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We live, welcome everybody to another of our learn with nurses sessions. Er, this I think is the last one before Christmas. So, er, yeah, very delighted with lots of people that are here to join us. So those eagle eyed people there will notice that I am not Becky. Becky is unwell. Unfortunately. So my name's Michaela and I normally do the like the BP and cholesterol ones. So I'm, I'm going to tell them my screen off for now. I'll be back at the end of our session when it's going to be looking at the evaluation and the questions. But for now I'm going to hand over to Cram, who is going to tell you a little bit more about himself and a little bit more about um well, those hormones, thank you cram over to you. Thank you, Michaela. Thank you so much for the introduction. Uh Well, I think we've done a few webinars now. So those of you who are joining us again, uh having uh joined us on the previous webinars, we'll know my name is Vikram Ta. I work at the UC H and HS Hospital in the Reproductive Medicine Unit. Uh I do menopause clinic at UCL H I also work in the private capacity at 10 Harley Street for the menopause clinic, London. And we're going to talk today about HRT hormone replacement, what it is, who needs to take it? Uh What benefits and risks uh does HRT have uh who should consider it for different indications? And also uh what's the evidence behind its benefits and risks? And a summary, a broad overview of uh hormone replacement therapy. Now, I'm going to share my screen uh in a minute. So hopefully you will all be able to uh see my slides in some of the uh graphs that I have there. Uh So if I minimize that, go to the presentation uh play from start, that's it. Thank you. Thank you, Michaela. So we'll make a start straight away. So I'm going to use 2025 minutes to do a rapid fire uh top uh sort of um lecture or I wouldn't say lecture but slides on the menopause HRT and then uh the rest of the 20 minutes. Hopefully, we can spend taking lots and lots of questions from you. That's the critical part of today's session. So just to say, we know menopause is going to affect about 50% of the population. And we know that about one third of women presenting to the health care at the moment are between the ages of 40 to 60. Another third are catching up very rapidly. Globally. About 700 million women are in the perimenopausal menopausal age group and about 70 to 80% of them will have some or other symptoms. Some may have mild symptoms. Others may go on to have quite severe debilitating symptoms. Women now spend about one third of their life in the menopausal phase. So this is not a minority issue. It's a major uh important health care um uh problem. I wouldn't say it is as a problem, but it's a stage of life in a woman uh that needs to be addressed because of the long term health implications as well as the quality of life issues. When does menopause happen? And again, this is important when we describe the use of HRT for a particular individual, we know that for most women, uh menopause will happen around the average age of 51. Now, that's based on caucasian population data in the Western world countries. If you look at women from different ethnic backgrounds, for example, typical Southeast Asian women or women from South America or Africa, they will have a slightly different average age of menopause. For example, in India, the average age is considered to be 46. Now, you can see that's five years earlier than the average age for Caucasian population. And these are important differences because your advice about HRT will depend, of course, on the timing of menopause, 10% of women will have menopause between 40 to 45 which is called as early menopause. 1% of women will have it below the age of 40. So one in 100 that's premature menopause and one in 1000 women will have it even under the age of 30. And so that's really very premature menopause and never say never. Women in their twenties can have a premature menopause. It's a very difficult challenging diagnosis for them to uh take on board. But it's important that the investigations and diagnosis happens timely and women are supported throughout their lives stages during menopause. And I'm just going to quickly spend one minute on this because we say that premenopause is before any hormonal changes start. Then the perimenopause happens. This is when the hormones start fluctuating. For most women, the fluctuations will happen for about 2 to 5 years between the ages of 45 to 50. That's a typical perimenopause, but perimenopause can go on longer up to 10 years or more. And then again, there is so much individual variation. Then menopause happens. This is when periods stopped completely, no more hormone fluctuations because estrogen levels are close to zero. And this is always a retrospective diagnosis once the periods have stopped for a year. Finally, you have post menopause one year since the periods have stopped and thereafter until the end of life. The key thing about the slide is that women who do develop symptoms during perimenopause and menopause can have it right in the early stage of perimenopause. So even though the periods are happening, the woman is having menstrual cycles, she can have lack of estrogen symptoms and HRT could be offered. And