The Dr Louise Newson Podcast - 220 - Hormones, HRT and advocating for yourself

Episode Date: September 5, 2023

In this podcast, Jill Chmielewski, a nurse, educator and women’s advocate, talks about her mission to guide midlife women to greater wellbeing. Dr Louise and Jill discuss the powerful and poorly understood role of hormones in women’s health throughout their life, HRT and the importance of women advocating strongly for their own needs. Jill advises women should prepare well in advance for the menopause, as hormonal changes can begin earlier than you may expect. Jill’s three top tips:  Educate yourself on the role of hormones and the impact these can have on your health, so that you are informed. Start thinking about your menopause early – and probably earlier than you may expect. You may notice hormonal changes in your thirties, so be prepared and plan which healthcare professional may provide the support that you need to manage your perimenopause and menopause journey. Embrace patient power – act as your own advocate and be persistent with your healthcare professionals about what you need. This includes if you are on HRT, as you may still benefit from tweaks to your current regime. For more about Jill visit her website here and you can follow Jill on Instagram @jill.chmielewski. 

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. So today on the podcast, I've got an American lady with me.

I've had a few people from America, and I'm sure I have a few more. So Jill Shimaleski is with me, remotely, not actually in my house, unfortunately. And we've been having a remote friendship, if you like, for, I don't know, over a year or so. And Jill's a nurse. And she spends her life probably as frustrated as me, but as passionate as me to help as many people and empower as many people as possible. Is that fair to say, Jill? That is, you said it just perfectly. We share the frustration, yes.

Yes. So tell me a bit about you and your background and why you're doing what you're doing, if that's, that's okay. Yeah, yeah. So I've been a nurse for 30 years and about, I would say about 10 years ago, I started, well, I had really always been of the mindset. It was more in kind of the prevention side of health care. Our system is so designed for sick care. And I always wondered why we weren't doing more to prevent disease from happening. And so that was sort of, even throughout my 30 years as a nurse, where I was coming from. And I started shifting then about 10 years ago when I went and became a health coach. I went through health coaching program. And then I went through a functional medicine

program. And I started to find that when I was working with patients, I was drawing in, I guess, attracting women, of course, more than men. And when I was finding in my conversations is these struggles and as I was thinking about them and having had learned more about functional medicine, which is looking at, you know, the root cause of things, I was really connecting a lot of their symptoms to hormones. It related to perimenopause and menopause. And at the same time, I was going through perimenopause. And I was having a lot of those same symptoms. And so I guess it just started to really occur to me that women were struggling with this. And I was seeing women over and over and over. And it just sort of opened Pandora's box where I had realized as a nurse, and I worked in

women's health. So I didn't know anything about hormones or this level of hormones, especially that I do today. And so I realized women didn't know about hormones. If I'm a nurse working in women's health and didn't know that much about hormones, women certainly didn't know about hormones. And so I just started going down that rabbit hole and have found myself with just this love for working with these women and just helping women to understand their bodies and understanding their hormones and really advocating for themselves. So I've just shifted so much in my work. And now I've really, I'm spending the majority of my time just educating patients.

I stepped away from working with patients one-on-one about a year and a half ago. And I'm just doing education solely at this point. Wow. So you can reach even more women in a more productive way, I'm sure. Yes. Yes, exactly. Yeah. And it is so interesting, isn't it? I mean, I qualified, oh gosh, nearly 30 years ago. I feel very old. I qualified in 94. And, you know, someone said to me recently, once you see the menopause, you can't unsee it. It's absolutely right. But I wish I'd seen it 30 years ago. You know, I reflect and I keep thinking, is it because I fell asleep in that lecture? Is it because I wasn't interested? But no, it wasn't. I just wasn't taught. And when I started to read, quite a lot more about the menopause

of eight years ago now just before nice guidance came out I started to become more interested in it and I had to keep reading and rereading the articles and thinking no I'm missing something here because everyone's telling me it's so dangerous HRT everyone's telling me those risks where every

single paper I'm reading actually is showing me benefits and I've done a lot of cardiology in my time I've done a lot of oncology I've done a lot of respiratory medicine and I've done all sorts of things, and also I've done a lot of rheumatology. So you think, well, what about diseases such as heart disease? What about osteoporosis?

