Menopause and MS

MS Plus acknowledges the traditional owners of the land this podcast has been recorded on, the Wurundjeri people of the Kulin Nation. We pay our respect to their elders, past, present, and emerging.

Jodi: Okay, wow, I'm super excited to be here today. I'm talking to Dr. Francesca Bridge, who is a neurologist and researcher at Alfred Health and Monash University and today we are talking about a topic that has really been gaining momentum, in MS, over time, and I think we'll finally be able to look at the impact that menopause has on women with MS.

So, Francesca, this is an area of interest. You've just recently published a fantastic article. Tell us how you got there and what sparked your interest in this area and, what do you see was the real need and the gap that we had in MS Care?

Francesca: Yes, absolutely. So before we start I might just clarify one thing and that's to acknowledge that throughout this discussion I will refer to women with MS and, by that what I mean is people who are assigned female sex at birth. But I do acknowledge that not all women will undergo menopause, not all people that identify as women will undergo menopause and, not all people who undergo menopause will identify as women.

So, just to make that very clear, we try and be diverse in how we approach these physiological changes in people as well. But, back to your question, I've always been really interested in women's health and Multiple Sclerosis, because we do know from all the studies that have been done that this condition really does affect women far more frequently than it affects men.

And we know that there's a huge variability in disease trajectories for people, so, what their MS looks like for them. And that's because of lots of different factors, but one of the factors that we think it's related to is hormones, and particularly sex hormones, and the reason we think about sex hormones in relation to MS, so I think there's a couple of reasons which really make us wonder about the role of sex hormones.

One is that very fact that women are more likely to be impacted than men, three to one ratio of women to men, and that once they have MS, people's clinical life or their disease life really varies according to their gender.

So, overall, this is a broader comment, but overall men have a worse prognosis and women tend to do a bit better from their MS outcomes than men. So, even though they're more likely to be affected, maybe their disease course may be a little bit less severe and, additionally to that we know that the periods of time where there are major changes in sex hormone concentrations, so by that I mean, probably the best research example of that is pregnancy.

And during that time when there's a huge surge over a course of many months of oestrogen and progesterone, we see that the MS becomes relatively quiescent and calms down, and people are far less likely to have disease activity, but at the postpartum period, once the baby's delivered and there's a huge drop in the oestrogen concentrations, there's a resurgence of activity.

So all of these things have really made us think, well, maybe sex hormones are having a part to play in MS, but interestingly, one of the other really important life stages where sex hormones change is that menopause period, but this has been a really under researched topic, and we haven't actually got a lot of data on what happens in this time, and I think that's incredibly interesting when we know that most people that will have MS will be women, and most women will be diagnosed when they're 20 to 40 years of age, not everyone, but most.

And so that means that huge number of our patients that we treat will go through menopause with their diagnosis already, and we don't have enough information to be able to tell them what that looks like, or to be able to help them with that transition. So for me, it just was a really big gap in our literature and what we know the science behind it, theoretically it would make sense, but I just didn't think we really have enough to guide us in this really important time in a woman's life.

Jodi: True, and I think for my 20 years of being an MS nurse it wasn't something we really talked about until probably the last 5 to 10 years. Before that, I don't think it was even really discussed and there's lots of reasons for that. I think generally in the community we're discussing it more, but also, there was more male neurologists, and it just wasn't something that really was discussed.

But once that door was open, to me it was really, “Wow, this is a big gap” because menopause, like you said, not everybody is affected by hormonal changes, but really the impact was probably once that door was open to discussing it, it became a really obvious gap, and so that's why I was so excited that someone was tackling this issue and saying “hey, we need actually to deeply understand this so we can actually help women face this time”, which for many people, it really does have an impact.

So, that's really exciting. So how did you, with your team of researchers, how did you decide to go about this? What steps would you take when you're thinking, how do we research MS and menopause?

