The Dr Louise Newson Podcast - 235 - Menopause and brain health: what’s the link?

Episode Date: December 19, 2023

In this episode Dr Louise is joined by world-renowned neuroscientist Dr Lisa Mosconi, PhD. Dr Lisa is Director of the Alzheimer’s Prevention Clinic and Women’s Brain Initiative at Weill Cornell Medicine in New York and author of bestsellers The XX Brain and Brain Food. Dr Lisa was studying nuclear medicine and neuroscience when her grandmother and her grandmother’s three sisters all developed Alzheimer's. Dr Lisa became interested in the cause of Alzheimer’s and why women are more susceptible. Her research has shown that, rather than a disease of old age, it starts in midlife and menopause potentially plays a part. Dr Lisa discusses her most recent paper, which found that women who took hormones in midlife to treat their menopause symptoms were less likely to develop dementia than those who hadn’t taken oestrogen. Finally, Dr Lisa shares three things to consider about female hormones: Oestrogen, and oestradiol in particular, is the master regulator of women's brains. It really is like saying that oestrogen is to your brain what fuel is for an engine. It keeps your brain running. Endogenous oestrogen (produced within your body) is different from exogenous oestrogen (synthetic). The bioidentical oestradiol is probably the best one to use because it really maps on the same circuits for your own endogenous oestrogen. I would love for all women to be able to make an informed decision about whether or not hormone therapy is a viable option for them. Many women who are eligible for HRT do not go on HRT out of fear and the fear comes from outdated information, mislabelling on some of the packages. Follow Dr Lisa on Instagram @dr_mosconi Click here to find out more about Newson Health

Hello, I'm Dr Louise Newsom. I'm a GP and menopause specialist and I'm also the founder of the Newsom 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 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 I'm very excited about this podcast. In fact, I've had sleepless nights because I've been very excited. I feel like Christmas has come early.

We're recording this in December. So I've got someone who I'm a fan girl, but I fan girl home intelligence. integrity and her work actually, and obviously her as a person, of course. So I've got with me the neuroscientist Lisa Musconi from New York. And we're just going to talk a bit about her work. But before we start, Lisa, I'm very excited. I can't contain myself. But thank you so much for agreeing to come onto my podcast. Thank you so much for having me. I also heard Liz Lept, so that's perfect. I have my cup of coffee. Cheers.

So it's very interesting, actually. I've just... been lecturing today, and it's the morning for you. For us, it's mid-afternoon. So I've lectured this morning to an NHS Trust in the south of England, some mental health workers. So I've lectured psychiatrists, some nurses, some clinical nurse specialists and some crisis workers, all about mental health and hormones with a massive response. It was great. Then I've just gone over to a GP practice near where I live and I've lectured to some GPs and to some nurses and some receptionists as well actually about hormones. And actually, I've screen grabbed the quote of yours to say about the menopause is about the brain.

And when I first learned about the menopause and even lots of people do, it's about periods, it's about fertility, it's about waiting a year since you've had your period stopping and then you can make this amazing diagnosis of a one-word thing. But actually, because I've got a pathology background, I'm very interested. in basic science. I have, the last seven years have stopped reading many novels and I'm reading papers and I'm reading about the power of our hormones in our brains and I'm also listening to women and what are the most common symptoms? Oh no, they're not the flushes and sweats. They are the brain fog. They are the anxiety. They're the low mood. They're the poor sleep. It's those symptoms

that are stopping people working, stopping women function, really making them a shell of themselves. and of course these symptoms are related to hormones in our brain. So for me, I've really changed the way I think about the menopause. I think it is more of a brain disorder, actually. It's not just an ovarian disorder. And it wasn't until fairly recently, I realised that our sex hormones, estrogen, progesterone and testosterone are produced in our brain.

