Speaker 1: This is a guide your light network production creating podcasts.
Speaker 2: With purpose because a lot of this doesn't exist in
Speaker 2: tax books, are in guidelines because as you know, you know,
Speaker 2: we only spend one percent of research funding on female
Speaker 2: conditions that aren't cancer, six percent for cancer. But you
Speaker 2: know ninety three percent of medical funding is not going
Speaker 2: to women. There's still menopause and perimenopause still get minimal
Speaker 2: lip service and medical training art to medical school push
Speaker 2: graduate training still hardly anything. You know, So we're trained
Speaker 2: to treat man and women or an afterthought.
Speaker 3: Welcome to the Things you Can't Unhear podcast.
Speaker 1: I'm your host, Maritza Barone. Get ready to hear moments
Speaker 1: that will help you to.
Speaker 4: See the world differently and.
Speaker 1: Inspire you to become the happiest, healthiest and kindest version
Speaker 1: of you. On this episode of Things You Can and
Speaker 1: here we delve deeply into the topics of verimenopause, menopause
Speaker 1: and hormonal health. I invited doctor Kerry Kashall, who is
Speaker 1: an Australian GP and menopause specialist, educator and passionate advocate
Speaker 1: for women's hormonal health to the show. She's got more
Speaker 1: than twenty years of clinical experience and has dedicated much
Speaker 1: of her career to helping women better understand the powerful
Speaker 1: role hormones play in physical and mental health throughout the
Speaker 1: female life cycle. This is a really powerful resource and
Speaker 1: conversation that we can refer back to when we advance in.
Speaker 3: These stages of life.
Speaker 1: I think what I took away from this, and something
Speaker 1: very important, is that this is not a time in
Speaker 1: life to be fearful. We can completely thrive throughout this
Speaker 1: stage of our lives, and we simply need to empower
Speaker 1: ourselves and make the right steps forward to choosing a healthier,
Speaker 1: happier existence. We have listener questions embedded in this episode
Speaker 1: as well, so we find out all about that ballely
Speaker 1: fat nutrition, sleep, exhaustion, and all of those questions that
Speaker 1: so many listeners have had, and also the pathway to
Speaker 1: prescribing HRT and what that actually means. Make sure you
Speaker 1: listen all the way through this. So much in this
Speaker 1: for all of us. Please let me know your thoughts
Speaker 1: and any further questions that you may have around this.
Speaker 1: There's so much support out there, so the more education
Speaker 1: and knowledge that we give ourselves, the more of a
Speaker 1: wonderful position that we're here in enjoy this conversation with
Speaker 1: doctor Kerry Cashell, Doctor Kerry Cashall, welcome to the Things
Speaker 1: you Can't and Here Podcasts.
Speaker 4: Thank you very much for having me. It's a pleasure
Speaker 4: to be here.
Speaker 3: It is a pleasure.
Speaker 1: I think we're talking women's health, women's hormones, and it's
Speaker 1: a topic of conversation that I'm finding very important at
Speaker 1: the moment. Just the more conversations I seem to be having,
Speaker 1: the more questions I have, which is.
Speaker 3: Funny, right, it just opens up a whole worms.
Speaker 1: So I'm pleased you here because you are the expert,
Speaker 1: and you're breaking things down in such a way that
Speaker 1: it's very easy for us to understand, even if we
Speaker 1: don't have a medical background. So thank you for that.
Speaker 1: I thank you on behalf of all the women out
Speaker 1: there as well. I'm going to doctors and still don't
Speaker 1: have the answers to their questions.
Speaker 2: Yeah, that's such a common experience. It's been my journey too.
Speaker 2: You know, as I'm sure you've heard people say, you know,
Speaker 2: we're not trained in female health. We most of what
Speaker 2: we learn in our medical degree is based around male physiology,
Speaker 2: the physiology of a white seventy kilo male, not even
Speaker 2: all men. And and you know, we get taught a
Speaker 2: bit about reproductive medicine, so how to get pregnant, how
Speaker 2: to not get pregnant, how to deliver a baby. That's
Speaker 2: a bit about breasts, but for everything else in the
Speaker 2: female body, it's just the small version of men, which
Speaker 2: of course it isn't. So I've very much been on
Speaker 2: my own learning journey about female health, and I think
Speaker 2: that's partly why I maybe am reasonable at trans that,
Speaker 2: because I've been on my own learning journey, and I
Speaker 2: can tell you it would have been much easier for
Speaker 2: the first twenty years of medicine if I'd had that
Speaker 2: knowledge at the start, you knew, rather than two thirds
Speaker 2: of or whatever it is, half the way through my
Speaker 2: professional career.
Speaker 1: I think a lot of us women are making a
Speaker 1: lot more noise about it now, So I think people
Speaker 1: are standing up and listening, and I'd love to hear
Speaker 1: a bit about your journey, if you're willing to share it, actually,
Speaker 1: because I think that really allows us to see, you know,
Speaker 1: put ourselves in your shoes and hear how it unraveled
Speaker 1: for you.
Speaker 2: Yeah, yes, no, it is the great thing. Well, I
Speaker 2: think perrymenopause itself is the great unraveling or rebuilding or rewiring.
Speaker 2: So yeah, so I trained in the UK, trained in
Speaker 2: Scotland as a doctor. I had originally wanted to be
Speaker 2: a fashion designer. That has had always been what I
Speaker 2: wanted to do, and then did a last minute pivot
Speaker 2: before I left school after being inspired by a doctor
Speaker 2: who was working in Northern Ireland with my godmother who's
Speaker 2: also a doctor, learning because we had a lot of
Speaker 2: gunshot wounds back in the eighties in Northern Ireland. So
Speaker 2: she inspired me and off I went to medicine and yeah,
Speaker 2: did all the usual stuff that doctors do in training,
Speaker 2: and then came to Australia in twenty twelve. We fancied
Speaker 2: a change of scene, so I came out with my
Speaker 2: husband and two boys and settled into a lovely life
Speaker 2: in the northern beaches of Sydney. And I think I
Speaker 2: was probably and then I was moving into my forties myself.
Speaker 2: I became interested in a lot more holistic medicine. You know,
Speaker 2: I have had more a lot more time with my
Speaker 2: patients working in Australian than I would have done in
Speaker 2: the UK. It's very time pressured there, so you're just
Speaker 2: kind of far fighting the whole time, where As working
Speaker 2: in practice here I was able to get to know
Speaker 2: people a bit better. I was able to move away
Speaker 2: from just that pill for every ill and looking, you know,
Speaker 2: having more time to talk about lifestyle intervention, more preventative medicine.
