Dr Louise Newson: [00:00:02] So Jay, I'm very excited for this podcast. We're recording it on a Sunday night because you're super busy. I'm quite busy, but you are a neurosurgeon. So you are the crème de la crème of medicine. I should be bowing and curtsying in front of you.  [00:00:16][14.3]
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Dr Jay Jagannathan: [00:00:17] Well, thank you for having me. I'm a big fan of your podcast. And so I think the value you provide, particularly for women in the perimenopausal phase, my grandmother passed away of a heart attack that went undetected after obviously after menopause. My mum developed breast cancer shortly after menopause. I think it's very critical, valuable information. And I really applaud your work. So it's an honour to be here.  [00:00:42][25.4]
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Dr Louise Newson: [00:00:41] Thank you. Well, I always try and think differently about things because I think it gets people thinking in different ways and that's what I'm doing about hormones, about menopause. But some people listening know that I actually wanted to do oncology many years ago. I wanted to cancer medicine and I only changed my career for lifestyle because I've got three children and I wanted to see them grow up. But my father actually died of a glioblastoma, so a brain tumour when I was nine. And I remember going to the operating theatre. I was so desperate to meet the, well, I met him when I was nine, but didn't really remember him, but the neurosurgeon, Professor Watkins in London. So when I, was a medical student, I went and watched him operate and met him and spent time with him. And you know, it's incredible when you see someone's brain, like you do it every day. But you know for most of us, it is an area that we'll never see and we don't think about often, I don't think. We take our brains for granted.  [00:01:38][56.5]
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Dr Jay Jagannathan: [00:01:38] Yeah, I think it's one of the biggest privileges for me in medicine is being able to operate in that part of the body because I think every part of body obviously is important, but to kind of be in an area which controls so much of your personality, everything that you know about a person is truly unique and it's something you never really lose the awe of seeing that no matter how many years you've done it for. So it's a privilege. I think the other part, you know, with respect to things like GBM. Is our knowledge, the prognosis for GBM in the last 100 years with all the advanced robotics, AI, hormonal therapy has really hasn't increased substantially. It's gone up maybe about four to six months over the course of many, many years. So it teaches you how much we have that's left to learn. And I think when we look at topics such as what we're discussing here, effects of hormones on brain health, on chemistry, on tumours, things like that. I think what we're talking about today, five years, 10 years will be completely different from what people will be talking about then.  [00:02:38][59.2]
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Dr Louise Newson: [00:02:38] Yeah, I hope so. I'm very interested in the role of hormones throughout our body, but especially our brain. And I'm also very interested in inflammation and about how our hormones can reduce inflammation in our bodies, in our brain as well. But a lot of people think once our brain has developed, there's a lot talk, isn't there, about children, adolescents, you know, their brain, how it develops. And then people think it's almost quite stagnant after then. But there's neuromodulation going on all the time, isn't there, in our brain? You know, our brain is constantly almost rewiring.  [00:03:11][33.0]
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Dr Jay Jagannathan: [00:03:12] The brain is constantly rewiring. There are certain parts of the brain, obviously, that tend to be more fixed. There's certain parts in the brain that tend to develop over the course of age. And the size and the shape of the brain changes too. You know, with all of us, as we get older, the brain mass tends to decrease. There're changes in proportions of areas, such as grey matter and white matter, that happen as we get older as well. And there are effects of hormones, such as estrogen, on those factors, I'm sure we'll discuss in this podcast as well. And even aside from the structure, there are areas in the brain such as fluid spaces, the ventricles, things like that, that change in terms of size and in terms of compliance as we get older, and all those have significant impacts in terms of cognitive function and in term of behaviour and other things.  [00:03:52][40.2]
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Dr Louise Newson: [00:03:52] Which is so important to know that we can constantly improve our brain function. We can improve the way the cells work and also the communication between different areas of our brain because different areas have different roles, don't they?  [00:04:07][15.1]
