Nov. 29, 2024

#133: The Menopause Conversation You'd Have If Your Bestie Was A Woman's Health Specialist. With Dr Nicole Avard and Georgina Drury

#133: The Menopause Conversation You'd Have If Your Bestie Was A Woman's Health Specialist. With Dr Nicole Avard and Georgina Drury

This discussion highlights the challenges and societal implications of menopause, particularly around access to care and workplace dynamics. It emphasizes the need for individualized approaches to Hormone Replacement Therapy (HRT), addressing risks for women starting late. The session explores the role of fluctuating hormones in symptoms, genetic predispositions, and the mental health risks tied to menopause. Workplace stigma, such as fear of judgment for symptoms like hot flashes, impacts retention and performance, underscoring the importance of leadership-driven dialogue and support systems. Solutions include training healthcare providers, leveraging technology for accessible care, and promoting menopause-friendly workplace policies as part of diversity and inclusion efforts to reduce stigma and provide holistic support.

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Season 131

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“This is not a women's issue: this is a societal issue. We all have women in our lives that we love, that we work with, that we care for, and we MUST be putting these conversations on the table.”

If you’re listening to THIS podcast, chances are you’re a veterinarian. That means that statistically, there’s about a 70% chance you’re a woman. That makes an honest, in-depth conversation about menopause not just relevant, but essential. This is that conversation. 

 

And even if you’re not a woman, or menopause is still decades away for you, you almost certainly work with or live with someone for whom this topic is, or will be, very significant. You should absolutely care about it- and know about it.

 

In this question-and-answer conversation, recorded live at the Greencross Symposium 2024, we unpack the science, symptoms, and solutions with Dr. Nicole Avard, menopause specialist, and Georgie Drury, founder of Metluma, a digital health initiative that supports women through menopause.

From understanding the biology of menopause to tackling its impact on mental health, career, and workplace culture, this is the conversation you didn’t know you needed—but one that will make a difference in your life and practice. 

 

Topics and Timestamps

[00:04:00] Menopause 101

[00:06:00] Biological Changes During Menopause

[00:08:00] Symptoms of Menopause

[00:12:00] Mental Health and Menopause

[00:15:00] Challenges in Diagnosis and Treatment

[00:17:00] HRT Safety and Benefits

[00:22:00] Myths and Misinformation

[00:32:00] Organisational Responses to Menopause

[00:40:00] Menopause Q&A

  • Gradual discontinuation of HRT.
  • Role of diet in managing symptoms:

[00:45:00] Advanced Questions on Treatment

  • Using IUDs vs. transdermal progesterone.
  • Blood tests for diagnosing postmenopause.
  • Role of testosterone in symptom management.

 

Speaker bios:

Nicole Avard

Dr Nicole Avard is a dedicated Menopause Specialist GP with 18 years of experience as an Integrative GP. As the Medical Director and Co-founder of Metluma, she is passionate about guiding women through the complexities of menopause. Dr Nic has supported thousands of women on their menopausal journey, offering compassionate and individualized care. 

Georgia Drury

Georgie is an experienced entrepreneur and CEO, with a passion for health and technology. As founder and CEO of Springday, she built the business into a multi-million-dollar global organisation, operating across 13 countries in ASPAC before exiting and moving onto her next venture. With Hummingbird Innovations, Georgie advises, invests, and collaborates with boards and organisations. She is currently Co-founder and CEO of Metluma, an exciting and innovative digital health initiative aiming to support women by taking a proactive approach to menopause.

 

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“Why Menopause Isn’t Just a Women's Issue: A Workplace Perspective”

Menopause is often seen as a women's issue, but it's actually a societal issue that impacts everyone. The episode explains why this is the case and what workplaces can do to support their employees.

Menopause is More Than Just a Personal Health Issue:

  • It impacts a large percentage of the workforce. Around 80% of veterinary professionals are female, and many of them will experience menopause-related challenges.
  • Symptoms can be debilitating and impact work performance. Symptoms can range from hot flashes and insomnia to anxiety, depression, and cognitive issues. These symptoms can lead to decreased productivity, absenteeism, and even early retirement.
  • The stigma surrounding menopause prevents open discussion and support. Many women feel uncomfortable discussing their symptoms, fearing judgment or negative career repercussions.

Creating a Supportive Workplace:

  • Start conversations and raise awareness. Open dialogue is essential to break down the stigma surrounding menopause. Encourage discussions at all levels of the organization, including leadership and HR.
  • Provide access to resources and support. This could include:
    • Information and education about menopause and its symptoms.
    • Access to healthcare professionals trained in menopause management.
    • Flexible work arrangements to accommodate individual needs.
    • Employee resource groups or networks for peer support.
  • Consider menopause-specific leave policies. This could include paid time off for managing symptoms or attending medical appointments.
  • Lead by example. Leaders and managers should model positive behaviour by openly discussing menopause and supporting employees.

By taking these steps, workplaces can create an environment where women feel supported and empowered to manage their menopause transition, leading to better health outcomes for employees and a more productive and inclusive workplace.

“Get Better at Recognizing Mental Health Risks During Menopause”

The episode highlights the significant mental health risks associated with menopause, particularly during the perimenopausal transition. It's crucial to recognise these risks as they can often be misdiagnosed as stress or other life challenges.

Here's how to get better at recognising mental health risks during menopause:

  • Understand the Hormonal Link: Fluctuations in oestrogen, progesterone, and testosterone, especially during perimenopause, can significantly impact mental well-being. These hormones affect neurotransmitters like serotonin, dopamine, and GABA, which are crucial for mood regulation, sleep, and cognitive function.
  • Recognise the Range of Symptoms: Menopause can manifest in various psychological symptoms beyond the commonly known physical ones. Pay attention to signs like:
    • Overwhelm and Irritability
    • Anxiety and Depression
    • Rage and Mood Swings
    • Cognitive Issues ("Brain Fog")
    • Sleep Disturbances (Insomnia)
  • Consider Menopause as a Contributing Factor: When encountering women in their 40s and 50s experiencing mental health challenges, consider menopause as a potential contributing factor, even if they haven't discussed it.
  • Don't Dismiss Symptoms as "Just Stress": While stress can exacerbate symptoms, it's important to differentiate between general life stress and the specific hormonal changes during menopause. Both can impact mental health, but require different approaches.
  • Encourage Open Communication: Create a safe and supportive environment where women feel comfortable discussing potential menopausal symptoms without fear of judgment. This can be within families, workplaces, or healthcare settings.
  • Advocate for Awareness and Education: Promote awareness and education about menopause and its mental health implications. This includes educating healthcare professionals to improve diagnosis and treatment.
  • Acknowledge the Severity: The sources emphasize the seriousness of mental health risks during menopause, highlighting the tragically high suicide rates among women aged 45-54 in Australia. This underscores the urgency of addressing these challenges effectively.

