The Dr Louise Newson Podcast - 267 - Easy when you know how: menopause care in Australia

Episode Date: July 30, 2024

This week on the podcast, Dr Louise is joined by Dr Ceri Cashell, a GP in Australia who specialises in female hormonal health. After completing Newson Health’s Confidence in Menopause course, Dr Ceri became passionate about educating both patients and fellow healthcare professionals about the importance of hormones, and busting myths around HRT. Here she talks about the advantages of longer consultations with patients and shares the things she thinks it’s important for healthcare professionals to know so they can improve their care of perimenopausal and menopausal women:  Understand that menopause can affect women of a wide range of ages, and to consider perimenopause when you are presented with multiple-system symptom clusters. Simplify your HRT regime. Use body identical hormones, oestradiol patches, gels or sprays, micronised progesterone and consider testosterone. Understand that women don't all absorb medication through the skin the same so you may need to tweak the doses. Know that not all oestrogens and progestogens are the same. The oestrogen in body identical HRT on its own has been shown to reduce the lifetime risk of breast cancer, while the body identical progesterone is not associated with any increased risk of breast cancer in the best data. Testosterone is licensed for loss of libido, but in clinical practice does seem to really help other symptoms of perimenopause and menopause and can really be a gamechanger. If you do prescribe more HRT, you'll see the most transformational medicine that you've probably ever encountered. You can follow Dr Ceri on Instagram @drcericashell Find out more about the Confidence in Menopause course here and the balance app symptom checker mentioned on the 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. Today on the podcast I'm really excited to introduce to you someone called Dr Kerry Cashel, who I've only recently got to know, but I feel like I'm become quite close to her. We watch up each other a lot and actually talk a lot,

even though she's the complete opposite side of the world to me. So Kerry is a GP in Australia near Sydney, and I had the pleasure of meeting her, and she arranged some great events, actually, when I was in Australia last year, talking to healthcare professionals, also talking to women and men about the menopause. And she like me, is it fair to say Kerry is on a bit of a crusade

to try and help as many people as possible to lead to our mission of improving the health of forewors? women. So welcome today. Thank you. Thank you for having me. So you like me, I think, have been exposed to menopause probably a bit late in life in the respect that I spend a lot of my time regretting things that I didn't know and I wish I knew as much as I know now years ago when I qualified. And once you see menopause, it's really hard to unsee it. It's like anything, it's so obvious what's going on. It's so obvious what's causing it's so obvious what the treatments are.

But if you don't know it, you don't know what you don't know, do you? Yes, that's so true. I think I realized how obsessed I was with menopause when I saw my seven-year-old's little description of menopause on a piece of paper. How when women go into menopause, they lose their hormones. She'd got that slightly wrong. And they start to forget things. But it's good because my mommy gives them medicine and they can remember things again.

Which is just so lovely, isn't it? Yeah, so my journey really started thanks to a patient and a GP friend who we were just chatting about stuff. The patient said she'd started on testosterone and what did I know about it? And I obviously, not obviously, but didn't know very much. And then a good friend at home, who's also a GP, suggested I also do your course. So then I did your course and then started listening to the podcasts. Yeah, and that was really the beginning of my journey into becoming this hormone-obsessed doctor, who sees hormones, you know, everywhere.

Although that sounds a bit evangelical, it's equally very scientifically plausible because if you say, they're just chemical messengers in our body that go around and tell ourselves what to do, when to do it, and, you know, keep us alive. So it's actually made medicine to me

much more easy to understand. It's kind of like there was a missing, sort of, I don't know, like a third of the jigsaw. And then somebody just put it in. I'm like, oh, so now I find I can manage diabetes a bit better. manage weight management a bit better, understand depression better. You know, chronic diseases make more sense. So it is, it's a very good foundation for understanding all of medicine, not just menopause.

And I think with your podcast and the different things you've introduced and this concept of reproductive depression that Jai Ashri Kalkarni, who's here in Australia, has been trying to mainstream, I think, for about 30 years. You know, looking at that really from the whole life cycle. So as a GP who sees women of all sorts of ages from, you know, from birth right through to when they die, you know, seeing teenagers who struggle with adolescent transition, especially ones that are maybe neurodiverse, you know, seeing those people really struggle with their menstrual cycle and their mood disorder, seeing women in pregnancy who have perinatal anxiety and depression, women who get premenstrual dysphoric disorder, women, you know, had somebody today. who came in about her pill and just said, you know, I feel awful. I didn't feel like this six months ago. You know, I'm anxious.

