The Dr Louise Newson Podcast - 215 - More than ‘a little vaginal dryness’: how vaginal hormones can transform lives

Episode Date: August 1, 2023

Are you experiencing symptoms like burning and itching around your vulva and vagina, or painful sex? Or perhaps you have the urge to wee more often or are plagued by recurrent urinary tract infections? Joining Dr Louise this week is trailblazing US urologist and sexual health doctor Dr Rachel Rubin, to address these common menopause symptoms and the relief vaginal hormones – often used alongside systemic HRT – can bring. Dr Rachel explains why we need to stop using terms like vaginal dryness and vaginal atrophy, which hugely downplay the impact of declining hormones on your whole genitourinary system. ‘When we say women have vaginal dryness, we minimise their symptoms, we minimise that it's no big deal, that you can just use a little lubricant, a little moisturiser,’ says Dr Rachel. Plus, Dr Rachel and Dr Louise also discuss DHEA – a hormone treatment which converts to estrogen and testosterone in the vagina – and the benefits this can bring to women struggling with genitourinary syndrome of the menopause (GSM), again often alongside systemic HRT. Dr Rachel’s three tips if you are struggling with GSM: Know that if you have any symptoms that affect your vagina, vulva or urinary system and you’re over the age of 45, you deserve a vaginal hormone product. Talk to your healthcare professional about access to this treatment that can prevent urinary tract infections, decrease your frequency and urgency of needing to urinate, decrease your pain in intercourse and lead to better lubrication, arousal and orgasm. Keep using your localised hormone replacement: it is a safe product, so can be used long term to sustain the benefits.  Click here to visit Dr Rachel’s website, and follow her on Instagram @drrachelrubin.

Hello, I'm Dr Louise Newsome. I'm a GP and menopause specialist and I'm also the founder of the Newsome Health Menopause and wellbeing centre here in Stratford-Pon-Avon. I'm also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments and often share moving and and always inspirational personal stories. This podcast is brought to you by the Newsome Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. Today I'm actually very excited.

I'm usually excited recording my podcast, but today I'm very excited because I have another very esteemed doctor from across the pond in America who's kindly agreed to talk today about her work and about some of her thoughts. And she's a sexual health specialist and a urologist. And I would say that she's probably a bit more gobby than me, but I don't know that you'll agree with that, Rachel. But she's very forthright.

She says it as it is, and I think that's actually what us as women need to hear. She's very evidence-based, very impressive, and I'm just delighted that you're here in front of me, Rachel. So thanks for joining me today. This has been a dream come true for me to just, even that you know who I am. And I know it's been hard to get our time zones correct.

So, you know, we could do this. So I'm just thrilled to be here. Oh, so tell me a bit about you then. You're a female urologist, and they are still in a minority. As many listeners know, my husband's a urologist. You specialize in different areas of urology, but there's still not many women. So tell me about your career. Yeah, I can't believe I just found out that your husband's a urologist.

So I am a urologist, and I did a fellowship in sexual medicine, and so I take care of all genders, and I do four things. I deal with issues of libido, arousal, orgasm, and pain in all genders. And that comes with a lot of menopause care. And so I'm very passionate about menopause care and also the genitoh urinary syndrome of menopause, right? All the bladder and vaginal and vulvar issues that happen in menopause. And I'm very outspoken. And yes, I think I'm good at this because I'm a urologist, that this is not just a gynecologic issue. But sexual medicine is just medicine. And it's really important that we start to talk about it.

Female urologists were about only 10% of practicing urologists, but the last time I checked, all women had urologic organs, which include the clitoris and the urethra and the bladder and the kidneys. So we have to start taking away from that the only doctor you need is a gynaecologist. Absolutely. It's so important. And actually, you know, you say GSM, genitone, Unary Syndrome of the menopause, I know it's a bit of a mouthful, but it used to be referred to as BVA, vulvo-vaginal atrophy.

