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And um welcome to our third of my name and I'd like to welcome. So, I'm Vic. I work at UCL, which is my NHS base. I'm a specialist in reproductive medicine and I do a large menopause clinic at L hospital. Um But I also do a bit of research and a bit of publications through L Institute of Women's Health where I'm on the radio, associate professor. So nice to join you all today. Brilliant. Thank you very much. So, I'm just going to share my now, what I want to say is, has anybody got any problem? I can hear a little bit of feedback. Oh, I left one. I, I think if you went while you're talking, maybe that will help. Let's try that. Is that walking? No? Well, luckily I'm only going to be talking. Oh, it's gone. I think I'm gonna go. So I'll make sure I'm on mute when you're doing it. So, um uh so when I speak, Debbie says I've got feedback and now it's gone. So we'll make sure we're both on mute when the other one's talking. So I'm just gonna share the slides now. Um and we can see them. So, here you go. It's 7 30 it's uh the 14th of July. And we're about to do uh the third of our series of the nurses, women in cardiovascular disease. And tonight it's about hormones, hormones. Now, remember we're not here to tell you everything. We're here to entice you to learn a little bit more while we're here and then maybe go away and do some more learning somewhere else. So we're really going to give you some. Well, I say we uh vi I's gonna give you some really good gems that are there for the social media people that are there. Remember at learn with nurses or at LW nurses hashtag Lwn hashtag learn with nurses. Um So remember you're using metal, I have to repeat this every time in case people are new. But at the end, you will get the opportunity to do your evaluation. The slides have been uploaded. So toggle this and your certificate becomes generated by you. So toggle that and that will sort you out for medal medal is totally open access. So um feel free to approach the guys. They're brilliant. So it's totally free for healthcare uh organizations and healthcare professionals to use. Absolutely fantastic. Um set up by a lovely cardiothoracic surgeon during the first lockdown. So this is part three of women in cardiovascular disease. The first one we looked at when it's a Rama and we looked at those inequalities that were there about women um who were possibly going in with heart attacks and being misdiagnosed and the implications of that. So, all of that real inequalities that sit there. The second one was looking at, well, it's probably not traditional atheroma. So that was spasms, vaso spastic angina, spontaneous coronary artery dissection, all of that side of things. And the third one, well, that brings us up to the hormones one which I have to say as a, as a woman who uh and I've just told everyone what I'm doing with the HRT on E email that um but yeah, very important for many of us. And of course, there is the quiz. So um we already know from session one that there are huge inequalities in cardiovascular disease. We already know from session two. There are huge inequalities that comes there in other forms of chest pain and I've already mentioned what they are. So now we're going to learn a lot more about, about hormones and which brings us nicely to the quiz. Now, I'm talking very fast to give Vikram more chance and more time to be able to talk. And so far, um when I did the slides this morning, 351 people had taken the quiz. Now it's over social media, but it's over our, our, you know, it's over the nursing side. So, you know, it's not many general public that are going to be involved, but actually there's a lot of that need to have got a lot to learn when it, when we look at this. And so I've, um, taken out some of the relevant questions with the answer. Well, with who said what and what they said was that for today, that bit cran will pick up on. So the first one is finding out smoking, is it more of a risk factor for heart disease for men than for women? And it is actually more of a risk factor for women and yet only fif just over 50%. Um, got that true. Got that right bit KCRA is gonna pick up on everything we say here that will lead in nicely to what he is going to be telling you early menopause and early birth and early periods is that associated with risk in latest cardiovascular disease in later life? And well, the correct answer is of course true. But look, there are still a lot of gaps in the knowledge. And then thirdly HRT, does it give some protection for heart disease when started early? And that's a nice big lump of people who said yes, but there's still a lot of people out there that don't realize that what, how it can help. So with that being said, I'm gonna hand over to you now vi you say next slide, I'll go on mute and er, you've got a good, a good 25 minutes, half an hour, even if you depends out how much you wanna chat. Thank you so much, Michaela. Thank you for that introduction. Uh That sets the scene for me to take on from here. Um And I'm going to largely concentrate on menopause, uh polycystic Ovarian syndrome. But of course, that's just the tip of the iceberg hormones affect a woman's life from puberty until menopause. So we're going to touch up on the most important bits in relation to heart disease um as it happens with changes in hormones. But of course, hopefully, we'll get lots of questions and discussion at the end so that we can elaborate on some things which we might not be able to cover within the next 20 minutes. So I'm going to start with a, a bit of basics. Uh Next