Dr Louise Newson: You know, we did a survey of 3,000 women recently and we only we found that 24% of them had been given any information about lifestyle, so diet, exercise and so forth, which is shocking actually, but I'm sure you hear it a lot in your practice as well. People don't think how important nutrition and exercise and sleep are as part of treatment for any disorder actually.
Dr Rupy: Welcome to the Doctor's Kitchen podcast. The show about food, lifestyle, medicine and how to improve your health today. I'm Dr Rupy, your host. I'm a medical doctor, I study nutrition and I'm a firm believer in the power of food and lifestyle as medicine. Join me and my expert guests while we discuss the multiple determinants of what allows you to lead your best life.
Dr Rupy: What we're talking about today will impact around half of the population, 100% of the time. Yet we don't prepare for it, there are no specific clinics within the NHS solely dedicated to the treatment of this expected condition. There is incomplete and misleading information and relatively little ongoing research on how to tackle this problem. And to compound this dire scenario, this condition impacts multiple parts of the body: bone health, heart health, brain health, skin health, mental health, sexual wellbeing and it costs hundreds of millions of pounds, if not billions, in direct healthcare costs as well as loss in productivity and quality of life. Now, if you've seen the title of today's podcast, you'll know that I'm talking about the menopause, but if you were confused and not immediately getting the answer, I honestly don't blame you. The menopause is shrouded in secrecy, stigma and unfortunately, millions of women across the world are simply not getting access to life-changing treatment which we already have. Dr Louise Newson, author of the number one Sunday Times bestseller, Preparing for the Perimenopause and Menopause, is my guest today and is one of the UK's leading menopause specialists, determined to help women thrive. And honestly, I love this book. I'm giving it to many of my colleagues because what Louise does is demystify the menopause and equips the reader with evidence-based advice and practical tips on HRT and getting the right treatment options and also why the menopause should actually be more accurately referred to as long-term hormone deficiency, which we talk about in today's pod. But it's also about how the right treatment complemented by optimising sleep, nutrition, exercise and mental health can be so effective. And Dr Newson, who is a GP and a menopause specialist, also produces evidence-based free content for women about the perimenopause and the menopause on menopausedoctor.co.uk plus on social media. And she's also the founder of the not-for-profit company Newson Health Research and Education, the award-winning free Balance Menopause support app and the Menopause Charity. She is the driving force behind this movement that is recognising menopause as something that we need to be more open and have more conversations about. We talk about a ton of different topics today. A lot of the information on HRT and a lot of Dr Louise's tips are in the book, so I encourage you to go and get it. It's a short read, it's pocket-sized and that's another reason why I love it. So the links to all that kind of stuff will be in the show notes and also on the doctorskitchen.com. And stick around right to the end because I'm going to give you some of my top tips around diet, exercise and longevity at the end and I'm sure you're going to really enjoy those. And if you haven't already, do join the newsletter, the doctorskitchen.com. You'll find things every single week that I share with you, something to eat, something to listen to, read or watch that will help you lead a healthier, happier life. On to the podcast. Louise, thanks so much for taking some time out of your busy schedule to sit down and chat today.
Dr Louise Newson: Oh, thanks for inviting me. It's a real honour to be here.
Dr Rupy: Yeah, we we chatted a couple of years ago and then COVID happened and then and then the the schedule just got hectic and stuff, but I'm really I'm really happy to be talking about this topic with yourself specifically. We've spoken about menopause but also women's health in general quite a bit on the pod and I think they're always the most engaged pods that we've had, the thing that we've had most feedback from. But before we dive into that and your wonderful book, I want to learn a bit more about you as not just a clinician but as a person. So tell me what what brought you to to go into medicine? Did you always want to be a doctor?
Dr Louise Newson: Yeah, do you know what? I did actually. I don't know why initially because I remember being really young and playing doctors and nurses with my father actually, making him be the nurse and I wanted to be the doctor. That's a bit. I think I've always been a bit geeky. I've always been loving work. I'm a complete workaholic, but I enjoy work and it's so it's fine. I'm not complaining about how hard I work, but I've always been, you know, my my sister was always out playing in the street. My parents would always say, go out and play Louise. I was like, no, I'm too busy, I'm too busy. And so, so I enjoy that. And then very sadly, my my father died when I was nine. He had a brain tumour. And I just thought, oh, you know, I really would love to really help people. I really want to help people more. And then I was scooped up to a really horrible actual boarding school. And it wasn't really a school set up for people to work. It were people from all sorts of backgrounds, but they were all people like me whose fathers had died sadly. So we were all a bit screwy. We were set up in this this really strict boarding school, but I really, really wanted to become a doctor. And so the only way I knew I could do it, might get out of jail card was to work hard, but then I got bullied at school because I was working hard and all that stuff. But anyway, it makes you a stronger person, doesn't it? I managed to get a scholarship to a sixth form, a really good school, Cheltenham Ladies College, and that changed the way I thought because people actually congratulated me for working hard and doing well and I thought this is really different. Managed to go to obviously medical school in in Manchester. But I actually always wanted to do cancer medicine, but I think that's probably because of my father and just thinking about cancer and thinking if someone can die at 40, this is too young, what can be done. But then at medical school, I took a year out and did a degree in pathology and immunology as well. So I've been very always interested in the sort of, you know what it's like, you you're breaking things down if you're not sure about something and you look at the basic pathophysiology, you look at common sense a bit. And so I've always liked sort of going back to the detail, not just thinking, oh, I'll take that for face value. And a lot in medical school, you learn, certainly we did in the 80s and 90s, you'd learn by rote and you'd regurgitate. And yes, it's good to get through an exam, but it's not enough when you've got a person in front of you. And then so I did I did hospital medicine, I did both parts of my MRCP, my membership of the Royal College of Physicians, wanted to still do oncology, but then I did an oncology job and I thought, I'm not sure it's really for me because there's just lots of things that weren't quite there for the person, for that individual. My husband's a surgeon, we got married and I thought, oh, if I'm blessed with children, it's going to be really hard to both of us have full-time jobs with rotors. It was a lot harder then in the 90s to do flexible working. So then I decided to go into general practice. I had to do an obs and gynae job, which I actually hated. I don't enjoy gynae. Don't get me wrong, I liked it, but I didn't see myself wanting to be a gynaecologist or an obstetrician. And so then I did general practice and it really opened my eyes to, this sounds really awful actually, to people rather than patients. And obviously that sounds a bit weird, doesn't it? But I think up until then, you I was treating disease and then suddenly and as a general practitioner, you're you're treating people who have diseases, but then you also think about disease prevention as well and you think about all the things and I know you know this as well that you don't get taught at medical school about looking after yourself, keeping out of hospital, how to be as healthy as possible. And then obviously, what goes wrong in in bodies? Well, people eat the wrong things, they do the wrong lifestyle, they smoke, they drink, whatever. But also if they don't have their hormones, it's a car crash, which we can talk about in a bit. So I've always been interested in the menopause and because I'm not particularly interested in gynaecology, I was never one of those GPs where all the women came because I don't fit coils or whatever. So I've always had a really good spread of patients, but then the more I saw menopausal women, the more I thought, oh right, well I'm going to give them HRT because it's evidence-based medicine, but then I would get a lot of backlash from my colleagues. And as I've already said, I've been bullied at school, so bullying by healthcare professionals is frustrating, but you you ignore the noise and do what you think is best. But then six years ago, the NICE menopause guidance came out, which really rubber stamped how safe HRT is. So then I became a menopause specialist, wanted to set up a clinic, couldn't do it in the NHS because I went to different CCGs, I went to big GP practices, said I really want to do more menopause work. And there's just no funding, there were no jobs. And so I set up on my own, just really I wanted to do one day a week to just help some of my friends. But then I've also, I've had this portfolio career, so I've done a lot of medical writing, so I've written a lot for patients actually, for non-healthcare professionals, but I've also done a lot of education through the Royal College of GPs, written a lot of e-modules, done a lot of sort of education events. And so I wanted to sort of reach out to more people. I don't I don't want to be someone that just, you can't see loads of people, can you? So I wanted to educate people, so women, but also those that were indirectly suffering with the menopause. So I set up this website, menopausedoctor.co.uk. And then I also then set up this not-for-profit company doing research and education because I thought actually a lot of it is because of this poor education or inadequate education. So I've sort of done this and it's just morphed actually. And you know, now I'm driven by the stories that I hear and the complete inequality and injustice of women. So it's been a very strange sort of path really.