I'm hypersensitive. Do you think it might be the pill? I was like, absolutely. It's very likely to be your pill. You know, right up to that perimenopause menopause transition. And really moving it out of this very classical hot flushes, a bit of irritability that happens when you're 50 to this whole spectrum of perimenopause that can happen at any age.

You know, I've got teenagers who have got premature ovarian insufficiency. So I have people right across the age spectrum who, you know, can benefit from this knowledge. Yeah. And I do think, I mean, in fact, I did go to someone at the Royal College of GPs about seven years ago to say, how do you relabel a disease? How do you redefine a condition? Because we should be seeing it as a female hormone disorder or female hormone deficiency because then you are encompassing people at all walks of life.

Because to wait until a year after our last period is often quite late for people who have been struggling for many years. And many people, as you say, have PMS or PMDD. And even just it's made to be sort of normal that we can feel a bit rubbish a few days before our periods. But actually that isn't normal because it's affecting us. And, you know, it just to feel flat and low, I spoke to a patient a couple of days ago and she said to me, I have one day a month, I just go to bed. For 24 hours, I just go to bed. I can't do anything. I can't focus. I can't think. I have joint pain. The whole world comes in and I just know it's easier to be in. bed the whole day. Now she's got three children and a job. Not always easy unless it comes at a

weekend where someone else can look after the children. But why should she be doing that? That's 12 days a year where she's literally incapacitated. And when she said, then my period comes and I feel fine again. So even she knows it's related to hormones. Yeah, I've several young patients who are like that. And I would never have thought of using hormone therapy in those. And it's still quite far down the guideline. It's still after SSRIs. It's still after the contraceptive. Yeah. But, you know, I've had these young women who have had, you know, a couple of days of feeling, you know, actively suicidal for years. And two months of using an estrogen patch and some progesterone, it's gone. Like, it's the closest thing I would say to a magic wand sometimes.

It is very transformational medicine and I feel like it is quite evangelical. And somebody did say to me a few years ago to meet in Louise, you're very evangelical about hormones. Don't you think you need to slow down and calm down a bit? And I was like, no, I want to shout from their rooftops, actually, because it's not fair that it's only my patients that are getting this feeling. Or, you know, there's only a minority of people we know who can access really good evidence-based treatment globally. It's a real issue. But also, I've always had a beauty, as you know, I've worked part-time doing many jobs.

I've always worked more than full-time when they've added together. But I've had a lot of time for this sort of blue-sky thinking, if you like. I've been able to get off that hamster wheel of medicine and reflect and read and digest quite difficult scientific literature. And I've worked for many years to sort of just translate it into short sentences so that people can understand. And I've worked for a company called Patients. Or Info for many, many years. And we started off initially just writing for patients because it was just before the internet started or around.

We didn't have Dr. Google. And it was quite a revelation to be able to print. off a patient information sheet and give it to a patient in front of you. Because before that, all we would do is print off a prescription and just give it to a patient. So to do that. And then after a few years, we dovetailed and we wrote for patients, but we also wrote for healthcare professionals in a more detailed way. I did more references and everything else. And people found that really useful. So if you had a patient with raised blood pressure, it would give you a summary of all the guidelines. It would give you a summary of the literature. It would give you a summary of the

treatment options. And then as the doctor, you could either Google it or print it off and it would be a really quick guide rather than having to go back and read the guidelines, read the evidence, work out which papers were good or not, you know. And so I've always done that. But I think what has happened, and I'm sure it's the same in Australia, that doctors are really, really busy. And so you haven't got, even if you've got all the will in the world, if you're working full time as a doctor, It's impossible to go home, read all this information, really unpick the evidence. And even the guidelines are a guide written by a committee looking at the best available evidence on the day the guidelines come out.

And evidence changes all the time. And so I think more and more when I'm looking and thinking about the menopause, I'm thinking about why is it that other people don't know what we do? And it's because they haven't got the beauty of being able to assimilate all this knowledge. isn't it? Yeah, no, I mean, I think that's, you know, over the past couple of years, having turned into a menopause obsessive, but, you know, reading, going back and reading all of the papers in their original format, I'm looking at the content and what was actually found, and often comparing that to the conclusion or the abstract, which was often very different. And you realize that

a lot of the time the conclusion is not a summary of the data or the results, but somebody's opinion and that has probably been you know probably one of the biggest shocks to me having gone back and suddenly starting to read a lot and realizing that if you want to really really understand something you do have to go back and read it for yourself and that is really unfortunate because especially for GPs you know and even more so in the NHS where they're doing a lot of the medicine that would have traditionally been done in hospital because of you know the system sort of crumbling I know my GP colleagues at home what they deal with is you know it's phenomenal But you can't be an expert in everything.

