Post-Menopause Health: What's Normal vs What You Can Change

Episode Summary

In this insightful interview, Dr. Heidi from Cayman Clinic shares her extensive expertise on menopause, post-menopause health, and aging women. Discover practical advice on managing long-term health, the role of HRT, and how women can optimize their quality of life after 60.

Key Topics

- Long-term effects of menopause
- Role of hormone replacement therapy (HRT)
- Strategies for maintaining bone, heart, and brain health

Chapters

00:00 Introduction to Menopause and Women's Health
06:13 Understanding Post-Menopause Expectations
12:00 Long-Term Health Considerations for Women
17:52 The Importance of Muscle and Bone Health
23:55 Navigating Hormone Replacement Therapy (HRT)
29:49 Sleep Disruptions After Menopause
31:13 The Importance of Sleep in Women's Health
37:12 Understanding Hormone Replacement Therapy (HRT)
44:02 Taking Control of Health Post-Menopause
49:55 The Impact of Historical Studies on Women's Health
56:13 Vaginal Health and Intimacy in Older Women

Resources

Cayman Clinic - https://caymanclinic.ky

Disclaimer

Breast Intentions is intended for informational and entertainment purposes only. The content shared on this podcast is not a substitute for professional medical advice, diagnosis, or treatment. Any views or opinions expressed by the hosts and guests are their own and do not necessarily reflect the views of any affiliated organizations. Always consult with a qualified healthcare provider for medical advice or concerns.

Resources & Mentions:

• Find Dr Heidi Fahy on Instagram (@cayman_clinic @haidehfahy) 

• Follow us on Instagram and Facebook (@breastintentionspodcast ) 

Connect With Us: Have a topic or guest suggestion? Email us at breastintentionspodcast@gmail.com 

Transcript

SPEAKER_04 0:00

Once the menopause is done, it's not to sit back and say, Okay, it's done. Now I'm just gonna. I remember quite quite distinctly a girlfriend of mine saying, Well, I walk up the stairs much more slowly, but that's okay because I'm getting older and I almost know, you know, okay, let's just sit, let's just go back and sit down again. What can I do to make sure as I get older I can maintain um quality of life that I've enjoyed thus far? I now don't have children, I can enjoy my grandchildren, uh, I don't have financial issues, you know, may have a husband you get on with, but what do I like?

SPEAKER_00 0:35

Yeah, you're like this conversation very often. Welcome to Breast Intentions, the podcast where we take off the bra of expectations and dive into honest, empowering conversations. We're your hosts, Nadine and Cynthia, two Canadian girls who swapped snow boots for Flip Flups in the Cayman Islands. This is your space to feel seen, supported, and a little less alone. So grab a cup of coffee or a glass of champagne and get ready for your weekly handful of truth, wellness, and empowerment. Welcome back to Breast Intentions. Today's guest is Dr. Heidi Fahi, physician, educator, and passionate advocate for women's health. Today we're diving into life after menopause. What's possible, what we may have missed, and how to truly step into some of our most vibrant, fulfilling years.

SPEAKER_01 1:25

So on today's episode, we have Dr. Heidi here from the Cayman Clinic. Welcome to the show. Thank you for having me. Well, thanks for coming on. Um, like I was saying earlier when we were talking, this is one area of very big interest of mine, and I'm sure it probably is of yours as well. Um, is menopause post-60. And we wanted to bring you on just to talk a little bit more about that. But if you can, do you want to give our listeners a bit of a background on how you got here, which is always very interesting to find out everyone's story on how they got here and um and what you're actually doing down here on the island.

SPEAKER_04 2:03

Okay, thank you again. Thank you for having me. I'm a um UK GP. Um, in fact, this is my 40th year of practice. 4-0-0 to 2026. So um as a female GP, um, very early on, you uh soon as qualification, you were you were encouraged to look at specializing. So uh I got my diploma of uh Royal College of Ops and Giny, obstetrics and gynecology in 1988, and following that I got my diploma in family planning and insertion of long-acting contraceptive uh uh services. So I've been practicing women's health since right at the beginning. Um as a general practitioner, you could uh run family planning clinics outside of the remote of your general practice. So women's health has been my thing for many, many years, and then um quite often I would end up working in a clinic where I was the only female. Uh so very much attracted that kind of work, and I've been enjoying uh doing so when I came here. Um I came by chance really, I just looked to see whether they wanted somebody to come work occasionally as I reduced my workload in UK, and I ended up working full-time, and obviously my skills in women's health has come in very, very helpful in providing family planning services and women's health, which is quite a bit of my work now.

SPEAKER_01 3:23

Right. Well, I I've seen you, I know a lot of people that have seen you, um, and I sing your praises all the time.

SPEAKER_04 3:31

So thank you. Thank you.

SPEAKER_01 3:33

So going along the lines of women post-menopause, what are women conditioned to expect to decline in their 60s, even when their bodies might be more capable of so much more?

SPEAKER_04 3:48

Um, as I was saying earlier, when you've done the menopause, there is a sort of period of time where you actually feel okay. And you've got to remember women in their 60s or late 50s, you know, they're probably they're in a good place for their job, family, they're probably having grandchildren, financially, probably you know, in a much better place. So there is there is a honeymoon phase, but there are there are changes happening which women do ex accept. For example, um changes in your body, the shape of your body, the way your hair feels, the way your skin feels. And um some of these things you've got and the other thing is women are conditioned to accept things. Women go through so many phases and changes in their bodies. Um, you know, you start with having periods when you're 13, you know, moment in your mind and your own business, and next one week of the month you're you know in pain or bleeding, and and then of course all the hormonal changes, the mood swings, and and then trying to get pregnant, then you try not to get pregnant, then you get pregnant, then you do pregnancy, um, and and then the traumas of pregnancy to your body, I mean, what do women not put up with really? Um, so so when it comes to to sort of late, once you stop your periods, actually you might be feeling okay, but there are things happening which are not as bad as it was. Um, and something, and some of the changes are very gradual, so you may not even notice it. So, as you know, your size changes, your body shape changes. I know for a fact I look at my body and my skin's starting to sag in some places. You know, it's going south. I'm no fatter or heavier, but my body is changing. And and yes, these are probably, you know, my hair is thinner, um, and so on and so forth. So a lot of things are quite subtle. What women don't consider is the the long-term internal effects of menopause, which now we are far more cognizant of and much more aware of, and women do need to be aware of. And I think awareness is increasing, especially with so much in the social media now. It's true.

