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Brilliant. Thank you ever so much. Everybody I know we've had Hi Poor, we've had a lot of interest in this session uh this evening. So it's great to see so many people logged on and thank you ever so much for, for, for putting in the chat. That's really good. So we've got Vitron with us again and we are gonna be discussing alternatives and non hormonal er treatment for menopause. So this is a really hot topic at the moment. Um It's really great to have vik room of us providing that education and providing that insight as well from, from his clinics and from, from his studies. So I'm not going to waste any time other than to say med or thank you ever so much for the platform. It is superb to be able to, to come to you this evening via, via this platform. Um What I will do is pass on to Vikram and let him crack on. We will have time for questions at the end. So if you want to put them in the chat or if you want to wait to the end of them, put them in the chat, whatever way range. You want to do it, we will get, get your questions answered. Ok, Vikram over to you. Thank you so much, Becky as always and thank you, Medal and nurses learn with nurses for the opportunity. Um I hope you can hear me well and I'm just going to try and share my slides for today. So let me try and share screen and I hope you'll be able to see my slides in a minute. Um There you go. Oh, I might need to share slides, I guess. Uh Let me come out of that. Oh, you might be able to see me. Uh Becky. Can you see my presentation? I can see your presentation. Yes, perfect. Perfect, perfect. So let me start from beginning. OK, so what we are talking today about is the alternative and the non HRT treatments for menopausal symptoms. And it's really important that uh I'll right from the beginning, I will say that although I do loads of menopause clinics at UCL H or otherwise in the private sector, I'm not an expert in terms of nutrition, herbal treatments and a few other complementary therapies. So really, I'm going to give you a take on what options there are. Uh when a woman has troublesome menopausal symptoms and she's not looking to use HRT, what are the options out there? Uh But we don't have enough time in say 2030 minutes to go into details of each. So if somebody is interested in pursuing a particular treatment or a therapy. It's important that you seek the specialist in the area. What I'm going to really provide is an overview so that people, individuals, clinicians are aware of what exists out there. If a woman would not like to use HRT or cannot use HRT. So just a quick overview, why are we talking about this subject? Because we know that women can have difficult symptoms, troublesome symptoms as they go through menopausal transition. Not everyone has a difficult journey. Some women may be lucky to have mild or minimal symptoms. Others will experience quite severe symptoms even for 1015 years. And it's those women who might seek help and support during a difficult time. Preperimenopause is the time when the symptoms may start first and this is when usually happens between 45 to 50. For most women in the Western population. We know that some other ethnicities such as the Afro Caribbean or Indian ethnicity, the the symptoms may happen much more earlier. Menopause may happen 1 to 5 years earlier and so, hormone fluctuations and symptoms really start around perimenopause and a woman should be offered non hormonal and hormonal treatments if she's finding that they're affecting her quality of life. For most women in the western countries, menopause happens around 5051. That's one year since the periods have stopped. And of course, since thereafter, until end of life, we call that phases post menopausal and the symptoms may start in perimenopause for majority of women will last between 5 to 10 years, but some may continue having symptoms even 1520 years and beyond. It's important also that we're touching upon natural menopause today. But of course, 10% of women can have early menopause. This is between 41 to 45 and that can happen for a variety of reasons. Uh, premature menopause is when it happens below the age of 40. We often term it as premature ovarian insufficiency, which can affect about 1 to 2% of women. And of course, there will be women who will have surgical or medically induced menopause. This could be due to removal of ovaries surgically that it could be due to chemotherapy medications which are toxic to ovaries, radiotherapy or interventional procedures. For example, pelvic embolization and for all those reasons, we are going to cover a little bit about all these today. The most important bit to say is when we talk about premature menopause, early menopause or surgical or medical premature menopause, HRT remains the gold standard. That's simply because women who have had menopause before the age of 45 will often need hormones to maintain their bones, their heart to have better effect