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Dr Jay Jagannathan: [00:04:08] Yeah, exactly. I mean, every part of the brain obviously has an extremely valuable role, I mean the frontal lobe is the area that kind of controls impulsivity, the cognitive thinking, what we think about personality, stuff like that. You know, there are areas of the brains such as the temporal lobe that controls more language, more spatial orientation, things like that, brain stem, which controls critical functions such as breathing, things that we don't even know that we're doing, but are absolutely critical for life. Other important connection is that within these parts of the brain. They're different types of neurotransmitters. Neurotransmitter are the chemicals, almost the currency that the brain uses to communicate with different parts. And these parts play significant roles in the overall internal milieu of the brain, as well as in communication with external hormones within the brain itself. And that also plays a role, those shifts also play a role in terms of how our brain develop over the course of both in our youth and as we get older. Now, the one thing that is true when we are very young is the brain's capability of remodelling is a lot more rapid. So you have something called plasticity. Which is the ability of these premature cells to really be able to remodel. We don't fully understand that obviously with certain areas of the brain, the hippocampus, the occipital lobe are able to rapidly remodel, for example, in a child with a brain tumour, I'll never forget from my training, we took out a tumour in the occiputal lobe of a child that encompassed basically the whole occiptial lobe, and in adults, if you had taken that out, the patient would have been blinded for life, but this child had it in infancy. And by the time she was two years old, was able to have pretty much normal vision, you know? So there is a degree to develop there, but obviously that does change as time goes on. But I think you're absolutely right that the overall functionality of the brain is incredible and it does change. And you know, that's something that we utilise for our benefit as well in terms of treatment and other things as patients get older.  [00:05:50][102.6]
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Dr Louise Newson: [00:05:50] Yeah. And so when I was experiencing my own perimenopausal symptoms about 10 years ago, the biggest thing that, well, the thing that worried me the most is my brain didn't function. You know, I was really struggling to remember. I couldn't multitask. I couldn't remember drug doses. I couldn't remember patient names, really basic things that, you know, were bread and butter really to me. But it was almost like thinking through treacle is really, really scary. And, you know, we've now got data from hundreds of thousands of women who use our free Balance app and the commonest symptoms are poor memory, low mood, irritability. You know, it's the brain that's affected most with hormonal changes.  [00:06:37][46.7]
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Dr Jay Jagannathan: [00:06:38] Sure, so there's an umbrella, you know, I'm listening to your podcast, you use the term brain fog, which is a common term that people use in relation to menopause. And there are several areas that may play a role in that. I mean, I think number one, decrease in estrogen level has been shown to affect glucose levels in the brain. As we know, throughout the body, glucose is an extremely important tool that the body uses for energy production, and that's extremely important in the brain as well. That's why when somebody, we have an athlete and they're kind of losing the energy to give them a drink, a Gatorade or something like that to help with that. So that's one factor there. Studies have also shown that structurally, the brain changes with respect to decrease in estrogen. Specifically, studies in the past couple of years looking at functional MRI treatments have shown that grey matter areas in the brain, the grey matter is the area that contains neurons. The neurons are what's fired that help us control the brain activity, supposedly the circuitry of the brain itself. That those tend to diminish as the estrogen levels tend to go down. And then there's also changes that happen with respect to neurotransmitters themselves. Estrogen has been shown to have a stimulatory role with neurotransmittors such as acetylcholine, with serotonin, with dopamine, which are extremely important in terms of pleasure responses, in terms alertness, in terms activity. And similarly, interestingly, progesterone levels have been shown to be correlated with GABA, which is inhibitory neurotransmitter. They've been shown to be related to things like relaxation and stuff like that. So that combination of effects, clearly there is a relationship between hormonal changes and both the brain chemistry and the brain structure that happens after menopause that play a role in many of those symptoms you discussed.  [00:08:16][97.8]