And you do rely on academic experts, pulling some of that information together and giving you a platform or framework that you can really use in clinical practice. And unfortunately, it often turns into opinion. So what you're getting from these experts is not necessarily the purest form of facts. It can once again be more opinion. And I think that's really, really hard. and I've noticed that in menopause. And a menopause, I don't know, seems to have become this battleground about, you know, is it right to treat women?

Is it not right to treat women? And I suppose, you know, I would take my professional lived experience and seeing a lot of women. I see, you know, women at all stages of life. But, you know, being able to present them with information that they can make an informed decision based on what's right for them. And it's interesting because a lot of surveys say, you know, the majority of women don't want to take hormone therapy, but unless I live in a bubble, that certainly isn't my clinical experience. You know, when women are given the facts, as I see them, you know, that this is just

replacing something that isn't there anymore, it's very possible it'll treat a lot of your symptoms with one treatment as opposed to multiple treatments. And there's really good data that it will reduce the risk of chronic disease for a lot of women. And these are the women do obviously live longer than men, on average, possibly because of our estrogen advantage up until the point of menopause. But, you know, a woman age 65 in Australia is four times as likely to be living with a severe debilitating disease compared to her male counterpart. So we might live a bit longer, but we're often living in nursing homes and, you know, not able to get out and about. And I think what most of us want is if we do get to, you know, live until a ripe old age, that it is a

ripe old age, you know, that you're able to get up off your seat and maybe you could walk down the street and that you can still carry out a conversation with your loved ones, you know, that you're not sitting in a nursing home with dementia or an osteoprotic hip fracture or something, you know, akin to that. So I think women are, when they're given the right knowledge, they're very able to make a decision and not all women want to take HRT, but I think they should be given the right info. And I think that is crucially important. And especially in general practice, it is about sharing decision making. And I know when I went from being a hospital doctor into becoming a GP, my trainer said, Louise, you're going to be a terrible GP because hospital doctors just tell patients what to do.

And in general practice, we share decision-making. I'm like, how do you share? Like, how do patients know? And he said, because you do. You ask them their expectations and you share with them choices. And I was like, how can you, you know, someone's got a chest infection. They need antibiotics. You say to them, do you want antibiotics or not?

He said, well, yes, try it. And actually, the more you do, and he was very good at teaching me this sort of open consultation, you know, why have you come? What are you expecting? Questions that if you've not asked before can feel a bit weird, but actually most people are really keen to be really involved in their consultation. And actually, when you think about menopause for most of us, it hopefully will last for decades. So making the right treatment choices is really, really crucial and it can take a while and everything else. But as you quite rightly say, Kerry, people have got to be given the right information. And I was at a meeting recently and some people were saying,

saying, well, when people have been given information about HRT and the dangers of HRT, most of them won't want HRT and self-care is more important. And I thought, that's really interesting because it depends on what you're being told. And HRT is only three letters in some countries. It's MHT, Menopause, Hormonal Treatment. And I feel that if we just talk about natural hormones, it's really different because most of the studies when you talk about risks of HRT are related to the synthetic hormones, which we don't usually prescribe or tend to prescribe because we know they've got some risks, especially of clot and heart disease. And they're not so metabolically active in our bodies because the synthetic progestogen doesn't have the same effect as progesterate, as you know,

and the tablet estrogen gets metabolized into many different estrogens, including eStrone, which is quite inflammatory. But the natural hormones are very different. So you can't then say all types of HRT is the same. And I think this is where some of the this polarised battle that goes on globally about HRT. Because every meeting we go to, we're hearing still about risks of HRT. But we know that they're talking about the older types of hormones. But people on the street, or busy, patients don't. But busy GPs don't either.