Speaker 2: But it was really twenty twenty one when a patient
Speaker 2: came in and asked me to prescribe testosterone for her,
Speaker 2: and I had no idea how to prescribe testosterone. I
Speaker 2: think I had a vague idea it was a female hormone,
Speaker 2: but had certainly not ever considered it as a.
Speaker 4: Two in my toolbox.
Speaker 2: And she said, you need to go on up skill
Speaker 2: and here's a course you should do, and so she
Speaker 2: sent me off to do this course. And that was
Speaker 2: of course by Louise Newsoen, who had at that point
Speaker 2: already over two hundred podcasts. And then it was listening
Speaker 2: to all those patient stories in her podcasts and different specialists.
Speaker 2: I could see so many of my own patients and
Speaker 2: my own patients experiences in that, and I realized I
Speaker 2: really needed to go back and start from the beginning
Speaker 2: understand what it was that made women different to men,
Speaker 2: those assigned female birth different to those assigned male at
Speaker 2: birth in terms of hormones, and then that's gradually grown.
Speaker 2: I've got a real interest in how other parts of
Speaker 2: female physiology are different, which would be certainly connective tissue.
Speaker 2: You know, we're a bit more bendy, and that seems
Speaker 2: to impact you know, our immune system or nervous system differently.
Speaker 2: So we are we're the same, but we're also different,
Speaker 2: and we need a different set of rules, we need
Speaker 2: a different manual. So I realized that as a doctor,
Speaker 2: I've been trying to drive ferraris, which I think that's
Speaker 2: the of the ferraris, using a kind of old Ford manual.
Speaker 2: No offense to men, but male medicine is a lot simpler.
Speaker 2: You know, they don't have these hormonal changes. You know, women,
Speaker 2: you know, are living in a constant state of flux,
Speaker 2: you know, from the time they go into puberty, and
Speaker 2: it really doesn't settle down until you're through menopause, which
Speaker 2: is really postmenopause, and at that point, your you know,
Speaker 2: your sex hormones have stopped, you know, this ruler coaster journey,
Speaker 2: but they've flat lined, which has its own host of problems.
Speaker 2: Whereas men have testosterone, it doesn't changes a little bit
Speaker 2: in each twenty four hours, but it's overall it's pretty steady,
Speaker 2: and then it just gradually declines a little bit in
Speaker 2: a healthy man over the decades. And obviously men can
Speaker 2: reproduce until they die, so they have a very different
Speaker 2: experience of life to women. Women very different.
Speaker 1: Yeah, yeah, I Q you, and you know what, even
Speaker 1: though it's complicated being a woman, I still choose to
Speaker 1: be a woman.
Speaker 3: You never, Absolutely yes, it is a wonderful and wild ride.
Speaker 1: Do a couple of things that you said there that
Speaker 1: I loved, and one of them being, you know, the
Speaker 1: time that you give to patients when they come in.
Speaker 1: Very often we feel rushed and we feel like we
Speaker 1: can only bring up one thing while we're sitting in
Speaker 1: front of a doctor and we're in and out within
Speaker 1: ten minutes, and we're like, hang on a minute, I
Speaker 1: didn't say this, and I didn't say that. We get
Speaker 1: home and we think, what if I had mentioned this symptom.
Speaker 3: Or what if I hadn't mentioned that?
Speaker 1: Would that have changed what tests I got or what
Speaker 1: diagnosis I was given? And you know, I went to
Speaker 1: a woman's health specialist about six months ago, and there
Speaker 1: was such a beautiful process because I sat with a
Speaker 1: nurse before going in to see the doctor for about
Speaker 1: twenty five minutes, and she pretty much asked me every
Speaker 1: single question now I could possibly be asked.
Speaker 3: And then I went and.
Speaker 1: Saw the doctor and she reviewed all of that, and
Speaker 1: I thought that was absolutely amazing because I felt seen
Speaker 1: and I was able to actually get it all out.
Speaker 1: I was able to verbalize exactly how I was feeling
Speaker 1: without being a drag or without feeling like I was
Speaker 1: feeling sticks time exactly.
Speaker 3: So I think that's super important. I love that you
Speaker 3: do that.
Speaker 2: Yeah, no, I think I mean time is, you know,
Speaker 2: is such a fabulous tool. Like we are trained, especially
Speaker 2: as GPS, to let our patients speak. But often people
Speaker 2: are coming in, you know, they're anxious, they're worried. They also,
Speaker 2: especially women, always seem to say, I'm really sorry to
Speaker 2: bother you. I hate wasting your time. You know us
Speaker 2: you're kind of coming in going I probably shouldn't even
Speaker 2: be here. I'm like, there's people always sicker than me. It's,
Speaker 2: you know, terrible things that women do to diminish their
Speaker 2: right to decent care themselves because of our system but
Speaker 2: that time giving somebody a chance to speak, but also
Speaker 2: then exploring, you know, being more proactive and you're questioning
Speaker 2: and you know, looking at all the systems so that
Speaker 2: you can see, like what's going on with your mental
Speaker 2: health and what's happening with your gut, and what's happening
Speaker 2: with your periods and you know, I've done a few
Speaker 2: reels on Instagram just recently about how our system, the
Speaker 2: way it's structured, both in the in the US, in
Speaker 2: the UK and in Australia, really pushes people to do
Speaker 2: this kind of ten minute medicine, which doesn't really allow
Speaker 2: somebody to come in and talk through all their systems.
Speaker 2: They're all their symptoms, so you're often you're dealing with
Speaker 2: one or two symptoms at a time, and it doesn't
Speaker 2: give you the opportunity to go right these twenty symptoms
Speaker 2: or you know, in the case of perimenopause, there's hundreds
Speaker 2: of symptoms because you've got estergen receptors in every single cell.
Speaker 4: Of the body.
