The Dr Louise Newson Podcast - 242 - Sex, hormones and the menopause

Episode Date: February 6, 2024

With Valentine’s Day just around the corner, this week’s podcast looks at how menopause can affect sex and intimacy. Joining Dr Louise is US-based Dr Kelly Casperson, urologic surgeon, author, and sex educator with expertise in hormones and pelvic health, whose passion is empowering women to embrace their best love lives. They talk about how genitourinary symptoms, such as recurrent UTIs, can impact sex, why communication is crucial and the importance of education in helping women make informed decisions about their treatment and health. Follow Dr Kelly on Instagram @kellycaspersonmd and listen to her podcast here 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. On this week's podcast, I'm delighted to introduce to you someone else from America who is a urologist, like my husband, but not like my husband, because she's female.

And so I've got with me, Dr. Kelly Casperson, who is a urologist who specializes in sex and hormones and helping people feel better and reduce the risk of diseases and everything else. So I've been stalking her quite a lot on social media more than she realizes. And I love her openness. I love her evidence-based approach. And I just love her way that she's just going to cut through all the noise and just get to her patients and really help. So welcome, Kelly. Thanks for joining me today.

Thank you for having me. It's a great honor. So my husband, as many people know, is a urologist. And what he knows about menopause now is very different to what he knew 20 years ago or longer when we were medical students. What I know about the menopause is very different. And actually today, earlier, I was talking to an ovarian cancer charity about menopause. And I was rereading some papers that I read many years ago about how women after a cancer diagnosis, diagnosis fall off a cliff and no one talks about sex and the majority of women do have problems

with sex and not just sex but sexuality actually and not just libido as in sex drive but just the libido joy of life and it's awful actually and I we can talk about so many things and we're going to have to talk quickly because we've only got half an hour but I'll probably have to get you to come back if that's okay Kelly but you know last night I was sitting there thinking I've always been really open as a doctor and I allow people to say exactly what they want. But actually, you have to ask the right questions. And yesterday I saw a patient of mine who had cervical cancer several years ago. She's really young.

She's in her early 40s now. The cancer diagnosis was seven years ago. She's had surgery. She's had chemotherapy. She had radiotherapy. She's, I hope, cured from her cancer. Yet she doesn't think she'll never be able to have sex again. And she's been told that things won't feel the same for her.

I asked her if, would you like me to examine you? And she burst into tears and said, oh my goodness, that would be amazing because it feels and looks different. I'm too scared to look. But I don't want to be 42 and never have sex again. And actually examining was really reassuring. That was an easy part. But actually, this is awful. So the more I ask, the more I see, the more I hear, the more frustrated I am. And I mean, are you frustrated, Kelly? Or is it just me? Oh, no. I'm a lot more optimistic now, five years into this journey than I was in the beginning because I actually see that it's getting better. I truly believe that there's something that's happened this year. It is getting better. But you're right. Like on the importance of asking the right questions, I think that's very

poignant because if you ask a woman, are you doing okay? And you have a power differential. You're the doctor. She's the patient. You say, are you doing okay? She wants to be doing okay. She's probably going to say, yeah, I'm doing fine. You're never going to know what's actually going on. Like asking the right questions is incredibly important to hear the story. And the other thing I notice a lot in my clinic, because I'm more urology based, is they'll come in for the urology problem, right? Bladder leakage or urinary tract infections, right? And you ask the questions, or you do an exam and you see that, you know, there's no labia menorah, the clitoris is atrophied. The clitoris has fymosis, so it's covered by skin, right? And then you say, you know,

You're sexually active. Is it pleasurable? And then I've never had an orgasm in my life, right? And that's not what they came in for. They did not come in for that problem. They came in for recurrent urinary tract infections. But there's so much under the surface. Absolutely.

And we do a symptom question now on every patient in the clinic. And it talks about libido. And actually, it's a segue in, really, because they answer the questions before they come. So they know that if appropriate, we will be talking to them. And I remember when I first started the clinic seven, eight years ago, and asking women, not just about whether they feel like sex, but whether they have sex. And most women, it's at least two years that they've had sex. And I was talking to someone yesterday, and she said, do you know what, I hate sex?

