got some testosterone on board, actually she's been able to go back on her electric bike that she has been used for a year because her muscle weakness was getting worse. Her brain is functioning better and she's more stable emotionally. And so this is a lady who was in her mid-60s who hadn't had an HRT. So it's got real important benefits for the older patients. And, you know, my mom, for instance, she was part of that typical WHA generation. She's in her mid-70s and she had a hysterectomy. She was on some HRT and then it was stopped because of the WHI and I think she thought, well, actually I'm fine. She has not slept well for 20 years until about two or three years ago and I said to her, Mom, I really think you ought to go and see your GP and ask

for some estrogen and see whether that helps your sleep. She has not had a disturbed night's sleep since she started her estrogen. And she never slept a full night sleep. So that's amazing, isn't it? And that's true of poor sleep. And we know that sleep is so important for your body cells to repair. It helps prevent heart disease. It helps prevent weight gain. It helps improve your recovery from illness and injury.

And it's better for you physically, but also you psychologically. So actually, you know, even just improving people's sleep as you get older, then actually you're going to improve their well-being. Yeah, absolutely. And I think what's really interesting is there's this whole thing about, aging and anti-aging and there's a massive debate about longevity and what we can do. But when we talk about biological aging, it's about low-grade inflammation that goes on in our body. And it's about these inflammatory processes that predisposes to diseases of aging. So many diseases,

as I'm sure as you know, that are associated with aging are heart disease, dementia, osteoporosis. And these are actually low-grade inflammatory conditions. And what's very interesting is when you look at where they've done studies, look at women that have had their ovaries removed at an early age, and then followed them up for diseases. All these aging diseases increase, but there's markers that you can look. So we're looking at some of the epigenetics way our genes change with aging, but also there's ways you can look something called methylation, where there's some chemical changes that occur in the cells. And we know that women who have an early menopause, they age a lot faster. And we know that's associated with these diseases. And it's very difficult.

difficult, isn't it? So there's lots of people say, well, at the 70, you are going to be aged, do our older, and are you reversing the biological clock? And it's a massive ethical debate. You know, Anna, how far do you go in medicine? Do you say, well, heart disease is aging. Let's not treat heart disease or some cancers can be related to age. So do we not do, so, and that's so difficult, isn't it? Yeah, but I think the important thing is actually aging and being strong physically, So it's not necessarily just about your heart health. It is about your bone health, but it's about your muscle health. It's about actually remaining mobile, keeping your balance, being able to remain independent,

being able to wash yourself and go to the loo on your own, to be able to get up from your chair, to get up from your bed, and remain as independent as possible. So actually, my argument would be is actually this is not about necessarily extending your life length. It's about extending your quality of life and your independent. and actually reducing the burden on your family, the health service, and also creating a better quality of life for you because actually you can remain independent for longer. You know, our muscles begin to melt away from the age of 30.

You know, actually, and that's what we forget, that actually we're starting this aging process and we can do something about that. And that doesn't involve medicine. That involves lifestyle. that does, I would argue, involve your hormones, actually. And importantly, estrogen for your bone strength, because actually if your bones remain strong, you can remain active and you're less likely to get a fracture.

But also really importantly, your muscle mass, and that is improved by weight-bearing exercise, strength training with weights, but also is improved by testosterone. And this muscle mass and your muscle stamina is improved. And in turn, what that does is it actually enables you to keep active, to work your muscles and to keep that muscle mass going. So it's partly that it helps your muscle mass,

but it also helps you be able to have the motivation and the energy and the ability to improve that muscle mass. Which is so important. And that's not about disease. That's just about absolutely keeping strong and fit and active. And we use this term, don't we, sarcopenia, which is basically loss of muscle mass, which does happen as we age.

