The Dr Louise Newson Podcast - 175 - Mood, mental health and hormones with Dr Clair Crockett

Episode Date: October 25, 2022

The focus of this year’s World Menopause Day is cognition and mood. In this episode, Dr Louise Newson talks to Dr Clair Crockett, a GP and menopause specialist with an interest in mood, mental health and hormones. Clair’s interest in the topic stems from her own experience of escalating anxiety, low mood and intrusive thoughts in the premenstrual phase of her cycle during her mid-to-late 30s. Through her own research, she looked for ways to help her symptoms including through lifestyle changes, supplements and antidepressants. While these all helped some aspects of her mental health, it wasn’t until she began taking HRT that the premenstrual mental health symptoms eased. The experts discuss the importance of considering hormones when helping women experiencing mental health problems and outline some of the ways they are working to improve education about menopause and mental health amongst healthcare professionals. Clair’s tips to women with mental health symptoms in perimenopause and menopause: Track your symptoms and periods, the balance app is a good way to do this. This will make it easier to relay to your healthcare professional when you see them. Ask who has an interest in women’s health in your GP practice so you can see the most appropriate person. Tackling mental health in perimenopause and menopause is multi-faceted, it can take a while to get it right through a combination of taking HRT, your food choices, exercise, and doing work that inspires you. Make peace with your body image and don’t let it stop your progress. If you’d like to read more about Clair’s personal experience of mental health and hormones, you can read her story here.

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 on my podcast I've got with me, Dr. Claire Crockett, who's a doctor that I've known for a little while now, but she's really become very important in my life, like lots of people,

because she's doing a huge amount of work, not just in the clinic, but liaising with lots of people, bringing groups of like-minded people together to really take forward lots of aspects of the menopause, but especially mental health and the menopause. which many of you know is really, really crucial and really important and underserviced and under-researched as well. So welcome, Claire, today. Hi, Louise. Thank you for having me. So I'm not sure how long we've known each other, but it feels longer than it probably is. You were introduced by another doctor that we both know, weren't you?

And then you came and started working in the clinic, but you're sort of a bit like me, really. It's taking over your life thinking about the perimenopause and menopause. Yeah, that's right. think. Yeah, definitely. Yeah, I was introduced by one of the a doctor that you knew that I had worked with as well, and she put us in touch with one another. And yeah, as you said, the perimenopause and menopause and mental health in relation to that in particular is something that I'm really interested and passionate about. So if you sort of look back in time, so certainly if I'd make you as a medical student, I wouldn't have ever heard about the perimenopause. I would have known

that the menopause causes few hot flushes and periods to stop. But I wouldn't have known anything about the Association of Mental Health and Female Hormones at all, actually. Were you aware of it at all when you were a medical student? No, not at all, I don't think. And even the perimenopause and menopause, even though it was probably touched on briefly, it certainly wasn't something that was a big part of what we were taught or expected to learn or cover. So it's something that I sort of developed a bit of an interest in and you sort of go out yourself and try and learn more about it. Absolutely. I mean, I did a lot of psychiatry actually in Manchester and I really, really enjoyed it.

And I remember doing a project actually for a lady that had an eating disorder and she'd sadly been abused as well. So there was lots of psychiatry going on, lots of mental health in her past history. But I'm sure looking back, her periods had stopped as well because of her eating disorder. and I never thought about, oh, her periods have stopped, therefore she wouldn't have hormones, therefore that would be impacting on her mental health. And, you know, that was 30 or years ago. I wish I could go back in time and just, you know, think about that. But if you're not taught these things, it's impossible, isn't it, to know?

Yeah, it is. And you just sort of follow the same pattern that you're taught about these different conditions and how you treat them. And it's really difficult sort of to step outside the box and take a fresh look at things because you're sort of in that process of thinking this is a psychiatric problem, this is a medical problem, it's really difficult. Yeah, and I sometimes think in medicine, we're all sort of a bit on a hamster wheel. We're just very focused and we do what we think is best, always think what is best,

but it's only what we've learned. And to think beyond the box is sometimes really difficult, partly because we haven't got time because we're so busy, but also it's knowing what to mean, who to believe as well, which can be quite difficult. certainly I know with a lot of medicine that I practice I've learnt from my own experience in general practice, you know, certainly even just having a child has made me realize how difficult it is to be a mother and then having various illnesses in the past. I've become a lot more aware of my own body.