SPEAKER_01 5:46

Yeah. Um we've had some really great guests on talking about bone density, talking about heart health, cholesterol, correct. Um, brain.

SPEAKER_04 5:55

Yeah, all that's so we're now living longer, and the the generation, the current generation, if they don't vape themselves to death, you know, they're gonna live into their hundreds. So a lot of women spend quite a large portion of their lives in postmenopause, um, you know, 30, 40, 50 years. Yeah, you're right.

SPEAKER_01 6:14

Yeah, compared to power many decades ago.

SPEAKER_04 6:17

When I first started, I mean one of the one of the good, you know, one of the things I'm very lucky I've lived through quite a bit of change, I've seen change. And women, you know, in the 80s and 1990s, you know, you you didn't live beyond the 70s. And in terms of you were, you know, you you were really breastfeeding pregnant or dead. And 57 you died. So menopause wasn't a big deal. Um so now that we're spending so much of our time, and what's what's really quite important to remember is our um life expectancy is increased, our um lifestyle is changing dramatically, but our bodies aren't uh adapting. So menopause is still at that age, you know, you still your fertility is still around about the same age. We are changing. So when some woman says to me, I'm quite happy to do this naturally, I challenge what is natural these days. What is what, you know.

SPEAKER_01 7:11

Um what did I say?

SPEAKER_04 7:14

Well, we have a discussion and I'm right. No, but you know, you've got to point these things out. You know, you you you know, we we don't spend much time thinking about these things. And I'm sure you found out from a lot of your um uh guests who are uh experts that uh women women live longer than men, uh, but we're more prone to dementia um and physical disability. One in three women have a fracture hip uh in older age, and that's my biggest fear. I don't want to fall over because that suddenly reduces your quality of life. So uh, you know, you have to point these things out. Um, and because we feel fine in our 60s, and we still can get up and you know play with the grandchildren and get up from a chair and go skiing and whatever. Uh and then the changes are so gradual, but now we're l really looking at the long-term um changes. So yes, a lot of things you can accept as okay, but we're now much more aware of the long term. What would what do you want to be like in your 80s? Right. And there's plenty of people around you, like you were mentioning your mom and aunts and they're in their late 60s, they're probably still, I mean, there's they're struggling, but you know, you don't consider them, you know, they don't have memory issues, or uh, you know, they they can't get out of a chair or um it's more um kind of uh the numbers that you're seeing on like blood work and stuff like that.

SPEAKER_01 8:35

And Canada, everyone's in Canada, but you know, to try and get a bone density scan is like pulling teeth. So Lord knows where they're even sitting. They don't even test vitamin D back home. So Lord knows where they're sitting with like their vitamin D levels and stuff like that. But to them they're good.

SPEAKER_04 8:54

Yeah, and and seemingly you are good. And um women as a you know, going back without repeating myself, have gotten used to changes in their bodies, so yes, it's another. I'm women incredibly resilient. I'm very good at putting up with um with things, you know, it's okay.

SPEAKER_01 9:10

Well, I remember when we were talking to the neurologist on the show, and he was saying that um like post-menopause, uh you kind of like fall to a new normal, and then your body adapts to where those hormones are now sitting.

SPEAKER_04 9:25

Correct. The b uh the brain ad uh adjusts, and um a lot of the feelings of the brain fog and the hot flashes and the temperature irradiation is just because because the brain isn't perceiving changes in the hormones and doesn't know what to do with it, but but a new norm forms, and that's why a lot of women feel fine, you know, life is pretty good in your 60s.

SPEAKER_02 9:43

Right.

SPEAKER_04 9:43

You know, if you go on holiday outside of school season, you'd be amazed how many old people are out travelling now and you know, couples and so on. Ah, uh, you know, trekking with their walking boots and looking, you know. So yeah. So it's a good there there's a honeymoon phase. Um and um the changes are subtle, but it's the long-term changes now, specifically because we're going to be living longer. Right. Uh longevity is we've achieved that now. It's quality of uh what your life is like while you're around.

SPEAKER_00 10:15

Right, because it's I mean it's great that people are living longer, but you don't want to be living longer if you're not correct mobile and appreciate it and do things. Correct.

SPEAKER_01 10:27

Yeah.

SPEAKER_00 10:28

Sorry, I've I've ruined your thing.

SPEAKER_01 10:31

We kind of actually took this like a different route because I think what we really have to hone in on on this podcast is more of okay, yes, I'm on the other side, but what now? Yeah, what can I do for myself? Yeah, absolutely. You know, checking your numbers and getting your lab work. But what would you say are maybe the top three to five things that a woman post-menopause should be considering?

SPEAKER_04 11:02

Absolutely. Um I think there is a lot of information out there, which is good. And I think um we're going through a phase not just for women in the 60s, but generally women are actually looking much harder at their uh their, you know, what am I here for? What I what do I want from my life? Um and I think um once the menopause is done, it's not to sit back and say, okay, it's done. Now I'm just gonna. I remember quite quite distinctly a girlfriend of mine saying, Well, I walk up the stairs much more slowly, but that's okay because I'm getting older, and I almost, you know, you know, okay, let's just sit, let's just go back and sit down again. So it's not accepting, or it's not even accepting, it's what can I do to make sure as I get older I can maintain um quality of life that I've enjoyed thus far. I now don't have children, I can enjoy my grandchildren, uh, I don't have financial issues, you know, may have a husband you get on with. But what do I like? Yeah, you're like I have this conversation very often with women. Uh, you know, some of the things that women do come and complain to me about, changing subject slightly, is you know, the things that people do notice is obviously weight gain, distribution of fat much more central. So that you know, women don't feel as attractive and clothes don't fit so good. Um, loss of libido, huge, huge issue. Uh, you know, don't feel like it and it's terrible for my assuming, but what can I do? It's fine, you know, that's just aging. And part of that is your image and how you feel about yourself, and also uh vaginal dryness, really common. And uh, you know, if that doesn't feel good down there, you know, and women, as I always explained, men have a very much, you know, sort of, I'd like to have sex, then you have sex. Women like, well, have I put the cat out? You know, is my kids okay? Have I done the shopping? Is the you know sprinkler on? And obviously, if your vagina doesn't feel great and it's gonna be uncomfortable, yeah, definitely not gonna feel like it. So so these things are important not to accept. And um, the other thing which women present to doctors, I mean, I may not see women who are quite comfortable with their menopause uh or seemingly recurrent UTIs, dreadful thing. Women come in and it's like, well, I used to get this in my 20s, now, you know, and it it's it's awful. And that is all through lack of estrogen in the vaginal tract and um bladder. So body image, weight changes, um things like memory and f fog and you know some things like that. But but those are the things that bring people to me. And then we talk about okay, what about your bone? What about your heart? Yes, what about your um your brain? Um, and definitely I can do something to uh help your uh vaginal tract, your gynee tract, but that's that's that's the easy bit, what about the rest? But you've got to remember that um estrogen is a protector for heart disease for women, and um women actually develop heart disease 10 to 15 years later. The teaching again going back to the 80s was um one in four men get heart attacks, but it's one in five women. You know, that was that's sort of a slight distinction, we're a bit better off. But that actually, after menopause changes, we become like men, our risks catch up, and it is um and you've got to put into perspective one in five isn't much better than one in four.

