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Attempting Motherhood
Attempting Motherhood: The Aud Way is a podcast for late diagnosed or late realised ADHD / AuDHD mothers.
It is hosted by Sam, an AuDHD ( autistic + ADHD ) elder millennial mom.
Episodes cover topics pertaining to motherhood, neurodivergence, the combination of those two and how they intersect.
Remember in this wild ride of motherhood, we're all attempting to do our best.
Attempting Motherhood
Perimenopause Myth Busting & Navigating MHT / HRT In Australia with Dr. Ceri Cashell
My guest, Dr. Ceri Cashell, and I get into all things Perimenopause and MHT / HRT today! We open with some Perimenopause Myth Busting and then dive head first into women's hormones and Menopause Hormone Therapy (MHT / HRT) - while the hormones we talk about are relative to anyone going through perimenopause, she outlines specifics about what is available in Australia, what is subsidized on the PBS, and what we'll have to pay privately for (spoiler, it's testosterone).
Head to the 24:40 mark to jump into the MHT / HRT breakdown.
Dr. Cashell is one of the co-founders of the new online education platform called Healthy Hormones. It's an Australia specific platform for educating other healthcare professionals and allied health professionals about peri-menopause about menopause and hormone replacement therapy. They are also developing a patient portal side where as patients, we will have access to information where we can learn more about our hormone journey and learn how to advocate for ourselves. Unfortunately she is not taking on new patients, but that is why her Healthy Hormones platform is so fantastic because we can still benefit from her work, even if we can't actually have her as our doctor.
Connect with Dr. Ceri Cashell:
Instagram @DrCeriCashell
https://drcericashell.com/
Healthy Hormones - https://www.healthyhormones.au/
Resources Mentioned:
Dr. Cashell's "Hysteria to Hero Doct
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Disclaimer: I am not a doctor, medical professional, or mental health professional.
I am sharing my lived experience. If you relate to any of the content in these episodes, do your own research and speak to a medical professional if needed.
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My guest today is Dr. Ceri Cashell. She is a GP with a special interest in women's health, which includes of course, menopause and peri-menopausal care. As well as mental health, adolescents and child health. She practices in Sydney's Northern beaches, though. You will hear, she is not originally from Sydney. She is a mom of three originally from Belfast, Ireland, who did her training in Edinburgh, Scotland, and landed herself in Australia a few years ago.
In addition to all of that. Because she has so much free time. She is one of the co-founders of the new online education platform called healthy hormones. It's Australia specific for educating other healthcare professionals and allied health professionals about peri-menopause about menopause and hormone. Replacement therapy. And they are developing a patient portal side where as patients, we will have access to information where we can learn more about our hormone journey and learn how to advocate for ourselves. Unfortunately she is not taking on new patients, but that is why something like her healthy hormones platform is so fantastic because we can still benefit from her work. Even if we can't actually have her as our doctor.
This was such a wonderful chat and I am absolutely going to have her back on the podcast. Again, we've talked about doing a whole episode dedicated to PMDD because it is so important,
but in this episode, we jumped the gate with some myth-busting about peri-menopause.
We go through. Menopause hormone therapy. M H T sometimes also called H R T. And especially what is available in Australia. I mentioned in. the episode that I am so glad we have access to information and that there are other doctors like her. Sharing information, but so much of it is U S centric. So for this one, I wanted to get Australia centric. For those of us living here, what's available. What's approved. And what's on the PBS, so it's not going to cost us an arm and a leg. Or should I say a uterus and an ovary to get. If you enjoy this episode, please share it. Please leave a review and feel free to send me any questions that you have for future 📍 episodes.
If we could start with some perimenopause myth busting. Yeah. And we'll do this kind of rapid fire style. Yeah. So if you could just say true or false.
Yep.
If there's things we need to come back to, we can. . And there's just 10 of them, so we'll just bump through them. Myths that I have seen around. True or false, you can't get pregnant in perimenopause. That's false. Yeah. Your lifestyle does not impact perimenopause. False. PCOS has an impact on perimenopause. Endometriosis may get better post menopausally. Depends on the MRA. I know that. Women don't start perimenopause before 40 years old.
Perimenopause can last up to 10 years. There's no benefit to MHT or sometimes called HRT if you don't have extreme symptoms. False. Perimenopause can create changes in your gut microbiome. Insulin resistance is common in perimenopause.
Not uncommon. Okay.
And perimenopause is a natural process and we should just deal with it.
Yes, but not on your own. Okay.
Let's jump in to perimenopause. I think first, people who've heard me talk have probably heard this, but I do just want to clarify for anyone who doesn't know perimenopause is the transition into it's five to ten years before you actually have that menopause.
Menopause is one day in time, twelve months after your last period. If you've gone eight months and then you have a period, you start the clock over. And postmenopause is after that. One day, so just terminology, because if we refer to different things, that way, people can understand and one terminology that I wanted you to talk a bit more about kind of alluded to it with the under 40 question.
Sometimes when people start perimenopause and they're under 40, I've also heard it talked about as insufficient ovarian syndrome. But is that when you start perimenopause before 40 or is that like when you cease? Menstruation before
40 and when you cease menstruation before 40 is premature ovarian insufficiency, which used to be called our primary ovarian insufficiency or premature menopause.
So PO POI is the preferred term because actually when women stop ovulating before four and they get a diagnosis of POI, there is still a small chance that they may ovulate randomly in the future. So they still have a risk of getting
pregnant. Interesting. And for most of us, if we just start perimenopause before 40, like I'm 37 and I've in the last six months just started, I know there's some of the signs, like cycles becoming shorter, eventually they're going to become erratic.
If someone has POI, what does that look like? They've just done the whole process earlier?
Yeah, so they, we think that their ovarian reserve has declined much faster and they've lost all of their viable eggs at a much younger age, so they really do stop having periods. Completely. So they've, they're not just stuttering, they've stopped.
And so that's the difficulty with perimenopause and it's also, and it's a confusing issue with the guidelines is that if you're concerned that somebody is menopausal before 40, you really should do their blood test. But the blood test will only diagnose the postmenopausal state.
So it, the blood test will never diagnose perimenopause and to be in perimenopause in your late thirties is normal because it is normal to be menopausal at 45. So we've got this age, normal age range for last menstrual period of 45 to 55, of which 51 is the average in the midst of that range. And if you take 10 away from 45, you get 35.
So we're going to have a lot of women who are in perimenopause in their late thirties. But our guidelines are, if you're thinking about menopause in a woman under 40, go and check her bloods. And I think that definitely confuses doctors a little bit because in perimenopause, your bloods will still be normal.