it's important to stress this because the traditional belief was that if the woman is having periods, she's having hormones, she should not be offered a charity. That is no longer true management of menopause related symptoms. Of course, there are plenty of ways of addressing symptoms. And it's important to know that while some women may have minimal or no symptoms, others can go to have severe debilitating symptoms. So there is so much of a variation in the menopause for every individual woman, every woman's experience of menopausal transition is unique and one size does not fit all. Some may have very minimal symptoms, others may have severe symptoms. So there are various ways one can address symptoms. If they happen, you have lifestyle modification that may suffice for some individuals changes at workplace to help with work, nutritional diet, self help interventions. You have alternative therapies, yoga, Pilates, reiki acupuncture, hypnotherapy. So many of them non HRT medications such as cloNIDine, gabapentin antidepressants or finally, you have menopausal HRT, which is what we are going to concentrate today about some of the other lifestyle and non HRT interventions will hopefully address in future. But today we do just the HRT. The aim of this is to improve quality of life to try and address the severe symptoms and of course, improve the long term health for the woman. What is HRT HRT is replacement of estrogen progesterone and testosterone. And this is primarily for the reason of symptom relief. So it can be given as local HRT. When we say local HRT, it's vaginal estrogen or it can be given as systemic HRT, which is estrogen in combination with progesterone plus minus testosterone, which is given either in the form of tablets, patches, gels, coils, implants. There are so many ways of giving hormones, not everyone needs or wishes to take HRT. But for women who are going through severe symptoms or wish to take HRT, it should not be denied where it can help. Systemic estrogen replacement therapy remains the most effective treatment for menopausal symptoms. And that is the indication for hormone replacement in the menopausal phase. If the woman perceives that the symptoms she's having, whether it is hot flushes, night sweats, brain fogging, lowering of mood fluctuating mood vaginal dryness changes to libido, whether it's sleep issues, joint pains. There are so many symptoms which are associated with menopausal transition. If the woman is being affected severely by the symptoms, then that is the prime indication where HRT can help and it remains the most effective treatment. What's the choice of HRT in the modern world? So there are so many different preparations of HRT to simply summarize when we choose estrogen, we choose the 17 beta estradiol as the preferred estrogen type. And that's because there is maximum safety and efficacy data for using estradiol in the preparation. And then they combine that with two forms of progesterone which are more popular in the modernity. You have the natural progesterone, which is the GEAN or you have dydrogesterone, which is usually part of the fe stone preparations. Now, why do we choose the progesterone which is natural or dydrogesterone? That's because these are slightly better tolerated than some of the traditional progesterones such as norethisterone or Provera or levonorgestrel because they're less androgenic. Now, I must mention that another useful progesterone is levonorgestrel coil, which is the Mirena coil, which can help a lot of patients who have bleeding issues on HRT. So it's the utrogestan, the digester and the Mirena coil would be the ones which are the best. They also have less risk of blood clotting and less impact of risk on of breast cancer. This is just a quick table and you don't have to go into details. I can share the slides later just to show you that the natural progesterone and the di progesterone are the best forms of progesterone in HRT. Because if you look at the androgenic action, they have very little or no androgenic action on the receptors. While all the traditional progesterones tend to be heavily acting on the androgen receptors. Transdermal estrogen preparations. There has been a big shift in HRT, prescribing towards transdermal patches gels or spray. Now, it's not a must that every woman should go for transdermal HRT. Because for some women, the patches gels may not work. And what are the indications where the patches gel spray should be always used? 1st. 1st, if a woman is taking some liver enzyme inducing drug, you want to bypass the liver by giving a charity through the skin. So that's one indication. For example, antiepileptic medication. If the woman has a severe liver disorder, you want to go for gel spray so that you can bypass the liver rather than the oral route. If the woman has a bowel disorder, which could affect oral tablet absorption, you prefer the patches or gel. If a woman has history of migraines, then again, transdermal seem to give a better stable level of hormone absorption. And then woman has lactose sensitivity. Of course, you will avoid the lactose containing tablets. Anybody with high BMI above 30 or age above 60. The first line will be transdermal because you want to lower the risk of thrombosis or stroke. Low dose vaginal estrogen. That's