Menopause

For the majority of women, the Menopause is a natural physiological process when their ovaries lose their reproductive function, don’t produce enough the essential hormone oestrogen and their periods stop. From the Greek word Menos (monthly) and pausos (ending). Medically, the diagnosis of menopause is made when periods have stopped naturally for 12 months. In the UK, the average age of the natural menopause is 51 years.

The majority of women start to experience symptoms due to the fluctuating and declining levels of hormones in the perimenopause from about the age of 45: it’s the time leading up to their natural menstrual periods completely stopping. 1 in 100 women will experience premature menopause (premature ovarian insufficiency) before the age of 40. Menopause may also be caused by surgical removal of ovaries (immediate menopause) and after some chemotherapy or pelvic radiotherapy. Some women will experience symptoms of the menopause whilst taking some medications including those used for breast cancer, severe premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD) and gender transition. Those who identify as non binary, if they have ovaries, can also experience menopause. Postmenopause refers to the time when an individual’s periods have naturally stopped for 12 consecutive months or when their ovaries have been removed surgically.

 Ovaries produce hormones such as oestrogen, progesterone and testosterone. We have oestrogen receptors in every part of our bodies, from our brain, heart, muscles, joints, vagina and bladder. We can experience symptoms when the amount of oestrogen in our bodies starts to decrease in the perimenopause, initially fluctuantly (up and down).

Majority of women will experience symptoms and 1 in 4 will report such significant symptoms which seriously affect their quality of life and their work life. These symptoms can last anything from 4 – 8 years and for some women, lasts well into their 60s. Some women will have no symptoms at all, their periods just stop.

Periods: Changes in the menstrual cycle is one of the earlier signs of perimenopause. Periods can become unpredictable: they can become heavier or lighter, they can last longer or become shorter, they can occur more frequently or miss some months. Periods can become more painful and some women can start experiencing symptoms of Premenstrual syndrome (PMS) or worsening of their PMS.

Helpful Tip: the Mirena IUS is very effective in controlling heavy menstrual bleeding and period pain as well as providing contraception. It can also be used as the progestogenic part of HRT.

A Hot flush is period of intense heat in the upper body, face and arms with flushing of the skin and profuse sweating, followed by chills. It is often accompanied by palpitations (unpleasant sensation of irregular or forceful beating of the heart) and a sense of anxiety. It can be triggered by small increases in core body temperature – caused by changes in the room temperature or triggers such as stress, rushing, alcohol intake, spicy foods or caffeine.

Helpful Tip: wear layers which you can remove easily to help you cool down

Night sweats are hot flushes which occur whilst sleeping, causing disturbed sleep by frequent waking, often drenched in sweat.

Helpful Tip: keep a window open at night or have a fan in your room to keep cool

Sleep problems: Night Sweats can cause disturbed sleep by frequent wakening. Sometimes, even without night sweats, some women have trouble getting to sleep, staying asleep, wake up earlier or generally have a poorer quality of sleep.

Helpful advice: Menopause and insomnia

Mood and Psychological symptoms can occur at times of hormonal fluctuation such as during the perimenopause, premenstrually or in the postnatal period. Depressed or low mood, feeling hopeless, tearfulness, mood swings, irritability, loss of patience, anxiety and panic attacks can be really distressing and often occurs out of the blue and completely out of character. These can lead to difficulty in coping, loss of confidence and loss of motivation.

Helpful Tip: Cognitive Behaviour Therapy (CBT) for Menopausal Symptoms helps people to develop practical ways of managing problems and provides new coping skills and useful strategies

Tiredness or exhaustion can result from poor sleep, low mood as well as reduced hormone levels.

Cognitive symptoms are common in menopause and can be caused by stress, tiredness, lack of sleep and depression. Oestrogen has key functions in brain health and is important for delivering glucose to the brain. As oestrogen levels drop, it can lead to a range of symptoms such as difficulty in concentration, difficulty in finding the right words, poor memory, being forgetful and brain fog (lack of clarity in thinking or “head feels full of cotton wool”). Some women are frightened that they may have dementia, especially if there is a family history but often, replacing the hormones early can improve brain fog.