And if you look up the word atrophy in a dictionary, it's withering and wasting away. Well, I don't want to think of any of my anatomy, withering and wasting away. But then it does focus on the vaginal, the vulva. And then often, even now, if you Google menopause or menopaus or symptoms, it will come up with vasomotor symptoms, so flushes and sweats, and vaginal dryness. It's all about the vagina being dry. And it was good that the terminology was changed to include genitone, urinary, so the urinary tract, but it's not just our vagina that gets dry in the metaphors, is it?

So I actually lecture on this frequently, and I believe the term vaginal dryness is killing women. Let me explain, right? When we say women have vaginal dryness, we minimize their symptoms. We minimize that it's no big deal, that you can just use a little lubricant, a little moisturizer. You're fine. It's just a little vaginal dryness. Suck it up, lady, you'll be okay. But it's not just a little vaginal dryness. It's urinary frequency and urgency. It's itching and burning of the vulva. It's difficulty wearing pants. I've had patients say, oh my God, Dr. Rubin, I can wear pants again. It changes your vaginal pH so that the microbiome changes and the bad bacteria start to grow. And so by losing the acidity of the vagina, you get bladder

infections, which can kill you and do kill people. And so the term vaginal dryness is killing women because there are women in lots of women who are dying of urinary tract infections, who could be prevented by being on vaginal hormones, which are essentially safe for pretty much everyone to use, which I'm sure we'll talk about. But we're not prescribing it because we think, oh, it's a little vaginal dryness, start with lubricants and moisturizers. And I just think we minimize women's experiences. And the problem is 70 and 80 and 90-year-old women don't associate their urinary tract infections

with menopause, but that is what is the cause. over time the tissue thins, it gets irritated, it loses the acidity, and it never gets better. No, and it is one of the few symptoms that really don't get better with time and often progress. When people talk about transitioning through the menopause, which I always find a bit weird because I'm not sure I'm transitioning at all as menopause or woman, but some people say, well, their hot flushes, their night sweats improve, their memory starts to come back or their fatigue might improve. But really, once people start to have those. symptoms without proper treatment. It's very hard to get on top of them because like you say,

there are anatomical changes as well that occur because of the hormonal deficiency that's occurring in those tissues, isn't it? Absolutely. The urethra starts to protrude. It gets red, it gets irritated at the vulvar opening. The labia manora shrivel up and disappear, those inner wings. When you're a baby, you don't have labia menorah, you grow them in puberty and you lose them in menopause. Can you imagine if men's penis shriveled up at age 52, we would have a vaccine available. I'm sure Pfizer, because they created Viagra, I'm sure they would have made it, just like they did the COVID vaccine, but the labia menorah disappear, and no one's talking about it. No one warns you about it. No one tells you about it.

And so you have changes. And so by us being uncomfortable with private parts is actually hurting women because we're not doing a very good job of preventing issues, right? We wear sunscreen to prevent skin cancer, we should be doing vaginal hormones to prevent the changing architecture, the changing microbiome and prevention of urinary tract infections. And you're so right, it's easy for men. They can just look down and, you know, see what's happening to their penis. It's not so easy for women. And sometimes they're not sure what's going on. And certainly I've been to a lot of menopause conferences now, and there's a slide that they always seem to show, or some people always seem to show, showing the sort of progression of symptoms with time. And it always says about

early symptoms of the menopause are flushes and sweats and then it can be tiredness and it can be memory problems and then further down the line it can be urinary symptoms and symptoms related to vaginal dryness or pain or discomfort and everything else but i have a real issue with that because i've seen so many young women who are perimenopausal and the first symptom they've had is urinary symptoms or i saw a lady recently and she said it just feels like a blowtorch in between my legs every single day. I've seen gynaecologist, I've seen neurologists, and I just can't carry on like this. So that was the only symptom that... It actually, I see this frequently in my clinic, and I believe there is a bimodal effect that you see people whose genital and urinary symptoms start before the,

like menopause and other symptoms start, so in their late 30s, early 40s, and they get told that it's BV and yeast and BV and yeast and that they get told it's stress, they get told all these things. And then, so it doesn't affect everybody, but there's a large portion of people where they start getting symptoms in perimenopause. And then there's the people who really start getting symptoms in their late 50s, early 60s, or 70s, right, it takes some time. And I believe, I haven't proven it yet, but I believe this is a testosterone story. This is an androgen story because the tissue, we have lots of data to show that the vulvar vestibule, the urethra, the bladder, the vagina has not just estrogen receptors, but testosterone receptors as well. And we know that a woman's testosterone can change