But certainly it was only when my hormones started changing. I realised how difficult it can be for the perimenopause. And I know you've had a bit of experience as well, haven't you, with your hormones changing? So do you mind just explaining what happened, Claire? Yeah. I've always had a little sort of some background anxiety, which has been reasonably manageable, but sort of as I came into my mid to late 30s, I really started to notice that there was quite a cyclical element to that.

And so in the couple of weeks, perhaps before my period, my cycles were still very regular. But in the couple of weeks before my period, I was really starting to notice that I felt more anxious. my mood might dip and it sort of escalated then over two or three years towards my late 30s and at times it could become quite distressing I might get suicidal intrusive thoughts it wasn't anything that I ever felt I would act on but they were quite distressing to have that repeatedly happening and then it almost got to a point where I knew it was going to come in that

lead up to my period and I think that's where I started to think of sort of put two and two together, I think, almost, and start to think, oh, perhaps this is hormonal. And I started to look into it a bit more. And I think that's where my sort of interest in this area really stemmed from then. It's very, very scary, isn't it? When you're having those thoughts and you know it's not rational and you know that there's no reason to have those thoughts, but you can't stop them. Yeah, it is distressing. So did you try and get help or did you speak to anyone about it? at all. I sort of spent a bit of time looking into it myself and seeing sort of what the background

to it might be and how I might be able to help myself, I guess was the first place that I started. And so I looked a bit at my lifestyle and looked at alternative treatments like supplements and things like that that I could try and introduce that might help. And I had taken satalopram previously and I did go to the GP. And this was before I'd sort of, of realise that there was a cyclical element to it and I did go back on to the satalopram but still I was still getting that dip before the period even when taking that and taking some supplements and things and it was I think my family noticed that there was a bit of a change as well and encouraged me to perhaps look at getting some more specialist help with things and so I chose to go to a

private menopause clinic to get a bit of time and understanding perhaps from someone that knew more about it to see whether they felt that it was significant or not. And did they think it was related to your hormones at the time? Yeah, they did. I think I tracked what was happening and sort of gave an explanation of what I was experiencing and yes, they agreed that it probably was hormonal in nature. And this was, I think when I was 38 or 9. And so we sort of had a chat through what the options might be of what we might do. And I'd sort of had in the back of my mind that I'd like to perhaps try some HRT to help. Because from the reading that I'd done, I'd found out that that perhaps was a good way to approach it.

And so the doctor that I'd had a consultation with agreed and that's what we did. we tried some HRT and it was really helpful. It took a little while to sort of tweak it to get it right for me. But it was definitely quite quickly. I noticed that I wasn't then getting that dip before my period each month, which was amazing, yeah. Gosh. And that must have made a huge difference.

Yeah, it did make a massive difference. And it's quite interesting, isn't it? Because if you knew no medicine, and if you just knew a bit about the menstrual cycle and about how our hormones change, it does actually make sense, doesn't it? Because we have this drop in estrogen levels before our periods. And quite a few women just feel a bit flat, don't they, for a day or two before their periods. Some women experience PMS or PMDD.

And this can also be related to changes in hormones, but I was always taught, like you really, I suppose, try different supplements, look at lifestyle. sometimes we used to give antidepressants, sometimes just for two out of four weeks to see if that helped and it certainly is a recommended treatment. But I remember sitting in Professor John Studs clinic about seven or eight years ago now. He was the first person I'd sat in a menopause clinic. I went up to see him in London and sadly he's died now, but he was very inspirational. People thought he was a bit of a maverick in his time, but actually he just taught a lot of common sense. And I remember seeing a lady there who described a similar story to you with some PMS

and he said, just take this gel, my dear, and come back in three months and I can tell you you'll feel better. And I said, Tim, what are you doing? I've never done that in my life. He said, Louise, I'm just topping up her hormones. She's still having regular periods, but I'm just topping her up for a few days before to stop this decline. And I thought, gosh, that's just common sense medicine. Why didn't anyone teach me that before? And it is sort of mentioned in Semis and green top guidelines, aren't there for PMS, that the Royal College of Robs and Guine, produced a few years ago now. And the hormones are mentioned, but there's quite a lot of mention of other treatments as well. So it's sort of hidden almost,

I think. And people just don't seem to think about hormones for first-line treatment. And I'm not really sure why, because there's no risk is there with having just some estrogen. No, particularly in younger women before the age of 51, there's no increased risk. we're just topping up the hormones that are already there essentially, aren't we? And actually it's safer than the contraceptive pill, isn't it? It is. Yeah, that's the thing that I think that is silly about it, really, isn't it? That people feel quite nervous about starting HRT and actually it is safer than the contraceptive pill.