on their cognition as well as to suppress unpleasant symptoms. So for them, HRT is really recommended non HRT medications will be if they can't use it for some or other clinical reasons such as blood clotting or breast cancer in the past or any sort of hormone dependent cancer in the past. But for majority HRT will be recommended. So we're going to focus on the group in early premature menopause where the woman can't take HRT. And of course, all other women who had natural menopause, they don't need to take HRT. So that's what we're going to cover. So, menopausal symptoms can be treated by a variety of options. HRT remains the most effective treatment. It helps with the bone and the heart health, but some women may have very mild symptoms. Others simply don't wish to have HRT. They don't like to take hormones. They may have cultural issues or their personal preference not to take hormones. Still others HRT may be high risk. They may have blood clotting problems or liver issues or past hormone dependent cancer. The most common being breast cancer or uterine cancer and that means they are high risk for taking HRT. And in all those situations, we are looking at what are the alternatives. So we're going to talk about a few things, the lifestyle interventions, the non pharmaceutical treatments and complementary therapies. We're also going to talk about pharmaceutical treatment which means medicines which are non hormonal, quick recap of lifestyle interventions. I think all of us know that healthy lifestyle becomes key uh in trying to manage the symptoms of menopause as well as protecting the long term health. So if you're smoking, then stopping smoking, uh, making sure that alcohol intake is limited. Uh, not having too much caffeine, which often triggers symptoms of menopause such as hot flushes or sweats healthy diet. Um, fruits, vegetables, wholesome meals, portion control, weight control becomes critical because again, the symptoms tend to be more severe. Higher. The BMI of the individual regular exercise is key and again, I'll touch upon exercise later but exercise not only helps with menopausal symptoms, it also helps with mental health. It helps with long term health protection and you of course, got stress reduction. Uh This is a difficult one because every individual responds differently to stress. But again, meditation or stress management is equally important and sleep hygiene and making sure you have a good bedtime routine and you're not listening to or watching screens at least an hour before you go to bed. These sort of things make small differences, but these are useful to avoid menopausal issues and some tips about a day to day. Um improving lifestyle and health is because of menopausal symptoms. Of course, women may find wearing loose natural fabric layers can help with flushes. Access to fans or cooling devices is really important, especially in hot weather. Avoiding spicy foods is known to help. Some women may have trigger of vasomotor symptom with spicy food. The same thing applies to caffeine and alcohol often is known to trigger uh flushes, stopping smoking, important increasing exercise because it tends to reduce all cause mortality, very good for health and of course losing weight exercise is shown to improve mood, improve sleep during transition. We recently had a big systematic review, analyzing different studies and randomized trials, looking at role of exercise, how it helps menopausal symptoms and sleep. And it did show that exercise does impact vasomotor symptom. It reduces the frequency of symptoms, it does help better sleep quality. So of course, there are controversial data and conflicting studies. But overall from the summary of evidence, it does seem to improve menopausal symptoms. It does also improve memory concentration. It protects the bones, especially if you do weight bearing exercise and weight bearing exercises, running, jogging, walking. Uh and of course, it helps control weight and if you're doing resistance exercises, that's very good for helping muscle health and balance. So, exercise has plenty of benefits and it's really important to stick to it rather than just trying to force yourself to do it. If you do it five times a week for 30 minutes, that's the best. And you can do yoga, Pilates running jogging, whichever form that you enjoy. Let's look at what happens with non pharmaceutical treatments. Now, non pharmaceutical treatments or alternative treatments, we talk about hypnosis. Uh We talk about uh acupuncture, yoga, CBT homeopathy, Ayurveda, and Chinese medicines. Now, hypnotherapy or hypnosis, there have been some randomized trials which did find that it reduced severity and discomfort from hot flashes. The studies are small, the number of individuals treated in these studies were small. So we really need large scale studies, bigger longer prospective studies to really understand how valuable hypnotherapy or hypnosis is in the long term. But it's reassuring that