Francesca: Yes, well I think the very first step, which is sort of what this article is a reflection on, is to think about what research exists already, because we need to know what we know and what's been sort of proven in the literature, that's our foundation to build the next work that we do. And I work within a research team of clinician scientists and research scientists that all share this common interest in women's health within Monash University and at the Alfred Hospital.

So, as a team we are working together to try and think about how do we best tackle these questions. So behind the scenes there is work to be done and we are working away with, a lot of work actually, at the moment trying to help to better address the holes in the literature.

But what this article really aimed to do was to think about, well, what's there already? And, I felt that one of the key messages that came from writing this article was that there is so much we don't know. It really just highlighted to me how lacking our evidence is at the moment.

Jodi: Yes, yes, that certainly struck me as well in terms of, you really broke down all the different areas, and saying, okay, let's have a look at each different aspect of MS, and how we are measuring, and how we're correlating the impact of menopause and the trajectory, how people go with MS in their life.

Probably the biggest question is, we don't really know if having menopause and the degree to which you have menopause will make your MS worse or not worse. But there's lots of other little questions that popped up along the way. So first, back to that definition of menopause, that's something that I was really interested in as well, because I don't think a lot of women really know, and you sort of get this sense of, well, I know that menopause is when period stops, but there's a lot of other things around that.

So how did you tackle that?

Francesca: Yes, I am a doctor, so I'll think about it from a sort of medical perspective, but the way I see menopause, I think we've got to think about two key things. People need to have symptoms of menopause first. So I guess the number one thing is, that it's a clinical diagnosis. It's not something that we can just easily do a scan or a blood test for. We need to talk and we need to work it out together.

So, it's a clinical diagnosis in the first instance, and it's made up of two key things. The first thing is the symptoms of menopause, and that's very variable for the individual, and I think the other thing that is a little bit trickier when we're neurologists and people that we're treating have multiple sclerosis is as you, I'm sure we'll come to talk about this a bit more, but there is sometimes a bit of overlap between the symptoms that you might have with menopause and the symptoms you have with MS, but the key things that we're listening for when we're talking about menopause is, do people have what we call vasomotor symptoms?

I think colloquially we refer to those as the hot flashes, but that's sweats and that hot wave that comes over people, and other things that can go alongside the changes associated with menopause, mood changes, thinking and cognition changes. We know that people will have changes to their urinary and their sexual function.

So, there's a whole host of symptoms that might go along with menopause, and those symptoms can actually start quite early, a lot before the menstrual changes even start. Often they're tied with this sort of menstrual irregularity that happens first, and so sometimes people can get even heavier periods or lighter periods or more variable periods, and so that period of time where you're having those symptoms but you're still menstruating, it's just a bit more irregular, we call that perimenopause. How long that lasts for is, again, incredibly variable. On average, it's about four to six years, but there's a whole spectrum there.

Jodi: Which is a long time.

Francesca: Which is a long time. It's a long time to be feeling all of those things and to have your cognition impact, it's really, it's a key point, and it's also, this is a bit of a side, but it's about the time that this is happening, it's often when people have big careers, they're managing a lot, they're juggling families, it really matters that they're feeling not themselves and they're not feeling their best self. So there's that, and then, if we think about the actual medical definition of menopause, that's 12 months either after the final menstrual period. So you need to not have had a period for 12 months.

Now again, in terms of a diagnosis, that's a little bit tricky because that's inherently a retrospective diagnosis, which means we can only make that diagnosis after you've had a 12 month period of not having menstruation. So, we can only look back and make that diagnosis and say, yes, you are now post-menopausal or you have been through menopause, so I think it is inherently, a very tricky thing to be 100% certain of.

Jodi: Yes, I think that's really interesting in terms of the change that certainly I've seen in my life from saying that menopause is not a blood test anymore. I remember a time thinking that menopause equated, you could only get that diagnosis if you had a blood test, but now it's changed to say when you start having those symptoms that's when it's called perimenopause and that that you don't need that blood test anymore So you when you say clinical diagnosis, it's about the person's symptoms, not about the blood test, which is a really important change as well in the way that we approach that as well, because I think that means that you ask more questions about it.