And that's quite readily prescribed, isn't it? Absolutely, especially to young people. Because when we look at the HRT that we prescribe, it's body identical. so it's the same hormone as we produce ourselves from our ovaries and the estrogen is through the skin so there's no risk of clot. And some people find that if they take the contraceptive pill or the progestogen-only pill as contraception, the progestogen in it is synthetic

and some people have some progesterone intolerance. So therefore their mood can even be worse actually. So I see, I'm sure you have women who have said, oh, I don't want to go on hormones because when I took the contraceptive pill, I felt dreadful or when I had the implants, I felt dreadful. or when I had the implants, I felt dreadful, my mood was really awful. But that could be quite different with HRT, can't it? Yeah, it can because we're using the body identical hormone.

So we're just replacing, we're giving it back in the same form as our body's used to rather than the synthetic forms that are in the contraceptive pills and things. And so often I see that, as you do, that women tolerate it far better and it's really nice to see what an improvement it can make. Yeah, and also we can change the days, can't we? Because when people start, often when they still got regular periods, they're still producing their own hormones, of course, because they're having periods.

But with time, as we get older, of course, our hormones are going to decline as well. So that top up can be a bit more, can't it? And then eventually it's most days and then every day, isn't it? And what I really like about all of this is that women are in control, aren't they? They can see what their symptoms are like. And sometimes I've had women who just do it two or three days before their period. And then when I've reviewed them, they said, oh, no, I've started to do it five or six days before. And then it just sort of gradually increases.

And it's difficult to know, isn't it, whether these women are perimenopausal or it's PMS. And there's no blood test to know the difference. But actually I always say to patients, it doesn't actually really matter because it's just a label, really, isn't it? It is a hormonal problem that we're correcting. Yeah, I explain it in the same way. And that because it's a safe treatment, there's no harm in trying. it, I'd just say let's try it, let's see if it helps. And I think, as you said, it's really nice that sort of something that's been controlling you, you take the power back over it and you can

change the doses around and sort of try to understand your body and get things right for you. I think it can be really empowering when you've felt quite debilitated by how you've been feeling. Absolutely. And I think that's so important, isn't it, and everything we do at medicine for the patient to be in the centre and the patient to be in control as well is really crucial. And I know I've been to a lot of meetings with very senior people telling me that we cannot be a hormonal problem if women still have regular periods. And I've really pushed back a lot about that. And often it's gynaecologists that are saying this. And I sort of think, well, maybe gynaecologists don't see women who have regular periods because, of course, why would you go and see a gynaecologist if you

have nothing wrong with your periods. So I can understand that they don't consider it, but when these people are writing guidelines for the whole of the UK, it's really quite obstructive, I think, sometimes for them to think like that, because certainly in general practice and in real life, we see a lot of women who have regular periods, but they're having hormonal changes. Yeah. I think that we do see that a lot, don't we? And I think that can make it really difficult when the guidelines are so sort of restrictive from that point of view, aren't they? And so people are reluctant to prescribe outside of that almost. Yeah, and that does make it very difficult for a lot of women. And so hormones are so important in our brains, aren't they? You know, everyone thinks

just about periods, but actually our hormones work all over our body. So in our skin, even in our nails, in our heart, and our lungs, and our kidneys, you know, everywhere is really crucial, even for just our cells to function. But our brains are so important because we've got various areas, haven't we, in the brains, that can really be effective by the lack of estrogen but also testosterone often in the brain too, can't it? Yeah, it can definitely.