actually it does have some short term benefit in the small studies that were done. So this would be one of the options for women not able to take HRP or not wanting to take HRP. Acupuncture is yet another one. Now, there have been lots of controversial conflicting data about acupuncture and menopausal symptoms. And we certainly need more rigorous well designed larger randomized trials to make sure whether acupuncture does really help or not. The trials. Actually, when they compared acupuncture to placebo found that acupuncture was more effective. But when they compared acupuncture to sham acupuncture where you had uh needles being inserted but not actually like an acupuncture treatment. The difference was not significant and therefore, it's questionable how much effect acupuncture has on menopausal symptom. Overall, there is a bit of body of evidence gathering that it will have a role for some women. It does seem to help with symptoms. The side effects or downsides are very little. So many women now choose acupuncture as one of the modalities for menopausal symptoms. What about yoga? Again, some studies have shown if you regularly adhere to yoga, it does reduce vasomotor symptoms. But again, small studies, limited evidence. In fact, yoga can help with so many other health outcomes, the balance and the muscle mass and the long term bone health. So again, it would be something that would be recommended simply because of its health benefits with, with, with some effect on the vasomotor symptoms of menopause CBT. Cognitive behavioral therapy is very useful. This certainly has evidence that women feel less bothered by hot flashes when CBD is done. It's very useful especially has been found in breast cancer survivors for sleep, for reducing hot flashes, night sweats. CBT tends to be quite effective. And so this is one intervention which certainly has evidence behind it. And I certainly offer it to all patients. Even those who find that their symptoms are not entirely taken care of by HRT CBT can always be very useful homeopathy, Ayurveda, Chinese herbal medicines. Again, there is controversy conflicting evidence whether these are not useful treatments or they actually do benefit a subset of women as long as you are doing these treatments with someone with experience in these treatments. It's important to recognize that the evidence for this is lacking. Of course, we need better studies, bigger studies which might show in future that there is some evidence that they do help with symptoms. Right now, the evidence remains poor having said that I do work with a clinic at the Royal London Hospital for Integrated Medicine who do offer different therapies including acupuncture and homeopathy. And we do find that women who are not able to access HRT often opt for these therapies, often find that they have some relief of the worst vasomotor symptoms when they use treatments like homeopathy, the safety profile of these seem to be good. And therefore, if a woman wants to choose this, as long as she chooses the right clinic and the reputable clinic, I think it's worth as an option uh in terms of non HRP management. Well, again, coming back to what about nutrition, diet, we know the basic norms, avoiding large portions of food, avoiding calorie or sugar rich and processed food that remains the same as anybody else. Uh in terms of menopausal transition and diet. But this cycle is important to understand is that what happens with midlife changes and the hormone changes is that there is a change in the gut microbiome. There's a change in the fat distribution, most of the fat gets distributed around the middle. And of course, there is weight gain at this time. As the metabolism tends to slow down, the insulin doesn't work as before that reduces insulin and lactin sensitivity then would mean there is a bit of leptin resistance and this will cause a decrease in the ability of the lactin in the brain to suppress the appetite or increase the energy use of the body. And that again creates a vicious cycle where insulin resistance and the weight gain becomes a vicious cycle. And so you want to break that by avoiding large portions, avoiding calorie rich processed food and of course exercise is equally important. There is plenty out there on the internet in terms of what supplements should be used and in terms of what diet should be used. And often there are contradictory views from dieticians as well as nutritional experts. All I can summarize is what is healthy eating, which is important that you have lots of fruits, vegetables, nuts and seeds, legumes in your diet. It's important to eat whole grain, fermented dairy, unsaturated oils. At the moment, we don't recommend any specific supplements for menopausal symptoms. Some of them may be helpful. For example, magnesium for sleep or Vitamin E is popular in terms of vasomotor symptoms. None of them have real good quality evidence backing them up, but women do choose to use them and some