Genital and urinary symptoms are often under reported by women, under diagnosed and under treated. The lack of oestrogen causes thinning of the genital and lower urinary tract tissues (urogenital atrophy or vulvovaginal atrophy). This thinning of the vaginal walls, reduction in the natural lubricants and loss of the stretchiness of the vagina can cause vaginal dryness, irritation, burning or itching. Sex can become uncomfortable or painful and the vulval skin and vagina can split and bleed more easily.

Oestrogen receptors are present in the bladder and the neck of the bladder, the urethra. The lack of oestrogen can cause the feeling of needing to pass urine more frequently, urgently, and/or irritation on passing urine. There may be more frequent urine infections or symptoms of urine infections without infection.

Helpful Tip: The best treatment for these genital and urinary symptoms is vaginal oestrogen (oestrogen which is inserted into the vagina via a tablet, cream, pessary or ring).  Non hormonal vaginal moisturisers (E.g. YES VM) used regularly, every 3 days, and lubricants used during sexual intercourse can also help relieve vaginal dryness.

Urinary incontinence and prolapse (bulging down of vaginal tissues) can get worse with menopause. Leaking urine is common but should not be accepted as normal. It is not something you just have to put up with as you get older.

Helpful Tip: NHS Squeezy App can help you with pelvic floor exercises. Consider a referral to a specialist pelvic floor physiotherapist.

Sexual Problems and reduced libido -  There may be lots of reasons for lack of sexual desire such being tired, poor sleep, low mood or irritability. It can also be due to low hormone levels, vaginal dryness and discomfort or pain during sex. Difficult relationships or a past history of trauma may also affect sexual desire and counselling may be helpful to explore psychological reasons for low sexual desire.

Helpful Tip: It is important to speak to your partner and explain how you are feeling. Look at ways which will help you remain close to your partner even if you don’t want to have sex. Male partners might find The Man Shed useful.

Joint pain and stiffness affects more than half of menopausal women, in particular, neck, wrists & shoulders. It can be worse after sudden loss of hormones for example after surgical removal of ovaries or with some breast cancer treatments. Backache, muscle aches and muscle heaviness can also be problematic.

Headaches, new or worsening of migraines may occur due to the changes in hormone levels in the perimenopause and can generally improve once hormone levels stabilise. Other symptoms such dizziness and palpitations (feeling of heart racing) can also occur even at rest.

Skin, hair and nails can become dry and more brittle with some women experiencing thinning of their hair. Some women can develop acne or an increase in facial hair. Skin can become thinner and lose their elasticity. Some women can feel a crawling sensation on their skin (formication).

 Helpful Tip: you may have to moisturise more frequently or use different, richer skin and hair products. Sun screen is important to prevent further damage to thinning skin.

Loss of fertility: For some, this may bring relief in no longer requiring contraception or risk of an unintended pregnancy. For others, the loss of their reproductive ability may cause sorrow, loss of purpose or regret, in particular if they have not had or wanted a pregnancy in the past or if they have experienced pregnancy loss or child bereavement.

Helpful Tip: women going through the perimenopause or have premature ovarian insufficiency will still need contraception. Contraception is no longer required after the age of 55

Weight Gain: Oestrogen is important for controlling metabolism and usually promotes fat storage around hips and thighs (Pear shape) which is important to support women’s bodies through pregnancy and breastfeeding. During perimenopause, lack of sleep, tiredness, joint stiffness and muscle aches can reduce the motivation to exercise or feel more fatigued after exercise. From the age of 40, there is about an 8% loss of muscle every 10 years (sarcopenia). Muscle burns more energy. Low mood can lead to comfort eating and excessive alcohol intact. The combination of the metabolic effects of lack of oestrogen as well as moving less and burning fewer calories can lead to excess fat, which is often stored around the abdomen and can lead to an increased risk of heart disease, insulin resistance and type 2 diabetes.

Helpful tip: Although lifting weights and resistance training is best for bones and muscle, do any form of activity which you enjoy like walking or dancing. It will benefit your heart, can lift your mood and can help you sleep better.

Coronary heart disease

There are oestrogen receptors in the blood vessels supplying women’s hearts. Before menopause, women have a lower risk of heart disease as oestrogen can reduce the build up of fatty plaques in the arteries supplying the heart. After menopause, the risk of heart disease increases. Stopping smoking, being physically fit and active and having a healthy body weight is also very important.