And I think we see a lot of women where that's the case and that they're troubled by not only depression, but suicidal thoughts, as we've mentioned, or sort of a fluctuating mood where they might find that they're diagnosed with bipolar disorder or all sorts of different psychiatric conditions then that perhaps could in part or in whole be related to the change in their hormones. And the approach to the management is very different, I think. I think that's a big part of what I'm enjoying doing and why this sort of works really important to me

is just to be able to sort of share that and increase knowledge and understanding to help other healthcare professionals and women. And there's been quite a response, hasn't there? So we've been working quite closely with various psychiatrists and I lectured at the Royal College of Psychiatrists in Edinburgh a few months ago. And we've had different psychiatrists actually that have reached out. And I know you're working quite closely with quite a few of them, aren't you? Yeah.

There's a lot of psychiatrists that are really. really interested in learning more about it, which is good. They're starting to see for themselves that this could be a factor and wanting some sort of input to help them improve their understanding so that they can help these patients, which is brilliant. And you mentioned the work that you've done with the Royal College of Psychiatrists' e-learning modules. And a few of us are putting together a second module. One of the psychiatrists that reached out to the clinic had wanted us to help her do that which is brilliant and yeah it's great to have everyone sort of coming together and trying to work out what's the best way to help women yes and it's great because you know the psychiatrists

are no different to us they haven't really had any education or training in the menopause and it's like that sort of light bulb moment once you see it you can't unsee it and a lot of them are realizing that many women that they see either as inpatients or in their clinics are women in their 40s or 30s and probably have got some hormonal changes but they've not thought to ask or the women haven't thought to realise the association. So it's really important that we can work together. So we as menopause specialists and GPs can get help if women have got a psychiatric problem, but also the psychiatrists and mental health teams can lays with us as well. And that's increasing more. And then obviously we're doing some research, aren't we,

with Olivia, who's a PhD student associated with Liverpool. university that we're funding and that's going to be really interesting work. I think there's a lot that's going to come out of that as well. But tell us a bit about the mental health symptoms that women experience when they, and like I say, not every woman has any mental health issues. Some people have none whatsoever, but a lot of people have some sort of low grade anxiety or just feeling a bit flat, don't they? But what about these sort of other symptoms that really affect people more? Can you explain what they are? I think as you touched, on anxiety is definitely one. Women will mention that they find that that either it becomes

very exaggerated or they might not have even had any problems with anxiety before and suddenly they're noticing that they are doing. Irritability is another symptom that women often find quite distressing and low mood obviously that we've touched upon suicidal thoughts and ideation. And also with unfortunately, we see. some women where it's escalated to a point where they might attempt suicide or sadly be successful at taking their own lives, which is really upsetting. And that's what we want to be trying to avoid. But often women as well will notice that they're very emotional. They might cry at very sort of at the drop of the hat, something that they wouldn't usually find, would

make them emotional. They just find that they might be in the island. the supermarket and start crying perhaps and those sort of things can really then affect them in their job as well because they might be working in a role where they have to stand up or they're used to standing up in meetings and talking and suddenly they feel that they can't do that anymore and it can really have a huge impact on their lives then yeah certainly no I hadn't realized how many women actually have very intrusive negative thoughts and often haven't spoken about it before I've had quite a few women who sat in front of me and said, look, I've never told anyone before, but I'm really scared. I often wake at three, four in the morning. And I, you know, really think about not having a future.

But a lot of women are, they have insight. They know they really don't want to do it, whereas there's quite a few people I've seen, and I'm sure you have in the past who have been properly clinically depressed, and they don't have this insight. They can't sort of think it through. So there is a difference, and that's what we're trying to tease out with the PhD, But it's very hard. And I think a lot of women think that if they tell people, then they'll be, you know, sectioned or being given drugs and not being listened to. And I think that's a real problem, actually. And the more we can educate psychiatrists.

And I was reading over the weekend, again, about these ketamine clinics. And there's a few over here. There's 256 ketamine clinics now in the USA. And ketamine, as I'm sure a lot of you heard, well, it's an anaesthetic drug, but it's also used as a street drug as well, isn't it? But it has been shown to lift some people's mood when they have resistant depression. I'm sure it would lift most of our mood if we took it.