People are being asked in clinic by neurologists and by their GPs, have you got any of these symptoms? Are you experiencing these things? And, I think there's still some GPs out there who wait for the blood test, but, reassuringly, that's less and less.

Francesca: Just to say, on that note, there is a role in some people for the blood test. As I mentioned to you before, I don't think we want to rely on the blood test, and the reason for that is that, I'll talk to you a bit more about this as we go through our conversation, but we know that particularly in this perimenopausal time those concentrations of the sex hormones can vary quite significantly, they can go up and down.

And so, if we sample the blood at a time when those hormones happen to be fluctuating and happen to be at a really high level, then we might be very falsely reassured, and we can falsely reassure you that the hormones are all normal, there's nothing wrong, we can dismiss your symptoms, and I think that's dangerous.

I think the other flip side of that is sometimes we can sample it and it might be having a low day or a low moment and we can think, “Oh gosh, you're really far advanced in this” and actually, it's very early days. So, I think we just need to not pin too much on the blood test.

But the other thing to say is that, as I mentioned to you before, we do need that menstrual history, and so some people can't give us the menstrual history because they've had a hysterectomy, or they've got a contraceptive device in. And so sometimes in that, there are certain populations, where certain people where we can't really complete the diagnosis without having some blood tests too.

So there is a role for both, but I just want to highlight that we probably just don't want to rely too much on the blood tests, and that in isolation, and not think about the whole person.

Jodi: Yes. Well, let's talk about those hormones, and the different types of hormones. Let's deep dive into those a little bit and, the main one is oestrogen, but tell me a bit more about the other hormones that you investigate. I know when I was reading an article, there was a new one that that I hadn't heard of, Anti-Mullerian Hormone (AMH), but tell me a little bit more about those.

Francesca: Yes, so I think, maybe I'll just talk you through about a bit of a picture of what's going to happen over that timeframe with the hormones and then what that might mean.

So, over the perimenopausal period, I think probably the place to start is actually with that hormone you mentioned, Anti-Mullerian Hormone. I'm going to refer to that just as AMH to save a bit of time. It's quite a long name, but AMH is a really interesting hormone and I think we're thinking about this more and more in relation to perimenopause and menopause.

So, we know that it peaks around the late 20s, and it's sort of a marker of a substitute or an indirect marker of ovarian reserve. So it's produced by the follicular cells in the ovaries, and so it gives us a gauge of how many cells we have left which gives us an idea roughly of how much ovarian reserve we have. So it peaks around the late 20s, and then it gradually declines over the course of the subsequent few decades and it's pretty much undetectable in most women by around 50 to 51 years of age.

So it's one of the earliest markers that ovarian reserve is starting to decline, as opposed to something like oestrogen or progesterone which vary quite a lot during the perimenstrual period, and really don't plateau or really decline considerably until quite late in that transition to the post menopause. So, I think if we just rely on those markers, sometimes we've missed the boat, and the changes that we're seeing actually happen quite a lot earlier.

So I think AMH is really interesting because it is one of those first early markers that ovarian reserve is coming down and maybe the hormones are shifting. In terms of what that means for MS, so what role might these hormones play in MS? Well I think, the evidence is probably best, and I think we've recognised in the past most of the role that oestrogens might play in neurological diseases. So the evidence in the MS field is pretty limited, but probably we know a bit more from other parts of neurology that have studied these sex hormones. So, the dementia research has done a bit around these hormones as well. And what we can say is that we think that oestrogens are probably quite neuroprotective and, within MS, we don't have great data to support that, but most of the data comes from animal models or very small clinical studies, but we think that sort of neuroprotection reduces the risk of neurodegeneration or the sort of gradual loss of nerve cells.