By understanding the hormonal basis, recognising the diverse symptoms, and fostering open conversations, we can better identify and address the mental health risks associated with menopause. This proactive approach empowers women and promotes their overall well-being during this significant life transition.

"How to Access the Right Menopause Care: Tips for Busy Professionals"

Accessing the right menopause care can be challenging, especially for busy professionals juggling demanding careers and personal responsibilities. The sources offer valuable insights and practical tips for navigating this journey:

  1. Advocate for Yourself and Be Proactive
  • Initiate the Conversation: Don't wait for healthcare providers to bring up menopause. Proactively raise concerns and ask questions about potential symptoms or treatments, even if you are in your early 40s.
  • Prepare for Appointments: Research potential symptoms and treatment options beforehand. Having a list of specific concerns and questions can help facilitate a more productive conversation with your GP.
  • Persist Despite Potential Barriers: The sources acknowledge that GPs may not always be well-versed in menopause management due to limited training and systemic issues within healthcare. Be prepared to advocate for your needs and seek out specialists if necessary.
  • Don't Dismiss Symptoms as "Just Stress": While stress is a valid factor, it's crucial to differentiate its impact from the specific hormonal changes associated with menopause. Advocate for thorough investigations and don't settle for dismissive explanations.
  1. Seek Out Specialised Expertise
  • Find a Menopause Specialist: Consider consulting a menopause specialist or an integrative GP who has expertise in hormone health and can offer more comprehensive advice and treatment options.
  • Explore Digital Health Solutions: Utilise apps like MetLuma to access reliable information, symptom tracking tools, and connect with healthcare professionals trained in menopause management. These platforms can be particularly helpful for busy individuals who value convenience and accessibility.
  1. Utilise Available Resources and Support
  • Leverage Workplace Support: If your organisation offers wellbeing programmes or access to women's health resources, take advantage of these initiatives. Advocate for menopause-specific policies like flexible work arrangements or reproductive leave to better manage symptoms.
  • Connect with Support Groups: Join online or in-person support groups to connect with other women going through similar experiences. Sharing experiences and information can be incredibly empowering and validating.
  1. Understand Treatment Options and Their Benefits
  • Explore Hormone Replacement Therapy (HRT): HRT can be a highly effective option for managing a wide range of symptoms, including hot flashes, sleep disturbances, mood changes, and cognitive issues. The sources debunk common myths surrounding HRT and highlight its safety and numerous health benefits when prescribed appropriately.
  • Consider Holistic Approaches: Alongside HRT or as a complementary measure, adopt lifestyle modifications that support overall well-being:
    • Diet: Focus on a balanced Mediterranean-style diet rich in fruits, vegetables, healthy fats, and adequate protein intake to manage weight, energy levels, and sleep quality.
    • Exercise: Engage in regular physical activity to support bone health, manage weight, and improve mood and energy levels.
    • Sleep Hygiene: Prioritize good sleep habits to combat insomnia and improve overall well-being. Experiment with techniques like relaxation exercises or a consistent sleep schedule.
    • Stress Management: Incorporate stress management techniques such as mindfulness, yoga, or meditation to alleviate anxiety and improve emotional well-being.
  1. Be Patient and Persistent

Finding the right treatment plan and adjusting to the changes associated with menopause takes time. Be patient with yourself and your body. Track your symptoms and communicate openly with healthcare providers to fine-tune your approach and achieve optimal well-being.

By being proactive, informed, and persistent, busy professionals can navigate the menopause transition with confidence and access the support they need to thrive in all aspects of their lives.