And, you know, it's very interesting when you talk about testosterone as well because I've been reading quite a lot about testosterone. And most of the studies, as you know, women is about libido. But there's some good studies in men looking at how testosterone can rebuild the myelin sheath, which is surrounding. It's this conduction surrounding of the nerves that helps fire our nerve impulses. So if we touch something hot, we'll immediately put our hand away. Whereas if the myelin isn't working very well, then it takes a bit longer.

but also it's the way our brains work on our function and, you know, you're saying this lady with Parkinson's, you know, there's all sorts of these things. And it has also been very anti-inflammatory in the brain as well. It's a biologically active hormone. And time and time again, we're told it's only for libido. Well, why do we have receptors in our brains and our nerves and our muscles? Who knows? Because no one's researched it, but it's about time we did. Because actually, if it is helping people regain their muscle strength, then actually, even if it's only improving by 5 or 10% that means people can use their zimmer frame independently. I really worry that I wouldn't be able to have a bath when I'm older. Some of you might have had I worry about osteoporosis because I think osteoporosis is fine is painful but it's very disabling as well. But actually I want to be able to have a bath. I want to, if I do have grandchildren if I don't, my friends might have them. I'd like to be able to lift them and put them on my knee. I, you know, I'd like to be able to hold a book in bed without feeling really tired. So these little things. It's also chronic pain, isn't it? Oh, I know. You know, if you have crumbling of your spine from osteoporosis, you are in constant pain.

It's awful. It's debilitating. And then you're on a whole host of very strong medication, which has side effects, which affect your ability to think straight, to affect your balance, and affect your bowels, get you constipated. And so actually, there are other, implications of that pain medication that as a result of your osteoporosis. Yeah. So we had a lady a while ago actually now, about six maybe more months ago who came for her 90th birthday. She decided to treat herself and she'd been suffering for many years and she didn't know whether her symptoms were related. The doctor that saw her had no ideas but she decided she wanted to treat herself to some HRT. And in fact, many of her symptoms did improve, especially sleep. And there isn't any

really strong evidence to say we shouldn't be giving hormones back. When we talk, you mentioned about WHOHI study, I mean, that was with the tablet estrogen and the older type progestogen. So usually, and I'm sure you're the same, Anna, that if we give HRT to older women, we usually start with lowish doses and we give it through the skin as a patch or gel usually with the natural progesterone as well. And so they don't have a clot risk, which is something we wouldn't want to give because as we get older, we're more likely to have a clot, aren't we? And it hasn't been shown to be associated with a cardiovascular risk. Some people worry that if they did have some heart disease, so some disease of the blood vessels, it could make things worse. But there isn't any

good data about that. And people worry that if there was a little clot as part of the atheroma there and the blood vessels dilated, because that's what happens with estrogen, it relaxes the blood vessels, then that clock could dislodge. But one of the treatments for raise blood pressure is our drugs that dilate our blood vessels far more, isn't it? So that argument, I think, I've done quite a lot of cardiology in the past. It doesn't really sit right. I don't know how you think. No, I would agree. And I think my experience of older women who start HRT when they're older, actually they don't need very much, very high levels. They need a little tiny bit to just control those symptoms. And also, I like to give them and make sure they're having

enough to protect their bones because if they're going to take it, actually, that's one of the reasons that I would encourage people to be thinking about it is actually partly to control their symptoms, but actually for those long-term health benefits in their bones. And absolutely, I think when you're younger, you sometimes need larger doses, but actually often when you're older, you just need a little bit to keep everything ticking over and feeling happy. And I like to, I often say to my patients, I like to think of estrogen as connect four counters. Do you remember of the game connectual. And I say to them that each cell has got a little cup that fits that connect four counter in it. And as you become perimenopausal, you lose some of your connect four

counters and you're topping up with some extra counters with your HRT. And then when you become menopausal, you've lost most of those connect four counters. And all those cells are sitting with those empty cups. And actually, when you're older, you just need a little bit of those connect four counters to fill in those cups and keep the cells happy. And I often think that the cells feel happy once they're complete with the counter in their cup. That's very good. Nandji, I like that. Won't be able to play connect four, the same with those red and yellow counters.

But the other thing we've obviously talked about HART, which is systemic hormone replacement therapy. But there's also vaginal preparations. And we know we've already said that urinary symptoms, vaginal, vulvaal symptoms, pelvic floor, urinary incontinence, all sorts of symptoms are related to low hormones, low estrogen and sometimes low testosterone in that area. as well. So one of the treatments that's very, very common is vaginal hormonal preparations, isn't it? And so women, whether they're on HRT or not, might still have symptoms. And these are very safe because they're not absorbed into the body. So women who've had breast cancer or are on treatment for breast cancer can still very safely, usually use those preparations, can't they? And they can