Progesterone probably has a similar relationship to oestrogens, and it's probably neuroprotective as well, so there's an adjunct to oestrogens. It has been thought to potentially improve axonal damage, and maybe some of the myelination repair as well. And obviously that's very important in MS, where the myelin gets damaged, and then AMH, again, the literature is quite lacking. It's sort of, as you mentioned, a new topical hormone that we're all starting to think about, but there have been some studies that have found that, as AMH declines, there has been some changes in brain atrophy within women with MS.

So, for example, over that menopausal transition with the declining AMH levels, the brain radiological markers of how many nerve cells you have, have slowly decreased over that period of time as well. So that makes us think about, well maybe AMH levels are actually playing a bit of a protective role in that setting.

Jodi: So overall in your research, was there any research that sort of really matched confidently these hormone levels and neurological impact in terms of MS getting worse? Was the MRI worse? What sort of things did you look at to say, “A and B equals C”?

Francesca: Yes, so I think that, that is the really tricky thing for this. I think what we can say by looking at the whole picture is that there are small pieces of evidence that, in their own probably aren't sufficient to say that this is definitely having a role, but when we look at the summation of all of the little bits of literature, we can get a bit of a picture that gets built.

So, the kind of conclusions I'll talk about maybe aren't specifically from one study, but lots of different studies that kind of point us in the direction that we think is what's happening. So, what I would say to that is that what we think is happening is, and from the, you mentioned the radiological markers, that there is less evidence of inflammatory lesions on these MRI scans, and so it's less inflammatory relapses. That kind of picture that we see in people that have the relapsing-remitting inflammatory Multiple Sclerosis, we see less of that on the MRI scans over the menopausal period. But what we start to see is these other changes, for example, what I was mentioning before, which is that loss of brain volume, that brain atrophy that can start to occur at that time.

And so what that makes us think is, well, maybe people aren't having such an inflammatory type of MS, maybe they're actually starting to transition to a more, neurodegenerative type of change, or maybe, in colloquial terms, we use it, in MS we say, maybe they're changing to a more progressive phase of their MS, and that's been shown in the radiological studies, but I think it's also probably shown in the clinical studies. There's been a study that found people didn't have as many clinical relapses, but they had insidious decline in their clinical outcome measures of disability.

So things were starting to slowly change in the absence of clear inflammatory relapses, and I think that fits with what we think is happening in that period, this is a very global sort of perspective, this is not everyone will hit menopause and change to a potential progressive picture. I think I really want to discourage that thinking, but some people might start to notice that things change a little bit in that respect. And I think, the other thing that I do want to be very clear about is that it's really difficult for us to be able to 100% tease out well how much of this is the result of hormonal changes related to menopause versus how much of this is actually related to aging.

So, historically what we've thought is that as people age, their risk of progression increases, and it does tend to correlate with the sixth decade of people's life when they're in their 50s, there's more progression that comes through. And so, that might just be the result of what we call somatic aging, so the changes to the cells in our immunology that happens with aging.

So what we don't know is, is this process, is what we're seeing in these changes that happen in MRI scans and things, are these directly related to the sex hormones and to menopause, or is what we're seeing, is this more a result of age? And what I suspect, but I don't think we've got enough studies to prove this, is I suspect that there's a combination of the two.

I suspect that with aging we do start to see this pattern, because we see it in men, not only women. But, I suspect that the hormonal changes are probably exacerbating some of that change that we're seeing and so maybe the two are kind of working together to start to show this different picture, but I don't think we have enough evidence yet to fully confirm that hypothesis.

Jodi: Yes, and do you think probably one of the questions I suppose most people have was, is the worse your menopause symptoms are, the more likely you are to do worse in MS? Is there any research around that or is that still an unanswered question as well?

