Dr Louise Newson [00.00.00] In my podcast today, I've got Dr Fionnuala Vernon with me, who's a GP and educator from Ireland. We have a really open conversation about how the healthcare system is failing women and how we need to improve education for all healthcare professionals. So hope you enjoy it.

Dr Louise Newson [00:00.19] So exciting. You're over from Ireland

Fionnuala Vernon [00.00.22] Yes

Dr Louise Newson [00.00.22] Last time I saw you was in the conference, I think..

Fionnuala Vernon [00.00.25] Yes so, we were in the Royal College of Surgeons – great day.

DrLouise Newson [00.00.26] Yeah,which was great actually, this was a conference that I'd organised for healthcare professionals, and we had people from 18 different countries.

Fionnuala Vernon [00.00.33] I know, it was amazing, yeah.

Dr Louise Newson [00.0035] Yeah - I did say to someone it felt even more exciting than my wedding, and they said that probably wasn't the right thing to say.

Fionnuala Vernon [00.00.40] Yeah. Paul was really reassured by that I’m sure

Dr Louise Newson [00.00.42] My husband was there…

Fionnuala Vernon [00.00.42] He was yeah – he spoke, he was great.

Dr Louise Newson [00.00.44] But it was what I found about that day. I don't know what you felt sort of sitting there, was that everyone had this fire in their belly. Everyone was like looking at hormones in a different way. There were gynaecologists there, there were psychiatrists there, there were GPs there nurses, pharmacists, people coming from all sorts of educational backgrounds.But there was this real and it got noisier and noisier, actually, as the day went on, didn't it?

Fionnuala Vernon [00.01.09] It did. Yeah, it was a kind of an unruly bunch of the end we're there with very like minded people, cardiologists, surgeons,gynaecologists, GPs, nurses, as you say. And the fire in their belly is coming from people's kind of want and need to help patients and to make a change. And I think that momentum was very palpable on that day.

Dr Louise Newson [00.01.30] Yeah. I mean, I was really honoured, because we had great lectures, including, as you know, from US and Singapore, and they came because they wanted to. The conference was not funded by pharmaceutical companies, so it, you know, we had a really lean budget, but everyone knew that, and that was fine. But also, I've been, and I don't know if you have, but you probably have been to conferences where in the break people are just a bit awkward. They're not really chatting, they're not talking, you know, and it's almost a bit hostile, whereas here it was very inclusive.

Fionnuala Vernon [00.02.01] It was lovely. And it was just great, even just to get kind of anecdotes from other clinicians. And, yes, yeah, it was a really, really great day.

Dr Louise Newson [00.02.10] Yeah, because, you know, medicine, I've said before is a science and an art. So, the science is, looking academically at the papers, we have guidelines, which are as, as the word implies, a guide, but also,it's a patient experience. This is the art of medicine, isn't it?

Fionnuala Vernon [00.02.26] It is yeah.

Dr Louise Newson [00.02.26] And I made sure that the lectures all spoke about patients, because I've been to many menopause conferences where it's all about slides and figures and statistics, never once about Mrs. Smith, 49-year-old lady who's given up her job, who's struggling with brain fog or memory problems and sore joints. So that brings it back to the reason that we went into medicine, isn't it really?

Fionnuala Vernon [00.02.48] Well, that's the reason. I mean, certainly that's where the conference really resonated with me. We see patients all day,every day, patients who are really struggling. And I loved Haley and Jay. That was such a great conversation, and they were so brave to come and tell their story. And I know patients like that, and it's lovely for patients, for your listeners, to hear their story, and lots of that is going to resonate. So as doctors, we and especially as GPS we are best placed. 90% of all of the work of the NHS happens in primary care. So we live with patients. We'rein their communities. We know the difficulties you're facing, and conferences,for me, are bringing our patient experience, meeting the experts, having then those connections that if we are struggling with evidence, or we're not too sure, or we need a little bit of support to treat maybe difficult cases. We've got those connections, and I think that's why it was such a lovely, lovely banter, great rapport, because it was very open, and people were very generous with their advice and support. Which is great

Dr Louise Newson [00.03.55] Which is great, and it's also, you know, we know it's a global problem that hormones are not being addressed enough for women. But when you talk to other healthcare professionals in other countries,you know, in in Iceland, in South Africa, in Netherlands, they're all experiencing the same. And actually, when you say, oh, I you know, what's your experience of testosterone with your patients, or what are the symptoms that they get. You know that it's, you know, women are the same really, you know,biologically, we're the same. We might present differently different ethnicities and also have different health beliefs as well. And that's, that's one of the things that you hear more and more actually, from other countries, is this, the patients, the women, have been scared away from hormones for the wrong reasons often, haven't they?