Speaker 2: You know, you could be going back and forward for
Speaker 2: you know, twenty years before you realize it's all perimenopause,
Speaker 2: or it's all a connective dishy disorder or it's all
Speaker 2: in other immune disease. So that time is although you
Speaker 2: can spend you need to spend more time at the
Speaker 2: beginning in the long term, even like over the next
Speaker 2: even over you know the period of the next year,
Speaker 2: you will have saved so much time you will have
Speaker 2: saved you know, whichever you know system it is in Australia,
Speaker 2: the medicare system, it's actually it's much more cost effective
Speaker 2: to spend that extra time at the beginning. Look at
Speaker 2: all the symptoms, see how they're connected. And often treatments
Speaker 2: are very similar for you know, different symptoms in terms
Speaker 2: of lifestyle. Yes, there's some differences in the drugs, but
Speaker 2: it's a much more efficient way. And you, as you
Speaker 2: experienced as a patient, you felt heard and you felt validated,
Speaker 2: and you know, it's a much more positive experience for
Speaker 2: book doctor and for a patient, I would say definitely.
Speaker 1: And you know, as patients we forget it's a business
Speaker 1: as well with GPS, and you know time is equals
Speaker 1: equals that money is money ultimately, so you know, at
Speaker 1: the same time, we do want to feel like our
Speaker 1: time is value.
Speaker 3: So I love how you've broken that down.
Speaker 1: I also what you said earlier, I loved in that
Speaker 1: that you're helping to educate other doctors. I think that's
Speaker 1: a huge thing because that isn't a standard education platform
Speaker 1: that people are getting, as you're saying, through medical school
Speaker 1: and learning about this at a deeper level. And you know,
Speaker 1: I've been watching your Instagram over the last couple of
Speaker 1: weeks and you know, just learning so much from that
Speaker 1: as well. And I think you know resources like that,
Speaker 1: and you're putting these scenarios out there that you know
Speaker 1: you've spoken to your patients about and us hearing sort
Speaker 1: of how you've worked or it's almost like detective work,
Speaker 1: trying to get to the bottom of exactly what that
Speaker 1: woman is going through.
Speaker 2: Yeah, very much so. And I mean it is also
Speaker 2: like we know in terms of how humans learn, we
Speaker 2: do learn by storytelling, so me telling and a scenario,
Speaker 2: and they are they're never exact scenarios because obviously the
Speaker 2: patient confidentiality always think I better said, this is not
Speaker 2: any one person. That's usually you know, e merge of
Speaker 2: different different themes. But we do learn by storytelling, and
Speaker 2: it is something we do in our medical training. But
Speaker 2: you know, it's much better for me to tell the
Speaker 2: story of the lady coming in, who's anxious, wonders if
Speaker 2: she's got ADHD, he's got heavy periods, and all the
Speaker 2: things that me saying perimenopause might make women anxious. It
Speaker 2: may also you know, it's it's much more real, and
Speaker 2: our brains like that. But you're right, you know a
Speaker 2: big part of why we set up Healthy Hormones was
Speaker 2: that we as a you know, as a group, realized
Speaker 2: we hadn't been trained, you know, we'd gone off and
Speaker 2: done our own training. We wanted to make that better
Speaker 2: for other clinicians, because most doctors want to do the
Speaker 2: best by their patient. But it's you know, we're also
Speaker 2: navigating a world of so much stuff that we need
Speaker 2: to learn and stay on top of, and we wanted
Speaker 2: to make it easy and accessible, which is why, you know,
Speaker 2: our clinical education on our Healthy Hormones it's an app
Speaker 2: that sits in your pocket. You know, as a clinician,
Speaker 2: you can type top and they've got marits in here,
Speaker 2: and she's having this problem. You know what shed to
Speaker 2: do now? Because a lot of this doesn't exist in
Speaker 2: textbooks or in guidelines because as you know, you know,
Speaker 2: we only spend one percent of research funding on female conditions.
Speaker 4: That aren't cancer.
Speaker 2: Six percent for cancer, but you know, ninety three percent
Speaker 2: of medical funding is not going to women. There's still
Speaker 2: menopause and perimenopause still get minimal service in medical training
Speaker 2: at medical school, postgraduate training still hardly anything, you know.
Speaker 2: So we're trained to treat men and women ear an
Speaker 2: afterthought and that really needs to change. But while it's changing,
Speaker 2: if it is even changing, that's where we're really wanting
Speaker 2: to improve it because it's a somewhat mikes life better
Speaker 2: for doctor's clinicians he treat and women themselves, you know,
Speaker 2: So that's a when for everybody.
Speaker 3: Exactly exactly right now.
Speaker 1: Last week I dropped an episode with a brilliant breast surgeon.
Speaker 1: Her name is doctor Yasmini Kevridge, and she operates in
Speaker 1: top Melbourne hospitals and we had a conversation there that
Speaker 1: has really stayed with me because I gave her a
Speaker 1: scenario as well. I'll explain the whole situation to you
Speaker 1: and I'd love to get your take on this. Actually,
Speaker 1: if anyone who hasn't listened, go back and listen to
Speaker 1: that episode after this one, because it's it's super important.
Speaker 1: Now the rates of breast cancer are one in seven
Speaker 1: women in Australia right now. And I gave her a
Speaker 1: situation where, because a lot of women are taking hormone
Speaker 1: replacement therapy at the moment, if a woman had presented
Speaker 1: with well, hadn't presented yet, but it was she had
Speaker 1: breast cancer but didn't know she had breast cancer and
Speaker 1: she started taking hormone replacement therapy, would that be detrimental
Speaker 1: to that situation or to that diagnosis or would that make.
Speaker 3: That cancer worse?
Speaker 1: And she insisted that it is super important for women
Speaker 1: to have a breast examination or a mammogram prior to
Speaker 1: having hormone replacement therapy, and because she's a breath surgeon,
Speaker 1: she always does that when she prescribes HRT.
Speaker 3: And then I did a poll.
Speaker 1: I did a poll on Instagram that bewildered me actually
Speaker 1: because I put it out to everyone who was following me,
Speaker 1: and I said, page's curious for those who are taking
Speaker 1: HRT at the moment, were you offered a breast examination
Speaker 1: or a mammogram before being prescribed HRT? And eighty nine
Speaker 1: percent of people said that they weren't. So I just
Speaker 1: want to get your perspective on this to see if
Speaker 1: you think it's necessary to see if that's something you
Speaker 1: do and just you know, open that conversation up again.
Speaker 2: Yeah, now that is such a good question, and yes,
Speaker 2: it is probably slightly surprising. What you find in your pool.
