The Dr Louise Newson Podcast - 263 - Dr Corinne Menn: I’m a doctor who’s had breast cancer – here’s what I want you to know

Episode Date: July 2, 2024

This week on the podcast, Dr Louise is joined by Dr Corinne Menn, a New York-based, board-certified OB-GYN and North American Menopause Society Certified Menopause Practitioner, with more than 20 years of experience caring for women. When she was 28, Corinne was diagnosed with breast cancer. Following her BRCA2+ diagnosis, she underwent multiple surgeries and chemotherapy then navigated pregnancy and menopause plus longer term survivorship issues. Corinne received support from the Young Survival Coalition, an organisation that advocates for women under 40 with breast cancer, and worked with her oncologists to manage her pregnancy, menopause and treatment options. She feels passionately that women who have or have had breast cancer receive individualised care and treatment for their cancer and menopause symptoms, and shares three tips to help with quality of life:    Do not minimise your menopausal symptoms, your hot flushes, your night sweats, sleep etc. So whether you use hormonal therapy or non-hormonal medications, make sure you get help and can sleep so you function better and breaking the vicious cycle of spiralling menopausal symptoms. Please do not neglect vaginal sexual health. Again, if you can preserve a little bit of that, it can stop a negative cycle of suffering, of urinary tract infections and relationship and intimacy issues. Scheduling time to have a separate appointment with your oncologist and your GYN. Come prepared. Listen to Louise's podcast. Listen to Menopause in Cancer podcast and Instagram page. Be empowered because you and your quality of life are worth it. You can follow Corinne on Instagram at @drmennobgyn 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. Today on the podcast I'm super excited to interview another American guest, actually. Someone called Dr. Cohen Men, who some of you might follow on Instagram, you all should follow, who I've,

been watching from afar for a while and I love her brassiness. I love her clear direct approach actually which is what most of us as women want. We want somebody who's direct, no nonsense, but also understands and there's a lot of understanding and caring and empathy that comes from her as well. So Dr. Corrieman works in New York but she's going to just talk a bit about her story as well because as clinicians and I've mentioned this before in the podcast we are shaped by our previous experiences and I feel very strongly that even negative experiences can be turned into very positive. So for those who have suffered grief in the way that I have, I have to make myself stronger because of losing someone close to me. And that's the same with different

diagnoses, different conditions, all sorts. And Corin has really made her past medical history into a strength. It's my impression, but you might correct me or tell me differently. So welcome to the podcast and do you mind just telling me a bit about you and how your past has shaped you to what you're doing now? Absolutely. So really it's everything. And so just let's get right into it. So, you know, so I'm a board certified OBGYN and back in 2001 when I was a second year resident in New York, newly married to my college sweetheart. And about six weeks prior, my mom had, you know, died of ovarian cancer at age 54. We had no family history of breast or ovarian cancer in the family, and this was a shocking, obviously, turn of events. Right before her death, I had felt a small lump in

my breast, and it had been evaluated by my GYN, and many of my fellow female OB2AN residents had felt it. They're like, oh, it's a fibrodden number. You're too young for breast cancer. Don't worry, it's not a big deal. Just watch it for a little bit. So I did, because I was too busy learning to be a doctor to take care of myself. So right after my mom had passed away and right before the holidays in 2001, I was diagnosed with stage 2A ER positive breast cancer. It was obviously a devastating diagnosis. And, you know, what ensued from that was really a dramatic change in my life and really my career and in my outlook on everything. And like you said, sometimes you have to turn it into, you know, silver linings. And I have a lot of silver linings. And I have a lot of

silver linings from this. You know, I wound up having bilateral mastectomy and, you know, reconstruction. I had six months of chemotherapy. I did save some embryos prior to starting chemotherapy. And interestingly enough, they used tamoxifen to stimulate my ovaries because premenopausal women, you know, if you use tamoxif, then it actually increases estrogen and increases opulation. So I got a bunch of eggs and then we saved them as embryos, you know, prior to chemo. And then, you know, went through menopause three times due to treatment. So first temporarily from chemotherapy. And then after chemotherapy, periods came back.

Then they put me on loop run and tamoxifen. Did that for a while. Then decided to take a pause of my adjuvenedricin therapy. And I attempted pregnancy and got pregnant without the use of those embryos, got pregnant on my own. And, well, with my husband. And I have a very healthy, 18 year old daughter now, then went back on tamoxifen. So, and at that point had said, yeah, I'll just do tamoxifen without any of luprotten because that was extremely difficult for me.