the local estrogen can be used. If there are only symptoms of vaginal atrophy, you don't have to use systemic estrogen progesterone in that case. So you have low dose vaginal tablets, pessaries creams or a vaginal ring. They can all be used for vaginal atrophy symptoms alone or you can also combine them along with a systemic HRT contraindications. Caution. Again, there is a big list there and I'm not going to spend too much time because we only have 25 minutes. All I would say is the two most important contraindication is somebody with undiagnosed bleeding or endometrial problems or somebody having current thromboembolism blood clotting issues and of course, the current past or suspected breast cancer, these remain contraindications for HRT. I mean, some women who have already had treatment of thrombosis who are on anticoagulation, you could go back and give them HRT. Similarly, those with triple negative breast cancers who have completed their treatment and would like to consider HRT even can do that with caution. But these usually happen in liaison with a hematologist or an oncologist. Some of the prescribing tips from my side is if you're in a clinic and you're looking at a woman who is asking for HRT one size fits all approach does not work. Every woman's response to tablets. Patches, gel spray will be individual will be unique and you may have to try a few preparations before you get the dose and the route, right? You must prescribe at the lowest dose that treats the symptoms and then slowly increase the dose depending on what symptom relief and side effects. The woman is having blood tests are not usually required for diagnosis of menopause unless the woman is below 45 or below 40 where you're suspecting premature menopause. For all women above 45 with typical symptoms. You don't need blood tests to diagnose menopause. But if a woman is not responding to HRT in those situations. Blood tests can help you determine whether the woman is absorbing the medication. So if you do a blood test for serum estradiol, you can guess how much estrogen she's getting from your HRT. And whether you need to change the route or the dose of HRT. Those women who are diagnosed with primary ovarian insufficiency, which is the premature menopause, they will often need more estrogen. So younger women need higher doses as compared to women in their fifties and sixties. Again, for younger women, you have a choice of pill versus HRT. Some women may wish to use contraceptive pill rather than the hormone replacement that gives the additional benefit of contraception, which the HRT does not have who takes a bleed HRT and a bleed free HRT. So you can have cyclic HRT that gets a monthly bleed and you have a completely bleed free. HRT. Now, cyclic HRT is useful for women who are perimenopausal, who are still having some periods or who have just stopped their periods within the last one year. Bleed. HRT helps because it causes less irregular bleeding. Well, if the woman has been more than one year since her last period, then usually bleed free HRP is recommended and usually that will not cause any bleeding, but you could experience some breakthrough bleeding. In the 1st 3 to 4 months, we talked about vaginal estrogens. These are very effective for vaginal dryness, painful sex. They can also help bladder function and pelvic muscles. It's suitable for women and can be used as long as required because there is very little or no absorption in the body. So, if you're only using vaginal estrogen in pessary cream or a ring form, you don't need to supplement progesterone. And also remember that this can be used long term as long as required because there is minimal absorption in the body. There are other treatments for vaginal atrophy and I'm not going to dwell on them too much today. You have a DHEA pessary, which is now available in the private sector, not yet available on the NHS, which contains DHEA, which is a precursor hormone, which can be given vaginally daily. And you have an Ospemifene, which is an estrogen receptor modulator that can be given as an oral medication for treatment of vaginal atrophy once daily. Then you've got body identical and bioidentical HRT. We hear a lot about these two terms in media as well as in when patients come to us in demand for body identical. HRT. Most of us will know that body identical. HRT is the one that we recommend in the UK. It's a combination of estrogen and progesterone and basically, these hormones are very similar to the ones that the ovary produces naturally. They're all obtained from plants such as soy and yams. It's well studied regulated bioidentical is not recommended by the UK. Bodies such as the British Menopause Society, these are custom made preparations which are used by individual clinics and there are various combinations of estrogen progesterone compounds. We don't have long term safety efficacy data for them. And so right now, they are not recommended in the UK. This is a guide for clinicians who want to use HRT very basic guide. And again, I'm not going to dwell too much on this. We can catch up on this in the question answer session or you can of course have my slides, but it basically gives you a flow chart, how you would choose sequential or continuous HRT for women with a uterus and without a uterus. Now