Speaker 2: Where I come from is that breast cancer and hormonal
Speaker 2: treatment of perimenopause and menopause are two separate things which
Speaker 2: obviously overlap because the woman there's an increased risk of
Speaker 2: breast cancer as women get older. So the majority of
Speaker 2: breast cancers are in women over fifty, and the majority
Speaker 2: of women who are taking hormone therapy are over fifty
Speaker 2: as well, So there's this overlap in terms of what
Speaker 2: we know from the data. Does I suppose one of
Speaker 2: the questions is does hormone therapy increase the risk of
Speaker 2: getting breast cancer? Does it promote the growth of breast cancer?
Speaker 2: So what we know from the largest control trials that
Speaker 2: we have, which would be the WHI the Woman's Health Initiative,
Speaker 2: which used a different type of use different types of
Speaker 2: hormones than we use today. So it used conjugated equine
Speaker 2: estrogen which is the horses estrogen, and synthetic progesterge majoxy
Speaker 2: progesto and acetate and then a group of women only
Speaker 2: use the estrogen, the equine eestrogen in the woman who
Speaker 2: took the combined hormone therapy, they saw those women, if
Speaker 2: they got breast cancer on hormone therapy, they did better,
Speaker 2: so they had better outcomes with their breast cancer and
Speaker 2: they had a reduced risk of death. But there was
Speaker 2: perhaps a small but there's it's still not strong that
Speaker 2: this was even statistically significant. There was perhaps a small
Speaker 2: increased risk of getting breast cancer in the woman taking
Speaker 2: combined hormone therapy, but that is in.
Speaker 4: These older, older drugs.
Speaker 2: So then they looked at women who only took estrogen
Speaker 2: because they'd had a hysterectomy. So standard practice at that
Speaker 2: time and still today is that you don't need progestogen
Speaker 2: if you don't have a uterus. The women who were
Speaker 2: taking estrogen had a reduced risk of getting breast cancer
Speaker 2: full stop. So women who only took estrogen reduced the
Speaker 2: risk of getting breast cancer by a quarter, and if
Speaker 2: they did get breast cancer, like the women on the
Speaker 2: combined hormone therapy, they also have better outcomes. So it
Speaker 2: looks like even in using these more synthetic forms combinate
Speaker 2: the progestogen perhaps, but even that wasn't actually hitting statistical significance.
Speaker 2: There is perhaps a small increased risk of an extra
Speaker 2: one case per thousand women getting breast cancer with estrogen.
Speaker 2: Your risk is actually reduced when it was estrogen on
Speaker 2: its own, and women in both groups, if they did
Speaker 2: get breast cancer, did better. So back in the nineties,
Speaker 2: about forty percent of women in the US, in the
Speaker 2: UK we're on hormone therapy. The risk of getting breast
Speaker 2: cancer was about one in twelve. Today it's in Australia
Speaker 2: it's about fifteen percent, so about one in six women
Speaker 2: are on HRT. But the risk of breast cancer has
Speaker 2: dramatically increased, So hormone therapy use has decreased, breast cancer
Speaker 2: risk has increased. So there is no study that shows
Speaker 2: that hormone therapy consistently increases the risk of breast cancer.
Speaker 2: What we have show is the estrogen on its own
Speaker 2: reduces breast cancer and that women who get breast cancer
Speaker 2: on h r T tend to do better. Then you
Speaker 2: look at then you look at breast cancer increasing, and
Speaker 2: it's critical that women in their forties, fifties, sixties, you know,
Speaker 2: get their breast screen So it's separate, but it doesn't
Speaker 2: mean if you're somebody you don't want a mammogrammar you
Speaker 2: don't want breastcraining. I wouldn't deny you hormone therapy on
Speaker 2: that basis, but I think it's a good idea to
Speaker 2: get breast screening as a woman who's getting older, because
Speaker 2: you know, there's your breast is subject to a lot
Speaker 2: of insults through life. It's tissue that is really affected
Speaker 2: by changing hormones, stress and life.
Speaker 4: The real risk factors for breast.
Speaker 2: Cancer are being female, sounds obvious, getting older, carrying excess weight,
Speaker 2: drinking alcohol, smoking, and then there's the things you can't
Speaker 2: do anything about, which is well being containing a boy,
Speaker 2: being a woman, or getting older. But your family history
Speaker 2: and if you have an inherited answer gene like the
Speaker 2: Blacker gene or Lynch syndrome, so really important that we
Speaker 2: look at family history, that we offer those women earlier
Speaker 2: brass screening, more enhanced bress screening, more regular brass screening,
Speaker 2: and certainly encouraging women to get genetic testing. But sort
Speaker 2: of seeing them is two things that are separate that
Speaker 2: do have an overlap, but we have to be really
Speaker 2: careful that we don't scare women, but equally that we
Speaker 2: encourage good screening. That kind of roundabout way of a
Speaker 2: complicated answer.
Speaker 1: Yeah, and that's the last thing I want to do too,
Speaker 1: is scare women. It's just about sort of empowering ourselves
Speaker 1: sometimes with the information that what we need, that we've
Speaker 1: made the right decision for us.
Speaker 3: I think, can you talk me through what you the.
Speaker 1: Practice you use when you prescribe HRT, because it is
Speaker 1: so interesting to me to sort of hear a lot
Speaker 1: of different experiences that my friends have had or people
Speaker 1: that I know have had when they've been off at HRT,
Speaker 1: and also the reactions that they're having to it as well.
Speaker 1: So I'd love to Yeah, so what would the recommended
Speaker 1: procedure be for you if someone comes in and asks
Speaker 1: for on my replacement therapy?
Speaker 2: So we're always taking a history, so we're always looking
Speaker 2: at your different symptoms, and you know, because there are
Speaker 2: hormone receptors in every single system and sell in the body,
Speaker 2: we're always trying to work out is this a hormonal
Speaker 2: shift or is this something else is happening alongside And sometimes,
Speaker 2: and you know, not infrequently, it is both. So I
Speaker 2: like to see where woman's at, what are the symptoms
Speaker 2: that are really bothering her, and then doing that full
Speaker 2: screen and looking through you know, I use a symptoms
Speaker 2: screener which doesn't have all symptoms on it, but it
Speaker 2: probably has some of the most important ones, and looking
Speaker 2: to see where she's struggling in those domains. I do
Speaker 2: do blood tests quite quite frequently. You can't diagnose perimenopause
Speaker 2: or from a blood test. It's a clinical diagnosis because
Speaker 2: your hormones are changing, you know, day to day, week
Speaker 2: to week. I'm more doing blood tests to rul out
Speaker 2: other things like thyroid disorder order, immune disease, obviously increases
Speaker 2: in perimenopause, iron deficiency from the heavy periods, you know,
Speaker 2: things like that. And then again that wouldn't stop me
Speaker 2: from starting hormones in that first appointment if somebody was
Speaker 2: very keen to start. So depending on somebody's age, also
Speaker 2: if they have heavy periods and their need for a contraception.