And then I did a neurology job for six months as well as part of my medical draining and, you know, dementia. All these really, really important diseases. It's almost that we know that taking HRT, as you know, reduces the risk of these diseases. But we've been told time and time again there's not enough evidence. And I know in the UK, our societies keep saying there's not. enough evidence for primary prevention. So that's giving HRLT to reduce risk of disease. Your North American Menopal Society and various other committees have recently produced a task force, haven't they, to say, a document to say, we should not be prescribing for primary prevention.

Yet, you know, HLT is licensed as a treatment for osteoporosis. We know it reduces risk of osteoporosis. We know it reduces risk of heart disease. So why are people so scared of HART, do you think, jail because they're scared over here, but I know they're really scared over with you. They're really scared over here. I mean, it's so interesting. I think it really stems. I think we go back to the WHA, the premature, you know, ending of the WHA. I think still the messaging, sadly, 21 years later, which am I ever doing my math rate, is that hormones cause breast cancer. That was debunked a long time ago, but that has still been the messaging. Yes. And I think kind of back to your point about what you learned in medical school and what I learned even in nursing school, yes, it's about HRT, but it's hormones

themselves. We know that hormones physiologically what they do in the body. We've learned so much about their impact and that there's hormone receptors from head to toe from the brain to the blood vessels to the muscles, the vagina, the urinary tract, digestive tract, you know, everywhere, the immune system. So when we're talking about, especially bioidentical hormones, replacing hormones with bioidentical hormones, the same hormones that are found. in the body, knowing what hormones do in the body, we can make some generalizations and conclusions just based on what we know about hormones in the body. Somehow these hormones have been so demonized, yet, you know, we freely give insulin and we freely give thyroid hormone, although for some women,

it's a struggle to get even thyroid hormone, but these sex hormones, and maybe it's because they're considered sex hormones, quote unquote, that they're just been tied to reproduction. I think you're absolutely right. Yeah. Yeah. I think this is what's, when I've been trying to reflect, and I do, it's a bit like when I argue with my children when they were teenagers. You try and look at it on their side as well, because otherwise it gets too difficult. So with this, I've really tried hard to think about the other side, like what is the reason here? And I think there is two things actually. I think people are so scared about breast cancer that they won't look beyond it. And we know, and I've talked about this a lot more

on the podcast and previous episodes that the risk of breast cancer, even looking at the WHA with the worst type of combination HRT, the risk was not statistically significant and it was lower than other risk factors for breast cancer such as being overweight, drinking alcohol, not exercising, and actually longer follow-up data showed that women who had a hysterectomy

and had estrogen only had a lower risk of breast cancer. But all the women had a lower risk of dying from breast cancer. So there seems to be still this fear of breast cancer. And we know, obviously, none of us want to get breast cancer, but it's common. It affects one in seven women. And so one in seven women taking HRT will develop breast cancer. It might even be even less if it is protective in some way. But even so, there will be women across the world who will be taking HRT and develop breast cancer.