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Dr Louise Newson: [00:08:16] Yeah, which is so important because once you understand the basic neurophysiology of hormones, it makes it so much more obvious why people are experiencing symptoms and, you know, the way that the neurotransmitters work together, a lot of people will have heard of serotonin and dopamine, but don't realise that actually all three hormones, progesterone, estrodial and testosterone, you know, their levels really can change the levels of of neurotransmitters such as dopamine and glutamate, acetylcholine and so forth. And so there's no surprise that we have so many symptoms affecting our brains.  [00:08:49][32.7]
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Dr Jay Jagannathan: [00:08:50] Yeah, absolutely. Yeah, I think there's definitely a relation, I think, obviously, the structural and the functional relationship play a role as well. So I think these changes in neurotransmitters likely also play a rolE in terms of how the grey matter changes and stuff like that that we see as well, and I think as the technology with the image improves, and that's the main thing we're seeing now, in terms of MRI technology and the ability to kind of link with AI, the functional and the structural aspect, I think we'll see more of this data coming to light.  [00:09:15][25.5]
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Dr Louise Newson: [00:09:15] Yeah, which we need to really, because, you know, one of the problems is that makes me feel very sad at least is that women aren't believed. You know, if I had a rash, I could show you my rash and you could diagnose it, you could give me sympathy. If I tell you that I'm not thinking clearly, you, know, is it because I've just had a bad night's sleep or is there something structurally going on? And a lot of people are very scared of, you now, am I missing something else going on in the brain. And lots of women come to us and think that they have dementia, you know, there are lots of conditions in the brain that can cause memory problems, personality changes as well, aren't there? [00:09:52][36.0]
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Dr Jay Jagannathan: [00:09:52] Right, so any kind of symptoms that are different from the norm warrants further investigation, you know, irrespective of whether you're a male or woman, gender, race, whatever it is. So it does. I mean, I think one of the things we often see, you know both you and I in our respective fields when people are embarrassed or shy or they've been told to brush these symptoms aside. And obviously that's not the right answer. I mean I think nowadays one thing we have nowadays that we didn't have even 20 years ago is we have the ability to order testing and ability to investigate these things much better than it was. So, I think that's the first part of it. Specifically as it relates to menopause, I mean, I think a lot of those changes, there are treatments for it. I think the important part about it is that there are, maybe not definitive solutions, but there are treatments such as hormone replacement, things like that, that can be a benefit.  [00:10:35][43.2]
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Dr Louise Newson: [00:10:36] Absolutely. And I often say to patients, you know, once I've rebalanced your hormones, you know, usually all three actually, progesterone, estradial, testosterone, and wait for a bit because they can take a while to have an effect. And then let's see what else is going on. I remember reading a few years ago that the first thing, or one of the first things that happens in our brain, if we have a head injury or stroke is that our brain produces more progesterone, men and women actually. And it's very, it's, very repairing. It's a very repairing hormone restorative and it's interesting. I mean, I used to work in a stroke ward many, many years ago and never ever crossed my mind about progesterone and these women, mainly women that had strokes, but men as well actually.  [00:11:15][39.1]
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Dr Jay Jagannathan: [00:11:15] Right. So progesterone, yeah, I mean, it does have a protective effect on the brain. And we talked about the relationship with that in GABA, inhibitory neurotransmitter. You know, as I think we talked about before we got on the podcast, there's a lot of data that shows progesterone. So when you look at brain tumours, meningioma specifically, benign brain tumours. Up to 90% of them will have progesterone receptors. And a progesterone receptor positivity in meningiomas has been shown to be correlated with a decreased risk of recurrence. So, there is positive effects of progesterone from that standpoint as well.  [00:11:46][30.7]
