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Yeah. Can I just check, can you hear us? Ok. Yeah, someone can type in the chat to check that they can hear us. All right. And I need to do what? So put myself appropriate things, ho ho and um you need your 10 screen. Um I think we can. Oh, maybe no, I think it will just on this week. Yeah. And then if you the hours on the bottom side just go along here as it is, right? Ok. Should we make a start then? Ok, fine. Um Cool. Right. Um Well, thank you uh for Sarah for the invitation to be here this evening and thank you to you all for coming on a horrible November evening. Um I am Lucy New Croft and um I work as a salary GP internationally. Um I am also a British Menopause Society, accredited Menopause Specialist and also a mentor for thera on their menopause mentoring program. So today really is a kind of introduction to menopause. Really. Um I'm sure you're aware of all the media hype around it. Um I don't know what specialties you're in at the moment, but certainly if you dip a toe in general practice. We're drowning under menopause. So I'm sure you will get exposure to it in that. And, you know, it's, it's relevant to everything. If you're an orthopod and you've got a woman coming in on patches, you need to know how to manage her if you're a medic and you've got somebody with hypercholesterolemia, you need to know the impact of HRT on that. So, um, you know, 51% of the population will go through menopause at some point. So it is a big topic and uh you know, I think it's good that it is getting the attention that it deserves at the moment. So basically this evening, um we just want to sort of go through and talk about how to assess women um with symptoms of perimenopause and menopause. Talk about the non hormonal options for management. Discuss the risks and benefits of HRT, explain how to use a different HRT preparations. Talk about the management of genitourinary syndrome of menopause and also touch on the contraceptive needs of perimenopausal women. Ok. So we're gonna break it down into a few sessions. Um Based the introduction of what is menopause. Then we talk about the symptoms, then we talk about GSM, then contraception sort of plan a break kind of in between the, the treatment and the GSM bit because the treatment it's quite weighty. Um So, uh we will have a sort of 10 minute break then if, if you're flagging, um and then come back. Ok. Um, questions ask away. Um You know, if there's anything that comes up, just stick your hand up and we'll answer them as we go along and anything we haven't covered, we will mop up at the end of the session. All righty. So what is menopause? You guys probably remember more about this than I do. Um But basically, um, during men when you are born, female, you have a finite number of follicles in your ovaries. And as they mature through puberty, they release an egg every month which drives the menstrual cycle. Um during perimenopause, the number of follicles becomes depleted and this results in a fall in the production of estrogen and progesterone. This then removes negative feedback on the pituitary and causes an increase in FSH and LH levels. As you can see from the graph here that your progesterone and estrogen levels rise as you go through puberty uh to me and then they're pretty constant during your fertile years. Obviously, you have the monthly fluctuations with the menstrual cycle, but generally, there's not much difference um in the levels through that time. And then as you get to sort of your mid thirties, your progesterone level actually starts to fall away um quite gradually. Um And then a couple of years, about 5, 10 years later, your estrogen level starts to dip. But unlike progesterone, which does this nice kind of fall away, it does that and that's why you get all the symptoms you get with it. Um And that can go on for several years with this sort of hormonal storm if you like until you hit menopause and then they, the levels flatten and you can see from here, post menopause doesn't mean you have no estrogen at all. It just means you have less than you did beforehand. And so, uh that's what causes a lot of the symptoms that women experience. So these hormonal changes then mean that the uterus is no longer reliably stimulated to shed the endometria monthly as a period, which causes irregular periods and sometimes heavier periods until eventually periods stop. So we talk about menopause, but actually, there are three distinct phases of menopause. Perimenopause is that time from when women first notice symptoms um until the diagnosis of menopause and the average age for the start of perimenopause is 47. But I know I'm seeing women in their early forties. Now presenting with symptoms, which may be related to perimenopause. Menopause itself is actually a retrospective diagnosis and literally means cessation of periods. Um And you can only diagnose it 12 months after your last period, assuming that you're not on contraception, you have no hysterectomy other things. And then that post menopause period is everything after that last menstrual period. Now, in generations gone by women would have their menopause in their late forties and life expectancy might be 6065 if they were lucky and that was it. But now with life expectancy increasing and also menopause happening at a younger age, then women are spending up to a third of their life in their post menopausal state. And that has implications for their cardiovascular health, their bone health and other things. Ok. So menopause ie, the cessation of menses usually occurs in the UK between the ages of 45 and 55. The average age in the UK is 51. Um And by 54 80% of women will have stopped their periods. That does mean 20% of women will still be having periods beyond 54. And that can sometimes cause a bit of confusion because then you're not quite sure if they're having irregular periods. Is it pathological or is it just normal, um sort of ending of their, their cycle? And then there's a special category of um women who have surgical menopause where they are basically thrown headlong into menopause after having oophorectomy. And sadly, a lot of women aren't aware of this prior to having surgery or at least they don't remember anything about it and also are not always brilliant at giving them HRT to come out with either. So you get these women who have hysterectomies, oophorectomies and then wake up with flushes, sweats, everything else like somebody has flipped the switch and then sort of filter through to you several months later because they're feeling crap. So normal menopause occurs after the age of 45 if it occurs between 4045 we call it early menopause. And that affects about one in 100 women and then premature menopause occurs when periods stop under the age of 40. And that affects one in 1000 women and is termed premature ovarian insufficiency. And these women, it's important you diagnose them because obviously, if their periods are stopping in their twenties and thirties, they've got an extra 1015, 20 years of estrogen deficiency. So they need to be identified, diagnosed and treated promptly to reduce these longer term risks to their health. So I'm sure you're aware of the kind of headline symptoms of menopause, the hot flushes, the sweats that you know, they're the things we hear a lot about brain fog is seems to be overtaking everything. Everyone's got brain fog at the moment. Hopefully, you can see from here. Actually, there are a load of symptoms which might be related to menopause. And the difficulty is a lot of these things have a lot of overlap with other conditions and also with life. So it can be really hard to pick apart what's due to perimenopause menopause, what might be due to other things, what might just be due to, you know, working full time raising a family, running a house, having elderly parents. So it can be a challenge. And I think it's important to explore all of this with women when they present. There are some red flag symptoms which you don't wanna just attribute to menopause and ignore. So, if a woman presents with new onset heavy bleeding, especially if she's over 45 you want to investigate that and exclude any underlying endometrial pathology. If she's got postoral bleeding, that's not a typical menopause symptom. And you wanna check her cervical screening history, examine her and refer her off to colposcopy bloating. I'm sure we're all aware is one of those nonspecific symptoms which can be associated with ovarian cancer. And we all know how difficult that is to pick up early and how a late diagnosis often means a poorer outcome for women. So, any bloating don't just think is menopause. Do you see a 125 check? And in fact, the talk recently, um, it was suggested that if you're referring a woman with gi symptoms and the pain, a bit of change in bowel urinary symptoms, if you're going to be referring her to colorectal for a fit test, do a ca 125 as well because she might have ovarian pathology. And by the time the bowel team have gone through their investigations, her ovarian disease is spreading. So check a ca 125. It's not a brilliant marker. Lots of intraabdominal pathology can cause it to go up. But if it is raised, you at least, then might consider ovarian pathology as a cause for it. Certainly fluctuating progesterone can be associated with bowel symptoms, but new onset bowel symptom symptoms persisting for six weeks, need investigation in their own right as well. Ok. So there are various symptoms scales and trackers available. There are lots of apps women can get Balance app is one of them. Um, this is one from, um, Rock My Menopause, which is a good website to refer women to for information. And the green climacteric scale is one that's been around forever and it just helps women to kind of hone in on what symptoms are bothering them. And it can also be useful to check response to treatment as well. So how long do symptoms last? And women will always say, ok, well, how long is this going to go on for reality is I have no idea. Um, 18 to 90% of women will experience symptoms of some sort and they will typically last for 2 to 5 years and average duration being four years, but 10% still have symptoms after 15 years and if they're still ongoing, then they are likely to be for the rest of their life. So I see a lot of women who missed H RT last time when they were going through their menopause because it coincided with the, the million women study and um, the women's health initiative and all the adverse publicity around it. And now they're coming because they're still having symptoms that they had 1520 years ago. Um However, if they had symptoms 1520 years ago and then they got better and now they've got new onsets of flushes and sweats and things like that. You want to look for other underlying causes for that and not just think. Oh, it must be menopause. Yeah. Just a quick question. What was the million women? So, we come on to that a bit later but back in 2000, um, I remember it. You won't. Um, There was um H RT, basically, there was a huge media ferro about how dangerous H RT was um is associated with increased risk of breast cancer, increased risk of cardiovascular disease. And it was based on two studies with huge numbers of women. One was the million women study and one was the women's health initiative. Both of these studies were flawed, they were published before they'd actually been properly reviewed. So they just picked up different bits and published them. Um And um actually when you look at the women that were involved in these studies at the time, they were largely in their sixties. So not a target HRT group, a lot of them had other risk factors like um hypertension, obesity, they were smokers and also the HRT we were using at the time, it was different to what we're using now. So it was a lot of synthetic hormones that were being used, things like Premarin, which is derived from pregnant mar's urine. Um So, you know, these were riskier preparations as well. And if you like it was a perfect storm of having women with other risk factors who were outside the target range and giving them synthetic hormones did cause increases in heart disease, breast cancer. What I would say about them is that although they've largely been sort of discredited for those findings, the women involved in them have been followed up over the 20 years since. And a lot of the data we have about the safety of H RT. Now, in terms of cardiovascular risk comes from following up the women in these original studies. So although initially they kind of brought H RT crashing down and women came off in drove. Then the follow up data actually is supportive of its use now. OK. Um So yes, so some women will still have symptoms for a long time and 25% of women will describe their symptoms as severe or debilitating. So, you know, this isn't just something to dismiss. Some women really, really struggle some quotes from women um about the impact of menopause. Um I lost my job. I was medically retired. I was devastated. I was worried it was the early signs of dementia and I hear that a lot. My husband doesn't understand what