But actually, also, we know from studies, that women who develop breast cancer when they're taking HRT have a better. prognosis than those not taking HRT. So there's this fear of breast cancer, but there's also this complete, like you say, misunderstanding. And people think that sex hormones, I think because they've got the word sex in, maybe it is more of a sort of nice to have rather than a necessity. And I know you follow me on social media and every so often, it's been a quiet lot the last few days is all you're doing is talking about HRT. Women have survived for years without HRT. Why we having to be, you know, taking it now? And of course women have survived. They've existed. But you have to look at basic, I think, pathophysiology. You look at what these hormones are

designed to do. They're not just designed to live in our reproductive systems. Like you say, they're designed to help our brain, our bones, our hearts, our bodies function. And this is where it's such a struggle. And I think people forget that there are benefits of HRT. And a lot of the work I'm trying to do at the minute is look at the risks of not taking HRT because then it changes a conversation quite a lot more. And you're absolutely right. We need to be thinking about preventing diseases rather than treating diseases. None of us want to be here. We want to be healthy. And our health systems are not able to treat the people that they have now. And certainly just looking in our country but also in the US the rates of incidence of obesity, of cardiovascular disease,

of dementia. It is out of control. But we have a treatment that we know reduces the risk. And if I was comparing recently from the studies the risk reduction of giving HRT to reduce the risk of a heart attack compared to the benefits of using a statin to reduce a heart attack. And you know, actually when you look at some of the figures, HART reduces the risk of a heart attack more effectively than taking a statin. Yet certainly over in the UK when I was a GP, we were encouraged all the time to prescribe statins. And I don't know, what's it like over with you with statin prescribing? Yeah, statin prescribing is, from my perspective, it's out of control. That is sort of like the go-to for everyone. And as you know, I mean, 50% of people who have heart attacks have high cholesterol,

50% low. So to say that lowering cholesterol is the key, you know, it's more about inflammation and other things, I think we're always looking for this one thing. Yeah, absolutely. And I think also sometimes people want to take a tablet because it's easier than thinking, taking a step back, looking at their lifestyle, you know, if there was an exercise tablet, we'd all take it, wouldn't we, to save us having to exercise. But actually, when you do exercise, you feel so much better and you wish you did more. And it's one of those things. But I think when I look at staff, And obviously they do have a role for people that have had a heart attack, people that are high risk. But this is talking about people who haven't got heart disease, who have been picked up with the high cholesterol.

There's been very few good quality studies. I don't think any good quality studies looking at women. So we're just extrapolating men's data when we talk about this. But also, when you look at the pathways where statins work, where they affect the enzymes, it comes from obviously cholesterol. but our sex hormones actually come from cholesterol as well. And so I don't think any work's ever been done on it, but I often think, I wonder if statins are reducing our own hormones as well,

because we know that a lot of people who take statins feel more tired, they get muscle and joint pains, they don't feel great. I would love to measure their hormone levels before and after. This is men and women, actually, their testosterone and their estrazine levels before and after, because I think there would be a decline. But it's, you're right, we just don't think about hormones in the way that we should. And I think the other thing is that it's the biggest motivation for me really is thinking about women's choice. And that's the saddest thing is that women have not been allowed to make a decision,

but they've also not been listened to. I go to lots of meetings where I hear people say, women expect to feel better with HRT and it's ridiculous. they think that their sleep's going to improve or their muscle and joint pains or their memory and they're putting everything down to their hormones. And it's a very sort of patronising society, I think, we live in. And anyone that's worked in women's health will have listened to some horrendous stories from women. And I am not saying that every single symptom is due to hormones.

You know, we all have bad days. We all have symptoms. You know, when I get a headache or a migraine, I can't always blame my. hormones but if my hormones aren't right my migraines are triggered all the time and I know I feel awful but you know listen to me as a patient help me talk to me you know and this is what we're hearing all the time on your social media on my social media and just whenever we speak to women that they're not being believed somehow is that the same over in america totally i mean it's not only it's just their symptoms are dismissed or seen as unimportant or you know i think women have

such great intuition anyway. I mean, we typically know when something's off in our body. We're the ones living in our body 24-7. I mean, men too, but we're living in our body 24-7. So to see a doctor one time a year, you know, they're not living with us day to day. So I think, you know, our health system is not set up in a way where there is even time to, like, have this really thoughtful discussion back and forth between patient and provider. And I think that's a huge issue that we see over here. There aren't really, you know, menopause conversations. you only get a 15-minute conversation with your doctor as it is. You know, our doctors are not in the know.