coming to how long can some take HRT and how you come off HRT if you wish to do so? HRT can be commenced any time as long as there are vasomotor symptoms even in the early perimenopausal phase. And there is no arbitrary limit to duration of use of HRT. Most women will use HRT for somewhere between 5 to 10 years, but you could continue beyond 6065 if the symptoms are still present, if the woman thinks that her benefits outweigh the potential risk. And that's why we say have an annual review every year. And if benefits outweigh risk, there is no arbitrary upper age limit for women with poi premature menopause, we recommend they should have HRT at least until 50 then they can choose to continue if they wish for symptom suppression. When somebody comes off. HRT again, women can either completely stop it suddenly or make a gradual decrease in dose and come off. In my own experience. I always say gradually reduce the dose if you're coming off because if you stop suddenly, you're more likely to get some rebound symptoms. There are some benefits of HRT which are, in addition to the symptoms, suppression, HRT reduces risk of osteoporotic fractures, osteoporosis. It's one of the first line preventive strategies for osteoporosis in women under 60. In fact, it also reduces risk of heart disease. If you start it within 10 years of starting of menopause or below the age of 60 it will reduce risk of cardiac events. There is some evidence that it may help with cognitive function, but we don't have definitive data yet. So we'll have to wait for definitive scientific studies to say whether it could be a tool useful for preventive cognitive decline. Some of the common side effects of HRT. Uh This can happen usually in the 1st 3 to 6 months. Uh and these are the most common being breakthrough bleeding. It's very common in the first six months of starting HRT. The most important things to check is check compliance. Maybe the progesterone dose is low. So you can go up the dose and it should stop the bleeding if the bleeding persists more than six months do of course, refer the patient for a scan. But the chance of finding a pathology on bleeding on HRT is extremely low. Unlike post menopausal bleeding, the bleeding usually happens due to combination of hormones rather than a pathology. So slight adjustment to the progesterone dose should take care of the bleeding. Other common side effects are breast pain, bloating, nausea, headaches, and these will all wear off in the 1st 3 to 4 months of using HRT, often reduce the estrogen dose and gradually build it up and that should take care of some of the common side effects. Some women can have progesterone intolerance or sensitivity and usually they will have lots of premenstrual bloating like symptoms. Cyclical mood changes may be present for those women who have real progesterone intolerance and can't take the common progesterone preparations. You may have to try different oral progesterone, micronize progesterone, the Mirena coil tibolone or sometimes use a specific regimen where you only give progesterone every 2 to 3 months to try and reduce the progestogen exposure and try and reduce the symptoms again. I've gone through a bit fast so that we cover a broad overview, but I can come back to these in questions if you want more, more details. A word about testosterone, its levels decline in the menopause. Women produce lots of testosterone in health. And with menopause, there will be a drop in testosterone. The main effect of this is reduced libido for some women. And we do have gel creams in plants. With the aim of giving about five mgs of replacement every day. You can monitor this by using testosterone level in the blood. Once every six months. The main indication is low libido. Despite taking good estrogen progesterone, HRT side effects with testosterone are uncommon. If you exceed the recommended dose, you can get a bit of increased body hair or acne or oily skin. But of course, if you stay with the doses that are recommended, the chance of that is very low and randomized trials don't show any risk of cardiovascular disease or breast cancer with the use of testosterone. So finally, last four or five slides and that's mainly on the risk attributed to HRT breast cancer. This is the one risk that puts off so many health professionals and women from using HRT. Remember, estrogen alone is associated with little or no change in risk of breast cancer. That's not the hormone that's linked to breast cancer. From randomized trials, estrogen and progesterone. The combined HRT can slightly increase risk of breast cancer and the risk will of course, be related to how much or how long do you take the HRT? And that's a nice picture that I often use in my clinic is if you look at women between say 50 to 55 and give HRT to about 50 women and compare them to women not taking HRT. You can see three out of 50 will have a background risk of having breast cancer, but only one extra case will be there if these women take HRT for five years. So the absolute risk is extremely small, has to be balanced against the benefits. Blood clotting is the other risk that's often quoted. Remember that the risk of blood clotting with HRT remains low. Even with oral preparations, it's lower than the contraceptive pill. It's lower than pregnancy. But