Speaker 2: And I would always say if you have finished having
Speaker 2: children and you're in a long term relationship of the
Speaker 2: sectomy is definitely the safest form of contraception for women.
Speaker 4: So it's hugely underused.
Speaker 2: You've carried that burden for twenty twenty five thirty years,
Speaker 2: so somebody can take that on if that's the relationship
Speaker 2: you're in. But so if somebody does still need contraception,
Speaker 2: or if somebody has really heavy periods, then something like
Speaker 2: the hormonal IUD can be a good tool to use,
Speaker 2: which can also be used as part of your hormone therapy.
Speaker 2: Some of the progestin only pills are quite good again
Speaker 2: for heavy periods for women who get really severe cyclical symptoms,
Speaker 2: you know, where they get what we call pre menstrual
Speaker 2: dysphoric disorder, which you can have from as soon as
Speaker 2: you start periods, or it might only develop after having children,
Speaker 2: or it might only develop in perimenopause. Some of those
Speaker 2: women do do better to have their cycle flatted us,
Speaker 2: you know, using a contraceptive pill, but not all so
Speaker 2: it's sort of just working around things like heavy periods, contraception,
Speaker 2: and then a lot of women just want to go
Speaker 2: onto natural hormones because that is what we know is
Speaker 2: the safest and in general the most effective for mood symptoms,
Speaker 2: for sleep, for fatigue, and I'm usually starting if somebody
Speaker 2: has had kind of a pretty ordinary, unexciting life up
Speaker 2: until this point, and everything's just going about south.
Speaker 4: You know, if they aren't, if they haven't.
Speaker 2: Also got query IDHD or hypermobility or a long history
Speaker 2: of allergies and sensitivities, I would usually start them on
Speaker 2: body identical estrogen, which is estradiol as a patch or
Speaker 2: a gel, and some body identical micronized progesterone, which comes
Speaker 2: as a capsule. If you're somebody that has a history
Speaker 2: of everything, of being sensitive to everything, you know, perfumes, foods,
Speaker 2: I think I've got ADHD. I react to everything. Then
Speaker 2: I'll start one hormone at a time. And if, for instance,
Speaker 2: your main issue was that your mood was dipping before
Speaker 2: your period, I might start just on some cyclical progesterone.
Speaker 2: If your main issue is in so many again, I
Speaker 2: might go with progesterone first on its own. If you're
Speaker 2: using estrogen and a woman who has a uterus, you
Speaker 2: have to have some form of progestogen, whether that's natural progesterone,
Speaker 2: a contraceptive pill, or a hormonal ID So you're kind
Speaker 2: of going down these different different pathways depending on the
Speaker 2: individual woman's needs. And then if a woman has significant
Speaker 2: genital or urinary symptoms, so vaginal dryness, discomfort, pain, discomfort
Speaker 2: during sex, urgency of urination, get up at night, lots
Speaker 2: of UTIs really love a bit of vaginal hormones. You know,
Speaker 2: billions of dollars spent up here and crickets for down there.
Speaker 2: So yeah, using some vaginal hormones, which not all women
Speaker 2: will need as their systemic hormones settle down, but you
Speaker 2: know about a third of women do need. And then testosterone.
Speaker 2: So testosterone is licensed for postman apozzle, libido, it is
Speaker 2: made in Australia, it is approved.
Speaker 4: But there are a.
Speaker 2: Lot of perimenopausal women who also find that they benefit
Speaker 2: from testosterone. And then there's lots of women where testosterone
Speaker 2: doesn't make any difference at all and it comes as
Speaker 2: a cream. But I tend to stagger, you know, the
Speaker 2: estrogen in bergestone, usually going in there first and then
Speaker 2: reviewing where somebody's symptoms are at after a couple of months,
Speaker 2: and then maybe adding in some testosterone if they've got
Speaker 2: symptoms that suggest they might benefit, like lu libido or
Speaker 2: fatigue or brain fog. And of course, yeah, so it's
Speaker 2: not a magic bullet. You know about a third of
Speaker 2: women think it's brilliant. A third of women say it
Speaker 2: makes a lot of bit a difference. The third of
Speaker 2: women say it does nothing at all in terms of testosterone,
Speaker 2: but the majority of women do respond okay to body
Speaker 2: identical hormones. It is important to start low and you know,
Speaker 2: build up the door slowly, especially in women who are hypermobile, neurodivergent,
Speaker 2: who I've got issues because you know, these are bodies
Speaker 2: that are hyper responsive to change, including putting in hormones.
Speaker 3: Yeah right, wow, So there's just so much for us
Speaker 3: to learn.
Speaker 1: I feel like that's why these conversations are so important
Speaker 1: for me and us to have and to be able
Speaker 1: to have as a resource here when we need it
Speaker 1: to be able, like, oh, we.
Speaker 3: Have an hour with doctor Caring, how we can hear
Speaker 3: exactly her opinion on this stuff.
Speaker 1: I've got some listener questions that I'd really love to
Speaker 1: run through with you if we've got some time, because
Speaker 1: I think, you know, just hearing from women in this
Speaker 1: age of life, there's just so many different things going on,
Speaker 1: and I'm just going to throw some.
Speaker 3: Out for you if that's okay.
Speaker 4: Yeah, all right.
Speaker 1: So listener question one was during menopause, my sleep suddenly changed.
Speaker 1: I wake up at about three or four am most
Speaker 1: nights for no reason and can't get back to sleep.
Speaker 2: Is this common, extremely common, and often one of the
Speaker 2: earliest symptoms in perimenopause, And it's because estradiole estrogen and
Speaker 2: progesterone are really potent neural transmitters. You actually you also
Speaker 2: make your malatunin from gesterone, so those would be direct reasons.
Speaker 2: So there's the direct effect of changing hormones in your
Speaker 2: brain will really affect your sleep architecture. You've got that
Speaker 2: anxiety from decreasing hormones, which also then can drive insomnia.