As you were saying, it's not for lack of maybe not wanting to know, but doctors were not trained. I mean, I think in the United States, I remember an article that came out in 2018, and it was like 20% of medical schools even offer a menopause training course, and it's an elective. And this includes OBGYN, so your obstetrician and gynecologists. And most obstetricians and gynaecologists, unless they've sought out, additional training in this aren't comfortable having conversations about menopause. They don't know what to do with menopausal women because again, hormones haven't been taught. So we as patients don't know,

right? Absolutely. And I think it's really hard to know where to go because although it's traditionally being gyne or OBJN, you know, why should they? Because actually what happens when we're menopausal is we don't have periods. We don't have any gynecological issues. Yet we're all told we need to go and see a gynecologist. Well, the poor gynecologists, they're actually trained in surgery. They're trained in, you know, when people have gynecological problems, well, actually, just taking me as a menopause of a woman, I've had a hysterectomy, I haven't got any gyni organs, and I've still got my ovaries, but even so, I don't have any problems. I don't have any symptoms. So why should I see a gynecologist? And so I feel sorry for the gynecologists, actually, that they're always

being pushed into menopause. But then family physicians aren't being taught. But then actually, a lot of work I'm doing is about nurses and pharmacists actually, because they, including you, but certainly over here, the nurses and pharmacists are really motivated because it's a bit like years ago, we used to do all the pill checks and contraception and asthma and diabetes and long-term conditions. And then quite rightly, the nurses then became trained and it freed us up to do other things. And it's very empowering. And I think there is something about talking to a nurse, actually. People open up a bit more. Doctors, as you know, are quite chaotic. We go from one thing to another to another, whereas nurses are very, a lot more structured with the way that they

listen and talk and go through protocols better. And often they have longer appointments, but I think there is this sharing that happens a bit more, doesn't it, with nurses sometimes? I totally think so. I mean, I think we are, yeah, we're just caregivers. It's not that the doctors aren't, but we're really trying to just offer our, it's like the nature of our conversation is just this more back and forth. They probably are more relaxed with us. They feel a little bit more as we're asking questions, especially because we're taught to ask these very open-ended questions and they start to pour in their answers.

And then it just, they keep going and keep going. And, you know, lo and behold, you realize they've really been struggling with this. So I think, you know, having education not only among our, I mean, our patients, need the education as well. Like we were just talking about sex hormones are not just about periods in pregnancy. They're about the whole body. So I think for a lot of the women here, they'll say, you know, I'm mid-30s, late 30s, and I think something is not right in my body, but they're absolutely not connecting it back to hormones. So if they had a little bit of that know-how, that would be really helpful because they would know that this has something to do with hormones

changing. If we could get the nurses on board to sort of start understanding this as well, I didn't learn this in nursing school. But, you know, this is where I think this holistic approach, getting everybody and every specialty as well. Because like you said, patients are often here referred to the, you know, if they're having mood issues, it's going to be the psychiatrist. Well, the psychiatrist doesn't know much about hormones or if they're going to the cardiologist for issues. The cardiologist doesn't know. And they're sort of being sent from doctor to doctor. So it's like we need to get everybody just on the same page, knowing that this is something that happens to women.

And it's not going to happen when they're 50. It starts way earlier. And I think here in the United States, that's another big, I think, myth women think about menopause happening at 50 or 51 or 52. And they're not expecting any changes to start happening before then. They see it as just the end of a period and that's it. And there's this whole other set of, there's a journey to get there. And there's a set of like silent physiologic changes, bone loss, blood vessel changes, cognitive changes, all of these things that they're just not made aware. of and that's stuff that I think is so important that we continue to share with our communities