Fionnuala Vernon [00.04.43] Yeah. I mean, it is absolutely a global problem, and we've always had a very interesting relationship with menopause in Ireland, because traditionally, well, there have been church views and things like contraception. So traditionally we'd have maybe larger families, maybe 10/12,kids. One of my patients is one of 19 children.

Dr Louise Newson [00.04.59] Oh my gosh.

Fionnuala Vernon [00.05.00] So you can imagine when, when, when his mom got to the 19th baby, when menopause came. It was probably a welcomed relief.Period stopped. There were no more kids. So for those women and now they, I mean, we obviously don't have have as many, many kids start per capita, but, but in other in other countries and in other tribes and in other communities that may still be part of their culture, but we didn't know. We didn't know the symptoms,especially the mental health symptoms, they are probably the most prevalent and the most distressing symptoms that people come to us with and I think that's probably those are the symptoms that have the biggest impact on relationships,as Jay and Haley chatted to us about – in Ireland where we have one of our biggest clinics. We have a beautiful Georgian city the top of the city. So, we have a huge park, not dissimilar to Hyde Park. We have a former women's jail,and it closed in the 1960s and then at the bottom of the town, we have an old asylum, a mental health asylum, for want of a better word. And the number of patients I see now who, with the education that they're getting on your platforms and other platforms, are now joining the dots. And while those patients who were inpatients in either the jail or in in the mental health asylum will never have the opportunity to thank you for all the work that you're doing, some of those women are being exonerated. Some of those women were now giving an explanation as to how they were there. We also see, again,as GPs, we see the children of those women, and the children who very often,they'll say, I didn't have a relationship with my mum at all. You know, we didn't get on. There must have been a personality clash. It must have been difficult. And now, when they're looking back, they're saying, actually, there maybe was a different reason. And they, interestingly, have a story to tell.When I ask about the older siblings, what? What were your older siblings relationship with your mum? It was great. They don't remember difficult times.They remember great times. So it's us tying that all together, looking back over history, looking back over generations. And certainly, as GPs, we are interested. We want to know. We're interested in your social history, your family history. And very often, as GPs, we know the history because we know your families, communities.

Dr Louise Newson [00.07.28] Absolutely, it does really connect. But the thing is also is it's often all in the history, isn't it? And there's something I was taught at medical school. Take a really good history, Louise, listen to your patients. The story is there. You have to ask the right questions, but I didn't ask the right questions for many years, because I didn't think about periods. I didn't think about hormones changing. I never thought about mental health and hormones, because doing psychiatry, no one taught me, and I shudder when I look back. But medicine is progressive. You learn by experiences, you share the knowledge, and also you work out, could it be a placebo? Could it be a coincidence, or could it be that hormones have a role in the brain? So that's going back to the old textbooks, really.

Fionnuala Vernon [00.08.10] Yes, absolutely.

Dr Louise Newson [00.08.10] Realising that, of course, they have a role int he brain. So therefore it makes sense. And when things make sense, you join the dots, don't you?

Fionnuala Vernon [00.08.16] Yeah, absolutely.

Dr Louise Newson [00.08.17] You then think about other patients. But Haley's experience was really interesting because it was so extreme. But I've seen a lot of similar patients as have you. But then when I met her the first time, and I just asked her the very simple question, How did you feel when you were pregnant?

Fionnuala Vernon [00.08.34] Yes. That’s a real game changer isn’t it?

Dr Louise Newson [00.08.36] It is yeah. And then I also the other question was, you know, how did you feel when you were having your periods? That run up to your periods. How did you feel? She said, no, that was, that was the time I was drinking more. I felt awful. And then it's night and day when my period comes.

Fionnuala Vernon [00.08.51] So sad.

Dr Louise Newson [00.08.52] So she's told me, in a way, that my hormones have affected my mental health, but no one had picked up on it.

Fionnuala Vernon [00.08.57] It's so difficult, and that's what this is,very frustrating. And I see patients like this, and we've always great banter in clinics. I mean, the things patients tell me are, you know, sometimes they are hilarious. And I said, please, can I repeat that? Because that's so funny.And then other times, we hear really sad stories. And one patient, not dissimilar to Haley, and we're chatting, and the tears just streaming down her face, and I'm saying, is there something, you know, and she she's now connected this with PMDD, and she's saying, have all my admissions to hospital, or have my mental health breakdowns, my relationship breakdowns, the ability to not be able to meet someone, all been affected by hormones, and that is something that someone could have fixed had they realised that and that that's grief.