I've been hoodwinked for the last 53 years ever since I was born thinking estrogen is produced from our ovaries. It helps regulate our periods because that's what we learn at school. But actually it's produced in our brains as well. Well, so I've got loads I want to talk to you, but we're just going to really focus on you and your work. So obviously you're not American, but you work and live in America now. So tell me why you are interested or why you are still interested in the brain and just a bit of a history really about your work, if you don't mind. Of course.

I have been interested in the brain for the vast majority of my life, to be honest. So I was born and raised in Florence in Italy. and my parents are both nuclear physicists, both of them, which was quite interesting. In childhood, many ways, I bet. I had no idea who Cinderella was, but they knew everything about relativity and, you know, positive emission tomography and radioactive decay, which was fun in some ways. But my mother, my mom, was teaching nuclear physics to students who then transitioned to work in nuclear medicine.

And often enough, because this is Italy, and nuclear physics is a very small university. There aren't many people, so it was very family-oriented, and the students would come over on weekends to talk with my parents and really ask more questions and learn things better, but they would babysit me at the same time. And so I remember there's a colleague of mine

who's now a professor at the University of Florence who would just walk me around on his shoulders talking to me about Adams and, you know, different variety of isotopes and things you can do. And then I started looking at brains, and I found it so incredibly fascinating. And when I was maybe 10, I think I told my grandmother that I wanted to be a psychologist and she did not speak to me for three months. She said, absolutely not. Really?

There you go. Yes, you can't be a psychologist. I don't know why, but she had a sense that they wouldn't be a psychologist. a good one, I guess. But then when I started my PhD, I was studying nuclear medicine and neuroscience. And my grandmother started showing signs of cognitive impairment, which then progressed into a dementia diagnosis. So she had Alzheimer's disease, which was very, very shocking and very frightening. And my grandmother was one of four siblings, three sisters and one brother. and all three sisters developed Alzheimer's disease and died of it,

whereas the brother did not. Gosh. Yes, it was really quite, it was very scary. I'll be honest, it was very scary. I was doing my PhD at that time, and I was asking, is it just me? Is it just my family? Or is there a connection between Alzheimer's disease and female sex?

Does Alzheimer's affect more women than men? And they would be like, yes, it does. unfortunately, almost two-thirds of all Alzheimer's patients are women. And I was like, but why? What is the reason for that? What's the cause? And the answer back then was, well, Alzheimer's disease is a disease of old age and women live longer than men. So unfortunately, more women than men end up developing. Families were living with Alzheimer's disease. And at the time, I was saying, well, but the difference is not that wide, right? So in the United States, it was in the States. I did my PhD at NYU medical. And in the United States, the gap is four and a half years. So women

live four and a half years longer than men. But in the UK, for instance, the difference is two years. And Alzheimer's disease and the men is the number one cause of death for women and not men. So then a lot of my work and other people's work was really focused on showing that Alzheimer's disease is not a disease of the old. It's not a disease of a disease of old age. It's actually a disease of midlife with symptoms they start in old age. But the pathology of Alzheimer's disease, all the negative changes that take place in the brain are very slow, they're very deliberate and they're silent. You don't know that you have them for decades until the symptoms become clear in the clinical workup. But it really takes a long time and we can find

the red flags of Alzheimer's disease. We can see the beginning. of the Alzheimer's plaque, the tangles, and the neuronal loss in midlife. So that completely, finally changed the question. So, okay, so what happens to women and not men in midlife? They could potentially increase the risk of Alzheimer's disease in women, right? And we show that menopause potentially plays a role, and they think is becoming more and more accepted now that menopause is effectively, a female-specific risk factor for Alzheimer's disease.

So this has been, that's how I'm here talking to you about menopause. Yeah, and it's so interesting, I think, isn't it? In lots of things in medicine and life is that it's very obvious, but the obvious things are not thought of. And you're absolutely right. When I was at medical school, I was taught this increased risk of Alzheimer's is due to women living longer. And I then thought, but it's not a sudden death.

It's not something they suddenly die overnight. That's what's really strange. And then I did a pathology degree, so I've got BSC in pathology, and we did a lot about all sorts of things, but we focused, one of our modules was about the brain, and we learned about tau protein. We learned to our amyloid. Then we learned a lot about inflammation as well and about how our immune cells can become very pro-inflammatory.