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Dr Louise Newson: [00:11:46] Yeah, and increasingly, we give progesterone to women who've had a hysterectomy, I feel a bit embarrassed as a doctor for many years, I've been told only give progesterone if a woman has a womb, but actually all women have brains and we know that, you know, progesterone has an important role in brains and a lot of people like the effects of progesterone, you know, I am, it's all about getting the right dose and type and often when, when we talk about progesterone, people group all hormones together. Whereas when I talk about progesterone, I just mean an exact replica of our own progesterone hormone. Whereas there are a lot of synthetic progestogens or progestins you say in the US, which are not the same chemical structure. And they often can really negatively affect people's mood, memory, and so forth. And then you also mention meningiomas, which are benign brain tumours, but there does seem to be an increase in incidence recently. We don't really know why, but there has been some association with some synthetic progestogens and whether it's because they're blocking the natural progesterone or they have their own sort of almost toxic effect on the brain, we don't know, do we?  [00:12:55][69.0]
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Dr Jay Jagannathan: [00:12:55] I do think you're right in terms of synthetic progestogen, especially that is a concern because obviously we know that there may be enough variation in terms the receptor itself that maybe in terms how it binds to the receptor might be different or might bind to a different receptor site. Obviously these are speculative things I'm saying, but it may have a different effect from a natural progesterone that maybe has a protective effect.  [00:13:17][21.9]
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Dr Louise Newson: [00:13:18] Yeah, and we know that, for example, even if you look at the cardiovascular system, progesterone is very good and anti-inflammatory, whereas the progestins increase risk of cardiovascular disease and increase inflammation. And having an estradiol and progesterone receptor is actually good because we have them naturally anyway. So it's, but it's there's so much we don't know because people have been scared away from hormones, especially when you talk about hormone replacement for decades. I mean, I don't know how much training you got when you were a junior doctor or an undergraduate about hormones? [00:13:52][33.9]
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Dr Jay Jagannathan: [00:13:52] Probably not enough, you know, I mean, I think the problem, you know, and I feel like neurosurgery, you're so focused on the on the certain technical things, you know, the general part, but you know one question I have for you is that some some patients I've talked to, or some physicians I've talk to, dealing with patients who have these symptoms, these perimenopausal symptoms, advocate early replacement of estrogen, they say if you wait longer, the effectiveness can go down. Is that something you see in your clinical practice?  [00:14:14][22.1]
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Dr Louise Newson: [00:14:15] So it's really interesting actually, because it really varies the response to hormones and I was taught many years ago that there's some methylation of the receptors and actually people who have longer without hormones will less likely to respond, especially in the brain. But then Lisa Mosconi's work, who's a neuroscientist as you know, found that actually when people are deprived from estradiol for a long time and then have it back, their brain responds very quickly. I certainly see women, we sometimes see women who are in their 70s, 80s, who've had 20, 30 years without hormones and then deciding they want them often to improve their bone density, but their brain just works again. I think it all varies and also it's not just the estrogen, it's also the progesterone, but in our experience testosterone makes the biggest difference to brain, especially cognition and mood actually. So often it's not until all three hormones are balanced.  [00:15:13][58.1]
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Dr Jay Jagannathan: [00:15:14] Okay. Okay, sure. And yeah, I think on that note, the other area that we deal with it from a neurosurgical perspective is the effect of these hormones on the spine, right. And there's a lot of data when it comes to things like back pain, osteoporosis, things like that, that I see kind of later on in the course, where obviously these are factors that you have to take into account with respect to hormone replacement therapy, in particular as it relates to the perimenopausal period, the protective effect of estrogens in terms of bone density and things like that. As well as changes in estrogen can affect ligamentous factors and stuff like that can lead to things like back pain and things like that in patient tests.  [00:15:52][37.8]
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Dr Louise Newson: [00:15:52] And I'm really pleased you mentioned that because one of the things I'm most scared of being menopausal is osteoporosis of my spine. I mean, I wouldn't like an osteoporotic hip fracture, but it's my spine and I think people underestimate the importance of the spine until there's a problem and they're really painful. Like you say, those fractures, sometimes they can be repaired, but not always. But the other thing is that our hormones can modulate the pain receptors as well. You know, they actually stimulate the opioid receptors. So a lot of people would have heard of opioid drugs such as morphine, but actually our estradiol, progesterone and testosterone can modulate pain in beneficial ways, which a lot people don't realise, but also reduce inflammation and like you say correctly, to strengthen the bones, so reducing the incidence of osteoporotic fractures of the spine.  [00:16:46][54.0]