find them useful. Vitamin D is the only one that we recommend, especially if we are concerned about the bones. And this is usually in the form of a 400 international units or a 10 mcg supplement every day, especially in winter months when we don't have sunlight. Otherwise, if you have access to sunlight and you're eating oily fish, eggs or breakfast cereal, almonds, walnuts, mushrooms, then generally you can get a significant Vitamin D even with sunlight and the diet. If you have history of osteoporosis, osteopenia, premature menopause, you might want to take a bigger supplement up to 1000 units of Vitamin D every day. Calcium is best through food. We don't necessarily recommend calcium uh uh supplements unless you have a particular reason to take them. But there's deficiency of calcium. But generally, if you have dairy foods like yogurt cheese milk or you're having plenty of meat, fish, eggs, beans, lentils, greens, whole meal bread or fruits like figs or oranges or broccoli kale. Uh veggies. Usually you will get plenty of calcium through a healthy diet. Omega three is controversial. There is some benefit that has been associated with these supplements. Many of the other claims about heart disease have been controversial, but generally, it doesn't have any side effects. And so often, most healthy diets will include some sort of omega three. There's no evidence particularly in terms of vasomotor symptoms. Uh but it's generally part of healthy lifestyle and so sometimes flaxseed soya or green vegetables, nuts are usually the source with that. Besides the oily fish, I talk about phytoestrogen. This is often uh a topic that gets talked about when we consider alternatives to HRT. Now, phytoestrogens are actually dietary sources of isoflavones. Uh And, and these are isoflavones and lignans are the two forms of phytoestrogens. Phytoestrogens are plant estrogens which behave like estradiol in the body, but they're 1000 times weaker. So there is some benefit that the woman will have in terms of symptoms because they behave like estradiol, but it's a very, very weak oestradiol, almost 1000 times weaker. And, and of course, there are different sources of these isoflavones and Lignans, which I have just mentioned on the slide. It's important that if you're taking isoflavones, you need to take a lot if you're thinking of having symptom relief from isoflavones and Lignans. And it's also important to know that not everyone will have the same benefit because there are certain enzymes in the gut which need to break phytoestrogens so that you get benefits from it and not everyone has the same enzyme activity. So it's one of the options. You can always try if you're symptomatic following uh treatment of say breast cancer or other cancers where you really can't take HRT having good phytoestrogen based diet will help. However, it has its limitations, sleep hygiene and stress reduction is very important. Uh and sleep often uh uh is is determined by a bedtime routine, avoiding screens before sleeping magnesium may help some women making sure that you actually have CBT for sleep if it becomes a bigger problem. Uh Stress reduction goes hand in hand with sleep and there are various things which can help with the sleep routine. Again. Uh details will be uh will run short of time today, but that's important. And you might seek a specialist advice or use apps like sleep or others that sleep might improve with the use of these technologies, herbal and botanical therapies. These are classed as food supplements. There are lots of herbal and botanical preparations which are available for menopausal symptom relief. The trouble is that the quality control on these preparations is not uniform and standardization often is not required. And that's what worries many of us because sometimes the information on the pack and the contents may be unreliable. Often many of them are available over the counter internet and therefore are unreliable. The contents, the dose, the contaminants and the caution may not necessarily be properly mentioned on the pack. So to kind of avoid this confusion, there has been the thr labeling that's traditional herbal remedy. It's basically a regulatory process that has been adopted in the UK besides Europe. And what happens is if you see the thr mark on a herbal preparation, it just means that there's probably a better quality control there. Now, herbal and botanical therapies which are popular include Black Cohosh Sage, uh Ginkgo, Biloba, Saint John's Wort evening primrose oil. Those are the most popular ones. Uh They work for some women symptoms may be lower, especially sage, helps with hot flushes. And so also does the Black Cohosh. The problem is many of them will interfere with other medication. For example, Black Cohosh or Saint John's wort can interfere with tamoxifen. So if you are a breast cancer survivor and taking herbal medication, you must check that it's not blocking tamoxifen activity. Some others can also