And we learned a lot about mitochondrial function too. Things that we never had time to. to talk about when I was doing my basic medical training, but to dedicate a year in pathology and looking at the link even between atheroma and dementia and other inflammatory conditions and thinking about inflammation causing all sorts of diseases and then also learning many years ago that our hormones, estrogen and testosterone can reduce tau protein. They can reduce amyloid deposition and then thinking, oh, right, so midlife, things that are more common in women, the things that start to be diagnosed. And then I went to a lecture seven years ago,

or maybe eight years ago now, with Walter Rocker from the Mayo Institute, who's done a lot of work, women who've had, I'm sure you know his work, women who have had oophrectomy, so I've had both their ovaries removed at young age for various medical reasons. And he's followed them up and looked at their incidence of diseases. And he's got this graph. And I remember looking thinking, oh my goodness me, it's all there. So women, as some of the listeners might know, if you're younger and have an earlier menopause, then there's this increased risk of all these inflammatory conditions. So heart disease, osteoporosis, type of diabetes, but also Alzheimer's, but also Parkinson's disease, also multiple sclerosis. And then even drug addiction, psychosis,

bipolar, clinical depression, he's shown it all. And then you think, well, why is it? Is it a coincidence. Is it these women are grieving their ovaries? No, of course it's not. Look at the biology. Look at the pathophysiology. And so it's all there, but I think often in medicine, we're always, well, there's so much, not we, I'm not, but there's a lot of people who are trying to find this new drug. There's a lot of sponsorship by pharma. There's a lot of, especially obviously, and understandably a lot of research going into cancer and sort of cutting edge technology. So when we think about, oh, hormones, they're generic, they're off patent, they're and not really cheap.

Like, why would someone invest in looking at that? But then my pushback is, but it's affecting 51% of the population. And actually, the 49% of the population who aren't women have testosterone, and we know low testosterone in men, increases risk of all the inflammatory conditions as well. So it's sort of under our noses, and we're not really, so your work is starting to show

because we need to demonstrate, but we don't always need a randomised control study to show something works in science, do we? I agree with you. We're always caught in this loop that a lot of the research is observational and we need clinical trials, but it's not feasible to do clinical trials for everything

and especially for something like hormone therapy that should be taken in midlife. And then you're trying to measure the impact on something that's going to be measurable. Like Alzheimer's disease diagnosis, 20 years later, 30 years later, You just can't do trials like that. So what we're trying to do now is to do like the women's health initiative, but do it right?

Yeah. So we're testing hormones in peri-menopausal women and early post-menopausal women who have the symptoms of menopause, the neurological symptoms of menopausea, the heart flashes and not sweats. But especially the brain fog, it's my thing, you know, just trying to avoid getting foggy brain and the memory lapses and the forgetfulness. Can we avoid that? Can we reverse that? And we are not going to wait 20, 30 years until someone develops dementia. But what we're doing now is that we're doing brain scans. We're doing brain imaging at the same time that the women are

taking the hormones. And then we repeat the brain scans over time to track the progression of changes, which is a much better way, in my opinion, or testing what the... HRC. Oh, there is. Yes, thank you. You know, no. So we're doing brain scans that look at metabolic activity in the brain. We're looking at mitochondrial ATP production in the brain.

We are one of the very few centers in the United States that have these technologies. It's called 31 phosphorus MRIs magnetic resonance petroscopy. And we have a very high resolution machine with a very nice coil. that allows us to map the intracellular ratio of ATP to PCR to phosphocreatin. So it's the amount of ATP, the amount of energy, molecular energy, has been produced in the brain relative to your energy bank, if you will. How much of this ATP do you burn, how active is your brain? So we do that.