sort of later on in her late 30s, early 40s, early 40s, we see libido drop, and we do see changes in the bladder, urethra, vagina, and vulva at that time as well. And so we see a real benefit for both for vaginal hormones in either vaginal estrogen or in some cases vaginal DHA, which is the only androgen product that we have available right now that are very beneficial. And the cool thing is, is that vaginal hormones don't hurt anyone. There is no risk, no harm to using vaginal hormones in the perimenopausal or even premenopausal period. Do we need more data on efficacy?

Absolutely. But giving a local dose of hormones to the vagina does not increase blood levels of hormones at all. In the AUA, the American Urologic Association has guidelines on recurrent urinary tract infections that came out in 2019. And the brilliant thing that it says is that Perry and postmenopausal women, Perry, they put that word in there, perimenopausal women with recurrent UTI should be given vaginal hormones. And so the problem is, is not everybody reads the AUA guidelines.

And they say, oh, well, you're still getting your period. So your hormones are normal. There's nothing to do. This is not hormonal. And it's probably not the case. It's probably not true. Yeah. It's very interesting.

You mentioned testosterone because we see a lot of women in the clinic who have symptoms more of testosterone deficiency than estrogen deficiency. And we follow the nice guidance that say start HRT. And if women still have reduced sexual desire, then you can add in testosterone. And a lot of women do have reduced sexual desire. But we find that so many women have other symptoms that improve, especially cognitive symptoms, muscle and joint pain, sleep, all sorts of symptoms. But also urinary symptoms, I see a lot of women who have been back and forth to urologists,

all sorts of investigations. Give them local, so vaginal hormones, give them HRT. They do improve. But then you add in testosterone, and they're like, wow, this is incredible. And you're absolutely right. We have estrogen and testosterone receptors all around our vulva, vagina, our clitoris, our urethra. And I was at a European menopause conference a few weeks ago. And they showed this picture with the dots showing the receptors in different colours, estrogen and testosterone. They said, well, we know why we have, or why women

have, it was a man, obviously, lecturing, of course, saying we know why women have estrogen receptors and they can respond very well to vagina and estrogen. What we don't know is why women have testosterone receptors around there. And I actually... Why? So then I put my hand up and so it's absolutely fascinating. But I find in my clinical practice, using intra rosa, which is DHEA, vaginally, as you know, it converts to estrogen and testosterone in the vagina, but seeps out to all those areas.

That seems to have a bigger effect on women than just estrogen alone. And they said, oh, we never prescribe it. We wouldn't see that results. don't prescribe systemic testosterone. And it was around that time that your great paper came out or your presentation with your poster talking about using intramosa. So it's brilliant. Yeah. So we looked at this because, you know, we love vaginal estrogen, right? Vaginal estrogen is wonderful because it's the affordable option for most of our patients. And so what I always say is the best GSM therapy, the best therapy to prevent UTIs, urinary tract infections,

is the one your patient can afford and that will use forever till death does she part. And so I'm not here to say you must use vaginal DHA. But because we know that the receptors have testosterone in them and that sometimes it's an androgen story, we believe that vaginal DHA, and that's why it was invented, was probably it has a really nice property to the tissue. And so we need a lot more data to show that. And the data that we did have was really to prove that vaginal DHA also reduces urinary tract infections the same way vaginal estrogen does, which we did show that.