interfere with other medications such as hypoglycemics or immunosuppressant medication or the sedatives. And so it's very important to check with your physician that the herbal products you are taking are not going to interfere with other medication. The overall evidence for their use remains quite uh weak and we certainly need better studies in the long term, especially randomized trials with good number of women to recommend these to women. A quick word about vulvovaginal atrophy, which is another uh difficult symptom of menopause, especially premature or early menopause. Uh If there is vulvovaginal symptoms, dryness of vagina, painful intercourse, bladder issues, uh for some of them may be helped with lubricants, moisturizers which are available over the counter. And there are some non hormonal or hormone modulator medications such as the DHEA pessaries or OSEN, which is an estrogen receptor modulator, which are available, which are not directly HRT but can help with symptoms. Vaginal laser treatment is again offered in the private sector has no big evidence backing it. There have been some studies which have shown short term benefit for a year with repeated treatments up to 3 to 4 times with vagina laser, but the long term outcomes are unknown and it usually is quite expensive with limited evidence for efficacy. And so something I don't recommend to my patients. So finally coming to the pharmaceutical base and that's medicines which are uh not complementary therapies, but also not hormone uh content. So, of course, the most effective out of the three groups of drugs we have is the SNRI or the SSRI commonly described as antidepressants. So you have venlafaxine, paroxetine and citalopram. These are the three most commonly used Ssris. Uh Venlafaxine is the most popular used in a dose of about 37.5 to start with up to 1 50 mg. And the only real contraindication being very high BP. These can help with mood can help with hot flashes, night sweats and improve sleep. And of course, these are something which are quite commonly used by women who cannot take HRT or would not like to take HRT but are suffering from symptoms. Paroxetine. One should be careful about because it can interact with tamoxifen should not be used in this group of women. The other drugs which are used to suppress menopausal symptoms are of course, antiepileptics such as gabapentin can be used in a dose of 3 to 900 mgs a day pregabaline also. And cloNIDine, which is a antihypertensive alpha blocker and is the only licensed medication for this use. And all these have their own side effects though. So, although they may suppress the worst hot flushes and the night sweats, they can cause dizziness or a bit of sleep issue, sedation, dry mouth constipation. So again, these need to be discussed with the woman before you offer medications such as gabapentin or cloNIDine. There is hope there are novel treatments on the horizon. And one of the peculiar ones that we talk about is the neurokinin three receptor antagonist. This is a novel treatment for menopausal hot flashes. I've just quoted the paper which started and got the ball rolling in 2017. There have been a number of new studies. In fact, the last one was again published in Lancet last year. And it's a small study so far. But it does look like the neurokinin three receptor antagonists are going to be drugs which will help prevent hot flashes. What they're blocking is they are blocking some receptors here, which actually cause the brain to stimulate hot flash formation. So they're blocking a pathway in the brain that actually stimulates hot flashes. That would mean that these are non hormonal. And if they prove to be effective and so far, they do look effective from the limited trials we have, then these will be certainly a breakthrough treatment for, especially for women with hormone dependent cancers such as breast cancer. The trials have been short so far and the only side effects with these have been a bit of somnolence and a bit of headaches. But again, nothing significant. The efficacy does seem to be good. We need more evidence from the long term efficacy but something to look forward to in the near future. So that in a nutshell is an overview of the different treatment options that we have when we describe menopausal uh uh alternative treatments. Uh hopefully you will have plenty of questions for me. Uh So we will get back to questions. I'll stop shedding my sls and that. Thank you. Thanks a lot, Vikram. Um There's a question came in quite early um from Juliet. Um She says she knows a person who's had overactive thyroid at the age of 30 since 33 years old, she hasn't had a period. Do you think that's early menopause? Well, it's difficult to say just on basis of that particular history. Um And again, thyroid itself being very low on thyroid or hypothyroidism can delay someone's periods and periods may stop for a while. Uh What is important is to look at other things, for example, have the periods