Dr Rupy: Yeah, no, it has.
Dr Louise Newson: That's a very long answer, isn't it? So I'm sorry about that.
Dr Rupy: No, no, I mean that I mean, you've done so much in that in that period. And the one thing that really stands out to me is that word drive that you just mentioned there. You've got this huge drive. And I not to turn this into a therapy session that you didn't realise you're going to have. But you know, bullied at school, lost your father very early, bullied by other healthcare professionals. It kind of just seems to me that you're always coming up against injustice.
Dr Louise Newson: Yeah, and I think I think the thing is, I don't know about you, but as you age, you think when something awful happens, there's two options, isn't there? You can crumble or feel really woe is me, this is terrible. Or you can think, right, I've got to use that as a learning tool and I've got to move forward. And I think, I'm sure you're the same, in medicine, it's a real privilege. You always speak to people who are less fortunate than yourself. Don't get me wrong, that isn't a privilege, but it shows you that there is so much suffering and it's suffering that you don't always know. You can always look at someone and think, oh, haven't they done well? Haven't they got a nice house or car or they've told me they've gone on a nice holiday. Everyone's got a story. And so I'm I'm sort of also know, I suppose the fragility of my father's life is that life's really short, isn't it? So we've got to make the most of it and I strongly feel you've got to do what makes you happy, even that even if that isn't quite what other people want you to do.
Dr Rupy: Yeah, yeah. And where where do you think this is coming from, this sort of reluctance to appreciate the menopause and the treatments that are evidence-based and the access, you know, it seems just like this this huge injustice that people still today in 2021 are inadequately prepped to deal with it themselves and also the professionals are inadequately prepped to to treat it.
Dr Louise Newson: Yeah, I think about this a lot actually. And I think it's because the menopause has never been seen of as a disease. So when when they they've discovered hormones, obviously when they discovered insulin, associated with diabetes, when they discovered thyroxine, hypothyroidism, when they discovered oestrogen, they associated with hot flushes, nothing else. And that was that that was that I think when you go back in time, that's a real problem. And then I think there's another thing is that it's a women's problem and women are just not listened to actually. So if you think back in the Victorian times, think about hysteria, you know, associated with that word hysteria, hysterectomy, you know, then you think about asylums, who's locked up in asylums? It's usually crazy women, isn't it? You know? Even back to my psychiatry days, I think about ECT that was done, the electroconvulsive therapy, it was always women. And actually, I'm sure they were all menopausal women. I didn't know about that. I didn't even know to talk to it. And then I think also, in medicine, it's always been a gynaecological specialty. And if you think about it, if I had diabetes, I wouldn't go and see a pancreatic surgeon, or if you had an underactive thyroid gland, you wouldn't go and see a head and neck surgeon who operates on thyroid glands. You'd see either an endocrinologist or you'd see your GP. So, but the problem is endocrinologists, they're fantastic and most of them don't actually have any training in sex hormones. GPs, we already know most of them don't have training in the menopause. And poor gynaecologists actually don't really want to be seeing people who don't have periods in their clinic. They want to be operating and helping people who have heavy, difficult periods or other gynaecological issues. So there's been this big void for healthcare professionals. And then women really have just been told to put up and shut up really. And actually some of it is because there's been no treatment because everyone's been so scared of HRT. So what's the point of even getting help? But then also there's a lot of been misunderstanding actually. You know, people think that they're going mad, they've got dementia, they've got arthritis, they've got fibromyalgia, they've got chronic fatigue even, or long COVID now. And so there's this mislabelling of women as well by themselves actually because they haven't had the tools or access to information to even know what's going on themselves.
Dr Rupy: Yeah, yeah, yeah. I mean, there's so much in that, I think, in terms of the vernacular that we use, the specialties that are sort of passing the buck, you know, across different areas, and just how complicated this this condition is, affecting multiple different parts of the body that we'll go into. And I like the way you describe this as a long-term hormone deficiency. And that's probably, in my mind at least, when I when I saw it written like that, I was like, that makes so much more sense. And I think we need to get used to describing it as such because it it would even to someone who isn't from a scientific background, they understand, okay, it's a deficiency and this is why it's having such a drastic effect.
Dr Louise Newson: Yeah. And a few years ago, I actually went to the Royal College of GPs and I said, how do you change terminology of something? Could we call it FHD, female hormone deficiency, rather than menopause? Because actually the perimenopause is still this female hormone deficiency. And even things like PMS are as well, actually, or PMDD, or postnatal depression, you could argue is. And they said, oh, really, it's just the menopause, you know. But it's also not just a hormone deficiency, it's a it's a hormone deficiency with health risks as well. And I think you can have this whole debate and I'd be interested to hear your views about obesity. Is obesity a disease or not? And I think you could you could argue it either way very easily. No one would be right or wrong. But what we all know 100% is obese people have an increased risk of diseases, don't they? And this is 100% menopause, you know, the oestrogen is so important and testosterone as well, but it affects every cell in our body. If something has a receptor on and works better with it, then obviously the body's going to suffer without it.