And I had shared decision making with my oncologist. And we decided that that was an appropriate option for me. And I was tolerating that pretty well in having normal, you know, menstrual cycles on my tamoxifen doing things and probably felt the best in terms of since cancer, you know, because looking back my worst symptoms during chemotherapy, then after when I was initially on the tamoxifen and a lupine was the severe, dramatic premature menopause. And looking back, the mood, the hot flashes, the night sweats, the joint pains, the fatigue. Yes, it was probably partly due to chemotherapy and the anxiety of having a cancer diagnosis. But knowing what I know now, a lot of it was this iatrogenic menopause that no one, no one

helps me with because I didn't have any knowledge at that time. And then finally, I made the decision to have ovaries removed because my mom had died young of ovarian cancer. And at the time, I was tested negative for the BRCA 1 and 2 gene. And it never sat right with me. So I just said, listen, I want the ovaries out. I've already had one baby. I'm done. We adopted our second child from Guatemala and she's 17 now.

And I just was like, I'm done. And probably in some ways, that was a good decision. But in other ways, I was not prepared for what ensued next, which was surgical menopause at I think it was about 34 at the time. And that was dramatic. And that is when I started to realize, like, wow, I need to learn to, what am I going to do for myself? And I was starting at the same time, I was in private practice and taking care of, you know, lots of women coming in with menopausal symptoms, and I didn't know how to take care of them.

So that's when I got involved with the North American Menopause Society, got certified, and just did a lot of self-education. And so, yeah, it changed my career period then, and I started to really tailor my practice to caring for menopausal women and breast cancer survivors. And I stopped at that time. It's very interesting, isn't it? And breast cancer is very common, as you know, it now affects around one in seven women. And when I was a medical student, I wanted to be an oncologist, actually. And the incidence was about one in 12 in the 80s when I was a medical student. And I did an oncology project. And I've just recently found it. It was in my mom's

cupboard. I was trying to look for her wedding photos. So I could see some photos of my dad's getting married to show my children. And I found this project. And it was really interesting because it's about how people's understanding of their treatment is very poor and even understanding of cancer. Now, I'm quite old. So when I did this project, we didn't have the internet and we didn't have Dr. Google. And so my remit was to write a patient information booklet about tamoxifen because it had recently sort of starting to be used. And I was in Manchester, a big oncology, a breast cancer unit, amazing professor there, Professor Tony Howell. And I started to question patients and say, what's cancer? And they said, it's death. I said, no, it's not. You're not going to die from this.

They said, well, that's what cancer means? And I said, what does chemotherapy mean? That means hair loss and being sick. I said, but what's the actual chemotherapy? I don't know I'm just been given it. So I went back to Tony and I said, I can't just write about to moxophofen. I'm going to have to write about what is breast cancer and what are other treatments. And so, I'm I did all this work and I got my leaflets out that I wrote recently as well. And I wrote about aromatase inhibitors and I said side effects can be hot flushes and menopause and I really dismissed them. Like it wasn't really a big deal. It was more about, you know, the benefits of the treatments and everything else then. So what I did learn from that experience was that women

didn't know enough and they were too scared to ask because then I said to Tony Howell, right, your patients don't even know what cancer is and you're treating them for cancer. They don't know what chemotherapy is and you're writing it up and giving it to them all the time. He said, don't be ridiculous. I said, ask the patients. So the next patient that came in was someone had known for about three years and she was just a routine review and she was doing really well, good prognosis and he said, oh, Mrs. Bloggs, could you just ask me, because I've got this young student with me, who's a bit cocky, what is cancer? And she just went when it means death. And I'm really grateful that I'm still here and it's all because of you and the treatment I've had.

And he looked at me and went, mm, okay, I've got work to do them. And he went off and did some communication skills. And his communication was brilliant. But it just made me realise then, because then in the 80s we didn't have so much shared decision making at all. So I learned then that, but I also learned that the side effects of some of these treatments are, as you rightly say, the same as menopause. But then I didn't know anything about the menopause. And so when I started do my clinic and I saw not just women who've had breast cancer on the, like you say, and atrogenic, a drug-caused menopause, but just natural menopause as well. And they're telling me about their fatigue, their joint pains, their vaginal dryness that they can't sit down,