It just does nothing for me. I lie there and think, oh, no, I'm going to have to go through the motions. And she said, do you think that's my hormones? And she's been married for ages. She loves her husband. I know she does. But it's that whole, like, it's awful. actually, that men are now to talk about sex. They can just go and buy Viagra. They can do all sorts. But women, it's

like shameful if we want to have pleasurable sex almost. And that's just gone on in the history of women for centuries, hasn't it? Yeah, I remember talking to a big expert in female sexuality as I was kind of going through my journey and still learning. This is before I wrote the book. And we were talking about desire, right? And I'm like, now you're assuming the woman's having good sex when she's having it. And he's like, well, of course, we're assuming when she's having it, it's good sex. And this is a man expert. And I'm like, there's the problem. Right. Because here we think, like, you don't desire sex, but then sex is amazing when you have it. You just don't desire the amazingness. And it's like, no, sometimes you don't desire mushy broccoli. And there's nothing wrong with not desiring mushy broccoli. Right. So you really do have to ask all the different questions because a lot of women will come in thinking they have low desire when in fact it's incredibly painful. Yes. Right? And so I tell women like, you don't have two problems. You don't have low desire and pain. Of course you don't desire hitting your thumb with a hammer. And that's really important, you know, especially thinking about urinary symptoms.

So I see a lot of women, as I'm sure you do, who have urinary tract infections or cystitis after having sex. It can be very common when you've got some changes that occur when you've got low hormone levels. And it can occur when with contraception if their testosterone levels are low, of course. And so a lot of women are so scared of having. sex because they're worried about having a UTI or cystitis after. So they might find the actual sex amazing. They might have the most incredible orgasm. But if they know they're going to be blighted with getting up in the night, having cystitis, not being able to function at work, feeling in a lot of pain, discomfort, and not wanting to take antibiotics. And no one's talked to them. There is

treatment that can prevent that. That will affect your experience, ain't it? Oh, 100%. You start avoiding it, Right. And if you start avoiding it, especially if you're not communicating with your partner about why you're avoiding it, then they have to assume because they have to try to figure it out. Does she not love me? Is she seeing somebody else? Like it goes poorly quickly. Absolutely does. Especially when we've never been taught how to communicate about sex, right? There's people who've been together for years who've never talked about their sex life. Everybody's just sitting around assuming things about each other. Yeah, I think the only thing that's more embarrassing to talk about in sex is money and people don't talk about what's in your bank account. But we should be talking to. our partners and I've been horrified over the years, women telling me how painful it is, how it's just the most uncomfortable thing, it brings tears to their eyes. And yet they won't talk to their partner because they say, I know sex is really important and I know he enjoys it and I want to give him pleasure. And I'm just like, hang on a minute, if he had a big sore down his penis, he would be telling you. Like, why can't we be talking? And then it's not even just about penitative sex or sex with another person.

it's any sort of sexual pleasure. And we know, and we don't need to go in big detail, because I've talked before another podcast about this diagnosis of HSDD, it's hypoactive sexual disorder. Even that's a mouthful. It's a mouthful. I think it's actually worse than GSM. Yeah, it is. Because we know that it affects around 25% of menopause or women from the studies.

But if you look how you make the diagnosis, it's the most barbaric, old-fashioned, degrading thing ever. I don't know about you, but you have to wait until women are severely affected and it has to be for a minimum of at least three months. So you can't have two months of feeling like awful and low sexual desire. You have to wait for three months. There's so many things. I don't know what you think, but it just doesn't feel right somehow. Yeah, the bar is so much higher. I mean, Viagra's been around in the US at least since 1997, 1998. It has side effects. Viagra has side effects, people. Like, this is not a sugar pill. It's not without it. It's issues, but by and large, it's very safe, right? And we give it to men whenever they think about it,

right? We're like, oh, you need just a little more confidence in the bedroom, have some Viagra. Like, we're just giving it out like it isn't anything. And that's the power, I would say, of the female urologists in the menopause movement. We take care of men. We know how they're treated. We don't say, I'm sorry you're having erection issues in low energy and you have low testosterone. That's just what getting old is. Have you tried acupuncture and want? line, right? But we'll say that same statement to women. And I just think the gynecologists do not have that male lens that the urologists have. Yeah, it's a very interesting perspective. And I've spoken before in Avran Blooming, who we both love and admire, talks about if you say to a man,

you are going to be guaranteed to have a condition where your penis is going to shrivel, it's going to be painful to have sex, and your brain will become like mush. You won't be to think properly and 10% of you will give up work because of this condition. But there's a treatment, but we're only going to give it to the minority of you. It just wouldn't happen. But especially when you focus on sex and it's a generalisation here, of course. But for many men, sex is really important. It's really important for men and women and everybody, actually, or sexual pleasure. So why should it be stripped away from us when we become menopausal? The number of women I have messages from, and you probably do all over the world, to say, I can't