Yes. And I know sometimes in late perimenopause, say when you're getting much closer to the actual menopause date, then checking things like FSH can be a little bit of an indicator. But when it's very early, it's really just like, you got to trust us. Yeah, most doctors unfortunately don't do.
Yeah, that's that is a huge difficulty so yes so in late perimenopause, really, probably once you've stopped having regular cycles and you're skipping a few months at a time and you'll see that FSH going up, because the FSH is, as you know, produced in the brain.
And it goes up when there's not enough estrogen being produced by the ovaries that, because there's not enough ovulation happening. So you need to have consistent failure of ovulation for the brain to pick up that there's no estrogen. And then it suddenly goes, and starts to pump out more FSH, but that's really, as you say, it happens really late in the piece and a lot of the earlier symptoms are, psychological or neurological symptoms and, often coincide with lots of other things in life that you might blame instead of perimenopause.
So much. And also too I think this was a little bit my case. I don't know. The waters get muddy, but I think a lot of women were having babies later. So we're going right from postpartum where your hormones are all wacky anyways. And especially if you're breastfeeding, who knows how long that can go if you're, breastfeeding and you may step right from postpartum into perimenopause.
Yeah, absolutely. So it's, and when you're breast, if you're breastfeeding and you're breastfeeding exclusively, then you, a lot of women don't ovulate. So in a way, some of those symptoms might be similar to, perimenopause and menopause, because you've got really low levels of estradiol and progesterone and often testosterone is very low and when you're breastfeeding.
And it never occurred to me when I used to get drenching night sweats when I was breastfeeding that was, I just knew it was breastfeeding sweats. It never occurred to me that it might've been a similar process to what you get in menopause. But yeah, quite right. The women, I think that's, and you just assume that then all of that overwhelm and anxiety.
Anxiety and insomnia is because you've got a baby or a toddler and a baby , and nobody thinks maybe there's something more biological going on. We're always looking at the environment and the other things that are happening. Instead of thinking what might be happening inside the brain, could that also be impacting?
Which of course it often is,
and I think so many doctors don't understand the hormonal of. In that your estrogen is low, your oxytocin, your prolactin are high, what's going on when you're breastfeeding? And then like I breastfed for two and a half years, but I started having a cycle or, having my period again when she was nine months old, I felt really gypped because everyone tells you as long as you're breastfeeding.
I got nine months, but I was really hoping for a bit more. But when that happens, like then your hormones are seriously because your cycle is trying to come back. You're still. And she was like. a boob monster. She still was breastfeeding loads throughout the day, all night long. It was a lot.
And I think if doctors understood a bit more just about hormones in general, if they understood about hormones, we would not be where we are, but
especially in the postpartum period. I think, I think it's exactly as you say, if we understood that ovarian hormones are actually brain hormones, really trying to re frame them as their most potent effect are in our brain, and that's, obviously why women experience.
perinatal postnatal mood issues. That's why women get premenstrual mood issues. That's why we get perimenopausal mood and cognitive issues. That's why women who are neurodivergent struggle at a certain part of their cycle, that these hormones are, have been hugely under recognized for their potency in the brain, working.
On all of the circuits, we now appreciate some of us appreciate the estradiol and progesterone, our potent actors, with our serotonin, with our dopamine, with our GABA, with our glutamate we don't have as much, really very much data at all on testosterone in the female brain, but, it is produced in the brain as well.
So anything that's being produced in an organ Is likely to have a function and most things happen in our body for a reason and not just for the crack.
Yeah, I do. I've said in the past that I think it's such a huge disservice that they're labeled sex hormones because then everyone only thinks of, they're regarding reproduction, but they impact every single part of our body, which is also why.
You know, We see like, Dr. Lisa Mosconi's paper that came out with the estrogen receptors in the brain, but even if you just look the rates of osteoporosis in women versus men, okay what's the differentiating factor there?
I know it's, yeah, it's crazy, so once you like, you drill down to it, somebody asked me, where's the paper that shows that you've got estrogen receptors in every cell of your body?
And there isn't a paper that actually says that, but we know that. Mitochondria, the little battery packs in ourselves, they are covered in estrogen receptors and every single cell in our body has got mitochondria apart from mature red blood cells. But, so we do know, so estrogen is there and it makes sense, so like the hormones that are, if you say they are primarily there to make us reproduce, that is the primary function of most cells is to keep reproducing and, and stay alive.
So it makes sense that there's sex hormones in every cell. The alpha body, because our, most species, the primary function is to live long enough until you reproduce and keep the cell line going. So it makes sense that these are hugely potent, but their function is so much more than just reproductive capability.
It's. Staying alive to reproduce, it's finding a mate to reproduce with all of these, you know, finding enough food, keeping warm. These are all quite complex 📍 activities, so it makes sense that those hormones are driving us to do all of those things as well. Yeah, it makes perfect sense once you think about it in its entirety.
When you actually break it down and think Oh, let's think about evolution.
Yeah.
Yeah. So with perimenopause and oftentimes. MHT Menopause hormone therapy is used. I guess that's probably a myth we could have busted also that. For a long time, people didn't get supplemental hormones until post menopausally, and now, thankfully, we have understood that they can help mitigate some of the symptoms of perimenopause and make that transition easier, but is there a minimum age that, or like a minimum symptom presentation to when MHT would be appropriate?
So not in my opinion, I think really, everybody's symptoms are, they mean different things to different people. So there's not like a score or a certain number of symptoms that you are a certain level of suffering that you have to achieve for me to say, okay you're suffering enough.
Let's try some hormones. It really does vary from person to person on what they want to try. And there's certainly no minimum age to try hormones, in the UK and their PMS clinic really since the 19. Like late 1980s, they would have used hormone therapy, in the same drugs that are in HRT or MHT to treat PMS and postnatal depression and very effectively and there's some good data on that.
And that's something I would use as well. So I do use body identical hormones to treat premenstrual dysphoric disorder and it can be very effective. Whether it's perimenopause or whether it's PMDD or whether it's postnatal depression, there's certainly room to try body identical hormones in all of those women.
Definitely not a minimum age or a minimum level of suffering. And then it's just working out what works for somebody, and obviously always looking at the other things that make a difference, like your nutrition and your level of movement and your social connection on your sleep and your alcohol intake.
None of us who work in this space just think that hormones are going to work on their own, but they often do allow people to make the lifestyle changes that are so important, so if you're not sleeping. Or you're aching all over or your anxiety is overwhelming. It's really hard to get off the sofa to go and do some exercise.
It's really hard to make good food choices and often your sleep's terrible. So by fixing, some of that pain, some of that motivation, some of that sleep, women really then go on to make all of the other changes that make a huge difference. And, the whole package comes together.
And that really helps. Often, really improves all of the symptoms for most women, but not all. So definitely no minimum age, definitely no minimum level of suffering.