stopped any time before? Is it the first time that there's a big gap, have they gone on for more than four months uh without restarting again? Have they had any symptoms of menopause, like the hot flushes or night sweats or any other symptoms? And then of course, if it's been more than 3 to 4 months, it's important to have a quick check of the bloods that will make your clear whether it's actually something that's heading towards premature menopause or it may, this may just simply be something else like PCOS or thyroid issues. Great. Thank you do. It's just added uh more than 14 years, no period. So, yeah, again, it's, it's, it's dependent on, on much more than, than that. So, because 14 years is a long time to go without a period. So she should certainly be seeing a physician or a GP right now and get some bloods done that will nail the diagnosis but it could be poi you need to see somebody. Yeah. Ok. Doke. Ok. Any more questions coming in then from the chat. Let me just scroll down just in case there's anything I've, I've missed. Um, one thing I want to pick up on vaginal laser treatment. What is that? That sounds, that doesn't even sound nice. I've gone through these quite quickly because we wanted to cover and give time for questions. So I may have been pretty quick with most options but feel free to ask questions. But vagina laser is a known form of treatment. What it involves is basically you go to your physician who does it, they do a speculum and then in the vagina, they would introduce a device that would apply laser to the vaginal skin. It's different forms of laser are available. It's a CO2 laser or European laser and there are different devices which are still being patented and tried in the US and some of them. Now in the Europe, the studies are limited though is that it's usually uh expensive treatment offered in the private sector. And when you do have a laser session, you have to do it at least two or three times to get the necessary effect on the vagina. So it's meant to increase vaginal blood supply, improve the moisture, take away the dryness, give some pelvic strength to the muscles but they seem to be short lasting, which is my problem with it is that the studies are limited and the effect seems to be short lasting for a year. So you're maybe back to the same position after that. So we need bigger, longer trials to say this certainly works for most women. Right? Ok. And I think really the main theme running through this is the lack of trials, isn't it? The lack of clinical evidence for a lot of this? Um And obviously you haven't got the PHS back in for things like CBT or acupuncture. So you can see why there is a shortfall. Ok. Carrie Thompson is asking, do you recommend any specific CBT resources? Is there anything out there? Well, I certainly rely on GP S for that because in my clinic, for example, I would always write back to the GP because the GP S in the primary care will have links to CBT services, whether it's online, whether it is face to face, which is becoming less common now. But again, they will have individual areas will have their preferred CBT provider or a clinic or a specialist who does it. So I would often say find the best person where you live or where you work in the local area. I often um often signpost people to different providers, but I don't have any preferential ones as long as they are reputable and they, they basically have a good clinical service then that's it. You may find information about CBT on the BMS website. Quite useful. The British Menopause Society runs a course on CBT for specialists and they have lots of information on CBT as well. So do look at that resource if you want more information useful. And I guess on along the same kind of lines, then, um Zoe's asking can uh non pharma measures be prescribed? So could, could acupuncture be be prescribed? Could CBT be no. So it's not looked at as a regulated medication so often, uh your GP uh may, may not believe in acupuncture for example. And so they will not be uh they will not have to prescribe you this. As I said, I'm lucky because where I work, I have access to say the Royal London Hospital for integrated medicine. There are providers like that where I can do a direct referral because I believe that some women will benefit from alternative therapies. I don't think all doctors or primary care physicians will have access to a hospital or clinic like that. So most women often find their own acupuncturist or a herbalist or a nutritionist and they often go into private sector or pay for it themselves. If you have a particular GP who has links with such clinics or integrated medicine clinics, then it's great because they can refer you there. Yeah, that makes sense. And what I will say just quickly before we get onto more questions is if there is any particular um intervention that Vikram has mentioned tonight that you feel we would benefit from getting a speaker on to discuss, then just put it in the