we looked at data of 22,000 people on vaginal DHEA and compared it to 22,000 people who are matched for diabetes and age and comorbidities all. It was unbelievable. And then you looked at the year after they started this therapy and the incidence of urinary tract infections. And it reduced by half. And then that was really stable with every age, especially in the over 70 crowd. And so that really showed us that we can reduce urinary tract infections with vaginal DHA, just as we can. can with vaginal estrogen. And so do we need more data to show the why you would use one over the other? We have a little data. There's one paper that shows that women who do vaginal estrogen, but they still have symptoms. You switch them to DHEA and you can rescue and recover. So that's, I like it for

that. And in America, we can often get prior oaths, you know, when we have that situation. We certainly have women who will not use estrogen because of the word estrogen and vaginal DHEA is not the word estrogen. And the data shows no increase in systemic blood levels. of estrogen or testosterone. We have women who really like the product because it's palm oil and dhia. It's very lubricating and moisturizing. So it really is a nice product. So the point being is that it adds options. As women, we need options because as you know in your clinic, not everyone responds to the same therapies the same way. And so some women love putting creams in their vagina. Some women hate putting creams in their vagina. Some women like rings. Some women like tablet

inserts. And so the other area of concern really is what's called the vulvar vestibule, which is the area that surrounds the urethra and right at the opening of the entrance of the vagina is actually bladder tissue. And it's commonly the most painful part that women have pain with penetration, pain with sitting and it's irritating tissue that can create urinary urgency. And we find that sometimes vaginal estrogen is not enough to help that tissue at that opening. And so that DHEA, and there's a paper that just got accepted of colleagues of mine that really does show improvement in that vulvar vestibule bladder tissue that surrounds the urethra with the DHA, which is really fabulous.

So I think most of our guidelines and data for testosterone say, yes, it's good for libido. However, we can't ignore the fact that it's probably good for more things than just libido. We just need more robust data. And the problem, because we don't have products, a lot of products, we don't have a lot of interest in studying it. We don't have a lot of money to do big projects and to do good research requires a lot of resources. And so guidelines change because we do more data. We get more information. And they change because of people like you who see things clinically and then study them. And thank God for what you're doing, you know, where you see changes, you see trends, you see people and then you say,

why is this happening? How do we study it? The only reason we have been able to solve really complex issues like persistent genital arousal disorder is because groups of patients work together and say, well, this worked for me and this worked for me and why? And then we look back and say, why did it work? And then we study it. And so that's how science evolves. Yeah. And it's very interesting, actually. I was reading some work by David Sackett. So in the 80s, he wrote about evidence-based medicine. And he was also very clear that it's not just about randomized control studies. It's about clinical evidence as well. And we seem to forget that. There's a lot of things that people are now saying if we haven't got a randomised control study, then it can't be right. And actually we have to remember

not everything is tested as a randomised control study. And actually, if there are trends and they make sense biologically as well, then we shouldn't ignore the signals. And I feel with testosterone, there's a really big anti-testosterone sort of almost not campaign, but a group of people, not just in the UK, but globally as well, who keeps thinking it's placebo. And now there are certain gynecologists and groups in the UK are saying that women have to be severely psychologically distressed with their reduced libido before considering testosterone, and they also need to have a full biopsychosocial assessment. And I find, as a woman myself, who takes testosterone, quite distressing, actually.

my libido changes every day, every minute of every day, you know? And actually, so if you assess me now doing a podcast, my libido is probably pretty low and my husband's gone away for the weekend. So actually, I'm not really thinking about sex, but does that mean I shouldn't have testosterone now? Well, actually, we also know we've got testosterone receptors in other areas of our brain and our muscles and our joints. I'm very scared of osteoporosis.

So testosterone, we haven't got a good RCT in women, but it probably does help strengthen our bones. and I've really suffered with recurrent UTIs, so I really want my urinary tract to be as healthy as possible. And as she's a woman, can't I choose to have my own hormone back? Why is testosterone so dangerous, you know? Say that part louder. And I think, again, men get to choose, right, if their testosterone is low and they have the signs and symptoms of testosterone deficiency, the guidelines support giving men a trial of testosterone for six months to see how they feel.

And 80% of my male patients feel incredibly better. Their mood is better. Their energy levels are better. Their drive is better. I say 80%, because I think 20%, and I see this in my female patients too. 80% who take testosterone are like, oh my God, I got one last week who said, Rubin, that was the piece that was missing, right?