out of the ones that we use, you can see the patches gels have no risk of any uh blood clotting or thrombosis. It's only the oral estrogen that can increase the risk. So we often say if you're below the age of 60 your risk of blood clotting or stroke is quite small, it won't change with HRT much if you're above 60 or you have some risk factors such as high BMI. That's when you should be trying to use patches or gel rather than oral preparation. Finally, heart disease, as we said before, if you start HRT, early before 60 heart disease protection is obtained from HRT. The risk is not increased. Even if you start it after the age of 60 you may not get the benefits, but there is no increase in severe morbidity or any other cardiac events just because of use of HRT. So since publication of some of the old study results, like the million women, a lot has changed. The modern HRT is much more body friendly has benefits which need to be balanced against some small risk and every woman's experience is unique. So you will have to individualize when you prescribe HRT, but every woman will make her own choice, depending on her unique set of benefits and risk. Thank you for listening. Uh And I'm open to take any questions now. Hopefully you will have plenty to ask. Uh We'll try to cover as many as we can or cover them in future by B as well. Thank you. Lovely. Thank you. And I have to say I was glued to that. Um Really listening to um what many women? This is an interesting and very important topic, not just for our patients, but for ourselves as well. So we have our first question that's come in and I'm sure more will be flying through. Um So somebody with uh some I was put down. That was brilliant. Thank you. That was our first lovely comment that's come through as well. So, so Suzanne's got a question saying a total hysterectomy but with ovaries left, will they go into menopause as normal or earlier? What are we generally, if you have a hysterectomy, you tend to have a menopause earlier than naturally, you would have been destined to. It is thought that having hysterectomy does interfere with the blood supply in the pelvis to the ovaries. And that means you tend to have a slightly earlier menopause usually within the five years of having the operation. And so if you have that be prepared, you might have an easy menopause, you might not have a lot of symptoms, which is great. But if you start experiencing symptoms because it's a surgical menopause, it can sometimes be a bit more severe. Then of course you should access HRT non HRT, all interventions will be open for. Yeah, lovely. Um So we're getting a lot more like great talk and excellent stuff coming through. So now we've had another client coming through saying remember the previous VT E? Um and that sounds like a really, it sounds like it. It's a topical or transdermal is a good option but that lots of people are being told or lots of women who are being told that because of the VT eh RT is not an option. So what what can I say back to their doctor? So it depends on what kind of VTE or blood clotting or thrombosis you had generally it's true that if you use uh HT in the form of gel patch implant or spray, you're unlikely to increase your risk of clotting. Now, there's one caveat here is all the studies that have been done to show that gel spray or transdermal HRT is safe have really been done in healthy women with no background medical risk of blood clotting. So when we say that it's safe and it doesn't cause blood clotting, we extrapolate data which has been tried in women without any background risk. And we then put it to women who have had thrombosis or a background thrombotic condition. So far though, in the last 10 years after using all the transdermal preparations, the, the our experience is very reassuring. It looks like it doesn't increase the risk of blood clotting. So, having a blood clot is not a contraindication. You should let your GP know that transdermal is safe if they are not confident or they do not have enough expertise. They can refer you to the NHS Menopause Clinic. And usually in that clinic, there's a hematologist who liaises with the menopause specialist will still be able to offer you HRP very few conditions. You could have an anticoagulant along with your H RT and that should make you thrombosis proof. Uh So, yes, those are the two options. You can. I like the thought of that. That's, that's brilliant. Now, I um had another message that came through, not through this route but through a slightly different route. But if there's, if you've got a woman who's on a combination of medication, so the pill, HRT, no, the pill, not HRT. The pill, an antidepressant and a beta blocker would, but consider thinking they might have. Is it possible? Do you get symptoms of the menopause? Can you be going through the menopause then? And would those other medications be masking symptoms of the menopause? And should they go to a menopause clinic or what, what do you think there are always medications which can mask or sometimes mimic symptoms of menopause. For example, beta blockers may not allow the palpitations to come through. Uh Similarly, for example, if you're an antidepressant, they themselves can cause you some hot flushes occasionally or may disturb your sleep. And so