really make a difference for a lot of people, can they? Oh, they can be, yeah, absolutely. Well, one, they can be transformational for reducing infection. And actually, if you're reducing the risk of infection, actually, potentially if you're getting recurrent infections, those infections could become quite severe and you could end up with eurisepsis, so a widespread infection, which is awful. But also, they're debilitating having recurrent urine retract infections. And a lot of women put up with the symptoms of dryness or the symptoms of irritation or discomfort and feel that that is just normal part of aging. And actually, you're absolutely right that vaginal estrogen is very safe and is very easy to use. And for anyone of any age, actually,

but as you get older, it's still very easy to use. It can be just as a cream that you can even just wipe on the outside. It doesn't necessarily mean it has to be on the inside. And that can be used, you know, from yourself, but also if your housebound and you need carers, or if you're in a nursing home, then actually your carers can use that. And that can be part of your self-care, but also it can help reduce your risk of incontinence and then you'll reduce your risk of pressure sores or soreness from your incontinence, reduce the risk of you needing to use pads all the time. And that is, I think, should be available for all women. that's part of it being a holistic patient care.

And I think we readily prescribe things like Pritha barrier creams, so Cavillon or Pro Shield. These are all some special creams that help protect. Actually, they're brilliant, but actually we should be thinking, does some of these women need some vaginal estrogen to improve their bladder function, to improve their pelvic floor?

And then they wouldn't need the barrier cream because actually their incontinence would improve. Yeah, and it's so important. I used to when I was a GP, quite a few women who had dementia, they would be getting out of bed several times in the night. Their sleep was disturbed, as we've already discussed, but they'd even have to get up to go to the toilet and they'd wake up their carer. They'd sometimes fall. And the carers, often it's their lung-suffering husband, would be absolutely shattered because they were getting interrupted sleep. And it wasn't, when they were being woken up, it obviously wasn't

in their own sleep rhythm as well. So sometimes there's a little estring, a little flexible silicon and ring that lasts for three months. I would insert it every three months because I'd usually see these people for their blood pressure and whatever else. And that would really make such a difference, not just to them, but their carers as well, because they would sleep, less risk of falls, less risk of urinary symptoms. And if someone with dementia sleeps better, then their cognitive state often improves as well. So there's a huge amount we can do. And I'm certainly, and I know you're not, we're not agist, just because someone's got a date of birth, a certain number doesn't mean that they can't have some holistic menopause care. So it's really important,

I hope, for those of you that have listened today, can share it with your maybe elderly relatives or just yourselves, really, and think about it. So we've covered a huge amounts of information. And I'm very grateful for your time today, Anna. But just before we finish, you've got to do three take-home tips. So sorry, but three take-home tips for people who maybe have been struggling for many years or know people that have been struggling for many years. What could be done? Yeah, so I would say it's never too late to start HRT, and it's never too late to have that discussion with your health practitioner, your nurse, your GP. Actually, remember that it can cause a multitude, menopause can have a multitude of symptoms.

And if you choose to try it, remember that you don't have to continue it if you don't like it. So nothing's ever forever. So that would be my first thing. It's never too late to start. Never be told you have to stop HRT just because of your age. I think that's really important because actually lots of patients quite often ask me, when do I stop my HR team? How long do I am I on this for?

And I always say, well, I personally never want to stop mine. And I would really advocate that you would never stop yours because I don't want to give you the benefits of good strong bones, good strong muscles, cardiovascular disease prevention for five or ten years. And then say, I'm really sorry. I think you now need to just go out alone and not have those benefits. Actually, I want you to keep having those benefits to have an independent, strong, aging process and to minimise the chance of a fracture and the consequences of that.

So that would be a bit of a long-winded, well, or second one. And third one is, I would say, it's very important to keep active. Keep active to keep your mobility, your balance, your independence as you age. and I think some of that is about being able to keep active. So keeping your joints pain free, keeping your muscles strong and keeping your balance so that actually you're able to keep active for as long as possible. And the more you use your muscles, the stronger they're going to be.

So actually it goes hand in hand, I would say, with, you know, taking some hormones to enable you to maximise the chance of keeping active and keeping that body strong and fit and healthy and able to perform for you to help yourself keep as active and independent as possible. Excellent. Really good sound advice, Anna, and I think that's really important way to end is about whether you take HRT or not, exercise, keeping active is really key for all of us. So we need to get off now and start to walk around, even though we're really hot. So thanks ever so much for your time today, Anna, and I hope that's been useful for everyone.

So thanks very much. Oh, well, thank you very much for inviting me. It's been a pleasure. 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.