Dr Louise Newson [00.09.44] Yeah

Fionnuala Vernon [00.09.44] That's a grief reaction for her.

Dr Louise Newson [00.09.46] It is. I've seen it a lot, you know, I'm used to it now, but when I first started, I remember lady came back to me and she started crying, and on her symptom questionnaire score, everything was better.And she was young. She was only 44 and she'd had symptoms for about 10 years,but before that, PMS and PMDD, and she started crying. I thought, what have I done? She said, I'm just grieving for those years that I've lost. I could have felt like this. My life could have been different. And I thought, gosh,actually, this is really, really significant. And you know, as doctors, as GPs,we often only have really short consultations, but I think, you know, we can make a huge difference in 10 minutes. To a good or bad if we get it wrong.Yeah, and it's a lot of responsibility, actually, isn't it?

Fionnuala Vernon [00.10.35] Huge responsibility, and it's probably, you probably, I mean, I went into general practice because I absolutely loved everything. I did, loads of obs and gynae. I'm in my 20th year as a doctor. I graduated 20 years ago, this this summer, and I loved psychiatry. I loved obs and gynae. I loved it all. Loved pediatrics and general practice. Let me have it all. Um which was, which is amazing. So, it means that we can, we can call on our experiences and lots of other aspects of our learning. I'm a GP educator. I train GPs, and I'm really passionate about education, and I'm really passionate about about kind of encouraging our GP trainees to stay in the workforce, to be interested, to ask these questions, and if we can educate patients to know what to look for. We also want to educate we're educating men.We do a lot of work in industry, so we want to educate men. And I know that there are people out there who Haley's story will have resonated. There might be some of the conversation that are resonating with people today. It's very difficult for them to find the words. Now, choosing your timing, and you know would would be very important, but even just linking the podcast, even if you can't find the words to say to someone, to reach out, just link the podcast or just send, send a link, and hopefully some of what we're talking about will resonate, and they'll know what to ask for, know what to look for.

Dr Louise Newson [00.12.01] I mean, I feel women are learning really quickly actually, and their partners, their work colleagues. So, men and women get it, actually, but there is still a real resistance from healthcare professionals. There are some doctors, and I spoke to four yesterday who are really keen to do menopause as their future career and hormones. And they said to me, gosh, Louise, it's amazing. I love it when people come into the clinic,they think they've got hormonal issues, they might be perimenopausal, PMDD, and I just love it. It's great. It's so transformational. But then I have other people saying to me, Louise, because of your work, we now are seeing far too many women in our surgeries. We're so busy with menopausal women that we can't get to see other patients, they think they've got perimenopausal symptoms, and how dare they think that they've never had hot flushes. So, there’s this sort of it's like a parallel universe, really. And if, as healthcare professionals,we had better education, we could serve our patients better. I was at a conference recently in Spain, and they were saying, we have to do this blood test in young women, the raised FSH blood test, to make a diagnosis of POI,premature ovarian insufficiency. So I asked the panel for the evidence, because I haven't read the evidence that is very clear that 100% of women have this raised test, because in my clinical practice, I see a lot of women with a normal level or the low level, and they've definitely got POI or they’re perimenopausal of a young age. So, then someone on the panel, a professor, said to me, but Louise, how else would you diagnose? And I said, by taking a really good history

Fionnuala Vernon [00.13.39] Medicine is not black and white

Dr Louise Newson [00.13.40] I said, but in other things, in medicine, we don't always have a test. So, I have migraine, you can take a really clear history, and you'll be very clear that it's migraine. You don't need to refer me to a scan or a blood test or anything. And also, often in medicine, we give a therapeutic trial. So, there's often a push back saying these women think that testosterone will improve their mood or oestrogen will improve their joint pain.Well, we don't know whether it will or won't, but we try to see, and we do this with other medicine.

Fionnuala Vernon [00.14.11] Yes, of course.

Dr Louise Newson [00.14.12] I don't quite know why sometimes people are so scared, but it's also because they've they haven't been trained, and I wasn't trained before. I didn't have that knowledge. So, it's difficult.