You got me, you know, my estrogen progester, but that testosterone, now I feel like me. Now I feel like me. So we actually have to be talking about gender affirming care in a broad. odd sense. If you want breast implants and you say, I will feel more like me if I get breast implants, you can invest in your body and get breast implants. And I don't want breast implants. That sounds not good for me. You know, and so it has to become this body autonomy thing. If a man says I'm bothered by how big my prostate is. I am peeing all the time. I am up all night. And that is not good for my mental health. I would like a surgery to open my channel. You know, it has nothing to do with cancer or

or life. It's quality of life. We say, okay, your body, your choice. If a man gets prostate cancer and it's localized and he says, gee, I'm dragon. I don't feel good. I have low libido and erectile dysfunction and his testosterone is low. We, with evidence-based and shared decision-making, we offer testosterone therapy and his body, his choice. And so all we're saying on the female side is we do the best that we can with the knowledge that we have in 2023. We are constantly going to learn more and see more and study more. And we will always change our evidence and change our guidelines. But at the end of the day, you get to decide what you do with your body, right? You get to decide, do you have that glass of alcohol? You get to decide if you eat the French fries. You get to

decide if you exercise every day. We don't force you to do those things. And so gender affirming care, you know, and I think, again, our understanding of transgender medicine is that when you get to choose what you do, like, you could choose. That means, you know, you can change your mind. And we do the, do we have all the evidence of what is safe and what the long-term risks are? That's why we study it. And so we continuously have to gather data and do shared decision making with our patients, but we have to stop telling women, you can't do this. You absolutely cannot do this. We never say that to men.

Like, you absolutely cannot do this. We say, well, we don't recommend this. We don't think this is a good idea. But like your body choice, it is unbelievable. I totally agree. I really feel very strongly that as a doctor, I could never say no to people unless it's obviously completely reasonable, but I would still talk about how unreasonable it is. And a lot of women want something knowing that there isn't long-term data, knowing that there could be risks, but they also

know there are benefits. And I think when you think about well-being, it's really difficult to actually measure in studies. So, for example, I know taking testosterone, I can sleep better, but also I can empty the dishwasher quicker. I can put a load of washing on quicker because it's not such a big effort. Now, actually, that sounds really small, but, you know, when I'm busy and I've got three children, my husband's on call, the dishwasher has to be emptied. And if it doesn't, then the house gets a mess. And then I get more stressed and da, da, da, da, da. But that's very hard to put, you know, a randomizer control study does taking testosterone improve your ability to. Well, so we've actually, you know, it's actually very interesting. And a lot of, as I said, a lot of what I do in, we see in the male sexual medicine world, I actually apply to the female side. And there was a big. study called the aging male study. And they took older men, right? And with like not healthy guys, and they gave them testosterone for a long time. And they followed them. And they came back. And what was

improved? Well, their erections got a little better. Their libido's got a little bit better. And their quality of life got a little bit better. But it wasn't like their grip strength was so measurably better or their endurance was measurably a lot better. And so what was fascinating, Dr. Newsom, is the headline was, testosterone doesn't work. That was the headline. testosterone doesn't work, whereas the headline should have been, testosterone is not harmful for old sick men and makes them feel better sexually and makes their quality of life better. In fact, it told us that it works fabulously, right? And that's the exact same story on the female side.

There is no data showing major harm. There is lots of data showing benefit. And so it really becomes the discussion of do we know everything? No, but the data is overwhelmingly positive. and you could try it for yourself. And once you try it, you can decide if this is something that you continue as part of your regimen.

Absolutely. Putting patient choice is so crucial, but yet we sort of forget that. And with testosterone, one of the other things that a lot of people are worried about about the risk or theoretical risk of clitoromegaly,

so the clitoris becoming enlarged. And I haven't had any problems with any of my patients, but what I have had is that women can find their clitoris again. Because, again, as you were saying, the anatomical changes that occur, often the clitoris becomes a lot smaller. You know, it's harder to arouse as well and doesn't have the same sensations without hormones.

So a lot of people are very grateful that they can find their clitoris, as opposed to this clitoral megali, which has connotations of this massive thing growing between our legs and men are being scared of it. I don't know what it's like in your clinical experience, Rachel. We've never seen it. There is a movement. A Cosmo has written about that women are trying to grow their clitoris, in fact. which is kind of interesting.