But it's not something that we would want to prescribe, never prescribed it, but or give. And I reached out to a professor who runs one of these clinics in the UK this weekend. And he said, yes, I think you're right, Louise. I think maybe we should be assessing women for perimenopause or menopause before prescribing ketamine. It's like, yes, I think you should actually. And, you know, we get a lot of flack for prescribing women their own hormones back by giving them HRT. But these clinics have seemed to just be popping up and increasing because, you know, women are desperate to feel better. We hear it time and time again. But I strongly feel that we should be looking at the obvious things,

i.e. hormones, before rushing into something like ketamine. No, I totally agree. And some of these treatments have really nasty side effects as well that can cause a lot of problems for a long time in women's lives, not just ketamine, but some antipsychotics and even some antidepressants can have quite negative side effects that can really exacerbate menopausal symptoms. Well, that's right, because certainly some of the antipsychotic drugs and some of the other drugs that are given can actually suppress our own hormones, can't they? So if someone's perimenopause, all got some PMS, and then given one of these drugs, actually, it can induce a chemical menopause. It can actually lead to a menopause. So it's making the hormonal changes even worse.

And there's no reason why women can't have HRT as well as these drugs, is there? No, no, not at all. And often, I think it can improve the function of, I think there is some evidence that SSRIs, which is like satalopram, floxatein, certuline, certuline. antidepressants like that, that having enough estrogen on board, if they're necessary to have the SSRI as well, will make them work better. And that's really important. And I wish I'd known that before, actually, when I was a general practitioner, because I sort of now think, really, every woman who's in their 50s, so it's likely to be menopausal and 60s and 70s should be considered to have estrogen as well as their antidepressant if they need an antidepressant. And actually, Women in their 40s are likely to be perimenopausal, women in their 20s and 30s, a lot of those will be

perimenopausal or menopausal. So everybody who's a woman who has an antidepressant should be considered for hormones as well if they need it. And it's likely that will improve the efficacy of antidepressants as well. Yeah. And we know that antidepressant prescribing has really increased, hasn't it, since prescribing of HLT has reduced? Yeah, it definitely has, I think, particularly in the peri-mepressant. menopause, I think, because when women still are having regular periods, then as we already touched on, it's felt that perhaps HRT isn't the right thing to be doing if the periods are still regular. And so then if women are presenting with mental health problems or psychological

distress, then an antidepressant is an option to try and help that perhaps clinicians feel more comfortable with. And I think it does help to a degree sometimes, but if it's the hormones that are causing the symptoms, then it's giving the hormones back that's going to improve them. Yes, because we know it might help. Sometimes it helps with the basimotor symptoms, but it won't help with the future health or it. It won't help protect bones and heart and brain as well. And like you say, some of the side effects can be really quite distressed actually.

Some of the stronger antipsychotic medication, even some antidepressants, like metasopine, can cause people to put on weight, can cause people to have sleep. disturbances can actually make their mood actually a bit more blunted and they enjoy things less. They get less sad but then they enjoy things less as well. And quite a few women, I've spoken before on the podcast about weight gain and a lot of people tend to put on weight because of the metabolic changes that occur in the menopause. And then if they're given medication that will increase their weight, that can be quite a negative cycle as well, can't it? Yeah, I think it can. It can be really difficult. It's certainly something that I've struggled with a bit

myself is that trying to maintain a healthy weight and starting to feel better from the HRT, but then it can be quite destructive. Then you're trying to sort of work on your lifestyle alongside the HRT and other things to get yourself feeling better, knowing that all of those factors together are what's going to get you to a place where you're feeling better. and there's still sort of this pressure on women to have a sort of ideal body shape and body image. And it really can be quite destructive then having a negative body image and feeling that even if you're feeling better in yourself and you're exercising regularly and doing all of the things that you know are going to help how you feel that still you might look at yourself and feel that it just really still affects yourself esteem, even though you are beginning to feel better. if that makes sense. It makes complete sense and I think that's really sad and hard and society can be really quite harsh and certainly a lot of people are pushing back on the work that I'm doing. As you know,

I get a lot of toxicity and bullying with my work and recently I was a meeting and they said, well, it's outrageous actually because all women want to do is look like Davina and that's why they're asking for HRT, the so-called Davina effect following the documentary. And I feel really sad about that because, you know, don't get me wrong, Davina's great, she's got one of body, she's really fit. You know, fitness is her life. But actually, I don't take HLT to look like Davina and I don't think anyone should be encouraged because all we need to do is be the best version of ourselves. And that doesn't mean we have to be a certain dress size or a certain wear a certain clothes or have our hair a certain way. And I also really strongly feel and I

know you do that HRT is not a lifestyle drug. It's not to take us to give us a certain look. Look, you know, I take it mainly because I'm scared of osteoporosis, actually, and I'm really worried about dementia. So they're the reasons. I don't really care what I look like, because I know it's taken me a long time to realize that, you know, my body shape will not really change, you know, it's, I'm always going to be flat-chested. I'm always going to have, you know, bigger thyroid.