their urinary symptoms, their inability to sleep, to function, to think, their low mood, their anxiety. I went back up to Manchester and met Tony who had sort of close to retirement. I said, Tony, did you know that it's more than hot flushes? they're menopause. He said, no, it's not that bad. I said, really, have you really experienced? Do you ever ask your patients? And he said, well, no, not really, because some of the brain fog and the joint pains, that's just due to the drugs. I said, but it's because they haven't got hormones. And it made me realize because I'd never thought about it, because no one had taught me about the menopause. And sort of fast forward on decades later, 30 or years later, we're now having a

conversation which I wish I'd had in the 80s and 90s actually. And I feel that a lot of the work we're doing all of us together is allowing people to understand what's happening to their bodies. So even before we talk about anything related to treatment, it's understanding and a lot of patients I see and I'm sure you do as well, Corina, so relieved to know that their brain fog is due to their menopause not due to chemo brain or not due to brain metastases from their, you know, very treatable breast cancer. So, but no one's explained to them and they're too scared to ask in the cancer clinic in case it's related to their cancer. So I think this knowledge is so important, isn't it? Yeah, it is. Women, you know, and I know, I think I did this with my oncologist too, because we are

very grateful for the oncologists, you know. And I had a wonderful. oncologist initially and then when I moved my follow-up long-term oncologists, they did do a lot of shared decision-making with me. But I think it's because, you know, I am a doctor and I knew what questions to ask and went to and I could push them. But even me, I was reluctant to complain about what seems like minor, quote-unquote, symptoms of, say, sexual dysfunction or, you know, lots of vaginal dryness and pain, the libido or the sleeping in this because in the big scheme of things that seems silly, right? But actually it's really not silly because, you know, I think it's less than 60% of people even complete their adjuvant intracin therapy. They give up. I have patients who, you know,

never bring up the symptoms. And so I have heard from oncologists, they're like, well, most people actually really deal with it pretty well. It's like, no, no, no, they're really dying on the inside. They're just not telling you. And I, you know, I've learned this just from myself because I know what I kept quiet for years until honestly recently when I look back, I'm like, I'm crazy that I didn't really push and say, hey, like, I'm really depressed and this is really affecting the quality of my life. And I can't exercise and I've gained 30 pounds and it's affected my relationships. And, you know, I've got osteoporosis now and I'm really worried about these long-term health effects. And I didn't, right? And so, you know, if you don't tell your oncologists,

they don't know, they can't help you. They're not going to offer you the different adjuvant endocrine options or other things to help you. But oncologists have to ask as well. And unfortunately, you know, particularly the U.S. I know the health care system is not set up to give doctors and patients space to talk. That's why I think right now the positives of Instagram and social media is at least patients are more educated because a self-educated patient who's armed with a little bit of knowledge, a list of questions to ask. You know, if you go in and you make time and you carve out that appointment with your oncologist, you're a lot more likely to get answers. And if they're not willing to give you answers, well, then that's the red flag. You just need to simply find a new

oncologist simply, right? But this idea of shared decision making, I think is so paramount in anything we talk about in women's health. Because for instance, in all of these young premenopausal breast cancer survivors out there who are, you know, getting diagnosed, hopefully, you know, early stage. But at any stage, I find that many of them are not actually given the data on, you know, what their options are and that adjuven endocrine therapy needs to be individualized and tailored. And there are very small percentage differences, say, between having normal menstrual cycles and just adding to moxapin, so not stopping your ovarian esterate reduction. versus ovarian suppression with tamoxifen versus the highest level would be ovarian suppression

with an aromatous inhibitors. Yes, there's differences between those, but those differences are small, and that difference might be more meaningful if you've got higher burden of disease, but it may be very unmeaningful for low risk of disease, and also you deserve to have that choice, right? So just talking to patients about symptoms while they're being treated and what you're their different options are, is part of shared decision making that's not happening. I mean, I see patients with 1A breast cancer with bilateral mastectomies who are told they need to be on an AI in ovarian suppression and it's ludicrous. I mean, they're suffering and their lives are

falling apart from it. Now, the stage 3 patient with 20 positive lymph nodes, it might be a different conversation there. And we can help her so she doesn't go off of it, right? And we can be a prolactive. Absolutely. And we have to remember that the majority of women, thankfully, who have breast cancer, don't die from their breast cancer. They die from heart disease, actually. And they still have to live. Many women we see in the clinic tell me, I'm existing, Dr. Newsom, I am not living. My enjoyment of life has gone. I can't, you know, sleep at night, I can't function. They know there's lots of other things they can try. And they have tried many supplements, they've tried sometimes some alternative prescription medication,