SPEAKER_03 14:09

Well, it seems at the time, I don't know. Naive 20-year-old medical students saying, Oh, that's good. Uh five sounds much better than four.

SPEAKER_04 14:16

But but we we we kind of you know you gotta remember the heart disease is the main cause of um uh death uh for as you get older, and gotta put that into perspective. Um so heart health, really important. Um and then it's it's great that you know you you know, losing weight and changing the shape of your body is great, but those things are probably things I need to I do talk about and we we go through what can we do? And obviously we'll talk about that as as we go along.

SPEAKER_01 14:43

So if we kind of go along the lines of um bone density and muscle loss, what should women in their 60s understand about muscle loss and how it impacts metabolism and weight?

SPEAKER_04 14:55

Okay, this is something which is really important and it's at the at the heart of a lot of the things that women um go through after menopause. We naturally lose muscle mass. Muscle is really healthy, it burns calories, you know, and it supports your joints, supports your bones. So whenever you have an injury, I mean, if you've you know if you've ever had been to a doctor's because I've hurt my knee, the talk is always is build up your muscles around that joint to support that joint. That's that's that's classic. So as women naturally lose muscle and that's replaced by fat, we are losing a lot of our metabolic um advantages. And then insulin resistance is something which is really big now. We talk about insulin resistance. Um so so the first thing any woman should be thinking about is maintaining activity.

SPEAKER_01 15:46

So now let's say a woman is post-menopause and she's noticing a lot of these changes, and maybe now has had um a bone density scan and has a little bit of a scare and has been told that she needs to start exercising, but she's never done it. Yeah. And now she's in her 60s. What do you say?

SPEAKER_04 16:07

So there's a lot of evidence that doesn't matter when you start. You actually do, you can improve your muscle mass and your your um muscle and bone wellness 30, 40, 50 percent. So there's n it the the issue with that is never done it, so I'm not in the habit. Um it's never too late. Totally. Well, what what's the option? Uh right. This is this is what's gonna work for you. If you really take seriously your well-being, health and and wellness as you get older, this is you have to but you know, I I do say you don't have to wear a lycra and stand in the gym looking yourself in the mirror, seriously. Any exercise that you've got to do something which you can enjoy. Whether it be digging, you know, going in the garden and moving things around and uh uh you know going for long walks, using your body weight uh to instead of dumbbells. I you know, we used to say take a couple of tins of baked beans, you know, in the kitchen and and and it works. Um uh so you know it doesn't have to be anything major, but what suits you and but but it it has to be something uh daily, you know, even if it's just a you know, you have to mix it, that's the other thing. It's not a case of just go to the gym every day and pick up weights or whatever. One day is cardio, cardio walk, you know, do your own housework a little bit, move things around. Um uh if you like going to the gym, swim here, swim, you know. We have good weather. In the UK where I come from, half the time you're too cold to even leave your bed, you know, and you have to force yourself. Yeah, it is it is hot weather, but you can you can work around it.

unknown 17:40

Okay.

SPEAKER_01 17:41

So bone density or muscle is one of them.

SPEAKER_04 17:45

Yeah.

SPEAKER_01 17:46

Um the other one, which I do hear uh about a lot of women post-menopause is high cholesterol.

SPEAKER_04 17:53

Yes. So cholesterol traditionally does go uh I mean people always known this, the cholesterol does go up as you get older. Men and women, actually, to be fair. Um and um the main three factors for heart disease are cholesterol, smoking, and blood pressure. So it's just not cholesterol. So you've got to look at this. So whenever I counsel women, we we do discuss cholesterol, do you smoke, exercise, all the rest of it? Genetics, really important. You know, what kind of heart disease? You I find there's people who have heart disease in the family, those have cancer, some both. But you you get an idea of what their risks are for cardiovascular disease. But cholesterol's really become important. I mean, traditionally, you know, we used to joke that every cardiologist takes a statin, regardless of what their cholesterol is, because they know the benefits of it on the vascular disease.

SPEAKER_01 18:42

Oh, you mean like every cardiologist? Yeah, exactly.

SPEAKER_04 18:45

So it was it was sort of always, you know, because they see it, because they see. Now cholesterol actually, I mean, it's a really exciting time at the moment. Apart from us all become much more aware, cholesterols take another uh coming leaps and bounds. It's not just looking at a total number, we look at uh the uh the good and bad cholesterol, and even bad cholesterol has now been divided into uh very bad and really bad, you know, sticky and not sticky. No, but basically, does this cholesterol equate to having plaques in your heart? And now, not only do we just take the cholesterol, we discuss, as I said, genetics, and then we can break down a cholesterol into good and bad. And then, of course, now we have this wonderful technology of checking to see, looking for buildup in around the heart. So we do um we measure calcium with calcification on these plaques, albeit it's it's a it's it's a bit of a blunt tool because if you've got soft plaques, there's no calcium, so you might not see that, but you know, you work with it. If your calcium's if you haven't got any calcium, that's really reassuring. Uh but there's so much you can- I mean, people worry about their diet. You know, I've had three eggs this week. Seriously, yeah, it's it's not, you know, you've got to enjoy life and and don't don't worry too much about. And I say to people, unless you're very overweight and you're eating half a side of bacon every day and drinking full fat milk, there's not much you can do with your diet, but it's something which we can address.

SPEAKER_01 20:03

Okay. Um, so women, actually, just going back to the bone loss and and and muscle loss, how concerned should a woman postmenopause be about bone loss at this stage? And is it reversible or just manageable?