It's just the way I am. And I think you've got this pressure from society, and I think that can be really difficult, can't it? And people can really judge you because they might think that you don't exercise or that, you know, someone doesn't eat healthily because they're not the same size as Davina, for example. And then that puts a lot of pressure, doesn't it, on somebody who is already feeling pressured? Yeah, it does. It does. And I think that's something that's really important to recognise is that just by looking at someone, you can't tell how fit they are or, as you said, what their diet is or how much they exercise. You can't tell that just from their dress size. or how they've got their hair. No. I just think at that time in the perimenopause and menopause where you're sort of transitioning

and there's a lot of change going on in your body, then sort of having that negative body image and not feeling comfortable in yourself just makes it even harder. Absolutely. I see so many women in it's that sort of cycle, isn't it, where you feel really bad about yourself, your mental health stand. You might have put on weight through not changing your diet because the metabolic change is often mean that women put on weight and then people can comfort eat but then they find it hard to exercise and it takes a long time and you know if people have been suffering for three or four years

it's often going to take three or four years for them to feel better and you know get back to how they were before and it's not a quick fix and I think we do spend a lot of time saying to women that you know you're not going to take HRT for three months six months and then feel amazing and it's not as you quite rightly say not just HRT it's looking at at everything else as well. And sometimes, you know, what we eat, I look at what my teenage children can get away with eating and I certainly couldn't do that. But, you know, our metabolism's changed just because we age, don't we? And, you know, our choices of food often have to change as we age as well. So it is really important that any of you who are needing help, see someone

who is very holistic with their approach because we know that looking at diet and exercise and sleep and well-being and even the type of exercise is really important. So there's a huge amount that needs to be done and all of this obviously can have a negative or positive effect on mental health depending on what advice and treatment's given. So there's a lot we need to do and there's a lot we're doing and I'm hoping that maybe Claire can come back and report about some of the other work that we've been doing behind the scenes which I'm really hoping will come to some great projects. So I'm really very grateful for the time that you're spending and we'll continue to spend in this area. But before we finish, do you mind just giving three take-home tips, really?

I'm happy for you to choose, actually, your take-home tips, because I know you've done your homework and prepared. So what three tips are you going to say? One of the things I was going to say was just about trying to track your symptoms. The balance up is a really good way of doing that to try and sort of get a good picture of what you're seeing in the symptoms you're getting when you might perhaps feel more anxious or when you might perhaps feel your moods dipping and tracking that so that then you've got something that's easy to relay then to the clinician that you're going to talk to and perhaps approaching your GP reception and just saying is there anyone that's got an interest in women's health or anyone that might be

quite open to listening to what you've learned about yourself by doing this and just seeing whether you can then come to an agreement about perhaps what might be the best way to approach the symptoms and help manage them for you. And then also just, I think as we've touched on just understanding that it's quite multifaceted all of this and there's lots of different pieces that need to come together and it can take a while to get it all right for, you and just being willing to learn more about yourself, I think, and get your HRT right, think about food choices, exercise and work that inspires you, which is what I'm doing now, which is great too.

And then also just thinking about going back to the body image and just trying to make some peace with that. So that's not stopping your progress, I think, is something that I've definitely learned has been helpful. And yeah, I think hopefully all of those things coming together will be helpful from a personal perspective. It is really important. I'm really grateful for you being sort of showing so much actually. But I think it is. It's about being confident and feeling at ease with yourself, actually. And I think so much of us as women often put ourselves down and we're always seeking better and I know my self-esteem is very low at many times.

And then I think, well, what would I tell an identical twin? would I try and encourage others? And I think it's really important, but we've got to start with our own, haven't we? And sort of realizing that none of us are going to be perfect, but we might as well try to be the best version that we can and actually use our skills to help others as well is really important. So great advice. And thanks ever so much for your time today, Claire. Oh no, thank you so much for having me. For more information about the perimenopause and menopause, please visit my website balance hyphen menopause.com or you can download the free balance app which is available to

download from the app store or from Google Play.