slide, please. So what happens with menopause? Um One of the reasons menopause and heart disease came to the forefront when discussions happen about heart disease in women is because the risk of heart disease, of course increases after a woman goes through change. Um And before menopause, we know that women in general have a lower risk of being affected by coronary heart disease. Um And that risk then becomes equal to, to the risk that men have after the menopause. So the risk increases and catches up with the one that happens in men. Next slide, please. Now, why does that risk increase? So what does this tell us about the hormones? What are they doing for women uh before menopause, that changes after menopause. So, of course, we know estrogen uh which is mainly the estradiol component of it. Um is a heart friendly hormone. It's the key female sex hormone, which keeps the bad cholesterol levels low. It's meant to keep the LDL cholesterol low. It reduces the risk of fatty plaques, uh atherosclerotic plaques building up inside the blood vessels. So, in a way when the woman is menstruating, have having good levels of estrogen during the premenopausal phase, it's meant to keep the blood vessels very supple. Now, the loss of estrogen hormone which will happen around perimenopause and menopause. Uh because estrogen is produced by the ovaries and as perimenopause menopause happens less and less estrogen will be produced. This increases the risk of coronary arteries narrowing. Uh the build up of plaque will start and of course, the process of atherosclerosis will increase and progress and worsen from this point on. So that is the big change. We know that does happen when perimenopause starts. So the reason I'm stressing the word perimenopause is because the changes start early. It doesn't have to be that the woman has stopped periods and is producing no estrogen from ovaries. It's actually the perimenopause just the dwindling just lowering of the estrogen level, that's already starting. Some of the changes happening in the heart and the blood vessels. And of course, as the blood vessels become stiffer, they will then cause. So many other changes. For example, the high BP will kick in and of course, the risk of some of the plaques breaking up and the heart disease coming um becoming obvious, become more. So the risks will increase as the progression from perimenopause to menopause and complete uh stopping of the production of estrogen will happen. Next slide please. A what about PCOS here? Um because this is again, one of the commonest endocrine condition that affects almost one in 6 to 1 in seven women. And so, of course, PCOS itself contributes to an increased risk of heart disease. And it's sort of indirect pathology from the limited knowledge, the limited research data we have about PCOS. It looks like it's the insulin resistance and the diabetes that the PCOS causes is more relevant in terms of the increased risk of heart disease, not just per se, the condition. So often the blood glucose will be higher and that this leads to over diabetes. So all women with PCOS have a higher risk of diabetes in future life. Almost one or two in every 10 women will go on to develop diabetes. And of course, there are additional risk factors. For example, age above 40. If there is family history of diabetes or diabetes during pregnancy, gestational diabetes discovered during pregnancy BMI being more than 30 itself is an independent risk factor. But PCOS is often associated with high BMI and all these will then contribute to an increased risk of heart disease. Women with PCOS tend to have higher blood pressures and again, it's a metabolic syndrome, the insulin resistance, the obesity, all that will contribute to higher levels of BP. Indirectly, again, an independent risk factor for heart disease. And so of course, if you start with PCOS and then end up having menopause, that's again adding to the insult. So the lack of estrogen then will further worsen any changes that may have already happened due to PCOS as a basic first primary condition. Women with PCOS on an average have menopause a bit later. That's because of the number of follicles. They have the ovarian reserve with eggs they have. So they might enter menopause a couple of years later on an average, it varies from woman to woman, but that's usually what we see. But of course, once menopause happens, the estrogen levels will decline and all what I said on my previous slides will apply to women with PCOS as well. Next slide, please, premature menopause. Uh specifically um discussion needs to happen because about 1 to 3% of women, 1 to 3 in 100 will have premature menopause. So that is menopause that happens below the age of 40 and about 10% will have menopause between 40 to 45. And that's often described as early menopause. So you have premature menopause below 40 about 10% having early menopause 40 to 45. And again, observational studies in most uh studies, retrospective studies show that the incidence of heart disease is higher uh if it premature menopause as well as early menopause. And that's obvious because if you lose your ovarian function and you have estrogen deficiency very early in life, then definitely it's going to be detrimental to blood vessels and heart. So these women can have quite severe risk of heart disease early on in their lives. Hormone replacement is absolutely crucial. Um if you have poi or early menopause below the age of 45. So currently we treat early menopause more or less similar to premature menopause. So any woman stopping her periods before 40 having NPO or early menopause, it's absolutely