I'm going through and I thought I was going mad and the menopause nearly killed me. And it's no coincidence that the peak in the peak incidence of suicide in women is in the 45 to 55 age group, menopause obviously has a huge impact in the workplace as well. Uh 14 million days of work are lost every year due to symptoms of menopause. But if you look at the sick papers, they're not gonna have menopause on, they're gonna have fatigue, they're gonna have a stress related problem. They're gonna have anxiety and depression on that. And actually, if we were honest and sudden witnesses menopause, then perhaps, you know, it, employers and other organizations would be more sympathetic to it and realize how big the problem actually is. 10% of women actually give up their jobs due to their symptoms of menopause. And you know, these are women at the top of their game. They're, you know, they're your chief execs, they're your partners in law firms, they're your bankers and they just cannot function and they leave their jobs fortunately with all the changes and the publicity. Recently, lots of employers now have menopause policies and lots of institutions have menopause policies for staff. And you can get further information on these from the Faculty of Occupational Medicine. You can also find information in unison and United as well. Have got good information on menopause in the workplace and policies for, for companies to follow. Cultural factors are important in menopause, not everybody is the same. Um Women from different ethnic backgrounds may show different symptom patterns and it's recognized that women from Southeast Asian backgrounds tend not to have too much in the way of flushes and sweats, but will often present with fatigue and joint pain, which if you're not thinking of menopause will lead you down that rheumatology route of doing lots of blood tests and x rays and referring on when actually, it may be menopause. Now, that's not to say that you say, oh, it's all menopause and ignore some rheumatoid arthritis or something. But just keep it in mind that actually, could it be this by all means, do the test but think what could it be this, you know, women from a Carribean backgrounds go through menopause at a younger age and also have much more severe hot flushes and sweats. Um So again, being aware of that and supportive of these women, obviously, this can make recognition more difficult and may lead to lots of unnecessary investigations while symptoms remain untreated. And in some cultures, menopause is taboo. You know, women's health, generally, sexual health isn't talked about and some languages don't even have a word for menopause. So how do you talk about something which doesn't exist in the language? So, in certainly certain groups, it's really difficult and um just to be open minded and consider, could this be menopause? So how do you diagnose menopause? Well, you could probably get lots of women come to you saying I want a hormone test or I bought a hormone test and actually there is no good test to diagnose menopause. If a woman over 45 is presenting with uh pha of moor symptoms, hot flushes, sweats, menstrual irregularities, you can be pretty confident that this is likely perimenopause. Also, if she's not at a period for more than 12 months and is non contraception, then you can be confident that what she's going through is menopause. Nice guidance does suggest that you might want to check an FSH in women between 4045 with symptoms. Although when I check it, it always comes back normal. So I check it less. Now. Um, you know, it will only be raised if they are actually post menopausal and by then they're gonna stop their periods anyway. So it's not a really helpful test. It is useful though, in women under 40 where you'll suspect premature ovarian insufficiency. So, women under 40 presenting, particularly if they've got four months of amenorrhea and not on hormonal contraception associated with hot flushes and sweats, then do an FSH. And if it's raised, repeat it in 4 to 6 weeks, we traditionally say that periods of funny things, everyone gets really fixated on this 28 day cycle and if it's less or it's more, it's wrong and there's something going on and, er, and they get really stressy about it, but normal cycle is anywhere from between 24 to 42 days. So, anything within that is still considered normal and sometimes you'll miss a period and it's not because you're pregnant. It's because that's just what happens or you're stressed or you're ill and you just won't have a period that month. And traditionally, we say, well, we don't look to investigate causes of a amenorrhea until they've been six months without a period. But if they've got flushes and sweats, you'd investigate it at four months because you wanna pick up these po i patients. If you do pick up ap patient, they need to be referred to specialist menopause clinic or specialist endocrinologist, whoever locally is running the service for these women because they need Dexa they need um they need hormonal treatment either in the form of um combined pill if appropriate. And some women prefer that to HRT or they need to be started on HRT and they need to continue it until they're 50. Um good. Uh Yeah. So FSH, if you're going to test it, ideally, you need to do it on day 2 to 5, their cycle, that's easier said than done if they're having irregular periods. And if you've got to wait two weeks to get an appointment for a blood test, so when you can is reasonable, but ideally day 2 to 5 and if it's greater than 30 it does indicate the degree of ovarian insufficiency. You need to repeat it 4 to 6 weeks later and you need to be mindful that some things will affect the FS H. So you can't check an FS H if A woman is taking combined hormonal contraception and you can't check it if she's on HRT either. So, if they're on either of these treatments, they'd need to stop the method for six weeks and then check it. Most women on HRT do not want to stop their H RT for six weeks so they can check a blood test. Ok. It's also affected by depo as well. So if you're gonna check it on someone on depo, you need to do it at the sort of 1011, 12 weeks during the trough level, rather than when they've just had it. Otherwise you'll get, um, skewed results. You don't have to do investigations on a woman with menopause. If you're confident in your diagnosis clinically, then you can go ahead and manage it. But there are some tests that you might consider in some circumstances. So a woman who's coming in with heavy bleeding, you might want to check a full blood count and a ferritin in her. If she's complaining of fatigue and lethargy, then you check thyroid on her, need to check ABM and ABP for baseline, particularly if you're gonna go down the H RT route with them. And you know, a lot of these women are generally fit and healthy and don't see you very often as a GP. So while they're there, you might want to think about offering them a lipid profile and HBA1C to screen for diabetes as a bit of sort of health promotion and prevention. Um You don't need to do a breast or a gyne examination on them unless there's clinical indication to do so. But it's a good opportunity to check that they are up to date with their cervical and breast screening and encourage them to make appointments if they're not. And then as I said, if they have got poi they're gonna need a Dexa as well. Ok. Any questions on presentation or diagnosis of menopause? Sorry. Yeah, good. Um You mentioned that if they have the depo it can sway the FSH. Is there a pa which sways it or is it just it uh it causes it to only remember now um it causes it to be falsely elevated. So you get the negative feedback. So yeah, so it'll come back raised because they've got depo which is suppressed on the FSH. Sorry. It was just, it was just causing the FSH to go up. Yeah. You know, with like the combined pill with that. Um I think it like stops the release of an egg. Does that mean that it preserves your egg and you'll maybe go through menopause later? Yeah. No, because it's more to do with the kind of the quality of the eggs and over your lifespan that diminishes. So if you're on the pill and you're suppressing ovulation, it doesn't mean that you kind of store them up for later and you'll go through later. Menopause the quality just depletes anyway. So it doesn't affect when your menopause starts. I just a quick ask what depo is. Sorry. Depo Provera um is contraception injection? Yeah. And the same applies to Cyana Press as well, which is the subcutaneous version of it. Ok. So treatment of menopause symptoms. So there are several options to consider when talking about management of menopause symptoms, um broadly described as lifestyle factors, herbal and over the counter treatments, nonhormonal prescribed treatments and then H RT. So regardless of what else a woman may be interested in for her menopause, it's really important to talk about lifestyle factors with her because there's evidence that certain things will make symptoms better or worse. So women should be encouraged to maintain a healthy weight because being overweight causes more problems with flushes and sweats. You should be encouraged to exercise regularly, not just for their men, of course, but for all the good things that exercise does. And by that, we're talking about their 150 minutes of moderate intensity activity a week and also doing strength training at least twice a week as well because once you hit 40 your muscle bulk diminishes by 10% per decade and that accelerates after menopause as well. And obviously, if you've got sarcopenia that's going to affect your metabolism, it's going to affect the integrity of your joints. So encouraging them to do strength training a couple of times a week as well as the cardiovascular stuff. It weight bearing exercise is also important for prevention of osteoporosis as well. So it's great if they love cycling and swimming, but they actually need to be getting impact through their joints in order to support their bone health as well. Practical things like keeping the body cooler. So, you know, wearing layers, they can take off and put on again. There's lots of menopause clothing you can buy now, which is targeted um to help some women find it useful. But I think basically, if you wear natural fibers, then you're, you're doing the right thing and try to avoid triggers for hot flashes. Some women find that caffeine or alcohol will bring it on. So try and avoid that spicy foods, things like that. So if they recognize something is making it worse, try and encourage them to limit their exposure to it. There's a lot of um sort of uh research around the mind and body aspect of menopause management. There is good evidence for cognitive behavioral therapy for hot flushes and sweats in menopause. And in fact, the new updated nice guidance puts a lot of emphasis on CBT for menopause. However, if you can find somebody who can do CBT for menopause locally and you can refer your patients to, then let me know because I am, it doesn't exist. Um There is however a really good book called Living Well Through Menopause, which was authored by Myra Hunter who is a psychologist in Kings who did the men Os trials into CBT and menopause. Um And I recommend that to all patients because it's very much focused, not only on the CBT side of it, but also a lot of the kind of non drug treatments of it as well. And it's, there are little exercises in there that patients can work through as well. There's also some evidence for hypnosis in management of hot flushes and sweats and pace breathing as well. The jury is out on sort of yoga and acupuncture. Again, there's not huge studies in it, but some women find it helpful. Some women find it doesn't make any difference and an emerging sort of treatment is cold water swimming. Um, and lots of women who do it find it does help with their symptoms. Again, we haven't got randomized controlled trials for it. Um If you go into any pharmacy or health food shop, there are shelves of menopause products. Um, whether that's herbal stuff, whether it's vitamins and minerals, you know, the market is awash with them. And as clinicians, we're never gonna know enough about them to be able to, to recommend them with any kind of conviction. Um But there are some that, you know, are commonly used and there's a misconception that actually because they can get them off the shelf and they're herbal and they're natural, then they're safe. But actually, that's not always the case that cohosh is some evidence that it helps with hot flushes. Um but not particularly with mood and anxiety, but it's also an enzyme inducer and interacts with other medication. And we're not sure of the risks associated with that, particularly it can be associated with liver toxicity as well. And I've got a colleague who's a menopause specialist to women with liver um failure thought to be due to black cohosh. Um So, you know, it, these things aren't as safe as people think they are Saint John's Wart. We often ask about contraception because again, it's an enzyme inducer and interferes with hormonal contraception. It can