Francesca: That's still an unanswered question. So I might just talk you broadly through what I found in terms of what people thought happened to their MS through menopause. If I've got my scientist hat on, I think one of the important things is, how do we measure this? How do we measure what people experience? And there's a number of different ways that we can do that. So we can ask people and we can ask them through surveys, well, what did you notice that happened to your MS as you went through menopause? And the studies that have done that have been quite small. We're limited by how many people they asked, they've showed quite a significant amount of variability. So some women felt that their MS got significantly worse. Some women felt that it didn't really change much, and a small number of women actually thought their MS got a bit better.

So I mean, that's a huge spectrum, and I think that's probably speaks twofold. One is that, as you mentioned, people can experience menopause in a number of different ways, some people have really significant symptoms, and some people have very mild symptoms.

But also, MS is highly variable, and some people have a lot of issues with their MS and that some people really don't have much at all. So I think what I take from those studies is that this is not a one size fits all model. This is, some people will really notice a difference, and some people won't.

And so I don't want to alarm people to say that everyone that goes through menopause is going to notice a huge change to their MS, and it's going to be catastrophic because I just don't think that's the case. Then we can think about, well, what about these more, in inverted commas, ‘objective measures’, clinician-based measures of measuring disability, which are good in some ways because they examine patients’ clinical examinations as well.

They've also got their limitations because sometimes a lot of these measures don't pick up enough on really important changes that people experience, particularly I think in the MS field, a lot of these objective measures don't really capture cognitive changes enough and they don't really capture fatigue markers enough as well, and those symptoms are actually really important when we consider quality of life and well-being for women with MS. So, the caveat to that is, these aren't always the best markers, but they're another way of measuring something, and so what they found was, clinically, people were reporting less relapses, but this gradual change in their disease.

And then I think what they did was a couple of studies actually have looked at, what's the pattern, what's the slope of change with women after they go through menopause versus what was the slope of change before they went through menopause? And a couple of studies have showed that after you go through menopause, that slope of change really increases.

But again, very, very small studies and other people have tried to replicate that and haven't found the same thing. So I think it probably speaks to the fact that we actually just haven't looked at enough people because if we're not capturing enough people, we can't get a really clear trend because there's such variability between the individuals, so we need to do bigger studies to look at this question better.

And there was another study that found that if you were younger, if you went through menopause younger, you were also more likely to reach secondary progression younger, there was association between early menopause and secondary progression. So I think that again is a hint that maybe something's happening there, but again, not enough to draw firm conclusions.

And then, the third way to think about, how do we measure this, is that we think about the radiological outcomes that we spoke about before.

And I think that, in essence, what those studies found again, was that there were less active lesions, but more brain atrophy and so this is probably in keeping with that overall picture that maybe things are progressing from a relapsing remitting type of MS to maybe more of a secondary progressive neurodegenerative type of MS.

These are clues that this might be happening, but I think it's not definitive. I don't think any of these studies have firmly worked out well, one, is this just a process that happens with age for everyone, and then two, it's really hard to even know, I mean, I think women that go through menopause and don't have MS, are also really likely to have, potentially, some brain atrophy that happens in association with their aging and, potentially, their oestrogen loss too.

So we don't know how much of this is unique to MS and how much of this is just general processes that we see with aging.

Jodi: So I think there's more recognition that something can be done about it or that there's an option. Did any of the studies that you had a look at, look at the impact of doing hormone replacement therapy, and whether there was any change to the outcome? I guess that's the ultimate goal, do something and you see a difference as well. Did you have any insights from the studies about women who started HRT?

Francesca: Yes. So, again, I'd like to just say that HRT is not the only answer to how to manage your symptoms around menopause. I think HRT is a really important part, but it's not the only thing. So just broadly when we're speaking about menopause, I think we do need to consider the whole person when we approach menopause and we really need to think about other strategies like lifestyle, and, non-pharmacological measures, and then other pharmacological measures, as well as other tablets that you might be able to take to help manage your symptoms, and then one of those options is menopause hormonal replacement therapy, HRT.