critical that she has hormone replacement because estrogen is going to prevent the damage to heart and blood vessels, prevent that extra risk of heart disease, which will come with premature menopause. Next slide, please. So, estrogen is the key hormone. Uh We know that estrogen replacement is associated with significant reduction in incidence of heart disease. Now, there have been such controversy about HRT over the years. So 20 years ago, when some big trials were published, the wh the million women study, there was a lot of negative press about HRT that HRT increases heart disease. HRT causes stroke or breast cancer. And there was a lot of negative theme about HRT, of course, things have changed in the last 20 years and we've had more studies. Uh better quality studies as well as more evidence to say that actually some of the results which came initially about HRT from those original studies had some flaws. Uh the way the studies were designed the population, they were looking at the kind of hormones that were used. And the modern HRT that we use is pretty much um similar in terms of the kind of hormones we used. But the quality of the hormones, the way we give them in terms of patches gels rather than tablets and how they are obtained rather than say animal derived hormones, they are plant based natural hormones. So there is a difference in the type of hormones we use. Although it's estrogen, progesterone and testosterone sometimes. And that is key because the modern hormones don't appear to be having the same set of risks or same severe risks that were often attributed to HRT 20 years ago. Now, any HRT hormone replacement contains estrogen and that is the hormone which is heart and blood vessel friendly. So, if a woman has HRT as part of her menopausal symptom management, the side benefit of it is that estrogen will reduce risk of heart disease if it is started during perimenopause or within the 1st 10 years of going through the menopause or having the last period. So the long term follow up data from large studies which are looking at HRT, looking at health outcomes, we know that there is no evidence for any detrimental effect with combined HRT estrogen and progesterone. So, the message is actually positive rather than negative. It won't worsen things, but it will give you a side benefit of heart and blood vessel protection if you're taking estrogen as part of your HRT for severe menopausal symptoms. Next slide please. So what is the best time to initiate HRT for menopausal symptoms? So what is recommended now from all the data we have and the reanalysis of the original studies is that if you start HRT before the age of 60 or within 10 years of the last period or even early, between 45 50 any time before 60 then you will reduce atherosclerosis. You will reduce heart disease and death from cardiovascular cause or death from heart disease. It will also reduce the all cause mortality. So there are significant benefits of starting HRT early HRT is currently indicated. If a woman has severe menopausal symptoms, it is not yet recommended by the guidelines to be started only for heart protection. Because if you start it only for heart protection that that needs to be balanced against the side effects and the risks, which probably we'll get to chat when we have a bit of discussion. Now, although benefits may no longer be the same. If you do end up starting HRT because a woman has symptoms beyond the age of 60 then it doesn't increase any cardiovascular event mortality, all cause mortality. So it you can even start it beyond 60 or after 10 years of menopause. You may not have the same benefits as you had before. As for example, starting it early within the 10 years. But certainly you're not going to see a certain increase in cardiovascular events or mortality. All these are usually discussions that we have with patients so that every patient is individual. We balance their risk factors, balance their symptoms against the benefits and risks of HRT. And every patient has an individualized plan for HRT. But the message is if you have to have it for menopause management within the age of 60 it does loads of good for heart. If you have it beyond 60 it may not have much benefit but certainly won't cause harm. Next slide, please. So if the HRT is required for menopausal symptom starting early is important. So if you have symptoms, which are affecting your quality of life, they are severe, you're going through perimenopause, start early rather than delay because the earlier you start earlier, you prevent any of the changes of estrogen deficiency happening. And so therefore more the benefit you will have from HRT, but it doesn't mean everybody needs HRT. So I want to make it clear, some women will not have symptoms. They will be able to maintain a good heart health with exercise, avoiding smoking, avoiding alcohol, excess eating, right, maintaining their BMI healthy, making sure their diabetes is under control. So it's not that everybody needs to take hormone replacement. But where it's indicated, it certainly has benefits when it's started for unpleasant menopausal symptoms. Next slide, please. So that's it from my side. Basically, the summary is plenty of positive messages in terms of HRT. But remember all the other lifestyle factors are equally important besides hormone replacement. If you have to take it, it is mainly for menopause management, but it has some side benefits. I'm hoping I'll catch up with you at the end because we'll have loads of questions, I'm sure. And then we can go into details of each of the points as needed. Thank you for listening. Wonderful. Thank