Fionnuala Vernon [00.14.22] It is difficult. It comes down to training,and it comes down to our fear. I mean, we went into medicine to help people,that's the bottom line. And we also came into medicine, took the Hippocratic Oath not to do harm. And sometimes to do nothing is no defense. It's harmful to do nothing, and we won't all be experts in everything, and it's very reasonable to put your hands up and say, this is not my area of expertise, but it is our job to signpost people to where to get the help and the support. And because menopause is not a linear thing. And I mean, I'd be very risk averse, you're a pathologist as well. So I mean, you are, as I say attention to detail and the science, but to diagnose diabetes is very easy. You're either a diabetic or you're not. You're either a really bad diabetic and really poor controlled or it's very well controlled. And I think because menopause and perimenopause is not a linear thing, it's difficult, but it's about the history. That's what we're trained to do. And it's inevitable that when we raise awareness, we've seen the same level of interest with things like prostate cancer, when when celebrities or when people who are very well known in the media develop prostate cancer, and then we'll see a surge in requests for PSA testing. And so it's inevitable that if we're raising awareness of menopausal symptoms and the issues we have with menopause that we're going to see more menopausal women? But we're trained to take the history, we're trained to understand, we're trained to exclude other things. Yes, we're very mindful of the fact that not everything is hormone related, but it's fuel. And I'd sometimes explain it to kids, I'd say, like, if your mom didn't, if your mom didn't put petrol in the car,wouldn't go very well, would it? And it's exactly the same. But if it’s thyroxine and your thyroid hormones, if it's your female hormones, even for men, if it's testosterone, there are countless examples.

Dr Louise Newson [00.16.14] Yeah, and it is really difficult, and it's the same in anything in medicine. You know, going back to my migraine, I might have a brain tumour, and every so often, someone will present with similar symptoms.And as a GP, you cannot test everybody. You can't do a scan on everyone. It's different in hospital, you have more access, but it's not appropriate,actually, to always be testing for people. And you know, some people will say to people, how do you know what if you're going to miss an arthritis for their joint pain. Well, we can make more than one diagnosis, is one thing. We can still send people for tests and give them hormones. Often in medicine, well,it's often not in medicine, just a one thing. There's lots of things. And recently, I've been talking to people who have been very socially, economically deprived, saying, well, these women have trauma, Louise, so it's not related to their hormones. Well, they have trauma. They've had difficult times. They might have drug abuse and alcohol abuse affecting their mental health, but they've also haven't had periods, so some of it is just five or 10% but that all adds up in a person's life, and I feel, as a doctor, we really need to be holistic.And also we can't just say, well, your hormones will fix everything for you. We have to be thinking about everything else too. But it's just this willful blindness that sometimes is happening, isn't it?

Fionnuala Vernon [00.17.33] Well, certainly, as GPs, as I said, we are best placed. We are in the communities. We also have the ability we know our patients really well and we have the ability to say, Come back to me. You know.And we know our patients so we can see for the net, it was one of the things we were taught from day one, safety net, if you're not any better, please comeback. If you're any worse, please come back.

Dr Louise Newson [00.17.55] Yeah, and we certainly do that a lot with patients all the time, because we're also, even if it is related to hormones,we sometimes change the dose, the type. We sometimes add in testosterone,sometimes progesterone, if, even if they've had a hysterectomy, and everybody's different. But I'll always say to patients, if this doesn't work, or if, you know, leave it this long. Or you know, like you say, if you have any symptoms that concern, you come back. But usually women know, actually, when you ask enough whether it's hormonal or not, because they've had similar symptoms just before their periods, haven't they?

Fionnuala Vernon [00.18.27] And women are very tuned in we're great talkers. I mean, we'll have these conversations in the tea room and on football sidelines. And we're very open, yeah, we're very open about our symptoms and chatting. And it's great to just create this really safe environment that women can continue to do that. Which is, which is great. As I say, even in the workplace, I would often say to patients, you know, don't be afraid. Don't be afraid. To mention hormones, don't be afraid. As I said earlier, it's sometimes some of the stories patients tell me are, some of them are very distressing,and some of them are absolutely hilarious, you know. So it's just trying to tie all of those symptoms in, and nobody is on their own that's really important,and that there is help and support there.