Dr Rupy: Yeah, it's a really interesting analogy actually, the obesity disease argument. And during my my masters at University of Surrey when I was doing nutritional medicine, that debate came up quite a bit during the obesity modules. And I I'm certainly varying on the side of it being a disease because the way we describe things means that we treat we we treat it in our heads and we we approach it in a very different manner. And I think when you look at the the vast array of causes of obesity, it it becomes clear that this is something that we need to provide a vast array of treatments for. And that can be in a variety of ways because the way we currently look at obesity, not to derail us too much, is just put them on a calorie deficit diet and that's all we need to do, whereas we know it's so much more complicated than that. Yeah. So let's talk a bit about the terminology here actually. So pre-menopause or perimenopause, just so we can anchor our listeners into exactly what we're talking about and and we can go into about why this long-term hormone deficiency is so problematic for a number of different areas of health.
Dr Louise Newson: Yeah, so menopause actually just breaking down the word makes it very easy. So meno is a menstrual cycle, so women's periods, pause obviously means stop. What's very weird about it compared to anything else in medicine is it's actually it's a retrospective look back in time diagnosis. So you can't make the diagnosis in most of us until there's been a year since the last period. And that's a bit useless, isn't it? If you're having periods that are coming and going, you might get to 11 months, have a period, and then you're still not menopausal, although you feel absolutely rubbish, you've got all these symptoms. And so most women it's just because their eggs run out. We're born as you know with a finite number of eggs in our ovaries, they run out. So all the associated hormones associated with that decline. But they don't just stop overnight, they gradually reduce, but they don't gradually reduce in a very nice way of going down. They go up and down, up and down all over the place. And in this all over the place time is the perimenopause. So peri just means around the time of. And so when hormones start to decline, periods start to change in nature or frequency and menopausal symptoms occur, we call this the perimenopause. And that can last several years, sometimes a decade before the official menopause. So, but some women can have an early menopause and that can just be a natural thing. They've just been born with less eggs and so they run out quicker. But some women have an enforced menopause. So if you have your ovaries removed, obviously your menopause are from the day, you don't have to wait a year for the diagnosis. But some women have their ovaries damaged by radiotherapy or certain drugs. And so sometimes it can be transient, it can be not a permanent menopause, but sometimes it can be longer. But one in 100 women under the age of 40 have an early menopause. We call that premature ovarian insufficiency, POI. One in a thousand under the age of 30. So there's a lot of women in their 20s, 30s, even teens actually, who will be perimenopausal and won't realise. And there's no test for it. So you can't just have a blood test or a saliva test or a urine test. It goes on symptoms alone really. And then once a woman has become menopausal, she'll always be menopausal. You don't, there's none of this you get through it or you come out the other side because this hormone deficiency will last forever. So a lot of people call that term postmenopausal. Premenopausal just means before anything, but you know, how do you know when that is? So it's a term that I wouldn't really use very much really.
Dr Rupy: Yeah, yeah. You mentioned testing there and I'm sure pretty much in every consultation that you do, somebody's asking about a test for the menopause or to see whether they're going through the change. What's how how do you respond to that question? And the second part to that is there is is there anything on the horizon other than a good clinical history that can help us?
Dr Louise Newson: Yeah, so no, you're you're absolutely right. A lot of people, actually who come to my clinic, they've they've all usually downloaded our balance app and they're really educated so they know. They don't tend to ask that. But you're absolutely right, a lot of people think that you can and there's a lot of marketing out there. So there are private clinics where you can get testing. There are stupid urine tests you can buy from boots and different chemists. So it's a big marketing ploy. But but if you look back, so a lot of the work I do is based out of the NICE, the National Institute for Health and Care Excellence menopause guidelines that came out in 2015. And they're very clear about blood tests. And they say if a woman is over 45, the blood test, the hormone blood test are a waste of time. Whereas we know about 9 million pounds a year is wasted in the NHS on inappropriate blood tests. So what a shame because that money could be really well used. Anyhow, they also say if you're between 40 and 45, a blood test may be useful. If you're under 40, then they do say it should be done around six weeks apart. Now, this blood test they suggest is called this FSH, the follicle stimulating hormone. And as you know, it's a hormone that our brain produces. So if our ovaries are working very well, we have low oestrogen, our brains go, oh, right, we've got low oestrogen, let's produce more of this hormone called FSH. So if the level's high, it shows that your body really wants a bit more oestrogen. But I've already said in the perimenopause, females hormones often go up and down, up and down. So if you have that blood test taken when you're feeling okay, it might be in the middle of the day and your oestrogen levels are normal, then your FSH level won't be raised. So you can have a blood test, fine, it's normal. And then they say have one another six weeks, six weeks time. Again, it could be the middle of the day, it's fine, normal. Actually, at 3:00 in the morning when you're having a night sweat, of course it won't be normal then, but no one in their right mind is going to come and do a blood test on you at 3:00 in the morning. And so when I started doing a lot more clinical practice in the menopause, I was doing these blood tests a lot. But then I would also see women that would come with me with printouts of blood tests they'd had over the last 18 months and there'd be normal one day, abnormal another day. But then I would ignore the blood test and listen to them and they would tell me that they had brain fog, reduced stamina, fatigue, muscle pains, headaches, that they had given up their job, their family had were really struggling, their partner had left them, they were getting vaginal dryness, recurrent urinary tract infections. And I then made that decision, how how kind is it of me to say to them, have a blood test now, have one in six weeks time, then come back in three months time, but your life sounds terrible to me. So then what I started doing was, well, let's give you some hormones and see how you respond. We can do a blood test, but actually once you're on hormones, the blood test isn't accurate because your FSH will have a normal oestrogen level. And they said, you know what, I can't go on any further. So I would give them hormones, see them after three months, and often they would really start to improve. And so now actually, I don't do the blood test. So I do go against the guidelines in that way because I don't feel that they're adding anything. And I'm sure you're the same in your clinical practice. I would only do any investigation if it's going to change my practice. And so and young women, as you know, really suffer with POI, early menopause, often because they're not diagnosed properly. It takes about seven years for diagnosis because people aren't thinking about it in these women. And we also know the health risks of the menopause are worse the longer a woman is without her hormones. So I think it's actually cruel to delay and delay and delay. You know, what the women want is their hormones back. And I also think what's the worst thing that's going to happen if I give someone a bit of their own hormones and they don't improve? If they came back three months later and said, you know what, I feel exactly the same, then of course I would be thinking, what else is going on? But that wouldn't be a hormone blood test I would do. I would be doing other investigations.