help with hot flushes and mood. Um and it can be useful in women with a history of breast cancer, but they can't take it if they're on tamoxifen. And again, there's interactions with other medications as well. You then come on to your sort of soya products and your isoflavones, your sort of phytoestrogens, Red Clover, um soya, these sorts of products. Um Red Clover, they found Red Clover was effective because it stimulates breast tissue in cows to produce more milk. So cows who eat Red Clover make more milk. Now, if you're taking something because you don't want to take hormones because you're worried about your breast cancer risk, you don't really want to be taking something that can potentially stimulate your breast tissue either. So again, it's this kind of just because it's on the shelf, doesn't mean it's without risk. And again, for that reason they're not recommended in women with a history of breast cancer. On the soya side of things, you'd have to eat a skip full to get true benefit in terms of your symptoms. So, you know, it's all good well and good as part of a whole food plant based diet. But if you're taking it to treat your medical symptoms, you're not probably going to get huge benefit from it. And then things like ginseng Chinese herbal medicine, there's no evidence really that they do anything for anything. But again, you know, some women will take it and they will swear by it. I've got a patient who thinks Agnes Cast, this is the best thing in the world um because it's sorted all her symptoms and she feels great on it and good for her. But other people will take it and they'll be like that doesn't do anything at all. So, you know, it's it as a doctor, you're supposed to know everything about everything. But the reality is a lot of this stuff. Certainly we never got any teaching on it when we were students and I doubt you get a huge lot of it now either. However, 95% of women will try these alternatives um to HRT, either because of concerns over the safety of HRT because they've got risk factors for um using hormones or because they prefer to try the natural option. So when those things don't work, they will often come and see their GP looking for other treatment options and there are some non hormonal treatment options which for women who can't have hormones or don't want hormones may be appropriate. There's a lot of, sort of, um, one of the things nice called up and was very clear to say was that antidepressants are not first line treatment for menopause. And this was back in the original guidance in 2015. But actually, you know, some women are dismissed, they go and see the doctor. They're feeling anxious, sort of skip over the fact their periods have become a bit irregular and they're not sleeping and they're getting hot flushes and they stick them on FLUoxetine and send them away. So yes, some people are treated inappropriately with them, but for other people, they may have a role to play. And certainly there's evidence for venlafaxine, paroxetine, FLUoxetine and Citalopram in the management of hot sweats and also in management of mood as well. Um However, having sat through a talk last week from a psychiatrist in London about antidepressants, I think we need to be very careful in prescribing these because these are also not clean drugs. Um And they have, sorry, no, it wasn't. It was a guy whose name, I forget he's Australian guy. Um but yeah, um he was talking about the MG deprescribing guidelines and I think it's fantastic you have guidelines on deprescribing because for years we just give more and more drugs. And actually, now there's a whole book on how to not give these drugs anymore. And he was saying that all the evidence that says, you know, coming off antidepressants is easy is in patients who've only been on them for six months. And we haven't got the evidence for patients who are on it longer. And then, you know, we always say, oh, well, when you come off them, you've got to come off it slowly. And he, we sort of go from like 40 to 20 to 10. And he's saying like, you reduce it by 10% of the previous dose. And so you might actually take 23 years to come off it, which we don't tell patients. And I guess a lot of us aren't aware of, but certainly it made me think, oh, you know, maybe we do give these out a bit too easily and maybe we don't give patients enough information. And the M hra earlier in the year um produced a statement about the impact on sexual dysfunction with SSRI S. And we have to advise patients of this now because in some patients, it's irreversible. So, you know, it's really sort of eye opening um here. So yes, it may help with brushes and sweats. But, you know, you've got to have these conversations with patients and paroxetine and FLUoxetine can't be used in women who are on aromatase inhibitors um for breast cancer either. So you think, oh, they've got breast cancer. They can't have hormones. Stick them on an SSRI, you can't, um, cloNIDine. Good old cloNIDine. I don't think anyone uses cloNIDine, but it is the only drug that non hormonal drug that actually has a license for hot flushes. It's been around for ages. It's an old antihypertensive. We don't really use it for that either. But some women may find some benefit for hot flushes, gabapentin. There's some evidence it helps with sweats and flushes where I work in, it's a wash for gabapentin and, you know, we are being actively discouraged from prescribing it for anything. One of my colleagues in the menopause service and that's it. So I'll send patients to him where we're struggling to manage and they come out on gabapentin and then I've got meds management telling me to get them off gabapentin. So it is tricky. And again, you know, gabapentin has got nasty side effects with it. So you've got to counsel these patients about it. What has been gathering a bit of momentum recently is oxybutynin, um which, you know, traditionally is used for urinary symptoms, but actually, it is quite good for hot flushes. Um And I've got a patient I saw recently who came in with a full house of menopause symptoms, but also new onset heavy bleeding. And I said, look, we can't give you hormones until we've evaluated your endometrium and we need to get a scan done that's going to take 8 to 12 weeks. And she's like, well, I can't not do anything. I said, well, how about trying some oxybutynin because she was also having urinary symptoms as well. So, how about this? At least we're doing something, not thinking it was going to do anything. And then I spoke to her last week after she did a scan and, oh, scan is great. So, if you want to consider HRT, no, no, no. my symptoms are great. My flushes have gone, my urinary incontinence is gone. I'm happier. And so it's like, well, good. So, you know, for some women that might be a good option anyway, even if they could have hormonal treatment, it may be better for their symptom profile. There is sort of light on the horizon. Um in terms of newer drugs specifically for hot flushes and sweats because obviously gabapentin, oxybutynin antidepressants have not been devised with that in mind, but Follinett or Viasa got M hra approval at the beginning of the year and this is a neurokinin three inhibitor and this works on the sort of thermoneutral zone in the brain. Um and it's non hormonal. So it's a good option for patients who can't have hormones and from colleagues who are prescribing it, it seems to work really well and is well tolerated. We did all think brilliant, a new drug we can use in patients with breast cancer who can't have hormones, but of course, they don't have any data on patients with breast cancer because they weren't included in the study. So at its statins, the SPC says don't use it in patients with breast cancer. But that is the people that it is being used in privately and it is working well and it's gone in for nice approval. So hopefully it will become available on the NHS in the next 6 to 12 months. And then we come on to H RT. And in reality, most of the patients that come to see their doctors, nurses, pharmacists have come to see you because they want H RT. So the idea is that H RT primarily reduces estrogen and that's what makes you feel happy. That's what makes you feel good. But if you've got a uterus, you also need progestogen to protect it from the effects of estrogen. And some women also require testosterone and that's a real hot topic. So there are different types of hormone preparations and we touched a bit on this earlier about the um the million women study. So traditionally review synthetic hormones. Um So ethynyloestradiol, the estrogen that's in the contraceptive pill. It's synthetic things like norethisterone lasr are synthetic progestogens. But over the last 1015 years, we've had newer products come to market which are body identical, um or regulated bioidentical and these have licenses and they are derived from natural products. So, Soya and Yam and they are modified to be similar to ovarian oestrogel, sorry, oestradiol progesterone and testosterone as it is possible to be. So, all of the oestradiol preparations in H RT now, um are body identical and estin micronized progesterone is also body identical. It's, it's not now, the only one, it was for a long time, the only body identical progesterone. We've now got Grex, which is also available as well, which is also micronized progesterone. What you might hear women talking about is bioidentical hormones and these are the compounded bioidentical hormones that they might get private clinics where they take a little bit of this and a bit of that and a pinch of this and a Sprinkle of that and they mix it up and they tailor it to their individual profile. So a lot of women who are on social media or following celebrities may have this in mind when they're thinking of H RT, these products are unlicensed. Um and are not endorsed by the British menopause society because we don't know the safety of it. We don't know whether they've got enough progesterone to balance the estrogen in it. A lot of them use progesterone creams and there's no good evidence that they're absorbed adequately. So if a woman was bought bioidentical hormones, she can't get it on the NHS and you would try and discourage her from going down that route anyway. Ok. So this is talking about the, um the studies that we touched on earlier. So it was actually in the late 19 nineties. There were two studies highlighting safety concerns around the risk of breast cancer and heart disease. But the women were not your target population. They were overweight with other uh risk factors and it was used in the synthetic hormones in H RT. That's not to say that HRT is completely without risk. Um, no drug is and certainly HRT does carry a small increased risk of some types of ovarian cancer compared to women who don't use it. Oral HRT slightly raises the risk of stroke and blood clots. But transdermal HRT does not increase venous thromboembolism risk. And there is a small increased risk of breast cancer with combined HRT, but there's no increased risk of dying. And there's a nice chart that uh it's coming up. Yeah. Um from um women's health concern which talks about the risk of HRT and breast cancer because this is one of the biggies that women still ask about. So, in a population of women between 5059 the number of women who will develop breast cancer over the next five years is 23 regardless of per 1000 regardless of whether they have H RT or not, one in seven women will get breast cancer in their lifetime. And that rate increases with age. If all of those thousands of women went on H RT, there'd be an additional four cases of breast cancer. If they all went on estrogen only HRT, they'd actually be for fewer cases of breast cancer because it, we believe now that it's the progesterone in HRT that and indeed, contraception that is associated with the breast cancer risk and not estrogen. And actually, that's probably makes sense because historically, estrogen has been used to treat breast cancer. So, um you know, that's the sort of thinking at the minute, if these women 50 to 59 were on the combined hormonal contraceptive pill, there would also be four extra in cases of breast cancer. Reality is women who are 50 to 59 are not gonna be on the combined pill. So that's a bit of a, a not very helpful um thing, but it just shows you, you know, there's no difference between the pill and H RT in terms of breast cancer risk and we certainly don't get particularly hung up on breast cancer risk when we're starting women on the pill for contraception. And that's actually got synthetic estrogen in it as well. If women drink two or more units of alcohol a day, there'll be five extra cases of breast cancer. So drinking two units a day of alcohol increases your risk more than using combined HRT. If they're smokers, there are three extra cases of breast cancer. But the biggie really is the BMI because women with a BMI over 30 there will be an extra 24 cases of breast cancer. And if you think H RT gives you four extra cases, obesity gives you 24. So it's a good opportunity to have a chat with women about this as well. The bottom one shows that