We look at MRI scans, of course. We look at inflammation. We do everything that can happen in the brain. And then we're measuring the markers of Alzheimer's disease, not in brain but in blood. We're trying to make it easier on the participants. They're young. You know, they're women in their 40s and 50s. So we're looking at the amyloid beta fragments.

We're looking at the tau proteins in blood as well. And the trial, we still have three years to go. But we're hoping that that would really help. I think it's going to be very revealing. Because so many women we see in the clinic and we see thousands of women are complaining of this brain fog that they cannot remember things. They're really thinking through tree. They're terrible. A lot of them are worried they have dementia.

Yes. There's so many women who come to us and they're like, I have a family history of dementia, which is the vast majority of the population these days. Unfortunately. Yeah, of course. And as soon as you start forgetting things, you panic, which is perfectly legitimate and reasonable. So they come to us. We do cognitive testing. We do brain scans.

And we make sure that everything is clinically okay. But then we also get the line, right? So that 10 years from now, if you actually have a problem or if you feel that you have a problem, that your cognition is getting worse, then we can backtrack and compare data at that point with your own brain and cognitive performance where you were fine. I think it should be part. Which is so interesting. I remember, sort of eight or nine years ago, I started to get more interested in the menopause and thought I really want to start a clinic.

So I went and sat in some other people's clinics because you learn as a clinician so much more sort of on the job. You learn how to talk to people, how to prescribe, which tests, all sorts of things. So it's great. And I remember sitting there with one of the doctors and saying, when do you know how to start HRT? When do you know when people are perimenopausal? How do you know? And he said, oh, Louise, it can be quite obvious. And I was thinking, I was 45 then.

And I thought, really, really, hmm, don't know. And then I decided to develop a website, write a website, and I just opened my clinic. And I work a lot in the evening when my children are generally in bed. And I remember going to my husband and going to the study and going, oh my gosh, I can't, I just can't think, I can't function. I feel like I've been drugged. It was not just a tiredness that you can go to sleep and you'll be okay the next day. I felt just awful.

Like I just could not think. And my brain is quite fast and I'm used to just like, I'm not very good at names, but otherwise I'm quite good at thinking about three or four things at once, and it's just one, something I've always done. And I just thought, I can't even. And he said, yeah, you look dreadful. And I was really scary, like, petrifying. And then I'd be with patients.

And I think, I just don't even know what they've just told me. Have they got a cough or have they got a runny nose? Or have they got? And I thought, I can't ask them again. And then I'd think, oh, yeah, no, they had urinary symptoms. I think they've got a urinary tract infection. Right, which antibiotics? Oh, my goodness, I can't remember.

And I can really see why people give up their work. And it's horrible. And most things in life, you know, if you cut yourself, you know it's going to improve with time. If you've got a bruise, you know, well, just give it. Or if you're overtired, just have a weekend and just relax and then you'll recharge. This was completely different to anything I'd experienced before. And I was just absolutely mortified. But even then, I didn't think it was my hormones.

I thought it was because I was trying to set up a clinic and do a website and look after my three children and la la. And even when I started my HRT, because I suddenly, after a few months realized, I had other symptoms, it held a bit, but not a much. And my mother-in-law kept saying, are you feeling better now? No, I just can't think. And then it was actually adding in testosterone and having the right dose of estrogen and waiting because it took a few months, actually. And then suddenly I'm like, gosh, my brain is back,

but it's back to how it should have been or how it was like eight or ten years ago. It's really, it's not just a little bit better. It's so much better. And you just wonder, like, is it because I'm using my brain more? it's got less inflammation, it's got more blood flow, it's using, you know, the glucose, metabolis, everything better because I've got the hormones, or what else is it going on in my brain? And actually, this is a problem often with dementia. It's quite hard to make a diagnosis as well.

Yes. And like you say, it's not actually about dementia. It's about memory loss. Like having a diagnosis of dementia, sometimes we would try and delay in general practice because it's such a big diagnosis without an available treatment often. That's right. But actually it's that journey to that diagnosis that can be really, really disabling, not just for the person, but those around them as well. So anything that affects our brain, especially our memory, is really petrifying.