Dr Rupy: Yeah. I think we're we're really lucky here in the UK and having had training within the NHS that we have that drummed into our heads pretty pretty early. You know, only do something that's going to cost something or potentially even worse cause harm if it's going to change your management. Whereas our colleagues in the states are I think a little bit more gung ho when it comes to investigations and and stuff. I mean, to draw an imperfect analogy, when I see people coming in and they have clear signs of concussion and the mechanism of injury does not sound dangerous, I'm not going to be running them to the CT. However, the number of conversations I've had to have with patients about them wanting to have further investigations, wanting to have the CT, you know, that's quite difficult for a lot of people to understand. And I imagine it's similar with with the menopause because we we like things to be very sort of black and white. We we want to see a test result.
Dr Louise Newson: Absolutely. Yeah, you're you're so right. And a lot of people say, well, I want to know where I am in this transition. It's like, well, I can't tell you. I don't have a crystal ball. There's no way of testing to predict how long a woman's going to have symptoms for or how bad her symptoms are going to be or anything else. And some people, when we give testosterone, for example, some people like to know how low their level is, or even their oestrogen. You know, I've had women who've had a hysterectomy and their ovaries removed and they say, oh, I just want a blood test to see how low. And it's like, well, it will be low, I can tell you. But sometimes they really want it. And you know, that's fine. I think anything in medicine, if you really want something, then you shouldn't be denied it. And and you know, when I was perimenopausal, I had symptoms for a few months and I'm so embarrassed because I didn't recognise them. But I did have blood tests done and when my testosterone was undetectable, I was like, oh, thank goodness, that's that will, you know, and of course that doesn't make a difference because I would have been on testosterone anyway because of my symptoms, but you know, sometimes it's quite nice to sort of realise that's why you're struggling. So, but it's about choice, isn't it? But I think it's important that we don't blanket just do blood tests. And you know, we often do do blood tests on women when they're on HRT to make sure they're getting a physiological response, that they're absorbing all right, because some women find that they need higher doses because they're just not absorbing it properly through the skin. So, you know, but I think anyone who's thinking of buying a blood test to diagnose the perimenopause or menopause should just keep the money in their purse really.
Dr Rupy: Yeah, yeah. I'm really glad you talked about that story about how you you struggled to diagnose yourself because it shows you how complicated this is. It's not just the typical symptoms of flushing and fatigue. There's a vast array of symptoms that can be quite easily ignored. And that actually brings me on to a point about what are the sort of lesser known symptoms that you come across that are indicators of hormone deficiency?
Dr Louise Newson: Yeah, it's very hard actually. If you think, I've already said that oestrogen affects every cell in our body. So you can't tell me one area that isn't affected. So even in our eyes, some people get dry eyes. You know, in our mouth, some people get burning mouth or dry mouth or ulcers. Irritable bowel syndrome actually, we've got we've got oestrogen receptors in our bowels. So a lot of women find they get bloating, they get some reflux. The psychological impact of the menopause is huge, which I hadn't realised until I've seen and spoken to the volume of women that I have. So not just the brain fog, but very low mood, very intrusive thoughts, ruminating a lot, very negative, very scary thoughts actually that often happen quite early in the morning and that's often when oestrogen levels are at their lowest. And those are the symptoms that are really affecting women the worst and even memory problems, you know, just this lack of concentration, general apathy, just feeling really flat, very joyless, just don't have that zest for life. And that's very hard to actually label, am I menopausal? But it's also very hard because a lot of those will tick boxes for depression as well. And so a lot of women, the majority of women I see have already been given antidepressants, but they know they're not depressed. You know, we also see a lot of women who have suicidal thoughts. In the last week I've seen 15 women who have been suicidal. And it's very different to talking to suicidal women who have clinical depression because they're very, very scared of their thoughts, but they don't want to act on them. They've got insight, whereas as you know, when people are very clinically depressed, their insight's gone and they're really in a very different place. And actually the women often say, well, it's when I had my ovaries removed, then all this started, or my periods changed, these these started. So it's those symptoms are the most significant because they affect people the most. I mean, there are other things like this sort of formication we call it, the skin, the sort of sensation of a spider crawling over your skin can be really weird, itchy skin can be very common, just pins and needles, tinnitus, you know, oestrogen affects the myelin sheath, so the way our nerves work. So those sort of very vague symptoms that people aren't just putting the putting two and two together really. But basically, I think any physician who sees an adult woman has to think about, let's exclude the perimenopause and menopause first.
Dr Rupy: Yeah, it's a really good point and I think that's why the balance app is so, I haven't used it all of it personally, I've just gone through the onboarding and looked at a few things, but I think that's such a good tool because you go through a lot that people can actually note down what their symptoms are and actually see, okay, maybe it is, maybe it is related to hormones.
Dr Louise Newson: Yeah, and it's seeing a change because, you know, even myself, and it's so ridiculous because I was getting symptoms as I was developing the menopause doctor website. I mean, that's just crazy, isn't it? So every day I'm writing about these symptoms and I am that woman, but I just didn't piece it together. So even when I was getting night sweats, I'd get out of bed and I'd get an go to the airing cupboard and get a towel to lie on because I thought I can't strip the bed because poor my husband would just go mad if I woke him up in the night time. So I'd be in this cold sweat and I'm not a sweaty person at all. And thinking, oh, I've got lymphoma, what's going on? This is really scary. And I had pancreatitis a few years ago, came out the blue. I don't I don't drink alcohol and didn't have gallstones. And I was really ill with that. So when I was in hospital, I kept getting night sweats or sweats in general. So I kept thinking, oh, I can't have pancreatitis again. But you know, as a medic, you catastrophize and you always think it's the worst thing. So so even though I had night sweats, which is a really common symptom of the menopause, I didn't put my symptoms of muscle pain and stiffness, migraines, joint pains, the sort of brain fog, memory problems, just irritability. I didn't put them together because I didn't have the balance app. I didn't have any tools. I mean, I had my brain, but my brain just wasn't working. And it's it's really weird when your brain doesn't work. I don't know if you've ever had, I've had a sort of chest infection, sinusitis for the last week, and I felt like a menopausal again. It's like, you know, when you have that really awful feeling where you're thinking through treacle. And so it's just trying to get through the day is hard enough. So you can't piece things together. You can't think in a normal way. And that's the feeling that I got. So it's very difficult. And that's why often you want someone outside to say, you know, if it's your partner or someone at work to say, Louise, you're just not yourself. Is everything okay? And I wish then someone had given me some information or actually just made just made the diagnosis for me.