those who exercise regularly, actually, there are seven fewer cases. So another good reason to, uh, to get them moving. The, um, there is a, a slightly different chart, um, which has come out in the last few years from the primary care women's health forum, which is available online and that sort of Strat um breaks it down into the different age groups. So if you wanted a breakdown of it, then that would be the place to look. So, yes, HRT has risks but it also has benefits. And nice guidance is very clear that HRT is actually the most effective solution for the relief of menopause symptoms including hot flushes, but also the other symptoms, you know, your brain fog your anxiety, the depression, the urinary symptoms, the joint symptoms. And it may also reduce the risk of heart disease, particularly in those women with early menopause premature ovarian insufficiency. It does reduce the risk of heart disease, it protects the bones and reduces the risk of osteoporosis. There was a thought that it might protect against dementia, but the jury is very much out on that because there are a number of studies which give conflicting views. Some say it does reduce the risk. Others say it actually increases the risk. So if you've got a woman coming to see you about starting HRT to reduce the risk of dementia and that's all then it it is in appropriate. So the benefits and risks of HRT should be discussed with all women. Take it into account their age, their medical history, risk factors and personal preferences for the majority of women. The benefits of short term use of HRT outweigh the risks. HRT is the treatment of choice for osteoporosis prevention for women who start treatment under 60 especially for those with premature menopause or poi. And for some women, long term use of HRT may be necessary for continued symptom, relief and quality of life and the dose of duration of treatment should be made on an individual basis. So we don't say anymore that, oh, you can only take it for five years or you can only take it if you're 55 women need an annual review, but then it's up to you and them to discuss. Do they continue? Do they come off it? And when it comes to coming off, it, it doesn't much matter whether they decide to cold turkey and just stop it completely or whether they decide to reduce it gradually. Um Obviously, when they stop it, they will get some recurrence of symptoms because obviously they're no longer taking their H RT, but very often these will settle down and you just need to encourage them to, to pursue if that's what they want. Having said that I've got women in their seventies and eighties who have been on HRT forever and are not coming off at any time soon. Um And that's their choice. What you wanna do in those women is make sure that they're on transdermal, which is the safest in terms of stroke risk and BTE risk and also on the lowest dose cos a woman in her eighties does not need the same dose of estrogen as a woman in her forties. So they might be on a pump of gel, they might be on half a patch, quarter of a patch even. So if you're gonna prescribe, HRT, what do you wanna know when you're gonna take a history? And you're gonna pay particular attention to their personal history, particularly of breast cancer, migraine BTE cardiovascular risk factors. Yeah. When you say risk factors of breast cancer, is that a family history of breast cancer? And if so is it in like a certain age bra? Because I know sometimes we don't consider people over 65 as family risk? Yeah. So um with breast cancer, obviously their personal history of breast cancer, but also family history of breast cancer. Generally, if a woman is diagnosed with breast cancer under 40 that's likely to have a genetic element. So she says, oh, my sister had breast cancer at 36. If she hasn't already been referred, she needs to be referred to the cancer genetics service to stratify her risk. If she said, oh, my mom had breast cancer in her fifties, that's more likely to be sporadic than genetic. And so that doesn't significantly increase her risk above the population baseline. But there are different tools you can get if you wanted to go through a woman, her a particular risk, but generally one first degree relative with breast cancer over the age of 40 certainly over the age of 50 you wouldn't be worried about that. You know, if auntie Nelly had it in her seventies, that's fine. Um, but if her mom and her sister have had it and they were, you know, around their forties or certainly under 40 then you would, you would exercise caution having said that that isn't a contraindication to H RT. Um, but you just need to have that discussion about the increased risks associated with it. Um You want to check her menstrual history, you know, when was her last period? If it's more than 12 months ago, she's postmenopausal. If it's less than 12 months ago, then she's perimenopausal. Um, you're looking for new onset, heavy menstrual bleeding, interco, intercostal, inter menstrual bleeding and postcoital bleeding. Um, and you want to investigate those again, family history, breast cancer also vte risk again. You know, if, if somebody had a, a DVT in their sixties, that's fine. If you know, mum had one in her thirties unprovoked, then you'd be thinking, oh, maybe there's something here, but transdermal would still probably be safe in those women because it doesn't increase their VT E risk above their background risk. So they might have a slightly increased risk because of their family history of VT E. But HRT doesn't increase that risk any further for them. Also gonna check their screening history. Their smears and mammograms are up to date and as we said, ABP and ABM I for baseline contraindications to HRT, these are the kind of the, the black and the white of it. In reality, in medicine, there's a lot of kind of gray. Um So, you know, patients, oh sorry, patients with um current past or suspected breast cancer would be a contraindication. There are women who've had breast cancer who are on HRT. Um but that's under specialist advice and discussion with their oncologist, their breast team and things like that. But I think in those women, it's useful for them to know that actually it's not completely off the card. So that's not to say that, you know, your average GP is going to prescribe it for them, but just for them to know that it might be an option for them if they're really struggling. Any other known or suspected estrogen dependent cancers, undiagnosed, vaginal bleeding, untreated, endometrial hyperplasia, talks about previous idiopathic or current vte. Again, if she's anticoagulated, that's fine and transdermal doesn't increase the risk. She had recent active um arterial thromboembolic disease, acute liver disease with abnormal liver function tests. And if you can find a liver specialist to tell you, what abnormal liver function test would impact on HRT you better than me because they all kind of dance around it. So, if they've got hugely deranged LFT S, you're probably going to be a bit more cautious having said that transdermal bypass is hepatic metabolism. So it may still be an option for them pregnancy. Obviously, they're not going to need HRT and clotting disorders. But again, we talked about um transdermal and then some cautions, you know, porphyria, diabetes, risk factors for vte history of endometrial hyperplasia, migraine, migraine, like headaches, increased risk of breast cancer. What's important to know is that the hormones in HRT are different to the hormones in contraception. So a woman with migraine with aura might have been told she could never have the combined hormonal contraception, but she could have H RT because their body identical natural hormones. So one of the things to sort of sometimes you struggle with is when it's drilled into you about contraception and UK me and hormones and migraines and blood clots. When you then come to think about HRT, you have to kind of throw that out the window a little bit and learn it again. Yeah, it's a rare condition. Um, of some sort. Um Yeah, that's true. Yeah, we're all done there. You are that your expert. Um I've never seen it in 20 years but it flags up in all the time for a possible risks if you have contraception and things. But yeah, you'll have to have a look at you. Yes. Google it later. OK. So if you've decided this woman would like, or if this woman has decided she like H RT. And you've decided there's no reason she can't use it. What are you going to use when the most important thing to consider is, does she still have a uterus? Because if she does, she's gonna need progesterone. If she doesn't, you can go straight down the estrogen only route for her. And that might be oral if she's got no risk factors, that might be transdermal in the form of a patch of gel or a spray. If she does have a uterus, you then need to decide. Has she got a Mirena in because she might already have a Mirena or a lever cert or a Ben Alexa or a 52 mcg leaving a gastro system. In which case, that can be used as the progesterone component of her H RT for five years. So as in if it was fitted three years ago, she's still got two years where she could use it for H RT. The license for these devices for Mirena has recently been extent or the the license hasn't, but the agreement has recently been extended that Mirena can now be used for eight years for contraception. Um And Ben Alex and Leer can also be used for eight years or they, because they're the same devices actually with the same hormone in the faculty of sexual reproductive health agree that they can all be used in the same way, but it can only be used for five years for H RT. And the license for them is actually only four years and nine months. But it's accepted practice, they can be used for five years. So if she's got a Mirena in again, her, she's got inbuilt progestogen cover for her endometrium. So you can go down the estrogen side of it. If she's got a womb and she hasn't got a Mirena, you're gonna have to give her progestogen as well as her estrogen to protect her room. If she is perimenopausal, ie if she has not gone 12 months without a period, you are gonna need to give her cyclical or sequential H RT. She, we'll bleed on that. The bleeding may be unpredictable. If she's been 12 months without bleeding, you can give her continuous H RT if she's eight months, nine months, 10 months and she hasn't bled. You're in that gray area where technically she should probably have sequential H RT. But then she's not gonna thank you for making her bleed every month. If she hasn't bled for nine months. But equally, if you put her on to continuous too soon, she might get unpredictable bleeding and then you might end up having to go and investigate her for it. So you have to weigh up the pros and cons with that ok. All women should be changed on to continuous HRT after they've been on cyclical for five years because they need the endometrial protection. You get better endometrial protection with continuous and cyclical and all women should be on continuous by the time they're 5554. Even if they're still having periods because you need that continuous progesterone for their endometrium. And there are a number of different preparations available in the combined product. Um Yeah, that's, that's ok. Um Would you consider putting in a coil if someone instead of making them take? Yes. And if that's the common, yes, it would be wonderful if all women had a coil because not only does it give them contraception because just because they're perimenopausal doesn't mean they're not having sex doesn't mean they can't get pregnant. So it gives them a contraception. It also gives them their endometrial protection for their H RT. And also if they're struggling with heavy periods, it will help with their periods as well. So you'll get three in one with it. But despite Devina having one fitted live on TV, nobody wants them, you know, everybody wants H RT. Nobody wants a Mirena. So, you know, we, we're really big fans of Mirena and the other devices because, you know, for 1015 minutes of discomfort, having it fitted for the majority of women, you get potentially five years of endometrial protection, eight years contraception and if you're having it fitted for bleeding, you can keep it in until the bleeding returns. And if you're having it fitted over 45 you can keep it in until 55 for contraception. So it's a really good method. Now, Maga and she didn't help by talking about her experience. And, you know, some women will have a lot of pain during it, particularly if they've got other conditions like endometriosis, adenomyosis, things like that. But most women and I haven't fitted them for a few years since I was in sexual health. But when I was fitting them every day, most women had a bit of a discomfort and that was it. You know. So I think nobody ever tells you when something goes, well, nobody goes on for it and say, hey, I had a Mirena. It's amazing. They all go, oh, I had a Mirena and I bled and I felt crap and it made me spotty and that's what people pick up on. But I guess the women who have Mirena and they're happy with it are getting