This is not a women's issue, this is a societal issue.We all have women in our lives that we love, that we work with, that we care for, and we must be putting these conversations on the table.So that's our intro.I think it just about sums it up.If our goal here is to help vets live happy and fulfilled lives as veterinarians, whatever that looks like for you, then this is probably one of the most widely relevant and potentially impactful conversations that we've shared on this podcast so far.
Because if you're listening to this podcast, I'm guessing you're a vet or associated with vet profession somehow.And if so, we all know that there's like a what, 80% chance that you have ovaries, which means that a good in depth, honest conversation about menopause is kind of essential listening.
And even if you are of these 20% of listeners without ovaries or your ovaries are like 2 decades away from menopause, you 100% work with or live with someone for who?This topic is very relevant, so you should care about it and know about it.This is a wonderful cohort of women, but it's let's get the men in the room, let's get our younger colleagues in the room, let's get the partners in the room and have that safe space.
I'm Ebert Hemstra and you're listening to the Vet World where we love to kick start important conversations in the veteran profession like this one.So let me give you a bit of background about this talk.We recorded it live at the Green Cross Symposium earlier this year.So when you listen to this, you're going to find yourself with me in a room with about 100 women listening to our guest experts, but also having very honest conversations and sharing their experiences and asking really in depth questions.
Our experts were Doctor Nicole Award, a menopause specialist with 18 years of experience as an integrative GP, and Georgia Dreary, who is the founder of Metluma, a digital health initiative aiming to support women by taking a proactive approach to menopause.Oh, and there was also Ben, one of the Green Crust team, who ran up and down with the microphone and then dropped a bombshell of a question right as we were wrapping up.
Now a quick note, because this was live and it was such an engaging conversation, some of our question askers couldn't wait to ask their questions, which meant that sometimes men couldn't get to them quickly enough with a microphone.So where the audio wasn't clear enough to hear the question clearly, I've used AI voices to ask the questions for them.
Which explains why you'll be wondering why were there so many Americans in the audience?And wow, everybody's so articulate and well spoken.To help you find the bits that are relevant to you, I've edit this episode into three main sections.The 1st 30 odd minutes is menopause one O one that is for everyone.
We cover what menopause is, how it works, what it does, what it looks like, what it feels like.Like, are you chronically tired and a bit depressed because you work 50 hours a week and you have needy teenagers?Or could it be because your estrogen levels are playing havoc on your metabolism?And of course, we talk about what you can do about it.
Then from about 30 minutes, we have a conversation about how we incorporate this knowledge into our workplace and into our culture as a profession to help and support those for who this will be a big issue, which as you'll hear, is not always everyone, but can be massive for some people.
For example, after this talk, a very well respected leader from a profession came up to me and said, you know, I very nearly quit my job when I was going through menopause.That's how bad it was.So how do we prevent that?How do we make space for someone in our organizations who's potentially going through a major physical and psychological period of turmoil?
And how do we think about ensuring it does not exclude them from contributing to our profession?And then from about 40 minutes onwards, we have very specific questions and answers.You know, when you're in a room with somebody who really knows this stuff and you go, I need to ask this very specific question.
Well, Doctor Nicole is that person.And the questions came thick and fast, but they are not necessarily relevant for many of us, or at least not right now.So that's our episode.I hope you find it useful.Please enjoy Doctor Nicole Avad and Georgie Drury with everything you ever wanted to know about menopause.
So those of you who do listen to the clinical podcast will know that I I utilize my vast ignorance, but usually I get to transpose that on two years of personal experience, which is not going to work in this interview.So we'll start it like we do the clinical podcast.
If it's OK with you as a scientist, you're a specialist in this.And we have a room full of scientists.When we talk menopause, can we recap the biology and endocrinology of the reproductive cycle of that weird species called humans, which we don't understand very well?
Sure, thank you for having me.Great to be here.So I'll give menstruation one O one.I'm not sure how it relates to animals, even though we are animals, but in humans, day one is the first day that we bleed and then FSH rises and estrogen rises to grow the lining of the worm, so the endometrium.
And then come the middle of the cycle, day 14 around about for most women, there's an LH surge and that prompts ovulation.And it's the dropping of an egg that then enables progesterone to make the lining of the womb nice and plump, ready to receive a baby.And if impregnation doesn't happen, then a bleed happens usually around day 28.
So that's kind of do you want me to dive into menopause and how it's different there?I.Think so, yeah.So let's define menopause first.So menopause in the human species is one day in a woman's life.So it's actually exactly 12 months after her last menstrual period.So everything before that is the perimenopausal transition and everything after that is post menopause.
So the perimenopausal transition in human species is anywhere from 4 to 10 years.Now some people are saying 12, some people are saying 15 years.That means it can happen as early as the late 30s, definitely happening usually in the early 40s and into the mid 40s and definitely by 50.
So in Australia, the average age of menopause is 51.So what's happening there is there is fluctuations in ovulation and it's that LH surge that therefore gets a little bit confused and the fluctuations in FSH and LH then 'cause fluctuations in estrogen and as a general rule, there's estrogen that's going up and down and progesterone and testosterone are on a general decline.
Over a lifetime.Over that perimenopausal.Transition.Yeah.So when when you're perimenopausal, your estrogen is kind of roller coastering a little bit and progesterone and testosterone are generally declining till post menopausal phase where they've bottomed out so to speak.So, so as opposed to before all of that, what is if you say estrogen is doing this during perimenopause, what does it do before that?
During the it's a, it's a smoother transition.So there is so in that kind of day one to 14 things, there is a rise of estrogen to grow the endometrial lining and then progesterone takes over as estrogen kind of declines.So we've got a smoother kind of transition when we're menstruating regularly as opposed to this.
Yeah.And just to clarify, perimenopause then, is that before and after the day of menopause?That's so the clinical definition.Pre.Yeah.So before.So the clinical definition of perimenopause is a change in your menstrual cycle by more than seven days for consecutive days.
So that's how it's formed clinically.Having said that, we'll jump into symptoms.There's a whole range of symptoms that can occur even before the menstrual cycle is changing.And I should also call out that change in the menstrual cycle can be other things as well.So it's important not to, not just to say oh, it's perimenopause and not speak to your GP around whether it's, you know, an endometrial polyp or something else that's going on with heavy bleeding or a change in the bleeding cycle.
OK.Is the change period what causes the physical manifestations which we'll come back to?Is that it for life of it?Is it like?That happens and now this is you forever.Or is it like puberty where there's a challenge and then?It's a bit like puberty.It's both.So it's it's the transition phase that can be quite problematic for women.
So in Australia, 20% of women will have minimal symptoms, 40 to 60% will have mild to moderate symptoms and 20% of women will have a really rough time of it.But it's in in the perimenopausal transition and that hormonal fluctuation that can be problematic.
And then often what happens is our human bodies are amazing and we find a new habitualisation and new equilibrium.A lot of the symptoms will resolve at kind of postmenopausally.We think about 10 to 15% of women will continue to hot flush into their 60's.The other symptoms that are often persistent is the dryness stuff, dry eyes, dry vagina and dry mouth.