And you've written a paper Hysteria to Hero Doctors. I'll put a link to it in the show notes because it's full of really good cultural history, but also really good information as far as how you would treat certain things.
And I was really interested to read. Like in regards to PMDD, you would use bioidentical hormones, but also that you often see a higher dose than, quote, unquote, normal is needed for those patients that experience PMDD, which just blew my mind because even just using it in general, for backstory, why it blew my mind a little.
Most women I know that have PMDD are offered birth control. I recently went to my own GP who I really like and she specializes in women's hormones and told her, I think I'm in perimenopause, and I'm having these cyclical mood issues. And she said I think you have PMDD, but she offered me just birth control.
And I said 1, we don't need it. And 2 like, I have a really terrible history with birth control. You and I have talked via message that neurodivergent women. Are at a much higher likelihood of developing depression from birth control, which is what happened to me. And so her only option then was to do progesterone only birth control, which I still don't really want to do because it's progestin.
And it was it left me with the understanding, she said if you really want to push, I can try MHT, but try the birth control first, which I don't want to do. So I was interested that you will just jump straight to it. Like hormone replacement therapy for someone with PMDD.
Yeah, it's this it's such a weird I don't know if it's a paradox, I don't know what the correct term is, but that we easily.
Use synthetic hormones and, all and all contraceptive pills have at least one synthetic hormone in them. We've only got two contraceptive pills with body identical estrogen. So Zoelli has got estradiol in it, but it's a set dose and it's probably Often too low a dose. And then there's a new pill called Nextelis, which has got Estetrol, which is actually the same chemical structure as Fetal Oestrogen.
And so it's possible that might work for some PMDD sufferers. And certainly Zoeli does have some evidence for working. But yeah, there's a really strange world that we live in that we are really happy to prescribe synthetic hormones to, girls as young as their teens when we really Don't really know what the long term data is, and I'm certainly not saying that the contraceptive pill shouldn't be used for people.
It's a great way of controlling your fertility, but it's not without its risks. Whereas body identical hormones, we're actually giving you something that's chemically identical to your own hormones. We've got quite good long term data. We can see that, you know, it's protective of the bone and there's good.
There's reasonable data to show that it's protective to the heart, and there's a tiny bit of data to show that it's protective of the brain. Whereas, with the synthetic progestins, we don't have that data. So it is strange. I don't really understand why the use of body identical hormones hasn't garnered more attention over the years.
When you look at the work that was being done in London in the eighties and nineties and the early turn of the early turn of century , early nineties, . Turn of the century, yeah. There's the turn of the century turn of the millennium. John Studd and I think Nick Panay worked alongside him and he's chair of the International Association of premenstrual Disorders.
They were using a lot of transdermal estrogen at higher doses. So I think the higher dose Transdermal oestrogen can sometimes suppress ovulation. So potentially almost could be a contraceptive, although we absolutely can't say that it is because we don't have the data for that. So it may be suppressing that, that variability and that flux of oestrogen.
They regularly use testosterone as well. So that seemed to be a potent part of the treatment. And then you've got women, some women, not all women with PMDD can take progesterone, but a reasonable number can. So I've got quite a few younger women who tolerate progesterone as in a natural progesterone really well but there are a small subgroup of women who hate any type of progesterone and you have to, that requires a wee bit more tweaking.
We think certainly a group of women with PMDD are probably, it's maybe more of a neurodivergent presentation of PMS, so whether the two together, and then I think, there's all these different sort of symptom clusters, with like hypermobility and heavy painful periods and, mass cell activation, there's these clusters of things that are going on and, that really deserve a lot more attention.
clinical attention to see, is there something underlying all of those? But yet crazy that we are so comfortable at offering the combined contraceptive pill, but we're scared of offering body identical hormones. It to me makes no sense. And, and there's huge pushback to suggesting that we use body identical hormones in younger women, especially ones who don't.
Make the traditional di definition of perimenopause. So if your periods are still regular, the guidelines would be, you're not in perimenopause, you're in pre menopause, therefore you can't have MHT, but maybe there are some women that respond to MHT in pre perimenopause or perimenopause. And I think we're just overcomplicating the issue.
Like we know that these hormones are potent. Actors in our brain, if women have symptoms that respond to hormones, then use the hormones that they respond to, because that makes sense. No risk of DVT with transdermal oestrogen, which there is with the pill, no risk of stroke or heart attack, no risk of that we know of with breast cancer with natural oestrogen either.
Yeah.
And what I like also about the idea of M. H. T. versus birth control, I mean there's so many things, but the tailorability, because like you said, maybe we need slightly higher estrogen, maybe we need slightly, and also testosterone is not in the pill at all.
Not close it. Oh, okay. So the pill actually reduces your level of testosterone.
So that could be one of the reasons why people do struggle on the pill, that they're actually losing their natural estradiol, their natural progesterone, and their natural testosterone. So that might be one reason why women are pill intolerant. It might be not so much that they, are reacting to the synthetic progestin.
It might be more that they're losing their natural hormones on the pill because they're not ovulating. Sorry, but you did say about the higher doses of estrogen. Why would that be relevant? And that's possibly because estradiol is so potent on the dopamine system. So for women with PMDD who are often neurodivergent having that high level of estradiol in the brain could be a godsend for their brain function.
And even
for if PMDD isn't in the mix, like we know people, especially who have ADHD, we understand there's certain points in our cycle where if you're low hormone, so typically week four and week one, you're going to be Struggling a bit more. Your medication isn't going to work as well and good psychiatrists or doctors, whoever your medication from are going to allow you to do cyclical dosing.
But I know a lot of people don't have that option and sometimes they'll chalk it up to being it being a. Controlled substance, which I shouldn't laugh it is, but also it's just like you are comparing me to a male who has a 24 hour cycle, who is going to give you the same results Monday to Sunday all day long.
And I'm going to give you different results 28 out of 28 days.
Exactly. And this is the whole craziness of our system. The sort of ovarian hormones, sex hormones, at least as one area that we have studied in women, men haven't really had much, we haven't really looked much at estradiol and progesterone in men, but we have looked at their testosterone, but but we're forgetting, how potent those hormones are in the body.
Always as part of, neurological, cognitive, psychological stuff. So although we've studied those hormones, it's really been focused on what we'd call bikini medicine, fertility and endometriosis, PCOS, and they're all really important, we're so much more than, you know, our pelvis.
It is, I think it very much speaks to like modern Western medicine being very siloed because. They're called reproductive hormones. We only talk about them so often, and they're only studied in regards to reproduction, and we forget how they interact with other hormones, with other neuromodulators, how they do, like you said, impact the dopamine system.