on with things and they've not got time to post about it. Whereas those who are not happy with it will find the time to move. So it's a brilliant method for sure. It would be fair to recognize though that women may not want to be on it because when it's time to take it out, there's no appointment or there's certainly fit in, taking it out is easy practice. Can take it out by just pulling the threads and I've got women who've removed it themselves. Um And it's also come out during sex. So taking it out isn't a problem, is fitting. It is the problem and there are a long way for lack provision, unfortunately. Um And that is something that obviously that's trying to address through um the women's health plan and things like that with Welsh government. But yeah, you know, it does take a bit of control out for the woman in that if she's got this device in and she's not happy with it. She has to get an appointment just to make an appointment to have it fitted in the first place. But you know, it still remains a really good method of contraception, a great option for HRT and a really good treatment for bleeding as well. It's across the country. Um The trouble is sexual health services. Contraception service has been taken out of health service and given to local authorities for funding. So that's separate. Uh some places the health service will fund the coils, but it won't fund other things. There's a huge mismatch of funding in primary care. You know, if you want to fit a coil, you have to take yourself off, go and do your training, you don't get paid for it, you pay for it out of your own pocket. If you don't want to run a clinic in your surgery, that's time that you're not seeing patients with everything else that's going on. So you're having to get somebody to backfill and it just don't. Yes. Yeah, exactly. In England with the I CBS, obviously things are slightly different in Wales. But, yeah, it, the large part of it is that the time and the funding, um, you know, you get reimbursed, the cost of the actual, you know, coil in the kit. You don't get back the time that it takes to fit it. And a lot of practices find that actually it's not cost effective to do it so they don't offer it, which is a real shame. And you know, there's a lot of work being done to be in England because they're ahead of us. But also within Wales about setting up women's health hubs to try and improve access and things like that. Yeah, you know, standing here saying a Mirena is brilliant. I realize it's only brilliant if you can get one fitted. Um And you know, it would be nice to think that things were getting better in that regard. So um we talked a bit about the different types of H RT. So um oral H RT um comes as estrogen only for those who either have a Mirena or don't have a uterus. It comes as sequential where you've got estrogen and progesterone and it comes as continuous and then the transdermals, you can either have it as a patch, which is your els your oest dots, your oestrogel Sandre Lenze spray have it combined with progestogen either cyclically or continuously. And then there's been a sort of big move towards kind of freestyle prescribing over the last few years where women go for the estrogen gel and then they'll have progestogen in some form. Um So then you've got micronized progesterone is the kind of the the most popular one because it's the body identical. Um but it's not brilliant for bleeding and there were supply issues a couple of years ago and it's part of the reason why Gyne are currently drowning and the women who are bleeding on HRT because when you split things out, a lot of a fair number of women, one H RT, they want estrogen to feel better. We've told them the progesterone increases their breast cancer risks. They're a little bit and then if you give it to them separately, some with the best in the world will not remember to take it because they've got their patch on. They change twice a week, once a week and they forget to take their tablet or they don't like it, they get side effects and because they've got it, they can choose not to take it or they just say, I don't want to take that and they don't take it. But when they're not taking it, they get unopposed estrogen which causes endometrial hyperplasia which causes bleeding and could potentially cause endometrial cancer. So, a lot of areas are set at dedicated clinics now to filter off the women who are bleeding on HRT. For the women who are bleeding post menopausally because women who bleed on HRT tend to bleed because they're on HRT. Whereas women who are not on HRT who develop postmenopausal bleeding are more likely to have endometrial cancer. So you want to get those women seen quickly and the ones who are on HRT who are unlikely to have it, you actually need to get them processed as well. So we're seeing a lot of, uh, a lot of referrals for that at the moment. Um, there are other progesterones, things like Medroxyprogesterone, Provera, depo Provera um can be given orally. Norethisterone can be given orally, although norethisterone is associated with increased VTE risk given orally. So we tend not to use that. And then the I US we talked about as well and these hopefully are just some of the products and packages, um, of the different preparations. So you've got your kind of estrogen only things here, your patches, your estrogel gel, your Sandri sachet. This weird thing is lens which is, um, a spray, which is the right. Hello out. Yeah, I think we're gonna appointment for it to get up on the computer. Still on. Yeah, the computer's still on. Sorry, everyone. You're right. You can still see back home. We just had an issue with the all good with a cookie or something while we wait and we have grapes as well. I go on sodium. Sorry, I mean, we're gonna have a break soon anyway. So if anybody does wanna go and stretch their legs or go to the loo or grab a drink then, well, it's, can you see that as long as everyone can see it just look like it's, we have to get it again. Ok. Well, since everyone's still here, should we just crack on them before it goes again? Um OK. So um yeah, lens spray um is estrogen which um they say to use on the forearm actually anecdotally, it's better absorbed on the thighs and it forms a reservoir under the skin. So it's a bit like a patch but under the skin. Um So that's um one of them, you then got the estrogen tablets, then we come on to the combined products. Um the sort of sequi patches, conti patches, sequi tablets, conti tablets. And then you've got ba which is a relatively new product which has got um uh oestradiol and also micronized progesterone in one tablet. So for some women, actually, oral HRT may be a good option, you know, if they're healthy BMI, healthy BP. Um no VT E risk factors that it's, you know, a good option for them and it may improve compliance and then Neutrogin and Mirena at the bottom. Ok. So the BMS talks about the, the strength of these preparations. Um and you can see from the table, it it considered ultra low, low, medium or high, practically. I think we sort of start everybody on a medium um can always increase it. Um in patients, you know, older patients in their sixties and beyond starting it, you would start them on a lower dose. But it's important, the amount of progesterone they have is proportional to the strength of the estrogen they have as well. Um And this talks about the relative doses of those compared to the uh the strength of the estrogen. The risk is if guidance came out last year. So if patients are on high dose estrogen, you actually need to double up their progesterone dose. So if somebody's on 100 patch, then you would need to give them 200 utrogest and continuously or even 300 cyclically, lots of patients don't tolerate the higher doses. So then you might be better off, that's gone off this time. Maybe they should be I students basically, it, it basically is you, you don't, you don't need trauma to be in this place where it just need. Can we take a break? Yes, go on then let's do that. I'm gonna, so I'm just looking at the light back on it for like three seconds and then come back because II think it might be a bit easy. These things are built. I thought so. Yeah. Did you press the timer button? Yeah, but even if I did like, oh maybe I think it's II have no idea what I, you know, I a lot. No. What do you mean? So and no, thank you. Thank you very much. Do you know we get the screen back then? Oh, and then the just pictures, it's ok since it's back. Let me on before it goes. Ok. Um, so we talked a bit about the problems with bleeding on HRT. Um, and it's important to advise women that a bit of bleeding within three months of starting HRT or unpredictable bleeding is quite common and there's nothing to be worried about. But if the bleeding persists beyond six months of starting or four months of changing, it suddenly becomes much heavier. Um or if they don't have bleeding at all for six months and then they start bleeding, you need to look at it because you need to exclude endometrial pathology. If that's all fine, then altering the progestogen part of the uh regime may improve the bleeding. So you could try increasing the dose or the duration of the progestogen. You could change the type switch to Mirena and the BMS published good guidance at the beginning of the year on this. And although it's like 49 pages long, there's actually a really good little flow chart on there on how to manage the bleeding problems if you want to look at it. Um And it talks about the risk factors for endometrial pathology and that will determine how urgently these women need investigating or whether you can just tinker with their HRT first. Um It talks about making noises, it talks about risk factors for endometrial cancer. So major risk factors are BMI over 40 things like Lynch Syndrome. If they've been having unopposed estrogen for more than six months, if they've some private clinics do this crazy Tricyclen HRT where they give estrogen for 12 weeks and then progestogen and estrogen for two weeks and repeat. Um It's not recommended. Uh And if you are going to do in women who are really progesterone sensitive, then they need to be having um quarterly ultrasounds which just isn't going to happen on the NHS. Um And if you forget to switch them on to continuous after they've been on sequential for five years um or if they've been having inadequate doses, um that's major risk factors and then the minor risk factors are just kind of less prolonged episodes of major ones really. Um ok. So all drugs have side effects. Hormonal drugs have lots of side effects. Some people have no side effects, some people will get them all. There's a lot of crossover between the side effects of progestogens and estrogens. Um and you know, breast tenderness, edema, fluid retention, headaches, mood swings, depression, acne, abdominal pain, bleeding, blood in nausea, cramps, indigestion get a lot of indigestion with um with eroge and that's one of the common side effects weirdly um bleeding. So if they are complaining of side effects and you can work out whether it's estrogen or proge and dominant, then you can try reducing the dose, you can change the roots. So if they're on oral, you can change it to transdermal um change the type um change the hormone that's in it. Um And review it in three months' time I mentioned tibolone because you love tibolone. Um tibolone is a synthetic steroid molecule um which is in essence a progesterone, but it does have weakly estrogenic, weekly pros and weekly androgenic properties. So you'll often see this in women who are given things like Zoladex for endometriosis and then need ad back um for the sort of vasomotor symptoms they get. So they use tibolone, they also seem to put women, older women um who've had hysterectomy oophorectomy on tibolone as well in terms of its effects and risks, it acts like combined oral HRT. So for a lot of women, it may not be the best thing to be on if they've got risk factors for vte things like that, say it's only used in postmenopausal women. But as I said, if they're on Zoladex, they'll to use it for that as well because it's like oral HRT, it's sort of the similar risks with breast cancer and stroke. Um And so it's not ideal and certainly there are some studies which show in women over 60 it does increase their risk of stroke. So, ideally, you want to get these women off it and if they must be on hormones, then putting them on to low dose transdermal um, testosterone I think is next. Um, everybody wants testosterone, not everybody needs testosterone. It isn't a fix all for everything that goes on. It is not the only thing that drives libido. Um, women produce testosterone. The amount does fall in perimenopause, but like estrogen, it doesn't run out completely. Um, you know, your adrenals will still produce testosterone even after your ovaries have stopped. Um And the only evidence for testosterone treatment in women, the only license is for, well, I say license not licensed. The only evidence for testosterone is in women with hyper sexual desire disorder, post menopausally. So women with low libido after the menopause, that's