feedback and then we can look to see if we can source somebody or if you know somebody give us a shout or, or, or give them a shout out via the, the er feedback form. That would be really good. Um OK. Next question, what can women do if they are perimenopausal and having heavy erratic periods? No abnormal abnormalities seen via, I can't pronounce it. Thank you, Vikram. So, heavy bleeding or irregular bleeding during perimenopause is very common. That's because of one, it could be just the hormones which are going up and down because of fluctuation. But it, it could also be that the pathologies uh like adenomyosis where you won't see anything on hysteroscopy, but actually the muscle of the womb is a bit thick and that often is an ultrasound diagnosis. That is usually the commonest cause for heavy bleeding during this stage. If the hys copy is normal, of course, there are many things to stop bleeding or heavy or erratic bleeding such as hormonal pills, uh progesterone only pills, you've got progesterone, long term, you've got Mirena coil, you've got ablation, therapies to take care of the bleeding, that's all to do with the bleeding. If you're thinking of menopausal symptoms and erratic bleeding, then of course, you can combine estrogen for menopausal symptoms with some of those treatments like the progesterone pill or the Mirena coil or after ablation. So, there are plenty of options for the erratic bleeding. You must see your GP or a gynecologist and they will be able to take you through three or four different forms of uh treatments. Right. Thank you. And another question here, what would you recommend for a lady who has vaginal atrophy, uncomfortable and very dry past hx breast cancer, estrogen sensitive C for HRT. So again, this is a good question. So past breast cancer and if you are suffering from vaginal atrophy, remember that you can still have all the moisturizers, the lubricants, the one brand that we like is a yes ye is a common brand. If those haven't worked for you, then of course, I tend to prescribe vaginal estrogen. Uh I remember that vaginal estrogen over now being used for last 1020 years in a very tiny dose, which is 10 mcg is now thought to be safe. Even if you have history of estrogen receptor positive breast cancer. In the past, the only change you might need to do is if you're on an aromatase inhibitor like letrozole or an estra, you might have to shift to tamoxifen if that's possible and you might have to discuss that with your oncology team. Otherwise women can safely have vaginal estrogen if the symptoms are persistent. I certainly have a lot of women in my clinic who use vaginal estrogen. We've always tended to do their blood levels to check if they absorb estrogen and it often comes back as need. So it doesn't get absorbed when you use a tiny dose vaginally. So do talk with your GP or your oncologist and they should be able to provide that for you. That's really good. Um And one, I think really popular question, to be honest is what would you recommend brain fog varum? That's a big thing. So brain fog is a symptom of menopause, lack of estrogen, lack of partly testosterone, I guess. Um But there's no one strategy there. Uh If you have, if you think this is started with perimenopause or menopause and it's a symptom, you only come across with this, then it's likely lack of estrogen. So, HRT does do good if hormone replacement therapy, if it's fine for you, there are no contraindication, you will find that the moment you start using HRT, brain fog will really improve if you're not a person who can use HRT or would not wish to use it. All the lifestyle measures we mentioned about healthy diet, exercise, adequate sleep, making sure you remain socially, mentally active, all those sort of things may partly help. But if it's typically during the perimenopausal transition, it's likely the lack of hormones, it will either pass away on its own in a few years. But if you're getting bothered by it, consider low dose transdermal HRT. Ok. And I think that is it for questions. You've seen the feedback form in the, in the chat. So please complete that cos that helps us and, and informs us with, with future training sessions, Vikram. And I will be back in the next seven. We've got every seven weeks now. Isn't it up until August? So, was it October August? Um, we will be discussing a, uh, a separate menopause hormone related topic. So do join us for that and do add into that chat and you er, into that feedback. Anything else we can cover? Thank you ever so much, everyone, Vikram. Thanks ever so much. Thank you. Thank you everyone for their time today. Always, uh encouraging when you join in and thank you, Becky for coordinating the questions because sometimes it's difficult to go back to them otherwise. But thank you so much for everyone and do give us your feedback. We like to keep improving these sessions. Thank you, Brill. Thanks ever so much. Everyone. Have a good evening. Have a good evening. Bye.