SPEAKER_04 20:19

So most of the changes in the body happen the first 10 years after menopause. So it's important to get checked really early. Um so once you know there is any kind of uh bone loss in particular, I mean muscle mass you can see, you know, and bone um it does run in families, so I always often ask, has mum got osteoporosis? So you have osteopenia where uh where there's uh some loss of calcium in your bones and there's osteoporosis. There is treatment. Osteopenia traditionally is treated with take vitamin D and calcium and do weight-bearing exercise and come back with check it again. I think that's going to become tighter as time goes on. I think there's my personal view is if I had osteopenia, I'd be wanting to do a little bit more. Uh there is medication that puts calcium back in the bones, uh, but you need to you need to do the exercise as well. The other thing to remember is it's not easy. You have to work with this, you know. This is there's no mag there's no quick fixes for any of all this. So to make pain maintain the bone density, maintain the muscle mass, and maintain the heart and the brain, we we have to work at it, and it's a daily thing. So that's something, you know, I think everybody would love to have a magic pill that you take, and uh uh and that's where you know digressing slightly, but women have got to be wary of what people put out there because it's the commercialism and people say take this and that will cure things. It doesn't. You have to you have to work. I even remember when I turned 40, I remember things just didn't happen anymore. I remember saying, I have to work for this now.

SPEAKER_01 21:47

Yeah.

SPEAKER_04 21:47

So so look for it and be proactive. And certainly exercising and uh taking a good diet full of calcium and vitamin D is really important, but see somebody about what I can do to put this calcium back. I don't want Wait two, three years and do another bone density, and you say to me, Now I've got osteoporosis. Which in fact I had a lady last week who has got high cholesterol and she'd had a bone density and it was osteopenia, but nothing had happened much. And it was like, okay, no, no, no. We we need to look at all this and uh infectious looking. Yeah. But I think part of it was, you know, well, I was told and I, you know, oh, you know, that's the way it is. Okay. I feel fine. Yeah, or oh well, that's part of aging. Right, right. And and now I think a lot of women in the late 60s are coming in, you know, have I missed a boat?

SPEAKER_01 22:35

That's the whole conversation. Yeah.

SPEAKER_04 22:37

And I and so there is a I'd like to encourage every woman of any age to go and discuss where they're at with their GP.

SPEAKER_01 22:47

So um are you of the mindset that HRT will help with uh bone density?

SPEAKER_04 22:56

Um yes, for sure. So the the situation with HRT in all the women is a little bit muddy because looking at some of the data that came out years ago, women who started HRT later in their 60s and um 10 years post-menopause, there's a lot of data to suggest that they're already developing a lot of the things like heart disease, and it may actually not be beneficial. I think there's a lot of data that needs to be collected, and uh the the advice is and I certainly my approach is on an individual basis, you know. I mean, if a woman comes in and they're doing everything right and they want they really are proactive, and we discuss it, and HRT is appropriate for what various reasons, uh, I think absolutely, you know, we discuss it and we take on board the risks and the benefits for that individual.

SPEAKER_01 23:46

So then do you find now that you almost have to ask Um, so let's say someone that's 40 is coming in and talking about HRT with you, and you were saying that you'll always look at like the history of the family, and let's say mom, who is now in late 60s, has um osteoporosis or osteopenia. Yeah, can you actually say though that this person in her 40s is susceptible to it hereditary from that side when the mom may not have actually used HRT? Like this would put the 40-year-old maybe more ahead.

SPEAKER_04 24:25

Yes. Yeah, I want a quick answer to your question is absolutely. Um, as I said, you've got to remember one in three women break hips, and that's osteoporosis. That's a big number. One in seven get breast cancer, one in three break hip. Um, and uh certainly I I do discuss that quite quite clearly. The the HRT hormone replacement is incredibly a valuable way of um avoiding a lot of the we we know that, but there's been so much scare about it, there's always a hesitation, you know, what about breast cancer? What about thrombosis? So there's a you know, you we I always had this conversation with women, like, you know, well, you can go with a natural way and do nothing, and then 20 years' time, you know, all your friends have taken HRT, they may be worse off, or you may it's a lottery, you know, you don't know what you're gonna end up with. But at the moment, I know it's worth taking risks for certain people. My biggest uh worry group are women who've got breast cancer uh and they cannot benefit from taking homicide. That's an area that really needs to be looked at um quite seriously and urgently because you treat the breast cancer, but they're suffering all the other effects of menopause and some of the medication they use for breast cancer puts you in even worse menopause. And life is really quite can be quite miserable. And a lot of these women we cannot, or we are starting to consider. But I'm told I my my remit as a GP is if I've got a lady who's terribly suffering terribly with menopause in their 40s or early 50s because they've gone through breast cancer, I have to discuss this with an oncologist to see whether it's appropriate. And damn right I do. And um, we do try and help them, but it's on a case basis, but that needs to be urgently addressed.

unknown 26:07

Okay.

SPEAKER_00 26:08

Just before we move on from the HRT, um so I guess a bl is a blanket statement. Is it fair to say that uh post-menopausal HRT could still potentially be an option? Yes. Okay. Again, a definite yes, yeah.

SPEAKER_04 26:25

But that's it was more on a case by case. Um and I think you'll find there'll be doctors who will be you'll see them across the whole board. There will be some who will be like uh evidence shows that it's not beneficial, and those who will say, Look, I feel you, and let's try it.

SPEAKER_00 26:48

But these are the risks. Right. Okay. Uh right. Why is sleep so often disrupted after menopause? And what can actually help with this stage?

SPEAKER_04 26:59

That's a really, really good question, and a really difficult one. One of my colleagues went on a week course study um on sleep, and I don't think she came out with any one answer. Oh no, if you expect me to say do this, and this will thought it. Um certainly we know estrogen is involved. Personally, I think women lose their knack to sleep as soon as they have children because you're forever on guard and your brain becomes, you know. I mean, I mean, I I again I joke that if a cat cries down the road and it's the same frequency as one of my kids, I'm awake. Yeah, right. Um, and there was a joke, did it, and I think it's true. So women when they sleep, they're only sleep 20%. With one eye open. With one eye open. Yeah, the brain doesn't shut down. But as you know, we we joke about it, but men can just close their eyes and they're snoring, right? Um, so I think women's brains are potentially trained to for wakefulness. Um again, you know, when women get pregnant, you know, they start losing sleep then, and yeah, we say, Well, you're just getting ready for your sleepless nights. And I think um, but uh but I have to say, sleep is is very important, there's no doubt. And I again it shouldn't be one of those things you should accept. Yeah, and there's a lot of uh low-hanging fruit kind of uh things you can do to improve on sleep. It's important, it's a big problem, is there a quick solution? No, and I don't think taking medications necessarily the long term because and alcohol, yeah, um, but there's a lot we I mean I don't want to go into detail now, but there's a lot you can discuss about how you can improve your sleep, but certainly retraining the brain to say, look, this is quite important. Yeah, I need the sleep.