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Dr Jay Jagannathan: [00:16:47] Right, so yeah, I think for osteoporotic fractures, I mean, that's something obviously, you know, women do tend to have a lot, significantly higher incidence, particularly later in life when compared with men, you know. And a lot of times, you know, what we see particularly now in patients who aren't necessarily on hormonal replacement, stuff like that, is that they tend to come back with more of these fractures. And you know they do get harder and harder to treat. They not only cause pain, but they can affect posture, affect balance, affect walking, things like that as well, so. I think, definitely, in addition to the hormonal side of it, I think kind of keeping track of that, you know, measuring bone density is extremely important in addition to appropriate training and resistance training and in low degrees, things like that have been shown to have major positive effects when it comes to preventing those kind of fractures.  [00:17:28][41.8]
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Dr Louise Newson: [00:17:29] Absolutely and your job isn't just the brain, obviously you've mentioned the spine, but also the peripheral nerves as well. It's really important because a lot of people get pins and needles and even restless legs and so people forget actually that the signals from the brain to the nerves and muscles have to be kept firing very quickly so we can be very responsive and reactive and I'm very interested in the myelin sheath so that If you can you explain what the myelin sheath is? [00:18:01][31.9]
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Dr Jay Jagannathan: [00:18:01] Yeah, so the myelin, if you think of a nerve as kind of like a giant wire, and basically you have a cell body, that's what receives the impulses from the outside. And nerves are similar structurally, both in the central nervous system, peripheral nervous system. What's different is how they're enveloped and how they are protected and the internal milieu. So you have the cell body that contains basically dendrites, which are little fingers that get neurotransmitters, which are signals that are sent from other nerves. It's processed in the cell body and then it's transmitted out through a thing called an axon, which is a giant wire that basically connects to other nerves. So you can have one nerve that supplies a million other nerves that kind of again signals to the rest of the body. So the myelin sheath is basically a kind of an insulation over the axon and what it's meant to do is to provide increased rate of conduction within the nerve itself. You can think of it as and so this conduction is called saltatory conduction. Saltatory just means it's jumping, so it tends to jump from node to node along the myelin sheath, and that significantly increases the rate in which impulses are transmitted. So understandably, if the myelin sheath is affected, which it can be affected both from hormonal changes, diseases, just multiple sclerosis, things like that, can affect it as well, that slows down the transmission, and as I was mentioning, if you think of a nerve as a relay station that connects to millions of other relay stations within the body. A damage, even to a small degree of the myelin sheath, can cause catastrophic repercussions when it occurs downstream. It may not just be happening with one muscle, it may be happening with millions of muscle fibres. That's why the myelination is important, and as you mentioned, the hormonal changes can play a significant role in that.  [00:19:41][99.5]
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Dr Louise Newson: [00:19:41] Yeah, I think it's so interesting. Several years ago now, I was giving a presentation about multiple sclerosis and the impact of hormones. So I went off and read quite a lot of papers and once I realised the importance, actually, especially of testosterone to really rebuild the myelin sheath and keep it as good and strong and healthy as possible, it then made me think, what I wonder, is that why more women than men are likely to have multiple sclorosis, which we know is a condition that can, the myelin sheath can be negatively affected and actually some studies have shown that men with low testosterone are more likely to have multiple sclerosis.  [00:20:17][35.8]
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Dr Jay Jagannathan: [00:20:18] Yeah, that's absolutely true. And the other thing that's really interesting about that is men who have been on anti-androgen treatment have also been shown to have some increased risk of disease like MS. And same actually, interestingly, with meningiomas too. You know, it's kind of an interesting area because it's, you're right, it as much boils down to the testosterone as it does to the estrogen. It's a balance, you know, and it's a very, very delicate balance that when it gets disrupted, you can have significant ripple effects downstream.  [00:20:43][24.9]