you very much. Now, we've already got some questions coming in and I've certainly got a few questions myself here. So, um I, I don't know if you can see the questions on the chat. We'll, we'll take them from the bottom and go up or actually, no, we'll take them to the top and go down. I'll read them out for you as, as you know, disease and affects thyroid disease, particularly underactive thyroid and in pregnancy. So I think um I didn't get the question fully, but it was about underactive thyroid and what impact it has on, on the heart disease. Is that correct? Yes. Ok. So there have been some studies looking at what impact estrogen and HRT have on the thyroid and vice versa. So far, we don't have any established evidence that there is definite impact of either some form of natural or HRT based estrogens on thyroid and also that it variations in thyroid or thyroxine dose has some impact on HRT. There is no such literature or or confirmatory data that they influence each other. What is important though is that uh thyroid on its own is an important risk factor. So, if you're underactive on thyroid, that itself can slow down metabolism and of course, increase cholesterol and impact heart health. So you want to make sure that while you're taking estrogen as HRT or you're having your natural estrogen through menstrual cycles, you want to make sure your thyroid is well controlled because both will be independent risk factors if they're not well controlled. Um for heart disease. Brilliant. Thank you. Now, I, I think between us, I've got a problem with the signal. So I'll talk a little slower because the echo, I, if you go mute, when I talk, then we'll work. So, um and I'll read the next one out. It comes from Debbie who's one of our trainers on lemon. So she does the respiratory, who says should women in the perimenopause or menopausal age receive a re a routine blood test from their GP for cardiovascular disease screening? Well, um usually the guidelines should be the same as national guidelines. So at the moment, menopausal bodies do not make a difference if you're in perimenopause or menopausal age group to say that you should follow something specifically different from what is nationally recommended. Now, I tend to do a huge menopause service in my clinic. And of we often say that if you've got risk factors for heart disease, whether it's family, risk factors or personal risk factors, I often say, see your GP and make sure you get the required screening maybe on an annual basis if you're fit and healthy otherwise, or if something has been already picked up, which is worrying high BP or cholesterol in the past, then you of course, need monitoring for that side by side how your menopause evolves. So, not specifically different, but as long as somebody is looking at the risk factors and keeping an eye on anything that's been picked up, I think that should be important. Brilliant. So the questions are coming in thick and fast now. So um as wants to know how old can you be to start? HRT? He's 62 old. No, in my books not. Um So again, it depends on individual scenario. Um Most women will often become symptomatic in perimenopause menopause, which is around 45 to 55. And so often that's the best time to start. HRT if you're symptomatic, if it's affecting your quality of life and work. But mean that if you're 60 you're still experiencing symptoms, you still feel there are some menopausal issues which are affecting you on a day to day basis, you can still have HRT. There's no arbitrary age for starting or stopping. HRT. It all depends on individual uh, discussion about benefits and risks specific to you. Brilliant. Um I've now got cathing. So what happens if a woman has never had HRT? It's over 20 years. Um, with, um, so over 20 years since the menopause with an underactive thyroid, which is treated with thyroxine. Well, if your thyroid has been treated with thyroxine, one would assume that the thyroid wouldn't have led to any increased risk because you've always had good thyroid replacement. And that means that it hasn't been undertreated at any point in terms of the uh lack of estrogen for the last 20 years. Yes. Um, the lack of estrogen would have meant that the protection estrogen was giving you before 50 or 45 that's gone, which is a natural part of menopause. But if you've been making sure that lifestyle wise you haven't been adding any other risk factors, then yes. Again, it's like most women who don't take HRT, it doesn't mean that you're putting yourself to a big disadvantage. What is more important is to maintain A, a good BMI, make sure you're not smoking, not drinking excessively watching your lipids, watching your diet. So, HRT would only be required if you were symptomatic and you were kind of worried to go on HRT, but suffering from symptoms, then that's something that you don't have to do. Now, you can definitely opt for a safe form of HRT. But if you're 20 years on thyroid well controlled, then all you have to do is make sure that your risk factors are well controlled. That's it. Exercise, diet and everything else. Be safe for anybody else. And I think if I pick up on that, that, that thought, the stream of thoughts that I know that was going on there is in my head, I was starting to think and I've scribbled down some questions and we'll come back to the questions in the chat in a moment is um I'm almost thinking, shouldn't every woman and I know you said no in the, in a little bit, but surely we should have, why not? Why we're giving statins to so many people. And I'm a great believer in statins. If we know there is some protection to be