and just get women in the know. Yeah, it's so important because, you know, I've mentioned before that I have quite a lot of young patients actually who are still in their teens and 20s, but the more I speak to women, there's a lot of women in their 30s and 40s who are having symptoms, but they're still having periods and they're being told they absolutely can't be related to their hormones. It's very hard to know whether it's related to hormones or not. Of course, it's a is, but I'll often say, well, if you feel as a woman it's related to your hormones, then I'm happy to listen to you as a doctor, and I'm happy to give you some hormones to see if you feel any better, because we know they're really safe, and if they don't improve your symptoms, then stop

taking them. It just seems to me really weird that we can prescribe the contraceptive pill very, very easily, very quickly, and actually the contraceptive pill has synthetic hormones in them, They have more risks. And actually, the risks are still very low. That's why we prescribe them a lot. But certainly over here, I don't know what it's like contraception in the US, but we're encouraged as GPs to prescribe progestogen implants. And progestogen, we used to be a depot injection, but we can still give that. And the mini pill as well, which is progesterone. Now, one of the ways these work is obviously stopping ovulation. If you stop ovulation, you're blocking your hormones. And so I really worry that we're actually giving a lot of women a chemical menopause.

And there are a lot of people who are teenagers and they feel really tired. They feel really demotivated. They feel really flat. And we have a big mental health crisis, don't we? Especially post-COVID in teenagers. But I do wonder what their hormones are doing. And we know that the combined contraceptive pull increases sex hormone binding goblin, so it reduces freely available testosterone,

as well. So are a lot of these young girls testosterone deficient? I'm sure they are. But why aren't we looking at them? I don't know whether you ever think about it, but it's something else I do think and worry about a lot. I do too. And I think even in the, I mean, definitely in the young girls. And I think that just is such a sign of what we don't know about our hormones. Because if we knew what our hormones were doing, we probably wouldn't be so willy-nilly about just taking the pill. Again, there's a right time. It doesn't mean that it's not appropriate at sometimes. But so, so, many women are prescribed it with zero risk benefit conversation. They don't really understand what it's doing in their body. It's really shutting down their own, you know, hormonal production and

interrupting that. And some women are on it for years, decades sometimes. And to your point, their testosterone is low. They have no progesterone. And they have no idea. And then we see this again in perimenopause, this sort of, there's going to be no conversation about HRT. They're denied HRT, but they're given the contraceptive pill. So we have a lot of work to do over here. I mean, if I had to like pick a word for it, I think it's just frustration. Everyone is very frustrated. Patients are struggling and frustrated and just needing support more than ever. And this is the sort of sometimes the best they're being offered is the pill, either for

reproductive issues when they're younger or period issues. And now here it comes again in perimenopause when there's a much, much, much better option. Yeah. And I think there is this real people are so scared when we mention the three letters, HRT or MHT, menopause, hormonal treatment. And, you know, I'd love to call it just hormone support treatments actually, HST, it'd be so much nicer. You know, my 20-year-old daughter, I hope she doesn't mind me saying, a lot of people know, she has really, really bad migraines. So contraception is difficult for her, but she's elected to have a J-DES coil, which is like a mini marina. So it's

a low dose of synthetic progestogen, but it's very low. So it's very good contraception. But it doesn't really often interfere with her own hormones, but her own hormones trigger migraines as well. And so she uses HRT, so or HST, hormone support, whatever. She just uses estrogen patches. So she has a constant amount of estrogen in her body. And she does use a bit of testosterone as well. And she feels great, absolutely great. But when she mentions that to people, they get really freaked.