They're the ones that can be problematic ongoing.Before we talk symptoms, is it worth looking at the hormones and what they do beyond reproduction?Think the main thing to know is that in the human body there are estrogen receptors everywhere.So we think that it's just about hormones and reproduction.
But there's Eastern receptors in our brain, they're in our heart, they're in our muscles, they're in our bones.So hence why the conversations around menopause, we say it's a Trojan horse to ageing well, there's so many conversations around how we protect bones, cardiovascular health, dementia, the risk emotional well-being above and beyond just estrogen and progesterone and what our wounds are doing.
And so for example, estrogen and progesterone are very powerful neurobiological regulators.So they, they have impact on serotonin.We are happy, stay calm hormone, dopamine, our reward hormone.Hence why the cognitive issues can be any big problem, because dopamine's our major neurotransmitter in our frontal lobe, which is for executive functioning.
And the other big one is Gabba, which is like a calming hormone.That's why sleep disturbance can be above and beyond hot flushing, because Gabba's like baby Valium or Xanax.I don't know.Do you get, do you get pets?I'm so liberal.Yeah, we give it to you.
I mean, Gabba's like it how our baby kind of Valium.So.So that's an example of how the hormones are so much bigger than just what we've what our bleedings.Do so, so the problems come from the estrogen doing this and then the rest of the hormones go what what's happening?Why we you know, up, down, on and off?
Yeah.And as we speak to you, you pop it into a contextual environment where women are often parenting up to parents, parenting teenage kids or kids in a time in their career where they're at their most productive and progressing their careers.
And it's you can just lose a sense of yourself when you wrap the kind of menopausal changes around that.So what does it look like and what does it feel like starting with?Had you asked Hugh?Starting from most common to.Yeah.So, so at Metaluma, we tend to categorize the symptoms into three buckets as we've put up here, we call out 28, you know, some people say there's up to 100.
There are other websites that do it depends who you speak to.But the main reason we call out 28 is we're trying to kind of call out the common ones and make sure that people are not just brushing everything down to menopause and ensuring that they're speaking to the health practitioners.And even some of the symptoms we've got up here, it's ensured that you speak to your health practitioner.
So the most common one people would know is hot flushing.As I said, hot flushing doesn't always come in the perimenopausal transition about, you know, 80% of women will suffer from hot flushing insomnia, as we discussed.And insomnia is independent of the hot flushing.Even the hot flushing can also cause insomnia.
Weight gain is a common one.That's because estrogen is an important regulator of insulin.And as a general rule, our calorie need as we move into our 40s and 50s is less.So women will often be eating the same, but their calorie need is less because of the changes of estrogen on insulin.
And estrogen is also important for muscles, so we're starting to lose muscle and get sarcopenia in this time as well.So the weight gain comes about because of those reasons.Headache, if you're a headache sufferer or suffered migraine previously to perimenopause and menopause, it's not uncommon that migraine can represent itself because of that estrogen fluctuation.
Joint pain is a common 1.Dry skin, dry vagina, what we call formications.So the sensation of ants on the on the skin can be a symptom.So they're, they're the common ones that walk through my door.The one that's often downplayed and very under recognized is the mental health issue.
As we discussed, because of those changes in serotonin and dopamine and GABA, the impact on overwhelm, rage, irritability, anxiety, depression, and sadly the highest suicidal rates in Australia are women aged 45 to 54.
So again, if this is a trigger for anyone, please just come and talk to me or reach out to EAP services.But I get really kind of passionate around the mental health implications for women at this age.And we need to be putting hormone replacement on the table as a, as a treatment option for such cognitive issues because of the dopamine.
So women often get concerned that they've got early dementia.Early dementia in humans is uncommon.Dementia before the age of 64 is rare.So you know, forgetting your keys and word finding abilities and forgetting names is is usually as a result of the dopamine impacts in the frontal lobe.
And then there's all the ones we don't speak about South frequent urine tract infections because of the role of estrogen on the vaginal microbiome.The need to urinate frequently, which I suspect for you guys as a cohort is could be difficult when you're in your clinics.Loss of libido, the impact of that on relationships, painful intercourse.
So it's big the.Thing that I think immediately is do they always come hand in hand?So for example, so we talked a lot in our profession about mental health, mental well-being, and now you overlay that on top of something.Would you, for example, could you, for example, get somebody who suddenly has anxiety or all the mental things and not necessarily the physical manifestations?
Basically what I'm aiming at is yes, have I got depression?Am I overworked?Is my job the wrong job?Is it just the kids or or is it maybe menopause?Absolutely, you can just get the mental health and that's why it's really hard to distill out like is it life, is it the kids?
Is it my job?And it's a bit of trial and error with treatment.So an SSRI like sertraline may well be the appropriate treatment for that circumstance.But if, if you're a non responder or if it's not quite hitting the mark, you know, it's just digging into, well, what other symptoms are in the physical or the, in the those not spoken about that might be indicating that actually we're on a perimenopausal transition.
It's really tricky because there's a dearth of research for women in this area at the moment.Like we're better at understanding the landscape around the safety of hormone replacement, particularly for women in their 50s and 60s.But putting hormone replacement on the table for women in their 40s for a whole range of issues is off ladle in Australia and it's just not being researched.
So we we have to start to change the landscape there.So if I go to my GP at 42 and I can't sleep and I'm really depressed I don't understand why I have anxiety tax.Is it common at this stage or not yet for them to say we should look at almost?
Not common at all.So you should.That's what we're asked.We're with so I meta Luma.We want to empower women with awareness and understanding to advocate for themselves and put it on the table as a conversation.OK, questions.So I've been to the GP and I'm only 42 and I've been denied everything.
Yeah, I want to cry.Sorry.They're denied as in the why, why, Why won't they give you stuff?Is there a reason not to?It's not part of the guidelines yet and as I said, it's off label so because the research isn't there.But is it potentially detrimental?We know that MHT is safe.
MHT.So hormone replacement therapy.So Australia calls it menopause hormone therapy, but it's the same thing as HRT.Yeah, OK.Thank Vicky.There's two prongs, I think, to answer this question.One is GP education and awareness.And I don't know what it's like in your world, but unless we have a demand or an interest or a need to upskill in such a specialised area, we just don't do it right because so much comes across our desk and we have to be across so much of things.
But.The problem is in medical school, you only need one hour in this.That is true.So we have a whole generation of general practitioners who have only ever studied about one hour of this in their entire lives unless they choose to specialize.Yeah.And that's something that's involving half the planet.
So there's awareness within the medical profession.It's just not being done in terms of research.So put.So why?Great question for you.Don't get me started on my feminist rant about women in research.So Professor Joe Shirashi Kulkarni in Monash University is amazingly passionate about this, and she's been trying to source funding to do trials for mental health and hormone replacement for women in their 40s for a long time.
Yes.So the question was, does the hormone replacement continue after you've hit menopause?So for those who came in late, menopause being one day in your life, which is 12 months after your last menstrual theory depends on your symptoms.So we used to say stop MHT after five years.That's out the window now.