When my estrogen is low. It makes sense too, because I have equated to like, your PMS is like a mini perimenopause every month. And some of us have very minimal symptoms, and some of us have very extreme symptoms, and it's the same once you hit perimenopause. Some women are really gonna feel it, and then other women are just gonna cruise
through
it.
Yeah, that's, yeah, that's a wonderful analogy. It's exactly that. So if you ask, there's very few women who have never experienced a premenstrual mood symptom. I can't believe that anybody, if they really look good at, you it's and you're always amazed that, you go, ah, that's why I, I slammed the door, or, but somebody's head off.
I want chocolate. Yeah, so all of those things, it impacts everything, from cravings, as you say, to being able to do well at school or, manage your job properly or just, parent or socialize or function. It's huge. Makes so much sense.
And you mentioned, obviously, bioidentical and synthetic hormones.
We see that, especially for some reason, I think, yes, a bit with estrogen, estradiol, but I hear so much more about it between progesterone and progestin and people being extra sensitive to those. Can you talk a bit more about if we have any speculations about why this? Might be. So
in Australia, just to be clear, because people get touchy about this, we call, so body identical is the, or the TGA approved versions, which is what I would prescribe.
It's not saying they're necessarily better, but bioidentical would tend to be compounded versions. So they are made in a pharmacy as opposed to a factory, and I'm not arguing about the merits of both, but most women can respond to body identical hormones in America. They tend to interchange those terms.
But in terms of sensitivity, it's very unusual to see somebody who is sensitive to estradiol, but I definitely have seen that in some patients to some people can be sensitive to supplementing with estrogen estradiol, but it would be more common to see it with the progesterone and progestins. And I think that.
Possibly because it's really potent on a particular receptor in the brain, the GABA receptor, and it works a bit in the same way that diazepam or Valium works. And you can get this, either really activating making people a bit irritable and agitated or really very moody. And, or you can get the converse where it actually just gives you a nice sleep when you feel a bit chilled.
So it can really have completely opposing effects. Effects in different women that's natural progesterone and the synthetic progestins are all have off target effects because it's like putting a square peg into a round hole, but it also will fit into other receptors. So the synthetic progestins have , some of them have a bit of estrogen activity.
Some of them had a bit of testosterone activity and some of them, and they all have a bit of progesterone. Your own activities. So you get these off target effects, which may or may not agree with you. You might and women often complain that they upset their tummy, get a reflux or constipation or diarrhea.
But the common thing would be those would be would really be that mood effect. Most commonly,
and you mentioned TGA, so let's talk about Australia specific because I said earlier, so much of the information. It's great. It's out there, but it's very US centric. Aside from like Dr. Louise Newson who does UK centric stuff, but in Australia.
What's available on the PBS and what do people have
to pay private for? Okay, so on the, so TGA means it's been approved for use. So that means that I can prescribe it easily. And then PBS means that it has a capped price on it. So at the minute we have got two patches that are on the PBS.
So that's Estradot and Estraderm. But there's a huge supply issue with patches. So yes, there are patches that are available on the PBS, but because we lost our weekly patch Climera in 2022, and we've had a bit of an increase in MHT prescribing, the patches haven't been able to keep up with demand. So the patches are great.
People love patches because you only have to change them twice a week. They're not for everybody, but they're certainly. Or were a great option, not a great option if you can't find it. So I think that's really destabilized. So many women who have been, really very happy and doing well on their patch and suddenly they can't get it.
And I saw one woman and she was actively suicidal because she hadn't had her patch. It was awful. So it's really, I think that's really very scary. And there's still this perception that it's a lifestyle drug, but actually it's a potent mental health drug. So yes, we have patches. That's the plain estrogen patch.
Then there's also a combination. Patch that's got natural estrogen in it. It's got the estradiol in it, and then it's got a synthetic progestin called norethosterone in it. So that's a nice, simple PBS option, and that's still very safe. So to unsteril norethosterone is probably very low risk. And it doesn't give you the nice effect of progesterone if you're somebody that likes progesterone.
But it's an easy option and it's there on the PBS. So it's capped. So that's, so that would be your cheapest HRT if you have still have your uterus. So it would be that combination patch. I tend to prescribe either the estrogen only patch or the estrogen only gel. And we do have one gel on the PBS, which is Sandrina.
Those are the little foil sachets. And women usually need one to two of those sachets. Sometimes women need more, especially women who've got PMDD. And that you apply every day as opposed to twice a week. So that's a good option that then you do need to have progestin with it. And most of us would prescribe progesterone.
So that takes us to the. Progesterone, which you take as a capsule and usually you take it orally. If you're in perimenopause, you take it for two weeks out of four or roughly thereabouts and at a dose of two capsules a day. And if you're postmenopausal, do you take one capsule every night? You can use it vaginally.
Some women prefer to do that and that takes a bit of tweaking, but it costs around about 40 a month. So that's the drug that we're really hoping to use. That gets approved to go on to the PBS, because that's the big cost limiting factor in HRT, and the reason that it's so important is not only is. You know that it is good to have a body identical hormone, but it's the one with the lowest associated risk of breast cancer and some studies even suggest it reduces your risk of breast cancer.
So really we want women to be able to afford to our, and to be able to access the safest form of hormone therapy, which would be estradiol as a gel or a patch plus micronized progesterone promethium. There's another gel.
Sorry, with, you said some women take it vaginally. I was under the understanding that vaginal.
Especially estrogen is what I normally hear, but even with this, it is typically not absorbed and have a high enough dose to work in a systemic, so full body, but it's the progesterone that you would potentially take that way. Different.
Yeah, so that is different. So the progesterone to use exactly the same progesterone that you take orally, and it is off, it's off label in Australia, but it is licensed as a vaginal product in the UK.
Okay. There's different studies, but some studies do show that when you use your progesterone, your promethium as a vaginal pessary, you actually get the same systemic, the same serum levels of progesterone as you would taking it orally. But it can reduce some of those gut side effects because you're not, it's not going through your gut first.
And it's certainly adequate to Keep the lining of the womb. No, but so it can give you a maybe a more gentle and dose that you can tolerate. And there's an argument that you could probably reduce the dose when you're using it, but generally, but I think that's overcomplicated for today. Yeah.
And then, and so and then there's there's there's there are oral. HRTs, there's tablet oestrogen, but I have found that I haven't really needed to move particularly away from gels and patches and progesterone, so yes, we've got these different oral products, but I think for most women, they get a better effect from the transdermal oestrogen because it goes.
Through your skin, through your subcutaneous fat into your bloodstream. So you get that estradiol. That's what works on your receptors. Whereas when you take a drug orally, when you swallow a drug, it goes through your stomach, into your liver, get and gets metabolized before it gets to your end target receptors.