Speaker 2: You've got a change in your gut microbiome as a
Speaker 2: result of changing hormones, which will impact on your production
Speaker 2: of serotonin, dopamine and melatonin and gaba and gaba is
Speaker 2: our lovely calming hormone. So progester roone particularly checks out
Speaker 2: often early in perimenopausit before estrogen even does. Progesteroms like
Speaker 2: Nature's valum so really common. But you've also got then
Speaker 2: this kind of cordisol spikes. There's multiple things that can
Speaker 2: be happening in terms of how our brain is getting
Speaker 2: cleaned overnight. You know, there can be problems, you know,
Speaker 2: in terms of your circulation that it can impact that
Speaker 2: brain blood flow. Your brain isn't able to wash itself
Speaker 2: as effectively, so get a bit of a toxic build up.
Speaker 2: Our breathing often changes because we lose a bit of
Speaker 2: airway tone. So about sixty percent of women who our
Speaker 2: postmenopause will have sleep apnea, and most of them are
Speaker 2: undiagnosed because they don't tend to snore lightly, especially if
Speaker 2: they're in a you know, heterosexual relationship. You know, their
Speaker 2: partner usually snortliders. So there's different things. So looking at
Speaker 2: gut direct effects on the brain, effects on the gut,
Speaker 2: and effects even on your airway tone, as well as
Speaker 2: the fact that you're often dealing with the you know,
Speaker 2: a busy job, older parents and maybe teenage kids.
Speaker 4: You know.
Speaker 3: Okay, so listen now, it is normal and it's common.
Speaker 4: It's not.
Speaker 1: Okay, it's yes, it's common, and it's not. Okay, we
Speaker 1: hear we hear you, all right. And the second question
Speaker 1: is around food. Are there certain foods that can make
Speaker 1: menopause symptoms worse?
Speaker 3: And on the other side of that.
Speaker 2: Nutrition health, Yeah, yeah, so it's really boring, it's but
Speaker 2: It's the same stuff that's good for everything, whether you're
Speaker 2: trying to you know, optimize your muscle mask you know,
Speaker 2: your bone masks, your brain health, your cardiac health, or
Speaker 2: your menopause symptoms. It's you know, eating enough proutein you know,
Speaker 2: choose a massive number multiplied by ten and you take
Speaker 2: away three. It's a lot eating plenty of pruting. So
Speaker 2: thinking of that is really building. You give yourself the
Speaker 2: building blocks to build cells. And then plenty of fiber
Speaker 2: not only maintains your gut health, but I always think
Speaker 2: of the fiber as kind of taking out the trash, so.
Speaker 4: All of those waste products.
Speaker 2: So really focusing on real food, you know, don't think
Speaker 2: about the diet. Think about real food, think about plenty
Speaker 2: of protein, plenty of fiber, healthy fats. You know, moving
Speaker 2: towards that kind of Mediterranean diet has probably got the
Speaker 2: most evidence for good health and does tend to improve
Speaker 2: menopause symptoms. Things that aren't your friend again, same stuff
Speaker 2: as you know, everything else. High sugar, alcohol, you know,
Speaker 2: create these erratic piaks and troughs with glucose, which your
Speaker 2: body doesn't like. It's already trying to deal with changing
Speaker 2: sex normal levels. It doesn't need sort of crashing levels
Speaker 2: of insulin and grellin going on as well. So trying
Speaker 2: to keep that lovely steady state of glucose as your
Speaker 2: fuel and your body from protein and fiber is much better.
Speaker 2: And alcohol and sugar, although your cravings often get worse
Speaker 2: than perimenopause due to falling progesterone and it can be
Speaker 2: easy to just reach, it will disservice you unfortunately. So
Speaker 2: but yeah, women who are more mass sell activated who
Speaker 2: can become histamine sensitive. So there's a whole lot of
Speaker 2: food different food groups that people can be sensitive to.
Speaker 2: But it's very different from person to person, and it's
Speaker 2: working out you know what is right for you, and
Speaker 2: it's very individual. So one person can do really well
Speaker 2: on a low histamine diet, somebody else needs something totally different.
Speaker 4: It's very personalized.
Speaker 1: And the sensitivities I think change so much at this
Speaker 1: age two in terms of you know, people could have
Speaker 1: two glasses of wine three years ago and now they
Speaker 1: have two glasses of wine and they just dead hard.
Speaker 2: And I think that I think that's there's different things.
Speaker 2: So it's the got microbiome changes and also our livers
Speaker 2: efficiency unfortunately does change it and really needs a lot
Speaker 2: more support than TLC. You know, the things you did
Speaker 2: in your twenties, your liver is just not going to
Speaker 2: thank you for at forty five, and certainly not of
Speaker 2: fifty five.
Speaker 3: This question is one that's also very common.
Speaker 1: Well, the love of God, how do I get rid
Speaker 1: of these menopause belly? Why do women's bellies just blow
Speaker 1: up at these sights?
Speaker 2: So multiple different things, and it doesn't happen to everybody.
Speaker 2: I think we need to study the women who managed
Speaker 2: to sort of sail through this. We need to find
Speaker 2: these unicorns and pin them down and you know, clone them.
Speaker 2: So we know that as estrogen falls, and probably also
Speaker 2: progesterone as well, you become more insulin resistant, so you
Speaker 2: do tend to start to store fat. Unfortunately, around the middle,
Speaker 2: there's another theory that maybe you're trying to create more
Speaker 2: estrogen from your fat cells. Your fat cells can produce
Speaker 2: estrogen called estrone, so there's maybe the brain trying to
Speaker 2: find ways to create estrogen. When you're ovarian, estrogen is
Speaker 2: declining and then obviously flat lining, so a big part
Speaker 2: there will be that change in insulin sensitivity, which drives
Speaker 2: increased visceral fat, subcutaneous fat, and also loss of muscle mass.
Speaker 2: So when you're losing muscle, you're losing that mitochondrial a
Speaker 2: little mitochondria and your muscle or in all your cells.
Speaker 2: But there's more higher density and muscles you're losing those.
Speaker 2: You're just not as metabolically efficient. So that's another thing.
Speaker 2: Then there's other there is other indirect things like that
Speaker 2: change in the got microbiome I think does drive weight gain.