I completely agree with you. I've spent most of my life really trying to understand what leads to dementia and what leads away from it. And the way we live in my household and my family is very brain-held conscious. My husband thinks I'm mad. But there are so many things that I do for myself and for my family that are really based on the research. And we've changed many things in our lifestyle based on science because I just don't want that to happen to me if I can.

Anything I can do that will take me away from that kind of outcome. I'm on. I'm doing it. Yes, my husband's the same way. Even our daughter, she's eight now, Lily's eight. and she knows everything about the brain. She can talk to you about menopause for like forever, for hours and hours. She knows everything about puberty.

She's ready. And what I think is very important is women also is to realize the menopause is not an alien event, but there's a rational biological basis for it, which doesn't make it any easier any better. But I think it helped to know that you're not being possessed by an evil spirit. I absolutely agree. And just having knowledge, actually people going, oh gosh, I haven't got dementia then. So it's related to my hormones. I really thought there was something else.

So having that knowledge is crucially important. But I spoke to someone last week who was telling me that she's only 38, so she's younger. She hasn't had many periods. She's had two this year and she had three the year before. And her sister had an early menopause. And she said, I just can't think and concentrate. But she had only been given antidepressants and trazodone, which is a really quite a horrible drug.

And she said every time they give it to me, I feel worse and I really can't think and I can't sleep and I'm getting flushes and sweats and I was a real mess. And I think, well, actually, why are we giving these people other drugs as well? Like there's one thing not having anything, but there's another thing having drugs that are actually going to impair cognition even more. And that can be really difficult for many people, can't it? I think at least here, the guidelines of professional societies have been updated to not only recommend,

but also really encourage women who are going through an early menopause or a premature menopause to take advantage of hormone therapy if they're eligible for it, which is a whole other kind of war. Yeah, I mean, our guidelines are the same, but it's really hard for actually women to be listened to. and some studies have shown it takes seven years for people to actually receive the treatment or the diagnosis as well. So I want to talk about the paper that you produced recently. I was very excited. Let's do it. It was so much work in study. There was so much work. And then people are like, oh, there's this review paper. I'm like, no, excuse me. It's another review paper is an actual statistical evaluation of 50 plus 52 studies, which is really a lot of work, in my opinion.

Yes, so it came out. And actually, there's lots of things that excited me, but saddened me as well, actually, about your paper because there was a review that was put in the British Medical Journal, the BMJ, a few months before your paper came out. Yes. And it reached the headlines, and it was saying, HRT increases the risk of Alzheimer's.

And I read it. And as you always do with the papers, you don't read the top line, you read the actual paper. And you realise this paper was putting together older types of HRT, different sort of studies. Even the conclusion said it's probably an association, not a cause, and we can't really interpret the study very much. So it should never really have been published. And I remember putting a little video on my Instagram to say, actually, it doesn't tell us anything. It's not very helpful. And there are different types of hormones. We know the synthetic progestogens have a risk of clot and stroke with them. So that can affect the vascular chore. And especially when we think about vascular dementia probably has a role as well. So it was a really awful stuff. But it went to the front page of the news. I was on national tele-tale talking about it. And then

your study came out. I thought, great, this is going to be front page of the news. Everyone will talk about it. And there was some media pick-out, but not in the UK to the extent. Oh, no, probably not in the UK. But here, the study was picked up by CNN, the Walls, and the New York Times. So that was quite hot for us. Which is brilliant. In the UK, we only report about bad news because that sounds like.

It sounds like it. Yeah. So tell us about it. So that study that you and I talked about, the BMJ studies, really were kind of not prompted our analysis, but was really like the last straw, I think. Because there was so, it's been years and years that people would ask. So can I take hormones? When do I take hormones? Do they increase the risk of dementia?

They reduce the risk of dementia. Is it protective is not? And every couple of months. months, there's a new study that makes the headline and people are really confused, right? So one month, you're told that you should go on hormones immediately and stay on hormones for life because that will reduce every problem under the sun. And then you get hit by headlines like the BMJ study to say exactly the opposite. And it's very scary.