So you don't necessarily get the pure potent form. So interesting. Most women will find that the transdermal products are more effective for them and it's safer. It has no risk of deep vein thrombosis or pulmonary embolus or stroke or heart attack, which is good. And then the last hormone then that some women, not all women need is testosterone.
And testosterone isn't necessarily a hormone that falls at menopause, it gradually, or it should gradually decline throughout the whole life cycle from your late twenties. But some women seem to have very low levels. And we know that our the way we test testosterone is probably not adequately sensitive, but it is what it is.
And, you do see a reasonable number of women who do respond to testosterone. And there's a, but there's also a reasonable number of women who don't feel it makes any difference. It's only licensed for postmenopausal women with hypoactive sexual desire disorder, which means low libido. Yep.
That's possibly because I think it's 70 to 75 percent of the studies into testosterone in women have looked at low libido. I think 10 to 15 percent have looked at bone density and a small few have looked at cognition and most of the. Okay. The research looking at cognitive effects of testosterone and women haven't really used psychometric tests that are adequate to pick up those subtle changes.
What I would see clinically as women just feel a bit more zesty or, they just have a bit more drive or they can find their words more easily. And I think those are really difficult things to measure. And yes, they may be placebo, but women see it stopping when they stop their testosterone, when they've got those benefits.
So anecdotally, most of us who are doing a lot of menopause care would say that. Testosterone absolutely does not work for everybody. It works for some women and it, but it's actually the cognitive effects that are more exciting than, a sudden, crazy sex drive. It's unusual. Some people do think it really gives them their sex drive back and that, but they're not the majority.
That's, they're it's the kind of libido for life, which is what libido means. It just means excitement for stuff necessarily have to be excitement for sexual intercourse.
But when we look at This is like really going off on a side quest, but when we look at the system and the patriarchy, they really only care because if you have low libido, and again, through the patriarchy, they're looking at like a heteronormative relationship.
What does it impact if you have low libido? It means your partner isn't getting As much as he probably wants to get. And so then, okay, let's fix that. And we don't care if you can't think straight.
Exactly. Exactly. It's crazy. I think most women are much more excited about being able to stand up in their job or be able to argue their point with their partner or their children, to be able to have the words to, being confident in whatever you're doing.
I think for most of us is probably more exciting than having a super high sex drive. But testosterone in terms of cost, it's. We're the only country in the world to have a licensed product for women, which is pretty cool. So it's TGA approved for women? TGA approved for women for hypoactive sexual desire disorder and postmenopausal women.
Interesting. So yeah, so we are very lucky in that respect.
So can women get it if they don't? If they're in perimenopause or if they still report having a normal sex drive?
So then your doctor would need to be confident in their prescribing that they're happy to prescribe it off label, which, some of us do, and we, because we prescribe off label all the time, a lot of drugs that we use and the pediatric and the population of people up to the age of 18 are off label.
So we prescribe off label a lot. A lot of the non hormonal drugs used in menopause care are off label. So it's something, that GPs do all the time, but you have to be confident. Confident in your prescribing and certainly, most of us were never taught very much about ovarian hormones at all.
Nevermind, testosterone being a female ovarian hormone. So that's, what really needs to change so that people can get a bit more confident, even just to prescribe it for low libido and the postmenopausal woman. But yeah, but it's expensive. So a tube of testosterone. And the pink tube is a hundred dollars that last three months.
So that brings your so your oestrogen, if you get your PBS oestrogen, your patch or your gel, that's 60, about 16, then your natural progesterone is about 38. So that's your, about 55 for oestrogen and progesterone. And then your testosterone is about 33, so that takes you up to 90. And if you also need some vaginal estrogen, which is on the PBS, that's another 16.
So that's 110. Wow. Yeah. So that's, yeah. So there is a male, there is a male testosterone product. Again, you have to use it off label but it's a third of the price and it just requires a bit more. bit more you have to be just a bit more careful with the dosing because it comes in sachets that are designed for men, not for women.
So you have to use a tense. So the woman
gets the sachet. It's not compounded ready made for ride. Okay.
Yeah. So you get to the tube of cream. You just have to, it's again, it's user unfriendly. It comes with a syringe that you have to draw at 0. 5 mils and cream doesn't go into syringe easily. So it's like a big edamame bean or roughly one and a half centimeters or the size of your fingernail, which fingernail, it's people just get used to their blob.
It's yeah, it's crazy. So that's the testosterone cream. And then the gel is. It's the same concentration. So you use the same amount. And one sachet would last should last a woman 10 days at the standard starting dose. Although I have seen somebody maybe accidentally use a bit more.
Yeah. So that's that way. We have to be very careful not to do that because you can get irreversible. Voice changes if if you do, if you're testosterone, so it is important if you're using testosterone that you have your levels monitored regularly, because, we know from gender affirming medicine that if your testosterone goes up above six and for too long, you can start to get a deepening of the voice and that's, it's important not to.
Unless that's something that you want most people to be concerned, especially people who sing. They don't want their voice to change. Oh yeah. Yeah.
And I guess too important to clarify. When you talk about off label regardless of what it is, that means it's not going to be subsidized by the PBS.
You're completely paying out of pocket, which is why, of course, like you said, that testosterone is so expensive compared to a lot of the medications that we are lucky enough to have subsidized on the PBS. Being 100 for three months supply, that's fairly expensive.
It's the same cost as the progesterone actually, so they're actually both the same because they're both around 30 to 40 dollars per month for each of those.
But women can claim some of that back if you've got a private health fund, you can claim some of your private medicines back. I think it's not much, but it's, you can claim a little bit back if you do have private health insurance.
With all of the different treatments, as far as the PBS is concerned, is there any health? Metrics that someone has to tick first, like a certain age or blood markers. I know with perimenopause, we can't really like we don't have bloods, but or is it as long as you're a prescribing doctor, they are happy to supplement and it's available to whoever gets a prescription.
Yes, technically, yes.
The labeling of most MHT says suitable for menopausal symptoms and one of them says prevention of osteoporosis and the testosterone. It's irrelevant because you're prescribing it privately anyway, but for the PBS ones, it's supposed to be for menopausal symptoms, which most people will take to include perimenopausal symptoms.
But the wording is ambiguous. But some people might, some doctors might interpret that to mean you can only use it once you're postmenopausal.
Of course,
So the system, in fairness to doctors and GPS tend to do a lot of the menopause care, you know, we're trying to keep up to date with every single specialty that there is.
And I think that. It is difficult because this was an area that was completely left out of our medical training. It's still absent from the medical curriculum. So unless you've chosen to go off and upskill in it, or had a patient to tell you to upskill in it, like happened to me, then, , it can be hard when you're not doing it a lot or you're not confident, to, to, and you're, most people are stuck.