And then they're grouping the natural hormones and even vaginal hormones with the same perceived risk as the older types. And this is a real barrier for women able to actually. access treatment, I think, isn't it? Absolutely. I mean, the whole case of using vaginal estrogen is, you know, such a case and point of misinformation from the medical community. Like I say to patients, like, this is the safest drug that I can prescribe. I mean, it's safer than drugs that I don't prescribe like paracetamol, because you can overdose on paracetamol. You can't overdose on vaginal estrogen, you know,

so, and I think, and I, you know, I recently audited our practices prescribing of vaginal estrogen and thinking we'd come out brilliantly because I was so female health aware. And as a practice, it was only 25% of women over 70 who were getting vaginal estrogen. So I was really disappointed because, you know, we know that, you know, something as simple as that will reduce your retract infections. And then the consequences, you know, that that can often lead to, such as delirium and falling over. Yeah, but you're saying 25%, and that is bad, but relatively speaking, it's really good because we know that some studies have shown only like 7, 8% of women

use vaginal hormones. So you're doing okay. But actually, I used to as a GP see many women who had recurrent urinary tract infections. They had noctuary, so they were getting up at nighttime to pass urine. They were having some incontinence, so some stress or urgent incontinence. They were diagnosed with overactive bladder. Some of them had chronic pelvic pain. And never once did I prescribe them vaginal hormones because I didn't realize.

the importance. And now we've got this prasterone, which is in Turozo, it's called in the UK, which is DHEA, which converts to estrogen and testosterone, which obviously helps all the testosterone receptor, you know, stimulates the testosterone receptors. It's transformational for a lot of women. Yeah. But I didn't know that. And if you don't know, then you can't prescribe something and help. So I feel really bad. But you're in the privileged position that you're still a GP, so you can see these women and probably treat them different to how you did in the past. I'm involved in a group of GPs, and we sort of feel like we have a little HRT support group here in Australia because, you know, there's Australia specific things. And we always feel like we're these crazy outliers, you know, and a frequent phase would be, it's like you've been in the matrix and you've suddenly woken up.

And there's this whole world of medicine that you knew nothing about. And there's a brilliant book written by one of our professors in Australia called The Secrets of Women's Healthy Aging. and I would say that's sort of mandatory reading for anybody in the health professional world because it really shows the lack of research into women's health over, you know, just and still, you know, the fact that women weren't included in studies, you know, until the 1990s, but a lot of pre-clinical research in animal models that really only changed in the last 10 years. But it is interesting, you know, there isn't enough research into women's health, but in hormone therapy, there is a reasonable amount.

but it's in the shadows. So that's what I find really hard. As you know, when we did our fun Advent calendar running up to Christmas with all the symptoms, I would go and research each new symptom and see if I could find some, you know, other papers on each of these, you know, all those random symptoms of tinnitus and hair loss and crawling skin. And I would come across papers, you know, like they're using estrogen, you know, is in a phase three trial for multiple sclerosis. I mean, that's amazing.

So why is that not a headline? You know, there's some really exciting. up or the different estrogens, you know, in breast cancer, you know, there's kind of all estrogens are bad. Well, maybe there's a good one and maybe there's a bad one. You know, maybe it's a bit more nuanced. So when we're trying to do shared decision making, the doctor does need to have the knowledge to share that with the patient. So I think that's been a big barrier and I do look back with horror. And I still see those patients, you know, there's people that, you know, probably had a good eight, nine years of perimenopause before I saw the light. And, you know,

in a few months, you know, one woman, I would say she really lost about eight years of her life. And so she would have been really a sort of premature o'er an insufficiency because her symptoms started in about 36. And she had seen multiple specialists and, you know, being put on various antidepressants, but had no hot flushes until she was 44. And when she came back in, I'd just done your course.

And I felt really guilty. You know, she'd lost, you know, all years. You know, she'd got divorced. You know, she hadn't been able to work. I mean, she was lucky because she was financially. sort of independent, but she had really lost a lot of her, you know, that would be really important years of her life in her late 30s and 40s. And six months of hormone therapy, she felt like she did 10 years ago. And, you know, it's, it is, as you say, it's just can be transformational.

Yes. And I don't think there's anything else in medicine. You know, I've worked in diabetes clinics or asthma clinics and it really can help, obviously, when you get the treatment right for many people but HRT when you get the right dose and type and that's really crucial for this conversation as well can really obviously improve symptoms but also I sit there quite smug thinking well actually these women are going to have stronger bones they have a lower risk of heart disease they have a lower risk of all inflammatory conditions actually and we know that people live longer but better as well and that's what you're saying it's not the age we die as well is really important I always think I had a lovely lady who was 92 when she passed away and she

This was probably about four years ago and she trained as a midwife in her earlier life and she was on a few medications by the time in her last year or two but I used to say I think you really need to stop your HRT because you're 89 or your 19 and she was like no she goes when you get to my age

you can tell me to stop it and you know I do think that probably allowed her to live this you know life where she went in and out of the city centre and went to ladies meetings until she was 91 which is perfect isn't it And, you know, we don't need to stop HRT at any age at all. Definitely not.