So it's really just about assessing what your symptoms are doing, usually winding off every 12 months or two years, seeing what your symptoms are doing and then reassessing MHT is safe.We think that the two things that people get scared about is breast cancer and plot.So the risk of breast cancer is probably about one to four per thousand women over 5 years, depends on how you're taking your MHT.
It's much safer if it's delivered what we call transdermally.So through the skin.The risk of clot is about two to three per thousand women over 5 years as well.The risk does go up when you're in your kind of moving into your 60s and 70s, particularly for clot and stroke, but it's still not massive.So it's just kind of conversations around, is it helpful for me?
Is it is it helping my symptoms?And then just wind not winding off slowly because if you withdraw slowly, you might start flushing and because you've had a sudden withdrawal of hormones and just reassessing.What is hormone only?What is the MHT like?We talked about the LH and estrogens that.
So it's, it's now in a well, there's many formulations.We used to use pregnant maze urine to make it Yeah and synthetic progesterones, but would now move to what we call body identical hormones.So they're actually pretty replicable to estradiol.
Is it?Is it estradiol?Yeah.So it's estradiol and progesterone and it can be testosterone, but again, off label in Australia.So in Australia testosterone is only prescribed for hyposexual dysfunction disorder.Don't exactly ask me what that is.I think libido is complex in women but if sexual dysfunction is very problematic for women then testosterone can be prescribed.
But MHT in Australia is estradiol and progesterone.I'm.Sure, you probably can't answer this because it's a fairly individual thing, but some of the emotional and cognitive symptoms that we're talking about, the brain fog, forgetfulness, the anxiety, low mood, I've of course have been to the GP because I'm under the standard age group.
They kind of are like, no, it's stress, it's stress.They have all of those same symptoms.It's clearly stress.Stress can also make your period irregular.All of which is true.I've also been advised just to go back on the pill despite not needing it for contraceptive reasons.And I guess is there any way at all to help differentiate between I am stressed because I am a middle-aged woman with a family and a full time job.
And so whenever you, your GP says, oh, is there anything stressful in your life right now?You're like, come on.And so my question really is, is there anything I can go with that's clearly this is not stress because of this?Or do I just have to try HRT and see if that makes a difference?
Oh the gosh, you're really putting into the pumpie.It's hard because I'm not one of those GPS I think.Well, I would comment as a consumer and I would say you've got to be your own experiment.And so not clinically, I can't advise you to do that.But as a curious human, and I'm sure a lot of you've got science in your background, you've got to test and learn for yourself.
And I think it's knowing what your triggers are and then knowing, OK, let's try this for six to eight weeks and see what happens and then advocate for yourself to say, well, no, let why can't I give this a shot for six to eight weeks and then come back?So that would be the non clinical consumer look at this.
I agree with Georgie, it's about conversations because it's impossible to discern, it's impossible.There are no blood tests.So it's really just about putting it on the table to trial.If you do cyclical progesterone for example does that in previously.
I always start with sleep.I'm like, if you're not sleeping, you're a shit show.And there are some, you know, holistic supplements that you can take instead of just resulting to the pharmaceutical as well.So Nick's a big prescriber for me because I've got my own guardian Angel sitting on my shoulder of magnesium and things like that.
So you could also add that to your mix.Just to, to double check, you said that there was no blood test.So are you referring to like the hormonal checks that you can?Because I went to the doctor and they did some sort of perimenopause check and they said no, no, you're perfectly fine.
But then I do get some of these.So I'm like, which am I more reliant on the actual blood test results or what's happening to the body?Your.Symptoms 100% OK, so, so the blood test, so it was a little bit of a ferthy, but if you're, if you're still menstrual and you're still, so you're still menstruating in any way, shape or form, the blood test is not so full at all.
So the difference is that if you have an IUD, if you've had an endometrial ablation or if you've had a hysterectomy and you don't know what your period's doing in that circumstance, sometimes the blood test is helpful, but you have to do an FSH at zero day zero and then FSL and an FSH six weeks later.
And if it's more than 25 on both occasions then you are definitely post menopausal.It tells me nothing about your perimenopausal genuine bone.Are they common myths?What will people hear from friends, mothers, GPS, things that you hear that you go?
I wish you would stop saying that.They will hear that it's an absolute train wreck and a disaster.And while we have to validate that some women would definitely suffer, we don't have to go into this pathologizing it with a load of fear wrapped around it.So it's both exist.
We need to support women to ensure that they're empowered and feel strong in transitioning through this phrase and that they're not suffering.But it's not a shit show for everyone.The other thing that's frustrating is, and I'm just going to call it out here, is click baiting a whole range of supplements to treat menopause.
It requires a holistic conversation around food, movement, sleep, stress, hormones.Like it's much bigger than just that.I understand why it's there because there's a gap in clinical care.I get it.So of course consumers are gonna fill that gap.Facebook is gonna fill that gap.
Exactly.Like, I get why it's there, but I find that frustrating.Yeah, in no way should you know, you guys went through COVID.We went through COVID, you know, it was awful.So being AGP is hard.And staying across, you know, we're showing up in systems where you have to see people quickly to make money to.
So there's no way you're getting through this, right?So just somehow treating menopause is not a GP problem, it's a system problem.I'm a big believer in less struggles is best, and I kind of got through it and I was kind of happy with that.But a friend just recently gave me a study of how many preventatives it.
Yes, like cancer, colon cancer, heart attack.Compared to breast cancer, which is generally treatable or mostly treatable, these conditions were really quite scary.Bone density, yeah.So so.HRT actually prevents like big numbers.
Big numbers like I'm the colorectal cancer.So, so again, this is a, a landscape that's changed, right?So it was always don't put women on MHD at all.Maybe 533 to five years ago it changed to, oh, it's safe now we can use, use it to treat symptoms.
And now we know, oh, there's all these other benefits.It's going to reduce our your risk of fractures within started of the 1st 10 years of menopause, reduce all 'cause mortality and cardiovascular disease.We think it probably going to help with dementia prevention, although the studies are a little bit still grey around that, but they're looking promising.
What's not clear at the moment is to actually go on it for those reasons.Yeah.So even for me, I'm like, where the splashing through the jungle, the where The Pioneers of this research.So then, you know, for example, it's like, are women that have more vasomotor symptoms, more hot flushes, more at risk of dementia and cardiovascular disease?
We don't know those associations.So that's why it's like if women have minimal symptoms and they go on MHT, what's their cardiovascular risk and dementia profile look like versus those that had severe symptoms.This is the stuff we don't know, hence why it's not just like everyone go on it.
What's the expectation to response to treatment if we say people should be experimenting with it?Is it AI start treatment and three days later I'm 20 again or some?People.Yeah, some people, some people are like, Oh my God, where have you been all my life?I think this as I said, I just rant and rant about sleep, the sleep implications.
As in, you're going to start sleeping better.Yes.So treatment of hot flushes and improvement in sleep because from improvements in sleep, everything else can come.You might feel a bit better to move, you might feel a bit better to.You're not going to be so tired to reach for the refined carbohydrates.And work when you do shift work.
Yeah, no, it doesn't.But no, shift doesn't work when you do shift work.But I mean, George, you can speak to work with nurses, so.Yeah.Doctor Kimmel Cronin from Essex University actually looked at nursing profession explicitly and interviewed nurses across seven countries.