Still scared, like a lot of women are of these kind of fears of dangers and risks of hormone therapy, so there's a lot of hangover from the fear mongering of the early noughties.
Yes, there's what I often call the lost generation of women who were impacted by the WHI and then all of the subsequent media that came out from that.
And we've had, 20 plus years of. Misinformation, essentially, and now it's a handful of doctors like yourself that are going out and educating and trying to not reinterpret the information, but like correctly interpret the information.
Yeah, I think it's just as we all know that, bad news sticks and bad news sells.
So even when they did the short term follow up of the WHI, I think after about five years, they were already walking back that risk of breast cancers. That was way back in 2008. They were walking back the results. And then this year they released their 20 year follow up of the data, which showed that estrogen on its own reduces the risk of breast cancer by 23%.
But that didn't even make it into the head, into the conclusion of the review article that was buried in the detail. And a lot of these articles are behind paywalls. So there's huge issue about how medical research is. It's produced on disseminated, on people, you can just manipulate it.
So cleverly to your own end. So I was, when I was reading the long term follow up, I was like, this is amazing. Look at this. This is fantastic. Why is nobody shouting this from the rooftops? But I don't know. I think there's human behavior don't like good news. But it also makes me feel there's more nefarious forces at work that don't want women to know that maybe estrogen is not the demon that we've made it, into, I've got a lot of sociopolitical opinion on why that might be.
We were getting a bit dangerous in the 1990s, rising up on with 40 percent of women on HRT and they realized You know, maybe it wasn't so much the patriarchy or, but maybe more. It's always the
patriarchy.
Yeah. But the capitalist patriarchy realized that, women on HRT had a reduced risk of heart disease and, had a reduced risk of osteoporosis.
So when women are living healthier, they're going to need less drugs and that's going to cost somebody a lot of money because pharmaceutical industry, about 40 percent of most wealthy countries, GDP. So if you start preventing a ton of disease. It's not really going to look very good for the balance books.
It's the same
reason information about different healthy eating. And I don't just mean as a broad, but when we look at how dangerous sugar can be and like, I have sugar and I am, I don't, we allow sugar in the house. It's fine. But when we look at how dangerous it can be and highly palatable foods and, um, foods that aren't really foods.
All of that information is still very on the fringe and very woo woo because it makes more money allowing it and allowing people to have it and especially somewhere like America where they have it, they get sick. We have a very, in the States, a very reactive healthcare system. In Australia, I find it's a lot more proactive, but in the States, you can't afford to go to the doctor.
And if you do go to the doctor, you're really sick, which means then it's going to cost even more than if you had gone when you were like a little bit sick and had a niggle and had a,
yeah, no, I think our, our system is pretty broken and then we always blame the individual, it's your fault, you're not eating well, you're not doing this, you're not doing that, but actually it's the society or the political decisions that allow us to have fast food in every corner and don't regulate, what gets sold in the supermarket and what targets kids.
All of that. Yeah. It's always profit over people. And I think that is, I do wonder how much of that has been a driving force in the whole hormone conversation because body identical hormones, because they're naturally occurring, you can't patent them. So the only thing that you can make money out of is the delivery system.
So things like patches or they're off patent. So there's very little profit margin in a patch. Which is probably why one of the main patches in Australia got divested. So there was no, it wasn't making any money anymore. And the same company is now release is currently releasing a new drug for hot flushes, which is worth, billions.
But it only works in hot flushes. It doesn't do anything else. And those companies have huge influence on policy. We've got these drugs that are probably expensive to make not going to make anybody a huge amount of money, but equally could potentially reduce the prescription and the need for multiple other drugs, medical devices, looking at knee replacements, hip replacements, all of those things.
If you, HRT dramatically reduces the risk of an osteoporotic hip fracture by about 50%. And there's a lot of money in, the hip replacements, just even that medical device. So it's not that it's, I'm going to be defensive of doctors. It's not us, we're not the bad ones. We want people to stay well, but we're really still practicing this very reactive medicine.
We really need to look at what is the ultimate and preventative medicine and absolutely. We know lifestyle is so important, but we're battling the job that the government should be doing in terms of food and access to exercise and, sports and schools, all of those things, that's, You know, there's very little the individual doctor can do that has to be a political job.
But when we look at female health, you just go, maybe we should just be thinking a wee bit more about the role of estrogen and progesterone and possibly testosterone in preventative health. And, it's, I find it interesting that again, that is such a subjective debate because there's a wealth of information showing that timely use of body identical hormones, or even synthetic estrogen reduces the risk of heart disease.
There's so much data, but yet nobody will allow that to be put into a guideline. And indeed say, there's actually no evidence to suggest it's true, despite it even being in the American heart association journal. But women could be potentially reducing all cause, most of their chronic diseases by time they use the HRT if they want to use it.
And two, if we look at health span, we also know that The statistic for the highest group of individuals who are having death by suicide is that it lines up with the typical age of a perimenopausal woman. And you think how some women are so much more sensitive and impacted by these hormones.
It's no coincidence that those two groups line up and that, that statistic parallels perimenopausal age. And also too, like when you're talking about hip fractures. And I had shared this with you of like my GP outlined as far as protocol of treatment, it would be checking B levels. Oral combined birth control, progesterone only birth control, SSRI, and then MHT as far as perimenopausal treatment and you had said that's also like the recommendations for menopause society.
But if we look at SSRIs, they can also increase, your risk of, yeah, risk of osteoporosis they add to bone mineral density loss, and the cycle just continues, but instead we hand out SSRIs like they are candy, the same with birth control, but that's like a separate, but we know SSRIs have less than desirable health outcomes as far as bones go, but no one is questioning that, and honestly, most doctors don't even know it.
So true. I only discovered that last year, so I, it certainly was news to me. There's quite a few drugs that we prescribe, again, because most drugs weren't studied in a female population. If you have that increased risk of osteoporosis, drugs like the drug proton pump inhibitors that reduce acid secretion increase the risk of osteoporosis as well.
So there's quite a few. But again, I think that's because a lot of our research has been in men and it hasn't picked up all of these subtle risks that we see in the female population, which is again, so wrong.
It's almost like we need to go back and look at every drug and say, is this really safe in women? There's a brilliant book written by a professor at Melbourne uni professor Cassandra Zucke called the secrets of women's healthy aging. The last couple of chapters of the book really blew my mind.
And it just went through all of these commonly used drugs that we prescribe all the time without second thought, including paracetamol and how they've really been, only studied in the male population and that some of these drugs have completely opposite effects in women, including naltrexone, which is to try and block the effects of opiates.