Dr Rupy: Yeah, yeah. Well, thankfully we have your app to sort of piece that together. But going back to what I was asking about, let's say we're in 10 years time and you had the potential to design the perfect test to look at, you know, whether you are in different stages. What would that look like? And are we any closer to getting some investigations in the future that could be a little bit more accurate other than just the clinical symptoms?
Dr Louise Newson: Yeah, so I am really interested in this biological aging. And when I say aging, I don't just mean we're looking a bit older and wrinkly. It's about biological aging and this whole term inflammaging, so inflammation and aging. I'm sure you're aware of it. And so this is where my immunology degree actually comes in handy because if you've got this low-grade inflammation in your body, whatever cause, inflammation is not good if it's in the wrong way. So this is what happens as you know with obesity, these fat cells produce all sorts of horrible chemicals in the body that are very pro-inflammatory. When you've got a lot of inflammation in your body, then it increases the risk of diseases such as heart disease, osteoporosis, diabetes, dementia, clinical depression. So all these are inflammatory or inflammatory diseases really. And so that's exactly the same with low oestrogen. When you've got low oestradiol levels, it switches on our immune cells, especially our macrophages in a very nasty way that is pro-inflammatory. If you plug in oestrogen, you get anti-inflammatory. So then the immune cells work really well, they're really healthy and then you don't get all these diseases or you reduce your risk of all these diseases. So if someone has their, for example, there's been some good studies, if someone has their ovaries removed at an early age and doesn't have replacement oestrogen, they have accelerated biological aging, if you see what I mean, and increased risk of all these diseases and more. So what we're looking at, we're working a bit with a company called GlycanAge and we're looking at you can do your your sort of biological compared to your chronological age. And this is all about the inflammation that goes on with our immune system. And what I'm really keen to do is to do some studies looking at women who are perimenopausal and see when that that change, that sort of big change in biological age occurs. And then we're also looking to see when you give oestrogen, how you can reverse it as well. And we've we've put in for a couple of really big grants and they've been turned down. Everything about menopause just gets turned down at the minute because people just see it as women just wanting to have nice hair or nice skin. They don't see it as the whole understanding. So when we've had the comments back from the grants, it's clear that people just don't understand it. And it's I can't believe how frustrating it is. This wouldn't be a one-off test like these stupid tests you buy from the chemist, but it's an indication. And it might be because your biological age is changing because you're putting on weight and you're drinking far too much and your lifestyle's changed. But again, it's a wake-up call and you know, I know all the amazing work that you're doing, you want to have, you want to try and get to that stage before you have your heart attack, before you have, you know, or before you're obese, you know, when when you just start to think, what's going on? And sometimes it's things that we know within ourselves because of the way we eat or drink or whatever. But then sometimes it's something else biological going on. And for a lot of women, it's the perimenopause or menopause.
Dr Rupy: I mean, this is, as you're describing it, it's so frustrating because we know, it's almost like preventative medicine gone back like, you know, back into the dark ages. We know 50% of the population are going to have this deficiency. So we really should be prepping with this. We totally should. And you know, I mean, before I left my general practice job, and I worked in a big big practice, we did a search to see how many women in our practice were on HRT who were living in nursing homes, residential homes, care homes, sheltered accommodation. And I'm sure you can guess the number was zero. And then a couple of the other doctors I work with here have done it on their practices and again, the number's zero. Now, I'm not saying that HRT will keep women out of these, but I am saying because we've got evidence that it reduces the risk of all those diseases and a lot of, you know, the biggest cause of death in women is heart disease and dementia, where we have something that will reduce the risk, but there's no there's no research at all in the UK looking at dementia and and HRT. Heart disease, there isn't either, nor is there diabetes. I gave a talk recently at the Royal College of Physicians about MS and hormones. You know, MS is far more common in women and this is an, you know, autoimmune disease is far more common in women. They get worse around the 40s, 50s. Well, you know, you don't have to be at medical school to realise that, you know, this is where hormones start changing. So, you know, prove me wrong. It's fine. I'm very happy for someone to say, Louise, you're talking rubbish. And I often do think I'm demented because, you know, because of all this antagonism I get, especially when I started talking a few years ago when I started to be a bit more vocal in the media, and I kept saying to my husband, I think I'm deluded. I think I'm reading studies that no one else is reading. Maybe there's something else. But I I haven't found anything else. All I've found is more research and more evidence how safe oestrogen is. And obviously now we've got the whole COVID thing, haven't we? And you know, women who take HRT have been shown to be less likely to die from COVID because it it, you know, affects our way our immune cells work, but no one's doing any research on it at all.
Dr Rupy: Yeah, yeah. We had Lisa Mosconi on a couple of months back, talking about her sort of frustration with bikini medicine and how women are sort of left by the the wayside when it comes to research and investment and stuff. And so that's that's really disappointing to hear about the grants not being approved. Um, to we don't have time to go through every single different element and I you've you've eloquently described all those different areas that oestrogen uh impacts, including the gut, which I was really interested to hear about. But one thing I I learned from the book, I learned a number of things from the book, but one thing that really brought my interest was the mid-age spread, which everyone is asking me about from my mum's sort of circle. So they're all like, you know, looking at my my recipes and they're like, you know, do you have anything for this? This is what happens. And it was surprising to hear about how this is related because it's almost like your body's physiological response to getting some low dose oestrogen. Can you can you talk us through that a bit?