So in terms of just general lifestyle things, I think these things are really beneficial from a menopause perspective, but also from an MS perspective. We really know there's a lot of research coming out of MS about the importance of brain health, so things like exercising, keeping fit and active, is just so important for our brains. Making sure we don't smoke is incredibly important for protecting those brain cells, and those things are really important in the menopause period as well.

When it comes to hormonal replacement therapy in menopause for women with MS, again, we’re really lacking in evidence. So, they've done studies where they've just asked women if they've been on hormonal replacement therapy, did it help? and again, huge amount of variability. A lot of women said, “yes, it did help”, it did help their MS symptoms and it did help their menopausal symptoms, and some didn't really notice change.

The tricky thing with those studies is that it's very difficult for them to then account for, well, what preparation of hormonal therapy were you on, and how long were you on that therapy, and what were your risks before you went on that therapy? So I think it's an important clue that maybe there might be some help, but we don't have enough to then guide clinicians to know, well, what do we actually prescribe?

So, now there is some early, randomised control trials that have been done, mostly in sort of just checking that it's safe and tolerable for women with MS to be prescribed a certain formulation of HRT. So these are very early preliminary studies, but a very important step in the right direction to objectively measure this.

And so what this phase one, two study showed was that, HRT was tolerable. So people didn't have a lot of side effects from it. It was good, and it did help a lot with their menopausal symptoms, which would be expected. That's what happens with the general population as well, and it didn't worsen their MS, which is really important.

Again, safety, but this study was done only over an eight week period. So it's a pretty short amount of time. I would say that is far too short an amount of time to know if it's going to actually change the disease course in MS. But that's the question, is this helping us to manage MS and menopause, because it helped to just address the symptoms of menopause, or is it what we call disease modifying, so it actually changes the overall disease course. And I think what we need is much larger, and longer, follow up studies. to really help us to better understand what the actual role for these therapies are in MS. But I think that's coming and very much an advocate to know.

Jodi: Yes, I think that I remember lots of discussions about understanding the impact, you know, it's all part of one big picture and that lifestyle does really matter, you know, exercise. I agree, exercise in particular had a huge impact as well, but the question about whether to or not, an addition to HRT was something that we really talked a lot about.

But also, I'm glad you raised the point to say HRT isn't the only option for actual medication and treatment as well to help women live with some of these symptoms of menopause consequences, they are consequences too, and some of the symptoms of menopause.

So that's all, that gap I think is really significant and given how many women really, like you said, the overlap of symptoms with menopause and MS just makes it so hard to pull apart, which is having more impact, which is getting worse, what's going to happen with that, so I can really appreciate how hard this research is going to be, and how hard it is for women with MS too, to answer those questions to themselves. Is this menopause? You know, I'm 45, 46. Is this the beginning? Or actually is it my MS getting a little bit worse? What can I do about that? You and I both say exercise, but other things as well.

So what are the next steps for the research that you see happening? Like, how do we go about answering these questions?

Francesca: Yes, so I think the key for us in the first place we are wanting to start is, we need to establish that it is the hormones or the menopause transition that is impacting the MS because it's really hard to target our intervention or our treatment unless we know what we're actually trying to address.

So that's what my research is looking into right now, is trying to really tease out how much of the change that we're seeing over this period of time is related to menopause, and how much of it is related to age? I'm not going to go into the details of the semantics, I'll bore you all, but, how to do that from a scientific perspective is actually really challenging.

So we're working on that at the moment, and I'm hoping to share more of that with you in the next few months. But then I think, what do we do in the interim while we're building this research? And I think, the key thing that I would say to women approaching this period is that it took us a long time, even as neurologists, to get comfortable with having family planning discussions with our patients.

But I would like to think now that that has become part of the neurologist toolkit. You know, as an MS specialist, I talk to patients about, well, what they're planning to do with their pregnancies all the time, and how the drugs that they're on going to affect that. That's part of our toolkit. We're all very comfortable to do that.