So really scary stuff. You just. Just assume that everything has been tried and tested properly, but you can't assume anything you can, it can assume that it probably wasn't tested in a woman is what you can assume. That's it, because we've
so long, we've just extrapolated data and assumed that women are just very small men and just lower the dosage and they'll be fine when that doesn't work.
I had mentioned earlier that there are a lot of doctors now. Yourself included, who are taking up the cause to try and educate people. You have started a online education platform, called Healthy Hormones, where you're doing just that. You're educating other healthcare professionals about perimenopause, about Menopause about the use of M.
H. T. So can you talk a little bit more about what it is and who it's available for?
Yeah, so three of us set this up. So we're three GPs all based in Australia and we really just, we're all really busy. We can't see any more patients. And it's really, I know how much my love of my job has changed by practicing this kind of hormone focused medicine.
Like I think I dodged a bullet of, professional burnout, absolutely love going into work. In fact, my day job, my working as a GP is the easiest bit of my week. All the stuff I do in the evening is much harder. So it was really born out of that passion of seeing women, Getting better, looking back at what, how we practiced before, feeling terrible that we'd missed all these women and not wanting other people to have that, wanting people to have the experience that we are having of this wonderful medicine and also not wanting more women to suffer unnecessarily.
So it's a education platform that we are building in our spare time, unpaid, unfunded. And so we've got a sort of a list of resources. For clinicians and then an online community forum where doctors, psychologists, anybody who's APRAH registered can come on and, discuss queries that they have about women, treating women in perimenopause and menopause.
Certainly for the doctors, a lot of that will be prescribing questions, but, we're getting some good chatter about what protein is right, what about magnesium, what should we do for, fit problems from the podiatrist, so really getting. A real mixture of, and that's, and it's really removing that siloing of medicine.
So we've got urologists, we've got rheumatologists, psychiatrists, GPs, gynecologists, podiatrists, physiotherapists, psychologists, dieticians on there. So we've got this huge, which is really what we should have in all aspects of health. So we really hope that we're going to bring, this wonderful community of lots of knowledge because I know a bit, but.
Under no illusion that I know anywhere near 10 percent of what I could know and having that community to be able to just go in and ask questions. And, a lot of these things are not in guidelines. They haven't been written up. It takes so long for research to get translated into a practical guideline.
I think about 17 years for really trying to keep up to date, seeing what's there. A lot of the research into women's health, there's actually quite a lot of good stuff, but it's just existed in the shadows. So trying to bring. That to the four, so other people can read it and try and make their own decision as well.
So it's a lovely community to discuss cases. People don't always agree and that's fine. Medicine's not black or white but it's just that shared knowledge, shared, shared experience of, things that we're finding is working. And we've also gone patient facing and we're trying to launch that properly, it's soft launch over the next couple of weeks where we'll then be doing weekly lives and
weekly, frequently asked questions. So that there's a lot of questions that people will ask me on Instagram and they tend to have common themes, you know, really, again, just trying to deal with, people at a big level, because a lot of women are struggling to get that on an individual base basis with their GP, but also it can, Take the pressure off GPs if, we're providing that kind of math level of information.
Cause a lot of the questions are the same, a lot of, there's a lot of commonality in the perimenopause and menopause experience, that you could probably easily more easily address like in that kind of big forum. It's been really, I've really enjoyed it. It's a lot of work.
I come home and I've got a seven year old and she said, are you menopausing again? Mommy go down to my computer. It's certainly busy when you've got a full time job and you've still got kids and then you're trying to build this, but it's definitely brought out my inner feminist and activist and advocate and it's, and that's a great space to be in, I just love it because I see the women getting better every day and I know there's women down the road or, across the country who are not, Accessing this care and a lot of them, it's so easy.
Some people are really complicated. HRT is not a, one size fits all. It doesn't fix everything and it doesn't fix everybody. But there's a large number of women who just need very basic hormone therapy and they're sorted and they're way off. There's women that come back in two weeks.
They're like, Oh, I'm sorted out. Happy day. And then there's other people where it really is complicated, but they're in the minority, so it's really, That desire to see more women, more doctors considering hormones in female health, thinking of hormones as brain hormones, thinking about not just our perimenopausal and menopausal women, but also our teenagers, especially girls that are neurodivergent, so that they can be Though many of them are just diagnosed with social anxiety, getting missing all of the correct diagnosis, and, really looking at the totality of their presentation and, getting in there in their teens, then, means that you're setting them up with Tools to get through their adult life, as opposed to developing mechanisms that aren't always the healthiest to try and cope, so which you're nodding your head.
You probably know what I mean, so to get in. So that's the thing that I've loved probably most about understanding perimenopause is that. Then understanding that whole female life cycle, so understanding your teenage girls, you're looking at perinatal and postnatal depression really differently, finding that there is all this evidence that these hormones could treat all of these conditions.
And they're actually probably a lot safer than the drugs that, as you say, we hand out a bit like candy in terms of SSRIs. And while, antidepressants still have a role and a place and often can work really well with. Hormones and for some women, they don't need them, and, and as you say, there's this really high risk time of suicide, between 45 and 54.
There's also a high risk of suicide in the postnatal period. , PMDD sufferers have a really high risk of suicide as well. And we are not treating these women. Effectively at all. And there is potentially for a lot of those women, a very easy, safe, effective treatment setting there that we could be using for crazy.
And to like with antidepressants, sometimes they have adverse effects. For some people, they make them more depressed or Apathetic to where that was always my experience was also now I think it wasn't depression. It was burnout, but they just made me completely numb all the time, instead of, fixing me, quote unquote.
I was just existing. I was just going through, but it's interesting that you're talking about the. The other end of the reproductive system when girls start to go through puberty, but it's I think that's another time where, again, we hand out birth control to any girl who's like, I have acne.
Okay, here, try this. Okay, one, maybe there's some other things we can do. Maybe pharmacological, maybe not, but also can we look at the whole picture? Can we look at you as a whole person? I'm one of those people you described that at 16, I went to a doctor and he literally walked in the room with a kitchen timer set to five minutes and set it down and was like, what's wrong?
And I very quickly tried to tell him and he was like, yep, you have anxiety and depression. Here's a 12 month supply of Zoloft. Off you go. No follow up, nothing. So I just went through the rest of my time thinking it was anxiety and depression and all the rest of it. And then. Have my kid and find out at 36.
It's actually ADHD and I'm autistic and my whole life could have been different. But I always say at least I know now, especially before perimenopause. Thank God. Thank God.
I do want to ask with healthy hormones, since you are open more. Patient information stuff. We know that not all doctors, unfortunately, are as educated and informed as you are. So how, if someone listens to this or finds you or comes across healthy hormones, how can someone take information and advocate for themselves to their doctor that might not be informed?
That might just go Whoa, no, I'm not giving you. Hormones.