Dr Louise Newson: Yeah, isn't it interesting? So for years, I I feel so awful. I've neglected so many women in my practice over the years because I never thought about their hormones. So women would come and I'm sure you've seen women as well with you, come to you and say, look, doctor, I've not changed my lifestyle. I'm eating exactly the same. In fact, I'm eating a bit less. I'm doing. And I'm putting on weight and it's all in my middle. I've got this tire. Why is it then? And you'd sit there and go, right, let's just go through. And you'd always find, you can always find something in someone's diet to change, can't you? Absolutely. But then they would feel real failures in themselves. And also a lot of these women would feel feel low and flat and failures anyway because they're menopausal. But obviously I never picked up on that because I didn't ask the right questions. But then when I was perimenopausal, a few times, I remember looking down and thinking, where's this I and I've I've always been quite trim. Partly I was stopping doing yoga because I was feeling so awful. But I also thought, God, this is just a bit of a tire here when I'm sitting down. I've never had this before. But then actually, again, you go back to the basics in medicine if you're if something doesn't quite feel right. So I've already said how important oestrogen is for our body. We need it to work. So if we don't have it coming from our ovaries, we have some from our adrenal glands. But then where else do we get it from? Well, we get it from our fat cells. So our adipocytes produce oestrogen. But what's really interesting for me actually, I think, is that it's not oestradiol, it's not this pure oestrogen that we this um the good oestrogen if you like that we produce. It's a quite a nasty oestrogen called oestrone, so it's very pro-inflammatory. And also, as you know, you'll probably know far more than me about the other cytokines and chemicals that fat cells produce, which are pro-inflammatory as well. So the body, bless it, thinking it's doing a really good job by giving more fat cells because it wants a bit of oestrogen to function, but it's not a nice oestrogen and it's got all the other dangers of the, you know, from the fat cells and being obese as well. So, so that definitely happens. That's a sort of pathophysiological response in the body. But then also, I've already said a lot of women feel really demotivated, they feel very flat, they feel they've got no zest, no stamina. There's this sarcopenia, loss of muscle tone. There's muscle joint pains are very common. So people end up not exercising very much. They also often comfort eat and there are a lot of people that do get sugar cravings because of the low oestrogen affects, you've got all these metabolic changes that occur. So people often don't eat, they don't want to cook in the same way because they're not motivated. A lot of women I speak to drink more alcohol just to numb their symptoms. And also, poor sleep is a really, really, really common symptom of the perimenopause and menopause. And anyone who knows anything about sleep knows that people who don't sleep well put on weight. And again, there's these metabolic changes that occur, which some of them aren't explained, but often you listen to sleep experts and they'll never talk about female hormones. So, you know, so there's lots and lots of reasons why people put on weight. And these all need to be addressed. And you know, we did a survey of 3,000 women recently, and we only we found that 24% of them had been given any information about lifestyle, so diet, exercise and so forth, which is shocking actually, but I'm sure you hear it a lot in your practice as well. You know, people don't think how important nutrition and exercise and sleep are as part of treatment for any disorder actually.
Dr Rupy: Yeah, yeah, absolutely. And I think, you know, some of the stuff that I'm doing with with my nonprofit is trying to get clinicians more confident talking about that in various different aspects of medicine. One thing that we haven't done a module on actually is women's women's hormones. So we definitely need to be looking at that. But I I gather you've done a bunch of stuff for the RCGP in terms of e-modules and and teaching and events and that kind of stuff. How has that been received? Is that is that still going or is that still, you know, popularized by by the college or?
Dr Louise Newson: So I've worked with the college for a long time, so about 15, 20 years actually, the Royal College of GPs. And I used to write a lot of the e-learning modules for them, did a lot in women's health, a lot on all sorts of other things. And then I did these things called essential knowledge update, EKUs. I don't know if you remember them. So I I started the first one. And basically when the nice guidance came out, so the National Institute for Health and Care Excellence brought out a new guidance, someone like me would in a very geeky way, go through it all, summarize it. So busy GPs didn't have to read the guidance, they could just go and we would do a little bit of a webinar, we'd sometimes do a little podcast about it. And and actually when you work part-time, as you know, it opens your mind. You're not on this hamster wheel of working, working, working. So you can think about other things. So it was a great way for me to really get into evidence-based medicine, but also think about other things. You know, if I had to do one on prostate cancer, oh my goodness me, that was really hard because I didn't know as much as I should. So you'd and you can't, although nice is excellent, you still want to look at the articles that they use, look at the research, make sure that you're happy and and also to explain it in an easy way for people. That's really hard, as you know. So when the menopause one came out in 2015, obviously I jumped on it and said, please, please, please, can I do this one? And did it and there was a really good response actually. And then I used to be a regional director for the primary care women's health forum and Anne Connelly who's the chairman is the women's health person for or spokesperson for the Royal College of GPs. So we did I did some conferences and whenever I did a conference or a lecture at a conference at the Royal College of GPs, it was always really well received actually. And then about four years ago, so before COVID, I gave a big lecture at the Royal College of GPs to, I don't know, about 3, 400 GPs about menopause and safe prescribing of HRT. And 99% of it was really, really well received, but you know, the 1%, I've already said, I've got a few haters out there. And so that's really difficult. And I think what's very difficult with me is that I work in a private clinic. So a lot of people have said, well, of course she's going to say HRT is good because she wants people to come and get HRT and then she'll make money from her practice. And this this this war has gone on for a lot for a long time actually. But actually, I think people are coming around to the fact that, you know, I give a lot of money to balance, it's a free app. It's got to get money from somewhere. I also set up a not for profit like you, you know, that's heavily in debt, but I give it money because I'm really committed to improving education. So, so I've been working with the Royal College, but I've also been working on my own with with three colleagues to set up an education program because when I've been talking about how women are neglected and actually how badly a lot of them are served by some healthcare professionals who are giving them antidepressants or ignoring their symptoms, again, the haters hate me even more. So rather than just winging, I thought, well, let's just do something here, Louise, because everything takes a long time. And I do need to add that I don't do any paid work with any pharmaceutical company. So I do not have any hidden agenda here. So I decided to set up this education program, but um, like you probably, I was just sick of going to lectures, spending all day sitting in a dark room, falling a bit asleep, picking up the odd note and thinking, right, I've had to pay for child care, pay for my train, sometimes an overnight hotel. I don't I'm not very social, but I don't drink alcohol. I don't want to be going out the night before. You know, so I decided to do it as a remote program. This was way before COVID. So, and then we also, I found that I learned the most about how to manage the menopause by sitting in clinics of my mentors. So what we decided to do was get some actresses and pretend that they were menopausal at different stages with different different other diseases and film them. So it's very awkward, we were filmed with these actresses in 10 minutes so we could show in 10 minutes you can really get on, sort these women out, really help them. And then we um, have got other lectures that we've filmed, some of them we've done lectures but also some really learned professors and other people. And then we've got lots of questions and links to evidence-based, so links to references, links to guidelines, links actually to patient resources as well. So it's a massive, massive piece of work that we did. And I wanted to do it with the Royal College of GPs. And they were very close