We can continue, which is absolutely brilliant. But we also, I think, was interesting even what your daughter said right from the start about it affects memory. And my youngest daughter, when she was seven, went to brownies and they all had to decorate a bag. And she decorated this bag, but it didn't have drippy glue and sparkles on. I was quite pleased, and it was rolled up in her pocket when she came out. But she'd just drawn a lady, and she'd put a line down the middle with a sunshine one side and a, dark cloud the other side. And the lady, half of her was happy, the other half was sad. And over the handle, she'd written HRT, HRT, HRT. And she said, this is before and after HART. So for her

perception, and it was around the time that unstated hormones as well, was someone going from very sad to happy. And actually, so again, she's thinking about the brain. And the more I read, the more I talk to Professor Kalkani, the more I read her work, the more I read other people's work, and the more we analyze our results of our symptom, the improvement in the clinic. Menopause really is a cognitive disorder. It's a brain disorder. I don't think it is related to our ovaries and periods

in the way that we've been told for many years. And we also know that our three hormones that we always talk about, estradiol, progesterine and testosterone aren't made in the brain. And they actually reduce inflammation in the brain. So if someone has a brain injury, one of the things the brain does is produces more estradiol, progesterine, testosterone, because it helps the way that our neurons, like, talk to each other and the plasticity of the brain improves. And we know I was talking to a researcher yesterday in

Yale University who does scanning of brains and, you know, how our structure of the brain and the way it works changes when we don't have hormones. It's all so obvious when we think about the commonest symptoms affecting our brain and we think about the biology and the pathology, the physiology of these hormones in our brain. yet we're still told it's related to ovarian function and it's like the gynecologists sort of own the menopause and over here in the UK most women can't get testosterone unless they get seen by gynecologist and I do sort of wonder why we have to wait for gynaecologists to be trained why can't GPs or neurologists or psychiatrists be prescribing I mean what's it like in

Australia? Is it? Who's the in control almost to menopause? Well, we have, I mean, there are, we are very lucky. We have some really good experts who do try and improve education for GPs and all doctors. But yet one of my big bug bears is that anybody who sees women should understand the effect of sex hormones on their body system because hormones affect every single body system, which just makes sense, you know, primarily we're here to reproduce whether you like it or not. And so I would love the day that I got a letter back from a specialist saying, I think this woman needs some hormone therapy, and I've never received that from anybody. I've not received it from a gynecologist, an endocrinologist, a neurologist, a psychiatrist, a rheumatologist, you know,

an ophthalmologist, and all of our hormones affect all of those systems. So I do really think it needs to be mandatory education in the undergraduate curriculum so that, you know, all doctors in training are aware of it before they come out. GPs are really well, positioned, however, to do that beautiful, holistic care. You know, so you will see the woman that has all of the symptoms or some of the symptoms that are crossing over multiple specialties, you know, the palpitations and the joint pain and maybe some nude symptoms. And so, you know, that's why something like your symptom checker is so good because if women

do that before and they're sort of aware of that, then they can come in and go, I've got all of these symptoms or I've got five or six of these symptoms. Do you think they might be related as opposed to, I remember, sitting there, women would come in with their list. And this was in the UK and you'd got your sort of six minutes left because he'd already dealt with the chest infection. And they go, well, I've got this list. I'd be like, OK, well, I'll do the top three and the next three you'll have to come back

because I can't run behind because it's so time pressured. And I'm really lucky, you know, here in Australia, I spend sort of 30 minutes with patients. It's a big difference. And that time, I think what you get out of 30 minutes is a lot more. than two, 15 minutes or three, 10 minutes. And I've got, you know, fabulous nurses who work alongside me, who do a lot of pre-screening. So they make sure they've done a bit of checking of the blood pressure. When was your bone density?

Have you used your mammogram up to date? Have you had your cervical screening? You know, let's do your symptom checker. And what do you know about hormones? So they come into me and they've already really been prepped. And that's fabulous because nurses, I think, especially nurses, obviously are mostly women. And practice nurses are often sort of in that age range where they're, you know, know they're really fantastic to understand and empathise and, you know, spend that way

bit more time with women. I think they're a brilliant resource. I'm very lucky to have such a great team. Yeah, no, we have nurses and pharmacists that work here and it's brilliant. But I think also as GPs, we're used to diagnosing more than one condition. We're used to managing more than one condition. And we're also used to sharing uncertainty with our patients. And, you know, as you know, we don't know how many of people's symptoms are related to hormonal changes. And that can be really difficult for patients when they've got a myriad of symptoms. You know, if they're getting joint pain, could they have an arthritis or could it be menopause? If they're having palpitations, could it be a cardiac problem or could it be just related to their hormones?