But we know that the clitoris and the penis are exactly the same thing. They are erectile tissue that is very testosterone sensitive and that, you know, they get erect, it gets hard, it arouses, and that it's hormone sensitive. And so, yes, we can see improvements in orgasm and arousal with the use of hormone therapy. But we have, you know, when you use correct evidence-based doses, you do not see a severe, you know, deepening voice or clitoromegaly or anything like that. And, you know, the worst thing you can do. see that I've seen, right? Somebody says, oh, my acne, I got a little more oily skin. I've got some acne.

You know, where I apply it on my calf, there's a couple extra hairs that grow in and I shave them off. I mean, you're not talking about, you know, massively harmful side effects. And we do a lot of scary things as doctors that have really severe and crazy side effects. We give chemotherapy, which is poison. We give, you know, we give so many things that are harmful. This is one of those things like it's not that serious, you guys. It's not that serious. And I think we want it to be more serious than it is, and it's not that serious. It helps women's sexual health. It doesn't help everybody's sexual health, but a lot of people's sexual health, and that matters to people. And we should listen to them and figure out what their goals are, because it's not everybody's

goal. If improving your sexual health is not the goal, then it's not, you don't have to do it, right? But don't deny other people from saying this is my goal and this is something I want to do. And we really do just, it's so wonderful when you see the benefits. And you're like, well, I didn't do that much for you. And you can really, you know, as you see every day, in your clinic, right? It makes a huge difference. Absolutely. And I think what it's very frustrating and I find very frustrating is that when I do my clinic, I see and listen to stories. The transformational nature of what we do in a clinic is huge. Yet away from my clinic on social media, I feel like I'm a complete failure.

And then I seem to get a bit more strength and think, actually, I went into medicine to help people who are suffering, not other people who hate me on social media. So it's really important that we stay focused and put our patients in the centre. And one of the things I wanted to just pick up on before we finished, Rachel, is you were saying about the expense of vaginal hormones, and obviously they depend, the cost, depending on what they are. And there is expense with HRT. And what some of our NHS England and the government are worried about if more women

take HRT, that's going to be a lot of money, because there's about 14 million menopause or women in the UK. And currently only 16% will take HRT. but if it's more, oh my goodness, that's a lot of money. But even if we just look at local, so vaginal hormones in reducing urinary tract infections, that surely must save money, doesn't it? In fact, we are looking at this right now, and we are gathering data to show if you can reduce urinary tract infections, which can lead to hospitalizations,

antibiotic resistance, high-dose IV antibiotics, or urgent care visits for urinary tract infections, we can save our government in the United States in the billions. And I'm not talking like one or two billion, like lots of billions of dollars a year if you do the modeling correctly. And so this is actually cost saving over time. And so especially vaginal hormones, right, for the 80-year-old, the money that is spent in the end of life for urinary tract infections is unbelievable. And so again, vaginal dryness, the term is not only killing women, but it is causing

your government an obscene amount of money. And so by using these vaginal hormones and changing the education around, these are bladder medications that prevent death, right? It becomes a whole different conversation. And so we must stop calling it vaginal atrophy. We must stop calling it a little vaginal dryness. And we must call it UTI preventing, you know, microbiome, improving essential oil creating magic that really will prevent urinary tract infections.

There is no other medication. at all, ever proven to reduce urinary tract infections the way vaginal hormones is. There's nothing. No probiotic. No cranberry pill. No antibiotic. There is nothing. No vaccine that they're coming out with that's going to truly cost your government a lot of

money that will work as well as vaginal hormones, which can be produced very inexpensively. The problem is in the United States is everyone wants money. And so they haven't until just a couple years ago, it's been very expensive and unaffordable for people. And now you can get a tube of estradiol cream for $20, which lasts two and a half months. That's the cash price without insurance. And so that has allowed our advocacy to get even louder because we have to tell women, you can afford this now. Five years ago, you couldn't.