where your evidence is for everyone else as it stands, there isn't any great evidence. Although patients will tell you that it's helped with their joint pains, it helps with their brain fog. Um and there are some studies being conducted now by Hida and the rest of the team at British menopause society to look at these other aspects of menopause and see whether it's uh there is any evidence that it actually works. Women need to be adequately estrogenized before you give them testosterone. If they go to private clinic, they come out with a bag with estrogen progestogen and testosterone in it. The problem is if they haven't got enough estrogen circulating testosterone is just aromatase to anyway. So they're effectively taking it but not getting the benefits of it. So, if their vasomotor symptoms are controlled on HRT, then and they're still struggling with libido primarily, then adding in testosterone is a good option. Oral HRT increases sex hormone binding globulin which reduces your circulating testosterone levels. So, if women are on oral HRT and have got issues with libido, putting them on transdermal main itself improve it without testosterone. There are no products licensed in the UK for women, for testosterone. Andro FM is uh prescribed on name patients privately, but we can't get it in the NHS. So we have to use male products test the gel tor testing. They're used off license and they're also used at much lower doses. Trouble is that testa gel comes in a sachet and a sachet. You have to eke it out for eight days. So women are very creative in how they do this. Some will make a, a hole in the corner with a pen and just squeeze out a little blob. Some um draw it up in a syringe and administer nat 0.3 mL every day. But it's not ideal and it's a bit of af but that's all we've got. Um we need to check a level before we prescribe it. Not because we're titr to the numbers, but because you wanna make sure they haven't got super physiological levels of testosterone before you give them more. And you need to check a level after three months and then annually thereafter, if kept within normal physiological limits, side effects are very rare um with women, but the reality is only about 50% see benefit from it. And if they're not seeing improvement at six months, they're not going to and a significant number of women will come off it then anyway, and may then be more amenable to considering other possible causes for their low libido and other things. So we talked a bit about when to stop H RT. Women on H RT need an annual review. Uh Just to check. Is it working? Have they got any other problems? Have they developed any other medical conditions? A bit like contraceptive review? Um If they need to be on it long term, then you want the safest regime, which is generally gonna be a transdermal preparation. If they want to stop it, they can either come off it gradually or they can just cold turkey. It um it's thought that gradually reducing might limit recurrence of symptoms, but the evidence isn't great really. Um And it makes no distance difference in the longer term to their symptoms. Ok. So that was your coffee break? You've had that um cracking on genital syndrome of menopause. This catch titled problem is really important um and often overlooked. Um Women will come and tell you they're having hot flushes, they won't come and tell you they have a sore vagina. Um 58% of women aged 51 to 60 get dryness or discomfort when having sex. 43% felt the symptoms severely affected their sex life. 28% avoided sex completely because of the symptoms, but 78% felt continuing sex life was important to them and only 22% have discussed this with the healthcare professional either because they're embarrassed. They don't know how to start the conversation, they don't know who to talk to. Um, you know, they might not feel happy talking to your middle aged senior partner. They might be happier talking to the practice nurse having a smear. And as we talked about, cultural factors are a big driver as well. We pick up a lot of this in smear clinics in the surgery because women can't tolerate the smear and then it needs the conversation and then we get on and we treat it for them. So, when would you consider this? Well, Thrush thrush thrush thrush as a GP, women seem to permanently have Thrush but they don't, they think they do and they'll go and get can done and it won't work and then they'll try the pessary and then they'll try the oral and it's not working. Thrush is really uncommon after menopause. So, if you've got a woman in her fifties with recurrent thrush, you really need to be thinking well, is it or is there something else going on? It's always worth, you know, if symptom aren't responding to normal treatments. It's always worth examining to look, to make sure she hasn't got lichen sclerosis, psoriasis or vulval, you know, vulval cancer, something like that. Um, do some swabs if you think it's thrush. Just to see because if she is genuinely having recurrent thrush, she might actually need a protracted course of treatment for it. But generally the itching, the burning, the discomfort is probably going to be more related to the changes due to estrogen deficiency effect in the vaginal tissues. And it's important to note that even women on HRT will get GSM because systemic HRT is not very good at treating it. So they will often need to be on topical treatment for it as well as their HRT women with recurrent uti s. Um you know that you're sending samples every other week and they're all coming back negative or mixed growth, but they're having antibiotics after antibiotics after antibiotics. At some point, you've got to stop and think is this really urinary or is it GSN urinary? Incontinence, urge incontinence prolapse. All of these can be associated with estrogen deficiency in genital tissues. The good news is it's really easy to treat and it makes a massive difference to these women. You recommend moisturizers and um lubricants first line um tell them to stop using fem fresh and all the other fancy products because they don't help. Um you give them something like a hydram all to wash with instead and things like Yes, silk skin Replens, regel are good moisturizers to use. Obviously, they need to make sure they're using lubricants during sex. Um and not the tingly ones, but the ones designed for perimenopausal um vaginas. Um And the reality is most women end up needing vaginal estrogen as well because these things sort of help a bit. But actually the difference vaginal estrogen makes is massive and it comes as pessaries, you've got Virex which has a reusable applicator. You've got Vagifem, which is a disposable. You've got vagi, which is oestrone, which is a less potent estrogen. You've got creams that used to be a vestin. It's not anymore, it's just generic oestriol. You've got blissel gel, which um is particularly good because it actually coats the vagina wall. So that's quite a nice one. If other things aren't working again, it's a less potent estrogen in it. So, um that might be a good option. And you've got Estring and you know, your women in care homes with, you know, chronic vulval irritation, recurrent uti s but not popping in an Estring. A little plastic ring containing estrogen into the vagina for three months and replacing it four times a year will save you an absolute fortune in trimethoprim. So, consider it in these, these women particularly, it's important to note that vaginal estrogen is not HRT if women read the SPC and some people do, it will talk about the risks of vaginal estrogen in the same context as the risks of systemic HRT and they'll get all flustered because this has already told me it was safe, but it's going to give me breast cancer and I've got to take progesterone. And in fact, I've had women go to the chemist to get their Vagit R and the chemist has said I can't give you this. You need progesterone, you don't, vaginal estrogen is probably as safe as toothpaste. Ok. We need to be less afraid of using it. Um It's the equivalent of taking one oral HRT tablet a year. So the risks associated minimal, the absorption, systemic absorption is minimal. It doesn't increase your risk of breast cancer. It doesn't need progesterone because it's not going to cause endometrial hyperplasia. And it can be really, really effective for these women. Unlike H RT, where you take it for a bit, your symptoms get better. You stop H RT, you might have a bit of a flare for a bit, but then your symptoms are burnt out with GSM. If you stop your treatment, the symptoms will come back. So the treatment needs to be continued long term. And you know, gyne menopause specialists say you've gotta continue it lifelong, you know, and they, they want to be carried out in their box with their bad r in their hand. So it really does make a huge difference. It says it shouldn't be used in women who've had breast cancer except on specialist advice and a lot of the breast teams are happy for their women to use it. It's always a good idea to run it past them. But we're moving now to thinking, well, actually, you know, if these women are having awful side effects because they're on aromatase inhibitors and they've got urinary symptoms, they can't have sex, they're feeling crap. Actually, taking vaginal estrogen is going to improve their quality of life and the risk of recurrence is tiny. And so most women will take that risk if you're worried about it, using vagus use, which is the lower dose, less potent forms. Ok. Any questions on GSM? Oh cool. Ok. Contraception in women over 40 this is important because women can get pregnant even if they are perimenopausal, they are still firing off eggs from time to time and if they're not on contraception, they can get pregnant. And as many women over 40 have terminations as under 18. So it's important to consider this. When you're consulting on menopause, the faculty have got good guidance on this. If you want more in depth reading on it, when you're choosing the contraception in women over 40 their risks of lots of things have increased compared to women who are 1617, 18. So their risk of VTE E is going to have increased, their risk of breast disease is going to have increased. You can see from here that um the VT E risk is largely driven by the progesterone in it, pregnancy is the biggest risk for VTE E So actually, although the combined pill has an increased risk, it is tiny compared to pregnancy. The older pills would like you leaving a gastro. So your Microgynon, things like that will uh cause an extra 5 to 7 cases. Um, in a per 10,000 women per year, the newer ones, um, the patches, the rings slightly increased risk. Again. Um, your third generations, your kind of Marlos ones, those sorts of drugs are slightly more thrombogenic. Um And your newer, you know, your really new ones, your Clara and your zo um, we're not really sure because they haven't been around long enough for us to have any good data yet. So contraception. Can you use a combined pill? Over 40? Yes, you can. There's been this sort of misconception that once a woman hits 35 you must stop her combined pill and put her on the mini pill and she's been on the combined pill for 20 years and she's very happy with it because her periods are very light and manageable. She, if she's got a, she's going on holiday and her periods due, she can run them back to back. She doesn't have a period. She likes it and then somebody says, uh uh 35 got to change you and they stick you on the mini pill and she bleeds all over the place and she hates it and she stopped taking it and then she gets pregnant. Combined, hormonal contraception absolutely can be continued in women over 40 indeed until 50 if they don't have any other risk factors, the biggest risk of VTE E is when you first start the pill or when you restart it. So women who take it for a bit and stop it for a bit and take it for a bit are actually at greater risk than women who are just on it continuously. Ideally, you want to give them a pill with as low a dose of estrogen in it as possible. But you also want to give them one with either norethisterone or even a GRE because these are less thrombogenic progesterones. However, Loestrin which fitted all of this is no longer available. So now you have to make the best choice you can of what we do have. So if you want to give him even a gastro, it's going to come with 30 mcg of oestradiol. So that's the microgyn yours. If you want to give him a lower dose of estrogen, which is less thrombotic risk, it's going to come with these G which is a slightly higher increased risk. So your and then Clare and zo at the bottom are quite good in perimenopausal women because they contain 17 beta oestradiol, which is the estrogen that's in H RT as opposed to Ethinyl Diol, which is what's in all the other contraceptive pills. So, actually, if they're perimenopausal, they're getting some hot flushes and sweats, they're needing contra uh contraception and there are no contraindications. Z and Clare are quite good to give them um to see if that also helps with their symptoms. Um You can give contraception alongside H RT. You can't give