had from HRT, then why don't we give it to every woman perimenopausal? You know, I feel like feeling like we need a poly pill for women. You know, we've got the statin and aspirin little beta blocker combo going on. That's trial in, in I in India. So can we have a poly pill for women if I was the boss and I could change things, I would give estrogen to everybody. But again, we have to be realistic here is that of course, remember that many women will not have any symptoms. So if you're giving estrogen only for the purpose of heart benefit bone benefit. And potentially there is some limited data to suggest it will also be beneficial in terms of preventing cognitive decline later in life. But, but of course, that needs to be balanced because some women may have blood clotting risk. And certainly some women do develop blood clots on HRT. And of course, you can minimize that with transdermal forms of HRT. But nevertheless, there is a small risk. Also, there is a risk of uh breast cancer, which is the other significant risk. And it's a very, very, very small risk, maybe something like five or 10 in 1000. But that risk has to be balanced. So many women will say I would rather do natural things to maintain my heart health because I'm not having symptoms. I wouldn't like to go down the even the tiniest risk of breast cancer. So in a way, HRT may not be for all, but the, the way data stands now, it may be one of the very good preventative strategies for heart disease prevention if we can find preparations, which will further reduce any clotting and breast cancer risks and make it even safer. It's certainly going to be one of the best natural candidates. I'll go to I I my little brain is thinking of about a billion questions and I know that I have to give some space there to the other people. But and I'll come back to my question in a moment. It was a follow up one but I know that somebody else has. Uh, no, I know what I was going to say that actually what you're saying is nothing really replaces good lifestyle, good lifestyle should underpin everything we do and that good lifestyle, we know that from the inter heart study, which looked at, uh, you know, 80 90% of all heart attacks happened for five reasons. You know, abdominal obesity, high cholesterol, high BP or, you know, the, the the usual things and our first session, we looked at when women were having these strange heart attacks, they form maybe the, the the smaller percentage that are there of the inter heart study, some weird ones and stuff. Um But we should be looking as well. These traditional risk factors are, should be underpinned everything we do and, and the extra bits will add value hopefully in specific places. Now, um I've got some more. Um So, oh, another good question coming in. Um Would you consider prescribing HRT for an asymptomatic woman, menopause wife who has a very strong family history with a CBD parent? Say they've had a heart attack under the age of 50. Well, this is the big one in the, it, it'll probably create a lot of controversy if I say yes, I will. So the answer to that is you would probably benefit from avoiding going through perimenopause and menopause where the estrogen lack will then mean that if you already have a strong family history. You have already a risk of heart disease. You're going to definitely increase that risk if you go through menopause. Um So if you're completely asymptomatic national guidelines, the research data, the conclusions right now will say no because you still have to balance your benefit for heart versus all the downsides of HRT and the long term risk personally. On an individual basis, I do see women who give you a history similar to yours and would be ready to accept the risks in terms of the benefits they would have for their heart disease. And I have offered HRT in that situation, but that's individualized basis. So if you're very keen, it's worth having a discussion with your health professional, whether it's GP or a menopause specialist, and they may be able to offer you, uh looking at the bigger picture rather than just concentrating on guidelines. And so if I pick up on what you said for that, and I think about so if I'm coming at it from a heart perspective, if I know someone's got a family history where it's premature and premature under the age of 50 is very premature in the context of heart disease, I'd be certainly making sure I wouldn't just jump in with saying HRT. But also what's that cholesterol? Like, what's everything else? And we really, you know, we know that, um, there are inherited high cholesterol conditions and we do sessions on FH where produces very young heart attacks. And let's say you were talking about a parent with a heart attack under the age of 50. To me, it would also was, was it your mum or your dad? Because if it was your mum, that's really weird compared to, um, being a man under 50 because of the protection that somebody may have had or a woman may have had for their hormones. Um, depending on when they might, may have had, it may have had the menopause. So more questions before I start quizzing you some more. These are um these are um so uh someone who with VV cancer go on. HRT. Simple answer is yes. If you've got vulva or vaginal cancers, they are not hormone sensitive. So if you need HRT for symptoms, then yes, you can certainly go and have HRT. It will not bring back your cancer because it's not hormone sensitive. This is one of the longest sets of questions that we've had on our session. So it, it, we'll be getting you back as a bit gram if you will come back for us later in the year. Now, can you can