find my clitoris, it's really shrunk. I am unable to orgasm. I know it's related to my hormones, but I'm not being listened to. I don't really quite understand the big problem. Well, what we've done in urology is we've treated the male sexual dysfunction without addressing the partner. And 90% of men are partnered with women, right? And so now men get the good fortune of seeing me in clinic. And I'm like, what's your plan? And they're like, well, I don't, they just want an erection, right? I'm like, well, who are your partners? Do you have a partner? You got to start there. Yep, my wife, yep. And we haven't had sex for eight years. And I'm like, is she seeing somebody? Is it painful? Have you talked about your new plan? I wish I could tell

you 50% of them have talked to their partner about this. I'm at 100% that have not talked to their partner. And so I give them a tough time about it. I'm like, listen, you're at the doctor. you're going to get a medication that's going to make you want sex more and have a better working penis. And you've not communicated that to the person you want to use your penis with? Sorry for being crude. Do you pay the Americans on? But it drives home a point. Yeah.

And it's very important. So my husband is, you might know, a genital urinary reconstructive surgeon. So he will rebuild penises often when there's been trauma or other conditions. but often the male and female partner will come in together and he'll increasingly look at the woman, especially if she is of a menopausal age, and say, directly, have you any discomfort problems? And the man's like, hang on, this is my consultation.

He said, no, you've already talked about, you know, sex and how important it is to be able to use your penis in that way. And the women are so relieved, like their shoulders just go down inches. And he says, I'll write to the doctor and say if they can prescribe you some vaginal hormones. And it's like, Paul, this is amazing. You'd never have done this five, ten years ago. He said, no, I didn't think because I've just been blinkered thinking about the man. But actually, I realised from talking to you, and actually the response I get from the women, is huge.

And that's one of the sort of throwbacks about Viagra and Cialis and these drugs, is that the more they're used, wonderful, but then it's unmasking these women who might have thought their urine retract infections was an aging-related thing. they might have not really thought that they had any problems with their vulva or vagina or surrounding tissues, but then when they have sex, my goodness, it's really uncomfortable. But they think it's because they haven't used it for a long time. That's right. One of my platforms, as you know, is that a penis will not fix a hormone problem. This myth of use it or lose it, right?

It's from a very old gynecology study that was correlation, not causation. Oh, it's terrible, but I still hear it. All day every day. You just use it. It's all over the internet. Yeah. Or then you just get some dilators and just use those. And that really doesn't feel right.

So we're talking about hormones. Now, we've always been naively taught that estrogen is the most important hormone. We have progesterone just to protect the learning of the womb. And there's a bit of sort of chatter about testosterone, but that's the male hormone. Now, the more I read about physiology of hormones, and I've read some amazing papers recently, all three hormones are really important, actually. progesterone is not just to protect the lining of our womb. Our brain produces this as well as our ovaries.

It's very anti-inflammatory. It has really important biological effects. Eustrogen is important. And testosterone is important. But we've always been taught the menopause is when our estrogen levels decline and our periods stop. But what about testosterone levels? They're not all in line with each other these hormones. And we have testosterone receptors on our vulva, our vagina, our perineum, our pelvic floor, our urinary tract.

So why are we always saying... Our brain, our bones? Yeah, precisely. So why are we saying, have your estrogen, make sure you're well estrogenized and then think about testosterone if you've got severe psychological distress with your reduced libido? I don't quite understand. Is that the same for you over in the US that you have to do that? Absolutely.

I mean, to step it out another 10,000 foot view is we have more hormones than those three. We've got tons of hormones. Those are just the only three that we know how to test and actually have a medication for, right? And I like to say that to be like, you guys, We're going to look back at this era as like bloodletting with leeches. Yes. Doing the best we can with a little bit of information. But what we did is we gendered the hormones.

We said estrogen is female, testosterone is male. And once we gendered that, we made it disappear from 50% of the population. I actually Googled the other day. I'm like, Google, what's an androgen? And it says the male hormone responsible for male sexual traits is kind of what Google told me. So I'm like, we've got a lot of work to do to get all the hormones back in the bodies. And this is a meaningful thing that I do. So I see a postmenopausal woman in clinic.