Dr Louise Newson [00.19.18] And I think training for GPs and all healthcare professionals has got to improve globally, because it's a global problem. All the guidelines are very clear that HRT is first line treatment for the majority of women globally, 5% of women take hormones. In the UK, it's about 14% and it's plateaued. It's not going up. That is not majority. So, like you say, there are harms of doing nothing, and we need to think about what are the risks to the bone health, the heart health, brain health, and day to day symptoms by denying an evidence based treatment because of unfounded fears. And this is where we really have a responsibility. I think to be training the medical students, junior doctors, senior doctors, different specialties. I mean, everybody should know something. Shouldn't they? Even if they don't treat, they should be sign posting.

Fionnuala Vernon [00.20.13] I suppose there's two aspects to that, and I think medicine has changed. So, we'd have had a, we would have had a very doctor centered approach to care for years, and now we're moving into this very patient centered approach, where we're asking patients to become involved in their decision making. And then there's also a piece of work around supporting colleagues. We're all on the same team, and I think that's really important.We're all on the same team. No one, no doctor, ever wants to cause harm to patients. And if we are supporting each other and with the evidence, with the anecdotal evidence, looking after patients, that's just better for patient care across the board.

Dr Louise Newson [00.20.50] Yeah, absolutely, and it is multidisciplinary,and we need to be involving all specialties and working together, and it's a whole history of medicine in women that there's always been this sort of antagonism, and people are sort of scared, or we do it this way, we're not going to change. And I do think social media is good and bad, but patients learn a lot from social media.

Some of it is bad and some of it is brilliant, but if they're not getting help from their doctor, it can be very difficult. I mean, I have a lot of women that contact me through my social media from Southern Ireland especially,who can't go and see someone else because they're very rural and they only have one doctor who’s telling them…

Fionnuala Vernon [00.21.37] You keep sending those lovely ladies to me –it’s good to get chatting to them

Dr Louise Newson [00.21.41] Yeah, yeah. But it's hard, isn't it?

Fionnuala Vernon [00.21.42] It is really difficult. And, I mean, the communities are difficult. We have a great we're on a we're on a crest of a wave in Ireland at the minute, we have had, we've had a very poor relationship with women's health that just, I suppose, again, it's a global problem. Women's Health has never had its place in the sun and it has never been given the funding or the time. And we're coming off the back of the revelations of these terrible atrocities in mother and baby homes, and I think we've lots of great women in politics, both north and south, and that makes a massive difference. Women get stuff done, and we are on the crest of a wave, as I say, where women are now using the momentum from that movement and all of their emotions associated what has gone before. And we had a big win in June this year across the country, that HRT is free to everyone in Ireland, so and that includes test us doing this. Yeah, but certainly in the south, testosterone is there, and it's a great win. Testosterone is difficult to get as we as we chatted about earlier on, but that's a great win. I mean that that's certainly something for us to boast about at home, and we're hoping to just continue on that trajectory.

Dr Louise Newson [00.23.00] Which is amazing. Over here, we have this prepayment so people can get HRT cheaper, but it doesn't include testosterone.

Fionnuala Vernon [00.23.07] So, in the north, we've we're NHS in the north, but we have free prescriptions. So, HRT is free, yeah. And in the south,it's a slightly different system, but now there's a new exemption card where HRT is free to everyone.

Dr Louise Newson [00.23.21] Which is great. So is HRT prescribing increasing in Ireland?

Fionnuala Vernon [00.23.24] There is an increased prescribing of HRT, for sure, and women are more aware, and women are coming forward. So in our clinic,we've taken physical clinics and an online clinic, and what I would do with patients is, because they're able to get their prescriptions free, I'll ask their GP, so it'll be a prescribing recommendation. And my GP colleagues are amazing. They're so understanding, and they are doing great work. And very often they left the phone, because I like to think I was approachable, they left the phone and they said, what were you thinking there? Or what was the rationale? And I am very risk averse person anyway, but it's great just be able to be able to have that conversation, and be able to get women, certainly,their oestrogen, their progesterone on the NHS or the HSC in the south, and just kind of, I suppose we're educating as we go

Dr Louise Newson [00.24.14] I've learned that a lot over the years in the clinic, because a lot of our patients start with us, and then they get their HRT, sometimes their testosterone, or sometimes they just come back to us every year, but we write really detail clinic letters. And then so many doctors I meet say, gosh, I've learned so much….

Fionnuala Vernon [00.24.30] We save your letters and we file them – they’re great reference

Dr Louise Newson [00.24.36] It’s great though isn’t it because that's the whole thing you, you learn by osmosis, actually, and the more clinically experienced you are, the more confident you are. But also, I'm, I'm very happy to share uncertainties with other colleagues. You know, oh, I don't know about this lady. I'm not sure. Do you mind seeing her? And we do that a lot. We're lucky in our clinic, we've got lots of doctors, but we're constantly asking each other. And I think that's important, because it can be quite isolating as a GP sometimes, can't it?