you, can you read this? I'll read them out. So everybody else can. So where do Kelly wants to know? Where do individuals stand if they've suffered from migraine for years in their younger years? I know you've previously had progesterone only contraception and a high family risk of breast cancer. So, um in a way, it's a very good question because it kind of looks at different things throughout the life course of a woman. Uh migraines uh are of course, uh uh sensitive to changes in hormones. Um and hormone changes can trigger migraines as well as sometimes hormones can mitigate migraines. The advantage with HRT is that HRT, unlike the progesterone only pill or the combined estrogen progesterone pill, HRT contains natural hormones and it doesn't need to be swallowed. It can be taken as a patch gel or a spray form. So, while the combined pill is contraindicated, if you have migraines, and therefore, you're given the progesterone only pill so that you don't have any migraine uh issue and the stroke risk, the HRT is safe. And if you take it in the form of transdermal patch gel spray rather than oral tablet, you can safely have. HRT. Most women find that their migraines actually settle down once they have good estrogen. Uh perimenopause menopause and lack of estrogen can trigger migraines make them worse. So if you're asking me in terms of whether this is in relation to HRT, then yes, HRT is completely fine. As long as it's transdermal and uh you're taking natural estrogen, you can take it, it might benefit the migraines. If you have family history of breast cancer, then the kind of progesterone we will use as part of HRT is usually something called natural progesterone progesterone, which is not shown to increase your risk of breast cancer for the first five years. And after that, there may be a very, very small increase. Similarly, there are some other preparations like the coil which may be safer than the traditional oral or other synthetic forms of progesterone. So again, talk to your specialist because even if you had migraine and the pop in the past and there is history of breast cancer, you can still have many options for menopausal symptoms and migraine management during perimenopause. Brilliant. Ok. So what he wants to know why is HRT contraindicated in ischemic heart disease? I'm sure. I think that's what you mean by IHD unless it means something else. But I don't know. Um Is it contraindicated? Well, it's not strictly contraindicated. Um So it's, it's, it's a caution that one has to exercise. Um So if you've had IHD ischemic heart disease, it means that some of the vessel changes in your blood vessels may have already happened for whatever reason, whether it's age, whether it's menopause, whether it's family history, genetic tendency, lifestyle issues. And therefore, when you sometimes give HRT, once the changes have already happened, you may not have much heart benefit or blood vessel benefit. That's in individual scenario. Similarly, you worry if you already have high BP, which is difficult to control or you've already had multiple coronary heart events, then HRT may sometimes is thought to destabilize the plaques which are already present. If you have a severe heart disease. Now again, this is something that's debated. Most women who start HRT even after 60 with previous events may not necessarily cease increase in severity of events or number of cardiovascular events. But in this scenario, one needs to individualized. So someone needs to see your history. How many events you've had, what kind of, uh, medications you take now and if worse come worse, if you were severely affected by menopausal symptoms, you could still take a very small dose transdermal preparation. But have a chat with your health professional because they will be able to assess what's the best for you. So, it's not a strict contraindication, you can take it, but there are caveats and we, you have to be careful with the type and the route of delivery. And I think that means that we just, uh, you know, many of us just don't understand that because I see that question. I think, well, absolutely outrageous. I'm sure you should be able to, but I'm not thinking plaque stability. I'm not thinking that which I should be thinking and I don't know why I wasn't thinking it, but I guess there's still a lot to learn for us on what, on the impact that hormones have. Um, and particularly obviously women's hormones have that. Um, we have so much more left to learn, I think it's, and it's getting really exciting. Um, the, the, the more it's moving. Not, not, well, from my perspective, not just from looking at the hormones, but actually that implication of the not having the hormones and the and then having them back. So, um Donna hope you don't mind if she's going, wants to find somewhere to refer to, but I just in the last five minutes, there's a really good question coming from Andrew saying, where does hr three fit into the trans community? Are you? Yes. So again, this is not specifically a specialist area I work in. In fact, we have a dedicated clinic uh in this area that is, that works at UCL and but of course, we do cross cover and we do come across patients in this situation. Um HRT applies to anybody who needs estrogen replacement. Uh will be similar, the principles will be similar if you need replacement of female hormones, uh that's estrogen. Uh then that's again, will be dependent on your background, medical history. What are the benefits? And if you need estrogen because you've had uh trans uh clinic uh treatment, then of course, you are going to be needing it as part of your