She's with her male partner. And I'm talking to her about hormones and why they're important. So I point at him and I say, do you know that his estrogen is higher than yours right now? And it blows their freaking mind for multiple reasons because the man doesn't think he has estrogen, right? And then now her estrogen is lower than his. It's like you guys our education is so poor. It's really interesting because even my mother, who is well educated, but she's not medical, we don't come from medical backgrounds, said to me a few years ago, I didn't realize that people

have hormones in their bodies. I just thought hormones was just HRT. So then I thought, oh gosh, and I have been a medical writer for many years, yeah. And I remember years ago writing about cancer and interviewing some people, because this was before the internet, I'm saying, what's cancer? and they said that means death. And I thought, hang on, no it doesn't. But who's taught them?

No one's taught them. You pick and it's just like anything you learn from whatever you read or what your best friend tells you. And so then I'm thinking more and more about hormones. You're absolutely right, Kelly, because we've got hundreds, thousands of hormones in our body and they work so beautifully to help our bodies to function because they're just these chemical messengers.

But then they've been defined as sex hormones. Well, they're not all about sex because we've already said they regulate every single cell process. actually, and they're not about gender either because we've already said women have testosterone and men have estrogen. But then actually people talk about ovarian hormones because apparently the menopause is when we haven't had a period or we're not fertile, but I don't really like those definitions. And they're not just ovarian hormones. We've already said they're produced in other areas of our body. Yeah. So why we're trying to put them into this box and it's a real problem when

we're trying to dispel all these myths and talk about how testosterone can improve brain function, not just about libido, or we're talking about estradiah reducing risk of cardiovascular disease and being a vasodilator and lowering blood pressure, people who have never thought beyond the ovaries are like, wow, hang on, I don't understand, well, how does this happening? Yeah. And then if people don't know that our hormones are natural, that they're going in our bloodstream and they're doing this all the time when we're younger, then it's quite hard to understand as well. I can see why we've got in this mess, but we need to unpick it, don't we, to help more people?

Yeah, and I think it starts with education. I was at this symposium in New York City this past week, and somebody said, does the pain with sex end when menopause is done? So to me, I'm like, okay, you have to go back to the basics, right? You are in a low hormone state for the rest of your life unless you take a medication. And even, like, you know, even ridiculous to me, people are like, don't call menopause a deficiency. We don't like how it sounds. And I'm like, well, I'm sorry you don't like how it sounds. You let other people know how you want it. But when a woman is walking around with less hormones than any man, compared to how she was functioning when she was saying she was functioning at her best, what do you want me to call that? If you don't want me to call that a deficiency of what her other baseline was.

It's really interesting, isn't it? I spoke to someone at the Royal College of GPs about eight years ago, and I was probably more gobby than I am now. Maybe I'm the same. I don't know. But I contact them and said, how do you change the name of something? I would like to change the name of menopause to female hormone deficiency, so FHD. And they were like, oh my goodness. And I said because once you start talking about deficiency, you're immediately thinking, how do I replace that? So if I said to you, Kelly, you're iron deficient. I think the first question you would say to me, if I was your physician, or how do I get more iron?

Is it in my diet? Do I take a supplement or whatever? Yeah, I wouldn't say you offended me, right? Yeah, precisely. Exactly. And so if I'm thinking about a phoenix, you know, female hormone deficiency, and I know it's a bit crass saying female hormones, because, you know, or an estrogen deficiency and a testosterone deficiency and a progesterine deficiency, they're all

different because some people, certainly in our clinical experience, benefit most from testosterone and least from estrogen, or the other way around, or they benefit from all three because they all work together in a beautiful way. Everyone's different. So that's fine, but we can't just be calling it menopause and periods. It just doesn't add up in my mind. Yeah, it covers up. what's going on, right? I think they don't want, because some people can't take hormones currently, and I think they don't want them to feel bad. But to me, I'm like, but the 97% of women who can take hormones safely, like we need to educate them about what's actually going on in their body. Because if you say menopause, it doesn't explain what's going on. And I think that's really

important because we don't know who can and can't take hormones. There isn't enough evidence. And actually, the more I read, estrogen, obviously we know, it's not just one thing. There's estradiol and eastrone. And eustrone is the pro-inflammatory part of estrogen that our fat cells produce that some oral estrogen is broken down to. And I've been reading some really good papers looking at the pathophysiology behind breast cancer. And it's more estrogen-driven than eustodial-driven, which more of us are realizing that. Yeah. So it's really important. And we're doing a lot of work behind the scenes for women who've had breast cancer, trying to really unpick this evidence because for them to be told they can never have estrogen actually is denying

them from lots of benefits without knowing whether they probably can't have Easterone but they probably can have Easterone we don't know but this needs to be done urgently to look but actually every time I put something on my Instagram to say menopals women have an increased risk of heart disease there's always two or three women will go that's really scaremongering please stop talking like this but that's like saying if you've got raised blood pressure, you've got an increased risk of a heart attack or stroke. It's just fact. Like, I am just a messenger for a lot of this. And I think it's blowing people's minds because they've just thought about HRT is dangerous.