Fionnuala Vernon [00.25.04] Yeah, absolutely. I mean, I came to England and Scotland for my menopause training. There wasn't the level of training, or there wasn't the availability of credited trainers or training programs. So, I mean, we can, I can get forward and back on the same day, and that's where I did a lot of my training.

Dr Louise Newson [00.25.22] Yeah, but sitting in in clinics, yes, I think just quizzing people who see a lot of patients is really important, because every, every clinic, I'm learning something and trying something different, and then if it works, great, if it doesn't work, then you might think, well, maybe not, but it's evolving, and there's so much in menopause hormonal care that we haven't got the research, but you can't wait for the research if you've got someone sitting in front of you.

Fionnuala Vernon [00.25.49] Well, that's it. I mean, we're building research. We're learning as we go. And I think that community again, back to that Royal College of Surgeons day that we had with you and your team. It's building that network of experts, and that's a really secure place certainly for me to find myself and be able to pass it on to patients.

Dr Louise Newson [00.26.07] Yeah. So how do you see things going in the next 10 years, if you were coming back here in 10 years’ time, how do you think landscape would be changing for women?

Fionnuala Vernon [00.26.15] I think we'll both be a little bit older and grayer. There's no doubt about that. I'd like to think that women's health is going to be put on the front burner going forward, I'd like to think that women will have that opportunity. They won't be the same barriers to accessing healthcare. I the NHS, well, look in 10 years, it's very difficult. At home at the moment, we are general practice is on its knees. We just, as I said before 90%of all of the work on the NHS is done in primary care, less than 10% of the budget. So it's very difficult, but I'd like to think that women's health will be further up the agenda. We will have more women able to access treatment for whatever it is they need, whether it's contraception, whether it's HRT, whether it's menopause care, we're all living longer as well, and it's very important that we have quality of life. So many of my patients will say, I want quality I don't want to live till I’m 120. I want to be able to live and enjoy my grandchildren, or enjoy my kids, or, you know, have not.

Dr Louise Newson [00.27.21] Yeah, and I think changing it to thinking about a way of preventing disease is really important. I was talking to an orthopedic surgeon in America, and she said all her colleagues don't even know that HRT is licensed to prevent osteoporosis. So, if we can see it as something to help symptoms and prevent disease, that's going to have a massively positive impact going forward. You know, there'll be less fractures, there'll be less heart attacks, there'll be less, you know, recurrent admissions to hospital,less urinary tract infections. So, it'd be great to see that landscape changing. Yeah, absolutely, but we still got a lot of work to do. Yeah, I know that a lot of healthcare professionals that listen to this podcast, GPS,pharmacists, nurses, what would you say the three things that we should do as educators or people that wanting education about hormones? What are the three things that we should be doing? Do you think?

Fionnuala Vernon [00.28.11] I think the first thing is remembering that we're all on the same team. We all have the same goals. We want to protect patients. We want to help patients. We do not want to do harm. Yeah, that isthe most important thing. We have a very safe space for sharing information and sharing guidelines and sharing anecdotes and conferences like yours in London a few months ago, attending very safe places and spaces like that can only improve the quality of care that we deliver. So I think that's certainly the most important thing from a healthcare point of view, and I am also an educator. So I think that learning and getting more knowledge, and, you know, being very open minded to change and being mindful of the fact that we probably don't have a lot of the evidence that we really need to be able to make the changes that we want to do, but certainly continuing to bang that drum and making plenty of noise, which is really important. And then I suppose the final tip is for patients and for them to have an awareness and for them to recognise symptoms of perimenopause and menopausal symptoms in themselves and their loved ones,and in loved ones that have gone before us as well. So, it's lovely to be in that position where we can shed some light on the history and the very difficult history and the very difficult times that patients have had before.But going forward, if they can't find the words, if they've had a catastrophic row with a sister or a loved one and they just can't find a way of healing those bridges. Or if they've had a complete breakdown in work and they can't find the words to go back link the podcast and, and maybe something will resonate and they might be able to reconnect those relationships, which is so important.

Dr Louise Newson [00.30.01] Oh, thank you well. Thank you so much.

Fionnuala Vernon [00.30.03] Thanks so much for having me – it’s lovely to be here.

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