Bone Health

Our bones are at its strongest in our 30s and begin to slowly thin from our 40s. From menopause, as oestrogen levels fall, bones start to thin quicker at a rate of 2% per year. This makes bones weaker and more prone to breaking with minimal trauma. About 1 in 3 women over the age of 50 will have a fracture (such as a hip fracture) resulting from Osteoporosis (thinning of bones).  You could also be at a higher risk of osteoporosis if you are under weight (BMI <20), very inactive or wheelchair bound, on long term oral steroids or have certain medical conditions (E.g. Coeliac disease or severe epilepsy), a smoker or drink alcohol excessively. Maintaining a healthy weight, regular weight bearing exercise, stopping smoking, reducing your alcohol intake and ensuring your diet includes calcium and vitamin D can help maintain your Bone Health.

Approximately 1 in 100 women will experience menopause before the age of 40 years, 1 in 1000 before the age of 30 and 1 in 10,000 before the age of 20.

It is strongly recommended that these women have hormone replacement therapy (to levels that would normally be produced by the ovaries) to control symptoms, reduce the risk of cardiovascular disease and osteoporosis, as well as to maintain sexual and cognitive function. HRT should be continued till at least to the average natural age of menopause (51). Menopausal symptoms experienced by women with POI may vary in intensity and can be intermittent due to fluctuation in ovarian activity. The combined contraceptive pill would be a suitable option for hormone replacement for younger women but HRT would give better bone and heart protection.

Hot flushes are associated with stress and anxiety and can result in social embarrassment and discomfort, lowered confidence and feeling out of control. Hot flushes can be visible and further increases anxiety which triggers further hot flushes. Night sweats causes disturbed sleep with knock on effect of tiredness, increased anxiety and worry of poor performance the next day, lowering self esteem. The anxiety/worry about having another disturbed night can itself trigger more vasomotor symptoms.

For many women who have not experienced psychological symptoms before, they can find mood changes, anxiety and fatigue distressing, out of character and unexpected. This can impact on their personal, social, home and work life. There are also other psychosocial life changes: pressures from work, aging parents (ill health or bereavement), children / young adults  leaving (or not leaving) home, loss of partner through death or separation, financial worries, negative attitudes to aging and the menopause, poor health, tiredness and sleep problems can all make the individual feel less able to cope.

In the workplace, 75% of symptomatic menopausal women report serious problems in dealing with the physical and mental demands of their work (low work ability). Hot flushes are reported as a source of distress and embarrassment for some, leaving them feeling at odds with their desired professional image.

The symptoms of menopause which are felt to cause the most difficulties at work are poor concentration, poor memory, lowered confidence, feeling low / depressed and fatigue.

Workplace environment such as stressful or high visibility work environment, hot or poorly ventilated areas can exacerbate menopausal symptoms.

Reluctance to disclose menopausal symptoms at work may be due to fear that their symptoms will not be taken seriously or fear of stigmatisation. Some feel that their menopausal status opens them up to being stereotyped and prefer not to reveal age or gender-related matters at work. When women take sickness absence because of menopausal symptoms, they do not always reveal the real reason to their manager. This is especially the case where their manager is male, is younger than them, is unsympathetic (E.g. line manager did not experience a negative impact of menopause themselves) or have cultural differences.

Making healthier life choices can help with some of your symptoms as well as help with your health and wellbeing in general.

Smoking, caffeine and drinking alcohol can trigger hot flushes. Stopping smoking and reducing your alcohol intake can also reduce your risk of heart disease and some cancers.

Exercise, in particular weight bearing exercise and lifting weights, can help maintain your muscle and bone strength both before and after menopause as well as improve mood, sleep and heart health. 150 minutes of moderate intensity exercise per week has been shown to reduce the risk of breast cancer.

Maintain a healthy weight. Being overweight or obese can make flushes worse and is associated with an increased risk of some cancers, heart disease, diabetes and blood clots. Being underweight is associated with an increased risk of osteoporosis. Many menopausal women need at least 200-300 fewer calories per day just to maintain their weight due to fewer daily calories being burnt off and the metabolic changes that low oestrogen causes. Adequate protein intake is essential for maintaining muscle and provides satiety (feeling full / satisfied). Calcium and vitamin D is essential for bone strength.

Self care, rest and relaxation can help you to feel calmer, reduce stress and anxiety. Activities such as mindfulness, meditation and yoga can be useful. Reach out to friends, colleagues and partners. Talk about how you are feeling and get support. If you are really struggling, especially if you are feeling suicidal, see your GP or call Samaritans.