Hormones are something that we may or may need. And menopause is just a natural state. But actually we've got to think beyond, because I worry, as I'm sure you do, about population health. And looking at all those diseases that are affecting us, not just killing us, but affecting the way we function. and live. And a lot of those diseases are the inflammatory diseases that increase when we don't have our hormones. And I think if we know that more as menopause or perimenopause or women, then we can make a choice that's right for us. But we can't make a choice on our treatment if we don't know all the facts. I see a lot of women say, well, I want to do something natural.

I want to do something natural. Yes. And to me, I'm like, I've looked at the data. I've looked at the death records that the world's kept, right? We're at an unprecedented time where we've never lived this long as a global community ever before. We are literally writing the rules for how to age well. We've never done this before, right? So I would say aging like this is not natural. It's never been done before. Infectious diseases and blunt trauma killed everybody before the age of 50, except for the outliers. And my second natural comeback would say, people are like, I want to do it natural. I want to do it natural. Giving yourself hormones that your body makes, they're identical, is as natural as you can get, and we have data to show those women are actually going to take less

other medications, less antidepressants, less high blood pressure medications, less other things for their bones, because they're taking a hormone that's natural. It's the most natural thing that we can do to keep you off other medications. You're totally right. I did a lecture last week for the Football Association actually with women's football because I really like what they stand for and I'm you know we're doing the same with how we're helping women of course but the doctor there who was fantastic I think I blew his mind because he'd only been taught that HRT is dangerous and it causes breast cancer so then he said well we need another randomized control study louise don't we otherwise we never know the benefits and what if there's a study in the future which shows how dangerous hormones are which was a great

question but firstly doing a randomized control study a is really expensive and no one will spend money on women. B, doesn't have to be, not everything is done with a randomised control study. Penicillin wasn't founded with a randomised control study. Also, it wouldn't be ethical to deny people in evidence-based treatment for a study. If you're looking at dementia risk, you're going to have to wait decades and we'll be dead by then. Sorry, Kelly, but, you know, if we did that sort of study. But also, I said to him, regardless of the evidence, it's just natural hormones. So why would we have hormones that would suddenly turn against us? It just doesn't make sense. Like, I've never known this narrative about anti-hormones with insulin. Thiroxin, there's always a bit of debate about T4 and T3 and the different types of thyroid hormones. But we don't unpick the evidence or try and sensationalize the evidence about natural hormones for anything else. And so why would it be dangerous? It just doesn't make sense if you think basic physiological processes, does it?

I agree. In the urology world, prostate cancer is a big cancer, right? Which is fascinating. If you look at testosterone treatment and prostate cancer survivors, you're going to have me back for this, but it's an allegory from what's going to happen with breast cancer. Mark my word, I'm seeing it coming. I know. Yeah, absolutely. Because I've lived through the testosterone fear with prostate cancer. And now we're like, hey, you have prostate cancer and it's mild and you want testosterone? Great. Ten years ago, you couldn't touch this stuff. We've come a long way. But to go back to the randomized control trial. With prostate cancer, you, you have. You have been a lot. You you can get radiation or you can get surgery if your prostate cancer is bad enough to be treated.

We've never done a randomized control trial. We never will do a randomized control trial because we need to treat guys and it would take decades to do. And we don't tell guys, well, we're just not going to treat you because we don't know which one's best. Yeah. We don't say that. We say there's risks and benefits. Let's pick one. We'll never have a randomized control trial.

We're not going to sit around and wait. We're going to treat you. Yeah, absolutely. I was talking to some people not so long ago who were very anti-exam. the work that I'm doing. And they were talking about the percentage of women that should be taking HRT. And they said in the UK 14% of women take HRT and they said that's probably too high. And I said, well, in areas of deprivation, it's as low as 2%. They said, well, maybe we should go back to doing that. And then I said, I don't actually care the percentage. I think it should be a lot higher. But in my mind,

100% of women who want to have HRT, which is an evidence-based treatment, should be allowed to have it first choice before being offered SSRIs or whatever else they're offered. And so this is exactly the same with prostate cancer or anything we do in medicine. It's about choice, informed consent, sharing uncertainty, sharing benefit, sharing potential risks and listening to what the patient wants at that time. Now, until that happens, I can't shut my mouth because I'm hearing all the time from women all across the world who are struggling to access hormones. Yeah. So it just seems such a A frustrating narrative, actually. It's insane.