It's really frightening. And people don't necessarily know how to read the paper like you did or the idea to read the fine prints. And I just want to say one thing about that study, that if you look at their own figures, the outcomes they reported were for dementia, right? Dementia is a little bit of a mixed bag. It's an umbrella term that includes many possible disorders that impact brain health and cognition. But when you look at Alzheimer's disease specifically, in their own study, the estimates were actually not significant. So that was already like, why is that?

not being a knowledge, why is the headline so different than the actual results of the study? But so many women just wanted to stop the few women who do take hormones for menopause, in this country at least, wanted to go off because of that study. And we're not doing that. We're not, obviously, the North America, the menopause society stepped up and said, no, no, no, this is not what we're doing. But I thought, we need numbers here, right? because we can't look at each isolated study and overdo it or underdo it. We need to get a sense of default picture because there have been many, many studies published

that looked at HRT in the risk of Alzheimer's and dementia. So there is a statistical technique that one can use that's called meta-analysis or one step up. You can do a multi-level meta-regression analysis, which is what we did. we did both, just for clarity, where you pull the data from all this difference. First, you need to identify all the good studies because some, you know, maybe not worth it. But the really good studies, you pulled them all together, we were able to rank about 52 that provided all the information that we needed for statistical analysis, and then you combine them all together. And the results, I think, were very clear, and we can look at the one figures from

the paper which I think are quite clear. This is what we found is my keynote talk. Very good. Look at that. Do you like, isn't it pretty? I made it. Yeah, I love that picture. We were WhatsApping it around various people when it came out. So talk us through it, Lisa. So this is estrogen-only therapy. So we were able, this meta-analysis was the first study that was able to look not just at any type of HRT together, but we were able to really look at estrogen-only therapy and estrogen and progestogen therapy. And then we were able to look at each therapy initiated in midlife or more than 10 years after menopause. And we were able to find differential effects on the risk of Alzheimer's disease and all-caused dementia. I would like to have a lot more

studies. But this is what we have, right? So this is the best we can do with the data we have at this point. So with estrogen-only therapy started in midlife, there was a significant 32% reduced risk of Alzheimer's disease and dementia later in life. And that was very significant and it was very consistent. So the variability was very small. The error was very small, which means then the vast majority of studies consistently reported a protective effect, which is what you want to hear. Yes, because. Yes, exactly. Now, if you start estrogen-only therapy more than 10 years after surgery or after menopause,

in this case is for women with hysterectomies, then the effect was neutral. There was no protection. There was no increasing risk. For estrogen progestogen, which is important. So that's the synthetic. progester. Yes. So the vast majority of studies, except for maybe one or two, we're using progestins. Only a couple we're using, we're looking at biodontical progesterone, but not in isolation, mixed with all different and other forms. So it's hard to, we could have possibly to tell them apart

in a good statistical way. However, even then, this combined therapy initiated in midlife or within 10 years of the onset of the manipulative. cause was associated with a 23% reduced risk of Alzheimer's disease and dementia. Now, this was a trend. Why? Because unfortunately, there are a few studies that were driving up this curve and made it only borderline significant. However, most studies were showing a protective effect, which is what is driving this

little cone downward, right? Now, over here is combined therapy started more than 10 years after menopause. And I have to tell you, this increased risk is not significant. Number one, again, is a trend, which means that there are studies that show protective effects and studies to show harmful effects or an increased risk of Alzheimer's. But this is really the women's health initiative that's driving the effect. If you take out the women's health initiative, then the effect is neutral. again. Yeah, which is really interesting. And as we know, there's a lot of women in the Women