Menopause is caused by low oestrogen levels so replacing this hormone back to normal (physiological) levels is a very effective treatment. Hormone replacement therapy (HRT) or menopause hormone therapy (MHT) does exactly that. It brings hormone levels back to normal.

Women with a uterus: Oestrogen stimulates lining of the womb so the hormone progesterone (or progestogen which is a synthetic version) is also taken along with oestrogen to prevent the lining of the womb (endometrium) from thickening up. If the lining stays thickened over a long period of time, it may lead to cancer changes (endometrial cancer) so it is very important to take both.

Combined HRT (containing both oestrogen and progestogen) is available as a daily tablet or as a patch which is worn continuously and changed twice a week. If you are still having periods, or you have had a period within the last 12 months (perimenopausal), you will be prescribed sequential HRT – this means you take only oestrogen for 2 weeks then both oestrogen and progestogen for 2 weeks then repeat. This will give you a monthly “period” (withdrawal bleed). If you have not had a period for at least 12 months (postmenopausal), then you can be prescribed a continuous combined HRT (i.e. every tablet or patch contains both oestrogen and progestogen) which will not cause a monthly “period” (withdrawal bleed) although can cause some irregular light bleeds when first starting HRT.

Oestrogen and progesterone can be prescribed separately. Progestogen can also be delivered directly into the uterus via a Mirena IUS which is very good at reducing the thickness of the lining of the uterus (endometrium), reduce bleeding (in many women, it can stop periods completely) and also provides effective contraception. 

Women without a uterus (after hysterectomy) can have oestrogen on its own without progestogen. Oestrogen can be taken as a daily oral tablet or through the skin (transdermal) such as a gel rubbed into the skin daily or a patch worn continuously on the skin and changed twice weekly.

Women who have had a hysterectomy for endometriosis should take combined HRT as oestrogen may stimulate any spots of endometriosis which may still be present outside the uterus which may cause symptoms to restart. Taking progestogen continuously along with oestrogen will help prevent this.

Vaginal oestrogen is given for vaginal and urinary symptoms. It can be taken on its own if genital symptoms are the only issue, or for some women, in addition to HRT if they are still having genital symptoms despite being on HRT (about one third of women on HRT need additional vaginal oestrogen). Vaginal oestrogen can be prescribed as vaginal tablets, vaginal cream, pessary or a vaginal ring.

Side effects of HRT: Most side effects tend to settle within 3 months of starting HRT or can be reduced by starting with a low dose or changing the type of preparation.

Irregular Bleeding: some irregular bleeding or spotting may occur when you start or change the type of HRT. This usually settles down. However, if the bleeding / spotting persist for 6 months or you start bleeding again after having had no bleeding for 1 year or more (postmenopausal bleeding) you must have this checked out. There are lots of causes for postmenopausal bleeding (PMB) but it can be a sign of cancer of the cervix, uterus or vagina. You should see your GP as soon as possible so that you can be referred for investigations.

RISKS AND BENEFITS OF HRT

Women who have or have had breast cancer or any other hormonally sensitive cancer (such as endometrial cancer) should not be prescribed HRT.

RISKS of HRT

Breast cancer - Understanding the Risks

·         For every 1000 women aged between 50 – 60 years, 23 will develop breast cancer regardless of any other factors (background risk)            

·         For every 1000 women aged between 50 – 60 years taking combined (oestrogen and progesterone) HRT for 5 years, there will be 4 additional cases of breast cancer.

·         The risk of breast cancer increases with age whether on HRT or not

·         The risk of breast cancer increases with the length of time taking combined HRT

·         Taking Oestrogen only HRT, adds little or no risk of breast cancer

·         Smoking or drinking 2 units of alcohol per week adds 3 and 5 additional cases of breast cancer per 1000 women respectively

·         Being obese (BMI >30) adds 24 additional cases per 1000 women

·         150 minutes of  moderate exercise per week reduces the risk (7 fewer cases per 1000 women)

·         The majority of women will not develop breast cancer because of taking HRT

There is an additional 1 case of ovarian cancer per 1000 women taking HRT (combined or oestrogen only) over 5 years.