SPEAKER_01 28:38

So for a woman that is post-menopause, let's say that um didn't use HRT and came to you and is suffering greatly from sleep, more than likely was probably suffering during that time. Is there an opportunity to use any type of hormone replacement at that time to help with sleep?

SPEAKER_04 28:57

Uh as a woman taking HRT, it's not really helping my sleep. Oh. Um I mean it it helps be for a lot of women going through menopause because often you're awake because of your temperature regulation going wrong and the hot, cold, hot, cold foot in, foot out of duvet. And so a lot of that is definitely improved. So in fact, if you go back to the 80s, HRT was used point blank, you know, uh without everybody to help with the menopause symptoms. And often it was the hot flashes that kept you awake at night. But generally the sleep that a 60-year-old plus or post-menopause woman plus is experiencing, it's not the same sort of uh lack of sleep.

SPEAKER_01 29:37

Oh, okay. Good to know.

SPEAKER_04 29:39

You know, the the I mean, you know, having gone through menopause, it's you don't sleep because uh you're one minute hot, one minute you're drenched, you're changing your sheets, you're changing your night, one nightgown. Um but sleep generally is not the biggest it's not it's not it's it's the hot flashes which respond to HRT, not the lack of sleep.

SPEAKER_02 29:59

Okay.

SPEAKER_04 30:00

I I certainly wouldn't, if somebody comes and says I'm not sleeping, my first response wouldn't be, oh just take some HRT, that's gonna improve it. If it's a part of a whole load of I don't feel well, you know, I don't have any energy to exercise, I'm sitting around all day, I'm brain fogged, I'm miserable, hence I don't sleep very well. All that, if you're feeling better in yourself, you might sleep better, absolutely. Yeah. But anything, you know, again, it's an individual thing. You've got to listen to people and you've got to see what what's uh what the issue is, and if HRT is, if hormone replacement is gonna help, absolutely. If that's uh and you know, the other thing I say to people is try it. You know, it you try it for a couple of months. If you don't like it, you just stop, right? You know, it's not and and in fact, again, a teaching is for up to a year, there's absolutely no change in your in your risk factors. And up to five years, your risk of breast cancer, for example, which does go up a little bit, um, is only after five years it goes up. So up to five yes, after five years. So so in the again, in the years before gone, we used to put people on HRD for five years and then we used to stop it. Yeah, right? And I remember my mother taking it at the age of 55, whatever it was, and she stopped at 60 because that was the even I knew that then that was how you did.

SPEAKER_01 31:12

Really? That's very uh I don't think I've ever heard that before.

SPEAKER_04 31:16

Yeah. No, five years. So literally I say to people, just try it for a bit. If you don't like it, then you don't have to take it. It's not uh, you know, if it doesn't help, that's fine. I have had women who've taken HRT and it just hasn't suited them. Um it's it's unusual, but you know, breast tenderness, I feel hormonal, um, but very, very unusual.

unknown 31:37

Okay.

SPEAKER_04 31:37

Most people love it. Yes. Yeah.

SPEAKER_01 31:40

We're both on it.

SPEAKER_04 31:41

Yeah, yeah. I I've been taking HRT, a bit of disclosure. Uh I I was one of those, my generation was, I can do this. I don't need any help. Yeah, yeah. And I tell the story how I really kind of started suffering in my sort of mid 50s. I actually went up to a local pharmacy who I know very well. I said, Can I please have some emergency HRT? And his response was, Dr. Fahi, you know you cannot prescribe for yourself. And she'd me away. But but you know, but you know, it's um and that was eight eight years ago.

SPEAKER_01 32:10

So and you said your mum was on HRT?

SPEAKER_04 32:12

She did take some HRT and um um absolutely, she was she was struggling. She's a nurse. She's 85 now. So she was six to twenty-five years ago. Wow.

SPEAKER_01 32:22

Which wasn't common.

SPEAKER_04 32:24

No. I mean, I do remember prescribing HRT. It was, you know, for women, but it was generally for hot flushes, it was all the physical things, uh, you know, to to and you did it while you did your two years, you know. Yeah. And then up to five years and you stopped. But now obviously we now realize that again, because life has changed, we're living longer, we're gonna be in menopause for a lot much longer. Lack of oestrogen causes uh uh is detrimental to our insulin, to our um cholesterol, to our heart, to our blood vessels, our brain, our bones. So it's now I mean, I have 80-year-olds who's still taking HRT, and uh they'll bite my hand off if I say you can't know it. Right. And I have in the past, I've had people come and see me, not here necessarily, but in UK, the GP start prescribing it. Through grapevine, they find us a GP who will they come and they'll go around till, you know, to find somebody to yeah.

SPEAKER_00 33:17

And I think that's a good message too. I agree. Don't necessarily accept it because you might just go, Oh some my doctor told me I don't I have to stop.

SPEAKER_04 33:26

Well, that's right. I mean, doctors, you know, you know sometimes I worry about this, you know. Obviously, you do trust your doctor, and what the doctor says is often right. And and there's a lot of difference in how doctors approach any illness from personal experience, experience generally, personal views, culture. Yeah. Uh, you know, that was one of your questions about culture, we'll come on to. Yeah. But doctors have cultures too. Yeah, for sure. And beliefs.

SPEAKER_00 33:52

Um, so what about brain fog forgetfulness and low mood? Are those common in post-menopause? Absolutely.

SPEAKER_04 33:58

I mean, it comes on with uh, you know, I I suppose most again, it's at its peak whilst your hormones are up and down. You know, when you spoke to your neurologist, he did say the brain's confused by all these, you know, what what is this? Because one minute estrogen's peaking and going down, the progesterone is here. So all the um the roller coaster of hormones is what causes the um all the brain fog and not being able to find words. And I mean, you know, I often ask women how things will work because that's where people are looking at you, yeah, uh wondering, you know, why you yeah. Um but anyway, but that yes, of course it is. Uh as I said, it kind of settles a little bit uh as you get older. Yeah. You know, you gotta remember women in often, the women I looked after in the 80s and 90s, often they didn't work, they'd stopped working to look after children, often didn't drive, often didn't have a bank account. Right. Well couldn't for Yeah, and and you know, the the brain was wasn't really necessary, wasn't being and now look at how women have careers and expectations and and the 60-year-olds who are now you know flying the crest of life. Absolutely, but you need to be a Toby again, and yes, yeah. What can we do to help with that? Yeah, the simple answer to that question is see a doctor who is sympathetic and understands and discuss what your symptoms are and uh what can we do to help? Um yes, HRT is definitely in the cards as far as I'm concerned, but we do discuss the you know how it's the first few years, but just because you've missed it, why would I say to somebody no you can't?