they've exercised, they stopped alcohol, they're not smoking, they can't do more themselves. But a lot of them say, I just want to try. But what's very interesting also is at the beginning of the conversation, you quite rightly said that tamoxifen can increase estrogen levels. Now everyone thinks that estrogen is the devil when we talk about breast cancer and treatment beyond. But actually lots of women don't, and oncologists actually, don't realize that tamoxifen does have this effect. And so estrogen isn't all bad and it's very individualized, of course. But the other thing you mention, which I think is crucially important, is about vaginal symptoms and urinary symptoms. And we give a lot of vaginal hormones, sometimes just vaginal estrogen, sometimes vaginal D-H-E-A, which is prasterone, which converts, as you know, to estrogen and testosterone.

And even that, it doesn't get absorbed into the body. but it can be transformational, can't it, for lots of women? Yeah, absolutely. And I think so here's like, you know, in medicine, we know it should be shared decision making an individual approach for everything. You know, your cardiologist doesn't do a one-size-fits-all approach when they're dealing with any cardiac disease or any other cancer. But there's something about breast cancer and estrogen.

And, you know, I truly believe all roads lead back to the WHOI. Because, you know, when you plant a seat of fear, you make women fear things that their own body makes. And so here's a simple example. Estrogen receptor. Breast cells have estrogen receptors. All breast cells do. They have progesterone receptors. So do your bone cells and your skin cells and the lining of your GI tract.

Okay. So if you get diagnosed with estrogen receptor breast cancer, it doesn't mean that estrogen caused your breast cancer. it just means that your breast cancer cells have an estrogen receptor on it. So it's one tool in this pretty large toolbox that we have now of surgery, immunotherapy, chemotherapy, and all the different types of chemotherapies. And yes, adjuvant endocrine therapy. So what can we do? Can we manipulate that receptor?

Can we degrade it? Can we block it so that it doesn't signal to the cell to make proteins and to grow and stuff? But it doesn't mean that estrogen was the cold. Brit, right? And I think that's an important thing. And, you know, women who have an estrogen receptor negative breast cancer, it means that those cells have differentiated. They've changed so much that they don't look like a normal breast cell that has estrogen receptors. So that's like a simple explanation right there that often is lost on most women, right? And there's also this idea of duration of treatment. Like there's a reason why in the studies and the standard of care is that women take

Tamoxifen for say five years or for a higher risk patient. Maybe it's 10 years. But it's not for 50 years. You know, that's not the treatment, you know. And so there's a point in time where you complete your treatment. And so, yes, we should talk about all the ways that we can support a woman during her treatment with her adjuvant and drug and therapy with her menopause. And like you alluded to, there's non-hormonal, there's local vaginal hormones, there's lifestyle. It has to be a big picture. And then within that, knowing being educated, that there's a rainbow of adjuvenendrican options. At the Metapause Society Conference this past fall, they invited a wonderful breast

oncologist out of Stanford University. And she says, listen, we've got to individualize early breast cancer treatment. And she has this beautiful slide, which maybe I'll post again on my Instagram, showing, you know, from the most quote unquote extreme to the least extreme of adjuvant intrepresent therapies and that you've got lots of options. And what you start with doesn't need to be what you stay with and you could pause. You could switch it up. And so when women understand that we have to think in a big holistic picture, that is super helpful. But then when we're done with that, we have to decide how are we going to approach her for the rest of her life. And, you know,

I represent kind of the young survivors. I'm a part of the Young Survival Coalition, which is the kind of premier worldwide organization for women under the age of 40 diagnosis of breast. We've got many years to live. And we're more than just our breasts. And you know what? We're smart enough.

We've dealt with hard enough things that we could handle a hard discussion. It was hard when someone sat down and says, okay, Karen, like, here's the different chemo regimens, and this one has this benefits, and this is what we know about this. And this is what we don't know for a 28. year old and this is what we do know and i was able to it was hard but i was able to think about it they did the same thing with lumpectomy versus mastectomy here's the risk the benefits and i was like okay i'm okay with that

and i made my decisions and my decision was different than someone else's decision right how come that goes out the window when someone's like okay i've completed treatment i'm disease free i'm early stage i'm low risk i understand that distant recurrences at like 10 years 15 20 years, it can happen. Listen, I'm 23 years out. I know my breast cancer still can come back. I understand that. It's a bad thing about estrogen receptor positive breast cancer, but my risks are low. And I made a decision after reviewing the data, sitting with my wonderful breast oncologist, leaning on the data, you know, put out by people like Dr. Avron Blooming, who is an incredible man and scientist who just it's not his opinion. He looked at the 25 studies of HRT after breast cancer.