Blood clots and stroke

·         The oral (tablet) form of oestrogen is associated with a small increased risk of blood clots which is not seen with HRT taken through the skin (transdermal). Women with an increased risk of blood clots (E.g. very over weight, obese, older age group, history of blood clots) can be prescribed the transdermal form of oestrogen. The type of progestogen can also affect the risk and there are safer options which could be prescribed.

·         There is a very small increase risk of stroke with oral oestrogen HRT but in women under the age of 60, the overall risk of stroke is very small. Standard doses of the patch or gel is not associated with an increase risk of stroke. Women at higher risk of stroke (E.g. Migraine with aura) can be prescribed the transdermal version of HRT.

BENEFITS OF HRT include:

·         Symptom control, especially if it is affecting quality of life

·         Maintaining cognitive function

·         Maintaining  sexual function

·         HRT, started early in menopause or within 10 years of menopause, reduces the risk of heart disease and heart attacks

·         Reduces rate of bone loss, reduces risk of osteoporosis especially for those who have other risk factors, and can be used as treatment of osteoporosis

·         Lower risk of bowel cancer

·         Additional progestogen, in particular the Mirena coil or in continuous combined HRT, lowers the risk of endometrial cancer

·         There is some early research evidence that starting HRT early in menopause could reduce the risk of developing dementia. Starting HRT at an older age however may cause dementia to occur more quickly. 

·         Overall, there is no increase of death from all causes (mortality rate) in women taking HRT compared to women who have never taken HRT

For most women, if starting HRT before the age of 60, the benefits of HRT outweigh the risks.

In women starting HRT when aged between 60 – 70 years, the benefits equal the risks. Starting HRT after the age of 60 does not lower the risk of heart disease but it is not thought that it increases it either.

Starting HRT over the age of 70 may have more risks than benefits.

When to stop HRT? There is no arbitrary age to stop HRT. Individual risk must be assessed against benefits. If choosing to stop HRT, it would be advisable to gradually reduce the dose rather than stopping suddenly. If choosing to continue HRT, women over the age of 60 should be prescribed the lowest dose of HRT which will control their symptoms and be on the safest preparation (E.g. transdermal oestrogen).

Bioidentical HRT

Bioidentical hormones are precise duplicates of hormones produced by the human body. These include estradiol (Oestrogen) which is in most prescribed HRT (tablet, patch and gel).  Utrogestan is currently the only regulated bioidentical progesterone available (oral capsules) for HRT prescription.

Some private companies have produced “compounded bioidentical HRT” but these are unregulated and have not gone through the same rigorous research as conventional and regulated HRT so are not recommended and are not prescribed in the NHS. To differentiate from these unregulated products, the regulated hormones which have been approved for prescribing in the NHS are sometimes called body-identical hormones.

Testosterone

Testosterone is produced in the ovary as well as the adrenal glands. Testosterone contributes to libido (desire for sex), sexual arousal and orgasm, and can also maintain muscle and bone strength, genital health, mood and cognitive function.

 Low testosterone levels are particularly seen in some women who have had their ovaries removed surgically, who have had medically induced menopause or very early / premature menopause. Not all women require testosterone replacement (as some is still produced by the adrenal glands) but if, despite sufficient oestrogen replacement, you are still struggling with low sexual desire, fatigue, brain fog and muscle pain, testosterone replacement may help. There is no testosterone replacement product for women licensed in the UK. What is prescribed is male testosterone products, but used at lower female doses and is off licence. Blood tests are required to ensure that you are not taking too high a dose which may cause side effects such as acne, greasy skin, increased facial hair and male-pattern balding.

Some women cannot be prescribed HRT (E.g. history of breast cancer) and some women may wish to choose complementary or alternative therapies to manage their symptoms.

CBT for menopause symptoms has been shown to be effective for many women.

Some women find certain herbal remedies and alternative therapies such as acupuncture useful. Phytoestrogens are found in certain foods and supplements. They have a chemical structure similar to oestrogen and can give a small boosting effect. Women who have had breast cancer are advised not to take phytoestrogen supplements but it is fine to have foods containing them.

Whilst antidepressants should not be used as the first line treatment of low mood associated with menopause, for women who cannot take HRT, certain types of antidepressants can be prescribed which may help reduce hot flushes and sweats as well as improve mood and sleep.