Yep. So the things that we would recommend people do, and we obviously plug for healthy hormones as we do have a symptom checker on there, but there's other symptom checkers. Louise Newson does a brilliant one from the balance website.
So I would always say, if you think you might be perimenopausal or menopausal, you probably are because women are really good at diagnosing themselves. And then the first thing to do is just got to do a bit of research because the more informed you are, the more able you are to advocate for yourself. So doing something like a symptom checker and then you can list and you can show that you've got all of these different symptoms.
It's unlikely that you've got 10 different disorders going on at once, and just understanding, as you said that, you might be perimenopausal in your late thirties. So that would be step one. So symptom checker, a bit of research. The second thing, and this is, it sounds a bit trite, but I would say bring either a friend or your partner with you to see the doctor because it really changes the power dynamic in the consultation room.
As a GP, you get really scared when somebody brings, you see them, they're going to kind of just bring in, you're like, Oh no, they've brought in the big guns. They've brought somebody else because there is a real power, Dynamic in there. Like we have a better chair. It's a bit higher.
You get the squeaky chair and we tend to be like, I'm really short, so I'm not that intimidating, but you know, it does, if somebody else is there, I'm a doctor, but I've also been a patient, you are really diminished when you go in, it is, it's scary, even as a doctor to be on the other side of the table, if you've got somebody else with you and they know what you want to get out of the consultation while you're sitting there , trying to take all the information in, trying to ask your questions.
But while it's also feeling a bit nervous, the other person usually isn't so they will sit there and go actually know that isn't what I don't think that's what you wanted to get out of it, is it? So that can be really powerful too. So I think a buddy and a friend, a partner who you've, obviously informed what you want before you go in.
If the doctor still isn't receptive and, a lot of us, do need to do a bit more upscaling you mind, could you do a bit of reading and come back, obviously suggest to your doctor, they might want to join healthy hormones and that might go down so well. And, or ask, is there another doctor in the practice?
That's more confident in prescribing hormone therapy. That kind of phrase tends to get us a wee bit annoyed because we want to be confident too. So it's using the right words to peak the type a personality of the doctors. They'll go maybe I might become confident in it because a lot of doctors will go off and read up about stuff.
Like most of us are pretty open. And so say, can you know, would you do a better reading or is there somebody else that might be happier to have a chat about this? And then I can come back. But if you still being met with the brick wall, then. The Australian menopause society does have a list of doctors who are registered with them, but that doesn't require any testing or assessment of skills.
We are hoping to launch our medical education course very soon. So we will then put a list of doctors who've completed our course on there. And the other way of finding a doctor in your area is through the perimenopause and menopause Facebook group. It's got about 40, 000 members, and they do have a list of doctors that people have had a good experience with.
That's great.
Yeah, so there's, so that is a really good and patient resource. For lots of different things. So it's called perimenopause and menopause on Facebook. Um, And that's just
Australia.
It's just Australia specific. So for people in Australia, that can be a wonderful, I also
think of people who live rural, like they don't have a lot of options.
So that's where Wellfem, which is a national telehealth service run by Kelly Tegel. So they offer telehealth throughout Australia and other people are starting to offer a bit of telehealth as a part of their standard face to face care. It's not something I do. I just don't have capacity. There are people building in those telehealth and we hope to be advertising those through Healthy Hormones saying these are people that, we know and are good.
Because it is, especially when you're spending money and you've waited all that time, you don't want to come away empty handed again and that's so painful. So yes, so certainly Wellfem is a great service. They, in their offering, telehealth across Australia. And then there's places we've got a list of a few people that we knew, but we're hoping to expand that list so that people can get it.
The other thing is the practice nurse. If you've got a practice nurse in your surgery practice nurses are often in that perimenopause menopause age group. My, I'm very lucky. I've got two amazing nurses who do a lot of pre screening for me. Anybody that comes in for their cervical screening gets asked about perimenopause because they both love it.
Perimenopause. So they, you can't get through the room without getting asked if you might be perimenopausal with them which is great. So often a practice nurse might, if they've had a bit of training and then in the public system, they are opening menopause hubs throughout New South Wales.
So in New South Wales, there are menopause hubs that are opening and that are supposed to be able to offer care for people who are more complicated or where GPs don't feel confident to prescribe, but that's still being established.
So good. I always, my other tip for people going in I love having Another person with you. I think that's such a strong, like you said, shifting the power dynamic. I have a list of questions and blood tests that I want to request.
I think my GP kind of rolls her eyes and giggles at me every time I go in because we sit down and she's okay, what are we doing today? And I just opened my phone and I'm like, okay, this is our agenda.
I love an agenda. I think it's brilliant. Patients go, I'm sorry, I've got a list no more.
That's great. Show me the list and then we don't miss anything. No, I love that. And this idea that you can't Google stuff, I'm sorry, I've Googled. I'm like why wouldn't you Google? That's what the internet is there for. If you're not going to Google your own symptoms, it doesn't mean that what you find out is correct.
But, some, quite often people come in and have Googled something and tell me something I've never heard of. And then I go, yes. That does look like that. I have no idea what that is. It's, it should be a partnership because, there's so much we don't know in medicine.
So when people Google or bring in lists, happy days. Still scared of the partner or the friend, that does still scare me. But that's a good thing. Yeah, absolutely.
Because it's going to bolster, because I never feel more
in confidence. Diminished. Yeah, diminished. Yeah, like I never lose my confidence as much as when I'm sitting with my doctor. It's pretty weird. I know, it's and I, I'm autistic. I do hours of research on everything that I'm talking to her about, and I still go in and feel like I know absolutely nothing and, I'm silly for even bringing these things up.
And, there's probably a lot looped in with that, but I think so many women do experience that, especially when we've gone through life being so dismissed by healthcare
providers. I think it's such a common experience for everybody. I would say that is actually the normal experience, whether you're neurodivergent or not, as people come in, apologize for wasting your time.
I'm really sorry. This is going to sound really stupid. Those are all like standard phrases that I hear all the time. And I'm like you can either be neurotic or you can be negligent. Don't worry about it. List. Brilliant. Research. Great. It's, but it's weird that just because you go, it's just a room with the desk.
It's bizarre how we have this power. It's really all, it's really, it's quite sad in a way that, somehow we've created this, fear cause it should be a partnership and you should be confident to come in and say, this is what I think. And, what about this? It doesn't mean we're always going to agree with you.
And that isn't always the best thing, but it should definitely be. Discussion.
Yeah, I agree. Having open dialogue and being able to come to a treatment plan that you both feel good about, especially the person taking the drugs should be something that's happening.
I appreciate you so much taking the time. I think we need to do a whole separate PMDD because it's
yeah,
such a complex and not enough talked about.