combined hormonal contraception and H RT. But if a woman is on the mini pill, she can carry it on and take HRT with it. If she's got the implant in, she can keep it and take HRT on top. If she's on depo, she carries on, she has H RT on top and of course, if she has a Mirena in and she's winning already. Um What I would say is if a woman is on the mini pill or the injection or the implant or the co and she's not bleeding, even though she may be technically perimenopausal, don't make her bleed. Don't give her sequential HRT. If she's not bleeding, put her straight on to continuous because no woman will ever thank you for making them bleed when they haven't done for years. So if she's amenorrheic on contraception, needing HRT go straight into continuous combined for her. When to stop contraception, all women can stop contraception at 55 even if they're still having periods because the chances of spontaneous conception and successful pregnancy are vanishingly small if they are officially postmenopausal because they've um not had a period for 12 months or because you've done FS HS and they've both come back positive. Then if her last period was after 50 she still needs to continue contraception for 12 months. If her last period was under 50 she needs to continue it for two years and can then stop it. Women with po I can sometimes ovulate. So even though we're saying, oh, you know, you've got premature insufficiency, ovarian insufficiency better go on to HRT to protect your bones. Actually, there's something like a 6% spontaneous conception risk in these women. So if they don't want to be pregnant, it's really important that they have contraception on board as well as their HRT and particularly in younger women with poi, they often like being on the pill because it gives them that contraception, it's also got, if you're using Zoli and Cla it's got your um to die on in it. And that is what her friends take, you know, H RT is what your mum takes and the pill is what your mates take. So younger women do like that. And on the subject of poi, the Daisy Network is a really good um website for information for patients and clinicians on poi. So it's worth a look at that. If a woman is on a progesterone only method of contraception and is over 50 would like to stop contraception, then you could check an FS H in her. If she's under 50 there's no point just tell her to carry on with it. But if she's over 50 you can check it. If it's over 30 you can tell her she can stop the contraception in 12 months. You can't check her if she's on the pill. And as we talked about depo, you need to check it in a trough. Ok. That's it. Any questions on anything that we've covered tonight or anything else with the, um, fact that the, like the symptoms don't have any causes, um, not menopause. So I would imagine there's quite a lot of overlap of mental health stress, those kind of things. How and then also all the other stuff you were saying about like discomfort and sex and how do you tend to approach them? Like, do you actively ask about them if they haven't, they haven't mentioned stress, they haven't mentioned as sex. Will you ask about them? Yeah. Yeah. I mean, coming from a sexual health background, talking about sex, you know, isn't. So if you're a respiratory physician talking about sex is a bit of a, oh, but you know, coming from women's health g you know, I'm comfortable talking about, I think a lot of time women might it a bit unexpected but they're happy to have it raised. As I said, a lot of time, they will mention to the nurse when they have their smear that they're having problems. And so that's how we pick a lot of people up. But certainly if I'm having a menopause consultation, I will ask about urinary symptoms, genital symptoms as well. Um And libido, um you're right, there is a lot of overlap. It's thought that if a woman has never had any problems with mental health and suddenly she gets the midlife and she's got real bad anxiety that is probably related to menopause. And HRT would probably be, be her better option. But if she's had issues with mental health problems over life, they often get worse at the time of menopause. But she may actually be better on antidepressants for it. Having said that a three month trial of H RT is incredibly unlikely to cause any significant problems to any woman as long as it's not contraindicated. And so sometimes they say, well, you know, they might not have the flushes and sweats, they might have the brain fog and low mood and explore what else is going on in life. And sometimes they say, oh, my mom has been diagnosed with breast cancer, my, you know, my husband's having an affair, whatever, there's a lot of stuff going on. And I'm like, well, you know, could some of this be feeding into it, but equally if she's feeling better in herself because she's on HRT, she may be better able to deal with those things as well. So it's, you know, it's having that discussion and, you know, what do you think is going on? What would you like to try and, you know, three months transdermal HRT if it works, it confirms your diagnosis. If it doesn't, then you can think again. Ok. And in terms of like your like how you work with patients, do you try to be seeing them for their follow up and keep that continuity? Yeah. So I'm lucky because I can, I run a monthly menopause clinic in our surgery. Um So uh first Tuesday of every month I have a clinic and I have three phone calls. I have no three face to face eight phone calls and I will see any menopause things. Um, patients can self refer, clinicians can refer in as well. Um And so, you know, we'll go through it and, um I will, if I start them on treatment, I will tell them we need to review it in three months, um, or to get in touch sooner if there are any problems with it. Um I also see them, they filter into my normal surgery as well. So, you know, it's nice to have your sort of menopause hat on because you can do a whole surgery and you're kind of in the zone, but I'll see them in between co PD and diarrhea and everything, you know. So it's kind of jumping around, which is what general practice is. My colleagues in the menopause clinic. Laugh because they have 20 minutes for a follow up on 40 for a new consult. I have 15. Um and I can probably bang out a decent consultation in that time. Now, obviously it'd be lovely to have more time and do it. But that's the nature of the system that we work in. But yeah, you know, the more you do it, the more efficient you get to asking the right questions, it's quite, can be quite close because the time constraints, you know, it'd be lovely to tell me about. But sometimes you've really got to kind of hone in on to, you know, particular symptoms. But yeah, I will always ask about what's going on. I will ask about genital symptoms. If you're going to start treatment, I'll tell them they need to come back in three months and generally they do come back and see me because I'm the specialist in the surgery, but not every surgery has somebody who specialists and not everybody has somebody who's even remotely interested in it. So, you know, it is a bit of a postcode lottery, unfortunately. Ok. Yeah, presentation you mentioned that we are seeing um earlier on, um I put on my other sort of, we're also seeing a lot of really high prevalence of they diagnose ad HD in your very much personal opinion. Do we think that there might be any Yola is a very, very loaded question, lots and lots of reasons, but sort of looking at all of those symptoms. And also knowing that this is earlier onset and saying this big correlation being really ad HD being a thing how are you address that? How are you seeing that in your view? Work? I mean, it is recognized that menopause perimenopause the hormonal changes do unmask a lot of things. We also know women are historically pretty good at masking and dealing with stuff. But when you throw the hormonal storm of perimenopause, it becomes harder to maintain that mask. So we do see a peak in women being diagnosed with ASDA D HD around the time of perimenopause Amy Grant in Swansea Uni here is doing research into it. She spoke at our conference the other week. Um And so, yeah, you know, there is certainly it's difficult to say uh you know, does menopause cause it or does it cause unmasking or, or what the relationship is? But we certainly recognize that a lot of women present around the time of perimenopause and subsequently diagnosed with, with neuro diverseness. I was just gonna say, what is it about um progesterone and estrogen when take an individual increases the risk of uh um breast cancer and endometrial cancer respectively. But when taken together, they seem to sort of cancel each other out in terms of cancer risk. Yeah. So for the, for the breast cancer progesterone is the risk of the two hormones. So women who take estrogen only HRT have fewer cases of breast cancer than women who take combined HRT, but they have to have combined HRT if they have a uterus because if they don't have progesterone, that estrogen increases their risk of endometrial cancer. So, progesterone is the one that increases the breast cancer risk. Estrogen increases your endometrial cancer risk. So you have to balance them out is that because of the effect of estrogen and the hyperplasia that it no, no estrogen stimulates the endometrium uh which then causes hyperplasia which then can project to um malignancy. So that's why they have to have progesterone. It's the same reason in women with PCOS who aren't bleeding, you induce a bleed in them because you want to keep that endometrium suppressed. So, yeah. So you'll get some women where, you know, they might have a family history of breast cancer but they need HRT and they've got a uterus. So you've got to give them progestogen. So you want to go for the most breast friendly progestogen, which would be micronized progesterone. Um So utrogest would be that, but utrogest isn't great for bleeding and it's not great for endometrial protection. So then you've got to balance that. So if they've got lots of risk factors, if they're diabetic, they've got P CS, they're obese. E progestin isn't great for endometrium. So you have to find the balance and you know, there's, there's a lot of gray in it. Yeah, off the back of that. Have you ever had to not give it to someone because you've had too many um s that could, it could increase the risk. Um I inherited someone from a clinic who was a breast nurse who had breast cancer, who had a history of breast cancer, who came out on estrogen for estrogen and testosterone. And it was when I was starting my menopause training and I was like, you can't be on all this. This is terrible. And then when I spoke to my trainer and I spoke to colleagues, they're like, mm, yeah. Well, actually, do you know what sometimes women make that decision? And when they've been through all the risks, that's the choice that they make. So I have said to some women, my colleagues that a woman in her late sixties on H RT because she had dry skin and wrinkles on her face and he put her on oral and I was like, oh my good God, what are you doing? Um So I got her in for a three month review and unsurprisingly, her wrinkles haven't got better. And I said you do realize you're gonna have a stroke on this, potentially an increased risk of breast cancer. And she's like, oh my God, no, I didn't. So I'll come off it and some women, you know, they come and their symptoms are like they might present like later in life, you know, 1015 years post um LNP and they had symptoms at the time and then they got better. But now they're presenting with joint pains and brain fog and fatigue and you're like, you know, there's lots of other things that could be causing this now. And you know, you're hypertensive, you're diabetic, you're smoking, we need to be looking at these risk factors. So there are some women I say, look, it's probably not the best thing to be on. Let's look at alternatives, let's look at other possible causes for your symptoms and address that. Um, but as I said, generally if the symptoms fit and there's no contraindications, then trial of HRT three months is unlikely to cause any significant problems to anybody. HRT is not a, is not an initiator for breast cancer. It's a potentiator. So if you're gonna, if you've got rogue cells, you've got them and HRT is just going to potentiate that. And women diagnosed with breast cancer on HRT are diagnosed earlier and weirdly have a better prognosis. We don't really know why, whether that's because we drum into them. They need to be breast aware and so they pick up on things or what. But yeah. Um So there are some women where it wouldn't be appropriate but then II have women who, you know, the guidance to say they shouldn't be on H RT and they are because we've had that discussion, that risk balance and that's the decision that we've come to. I'm not saying that every doc, you know, every GP is gonna put high risk women on H RT. It's very much a specialist thing. But yeah. Yeah. Yeah. He mentioned having your clinic and I was wondering that was quite a lot for us to take. I'm just thinking as someone