25% of American women in midlife are on an SSRI. And I always say, we need to treat depression. Absolutely. The amount of people who say they're treating my menopause symptoms with this and it's not helping. And those medications have significant risks, right? Here we are saying hormones are so unsafe. We give unsafe medications every day and don't think about it. We know there's risks to it.

Why are we so unique with this hormone discussion? It doesn't make sense, does it? Because, you know, we know that, for example, SSRI's increased risk of osteoporosis. We know not having HRT increases the risk of osteoporosis. You've got double whammy, actually. And we also know that the mortality after an osteoprotic fracture is about 20% in a year. So if you'd been diagnosed with some really aggressive cancer, there's not many that would kill 20% of people in a year. Whereas an osteoprotic hip fracture, people, people, go, oh, that's a bit of a shame, but it's just osteoporosis, isn't it? Actually, no, let's wake up to the fact that, you know, these conditions can be really, really affect people. It's a very painful way to die. Yeah. By the way, it's very horrible to watch somebody go through that.

And I think a lot of people don't know that, and I want to mention that in case anybody missed it, SSRIs have an increased risk of fracture. I did not know that. I asked my family practice friend, she did not know. I asked my orthopedic surgeon friend. He did not know. We don't communicate. Then there's been decades of research on this. Nobody's talking about this risk. So we think, you know, hormones are so scary and we're like 25% of the U.S. population female in midlife are on a drug that increases your risk of bone fracture and nobody knows that. Well, that's right. And there is some studies.

Now it's observational studies, which we know are not great showing there's increased risk of cancer with some SSRIs. Now it's not being replicated, but actually when you look at the methodological approaches for those studies, it's very similar to ones that have done in the past for HRT, like the Million One Men's study, that people still report and still can't back on. So you've got like double standards of the studies that you use. You know, there was one review recently in observational study for Alzheimer's and HRT. It was in the British Medical Journal. It wasn't a great study, the conclusion said we cannot say whether it's cause or effect, it's my re-association. You've got Lisa Muskoni's work, fantastic.

That doesn't get in any of the papers. They just want to talk about the risks. But if that risk for SSRI in cancer with the same sort of methodological approach, that's never mentioned. You know, or like you say, the osteoporosis risk, which is more out there, it's still never mentioned. And it's like you can't have one rule for one and one rule for the other. Treat all drugs the same.

It's fine. Yeah, the cholesterol lowering medications are not without risks. They're the most common medication prescribed in this country. Right. And cholesterol, we know cholesterol goes up in the postmenopause. So, yeah, I mean, I think of the work you're doing, the work I'm doing is like education, education. This is what I know. Yes. Women are smart. When given the information, they make exceptional decisions about their health care. The education piece is missing. Once they get educated, they're going to want hormones. the doctors need to get ready. Our healthcare systems, and your healthcare system too, is already full and spilling out the sides. We're so busy and so full. I'm telling you, these women are coming. They need people to take care of them. Absolutely. You're so right. So thank you ever so much.

Lots to think about it. And we are going to have to ask you to come back. Don't you worry? So before we finish, there's always three take-home tips. There's so many tips, really. But three things, let's go back to sex, because I'm not scared or embarrassed and you're certainly aunt either talking about sex. So three things, if people are listening and thinking, do you know what, I need to sort out my sex life, but I've not done it and I'm ignoring it, but I still love or adore my partner, whatever. Three things that you think they should do. Learn how to communicate. The communication's huge. And I realize that because I'm like, I can make your pelvis pretty functional, but if you can't talk about your sex life, I haven't helped you. Lubrication is everybody's friend. It only makes

things better. And vaginal estrogen is everybody's friend. Very good. Very easy tips, actually. But the first one is probably the hardest is talking. I mean, talking to the right people. It's probably the most important. And it is the most important with that shadow of a doubt. So keep the conversation going. And thanks. I've really enjoyed today. It's been brilliant. Thanks, Kelly. Thanks for having me. You can find out more about Newsome Health Group by visiting www.new.com.uk. and you can download the free Balance app on the App Store or Google Play.