I think a lot similar to your profession where there is shift work and you're, you know, in front of your patients all the time.So it's how can you have the flexibility to work with your symptoms.And so I do think that there is a lot of research explicitly be done in this space.We're doing a big study next month with nurses so we can report back on how it's working.
I think you've addressed this a little bit already, but given the variability in the types of symptoms that it's seen and the different experiences of different people, are there symptoms where we know that hormones usually work in terms of symptom relief?
And are there symptoms where we say, look, this is one where, you know, many people don't experience a benefit from hormones.So in the literature, hot flushes for sure.Should go away.Yep.OK.Yeah, 80%, eighty to 90% reduction, vaginal symptoms, vaginal dryness, prevention of recurrent Utis, definitely less research around, but clinically improvement in sleep and mood and cognition like the brain fog stuff.
So I came in a little bit late, but I'm also like this lady in the front.I've gone through it post menopausal, went through it all, still have sleepless nights, insomnia, night sweats, hot slashes going on to.I didn't want to go on to HRT because I sort of grew up with having a bad name so to speak.
So could I now go on it to help with those symptoms?Absolutely, yeah.I won't ask what your age is in front of the crab, but.Oh, I'm happy.I'm 62 I think.Hey.I've got 5 lovely grandchildren, so fine.So again, it's going to depend on who you speak to.
We don't have a lot of, you know, because you're in at that unfortunate age group where where it was like don't start MHT.We don't had it.Have a lot of virgin MHT is in their 60s.So the research answer is we don't know if it's safe because they we just don't know.
However, we know what the statistics are for breast cancer and clot for women in their 60s, which is, I'm not sure if you're here for that bit, but it's ever so slightly higher.You're probably looking at about four to seven per thousand women over 5 years.
I've got some slides.I've got stats on that anyway and I keep on my desktop.So the risk is low.You are probably outside the benefit of that for cardiovascular risk and bones because we know that that was in the 1st 10 years.But the short answer is yes, you can.It's just a risk benefit conversation.
What are the known contraindications, say Tati?Very minimal.So if you've had a hormone sensitive cancer, if you have active cardiovascular disease or a heart attack in recent months, if you have an active clot, if you've had a previous clot, it depends on the context of the clot.
So if the clot was provoked, so you sat on a plane for 20 hours and then got a clot, that's actually not a contraindication.If you've had multiple clots unprovoked, then usually I would send to a hematologist to get a review around that.That's about it.OK.Thank you.
Oh, so the migraines, is migraines with or a contraindication?Definitely contraindication for the pill.However, we think that if we deliver the MHT transdermally, then it's OK.It's a what we call a relative contraindication.In regards to you, you said that some women will have a mild time, some will have a severe time.
Is there anything that sort of predisposes you to one or the other?Oh I don't actually know the questions that I I know what predisposes you to your age is definitely when your mum went through it, so your genetics will define when you're going to go through it.But I'm not sure I'll have to dig into the literature for that for you.
It's a great question.I just thought of something, if you've had a history of post Natal depression or PMDD or anxiety or depression in the past, then for the mental health issues and that can it means you're at increased risk of mental health issues through the perimenopausal menopausal phase.
But with the symptoms, is it?More the.Loss of estrogen or progesterone that causes the symptoms.That's in the perimenopausal phase, it's estrogen fluctuation and general loss of progesterone and testosterone.And then in the post menopausal phase, it's the fact that they've all bottomed out.
It's very complicated and it sounds like is this where you come in Georgia where you're like, where do you find the GP that that knows enough about this and other specialists?Is there well again?Nick's a dying art because there's not a lot of her out there.So I think it's how can we help everyone find the Doctor Nick at scale?
And that's where I can come in and say, how can technology help with that?How can you go to an app in the first instance and ask the question?And I think that that's where we can actually help to educate women to say, hey, do I need to see a doctor or can I actually ask a question to a trusted source and be happy with what the results are?
And so that's where I think that we're working together at Metalluma to really try and solve this problem at scale because we want Doctor Nick to see the really, really complex patients.And then how can you use nurse practitioners or health coaches and really get access to the right information at the right time?
So large language.Yeah, sorry.AI is.Going to help you filter you this way.Pad to say yeah, you go.As much as Doctor Google has a place in life, we need to make sure that Doctor Google's actually trusted.And so that's where how can we create our own, you know, ChatGPT version of these questions so that everyone can access it?
Yeah.So what we're trying to do is make me redundant so I can retire.So I, I mean, vet care is probably similar.And I know I'm, I'm very aware of the significant issues in vet care and I'm, I'm very empathic around that for how you guys are showing up in a system that's also crumbling.So the GPS, as you've all experienced are often become the, the entry pathway to healthcare and the source of truth.
We're trying to flip that upside down and say, OK, how can we use large language models, AI, digital interventions to leverage empowerment, awareness, accurate information, knowledge, symptom tracking so that you know exactly what's going on for you.Refer up to menopause trained nurses to help guide behaviour change, stress management, all the things that you might need someone to walk alongside you with.
And let the doctors do just what the doctors do best, which is have the specific conversations around MHT or put her on the table as a prescribing option, or if it's a little bit more complex, make sure nothing else is going on.With 10 minutes to go, I want to start a conversation on something that's probably scratching the surface of something that deserves another hour chat, but I want to start it deliberately.
So a friend of mine's a senior HR manager in a large organization, not Green Cross.She's actively avoided presenting at the XLT.She's actively avoided delivering training because she knows she'll get a hot flush and she's worried that people will judge her and think that she's embarrassed because of the red rising up her neck.
Now we've spoken before, Nick, about the average age, the onset of menopause in Australia, the average age of female retirement in Australia being exactly the same.And that's not a coincidence, right?We've got 80% of our workforce are female and they're all experiencing challenges or will be experiencing challenges in the menopause space, and if not in the menopause space, other challenges that threaten their cognitive and emotional integrity as well.
Put on top of that another layer of menopause and it's easy to see that our recruitment and retention challenges are going to continue in the future.What can conversations sound like at the XLT level to start to shift the dialogue?I just want to call out that this gentleman here is an absolute Angel of mine.
He joined us in a room full of 18 amazing men that were starting conversations just like this.And it gave me hope for humanity when.So thank you Adam for bringing that up.And, and I agree with this is which Georgie will speak to.This is not a women's issue.This is a societal issue.
We all have women in our lives that we love, that we work with, that we care for.And we must be putting these conversations on the table because no longer can we suffer in silence.But you can take to how we start these conversations in work.Yeah.Well, I think it's if we do nothing, will things actually change.
And so it's we're on that path that we know that we're in this sliding retention issue.We were at the first place in history that we've ever had so many women over 40 in the workplace.What does that look like?And I think that the organisations that get this right, and I actually don't know if you've got gender neutral parental leave, but in organisations that are not so feminised, it's this whole piece of we've been able to have a baby and feel comfortable to say I'm pregnant at work.