SPEAKER_01 35:28

Well, and that's what I was gonna say too, where there's if you are post-menopausal, like you can still go talk to your doctor about some of the stuff that you're struggling with.

SPEAKER_04 35:38

Absolutely. I interesting, I had a lady in her 60s who's got a lot of um cardiovascular diseases, actually, you know, and her doctor locally uh felt uncomfortable and she wanted some HRT, she was 60 something, I can't remember. Sent it to me. And we discussed, I looked at all risk factors, we discussed it. Very happily, she clutched that prescription HRT, ran out of my room to the local chemist. Good on her, you know, and good on the GP who didn't feel comfortable. Yeah. Uh obviously I've taken on risk, but it's uh informed decision making involving her. She's taken responsibility for herself and says, Life is not that great, how I feel. And uh and in fact, a lot of the heart disease already exists. She's got all this, and she's in fact, she was on blood thinners, so I'm not gonna give her a blood clot.

SPEAKER_02 36:27

Right.

SPEAKER_04 36:28

Yeah, really? Uh don't cross your legs on the airplane, maybe. Uh now, and uh you know, she's having her mammograms regularly. Uh, a lot of women who I uh encourage to take HRT, we have a system of have have mammogram check your breasts regularly, have mammograms. Nowadays, um, breast cancer is treatable if caught early, so let's let's just be on top of it.

SPEAKER_00 36:49

Are there d delivery methods for the HRT that is more safer for women? Absolutely.

SPEAKER_04 36:54

It's a very good question, and that's something which we're very aware that if you use transdermal uh hormone replacement, it bypasses the liver, and a lot of the um risks of breast cancer and um clotting disorders is minimized. Okay. So that's like the patches or the creams. Yes, patches and creams and lotions and potions, absolutely. Wonderful as opposed to tablets. Tablets are easier, but for all the women I would really encourage. And we have so many lovely ways of delivering oestrogen now. Vaginal leaven, if that's someone's gonna vaginal rings.

SPEAKER_00 37:25

Yeah. Uh what lab work should a woman in her like post-meta menopause era? He asked me for.

SPEAKER_04 37:32

So hormones are really not no point anymore. I mean, I have some as you have this conversation. I can tell you your ovaries are not producing oestrogen, so there's no point wasting your money on that. But definitely cholesterol, uh, subsects of cholesterol uh now commonly done, certainly sugar, um, insulin. Well, if your sugar's slightly off, definitely do the insulin um levels, but it's not first line. But check for diabetes, check for your bone health, vitamin D, calcium, um they're the they're the main things, and then go from there. Um, I'm trying to think, I'm sure there's other things I do. Thyroid, you know, it depends on the symptoms you add things on. Yeah. But bone heart, um cholesterol is a big one. Yeah, it's a huge one. Yeah. Um you've got to remember though, cholesterol, it's it's not just a number. You've got to look at it in conjunction. I mean, often when results come through, whether it be an x-ray or a mammogram or a bone density, it's in conjunction with the person. You've got to look. You know, for example, somebody can have very poor bone density, but they're malnutrition, you know, they're not eating properly. You know, it's no good just saying, oh, well, take this and we'll make it. But what are you doing? You know, cholesterol's the same. Does the cholesterol number could be high? But for example, I have a high cholesterol, my eight, my good cholesterol is high, my bad cholesterol is also a little bit high, and I have family history, but my calcium score is good, you know. And uh Dr. Cardiologist, no name is mentioned, looks at me. I'm sure he's waiting for me to have a heart attack any minute, but my family history, but I've done all the work up. I have checked my calcium, I've checked my subsex and my cholesterol. I my I could blood pressure, very important. Don't forget blood pressure, it's not just blood. Check your blood pressure. And I'm sure your neurologist would have told you that one of the biggest things for dementia now, as well as cholesterol, is blood pressure. And, you know, in uh we used to sort of say 160 overnight is slightly higher, but now we need blood pressure much lower, much, much lower. So I encourage a lot of people to again, it's like, well, do I need to come? Can I come off these if I don't have salt in my chips? You know, uh no. Uh we need to reduce your risks, blood pressure needs to be as low as possible because it's damaging all the intricate blood vessels in your brain, your kidneys, and your eyes. By the time that damage is done, too late.

SPEAKER_01 39:40

Blood pressure tends to rise in women, men.

SPEAKER_04 39:43

Yes, uh particularly in women. We know estrogen, particularly as that runs out of the vasculature, blood vessels become less flexible. And that's something again for exercise, because you're exercising, you're expanding your blood vessels. You need that elasticity, you need that movement so to accommodate blood. And uh when they become static, that's when the heart has to push harder to get through. So estrogen again is involved with that. But generally, blood pressure goes up, and I think we need to be much more generally men and women, you know, let's not be sexist. Um strokes and heart attacks is one thing, but kidney damage and dementia really important thing.

SPEAKER_01 40:18

Yeah, yeah, yeah.

SPEAKER_00 40:20

Um, if a woman feels that like this is just how it is now, or you know, really wants to start making some changes, how can she start to take back control of her health?

SPEAKER_04 40:30

I mean, obviously, we've discussed about go and see a doctor and have you know various tests, but really they they need to appreciate the importance for themselves. A lot of the work has to be done by the woman themselves. So it's a change of mindset. Um and I sometimes worry because again, more and more be looking for quick fixes.

SPEAKER_00 40:49

Yeah, yeah.

SPEAKER_04 40:50

And I think Oh, especially, yeah, we are in that kind of era now. Everything's quick, everything's fast. Absolutely. You know, I mean, sometimes women list all the supplements they're taking, and it's like, okay. Yeah, well, and I probably can't tell you why. Or like, well, my friends take it this one, so she told me I mean to. I must have had three emails by creatine this week. And honestly, I'm Googling like everybody else. It's not medic, it's not medicine. And I don't know how to politely say this. This is not a medicine, so I can't, it's not been tested. But anecdote says, you know, but what what what else are you doing? You know, come on, seriously. It's a bit like when a smoker comes to see me and is worried about the cholesterol. Uh let's just stop, you know, you are anything you do with that, you're undoing with the smoking 20 times over. Let's start with you need to look at yourself and look at that woman you see in their 80s or your grandmother. What do you want to be looking like or feeling? Not even aesthetics, but how do you want to feel like? What do you want your health to be like? Because I never forget a district nurse in the UK, we look after all the elders who said, Well, it's what can happen to all of us, you know. I don't even horrified, you know, looking at this woman who unfortunately in her 90s in nursing homes has got dementia's bent over and is leaking urine, and I'm trying to put a pestery to hold her vagina up, you know. And uh, and you know, that is potentially reality, but actually, you know, no, you can change that. You don't have to become that person, but that can be reality. Um, but having said that, to be fair, I don't want to be depressing here, but I we do see women who do very well, you know, and they have never taken the menopause was nothing, and and they're going through life, and they might have even smoked and drank and seem to be still playing golf at 90. You know, there are genetics there, but I can't guarantee that you're gonna be that person. And majority of us are not. Majority of us will lose muscle, we'll lose weight, uh, height in our bones, and we'll have to lose use of our bladder and and possibly our brain.