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Dr Louise Newson: [00:20:43] It's so interesting because, you know, any condition that happens more commonly in women in the late 40s, we've got to be thinking about hormones. But a lot of women who are younger have low testosterone, you know, in their 30s and 40s. And they're still not thought about unless it's thought about in conjunction with estrogen and progesterone. So I feel very strongly we have to be thinking about these hormones separately because they have different functions and roles in the brain and the body. They work together, of course, but then they work with other hormones as well. You know, like you say, you've already said, glucose for insulin and thyroxine, for example, but there's so much we don't know, but we just need to know, don't we? Because if we're anything we can do to improve our brain function is key.  [00:21:27][44.4]
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Dr Jay Jagannathan: [00:21:28] Sure. And yeah, I think those are extremely important points. I think the other one point I really want to emphasise, we've talked so much about symptomatology related to hormones, about brain structure, about brain chemistry. And you know, because social media has a tendency to kind of promulgate kind of myths. The important thing to keep in mind is things like intelligence are not affected by these changes, you know what I mean. I mean, the symptomatology can be bad, those are areas we can treat. But it's important to note that even at the perimonopausal ages, in terms of being able to function in a job capacity or anything like that, there's really no reason why you can't be able to do that just because of these changes. These are symptoms that can be treated, but in terms overall IQ, intelligence, stuff like that. There's no reason to think that women going through those changes have any decrease compared to their male counterparts.  [00:22:16][47.7]
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Dr Louise Newson: [00:22:17] Yeah, I think when they're untreated though, I know hand on heart, I wouldn't be working as a doctor if I didn't take hormones. And in fact, I was, I changed, I used, I've been on testosterone for about 10 years and I use a cream, but recently I changed to the gel just because it's slightly cheaper and I thought, Oh, I'll just try it and see, and I could tell when I rubbed it on, it was floating off my skin and it only tookabout three or four days where I was just a shell of myself and my husband was like, you just don't seem to be listening. What's going on? You can't. And it was, it's really quite scary actually and I also get migraines as well. And if my hormone levels aren't at the right balance, and migraines are so intense and so severe, and that really affects the way that I not just think that I slur my speech, I can't, you know, function at all. Yeah.  [00:23:04][47.6]
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Dr Jay Jagannathan: [00:23:05] What do you think is the reason between the cream and the gel in terms of absorption? It's not as good or what is that?  [00:23:12][7.1]
Dr Louise Newson: [00:23:12] It's all absorption. We use the estradiol and the testosterone through the skin because then there's no clot risk, it goes straight in, we can tailor the dose. But it's the absorption and people's skin type is very, very different. It can be skin temperature, skin thickness, there's all sorts of things. But some people absorb better than others and we've published some data to show about a quarter of our follow-up patients need higher than licensed doses just to get adequate penetration through the skin and we see it a lot. I'm one of those people that just, I don't know, I've got the skin of a rhino. It just doesn't really absorb very well. And, you know, we can measure levels to make sure that the levels aren't high. It's not we're having high amounts in our bodies. It's just to try and get it through the skin, but having the right dose is really important because we know also that studies have shown that if the estradiol level is low in the body, then there's more inflammation in the body. There's increasing evidence, isn't there, about neuro-inflammation, so inflammation in the brain being associated with all sorts of conditions, including psychiatric conditions. So we want to be, you know, our inflammation in our bodies and brains needs to be as low as possible really for longevity reasons.  [00:24:27][74.8]
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Dr Jay Jagannathan: [00:24:27] Yeah, and you know, as we know more and more about it, a lot of those neurotransmitters we talked about earlier, too, things like dopamine and stuff like that, have been shown to have very critical importance in terms of the pleasure pain responses, and things like that. So given that we know that these factors are related to the hormones we mentioned earlier, likely it has a very important effect, not only on inflammation, but in terms our perception of the inflammation as well and how we respond to it.  [00:24:51][24.2]