clinic, monitoring your, your hormone replacement therapy. So we do uh have uh a specialist service that works in the area because you may need some blood tests to assess your levels. What kind of estrogen do you take? What kind of uh route and the dose that benefits you most in terms of the issues that are uh related to that particular condition. Uh in terms of managing your heart, uh risk, your bone risk, your general health issue. So definitely an area which needs much more research. Uh There's very little data in terms of HRT in trans population. It's a very underserved. Uh and it's a very neglected area of medicine. We need to do much better, but there are specialist services coming up now everywhere. So I'm hoping that you will get the right help to your GP. I was at a news today and myself were at a meeting last week when we spoke, I was at heart UK conference and one of the sessions there was um was about the risk of heart disease in people who are trans, in trans people and that um particular the risk is higher. So when you go from, when you go from male to female, the risk of heart disease is higher in, in a, in female than c female. So and that's yet to be fully on picked. It's only really at the beginning of that one. So I feel there's, as you say, a lot more work to be done, there's definitely lots more needed in terms of the data. It's so poor and we've neglected this area of medicine. So you're absolutely right. I think we'll have much more to say in the coming few years, guide, guide these clinics and the guidelines much better than where we are right now. Brilliant. So Um, now Dawn wants to know, what about HRT and diabetes in either symptomatic or asymptomatic? Is there somewhere good for them to refer to? So, do you mean I don't, are you meaning like somewhere clinically to refer to, or, or somewhere somewhere online to refer patients if you could just be clear? I think on that one. What do you think? Um, so this is about HRT V diabetes, right. Yes. Oh, yes, There is plenty on the websites for British menopause society in terms of different medical conditions and HRT, you'll have also very good resources on international menopause society. And of course, I think um learn with nurses will do some webinars. I'm sure about diabetes and so you have plenty more to look forward to. But, but the essence is diabetes is not a contraindication. As long as you have controlled sugars, you've controlled risks and complications of uncontrolled diabetes. The choice of HRT should be very good in terms of minimizing complication, using transdermal natural hormones rather than synthetic hormones. So, more or less similar to ID, but it's not a contraindication. Lots of women with diabetes have HRT safely uh lifestyle, the most key important factor there. So we've got one minute left and I want to ask you my uh specific one myself, if that's all right. We, so one of the things that I work in is around cardiovascular risk and um, and, and using predictive tools. So we have the J BS tools and we have the Q risk tools. Now it makes women, you, you either men or you're either male or female. So, it's absolutely binary. So it doesn't pull in anyone that's trans, but equally, it doesn't talk about menopause either. And I just love your thoughts on is the woman's risk exactly the same throughout her life. You know, does it go up in the same level of the risk of heart disease across the life? Course like men do? But like the age, I, I've just answered the question, why I would love to know your thoughts about the risk ends and the why it might end up in women. So I in predicting women's risk of heart disease, if you don't have menopause as a component, then that's not going to work because that's one factor that's going to suddenly change their risk. So if they are having a baseline risk of and it's slightly going up as the woman ages until 40 45 it's going to sharply go up after that because suddenly all the protection from estrogen is gone. So your prediction model or any algorithm you follow should have menopause which will suddenly increase the risk. What percentage risk depends on individual person, their men, how much hormones they have had in their life, their background, uh demographic factors. But you can come up with the algorithm that will give you at least um a big percentage jump around perimenopause or menopause. So it has to factor in that. I guess. I, I hope I have answered that to so many. Absolutely. Absolutely. Because at the moment, um, I'm going to wrap it up there. We have, you see, people have never thought about, um, um, yeah, so people are loving the session we've done tonight and, um, I'm gonna probably end it here. I'd just like to say thank you to Vikram for joining us. Hopefully you'll come back and we'll do some more particularly on, on any topic, any topics you fancy that's there. Um And I, I know that everyone's enjoyed it and we've never had such an interactive session and this is our newest style of doing um a bit of a discussion this way. So, really, really wonderful. So what and I'm gonna show you what we do now is to, this is the joy of meal is I press the feedback form and automatically people will be able to do their feedback straight away that gets them their um certificates and your evaluations and we'll be giving you the um summary of it all as well, Vikram at the end. So, um all we need to do to leave is press the little red phone button and you leave. It's such a lovely tool to use. Thank you very much, everybody. Brilliant, Vim. Thank you. Thank you very much. Thank you for your time today. Brilliant. Take care. Bye bye bye.