You then say I can go and have parental leave and then come back to work.These same women are now looking at that next phase of their life whilst they're going through perimenopause and menopause.So it's only the right time to open up that conversation and it's that whole piece of this is a problem with stigma and taboo.
And so it's what role does the employer have to help smash down that stigma and taboo.And as we've just spoken about, is it the employer's responsibility to provide access to medical care?And then the argument would be we just can't tell women to go and seek their own medical care if we've just learnt the doctors aren't trained in it.
And so it's what's that role of actually giving that safe space or that access to care?Then it's who will be funding it?That's another question.But it's if we don't do that, what's actually going to happen?And I think it is very data-driven.I know mental health in vets is not the best.
And so you add this to that layer on top, Adam, as you were saying, and it can be a really hand grenade just waiting to happen.And so it's how do you then bring it to the forefront and something that business should be addressing?It's one of those awkward conversations and awkward conversations only happen by starting awkward conversations.
And it means that we might stuff them up, we might say the wrong thing, but we can preface that by starting the conversation.And certainly, depending on the maturity of, you know, your manager or how safe you feel, I think it's about the organization creating safe space to at least start the conversation.
It doesn't necessarily mean that there's a fix going to be on the table, but at least understand the gravity of the problem.Start the awkward conversations, learn how to have those call conversations, and then you can understand what the needs and desires are of the people that need to be helped.And then asking the employees, it's like, what do you want?
I think it's, you know, actually getting consensus from the employee group as to if you've got benefits, you've got access to well-being, what does it look like for you really using that to help frame what your program is?We've just started a program with Unilever and overwhelmingly when they did their employee survey, it's we want access to Women's Health and we want access to perimenopause and menopause support.
What?Being what?Like what does support look like if they say we want access to support?In this instance, because we do offer medical support, so we do ran a randomized control trial with Western Sydney University and the research was funded by the Digital Health CRC and we we call it like the modern day mothers group.
So we had Doctor Nick with eight women in a group coaching session to unpack that experience.And then we deliver you with our team of health coaches and medical practitioners, personalized care programs over 10 weeks.And so then we see great, what has happened and what were the changes in that space and then how can we get even into more personalization depending on what you need?
And whilst I want to tackle some of that at an organizational level, I'm also a realist and I'd say don't wait.If there's things you can do at a practice level and area level that you think will start to shift the dial, that you can control, do that.Little pockets of excellence and micro experiments that pop up.
We can then grab onto those ideas, demonstrate the benefit and start to replicate that more at scale.Yeah, everyone in this room can download our app if you want and use the kick start code, press play, and then we can just get a sense of, you know, what the symptom load is across this group and then you can look at that uplift of health literacy as well.
I think one of the things I found going through was I would have days where I'll get up, get breakfast, crash, I'll be on the couch, cry, then I have to get up, get into work.I wonder if it's a thought that the industry or whatever might allow extra days for.
You know, we get our sick days a year, but just those few extra mental health days perhaps.So when you're getting to a point where you might be going through all this is to you go, OK, you might start needing more days off or whatever.You know, I have a fantastic, I work with a fantastic group of people and if I went to work and they'd know I've been crying.
It's hard when you've only got so many days to do stuff with and.So that's actually.Becoming much more normal and talked about in terms of having gender related or reproductive leave.More often talked about around for things like IDF treatments or even really bad PMS or period pain or gender surgery sorts of things.
So I suspect when that becomes mainstream enough for organisations like ours to take it up.That menopausal kind of symptoms should absolutely be a component of that.They've just had the Senate inquiry.I don't know if anyone's familiar with it.So there's been 286 submissions.
The Senate inquiry group heard representation across seven days.We were one of them coming in talking about technology.And there has been a big push for menstruation and menopause leave, so your reproductive leave.And I think where the government will land is that I think it'll be a business specific, so each business can say what's right for my people and bring it out.
And Deanne Stewart, CEO of Aware Super, is actually working with Curtin University on a Roy of that specific leave as well.Because at the moment, where's the research, where's the evidence, Where's the data that's actually going to work for my people?And so I do see that it will start to happen.But the flip side is as well, then you can say, well, who's at work if everyone's on leave all the time.
So I can see both sides to it.It's tricky and we, I mean, we ran a group with the executive leaders or women in their gifties and they spoke to in some of their organisations that it was just universal leave might just give women in certain age groups a few more days.
Don't make them quantify what that's about.And in fact, their experience was that they actually didn't take them.Yeah.And this is this other piece.Well, why do I need the leave?If I can get my symptoms under control, I don't actually need the leave.And so it's this fine line of what's the role for the organization to help in helping with symptoms so you don't need the leave.
So once again, it's the stigma and taboo, some exact said over my dead body, would I ever put my hand up and say I need menopause leave?And so that's where we're at.Just something you said before, I came off my progesterone estrogen recently.I just wanted to see whether I needed it anymore.
So I just stopped it and within a week I got the night sweats.And so I went back on to it.But did I just do it incorrectly again, depends on who you speak to, but in my clinical experience, I tend to get women to wind off over four to six weeks just so you're not getting that sudden withdrawal that may exacerbate your symptoms.
I mean, even if you pull it out quickly, if your symptoms are they'll go right.So over that kind of four to six week period, they should just settle if they're ongoing.So because of my symptoms I've been told to go back on the pill.Yes, that's an option.Lower dose pills can be an option, depends on what your contraceptive needs are as well, which you don't have to dive into here.
But the pill is a much higher dose.Side effects are higher, risk profiles are higher, contraindications are higher.Like you definitely.You've never been on it.Yeah.So if you've got migraine with aura, for example, you can't go on a pill where you can go on MHT probably we think particularly transdermally.
So it's an option, just different risk benefits.I just wanted to ask about IED.And versus transdermal progesterone in terms of health risks and benefits?So IUD will give you contraception if you need it.The main reason we give progesterone for hormone replacement ostensibly is for endometrial protection, right?
You can't take oestrogen alone because you're at risk of endometrial cancer goes up significantly.So we, you must deliver progesterone if you have a worm to for endometrial protection.And then there's the usual cognitive implications that can come with that and the sleep benefits, you're going to get less of those using an IUD because the IUD will just work mostly in the womb.
However, some particularly Professor Jay Shirashi has talks about IUD and the changes, the negative impacts that that can have on mental health.So it's not exclusive just to the worm, but in my clinical experience, you're more likely to get the bigger body effects if you're taking it transdermally or as a capsule.
Thank you.You're talking about like age of last period and our age group have a significant amount of Marine IUD's which didn't happen previously and the knowledge of that last date would be pretty vague for those people.So how does that impact hormone replacement or how long to go on hormone replacement?