therefore, it's sometimes reduced your libido. That's a common cause of reduced libido. So there are medications which can both mimic or interfere with menopause symptoms. But remember, menopause will never be isolated symptoms. You have a number of them, which usually interplay. And so if you think that this is not just the medication, there are more symptoms here than just the one that would be caused by the medication. Always suspect menopause is somewhere playing a role in a woman who is of menopausal age. There is no harm. Therefore, in trying non HRT or HRT, the intervention as a therapeutic trial for six months, you just use low transdermal HRT, you're not going to harm yourself, but you will come to know in six months how much of your symptoms were because of hormones because you will start feeling better if not hormones are not, ah, and would that be something you could go to the GP? And the GP should be comfortable with that. Yes, most GPS are now accessing good training from BMS, from Frh, from International Society. We see more and more GP S now confident dealing with even some of the relatively complex menopause scenarios. So, yes, and if you've not got any particular, uh, specialist GP in your surgery, you can always have access to a referral to a specialist. Brilliant. Now, there's more questions coming through. So I'll take us to the next one. If someone's had no menstruation for under five, for five years, they're under 60 with a history of hot flushes, mood swings, joint pains and a fall with a fracture and pain which prevents sexual intercourse. Could H RT be prescribed? And would it be again, I wouldn't be able to give individual advice because I think what you're describing is typical menopausal symptoms. You will benefit very much from HRT, whether it's vaginal estrogen or a combined systemic HRT. You must see your healthcare professional, it's very likely you will benefit from it. Yeah. Yeah. Brilliant, brilliant. And I've got another one. I didn't mean that to sound so specific. It was just, you know, for somebody in that, in that way. Sorry about that. Now does happen. Oh, we've got them flying through does have gyne problems for things like endometriosis or Polycystic ovaries. Does that influence the ma the age of menopause at all? Yes. So the age of menopause will be influenced by PCO S. Remember PCO S is a condition with more follicles, more hormones. So naturally you find that the age of menopause tends to be pushed by about 2 to 3 years. So an average age of menopause will be delayed with PCOS endometriosis on its own, doesn't do, that doesn't affect the age of menopause. But because endometriosis often gets treated with surgery, a laparoscopy to take the endometriotic bits away from ovary. Often that reduces the ovarian and hormones and you can end up having a bit of an early menopause because there has been interference surgically with the ovaries. Now, before I move on to another question there, I'd like to take you back to an earlier slide that you had and it was when you were looking at the age of onset of menopause. So you had uh the age of women in, in the, the Caucasian women in the UK versus women from India. And that's five years difference if uh what am I trying to get to is that replicated? So, so, so women who are Indian in the UK, are they likely to have an earlier menopause? And, and, and if I get to those sort of, if I think of other elements of health care and the inequalities that sits there with my public health hat on. And do we know that there is a, a real challenge and discrimination around women who are women whose ethnicity might put them more complications. And earlier men, I think it's an important point you raise. So we do know that the research in say Southeast Asian women or Afro Carribean women or South American women is very poor and most of the research into menopause and a charity has happened in western world and Caucasian population, what we know is Indian women in the UK follow a similar pattern. They do tend to have an earlier age at menopause, an earlier decline in their ovarian number of follicles and it comes to fertility. And so it looks like this is ethnicity or genetics that's playing a role more than the environment. But the data are so poor. We really need good studies in the minority population in different ethnicities to be able to recommend some specific HRT or medications that are tailored to them. That's going to be the work for the next 5 to 10 years and those studies are underway some of them. Yes. But there's plenty more to do. Yeah. Yeah, absolutely. I'm sure. So, um, a practical question now for, uh, if people for, for women who get skin irritation with the patches other than switching to another route, you know, is what can I do to help that skin irritation? Will you always get itchy if you do it? If you, you know, I don't know if you put the patches, the patches are designed to be put below the belly button. So you can use the tummy, you can use the thighs for putting on the patches if try and persist with it. Often women report that when they get the initial red reaction after they keep using the patches for a few weeks or months, actually, the skin does get used to it and you'll find the reactions. Go away. Try and move the area of the patch a little bit. So