to, because I wanted every GP to have access to it. And they were very close to doing with me and then they came back to me just at the 11th hour and said, actually Louise, there's too much diversity of opinion regarding the menopause and the management of the menopause. And did you know that antidepressants work very well for the vasomotor symptoms? Oh God. So I said, yes, I did, but actually they're not first line treatment and most women it's not the vasomotor symptoms that are affecting them. Never mind, thanks for trying. I will carry on on my own. As you as I've already said, I'm quite used to being bullied. So I decided to just set it up myself and we did start charging like 135 quid for it. And then Davina McCall's program came out, which I was heavily involved with. I helped quite a lot behind the scenes with it as well. I I just and I'd set up the menopause charity. And I said to the trustees of the charity, look, I'm just going to make this program free and we can we can announce through the charity, this is what we're going to do. And they said, well, you won't get much take up. I said, I don't really care. I really don't want women to suffer. And there's a real there's a real inequality out there. We know that women from low socioeconomic classes are more likely to be ignored, less likely to get HRT, ethnic minorities, all sorts. So I said, well, I'm just going to do it actually. So we made it free and we've now had over 18,000 downloads. And it's great actually. And actually this year when I went to the Royal College of GPs conference, I had a couple of posters and research I was presenting. And quite a few people came up to me. I was really embarrassed actually and said, oh gosh, you're Louise, I just like to say thank you. Can I have a selfie with you? This is amazing. And it's like, you've just changed my clinical practice. And actually a couple of nurses came up to me at different times and said, I just like to thank you because you've helped me or one of them said, you've you've saved my sister's life actually. She went on to your app and. And it's like, wow, but a lot of young doctors and older ones as well, but there's this sort of almost new generation where people are really realizing and and it's great actually. So it's worth the hours and the money and everything else to get that feedback. So, so I think there's a shift. I think the Royal College of GPs work tirelessly as you know in education. And I think the problem is they haven't quite got it. I've been trying to tell them for the last five years, but like a lot of people actually in healthcare, they just think, oh, menopause is something else we've got to do. Actually, leave me alone, we're too busy. But we also know that women who are menopausal are a massive drain to the NHS. So I'm working as an NHS advisor for the national menopause program. And we did some financial modeling looking at the cost of a woman. So most women I see, right, they've gone and seen their GP several times without any treatment. They've gone and had a heart palpitation test, so you know, 24 or 72 hour heart monitor test. They've had a brain scan for their dementia or headaches. They've had some x-rays because of their muscle pain. They've had multiple urinary investigations for their recurrent UTIs. They've had four or five antidepressants. They've often had various painkillers, sometimes they're on gabapentin, all sorts of horrible drugs. So what we did is we put the cost of every single medication, every single visit, every single visit and investigation to secondary care, which is more expensive. Then we also took into account that these women have lost their jobs, okay? So the cost of the economy as well. And we worked out that if 1% of women were like this patient, 1% of perimenopausal or menopausal women were like this patient, then it would save the economy about half a billion pounds a year. But it's not, I know it's more than 1%. So this is an underestimation. And and then we know that if they hire HRT that costs four quid a month, then, you know, so and that's why people are listening. They don't they know they won't listen about women. They won't listen about the injustice, but they will listen if it's about saving money. So I think people like the college, and it's not just the Royal College of GPs actually, any college, any, you know, cardiologist, neurologist, rheumatologist, they all need to know about menopause. So, yeah.
Dr Rupy: Yeah, absolutely. Yeah. I I I can't believe we've gone through uh almost an hour and we haven't actually talked about HRT. There's so much I want to ask you about. And honestly, I really respect the drive because I think, you know, if you do want to change the health landscape, it does take driven people like yourself to, you know, deal with the crap that you get from haters, deal with the rejection you get from grant funding bodies and stuff, and just push forward because you're getting that positive feedback from patients and and other clinicians, you know, who are who are waking up to this idea that it can be simple interventions and we need to better educate ourselves as well. So massive respect for that. Let's talk about a bit about um your decision tree when you see someone coming into to clinic um with regards to the the treatment uh uh treatments that we we can offer them. Um you've gone into a lot of detail in your book, so you know, we don't need to go into all the different types and everything because it's all there. But but at a broad sort of level, what what do we have available for people?
Dr Louise Newson: So the majority of women will benefit from having their own hormones back to treat this hormone deficiency. And there are different hormones, there are different types. So HRT is not a one-size fits all. So the most important hormone probably is oestrogen. We recommend having that through the skin as a patch, gel or spray. And the reason being twofold really. Firstly, when it goes through the skin, it goes straight into the bloodstream, so there's no risk of clot. It just gets absorbed straight away. Also, it keeps as this oestradiol, this really nice friendly form of oestrogen. If you have it as a tablet, it can get metabolized into oestrone, this not quite so nice type of oestrogen. So, so that's the easiest way of having the oestrogen. If a woman still has their womb, then they have to have a progesterone just to protect from the lining of the womb from the proliferative effects of oestrogen. And that can be the natural progesterone, which is a body identical progesterone, a capsule, or the marina coil contains a progestogen, a synthetic progestogen, very low dose, which can work well. And then testosterone actually is another female hormone. It's obviously a male hormone as well, but we produce four times more testosterone than oestrogen before the menopause. So testosterone in the guidelines, it talks about libido, but we know from clinical practice that often really helps with mood, energy, concentration, stamina. And so, problem with testosterone is it's not licensed for women in the UK. So women either work around it by getting the male testosterone, which is licensed, or there's a female preparation that's licensed in Australia actually, and hopefully will be licensed here soon. So there are options and so the important thing is that women receive the right dose and type that's right for them and sometimes doses change with time. And then, as you know, there are vaginal oestrogen and hormone preparations, which are not HRT because they just work locally. So for women who have vaginal dryness or urinary symptoms, they can make a real difference regardless of whether they take HRT. And then every single person, whether she takes HRT or not, needs to look holistically. So they need to look at their diet, their lifestyle and so forth. But for a lot of women, it's a lot easier to do that once they've got their hormones back. You know, to try and say to a menopausal woman who's struggling, right, you need to exercise, you need to change your diet. That's really not fair on them. It's like you wouldn't do that with someone with an underactive thyroid gland who put on weight. You wouldn't put them on a crash diet. You would balance their hormones and then go forward.
Dr Rupy: Yeah, exactly. It's it's, you know, pulling on from what you said earlier, it's a bit of a vicious cycle when you do have this hormone deficiency to expect everyone to have the motivation, the energy, the uh, you know, the drive to to to eat well, particularly when they're like sleep deprived as well, you know. So getting everything corrected uh to a degree and then giving them the life advice in, you know, as as part of that treatment package and looking at it a lot more holistically is certainly the way forward. It's a bit it's a bit of a shame, isn't it? That HRT has got this branding issue because it's been clouded by research that we know is out of date and it's been misinterpreted. I wonder if you could speak a bit more to that because even, you know, today with people who are very well educated on the subject, they still make the associations which are false and they don't appreciate this this risk benefit ratio, which I think is really important to to heighten people's awareness of.