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Dr Louise Newson: [00:24:52] Yeah, it's crucially important that we look after our brains and obviously hormones are important, but you know, what we eat, how we exercise, whether we drink or smoke, or drink alcohol rather, and smoke, all these things can really affect our brain function, can't they?  [00:25:06][14.3]
Dr Jay Jagannathan: [00:25:06] Yeah, so lifestyle changes. I think that's a very important point that, you know, that lifestyle, I wouldn't say changes, but lifestyle in general plays a significant role. We talked about things like resistance training. You know, one area I was curious is whether with testosterone supplementation, we're talking about whether you see an increase in muscle mass mass in women when they're getting that because that obviously is a is a critical area in terms of functionality. A few other things diet, Mediterranean diet, you know, in terms of all-cause mortality has been shown to be decreased kind of focusing,you know, less unprocessed foods, olive oil, things like that. You know I think decrease in alcohol, tobacco consumption are critical factors as well. I think particularly staying on top of bone density, we talked about that earlier. You know particularly in post-menopausal women is very critical as well  [00:25:51][44.8]
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Dr Louise Newson: [00:25:51] Really interesting. Yeah, I mean with testosterone, because we're using the natural body identical testosterone, muscle mass really only increases when people exercise. You know, the synthetic testosterone is quite different. You can get, it's an anabolic steroid, whereas natural testosterone isn't to the same extent, but a lot of people find that they can exercise better. And you know, maybe they've got less muscle and joint pain. They've got more stamina, they've got less fatigue, but they, you know it's easier to build muscle, but not to a ridiculous way. But we know our muscles are metabolically active as well, aren't they. So if we've got better muscle function, it's not just the strength. It's actually, they function better and that can improve the way our whole body and brain work.  [00:26:32][40.3]
Dr Jay Jagannathan: [00:26:32] Exactly, and I think the core muscles, particularly when it comes to the spine, the core muscle, the paraspinous muscles are extremely critical in terms of balance, in terms what you call sagittal balance, because you're really just stand upright. And we know as we get older, you know, with arthritis, with degeneration, men and women, but more pronounced in women because of these fractures and stuff that we discussed earlier, that's extremely important in terms minimising stress in other parts of the body, the hips, the pelvis, the femur, things like that. And so I think that type of strengthening, you now, doesn't necessarily have to be on to the gym and doing deadlifts, but it's in terms of core strengthening, posture strengthening, yoga, pilates, things like that. Swimming even, swimming is very good, low impact activity. Those can significantly decrease, build core muscle strength, improve posture and improve, decrease the long-term effects of some of these changes when it comes to the spine.  [00:27:18][45.8]
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Dr Louise Newson: [00:27:18] There's lots we need to do, so I'm very grateful for your time. But before I finish, I always ask for three take-home tips. As a neurosurgeon with all your experience with the brain, what are the three things that anybody listening can do to really look after their brain for as long as possible?  [00:27:34][16.3]
Dr Jay Jagannathan: [00:27:35] Number one never ignore your symptoms. As we mentioned earlier any kind of new symptoms, changes, there's no such thing as I think we both agree There's also things a stupid question when you see your physician. Always pay attention to that. Number two, lifestyle and brain health are are integrally related. Your brain is, controls every aspect of your life. So things like diet, exercise are extremely important and play extremely important role in terms of the overall health of the brain and the nerves in general. And number three, you know, I think the crux of here is that hormonal levels do change, particularly in women after time. I think these symptoms are expected as you get older. So don't be ashamed to talk to your doctor about hormonal replacement, about other options are available to you, particularly when you get to that age if you're having symptoms related to menopause and other things.  [00:28:24][49.6]
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Dr Louise Newson: [00:28:25] Lovely. Thank you so much for sharing your knowledge today. It's been great.  [00:28:28][3.1]
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Dr Jay Jagannathan: [00:28:28] Thank you very much, thanks for having me.  [00:28:28][0.0]