That's where the blood test can be helpful.So having an FSH day zero and then FSH six weeks later if it's more than 25.On both occasions you are post menopausal, prior to that it's in the wind.And then you we we're just being guided by symptoms.
So if you came to me with an IUD in and said I've got hot flushes and dry vagina and I'm weighing all the time, then I would speak to you about oestrogen replacement.And then depending on what your contraceptive needs were, whether you want to replace the IUD with progesterone for other symptom control or if you need contraception, then the IUD is fine.
I actually have some women that I put on both so I give them extra progesterone if their sleep disturbance is quite significant as well as their IUD.Would you recommend that test every year for those people who get their results back and it shows an FSH elevation?
No, well it depends on the on your symptoms.I don't really have a kind of hard and fast relevant to do it.I'd be guided by you on what you said, what your symptoms are doing and we'll then would say, OK, well, I'm sure it's the same in your world.I I never do a test unless it's going to help me with my clinical decision, Right.
So if I'm like, actually, let's just give MH two, you go and see what happens to your symptoms.I wouldn't bother.Yeah.I am on testosterone I don't know what that sexual thing I I would love a better libido I have to say but it hasn't made any difference to that.
But I'm just wondering if I'm having a placebo effect.I feel so much better with testosterone on board.Is this a placebo?Because you said it really is only for I can't remember what the name of the thing was for so.Hyposexual dysfunction disorder, whatever that HSDD.
Yeah.I'm not quite sure what that is either.No.Yeah.Anyhow, I don't think I've got that.My libido isn't any better, but I do feel better.But is it just because I thought it would make me feel better maybe?Or I really better maybe?Again, the literature is not clear on this.
You might be getting a placebo effect.But in my clinical experience and, and in other clinical experience, there is more kind of anecdotal data coming out that it does help with cognition and, you know, building muscle and overall well-being, even though it's not technically being able to be prescribed.
Yeah, I just feel less fatigued and just brighter.Yeah, you could say.Yeah.It's easy to tell the difference if after this talk you feel worse then it was perceived, but.Talking about Doctor Google, you can search and you'll get a list of thousands of things that you should try and do.
But do you suggest diet change at all?Like Can food help?I always talk to anyone about diet.Are there things that you should be avoiding?Well, it's fun police, right?It's caffeine, alcohol, spicy food.Yeah, that's right.
So into the hot flushing.It's the fun police, you know, smoking cessation.In terms of overall well-being, there's 2 broad areas we want to be eating more towards, like a Mediterranean style diet in terms of a broad range of vegetable fruit, bright coloured fruits and vegetables, healthy fats.
You know, to ensure that our eyes and vaginas are staying well lubricated.And as a general rule we are not eating enough protein, we are losing muscle.The rough guide is about a gram per kilo of ideal body weight.So if you're should be 80 kilos, you want to be eating 80 grams of protein.
So you're looking at most people, most Serbs of protein sources, foods.Are going to have. 15 to 20 grams of protein in it or even protein shakes.So things like that, while they may not directly impact hot flushing, for example, it's probably going to impact sleep because by eating enough protein, you're then not spiking your sugars and cortisol.
So they're then you're then not stuffing up your circadian rhythm.And so protein and then of course calcium and vitamin D to make sure that your bones are strong.So there's no specific diet for menopause, but we have to be talking about these things so that we can help you age gracefully.I have sincere apologies for coming back to both Doctor Google and whether we are over click baiting on the supplements.
No judgement.I had been under the impression that Soyuz and flavins were the one thing that did have some scientific that is true that is yeah, that is true.So so some evidence for soy isoflavins you.Still have to be careful with hormone sensitive cancers if you're taking it as a supplement.Also limited evidence for black cohosh.
About 60% of women will get improving in hot flushes over the short term.For that, it's just, I don't know what it's like in the BET world, but the literature around implementary medicines is very thin, 'cause you know, but yeah, there's some risks with, for example, there's been rare incidences of liver toxicity.
So part of the reason why I get a bit riled up about it is it's not that I'm against it, it's just that there are some risks and they've got to be discussed.Like you can't just take a whole bump bunch of soy isophilase as if you've had breast cancer.That's not OK.I was just going to ask, if you're on the pill, which is a form of MIT, and you're still got symptoms of that, but you're taking the pill for once for a specific condition that is related to perimenopause, excessive bleeding, and you still have those signs, Are you able to take estrogen and progesterone supplements on top of that?
No.So it would be a conversation around either changing the brand of pill that you're on, so changing the style of estrogen and progesterone that you're on, swapping to her MHT option that may also give you better cycle control.
So it's it's just a bit of an art in prescribing different options.Thank you so much.For sharing and thank you for.All of you for sharing to openly, it's as you say, it's a conversation that has to be had.We will put this on in the podcast.So share it with your friends and colleagues and everybody so that it's at least they can listen and open ears and start opening mind a little bit.
I know you're expecting me to talk about the newsletter now, but I'm not.I mean, you should definitely sign up for the newsletter.The link for that is in the show description.But I'm going to start something new in every episode.I'm going to sign off by reading you my favorite review for the week.And because I can, and because it's fun, I'm going to overlay it with the most dramatic or cinematic music that I can find.
And I'm doing this for two reasons.First off, a little bit of humble bragging stuff.It not humble, just bragging.Reviews make my day and I want to share them with the world.But the second reason is that I want to motivate you to post a review on your podcast player, even if it is just hitting that five star button.
Don't go leaving a bad review.I definitely want to hear about it if you didn't like it, but let's do that at private, OK?And while you are there reviewing, you can also.Follow the show.Because when you do that, you are telling your podcast player that yes, I like this podcast and like I said, that makes my day.
We work hard to make something that is useful to the vets of the world.And when you tell me that, you find it useful.Well, it's kind of like.A belly rub is for your dog, but Behind Belly Rubs.Reviews also help other humans decide that listening to this podcast is worth their time and subscriptions or follows.
Tell the algorithms that the vet felt is cool and the algorithms will then show it to more people and eventually Apple and Spotify will think that this is the best veterinary podcast in the world.In return for your kindness, I will keep doing my level best to work towards making this the best veterinary podcast in the world.
So here is this week's review.This one was for the clinical podcast and came through as an e-mail from an old colleague, mentor, and friend of mine.It starts with I've been listening to some podcasts while things are quiet at work and I thought I would give you some feedback.Now if you know Peter, who sent me this review, you would know that he is not scared of giving, let's call it constructive feedback when it's needed.
So I thought, oh oh.But he continues.They are fucking awesome.Don't change anything.They are perfectly pitched with the right amount of technical and underlying theory with sensible practical aspects as well.Time and time again, I find myself thinking a question just to have you ask it next.
I don't know if it's just because you and I think the same way, but I definitely find them ideal for me or where I'm up to in my venture.Thank you, Pete.That one is going straight to the pool room, otherwise named as the review page on our website.If you want to follow the show, just click the three dots somewhere on the page where you're listening to right now and hit follow.
If you want to leave a review for the show, you can do that on Apple Podcast by going to the show homepage and scrolling all the way to the bottom of the screen to look for the reviews.Or go to our website at thevetvault.com and look for the review button.Come on, give me that belly wrap.

Dr Nicole Avard

Georgina Drury