who might not know anything about it. Um, no. How do you, man, and then helping them make an informed choice to what they would like with so many, I don't know, I feel like this, I give someone a choice. No, but not sure that they actually, yeah, it's a valid point. Um, and, you know, I'm always surprised, I guess because of my background as a clinician that even other clinicians don't know much about menopause. And, you know, I see clinicians come to me as patients and they don't make that association that the fact that they're in their forties and their periods are a bit scruffy and they're getting some hot flushes is menopause. They're all coming because they think they're dying of something else. So, just like, ok, so, you know, if they, they don't get it, how is your average patient? You've got no clinical background, get the information. And so, you know, it is good like celebrities and everyone. Caroline Harris et al who raised the profile of it and got women thinking about it. There are lots of good resources out there. I direct women to Louise news's website still has lots of good information on there. If you just go over the slightly off license weirdly prescribing stuff. But, you know, talking about their cardiovascular risk symptoms, treatment options. Rock my menopause is a really good website, um which I direct patients to, there's also managed my menopause and these are, you know, aimed at patients. Um So those are good resources and sometimes we'll have a conversation. Sometimes I'll get patients and they'll come in and they say, right, and I'm in a menopause and I need H RT. And you're like, ok, and then you've got other people who come in and, and they just don't have the first idea of what's going on. So for them, it's a lot about exploring their symptoms, asking them what they think is going on and covering any sort of hidden agendas. Like, oh, well, my mum died of something when she was this age. And is it that, and then you know, the nice thing about general practice is you can bring patients back and you can use time to your benefit. So in those women, I'll say, well, it could be this that and the other don't have to make a decision. Now go away, have a look at this, have a look at these resources and then if you decide it's something you want to consider, come back and we can talk about it again because it is a lot to take in and in a 15 minute consultation, it's kind of like, oh, I feel like who at the end of it. So patients must be completely bamboozled by it, but it's working with what you've got really OK. I've got two questions. Um, one is just a, do you have that? Yeah. Um, and then is not, have, like a, more related to the topic. Question is a bit disconnected. Um, I was wondering if you find any particular demographic equipment and not, not so, yeah, I mean, it's probably skewed by my practice population. Um, you know, I work internationally which is a largely, well, you know, we've got quite broad demographic but it's largely Welsh, British Polish. Um we don't have many sort of minority ethnic groups there, but we do recognize that those groups often are underrepresented because they don't access healthcare in the same way. Um Cultural difficulties, the symptoms they present with and also um just knowing where to go for help. And um you know, I know colleagues across the country have done a lot of work with those groups in going into community centers, into other other sort of settings to deliver these sort of talks to them, to get them thinking about menopause. So, you know, it a lot of the women you kind of think of as the kind of the sort of white middle classes coming about it. And I suppose where I am there is a lot of that really. And you know, that's why it's important to try and raise awareness about that to everybody so that it is accessible to everybody. But given how difficult it can be to access primary care in general. And then to get specialist menopause advice, it's, you know, it, it's far from what we would like it to be. Um, but, you know, we're, we're trying, we're trying to do what we can but we recognize, you know, it's far from perfect model for sure. Ok. Yeah. So it's sort of time together a bit of the discussion. So, um, uh, I guess I'm kind of seeing it as like a, you know, like women grow up like having kids is like a big shift in and then just having the menopause is also quite a big shift. Do you see people are actively wanting to make a change in their lives at this point and maybe with the lifestyle stuff more than the, yeah, I mean, it can be a good opportunity, certainly. Um, you know, menopause is often portrayed as quite a negative thing, but some women actually do see it as a very positive thing because, you know, they're not having periods and they don't have to worry about contraception and their kids have left home and, you know, they've got time for themselves and it's a really good thing. Um So a lot of women do find it a positive experience. It is a life phase. Um And I think there is a risk of over medicalizing it. Um, you know, I'm kind of in the middle. I don't think we should dismiss it and say get on with it. You know, I had one woman who, who'd seen a consultant in Egypt who said, oh, women in Egypt don't have menopause, just get on with it. And I'm like, no, really, you know, she's really struggling. Um So, yeah. No, but equally, I don't think every woman needs HRT just because she's hit 40 either. So it has to be an individualized thing. Um, but um it is a good opportunity to do a bit of health promotion. It is a good opportunity to talk about, you know, how your diet will impact it, how your exercise, your stress management or sleep, all of these things can, can impact on men, of course, and some women are quite open to thinking. All right. Ok. This is a new chapter now and they see it as an opportunity to make changes to improve their, their lifestyle going forward. So I think definitely it's worth discussing that with them. And I'm a big advocate of trying to push patients to, to make changes, to take some responsibility for their own health and well being rather than clinicians fixing it all. Ok. Anything else? Um Yeah, like it was messaged into me. I was wondering if um from what I understand, if there are any risks to not taking HRT. So, yeah, that's a good question. Some women worry that, you know, this whole thing about H RT. Well, should everyone be on it then or should not anyone be on it or, or where does it? Go in women under 40 who are taking it because they've got po I or they've had chemo that's induced menopause or whatever, the risks are minimal and the benefits are massive. So, if a woman has poi if a woman has had risk reducing surgery because she's a B ra carrier, she's a oophorectomy for that. She needs to be on HRT till she's 50 that's counterintuitive because she's high risk breast cancer. She's had a mastectomy, she's had her ovaries removed and now you're giving her estrogen. But actually her risk of developing breast cancer is tiny now. But her risks of osteoporosis and early cardiovascular disease are her biggest risk factor. And don't forget the leading cause of death in women in this country is cardiovascular disease and then dementia breast cancer is not up there. Women are not dropping dead from breast cancer all the time. They're having heart attacks and strokes and they're having them largely post menopausally because their risk increases. So women under women under 40 need H RT till they're 50 because it reduces them in the 40 to 50 age group. The benefits of H RT still outweigh the risks. So not only do they get symptomatic control, but they also get that positive effect on their cardiovascular health. They get the positive effect on their bones in the 50 to 60 age group, the balance starts to tip because their risk of breast cancer, their risk of heart disease and stroke increases anyway. Um So you've gotta find that, that sort of middle ground with them, but they probably still get symptomatic benefit. But it's less clear if they will get the benefit in terms of their heart disease and their osteoporosis, their osteoporosis will still get some benefit from it. Their bone health, their cardiovascular benefits, they're probably not going to get any benefit, but it's not going to increase their risk. Um There's uh I talked about a cardiologist recently talking about plaque formation, how we start forming plaques from our like thirties onwards. And if you start HRT in your forties, when you've got very little plaque around, then actually it's protective. But if you start it later on in your late fifties and sixties, when you've already got significant plaque formation, there's some evidence that suggests HRT estrogen can actually destabilize those plaques and that's what causes the heart disease and the stroke. So up until 50 symptomatic relief and positive protective effects on bones and heart between 5060 balance tipping. So you still get symptomatic relief, you'll still get bone benefits, but probably not cardiovascular and over 60 you're not really going to get any cardiovascular benefit from it. Your osteoporosis risk is, you know, if you've not had HRT till 60 then your osteoporosis osteopenia is gonna have developed anyway. And H RT may stall it, but it won't replace this and beyond that, probably your benefits outweigh your risks. So not everyone should have H RT and it's certainly not advocated as prevention, but if a woman has symptoms of menopause, then it is recommended first line treatment for symptom control. And there are some benefits to it as well. That, that anything else. Yeah, that's fine. So, um, if they fatigue whilst the pregnant practice is symptom control, um, but then it's sort of that added, added bonus and benefit of, um, facts, cardiovascular risk right now, if he has someone who doesn't necessarily want H RT in clinic, but is wanting that like for protective practice, what would he use to almost like? Is there something else that you can use rather than HRT that gives the same sort of protective in sort of cardiovascular apart from lifestyle change? Or is it just an added bonus of HRT that does that? Yeah, I mean, it's, it's a bonus of HRT, it's not the indication for it. So, if a woman didn't have symptoms and didn't want HRT, there isn't a magic pill to give her that will still give her the, you know, the, the reduced cardiac risks and reduced bone risks for it. Obviously, lifestyle factors are a big part then um reducing risk factors, statins, um you know, cardiology say everyone should be on a statin. Um Yeah. Um and in fact, there was a very persuasive one recently. Um So every cardiologist takes one anyway. So maybe we all should because they, you know, do what they do. But yeah, there isn't an alternative to HRT. So it's gonna be, if you're not wanting H RT because you don't have symptoms and you don't want hormones, then it's gonna be looking at your lifestyle factors. Really? Ok. Ok. One quick question was, um, because as a GP, you see a lot of women, um, and you can see the patients of various systems di different systems in place that discriminate against them in various different ways. I was wondering if there's an area of health outside of menopause, you feel isn't focus enough that would greatly benefit women, all of them. I mean, I went to, I went to a meeting um in September up in Cardiff. The great and the good. I'm not sure how I ended up there. Um But probably because I'm friends Helen Monroe and she's on the NHS executive driving the women's health plan at the moment. And so it was all about setting up these women's health hubs and improving access to luck to menopause, to endometriosis treatment, everything. And I think she quoted something like for every pound you spend on women's health, you save 13 lbs in terms of reducing their cardiovascular risk, they're not falling, they're not depressed. You know, if you can address all of these things that affect women, then actually you will save money significantly in other aspects of health care. But it's getting people to buy into that. And because of the paucity of evidence. You know, everything is about numbers. If you want to do anything, you have to be able to give them numbers to show them that it works. And there's not enough research in women's health at the moment in anything that's pcos endometriosis, breast cancer, gyne cancer, anything. And so it's really lagging behind you all the data we've got on cardiovascular disease, hypertension is all coming from Framingham and the population at large, which has been largely male centered. And I think there is at least now a recognition that women are not just little men, we are fundamentally different. Our risks are different. Everything is different and you can't just extrapolate data that we've had for years based on men and apply it to women in the same way. So hopefully with that awareness, things may start to change, but it is massively underresourced, underfunded, under researched and you know, 51% of the population. So, yeah. Ok, great. Have a nice evening, you know, you. Oh, thank you. Thank you so much.