if it's a minor irritation to start with, just put the patch next to it in a, in a less irritated or less red area. So you can use the tummy for a week. The thigh is outer aspect of thigh for the next week. The inner aspect of thigh for next week, just keep circulating the area. If you've done this for 3 to 4 months, try different brands of patch. You have, you have Estradot, you have Estraderm, none of them are working for your skin. Then unfortunately you will have to change to a spray or a gel. Uh, but most women will find that if they circulate. If they rotate the area, use a different brand, you might just get away with the irritation you're getting and you might, I guess you might have people who are also like, some people are allergic to sticky tape plasters, all of that. Then then maybe they're more likely to be, um, you know, whether there's a lot of mast cell activation disorder out there. So you'll know if you're, you'll know if you're irritated or not by different things. And so, um, yeah. No, no, I, again, I'm not a, I'm not a catch person. So, um, so I, but I would like to know what, what below the belly button is that? Because there's, there's a, maybe a little bit more flesh and a little bit more meat for it to stick to. Is that, is that why it's below the belly button? Well, no, the simple reason why it's below the belly button is, is, is because the trials did it that thing. So it's a scientific, it's more than a, it's, it's sort of less than less scientific and more of the way the trials were done, all the patch trials were done with putting the patch below the belly button. So when they study it that way, that's all they can recommend it in a way. It makes sense is you don't want to get the estrogen too close to breasts. And that's one, another consideration is that if you put it on the upper aspect of body or closer to breast, although we know estrogen directly is not linked to any pathology as such. But again, if you put it locally, it might deliver a bigger dose to the breast and you want to avoid that. Yeah, lovely. So I we've got time for one more and we've just got one to come through soon, the slide will be up so the slide will be uploaded. Um But oh, I've got two. I've got two that's just come through one that's come through a message. Yeah, soon the slide will all be uploaded for you. You'll be able to pick them up another time. So two very quick ones. One, is there something we should know before recommending HRT to a patient with diabetes. Well, as long as the diabetes is well controlled, you have to make sure what complications the patient has already had. For example, if a patient is poorly, they have lots of cardiac complications, then you need to be careful about prescribing HRP, not that you can't, but the benefits may be little. And so you have to weigh is the patient really going to benefit from HRP if they've got lots of medical complications. If yes, then yes, you can still use low dose transdermal HRT for other patients with well controlled diabetes. No major complications. The HRT advice doesn't change. Absolutely. Go ahead and prescribe if that can improve their quality of life. So the last one now that's come through and it's come through a different route because they can't post in the chat and fibroids. If somebody's had fibroids, can they have HRT, yes, if you've got fibroids, you can have HRT, remember, HRT gives estrogen progesterone, both hormones can increase fibroid size. Overall, our experience is if you have a fibroid and you take HRT, it probably won't change in size over the years, it will stay the same. Some fibroids may actually regress. Uh although you're taking a charity, they'll become smaller. Some very few fibroids may grow. If you're very sensitive to the hormones they may grow. So, if you, what I do is if you've got a sizable fibroid close to five centimeters or more. I always recommend do a scan in six months or a year to assess how much your fibroid is growing. If it's not growing, you can leave it alone. If it starts growing significantly, you might need to rethink the dose of HRT or sometimes even remove the fibroids and then go back with HRT. Brilliant. Now, our last question has just slipped in and I think it might be a simple. Yes. No, I'm not sure. Does H RT increase weight gain? This is a very common one and often HRT is promoted as one of the ways to lose weight at menopause. The midlife weight gain. That happens for most men and women. The association of HRT with weight gain doesn't stand. So a lot of women on HRT lose weight, a lot of women don't change their weight and equal number of women can gain weight. So HRT on its own doesn't cause weight gain. It may cause a little bit of fluid retention, a kilo or two increase in your body weight temporarily for the first six months after which that fluid retention will go away. Brilliant. And so I just let that last question come in. So we are now there a absolute huge. Thank you Vikram. And this has been and I've learnt lots. Um and it's been really good. The comments and the questions have been fantastic. I think lots of people have joined for themselves. And also we will be passing it on to our daughters, granddaughters and our patients and our relatives and everybody. It's fantastic. Thank you for all the kind help.