They're not perfect studies. They have flaws. Some of them are not long studies. Some of them are longer, but all of them, except for one, points in the direction that it's not going to cause your breast cancer to come back. Do we have a definitive word on that? Absolutely not. But I was able to look at the studies and so should any oncologist and say like, okay, for any individual woman, And if she's really suffering and she's tried other things and she wants a tiny bit of her hormones back to help with her quality of life, then that's called shared decision making. And to say to a breast cancer survivor, absolutely no, that's not practicing medicine. And Louise, what makes me really angry is patients who are obvious, low-hanging fruit, so to speak, examples. All right, so here, like, like I have a good friend from the young survival quotas.

She's triple negative, right? So no estrogen receptor positivity. She completed her chemotherapy. She was early stage. And she went on to have many years with her estrogen levels very, very high. She was a broccoli one carrier. So she even went in and had a successful pregnancy. And then she said rightfully, doing the right thing at 39, she was like, okay, I'm getting those ovaries out.

Because I don't want to die of ovarian cancer. Now remember, blocking hormones and lowering hormones. hormones had nothing to do with her cancer treatment whatsoever. So she gets these ovaries out and she's plummeted into surgical menopause. She's really suffering. Her sex life, her day-to-day life, her weight, her cholesterol. I mean, you know, this is all you talk about, right? You know. And it was like, no, but you can't have any estrogen. I'm like, wait, she just had estrogen for 10 years since her breast cancer diagnosis. She had a baby. She had a twin pregnancy. She had had heavy periods for months. Like, what are you talking about? We're going to give her a tear drop

worth of estrogen versus the ocean that she was just bathed in for a decade. This is a triple negative. Give me a break. This is nonsensical. So she started with a little bit of estrogen and a little progesterone, top with her sleep. And after three months, we introduced a little testosterone because also blocking testosterone is not part of the treatment plan for triple negative breast cancer or positive breast cancer, the estrogen receptor positive. And it was like three months later, she called me crying,

saying like a light went off in my brain. Oh my God. I feel so great. And guess what? She did it with her oncologist in need. We worked together. And, you know, when I pressed him, I says,

was blocking her estrogen part of her treatment plant? No. Then why? Why can't this woman have a little bit back now? It makes no sense. It's a nonsensical to me. No, you're absolutely right. it makes very little sense.

And actually women are understanding it. And I got a message from somebody I recently, someone I went to medical school with, and he messaged me on Twitter and said, you need to stop doing your work because it's creating a lot of work for us. And he's an oncologist. So I phoned him up. And I said, what's going on? And he said, well, you're just talking about women being able to make a choice after breast

cancer. We get loads of women in our clinic now saying, can I talk to you about hormones? And I feel really uncomfortable doing it. Oh, right. Okay. Well, think about that. visual person. And think about their future life as well. And a lot of oncologists will say, well, women tolerate it well. And like we said before, a lot of women don't talk about the side

effects. Or if they try to, they're told, look, it's only a bit of urinary symptoms. It's only a bit of joint pain. Don't worry about it. Sort of suck it because you should be lucky you've had cancer. Whereas actually knowing the absolute benefits and risks is really important if the studies are there, which they're often not. So dealing with. uncertainty and we deal with uncertainty as medics every single day and that's what's really important. I was doing a presentation this afternoon for people with cerebral palsy and a lot of these women are told oh your cerebral palsy is progressing. It can't be your hormones. Well why can't these women have hormonal problems and the same with breast cancer when we look at the benefits for

HRT whether you've had breast cancer or not you've still got a risk of osteoporosis which will reduced by taking HRT. And some women come to the clinic and say, look, I had breast cancer 15 years ago. I'm more worried about my risk of osteoporosis. I'll deal with a recurrence if I have it, but I would like to protect my bones and I would like to consider hormones. Well, what's wrong with that? What's wrong with thinking, like you say, beyond breast cancer diagnosis? Whereas other women say to me, every day I worry about recurrence and I'm not going to do anything at all that's going to increase my risk. but I just want to talk through about what the menopause means and what else I can do. And that's absolutely fine as well.

You know, I don't judge patients by their decisions. I don't judge them if they drink too much alcohol or if they never exercise or if they over exercise. It's up to them, but we're here as their advocates, which is what Avron Blooming talks a lot about, about being a patient's advocate and allowing them to choose, but also knowing that what they choose today might be different tomorrow or next. week or next month. And that's really important.