Speaker 2: The change in quality of sleep drives weight gain, the anxiety,
Speaker 2: the cravings, you know, so there's direct and indirect effects
Speaker 2: of changing hormones on why you gain weight. And the
Speaker 2: things that you do to try and maintain optimal muscle
Speaker 2: mass rather than talking about weight, you know, are the
Speaker 2: usual things that you know, start weight training as early
Speaker 2: as possible. It's you know, with so many you know,
Speaker 2: girls falling out of sparksport in their teams, it's so
Speaker 2: important that you try and maintain that muscle mass. It's
Speaker 2: much easier to maintain it than to you know, start
Speaker 2: from scratch. But whatever age you are, you can build muscle,
Speaker 2: you know. And again that kind of nutrition and you know,
Speaker 2: and for some woman, you know, it's absolutely reasonable to
Speaker 2: look at, you know, weight loss medication. I do prescribe
Speaker 2: GLP ones. I do think they're very useful adjunct. There
Speaker 2: is evidence to show they work better alongside body identical
Speaker 2: hormones for menopausal women. But you know, we are lucky
Speaker 2: that we do. You have these medicaations, but they are
Speaker 2: not a replacement for a really good real food diet
Speaker 2: and weight training and regular exercise, going for a walk
Speaker 2: after dinner, trying to move as much as you can
Speaker 2: during the day, and checking that you're getting enough sleep,
Speaker 2: because enough sleep is a good way to lose with it.
Speaker 1: It really is the basics as and I feel like
Speaker 1: we've been told over and over again. Maintain sleep, good food.
Speaker 2: Yeah, good people, good good food, good people. Plenty of movement.
Speaker 3: Yeah.
Speaker 1: Now these questions are around hid tea again, because that's
Speaker 1: the buzz at the moment. One listener said that she's
Speaker 1: started on HRT patches, but now they're causing a real
Speaker 1: serious itch on her skin to the point where she
Speaker 1: can't wear them anymore.
Speaker 3: Is this common?
Speaker 2: Yeah, So the patches that we have, if you're lucky
Speaker 2: enough to get them in Australia, are using patch tech
Speaker 2: that is over twenty years old, so this is dinosaur medicine,
Speaker 2: so there's really not been any investment into making better patches.
Speaker 2: So that is a common problem. And because so twofold one,
Speaker 2: it's just they're just not a great They're often not
Speaker 2: a great product. We have a shortage of the really nice,
Speaker 2: little small ones. We're often using these much larger ones
Speaker 2: that have a much greater area of adhesive. But women
Speaker 2: in perimenopause do tend to get this up regulation in
Speaker 2: their immune system, so there's your skin becomes itchy and drier,
Speaker 2: so when you've got adhesive sitting on it, then you
Speaker 2: are more likely to react. So it is a common problem.
Speaker 2: You can do simple things to try and help, like
Speaker 2: some people use an asthma steroid spray to spray on
Speaker 2: their skin first, works a bit like you know, like
Speaker 2: a cordysome cream. But the problem is really that the
Speaker 2: patches aren't good enough. So there is two Australian women
Speaker 2: who are building a company to design women focused patches, small,
Speaker 2: not irritating stay that stay on that you can change
Speaker 2: once a week as opposed to every three and a
Speaker 2: half days, which I don't know who thought that was
Speaker 2: a great idea for perimenopozzle and menopausal So, yeah, we
Speaker 2: need new patches. Common problem. Yeah, asthma spray on your
Speaker 2: skin can sometimes help.
Speaker 3: There's a market to crack if anyone's pain.
Speaker 4: Yeah, let Lare Health look them up. Yes, they're looking
Speaker 4: for more funding.
Speaker 3: Amazing. So another listener, I've just started chad TA.
Speaker 1: My body feels like it's freaking out, hat racing, brain fog,
Speaker 1: I feel a little bit drunk.
Speaker 3: Is this normal when starting hate chad T?
Speaker 2: No, it's not normal, but it does happen, and that's
Speaker 2: why I would If somebody is getting side effects, I
Speaker 2: would start again and introduce one hormone at a time
Speaker 2: classic classically but not always progest Aroune can make people
Speaker 2: feel quite drugged, you know. So it can you can
Speaker 2: give you a real hangover effect in some women. And
Speaker 2: sometimes we change how we use it, like you can
Speaker 2: swap to using it as a vain vaginal pestory. So
Speaker 2: if that's happening, I would stop and restart and just
Speaker 2: do one hormone at a time and then introduce hormone
Speaker 2: two after a couple of weeks, so you can see
Speaker 2: what's causing a problem. And often you need to go
Speaker 2: and start much at a much lower dose and just
Speaker 2: go more slowly. And for some woman at the side effects,
Speaker 2: you can't. It's really difficult.
Speaker 4: For us small number.
Speaker 2: I've only got two patients who don't tolerate HRT, so
Speaker 2: for most women you can find a solution.
Speaker 3: Okay, what about natural another listener question natural options such
Speaker 3: as wild yam cream and those products out there, do
Speaker 3: they work to reduce the symptoms of perimenopause and menopause?
Speaker 2: I think I think in some people they can certainly
Speaker 2: help some of the milder symptoms, but you know, when
Speaker 2: you're really trying to get into the brain for significant anxiety, insomnia,
Speaker 2: mood changes, loss of joy, I think you really probably
Speaker 2: do need to do a pharmacological level product. I think
Speaker 2: there's also this misperception that if something is natural that
Speaker 2: it's totally safe, and that's not necessarily true. If anything
Speaker 2: that has an effect can have a side effect or
Speaker 2: a risk, and that's just how biochemistry works. So the
Speaker 2: good thing about regulated medical products is they have got
Speaker 2: reasonable amount of evidence behind them. But I appreciate not
Speaker 2: everybody wants to take you know, a pharmaceutical and certainly
Speaker 2: these natural products you know, just being careful that is
Speaker 2: something that has been tried and tested. Most things don't
Speaker 2: have a huge amount of evidence for being effective. And
Speaker 2: we know that the placebo effect is very strong. So
Speaker 2: most medications and supplements have about a forty percent placebo effect.
Speaker 2: So being cautious about how much money you spend. I
Speaker 2: still think if you're wanting to do natural, probably the
Speaker 2: best thing is you're nutrition, your exercise, your sleep, your
Speaker 2: boundary setting, your breathing.
Speaker 1: Let's talk about that whole mindset side of it if
Speaker 1: we can for a moment, I think, what advice would
Speaker 1: you give to women who are starting to feel effects
Speaker 1: of perimenopause or menopause. They feel like their body's changing,
Speaker 1: their minds changing, they're changing who they are. They don't
Speaker 1: feel like themselves anymore. Can you just give us some
Speaker 1: beautiful mindset advice around? You know what would Land really
Speaker 1: love in a nice way with these women?