Health Initiative study were actually women who were overweight, they had cardiovascular disease. And they'd also had oral estrogen and the synthetic progestogen. And so there were lots of things that weren't right. You know, I would never prescribe that type of HRT to someone in their 60s. So I think it's comparing apples with pairs, but I think what is really reassuring is certainly the first picture to show that estrogen-only HRT. So estrogen without a synthetic progestogen has got a lower risk, so she started early. So we know from other studies, the earlier people who start HRT, the better. And actually that's very comparable to the reduction risk people have a breast cancer if they have estrogen-only HRT as well. And cardiovascular disease. So we know

that estrogen actually isn't the enemy in our bodies and it's not the enemy in our brains. And I know that's fueling you to do even more research, which you can come and talk about in the future. But it's really important that we know that. And even looking at the curve, which could look scary, firstly, we don't usually prescribe those types of hormones to older women. And secondly, it wasn't statistically significant. So it doesn't mean that older people can't start taking HRT, but we give the body identical hormones. And know that there are definitely benefits to our bones, as well. well and probably for symptoms as well. So there's lots of reasons to consider HRT, but this paper

is really important to have a look at and take away the top tips, really, to help us catapult into doing more research in this area as well. We can't keep ignoring the role of hormones in our brains. So I'm very grateful for your time, Lisa, but before we finish, I'd always ask for three take-home tips. So three reasons why you think female hormones, especially estradiol, but also progesterone and maybe testosterone, but especially estrogen, three reasons why it's beneficial on the brain. In my field of neuroscience, we like to say that estrogen and estradiol in particular is the master regulator of women's brains. And that I think is an important concept because it really is like saying that estrogen is to your brain what fuel is for an engine. It keeps your

brain running. So I think the more research is needed because it's really, there isn't that much research. A lot of the work that we have is preclinical. And you know what happens in mice, very often stays in mice. We need to make sure that it translates to women and we need more options. We need better options. And we need more data to really be able to counsel women appropriately. Like we were talking about that before we started. But for some women, a low dose is enough. For some women, a high dose is better. How do you even make the call? We need to have better measurements. We want to measure estrogen in the brain. You and I were talking about that we're trying to do it now. Yeah. So that would be my first

take-on message is that estrogen is important for the brain. There's no denying that. Number two is that endogenous estrogen is different from exogenous estrogen, right? So when we say estrogen is the master regulator, estrogen is so important for brain health, we're talking about the estrogen that our bodies make. There are many other forms of estrogens that have been used pharmaceutically for women. And I think at this point in time, most people agree the bioidentical estradiol. is probably the best one to use because it really maps on the same circuits.

Your own endogenous estrogen estrogydides. So that's another important thing. And number three, I would love for all women to be able to make an informed decision about whether or not hormone therapy is a viable option for them. And what I mean is that we know that. There are women who are not offered HRT, and there has to be more education about the risks, I think, and some updates, maybe.

But there are so many women who are eligible and do not go on HRT out of fear. And the fear comes from outdated information, mislabeling on some of the packages, or, you know what I mean, the black label warning vagina, for a while. So I think it's funny.

important that all women have access to more information, to more updated information, so that if you choose not to take hormones for menopause, is your own personal choice based on preference and not with information or fear. Yeah. Right. And we're here to provide the information and then this is America. Everybody makes up their mind on their own for sure. Absolutely.

It's so important. Absolutely. And the choice has been taken away from too many women for too long. So it is absolutely having an informed choice, knowing benefits, knowing risks, and knowing uncertainties as well, because we never have the answer for everything, not just with hormones, but with everything. And then your own individual risk tolerance. I think it's something that needs to be included in the conversation.

You can't go to your provider and the answer is no, you're not going on hormones because this, this and that. There has to be a little bit more of a conversation about what are my priorities, what are my optimizing for? But am I scared of? Would I'm less scared of? And what do I want for myself right now in the future? And this doesn't, I don't hear that happening very often when you go to your doctor for a menopause consultation. So I think that should be if possible. Absolutely. So there's a lot we need to change, but certainly all your work. We're all very grateful for and we're watching with interest from the UK. So thank you ever so much for your time today, Lisa. It's been great.

Thank you. 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.