And not feeling to be bad about the decision they've made. Yeah. So it's so interesting. You say that the change, like you might evolve over time. For instance, when I was first diagnosed, I was petrified. I thought I would, I never thought I would ever be here. I thought I would be long gone, right? My breast cancer was the stage 2A.

It was a grade three. I had lymphovascular invasion. It had all these like aggressive markers. I thought I would never be a mom, you know, all this fear. And so the way I thought about things then was different. And it evolved and I got comfortable over time, right? But, you know, I think that this idea of what is valued in a woman's life really is very individual. And I find it really interesting that there's such support for shared decision making and options when it comes to pregnancy after breast cancer.

So it's very celebrated. thank God, and I was a recipient of that open-mindedness, even back in 2001. I was basically the positive trial, which the positive trial for anybody listening was a study that was recently published showing that women who have estrogen receptor positive breast cancer can pause their adjuvant endocrine therapy, stop it, use any type of fertility treatments needed, high levels of estrogen, get pregnant, breastfeed, do all of that, then kind of resume their hydrogen and chintraintrainerine therapy. And it showed no difference in recurrence or mortality. And so that was really celebrated at the San Antonio breast cancer conference. And Asco was all over the news.

And there's other studies like this that have shown those results. And that data was there, even when I was diagnosed 23 years ago, it was not as probably well presented as this positive trial, but it was there. And my doctors were willing to let me stop my tamoxifen and get pregnant, which I did and that was great. And so that's your decision making. There's, you know, but somehow, somehow, when you want to do kind of a similar idea of like, okay, I want a little hormones because I'm menopausal and my sex life is suffering and my quality of life is suffering, that is not as valued and that is shut down versus there's

such more openness about the fertility, which I'm glad. I'm not criticizing that. but can we value a woman's like life after her fertility ends because it seems very interesting that the oncology community is really willing to do shared decision making for pregnancy after breast cancer and that involves hormones but god forbid someone wants a 0.025 estrogen patch and a tiny bit of micronized progesterone or a little bit of vaginal estrogen and it's like that's crazy and irrational give me a break we're smarter than that So there's a lot we need to do.

I have to say, get a lot of emotion. Yeah, no, there's a lot we need to do. I'm putting patients in the centre of everything is crucial. So I'm very grateful for your time and your honesty and transparency as well, because that's really helpful for so many people. So before we end, Corin, I always ask for three take-home tips, and I've got about a thousand and three that I'd like to ask you. But if we just narrowed down to three things,

so there will be people listening to this podcast, who will either have had a recent diagnosis of breast, cancer or have had breast cancer many years ago or will know someone who's had breast cancer or might just be listening out of interest. But what are the three things that you think would be really useful for women with breast cancer who are menopausal as well? What are the three things that you think they should do that we're really going to help their quality of life? Number one is please do not minimize your menopausal symptoms, your hot flashes and your night sweats and sleep. So whether you use something hormonal,

systemic hormonotherapy, which I know most of you are not getting access to, you can use non-hormonal medications. And I know no one wants to add a medication. But if it's going to mean you can sleep and you're going to function better, you have to be a squeak wheel and get help with that. Because that's sometimes the first step in breaking this vicious cycle of spiraling menopausal symptoms. Number two, please do not neglect vaginal, sexual health.

Again, if we can just preserve a little bit of that, it can stop this negative cycle of suffering in, you know, urinary tract infections, but also, let's face it, relationship impacts in intimacy and all of that. So take those things seriously and be a squeaky wheel. There are many, many options. Be proactive. And then the third thing is, you know, scheduling time to have a separate appointment with your oncologist and your GYN. Come prepared. Listen to Louisa's podcast. Listen to menopause and keep. cancer podcast and Instagram page, be empowered because you're worth it, your quality of life is worth it. So those are my three tips. Really important. Please don't be afraid of actual estrogen.

Please don't be afraid of actual estrogen is the last thing I will. Absolutely. So just to reiterate, everybody really can have vaginal hormonal treatment regardless of their diagnosis or when their breast cancer is diagnosed because it is so safe and we've had more and more studies that been reassuring about that. So really important. So lots of great tips. Thank you so much again for your time and look forward to hearing how people respond to the podcast and hopefully find it reassuring as well. So thank you. Thank you, Louise, for having me. You can find out more about Newsome Health Group by visiting www.newsonhealth.com.uk. And you can download the free balance app on the app store or Google Play.