Speaker 2: So I would say, I'm fifty one, I'm living my
Speaker 2: best life ever. I've got almost full time GP, i
Speaker 2: have a second business, I've got three children, I'm still
Speaker 2: happily married.
Speaker 4: He might disagree.
Speaker 2: I would say, if you, if you educate yourself, you
Speaker 2: become empowered with knowledge and rather than leaving yourself to
Speaker 2: be blindsided, you know, by the twenty foot truck that
Speaker 2: premenopause can be educate yourself because if you go into
Speaker 2: this phase of your life with knowledge, then you can
Speaker 2: really make decisions that are right for you, and they're
Speaker 2: going to everybody's decisions about what they want to do
Speaker 2: is going to be very different, but that knowledge can
Speaker 2: be very grinding and validating to understand why you're experiencing things,
Speaker 2: and it's a wonderful period of rewiring. It's a time
Speaker 2: where you can start to put yourself first and stop
Speaker 2: caring so much about what other people think. We become
Speaker 2: this wiser, elder group of women who should be leading
Speaker 2: the world because the people currently in charge are making
Speaker 2: a mess of it. If there is more of us
Speaker 2: at the top, I don't think we'd be in the
Speaker 2: situation we're in. So really leaning into what your body's
Speaker 2: telling you, you know, getting well educated, looking for good
Speaker 2: sources of information. We think healthy hormones is brilliant, but
Speaker 2: everybody has their own, you know, health journey and health beliefs,
Speaker 2: and you have to find what's right for you, you know,
Speaker 2: staying connected to the good people in your life. You know,
Speaker 2: community and connection is so important for everybody, but I
Speaker 2: think women really do thrive on it, but equally don't
Speaker 2: overdo it. So educate yourself, stay connected, you know, and
Speaker 2: just recognize that this is a wonderful phase where you're
Speaker 2: moving into your There's loads of people have loads of
Speaker 2: different names for it, but you know, this is where
Speaker 2: you can really become strong and find yourself. And you know,
Speaker 2: I think you can really do quite magnificent things as
Speaker 2: you move through perimenopause and menopause. So yeah, own it,
Speaker 2: livette you know, you don't need to worry about what
Speaker 2: people think anymore. That's the best thing.
Speaker 1: Oh isn't that just the blessing that I sing on
Speaker 1: the cake? Absolutely knowing yourself at a deeper level. I
Speaker 1: love that you put it a light on this and
Speaker 1: and gives people hope and not not cloudy in fear.
Speaker 3: That we need to be feeful of these years ahead.
Speaker 1: And you know, life is over and we can't thrive
Speaker 1: or look good, or be strong or have great relationships.
Speaker 1: And I think the knowledge is great and important for
Speaker 1: us as women, but also if we can share the
Speaker 1: knowledge to our partners as well.
Speaker 3: So they can be prepared and empowered.
Speaker 2: With exactly Yeah, so they don't get hit by a
Speaker 2: truck that DA's a perimenopozzle woman.
Speaker 3: What has happened to my wife?
Speaker 1: Exactly right now, you do have the resource of your
Speaker 1: business that you help people with, and we'll share that
Speaker 1: in the show notes, so if anyone needs support even further.
Speaker 3: And your Instagram page, of course, is a wealth of knowledge.
Speaker 1: And there's actually a million other questions that I want
Speaker 1: to ask you in regards to what you share on that,
Speaker 1: but we will connect another time because I know time
Speaker 1: is limited today, but I would love to end today
Speaker 1: with you sharing a bit of a things you can
Speaker 1: on here moment that really helped you see life a
Speaker 1: little bit differently.
Speaker 2: I think in terms of medical knowledge, I really hadn't
Speaker 2: appreciated I'd never been treated and to treat women, and
Speaker 2: that was a light bulb moment for me and that
Speaker 2: has transformed how I practice medicine. And you know, I
Speaker 2: think it's a lot simpler than we've all been taught.
Speaker 2: You know, it's the basics that are critical, and you
Speaker 2: know the power of community and connection and you know,
Speaker 2: staying surrounding yourself with good people. I think is powerful
Speaker 2: and that's something I've been very lucky to have throughout
Speaker 2: my life. Yeah, and I think the value of connection
Speaker 2: is really underestimated. So that would be my thing to
Speaker 2: take away that don't ever underestimate the power of the
Speaker 2: people around you.
Speaker 1: And if you could share something with other doctors out
Speaker 1: there listening, what would.
Speaker 2: You say, Stay curious. There is so much that we
Speaker 2: don't know, and when you lose that curiosity, you're really
Speaker 2: wasting all of that training and experience that you've had
Speaker 2: to date. And there's so much that we need to learn,
Speaker 2: especially for our female patients, and just trying to maintain
Speaker 2: a bit of that compassion, you know, putting yourself in
Speaker 2: somebody's shoes and remembering how hard it is to be
Speaker 2: on the other side of that desk, you know, when
Speaker 2: people you know are struggling, you know, just remember that
Speaker 2: it's hard to be on the other seat, and being
Speaker 2: brave to you know, to advocate for your patients. That's
Speaker 2: something I've certainly really enjoyed doing, is becoming a patient
Speaker 2: advocate and trying to fight for a better system. And
Speaker 2: it does, it does. We do need clinicians in this space,
Speaker 2: advocate advocating for patients to really drive change. It shouldn't
Speaker 2: be up to the woman to do it for themselves.
Speaker 2: It should the healthcare system should also be advocating for
Speaker 2: better care for a woman.
Speaker 1: Here, Doctor Kerry Cashil, thank you so much for joining
Speaker 1: me on things you can in here. Make sure you
Speaker 1: go over to Kerrie's Instagram page. There's a whole thing
Speaker 1: going on about gel nails that I really wanted to
Speaker 1: talk to you about, but we'll do that another time.
Speaker 4: We'll have a Jawnelle episode exactly.
Speaker 1: And hypermobility, which is another important topic. But thank you
Speaker 1: for sharing everything that you have today around this important
Speaker 1: topic and we look forward to seeing what's Thanks for you.
Speaker 2: Thanks too much, met zeb thanks.
Speaker 3: For listening to the show. What did you think and
Speaker 3: what did you feel?
Speaker 1: Let us know by leaving me a message on the
Speaker 1: things you can't on here Instagram community.
Speaker 3: Page and if you can give us some ratings
Speaker 1: Love on your favorite listening platform