Women who are perimenopausal or who have premature ovarian insufficiency do still need contraception as the hormone levels can be very variable. It is advisable that contraception is continued for 2 years after the last natural period in women under age 50 and for 1 year after the last natural menstrual period if over age 50. If menopause cannot be confirmed (for example you do not have periods as you using hormonal contraception) then contraception should be continued till age 55.

HRT is not a method of contraception. You can use methods of contraception such as barrier methods, progestogen only pill, progestogen Implant, copper IUD or Mirena IUS alongside HRT. The combined hormonal methods and DepoProvera injection should be stopped at age 50. The Mirena IUS is an ideal choice as it has the added benefit of controlling heavy periods and can be used as the progestogen part of HRT with minimal side effects. You can discuss your contraception options with us at Highland Sexual Health or with your GP.

Why can’t I refer myself to the Menopause Clinic? The Menopause Clinic at Highland Sexual Health is an NHS specialist service providing additional expertise and care for those who have complex medical needs. Your GP should be able to provide you with routine menopause care and can refer to the clinic if appropriate. You can also request a referral to the clinic if you feel your symptoms are not well controlled, persistent side effects or have additional concerns you wish to discuss. There is currently a waiting list for an appointment.

Is there a blood test for diagnosing menopause? FSH (follicle stimulating hormone) levels rise in postmenopausal women in response to low oestrogen levels. During perimenopause, FSH levels can be variable. You could have a normal FSH level and still be perimenopausal from your symptoms and therefore checking an FSH level is not a useful test. FSH levels are checked in women under the age of 40 who have symptoms of menopause and their periods have stopped for at least 4-6 months (to diagnose POI). In women over the age of 45, the diagnosis is made based on symptoms and an FSH blood test is not usually required.

I have a family history of breast cancer. Can I still take HRT? Having a family history of breast cancer may not exclude you from taking HRT if you feel you need it to control your symptoms. You may have a higher background risk of developing breast cancer. Your GP can refer you to the Menopause clinic to have a discussion of the risks and benefits to help you make an informed decision.

HRT is not working for me. You may need a higher dose of HRT (especially if you are younger or have had your ovaries removed) or a different type of HRT such as changing from oral to transdermal. Some women may also need testosterone.

I am having side effects from the HRT. Depending on the side effects you are experiencing, you may need to lower the dose of oestrogen or change the type of progestogen. If irregular or heavy bleeding is an issue, you may need to increase the progestogen dose or change to a Mirena.

I have heard that HRT is dangerous. There have been many studies over the last 20 years and long term follow up evidence suggest that for the majority of women, the benefits of taking HRT outweigh the risk in women under the age of 60. Whether or not you take HRT is your choice.

I am over the age of 60, can I start HRT? Starting HRT after the age of 60 or 10 years or more since your menopause may not give you the same benefit (such as protecting your heart) as starting it earlier. However, if you are still having symptoms such as hot flushes and sweats, then taking HRT can help.

I am over the age of 70, can I start HRT? There are more risks than benefits to starting HRT much later in life. There is a higher risk of breast cancer and heart disease as you get older and some studies have suggested that starting HRT after the age of 70 can increase the risk of dementia.

I have a medical condition – can I take HRT? Depending on the medical condition, your GP may wish to seek advice or refer you to the Menopause clinic for a consultation to find the best option for you. There are certain medical conditions where it will be more beneficial to you to take HRT (E.g. conditions which raise the risk of osteoporosis) and some medical conditions or their treatments (E.g. past history of a blood clot, HIV) where a transdermal HRT would be safer -  A to Z of Menopause & Medical Conditions

I have been told I cannot take the contraceptive pill, does that mean I cannot take HRT? The combined oral contraceptive pill / patch is completely different from HRT and most women who are unable to take the combined contraceptive pill (E.g. due to migraines, risk of blood clots) can be prescribed transdermal HRT safely.

British Menopause Society videos of experts answering frequently asked questions

Women’s Health Concern  Factsheets from the British Menopause Society’s patient website

Menopause Matters – useful information from Scottish based menopause specialists

Daisy Network – for premature ovarian insufficiency

National Association for Premenstrual Syndromes

NHS Inform Menopause Platform

You can listen to our menopause specialist speaking to Sophie Donald on her podcast:

The Menopause with NHS Specialist Hame Lata - All Good in the Sisterhood | Podcast on Spotify

‎All Good in the Sisterhood: The Menopause with NHS Specialist Hame Lata on Apple Podcasts