And even my husband recently said, are you sure that this is okay? I said, well, she's seen a specialist. I don't prescribe obviously for her. And it's fine, but it's actually lower dose than if she was on the contraceptor pill. There's no risk of clot or stroke, which is really important because she's got to a severe migraine sufferer. And she feels better. So, but there is this sort of, what are you doing giving her HRT? Well, it's, you know, I'm just not replacing her hormones. I'm just, she's just having them supported so that she doesn't have these fluctuations and it's the same in people with PMS, PMDD. A lot of people are given antidepressants or they're given actually drugs such as Zolodex, which absolutely flaws their hormones and gives them

a chemical menopause. Whereas I think actually just rebalancing their hormones and keeping them smooth and flat at a level that's right for them can be transformational content. Absolutely. I think the same thing all the time. Oral contraceptive. seem like nobody even blinks an eye. And when we say HRT, that's to your point, I always say hormone optimization or let's optimize hormones because I feel like just the word HRT has this sort of, I don't know, there's something about it. And it must go back to again to like the WHRRX. But if we think about hormone optimization, that's really all we're looking to do is just optimize hormones. And I think to your point about if someone's in their 30s, you know,

if you've never had symptoms and all of a sudden in your mid 30s, late 30s, you're not sleeping, you're having anxiety, you're starting to have those symptoms, it probably is hormones that are changing. We know that hormones peak in their 20s. So on the way to menopause, we know they're changing. So treating with hormones or optimizing hormones at that point, HRT, optimization, whatever we call it, we see what remains after that. When you give someone hormones just a little bit to support, make sure that they're more balanced, oftentimes their symptoms are gone or just about eliminated. And you can see what's left behind. That's the most, I think logical first step versus going to an antidepressant or sending someone for, you know,

additional testing, which oftentimes women are getting sent for expensive testing. Yes. Because of symptoms when we know what's related to hormones. So start with the hormones. Optimize the hormones first. Then let's see what else remains, right? Well, it's keeping it really simple and cheap as well, absolutely. And I think there's been a, well, I know there's been a big pushback to some of my work talking

about we're medicalizing the menopause, whereas. I know it's been medicalised already. Most people we see are taking antidepressants. They've been on pain killers, sometimes taking sleeping tablets. They're on blood pressure lowering treatment. As I've already said, they're on statins. So they're on treatment already. But actually, this is treatment that isn't reducing their risk of future disease.

It's often not improving all their symptoms, otherwise they wouldn't be coming to the clinic. And a lot of medicines have side effects. certainly the more senior doctor I became, the less I would prescribe. And, you know, I actually shudder to think about what I was like as a junior doctor because we'd do these ward rounds. My job as the junior doctor would be to fill in the drug chart. I would just be told to fill out all these drugs and I would write them all up and then the patient would go home with this massive bag of drugs. No one would tell them what they meant because again, this was in the 90s. We didn't really have any shared decision making. And so if someone had come in with a bit of chest pain,

even if they didn't have a heart attack, they were automatically given all these, you know, blood pressure drug statins looking back. A lot of them were women who probably had pains because of their menopause. And so as I became older and wiser, I would end up reducing drugs rather than adding to them. But we've still got this culture. And I don't know how much is driven by pharma, how much is driven by targets, how much is just driven by uncertainty. Because sometimes if you're uncertain as a medical practitioner, You feel your patient's going to be happier with a treatment. But actually, often patients are delighted not to have treatment. They want to be listened and spoken to. And they want to decide whether a treatment is right for them or not. And more often, people don't want to take medication, do they? No. And if we're really talking about addressing the root cause of the issue, we go back to hormones.

And it's not saying it's for everything. But when we go back to basic physiology, when these hormones change, we know that this is what happens behind the scenes. Even the women that say, well, I had no symptoms whatsoever in menopause, we know that behind the scenes, her bones are changing, her blood vessels are changing. You know, there are cognitive changes. So, you know, we're just really looking at trying to optimize the body, help the body stay healthy for as long as we can. And if we're going to, you know, we weren't living this long. We're now living to be 80 years of age. You know, I think in the year 1900, the average life expectancy, I know in the United States was like,