And often we don't know. But it's okay. And that's one of the things I learned very early on in training as a GP. You can share uncertainty with patients. And we can prioritize as well, you know, which of the symptoms are affecting you the most, which are more likely to be related to hormones. Yes, I can give you hormones, but let's also keep an eye on this symptom or that symptom or maybe refer you to a test or maybe give you two treatments as well. And as general practitioners, I think we are really well placed to do that because we've had

such great broad training in multisystems. And menopause is a multi-system disorder. But menopause of women can have other conditions as well. You know, I have migraines which are exacerbated by my hormones if they're out of kilter, but I still have migraines and still need treatment for my migraines. And you would be wrong with if you were my GP saying, no, your migraines are only due to your hormones. Absolutely.

Yeah. And that's the same with lots of conditions, isn't it? Yeah. So I think we are very privileged. But I feel sorry for GPs who have got that missing piece of the puzzle almost because you'll never get people as better as you could if you weren't thinking about hormones. But I think there is a big shift.

And certainly when I came to Australia, I was a bit nervous coming as an English. GP trying to train and you were great because you'd organise this lunch where there were lots of different specialties as well it wasn't just GPs and the energy in the room was incredible actually and people were talking and one of your male doctors who works with you was brilliant because he's just his eyes have been opened and he's got this inquisitive brain and wants to learn and I was recently chairing a meeting in London and there was a huge thirst and appetite and people come up to me and say thank you because we've done your education program and we've just changed the way

we practice and we can see the effect it has. So I think things are changing. Absolutely. Yes. It's slow, but things are definitely changing. Yeah. No, my colleagues, you know, I work, I've got two younger male colleagues and sort of they're like, is this it? Is that all there is to it? This is dead easy. And I'm like, yeah, if you just removed, like everything, if you remove some of the noise, some of the older types of HRT, you forget about trying to use the contraceptive pill. If you know, if the person doesn't need that as contraception, and you just focus on, you know, your estradile, patch, your gel, your progesterone and maybe some testosterone, you know,

it becomes as simple as ABC, you know, and there is, there's tweaking and there's other things you have to consider other disorders, and you should check somebody's bloods because often women have something like iron deficiency. It's often a time that the thyroid starts to misbehave. You do need to check that there's not a cardiac condition. You do want to check that they haven't developed rheumatoid arthritis. But all of that, as you say, can happen while you're trying. on the side.

Yeah. And then they often come back. Yeah. And even the tinnitus has gone. And I think that's one of the most unexpected symptoms to improve. But yet again, there's multiple studies showing that hormone therapy treats and prevents tinnitus. It's just, they're just there in the shadows. They're hidden.

Yeah, absolutely. So there's great what we need to do. Between us, we can conquer the globe because we've, you know, you're the other side. Although, as people can hear, you're not from Australia. No. So before I finish, so Kerry, I always ask for three tips. So I'm going to just ask you, what three things do you think would be really important for healthcare professionals to know so that they are less scared of the negativity about hormones? So three things that will encourage them to learn more and help patients going forwards.

So I think the key things for me were to understand that menopause can affect what. women of quite a wide range of ages and to consider perimenopause when you get these multiple system symptom clusters. The second thing would be to really simplify your HRT or MHT regime down to trying to use body identical hormones, estradial patches, gels or sprays in the UK, micronised progesterone and then considering testosterone and understanding that women don't all absorb medication through the skin the same and so you may need to tweak the doses and the third thing is that all estrogens and progestogens are not the same and the estrogen in body identical mhd or HRT on its own has been shown to reduce the lifetime risk of breast cancer the body identical progesterone is not

associated with any increased risk of breast cancer and the best data still got a risk of below one and testosterone is licensed for loss of libido, but in clinical practice does seem to really help other symptoms of premenopause and menopause and can really be a game changer. I'm supposed to have been allowed one more thing. If you do start to prescribe more MHT, you'll see the most transformational medicine that you've probably ever encountered. Absolutely. So really great advice. And obviously we've got our confidence in the menopause course, which is always being updated. We've got new consultations that have been filmed. that are going out as well over the next few weeks and months.

So plenty to learn. And so thank you so much. And keep in touch. Keep doing your great work. And hopefully we can entertain you over in England at some stage. So thanks, Kerry. Absolutely. Thank you very much for having me.

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