SPEAKER_01 42:44

And well, and I do hear that quite often by women who are post-menopausal. It's like, oh, I you know, I flew through menopause and a little bit of hot flashes, but I'm I'm fine, you know, it didn't really bother me. When someone says that, do you ever have a conversation with them of like what's your bone density like or what's your cholesterol like?

SPEAKER_04 43:06

Or yeah, I mean I'm quite sympathetic. Obviously, you know, it is difficult to envisage risks when you feel fine. Yeah. You know, it's the same with um smoking, for example. You know, uh, you know, don't wait until you have a heart attack to stop smoking. But trying to I mean, it's it's this it's that difficult area as doctors we we struggle with. How do you persuade people or discuss risks when you don't feel you feel great? Um so you know, you have to be sympathetic. Absolutely, you know, your mum flew through it and you flow the and absolutely, I don't want to persuade you to be taking any medication, but let's look at your risk factors, you know. Again, always starts with what is what is your history, what has your health been like? And then mum, grandma, aunts, uncles, both sides. Uh what's your lifestyle like? Um and again, you know, you need to optimize those. There's no point. you know, me scaremongering when this person's smoking, drinking, and not moving after sofa and feels fine. Um so it there's a lot of work you can do, but gently, you know. Um I don't go and have saying, Well, June Raj, you're gonna be falling over and breaking up. You know, she won't come and see me again. Um but so you know it's education. A lot of it is education and pointing the right direction and saying, look, just go and look at this thing. And even when I discuss HRT or any kind of method of contraception even, you know, I I I want you to go and read about this. I don't want to sit here and lecture you. And in fact, a lot of good studies, people only remember 10% of what you tell them. Yeah. So when I hear, but like now hear my own voice, people switched off already quickly.

SPEAKER_00 44:42

Alright, what is realistically possible for a woman say in her 55, 60 in terms of energy, strength, weight and overall vitality?

SPEAKER_04 44:54

Totally, totally doable. Yeah. Totally should be taken seriously. Totally can feel much better for it. Uh totally has to be priority. I had a lady in the other day, she's 67. She was telling me she does Pilates two or twice a week weight training on Saturday and swims and whatever. And feels great, you know, but we both discussed how our skin is getting a bit creepy. Right. But she feels great. But you know there are times we both agreed that we feel tired. Yeah we you know we don't have the same energy but she looks great you know right uh and uh she feels great but we do you know but she's investing in her future and quite right too it shouldn't become a chore and I always say if you're getting miserable because of it right that undoes all the good you've again you've got to take this upon yourself as a way of life something you do in you you need to do it for for for you because A it's good for you B you've got to enjoy it too. Yeah it shouldn't be a chore it shouldn't be oh my god I've now got to go and do my 30 minutes weight training it got in yeah encompass it in your in your in your g in your in your body in under your skin right find those activities that you like and then you feel better and you look better hopefully you get that benefit but you're also investing in your future. Right.

SPEAKER_01 46:09

I wanted to like touch on maybe something from the WHI and how that's like carried an impact in women.

SPEAKER_04 46:19

Is this the studies in the 80s the million women the nurse study?

SPEAKER_01 46:24

Yeah was it the 80s? It was like 20 it was about 25 years ago.

SPEAKER_04 46:28

Yeah so uh there's and I think we're probably talking about the same thing maybe I've got my dates uh but there was uh a big study came out which after which all all the women in America particularly stopped taking HRT is that the one yeah so research is really important obviously and I mean as a medical student we spent months trying to understand how to assess studies and uh and uh research to understand the importance of it. You know you cannot just read the headline and then look at the bottom lines oh they say this and that must be right and um without going to too much detail a lot of the things that they concluded have now been um disputed. For example it was it was a lot of sort of not natural we do we do bioidentical oestrogen now a lot of the hormones used was large amounts unopposed in all the women between over 60 and 70 and the endpoint of heart disease and so on was worse and cancer and so on. That has been I mean I you know I've I kind of looked at it all under time obviously uh and there are people much better place than me who've gone through it with a tooth comb they tell me that a lot of those things are no longer valid. I do appreciate that we have to be cautious um with whatever we do. As a doctor you know I have to be my oath is to do good not harm and we can only go by what we have at the at the time at the moment. So again what's happening now is we're much more likely to be looking at it individually as opposed to blank it like they did oh everybody should take this this is a good thing. But I think there's going to be more research there's a lot more now awareness of women's health sadly most of the um information we have is based on men's health and you've got to remember women we were defined by our fertility and our cycles if you look at the women's hormone cycles you know the the graph goes up and down is estrogen, progesterone, FSH, LH, ovulation pregnancy you know there's none none of it is about what is this actually doing to the body. So it's a lot of work to be done and I say to people the pendulum swung a little bit so we're now pro and there's a lot of FOMO going on out there. Yeah yeah and I think women have to be very very cautious because they're a bit of a captive audience at the moment and I'm amazed at how many people suddenly now menopause specialists and give their bit of opinion which is great but really women um I I want to put a word of caution out there be careful because there are people who are possibly often well meant you know let me let me help you. I'm gonna give you this stuff this is going to make everything okay just be you know go to a trusted um and a lot of women talk to each other right yeah and I think that's really important. I had a lady come and say well you've put me on this patch but my friends are all taking this patch let's let's unpick that so it's a very individual thing and absolutely talk to each other and um but be careful because I think there's a lot out there. There are a lot of people selling their wear take my my stuff that I'm giving you um this and I think there's a going back there's all FOMO and that you know am I missing out and I think a good conversation should take a good 45 minutes at least if not an hour but the doctor going through everything and literature and reading um trusted sources right and make sure it's it's individual.