But now you can, thanks to some really incredible entrepreneurs and business people who see that, like, okay, we need to actually change things here. Yeah. And it's so crucial because the money that saved is twofold, I think. you're saving money for health economies because women aren't going into hospital with urinary tract infections, quite a few people when they go in and then some women develop Euro-sepsis, so they have quite long hospital emissions, or they're even just going back and forth to primary care. They're often having inappropriate urine testing as well, being sent

up to the laboratories. They're having antibiotics, which obviously is causing or can lead to antibiotic resistance. But then it's also the cost to the economy, because a lot of women actually, if you have got recurrent UTIs or you're having symptoms often can't work to the same capacity, or they're taking time off work, every hospital appointment. Or they're getting divorced because they have so much pain with any kind of intimacy, you know, the cost of divorce and the cost of, and that affects your mental health and quality of life. I mean, this is not just a little vaginal dryness. No, and also there's layers and layers of medication that is given instead.

You know, you've already said some of the sort of alternatives that are given, lots of people are given thrush type treatments, lots of people given antibiotics, but then because of systemic effects, a lot of people have painkillers. I see a lot of people who are on amatryptylene or gabapentin or progabalin. They're on sleeping tablets. You know, the list sort of goes on and on and on. And yet, no one's giving them something that's, what, $20, you say, for a few months. It just doesn't make sense, but it's because it's just a women's problem. It shouldn't be really spoken about. And it affects the majority of women have localized symptoms and all women become menopausal. And I think the other women where they're saying there's a few that don't have symptoms, it's because they don't talk

about it, actually. The genital and urinary symptoms are just, it is everybody. I mean, I can't say 100% of people and maybe some people's adrenal glands are working pretty well, but it is so, so common. We just don't associate with menopause. Frequency, urgency, leakage, you know, pelvic pain. we don't think about it as a hormone issue, but it is a hormone issue. But think of the 85-year-old woman who gets up in the middle of the night having to pee and she trips and falls and breaks a hip, right? The amount of money that goes into that and the likelihood that is going to kill that woman is incredibly high. And if she had been on vaginal hormones, we might get her sleeping through the night, not getting up in the middle of the night to pee, not risking that fall. And so we have to start

looking at this from a different lens. And because of what you are doing, you have the entire country looking at this through a different lens. And as much as you hate being yelled at on social media, for every person who is not nice to you on social media, there's somebody like me who is watching what is happening in Britain and who is literally sitting there scheming and talking to her friends in America saying, how do we do what Newsom is doing in Britain? I say this once a week. How do we do this here?

How do we gather an army? How do we change the narrative? How do we create this revolution? because it is so important. Women are not getting this information. They lack basic education on these things, and what you are doing is motivating us to keep going. So thank you.

Oh, you're very kind. What a lovely way to end. I'm going to start before you, you know, change your tune, but that's really lovely to say. Thank you very much. Well, there's a lot more we, and when I say we, I include you as well, to change the world for women

because it's the future health of women that worries me, especially as I have three daughters. Just before we finish, though, I would like to ask for three take-home tips. And I'm really keen to ask you just three things. So women who are listening who think they might have some symptoms related to GSM, gelator urinary syndrome with the menopause, what are the three things that they should do as a priority to help themselves?

If you have any symptoms, urinary symptoms, and you are past age 45, you deserve a vaginal hormone product talking to your doctor about it. It is safe for every human on earth to take. If you are on an aromatase inhibitor, we should have a conversation with your oncologist, but we don't have mega data showing harm, and we have unlimited amounts of data showing benefit. UTI reduction, decrease in frequency and urgency, decrease in pain with intercourse, better lubrication, better arousal, better orgasm.

And number three, I know I'm going way over, is that female Viagra has existed since the 70s. vaginal hormones is female Viagra, and it prevents UTIs, which Viagra doesn't do. So here you have a safe product that improves sexual health, prevents urinary tract infection, and really should be used very widely, and you have to use it forever, right? Till death do you part, because like sunscreen, and wearing your seatbelt, it will only work if you keep using it. Brilliant. Very good.

Love it. So thank you ever so much for your time today, and I'm sure that you will come back at another time to be a guest again. Rachel. So thank you. Anytime. Anytime. You can find out more about Newsome Health Group by visiting www.newsonhealth.com.uk. And you can download the free balance app on the App Store or Google Play.