Dr Louise Newson: Yeah, so I mean, again, I've already said menopause should be rebranded. I think HRT should be rebranded. We should call it, in some some places they've called it MHT, so menopausal hormonal treatment. And I actually think we shouldn't be calling it HRT. When we give it in the perimenopause, we're not replacing, we're just topping up. So, also, all the studies that show this risk, which actually has never been statistically significant anyway, have been with older types of synthetic hormones. The types we prescribe now are very different. For a start, they're derived from the yam plant. They're the same structure as the hormones we produce ourselves. There isn't really good, there's no randomized control studies in the in this body identical hormones. But I've already said, if you're not sure, let's think common sense. So if you'd come from outer space and had met you for the first day today and you've been told that oestrogen was dangerous, right? You might then say, well, so does that mean every young woman has breast cancer then? And older women who are menopausal with low oestrogen don't have breast cancer. And I would say to you, no, the other way around actually. Breast cancer increases as women get older. And it's far more common in postmenopausal women, not on HRT, than premenopausal women who have loads of oestrogen in their body. And then you might go, yeah, but what about pregnant women? They have really high levels of oestrogen in their body. Surely every pregnant woman has breast cancer. No, actually, they don't. So that's a bit of common sense, isn't it? Before knowing any of the data. So, and actually that that echoes what we know. So even this horrible study, the WHI study, when they followed women up who've had a hysterectomy, only had oestrogen for 20 years, there was a 25% lower risk of breast cancer. So oestrogen, I've already said how good it is. And also we know that women take any HRT have a lower risk of dying from breast cancer as well as a lower risk of dying from all these other diseases and other types of cancer. So it's anti-proliferative, if you see what I mean. And even in breast cancer, it's been shown to induce apoptosis, this programmed cell death. It used to be a treatment for breast cancer before tamoxifen. So, so that's common sense medicine, okay? The study was really flawed for so many reasons. And when it showed that there was this increased risk of breast cancer, it wasn't statistically significant. They pulled the plug on the study, partly because it was a billion dollar study and they had to try and prove what they were spending their money on. And it was in the 90s, it was a difficult time, um, financially for for um, America. So when they pulled the plug, some of the investigators said, don't do this. It's going to be the biggest travesty for women's health. It's not even statistically significant. The study wasn't set up to look at breast cancer. It wasn't set up for this. You shouldn't do it. He said, it's too late. It's gone to all the the the medical press, but also the the lay press as well. So it has been the biggest travesty for women's health for the last 20 years. And people, um, there are people, obviously I've already said a few times that hate me, but there's a lot of people out there that hate HRT. And it can be very emotional because I think partly, in their defense, if they've had a loved one that's had breast cancer who've been taking HRT, they are going to hate HRT even more. But breast cancer affects one in seven women, whether they take HRT or not. And so if you or a woman develops breast cancer who is on HRT, now they're always going to think it's the HRT. They're not going to think, oh, I clean my teeth every morning. It's it's cleaning the teeth. Or, oh, it's because I'm overweight, or I drink wine, or I've got family history. They're just blame HRT. And so then what these people, these academic haters, if you like, are trying to prove and prove more and more that HRT is dangerous is they keep regurgitating data. So there was a a study in the Lancet two and a half, three years ago, um, again showing, oh, HRT risk even higher. And what they did was they look at published and unpublished studies, put it all together, and it all talked about this breast cancer risk and they said it's more than we thought. It's, you know, there was nothing in this paper that was in the Lancet about benefits. There was nothing about mortality. It was just about diagnosis of breast cancer. But what was even worse about this one in the Lancet is that they went to the the MHRA, the Medicines Health Regulatory Authority, and said this is shocking. And so what did the MHRA did? They wrote to every doctor, they wrote to every woman on HRT and said, lowest dose, shortest length of time, HRT is dangerous. And so now, if you're a healthcare professional in a really busy GP practice trying to prescribe HRT, it comes up with these warnings saying, lowest dose, shortest length of time, danger, danger, danger. So these healthcare professionals go, oh no, I can't do that. I'm going to give them antidepressants instead. The women are going, oh, but it says here, it's really dangerous. And so I can completely understand what's happened. And the MHRA are not backing down, they're not changing it. And you know, it's like comparing apples with pears, just because they're HRT, they're very different types anyway. And so it's incredibly frustrating. You know, even I've already said oestrogen through the skin has no risk of clot. If I open my patches that I use, it will say risk of clot in it. If I prescribe patches for a patient, it will pop up risk of clot. Well, why are the MHRA doing this? It's not difficult.
Dr Rupy: The fact that it says that on the packet, um, I I actually I wasn't aware that it says that even though it doesn't go by the liver, such that it doesn't have that clotting risk. So that that is really, really frustrating. And I can sense your frustration. And you know, the fact that you can actually reason with people who still have that, um, that incorrect perspective on HRT, um, because of, you know, their personal experience, it's a very emotional topic, I find. Um, so and you know, I think it's only through education that we're going to pull ourselves out of this. I'm a firm believer that we should be teaching logic and how to interpret studies at school because we'd actually avoid a lot of these headlines, I think, if people actually were able and equipped to to go and like do a bit of digging themselves.
Dr Louise Newson: I totally agree. I mean, when, you know, David Sackett came out with evidence-based medicine in 1999, it was revolutionary actually. And but actually what we have also forgotten is what he also talks about is practice-based evidence and learning through patients. And that's really important. But I think what tops it all for me is patient choice. So earlier this year, the shared decision-making guidance came out by NICE. And that's very clear that that patients can be involved. And we know that anyway, of course we do. But that's really important when you come to HRT because if as a doctor, I'm seeing all these warnings and I'm thinking, oh my goodness me, there's this risk of breast cancer. But if my patient in front of me is saying, I don't mind about the risk, I really want to take HRT because I'd like my job back actually, and my mother died from dementia, my father had osteoporosis, I've read the evidence and I want to have it for the benefits, then can I have it? Then actually we can't be saying no. And so I think this is pivotal actually going forwards for the the future management of the menopause.
Dr Rupy: Yeah, absolutely. Louise, this has been fascinating, uh, and it's great to to get like a an inside view and and just how many challenges you've had along your journey as well. Um, but honestly, I really commend you everything that you're doing. The app is fantastic. The book is brilliant. I'm going to be recommending this to everyone. Um, and uh, yeah, thanks so much for your time. Honestly, I I really, really do genuinely mean that. It's uh, it's one of going to be one of my top recommendations, I think.
Dr Louise Newson: Oh, thank you. That's great. Thanks. It's been really lovely to have some time to talk to you today.
Dr Rupy: Definitely, definitely.