SPEAKER_01 50:11

Well and and this is really great because now that everyone's talking about menopause and it's in your face and there was this whole study that was done 23 25 years ago. And like you said there is a number or a group of women who missed out on at that stage and it's typically I think like women that are probably in their late 60s, early 70s right now. And so that's why I really wanted to have a conversation with you of like different areas and different things that women of that age need to still be aware of even though you know I already went through menopause. But what are now things that we actually can still look at or still consider and not all is is lost.

SPEAKER_04 50:59

I think that's a really good point and I think if I was in that cohort I'd be quite worried about my health in the next 20 years. And I think this is exactly why women of that age who've said oh I'm fine I've done it I'm through need to start and to be fair as a doctor I don't think I did as much about preventative as I am now because it was about managing the menopause process previously you know I feel bad take this it's a much harder conversation when somebody's through and feels okay to say well look there's more to it and there's no prevention now we need to you know you feel fine but you know that conversation you feel fine but let me talk about what could go wrong well you don't know it may not but you know but we are living longer that's a fact and women particularly have more disability in older age than men that's a fact so so 60 70 year olds um need to be cognizant that there is a lot that can be done to reverse even if they didn't do the stuff that could have been done or you know sort of in terms of taking HRT to go through menopause they've lived through all that but there's a lot that can be done to improve as we said you know 34% 30-40% improvement in your cardiovascular health in your bone health in your muscle health and the things you can do to maintain your brain health not to mention vaginal health you know I you know people don't seem to be mentioning that too much but intimacy is really important do you know how many women come and say to me I'm no longer having sex because it's too sore or you know I wish I could but as again it's a taboo area and you know one of the questions you asked was about culture. Culturally some women you know I do bring it up in conversations how's your vagina right um how's your bladder? Forget okay even if you don't want to have sex you're gonna have your bladder is going to become atrophied and you're gonna get UTIs and you incontinence is a huge problem at older age women. Yeah so forgetting everything else let me talk to you about and I have a gynecologist female friends and male now I shouldn't really but uh gynecologists who actually firmly believe every woman after menopause needs to be on vaginal estrogen. Okay. Blanket the risks are very low let very little gets um absorbed um into the system so even our breast cancer ladies uh are definitely I I still check when you see your doctor next oncologist can you ask her if I can give you some some vaginal estrogen because you know I need to check but every woman can have should have uh have a look at their vaginal and bladder health at the minimum. So not just due to dryness but for musculature thinning of the I mean I I you know I perform um papsimas on women and uh by time you're uh we stop at 65 unless there's been problems but by the time they're 60s it is the most uncomfortable thing. And women come having taken having to take something to calm their nerves for me to stick a speculum in and I can't even do that with c with comfort. So a lot of these women I should say just take some vagina extrusion for three months come back I'm not not touching that. Oh wow so there's no need to to suffer um that's a huge area why why are people not talking more about that?

SPEAKER_01 54:27

We did do an episode on vulvas oh with the dermatologist yeah yeah she's she's Mrs Mrs.

SPEAKER_04 54:33

Vulva great I'm so pleased she's here um but but inside but the channel health and sexual health yeah you know we all know that social isolation is is one of the biggest causes of dementia in old age and of course the way society is going we're not all living next door aunts and uncles and children are next door right some cultures still look after the elderly they're uh revered as people who are knowledgeable and wise and they look after them but there's uh a lot of elderly particularly women who are lonely and uh uh they could do with company and uh and intimacy is gone even in couples you know a lot of people say oh we'll be happy with this but right they've accepted that but uh I'm not advocating everyone should be having sex but women are still coming in their 70s and still sexually active and I help them with uh newly married do you know grey divorce a lot of women on I say to them look your divorce you haven't had sex for five years but you might meet somebody yeah that's you so if if your vagina is is required to be active is in a good you know we do have a giggle about it but it's true. I have got women saying I've met somebody I'm 60 but I've met somebody and I want to have sex absolutely right I can make that possible and I can assure you women who've had a vaginal estrogen which is safe when I check their uh not you know I'm not hurting them the the it it's all plump and plush and I say you know your service looks like a 20 year old at least one thing can make something that's right maybe not the wrinkles but the wrinkles are the least of our worries and I think that's the other thing sorry just to you know women um we're now relying more and more on our physical look um and that makes us feel better absolutely but that's just the surface you know and I say you know you you look beautiful but be be warned you know when when things go wrong with you inside you'll be that's far more important although this is important to have the fillers and the Botox and eyelashes and get your nails done but that's these are easy fixes but it's external. Right. Yeah it doesn't matter you have to do both. Yeah if your bones or your cholesterol or your heart is not where it needs to be these things are going to deteriorate and it was fine when we're when we were dying early didn't matter when we're now living uh longer and longer we need all these faculties to be it's a real sadness when you see 80-year-old dementia leaking broken hip and every time you break a bone you you become more fragile so you could be very fit and healthy my mother she broke her it wasn't my fault she was here she not on familiar she fell over broke her shoulder and from that day her health I used to be I used to have to run after her to keep up with her uh she was like but broke a bone your confidence goes because now she's looking am I gonna fall over it was such a shock and since then in the last five years her health has declined she lives alone COVID was terrible didn't see anybody her mental capacity we don't have dimension a family she's getting slow and uh it's really sad to watch um you know could I have done something about it? I mean she takes a blood pressure medication she's diabetic she does that she looks she's thin she goes to the gym three still three times a week she's doing all of that um but the you know um we we could I think about it now and I think the social isolation and that was big um the breakbone she has osteopenia but she's taking stuff with that now maybe I should have left told her to stay on HRT longer but you know that was 20 years ago in hindsight yeah yeah well I think that's it as well I think so too if anybody wants to yeah um if anyone wants to come and chat with you how can they get a hold of you? Just call Cayman Clinic Yeah Cayman Clinic um I think some people do you know there are there's a lot of conversations out there and I do get referrals which is great and I honestly I do my best I can. Majority of my work now is women's health um so really just call and ask to see me and we go from there. And then I do keep in touch via emails and so on. So once the introduction's done when we go from there. Yeah okay perfect no problem I do look after other people as well by the way you know and it's not just women's health but uh I do family quite a lot of family planning minor surgery children a lot but the majority of my work and actually it's really being it's quite useful being a woman of a certain age. Yeah you know empathy sympathy I've I've been there done that yeah I agree so that's perfect. Well thank you very much thank you for asking me I was delighted to come along slightly nervous not very good at you it went very well thanks for joining us on Best Intentions.

SPEAKER_00 59:15

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