But I don't think we do this enough around the perimenopausal period and we don't do enough around menopause. And so what I really want to promote, I guess, is both for neurologists to strike up the conversation, but also for women to feel empowered to have this conversation. To bring this up with a neurologist, if the neurologist isn't forthcoming, because we need to work together to try and tease out well, what are these symptoms and what can we do about them?

Too long, I think women have just learned to accept and dismiss a lot of these perimenopausal symptoms and say, well, maybe I'm aging. Maybe this is it. Maybe this is just me now, and a lot of people have just also not felt comfortable to have this, these are very personal discussions, my mood, my cognition, my sexual health. I don't really want to talk about that with my neurologist.

So I think unless we talk about these things, we're not going to come up with good strategies for how to manage them. So I really want to empower women and also neurologists to really think about this phase in a woman's life. Because the other thing to say is that the MS symptoms that overlap the most with the perimenopausal symptoms tend to be the, so called, invisible symptoms of MS.

The things like cognition, and sleep disturbance, and fatigue, and we know from looking at a lot of quality of life measures, these are the symptoms that actually impact quality of life. These are the symptoms that really matter. And, I think that we actually do have a lot, hormonal therapy, post op therapy might be one of the tools that we have in our kit, but we might have a lot of other things that we could do at this time.

For example, just, throwing out a few other things, you mentioned exercise, well that's really good for fatigue, it's incredibly important for mental health, it really helps with sleep. So already, regardless of whether this is menopausal related or MS related, we can still do things about it.

And then the other thing is, you know, even we've got medication therapies as well. So there are classes of antidepressant medications that can be really effective for some of those vasomotor symptoms for the hot flashes that people experience and, also happen to help with mood and sometimes with sleep. So I think we do actually have a number of things that we can offer people, but unless we're talking about it and unless we're thinking about it, we're not going to get better about managing it. And if we don't, then women are just going to suffer in silence.

And I just don't think that that's fair.

Jodi: Yes, and I often would say to women I was talking to, if you're not comfortable talking to your neurologist, it's okay to go and seek out a women's health specialist GP. People just didn't feel like they knew who they could talk to or raise the discussion about and say, oh, this is what I'm experiencing.

And that doesn't mean you necessarily have to change your GP forever either, it's just having that one discussion which says, “well, what would your advice be?” because these people deal with women's health issues all day, everyday, as well. So about extending that team, I think, to say, you can add other people to your team as life goes along.

There are actually a couple of other treatments that I've been reading about for the vasomotor, the symptoms as well, coming out.

Francesca: Yes, there are some new emerging therapies that are becoming available in the US and not available in Australia yet, but again, really promising, you know, the more we research and find, the more we'll be able to help people as they go through this transition as well, because, you know, hormonal replacement therapy is not for everyone.

Jodi: No.

Francesca: We need to have alternatives.

Jodi: Yes, and options for people, and not everyone can take hormonal replacement therapy. It sounds like you've got a lot to do Francesca, but I think the good take-homes are to just talk about it. And I often think women just say, “aah, I don’t know, I won’t worry about it, I won't even bring it up.”

But raise the discussion because there are options and there's more options than what you think that might be available to people. And I've had lots of people who, even a low dose antidepressant, was life changing for some women in their lives. You know, life changing in terms of, they finally slept and they finally felt a little bit better and, the sleep and the mood and all those things came together.

So it is sometimes only a simple change that can actually really make a difference. So, good luck with your research. We'll always help in whatever way we can. And I'm sure that, many women listening will absolutely love the fact that we are opening up this conversation now and that there is research going on into what all these hormones mean. I mean, what do they all mean in a whole woman's life? Like you said, right from, all through birthing to periods to menopause. And so, thank you for your time, and thank you for doing all the research that is so important.

Francesca: Oh, it's my pleasure, and thanks for talking to me about it too, because it’s so nice to have a platform to just discuss these things with other like-minded women.

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