50 years of age. Well, it's now extended. Women didn't go through menopausal 51, so women didn't experience these symptoms or these physiologic problems, right? Now we've extended people's lives artificially through all of these other means. We're keeping people alive with medications and surgeries. So to your point about medicalizing things, we are already medicalizing. So why not go back to the root cause of the issue? Address the hormones and let's see what remains. First is just throwing a bunch of pills of people. And yes, we talk, you and I both talk about lifestyle, yes, we want to support people and, you know, encouraging them to exercise and sleep and, you know, eating good foods. But when women are going through perimenopause

and menopause and they're trying to sleep and they want to exercise, but they feel like garbage. You know, getting some HRT on board oftentimes is the one thing that will help them to find they go, okay, I'm sleeping again. Now I feel like I have enough energy to go exercise or make a good meal or, you know, just really pay attention to my life and take good care of myself. It's hard when you're feeling flat and tired and having, you know, lousy sleep consistently for a lot of women, which is, you know, weeks to years, as you know. Yes. Yeah, absolutely. I mean, it's so barbaric. It's so horrendous what's happening to women. We've got a long way to go, but it's been, we do. It's been great having your knowledge and your enthusiasm shared on the podcast. I'm very great

for your time, Jill, and we're recording this on a Sunday night. So I, well, Sunday night for me, but it's still a Sunday. So I'm very grateful for you giving up your time. And I just hope that you'll be able to come back to the podcast in maybe a couple of years' time and tell me that things are improving. I think things are starting to improve because women are starting to understand and, you have a voice, which is really important. But I'd be really grateful before we end just to ask for three tips.

So three things that you think are making a difference to the work that you and that I'm doing over in the UK, three things that you think actually we should really carry on doing because they are helping. Yeah. So I think, I mean, the first thing is, I think just for women, I have to say women getting educated. I think that, and providers too, if we can get both providers and patients educated and on the same page, that's why I do. I hope in two years we are having this conversation and saying things are really looking. up because we have providers who are in the know and we have patients who are in the know. And we're starting to see that we're having more shared decision making. I think that's probably the number one thing that we need to keep doing on both sides. I would say, you know, my second sort of tip is really towards for women is to shop for a provider early. I think women are

really surprised by how early these changes are happening in their body. And just like we shop for our obstetrician or our pediatrician, think it's not too early in your 30s to start trying to figure out who that support, menopausal support person is going to be for you. And if you're educated, you're going to know what questions to ask so that you'll find the right provider. But start early. You may find yourself having to, you know, speak to five, six, seven providers before you find one that really is in that space with you where they're willing to do share decision making. So that one sort of is on the onus of the patient, but I think so important for women to just shop early because it will happen to you. It happens to every single woman.

everybody goes through pari menopause and menopause. So it will happen. So it's one thing to prepare for. And I think the third thing I guess is, and I guess it goes, I'm going back to, I think, women more than the providers, is really for women to be persistent, advocate for what you need. Don't be afraid to advocate for what you need. If you feel that something is happening in your body, it probably is. Track your symptoms. I think we've been so trained, especially in the United States, to just sit on the sidelines and let our doctors. you know, make the decisions or go in for that annual appointment or whatever it is. And if the doctor says no, oh, well, I think we have to advocate for what we need. Even if we're using HRT, I always tell

women, it's not a one and done. Your first dose is not going to be your last dose. So if you get that prescription, don't feel bad about calling the doctor for follow-up. Don't feel bad about saying, hey, you know, my symptoms are improving, I think, but I think I need some more tweaking. That's what this should be about. So I think for women to stand in their power and say, you know, be persistent in advocating for what you need. Brilliant. Love it. Patient power is really, really good. Patient power, right. Yeah, absolutely. So thank you ever so much for your very wise words and look forward to having you back soon. Thanks, Diel. Oh my gosh, thanks for having me. It's so fun. I'm so glad we connected and I would love to come back. So thank you. Brilliant. Thank you.

You can find out more about Newsome Health Group by visiting www.newsonhealth.com. And you can download the free Balance app on the App Store or Google Play.